1. Sir Donald Acheson was invited by Ministers on 10 July 1997 to undertake an independent review of inequalities of health in England. The commissioning letter from the Minister for Public Health is attached at annex A.

Terms of Reference

2. The Inquiry's terms of reference were:
(1) To moderate a Department of Health review of the latest available information on inequalities of health, using data from the Office for National Statistics, the Department of Health and elsewhere. The data review would summarise the evidence of inequalities of health and expectation of life in England and identify trends.
(2) In the light of that evidence, to conduct - within the broad framework of the Government's overall financial strategy - an independent review to identify priority areas for future policy development, which scientific and expert evidence indicates are likely to offer opportunities for Government to develop beneficial, cost effective and affordable interventions to reduce health inequalities.
(3) The review will report to the Secretary of State for Health. The report will be published and its conclusions, based on evidence, will contribute to the development of a new strategy for health.

3. The purpose of the Inquiry was to inform the development of the Government's public health strategy and, in particular, to contribute to the forthcoming White Paper, "Our Healthier Nation". A two stage timescale was agreed to assist this process. It provided for confidential draft advice to be presented to Ministers in advance of the publication of the final report.

Scientific Advisory Group

4. After initial consultations on the major issues of health inequalities in the summer of 1997, the business of the Inquiry was taken forward by a Scientific Advisory Group (SAG) of experts, chaired by Sir Donald and supported by a small Secretariat. The members of the Group were:

Professor David Barker frs, Director of the Medical Research Council's Environmental Epidemiology Unit, University of Southampton
Dr Jacky Chambers, Director of Public Health, Birmingham Health Authority
Professor Hilary Graham, Director of the Economic and Social Research Council's Health Variations Programme at Lancaster University
Professor Michael Marmot, Professor of Epidemiology and Public Health, University College, London and Director of the International Centre for Health and Society.
Dr Margaret Whitehead, Visiting Fellow at the King's Fund, London

5. The SAG met on 19 occasions between August 1997 and September 1998. It oversaw the process, received the evidence submitted and developed the recommendations and the final report.

Process

6. As a first step, the Inquiry commissioned a series of topic (or "input") papers from academics and other experts in the field. The purpose of the papers was to identify and summarise key issues and to allow the SAG to consider the state of the scientific evidence and possible areas for policy development in accordance with the Inquiry's terms of reference.

7. The Inquiry took a broad view of the causes and the impact of health inequalities on individuals and society. Accordingly, these papers explored aspects of the life course, of the economic, social and physical environments, and of the behaviours which affect individual health. Input papers on a total of 17 topics were presented to the SAG. They are listed in full in Annex D.

8. Most of the authors of the input papers consulted widely among a network of other researchers in the area. The papers were presented at SAG meetings by the author(s). Invited experts were asked to comment on the input papers as part of the SAG discussions. The main findings of the papers and results of the SAG discussions were summarised in a series of commentaries.

9. These input papers, and commentaries, together with other evidence were scrutinised by a separate Evaluation Group. This Group, chaired by Professor Sally Macintyre, Director of the MRC Medical Sociology Unit, was set up to provide a further element of peer review to the process. The members of the Group were Dr Iain Chalmers, Director of the UK Cochrane Centre, Dr Richard Horton, editor of The Lancet, Dr Richard Smith, editor of the British Medical Journal. The Group noted the lack of evidence to support many suggested policy interventions, and recommended that the Inquiry should make explicit the quality of evidence and argument used to support proposed areas for policy development. The SAG received a report from the Group and accepted its advice.

10. The SAG also received a number of presentations from other experts and from within its own ranks. These were usually less formal events, and the results were not considered by the Evaluation Group. They were, nevertheless, crucial in expanding and strengthening the evidence base of the Inquiry.

11. Written submissions were also sought from a range of bodies and individuals, and many additional contributions were received. This evidence was considered by the SAG and, as far as possible, fed into the development and review of the input papers. A full list of the presentations and submissions received is in annex D.

12. The process was also aided by a series of "chairman's briefings", usually informal discussions with experts covering issues arising from the consultation paper "Our Healthier Nation" and from the initiatives of other Government Departments.

13. The report's recommendations and supporting argument documented in this report are the result of all these processes.

14. Draft confidential advice was submitted to Ministers in July. This final report was submitted at the end of September 1998