EQUALLY WELL OUTCOMES FRAMEWORK
Equally Well Recommendation 72 stated that:
The Government should arrange for a clear analysis of the medium-term outcome indicators critical to achieving reductions in the key health inequalities outcomes. This analysis should reflect the National Performance Framework and the new relationship between the Scottish Government and local authorities as embodied in the Single Outcome Agreement process. It should be published by autumn 2008, in order to guide community planning partnerships and their constituent organisations in their own planning and performance reporting.
The analyses here meet Recommendation 72 by presenting outcome frameworks for each of the 4 priority areas identified in Equally Well where action is most needed to improve health outcomes. These are:
- Children's very early years, where inequalities may first arise and influence the rest of people's lives.
- The high economic, social and health burden imposed by mental illness, and the corresponding requirement to improve mental wellbeing.
- The "big killer" diseases: cardiovascular disease and cancer. Some risk factors for these, such as smoking, are strongly linked to deprivation.
- Drug and alcohol problems and links to violence that affect younger men in particular and where inequalities are widening.
For each of the priority areas, the outcomes framework sets out the following analyses:
Intermediate outcomes for environmental and behavioural influences on health that contribute to health inequalities and are suitable for inclusion in Single Outcome Agreements (SOAs). Improving these outcomes is likely to make a contribution to improving the measures of key health inequalities in Equally Well for assessing long-term progress in reducing health inequalities in Scotland: low birth weight, mental wellbeing of adults, healthy life expectancy and premature mortality. These in turn will contribute to achieving the National Outcomes identified in the diagrams.
Indicators from the National Indicators and Menu of Local Outcome Indicators (Version 2, October 2008) suitable for measuring progress towards intermediate outcomes and that could be included within SOAs.
Equally Well recommendations for activities and inputs that may contribute to achieving the intermediate outcomes.
What do we mean by intermediate outcomes?
Intermediate outcomes are about the underlying reasons for health inequalities e.g. poverty, lack of good employment, physical environments. All community planning partners are involved in influencing these outcomes; action is not exclusively for NHS Scotland.
Many of the intermediate outcomes also appear in other national strategies and frameworks. In particular, the outcomes identified are consistent with the early years and tackling poverty frameworks. Outcomes are also consistent with the drug and alcohol outcomes toolkit that will be published in December 2008 and outcomes identified for criminal justice authorities.
Why is it useful to identify intermediate outcomes?
The analyses present a menu of intermediate outcomes and activities that can be planned and delivered by community planning partners (separately and jointly) to help reduce health inequalities. They will be useful for community planning partnerships that identify local problems with poor health that contribute to national health inequality, and/or that identify significant health inequalities within their partnership areas. The analyses should also be helpful in identifying local priorities for SOAs and for joint thinking between local partners on the actions that each should then pursue.
How do the analyses relate to the Health Improvement Performance Management Review?
The analyses follow some of the same formats as the HIPM package, with the intermediate outcomes grouped into environmental and behavioural determinants of health inequalities.
The outcomes are also time-sequenced - they indicate the intermediate outcomes that need to be achieved before we can reduce health inequalities, although the outcomes do not correspond to particular timeframes - some intermediate outcomes may take a long time to achieve.
The analyses do not, however, attempt to model the causes of health inequalities or the complex interrelationships between them. As Equally Well spells out, there is not enough good evidence yet of what works in reducing health inequalities and influencing underlying causes, so the analyses are not a complete, evidence-based guide to the best ways of reducing health inequalities. Rather, they reflect the health inequalities outcomes described in Equally Well and the actions that Equally Well recommends based on our current understanding of the factors that influence health inequalities. Further work is required to identify intermediate outcomes relating to economic, social and physical environments that shape health inequalities and the effective actions for achieving these outcomes.
Nor do the analyses address the issue of who will benefit from the activities identified. Plans to achieve the intermediate outcomes need to consider the reach of the services provided to ensure that interventions (whether targeted or delivered to the population as a whole) improve the health of groups in greatest need. Likewise, measures used in local performance management processes need to assess outcomes across a range of different groups. This will assist in indicating whether outcomes for the population as a whole have improved and whether health inequalities have been reduced.
How do the analyses relate to SOAs and the recent SOA Guidance?
The analyses are in the spirit of the 2009 SOA guidance. In particular, they distinguish between "above the line" outcomes suitable for inclusion in SOAs and also provide some "below the line" information for use in community planning partners' own planning, performance management and reporting processes.
The analyses are not, however, specifically about "below the line" performance management within community planning partner organisations, for example, the HEAT targets for NHS boards. The Equally Well implementation plan indicates that further work will be required to identify shorter-term service delivery outcomes to form the basis of performance management of progress towards achieving the intermediate outcomes.
What happens next?
Scottish Government plans more work in 2009: to explore how HEAT can better reflect NHS action to reduce health inequalities, to identify local data or proxy data to measure progress against the long-term health inequalities outcomes and analyse further the potential activities and inputs of individual community planning partners that contribute to the intermediate outcomes.
The Equally Well implementation plan includes information about progress with Equally Well recommendations and support available for local activities and inputs.