General Recommendations (see pages 29-31)

1. We RECOMMEND that as part of health impact assessment, all policies likely to have a direct or indirect effect on health should be evaluated in terms of their impact on health inequalities, and should be formulated in such a way that by favouring the less well off they will, wherever possible, reduce such inequalities.

1.1 We recommend establishing mechanisms to monitor inequalities in health and to evaluate the effectiveness of measures taken to reduce them.

1.2 We recommend a review of data needs to improve the capacity to monitor inequalities in health and their determinants at a national and local level.

2. We RECOMMEND a high priority is given to policies aimed at improving health and reducing health inequalities in women of childbearing age, expectant mothers and young children.

Poverty, Income, Tax and Benefits (see pages 32-36)

3. We RECOMMEND policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits. Specifically:

3.1 we recommend further reductions in poverty in women of child-bearing age, expectant mothers, young children and older people should be made by increasing benefits in cash or in kind to them.

3.2 We recommend uprating of benefits and pensions according to principles which protect and, where possible, improve the standard of living of those who depend on them and which narrow the gap between their standard of living and average living standards.

3.3 We recommend measures to increase the uptake of benefits in entitled groups.

We recommend further steps to increase employment opportunities (recommendation 8.1)

Education (see pages 36-44)

4. We RECOMMEND the provision of additional resources for schools serving children from less well off groups to enhance their educational achievement. The Revenue Support Grant formula and other funding mechanisms should be more strongly weighted to reflect need and socioeconomic disadvantage.

5. We RECOMMEND the further development of high quality pre-school education so that it meets, in particular, the needs of disadvantaged families. We also recommend that the benefits of pre-school education to disadvantaged families are evaluated and, if necessary, additional resources are made available to support further development.

6. We RECOMMEND the further development of "health promoting schools", initially focused on, but not limited to, disadvantaged communities.

7. We RECOMMEND further measures to improve the nutrition provided at school, including: the promotion of school food policies; the development of budgeting and cooking skills; the preservation of free school meals entitlement; the provision of free school fruit; and the restriction of less healthy food.

Employment (see pages 44-50)

8. We RECOMMEND policies which improve the opportunities for work and which ameliorate the health consequences of unemployment. Specifically:

8.1 we recommend further steps to increase employment opportunities.

8.2 We recommend further investment in high quality training for young and long-term unemployed people.

We recommend policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits (recommendation 3).

We recommend an integrated policy for the provision of affordable, high quality day care and pre-school education with extra resources for disadvantaged communities (recommendation 21.1).

9. We RECOMMEND policies to improve the quality of jobs, and reduce psychosocial work hazards. Specifically:

9.1 we recommend employers, unions and relevant agencies take further measures to improve health through good management practices which lead to an increased level of control, variety and appropriate use of skills in the workforce.

9.2 We recommend assessing the impact of employment policies on health and inequalities in health (see also recommendation 1).

Housing and Environment (see pages 50-55)

10. We RECOMMEND policies which improve the availability of social housing for the less well off within a framework of environmental improvement, planning and design which takes into account social networks, and access to goods and services.

11. We RECOMMEND policies which improve housing provision and access to health care for both officially and unofficially homeless people.

12. We RECOMMEND policies which aim to improve the quality of housing. Specifically:

12.1 we recommend policies to improve insulation and heating systems in new and existing buildings in order to reduce further the prevalence of fuel poverty.

12.2 We recommend amending housing and licensing conditions and housing regulations on space and amenity to reduce accidents in the home, including measures to promote the installation of smoke detectors in existing homes.

13. We RECOMMEND the development of policies to reduce the fear of crime and violence, and to create a safe environment for people to live in.

We recommend policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits (recommendation 3).

Mobility, Transport and Pollution (see pages 55-61)

14. We RECOMMEND the further development of a high quality public transport system which is integrated with other forms of transport and is affordable to the user.

15. We RECOMMEND further measures to encourage walking and cycling as forms of transport and to ensure the safe separation of pedestrians and cyclists from motor vehicles.

16. We RECOMMEND further steps to reduce the usage of motor cars to cut the mortality and morbidity associated with motor vehicle emissions.

17. We RECOMMEND further measures to reduce traffic speed, by environmental design and modification of roads, lower speed limits in built up areas, and stricter enforcement of speed limits.

18. We RECOMMEND concessionary fares should be available to pensioners and disadvantaged groups throughout the country, and that local schemes should emulate high quality schemes, such as those of London and the West Midlands.

Nutrition and the Common Agricultural Policy (see pages 62-67)

19. We RECOMMEND a comprehensive review of the Common Agricultural Policy (CAP)'s impact on health and inequalities in health.

19.1 We recommend strengthening the CAP Surplus Food Scheme to improve the nutritional position of the less well off.

20. We RECOMMEND policies which will increase the availability and accessibility of foodstuffs to supply an adequate and affordable diet. Specifically:

20.1 We recommend the further development of policies which will ensure adequate retail provision of food to those who are disadvantaged.

We recommend policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits (recommendation 3).

We recommend the further development of a high quality public transport system which is integrated with other forms of transport and is affordable to the user (recommendation 14).

20.2 We recommend policies which reduce the sodium content of processed foods, particularly bread and cereals, and which do not incur additional cost to the consumer.

Mothers, Children and Families (see pages 67-77)

21. We RECOMMEND policies which reduce poverty in families with children by promoting the material support of parents; by removing barriers to work for parents who wish to combine work with parenting; and by enabling those who wish to devote full-time to parenting to do so. Specifically:

21.1 we recommend an integrated policy for the provision of affordable, high quality day care and pre-school education with extra resources for disadvantaged communities (see also: recommendation 5).

We recommend further reductions in poverty in women of child-bearing age, expectant mothers, young children and older people should be made by increasing benefits in cash or in kind to them (recommendation 3.1).

We recommend measures to increase the uptake of benefits in entitled groups (recommendation 3.3).

22. We RECOMMEND policies which improve the health and nutrition of women of child-bearing age and their children with priority given to the elimination of food poverty and the prevention and reduction of obesity. Specifically:

We recommend further reductions in poverty in women of child-bearing age, expectant mothers, young children and older people should be made by increasing benefits in cash or in kind to them (recommendation 3.1).

We recommend further measures to improve the nutrition provided at school, including: the promotion of school food policies; the development of budgeting and cooking skills; the preservation of free school meals entitlement; the provision of free school fruit; and the restriction of less healthy food (recommendation 7).

We recommend a comprehensive review of the Common Agricultural Policy (CAP)'s impact on health and inequalities in health (recommendation 19).

We recommend policies which will increase the availability and accessibility of foodstuffs to supply an adequate and affordable diet (recommendation 20).

22.1 We recommend policies which increase the prevalence of breastfeeding.

22.2 We recommend the fluoridation of the water supply.

22.3 We recommend the further development of programmes to help women to give up smoking before or during pregnancy, and which are focused on the less well off.

23. We RECOMMEND policies that promote the social and emotional support for parents and children. Specifically:

23.1 we recommend the further development of the role and capacity of health visitors to provide social and emotional support to expectant parents, and parents with young children.

23.2 We recommend local authorities identify and address the physical and psychological health needs of looked-after children.

Young People and Adults of Working Age (see pages 77-87)

We recommend policies which improve the opportunities for work and which ameliorate the health consequences of unemployment (recommendation 8).

We recommend policies to improve the quality of jobs, and reduce psychosocial work hazards (recommendation 9)

24. We RECOMMEND measures to prevent suicide among young people, especially among young men and seriously mentally ill people.

25. We RECOMMEND policies which promote sexual health in young people and reduce unwanted teenage pregnancy, including access to appropriate contraceptive services.

26. We RECOMMEND policies which promote the adoption of healthier lifestyles, particularly in respect of factors which show a strong social gradient in prevalence or consequences. Specifically:

26.1 we recommend policies which promote moderate intensity exercise including: further provision of cycling and walking routes to school, and other environmental modifications aimed at the safe separation of pedestrians and cyclists from motor vehicles; and safer opportunities for leisure.

26.2 We recommend policies to reduce tobacco smoking including: restricting smoking in public places; abolishing tobacco advertising and promotion; and community, mass media and educational initiatives.

26.3 We recommend increases in the real price of tobacco to discourage young people from becoming habitual smokers and to encourage adult smokers to quit. These increases should be introduced in tandem with policies to improve the living standards of low income households and polices to help smokers in these households become and remain ex-smokers.

26.4 We recommend making nicotine replacement therapy available on prescription.

26.5 We recommend policies which reduce alcohol-related ill health, accidents and violence, including measures which at least maintain the real cost of alcohol.

Older People (see pages 87-92)

27. We RECOMMEND policies which will promote the material well being of older people. Specifically:

we recommend policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits (recommendation 3).

We recommend uprating of benefits and pensions according to principles which protect and, where possible, improve the standard of living of those who depend on them and which narrow the gap between their standard of living and average living standards (recommendation 3.2).

We recommend measures to increase the uptake of benefits among entitled groups. (recommendation 3.3).

28. We RECOMMEND the quality of homes in which older people live be improved. Specifically:

we recommend policies to improve insulation and heating systems in new and existing buildings in order to reduce further the prevalence of fuel poverty (recommendation 12.1).

We recommend amending housing and licensing conditions and housing regulations on space and amenity to reduce accidents in the home, including measures to promote the installation of smoke detectors in existing homes (recommendation 12.2).

29. We RECOMMEND policies which will promote the maintenance of mobility, independence, and social contacts. Specifically:

we recommend the development of policies to reduce the fear of crime and violence, and to create a safe environment for people to live in (recommendation 13).

We recommend the further development of a high quality public transport system which is integrated with other forms of transport and is affordable to the user (recommendation 14).

We recommend concessionary fares should be available to pensioners and disadvantaged groups throughout the country, and that local schemes should emulate high quality schemes, such as those of London and the West Midlands (recommendation 18).

30. We RECOMMEND the further development of health and social services for older people, so that these services are accessible and distributed according to need.

We recommend a review of data needs to improve the capacity to monitor inequalities in health and their determinants at a national and local level (recommendation 1.2).

Ethnicity (see pages 92-100)

31. We RECOMMEND that the needs of minority ethnic groups are specifically considered in the development and implementation of policies aimed at reducing socioeconomic inequalities. Specifically:

we recommend policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits (recommendation 3).

We recommend policies which improve the opportunities for work and which ameliorate the health consequences of unemployment (recommendation 8)

We recommend policies which improve the availability of social housing for the less well off within a framework of environmental improvement, planning and design which takes into account social networks, and access to goods and services (recommendation 10).

We recommend policies which aim to improve the quality of housing (recommendation 12).

We recommend the development of policies to reduce the fear of crime and violence, and to create a safe environment for people to live in (recommendation 13).

We recommend the further development of a high quality public transport system which is integrated with other forms of transport and is affordable to the user (recommendation 14).

We recommend further measures to encourage walking and cycling as forms of transport and to ensure the safe separation of pedestrians and cyclists from motor vehicles (recommendation 15).

We recommend further steps to reduce the usage of motor cars to cut the mortality and morbidity associated with motor vehicle emissions (recommendation 16).

We recommend further measures to reduce traffic speed, by environmental design and modification of roads, lower speed limits in built up areas, and stricter enforcement of speed limits (recommendation 17).

We recommend concessionary fares should be available to pensioners and disadvantaged groups throughout the country, and that local schemes should emulate high quality schemes, such as those of London and the West Midlands (recommendation 18)

32. We RECOMMEND the further development of services which are sensitive to the needs of minority ethnic people and which promote greater awareness of their health risks.

33. We RECOMMEND the needs of minority ethnic groups are specifically considered in needs assessment, resource allocation, health care planning and provision. Specifically:

we recommend a review of data needs to improve the capacity to monitor inequalities in health and their determinants at a national and local level (recommendation 1.2).

Gender (see pages 100-110)

34. We RECOMMEND policies which reduce the excess mortality from accidents and suicide in young men (see also: recommendation 24). Specifically:

we recommend policies which improve the opportunities for work and which ameliorate the health consequences of unemployment (recommendation 8).

We recommend policies which improve housing provision and access to health care for both officially and unofficially homeless people (recommendation 11).

We recommend further measures to encourage walking and cycling as forms of transport and to ensure the safe separation of pedestrians and cyclists from motor vehicles (recommendation 15).

We recommend further steps to reduce the usage of motor cars to cut the mortality and morbidity associated with motor vehicle emissions (recommendation 16).

We recommend further measures to reduce traffic speed, by environmental design and modification of roads, lower speed limits in built up areas, and stricter enforcement of speed limits (recommendation 17).

We recommend measures to prevent suicide among young people, especially among young men and seriously mentally ill people (recommendation 24).

We recommend policies which reduce alcohol-related ill health, accidents and violence, including measures which at least maintain the real cost of alcohol (recommendation 26.5).

35. We RECOMMEND policies which reduce psychosocial ill health in young women in disadvantaged circumstances, particularly those caring for young children. Specifically:

we recommend further reductions in poverty in women of child-bearing age, expectant mothers, young children and older people should be made by increasing benefits in cash or in kind to them (recommendation 3.1).

We recommend uprating of benefits and pensions according to principles which protect and, where possible, improve the standard of living of those who depend on them, and which narrow the gap between their standard of living and average living standards (recommendation 3.2).

We recommend measures to increase the uptake of benefits among entitled groups (recommendation 3.3).

We recommend policies which improve the availability of social housing for the less well off within a framework of environmental improvement, planning and design which takes into account social networks, and access to goods and services (recommendation 10).

We recommend the further development of a high quality public transport system which is integrated with other forms of transport and is affordable to the user (recommendation 14).

We recommend policies which will increase the availability and accessibility of foodstuffs to supply an adequate and affordable diet (recommendation 20).

We recommend policies which reduce poverty in families with children by promoting the material support of parents; by removing barriers to work for parents who wish to combine work with parenting, and by enabling those who wish to devote full-time to parenting to do so (recommendation 21).

We recommend an integrated policy for the provision of affordable, high quality day care and pre-school education with extra resources for disadvantaged communities. (recommendation 21.1).

We recommend policies which improve the health and nutrition of women of child-bearing age and their children with priority given to the elimination of food poverty and the prevention and reduction of obesity (recommendation 22).

We recommend policies which promote the social and emotional support for parents and children (recommendation 23).

We recommend the further development of the role and capacity of health visitors to provide social and emotional support to expectant parents, and parents with young children (recommendation 23.1).

We recommend policies which promote sexual health in young people and reduce unwanted teenage pregnancy, including access to appropriate contraceptive services (recommendation 25).

36. We RECOMMEND policies which reduce disability and ameliorate its consequences in older women, particularly those living alone. Specifically:

we recommend further reductions in poverty in women of child-bearing age, expectant mothers, young children and older people should be made by increasing benefits in cash or in kind to them (recommendation 3.1).

We recommend uprating of benefits and pensions according to principles which protect and, where possible, improve the standard of living of those who depend on them, and which narrow the gap between their standard of living and average living standards (recommendation 3.2).

We recommend measures to increase the uptake of benefits among entitled groups (recommendation 3.3).

We recommend the development of policies to reduce the fear of crime and violence, and to create a safe environment for people to live in (recommendation 13).

We recommend the further development of a high quality public transport system which is integrated with other forms of transport and is affordable to the user (recommendation 14)

We recommend concessionary fares should be available to pensioners and disadvantaged groups throughout the country, and that local schemes should emulate high quality schemes, such as those of London and the West Midlands (recommendation 18).

We recommend the quality of homes in which older people live be improved (recommendation 28).

We recommend the further development of health and social sevices for older people, so that these services are accessible and distributed according to need (recommendation 30).

The National Health Service (pages 111-119)

37. We RECOMMEND that providing equitable access to effective care in relation to need should be a governing principle of all policies in the NHS. Priority should be given to the achievement of equity in the planning, implementation and delivery of services at every level of the NHS. Specifically:

37.1 we recommend extending the focus of clinical governance to give equal prominence to equity of access to effective health care.

37.2 We recommend extending the remit of the National Institute for Clinical Excellence to include equity of access to effective health care.

37.3 We recommend developing the National Service Frameworks to address inequities in access to effective primary care.

37.4 We recommend that performance management in relation to the national performance management framework is focused on achieving more equitable access, provision and targeting of effective services in relation to need in both primary and hospital sectors.

37.5 We recommend that the Department of Health and NHS Executive set out their responsibilities for furthering the principle of equity of access to effective health and social care, and that health authorities, working with Primary Care Groups and providers on local clinical governance, agree priorities and objectives for reducing inequities in access to effective care. These should form part of the Health Improvement Programme.

38. We RECOMMEND giving priority to the achievement of a more equitable allocation of NHS resources. This will require adjustments to the ways in which resources are allocated and the speed with which resource allocation targets are met. Specifically:

38.1 we recommend reviewing the "pace of change" policy to enable health authorities that are furthest from their capitation targets to move more quickly to their actual target.

38.2 We recommend extending the principle of needs-based weighting to non-cash limited General Medical Services (GMS) resources. The size and effectiveness of deprivation payments in meeting the needs and improving the health outcomes amongst the most disadvantaged populations, including ethnic minorities should be assessed.

38.3 We recommend reviewing the size and effectiveness of the Hospital and Community Health Service (HCHS) formula and deprivation payments in influencing the health care outcomes of the most disadvantaged populations, and to consider alternative methods of focusing resources for health promotion and public health care to reduce health inequalities.

38.4 We recommend establishing a review of the relationship of private practice to the NHS with particular reference to access to effective treatments, resource allocation and availability of staff.

39. We RECOMMEND Directors of Public Health, working on behalf of health and local authorities, produce an equity profile for the population they serve, and undertake a triennial audit of progress towards achieving objectives to reduce inequalities in health.

39.1 We recommend there should be a duty of partnership between the NHS Executive and regional government to ensure that effective local partnerships are established between health, local authorities and other agencies and that joint programmes to address health inequalities are in place and monitored.

We RECOMMEND that as part of health impact assessment, all policies likely to have a direct or indirect effect on health should be evaluated in terms of their impact on health inequalities, and should be formulated in such a way that by favouring the less well off they will, wherever possible, reduce such inequalities (recommendation 1).