PHIAC took account of a number of factors and issues in making the recommendations.

  • PHIAC considers a cross-government approach is required to tackle health inequalities and that high quality public services can make an important contribution. Although relatively narrow in scope, PHIAC considers that the interventions in this guidance will make a contribution to reducing health inequalities, particularly if set within wider health promoting policies (such as tobacco control and healthy eating).

  • The prevalence of diseases with a strong socioeconomic gradient may vary from one location to another. PHIAC recognises that people who are disadvantaged (specifically, those with a higher-than-average risk of premature death from smoking-related diseases and cardiovascular disease [CVD] from other causes) are not necessarily located in areas defined as disadvantaged. The guidance, therefore, is applicable to these people – regardless of where they live.

  • PHIAC is mindful that a lack of resources (within the NHS and other sectors) has sometimes confounded attempts to address health inequalities. Adequate resources (financial, time, equipment and people) need to be deployed effectively to meet the needs of people who are disadvantaged.

  • People who are disadvantaged face social and economic issues that may adversely affect their ability to respond to the treatments or advice on offer.

  • Few, if any, studies in the effectiveness reviews focused primarily on reducing health inequalities. Studies that did include relevant variables were not usually large enough to analyse outcomes in relation to different subgroups. As a result, it's unclear from these studies which methods are most effective at reaching people or groups that are disadvantaged. Smoking cessation and the provision of statins (both generally agreed to be effective interventions) provide clear pointers on how to meet the needs of people who are disadvantaged. They also form a key part of the government's approach to tackling health inequalities.

  • PHIAC would like to encourage research trials that are large enough to assess the impact of interventions on different subgroups. This is especially important where the topic is known to have a clear socioeconomic gradient or affects some ethnic groups more than others (for example, smoking and heart disease).

  • Given the paucity of evidence on how to identify and support people who are disadvantaged, PHIAC felt it was important not to be prescriptive but to encourage innovation. It believes local people and services should be given the support they need to develop a range of approaches to tackling health inequalities. New approaches must be evaluated to build the evidence base on how best to reach, engage and improve the health of people who are disadvantaged.

  • There is sometimes a mismatch between policy direction and service targets. For instance, the targets for NHS Stop Smoking Services do not focus on the most hard-to-reach groups, despite the thrust of stated policy.

  • PHIAC stressed that the quality and outcomes framework (QOF) needs to be modified to give GPs a greater incentive to find and treat those who are disadvantaged and at greatest risk of premature death from preventable conditions. GPs could play an important role in tackling such health inequalities and PHIAC considers that financial incentives would help. In the meantime, the Committee believes joint working with the voluntary and community sectors is needed to identify individuals who are not registered with a general practice. Similarly, joint working is needed to identify those who have been missed as a result of exception reporting.

  • The mapping review identified a wide range of activities aimed at both people who are disadvantaged and at disadvantaged areas. These activities appear to operate as discrete and specific projects. It is important to find ways to include these activities in mainstream services so that they are not treated as additional activities or exceptions to the general rule.

  • PHIAC considers that evaluation (including evaluation of the impact of services on different subgroups) should be an integral part of new policies and services.

  • The recommendations made in this guidance aim to support and complement other initiatives to reduce premature mortality. Of particular relevance is the coordinated vascular disease control programme commissioned by the UK National Screening Committee. This is set out in the UK National Screening Committee's handbook for vascular risk assessment, risk reduction and risk management. The aim is to identify and reduce the risk of CVD in the general population. Also of relevance is the Department of Health's vascular checks programme, announced in January 2008. This focuses on everyone aged between 40 and 74.