Jennie Popay, Chris Dibben, Emma Halliday, James Nazroo, Sue Povall, Mai Stafford, Pierre Walthery, Margaret Whitehead with Roy Carr-Hill, Paul Dixon and Hannah Badlands.
For further details contact ku.ca.retsacnal@yapop.j
This is an independent report of research commissioned and funded by the Policy Research Programme in the Department of Health (Evaluating the impact of New Deal for Communities on Health Inequalities: Phase 2. Reference No: PR-IP-0509-0180063). The views expressed are those of the authors and not necessarily those of the Department of Health.
Background and aims
The research reported here focused on the nature and scale of the NDC regeneration initiative and its distributional impact on inequalities in health and their social determinants. The overall aim of the NDC policy initiative was to bridge the gap between some of the most deprived neighbourhoods in England and the rest of the country in six outcome domains over a 10-year period: crime, the local community, housing and the physical environment, education, health and worklessness. There were 39 NDC areas, each receiving public funds of around £50M (£2B in total) from 1999 to 2011. This report builds on the work produced by the NDC NET to address the following research questions:
Is there any evidence that inequalities in health and their social determinants improved in NDC areas to a greater extent than in non-NDC areas of comparable baseline deprivation?
Is there any evidence that health and its social determinants have improved in NDC areas to a greater extent than in areas drawn from across the social gradient?
Do the impacts of the NDC initiative on health inequalities and their social determinants vary across types of NDC local programmes being implemented in different ‘types’ of areas, and if so what characterises NDC areas and local programmes that have seen the greatest improvements in health inequalities and their determinants?
What are the lessons for future initiatives aiming to reduce health inequalities?
Evaluation design and data sources
The evaluation comprised three work strands:
Work strand 1 involved the development of measures of the local context in which the NDC programmes were implemented and a typology of local NDC programmes. For this work we used secondary quantitative and qualitative and documentary data collected by the NET, publicly available quantitative data from other sources and new primary data collected from interviews and documents in a sample of NDC areas
Work strand 2 evaluated the impact of the NDC initiative as a whole, and different types of local programmes, on health inequalities and their social determinants. This work used data collated by the NET for NDC areas and their ‘matched’ comparator areas, selected from within the same local authority boundary and with broadly the same Index of Multiple Deprivation. These data included repeat cross-sectional and panel data from MORI surveys conducted in 2002, 2004, 2006 and 2008 for the NDC areas and their comparators; area-level time series data on hospital admissions and welfare claimant numbers for NDC areas and their comparators; and data from the HSE household surveys for 2002, 2004, 2006 and 2008 used to identify areas with high, medium and low levels of deprivation.
Work strand 3 involved the creation of a data archive making available programming codes and data for other users so that our analyses can be replicated. This legacy will allow longer-term follow-up of the impact of the NDC on health inequalities and their social determinants, as well as comparison of health and social outcomes in NDC and similarly deprived areas. We hope that this material will be hosted as part of the NET’s archive on the Sheffield Hallam University website.
Measuring the local context in which New Deal for Communities programmes were implemented
Although all NDC local programmes had the same purpose (closing the gap in the six outcome domains between the NDC areas and the rest of the country), the form that they took varied significantly as they sought to address local needs in very different contexts. We therefore developed new measures of these contextual factors including current and historical levels of deprivation and employment, and patterns of industry and migration. However, only the deprivation measured had any predictive power, possibly because of constraints in the data that we were able to use to capture historical context.
Developing a typology of local New Deal for Communities programmes
Our typology of local NDC programmes reflects the relative emphasis that they gave to three core dimensions: housing and environment, human capital and CE. Three types of programmes were identified:
type 1 – transforming environments: diversifying the social composition of the population through major redevelopment and changing tenure patterns
type 2 – incremental: increasing neighbourhood resources and moderate neighbourhood redevelopment
type 3 – strengthening people: building residents’ human capital and improving living conditions with little or no redevelopment.
The impact of the New Deal for Communities on the health of the ‘poorest’
Predictably, socioeconomic disadvantage was associated with poorer health in NDC areas, their comparator areas and high and medium deprivation areas derived from the HSE. Hospital admission rates were also much higher than the national average in NDC and comparator areas, particularly for alcohol- and drug-related conditions, and remained so over the 10 years of the programme. Most differences in health and social outcomes between NDC areas and their comparator areas were explained by the relatively more disadvantaged circumstances of populations in the NDC areas. However, there were a few exceptions, with respondents in NDC areas reporting higher levels of life satisfaction in 2002.
Markedly different pictures of changes over time are provided by our analyses of longitudinal and cross-sectional data. The longitudinal data paint a less positive picture, showing no overall trend of improvement on most outcomes in either the NDC areas or the comparator areas, with two exceptions. First, levels of satisfaction with the area actually declined over time between 2002 and 2008 in comparator areas compared with NDC areas. Second, NDC areas experienced a greater reduction in benefit receipt among lone parents than comparator areas, suggesting that the NDC programme may have added value to national programmes supporting lone parents to get back into employment.
In contrast, the cross-sectional analyses using MORI and HSE data found a general trend of improvement between 2002 and 2008 in smoking, mental health, educational attainment and employment rates in areas across the social spectrum. Importantly, levels of reported poor health appeared to decline faster in NDC and comparator areas than in areas with low deprivation and these improvements were greater in NDC areas than in areas with high and medium deprivation in other parts of the country.
There is also some evidence of a NDC ‘effect’ on the social determinants of health inequalities, with the proportion of people in NDC areas with no qualifications falling more steeply than that in the HSE low and high deprivation areas. This more rapid decline was also seen in the NDC comparator areas but these were relatively more advantaged and hence were facing a less severe challenge. Similarly, although the gap between HSE high and low deprivation areas widened on five of the six social determinants of health that we considered, only the gap in smoking widened between NDC areas and HSE low deprivation areas. In other words, the NDC intervention may have helped to prevent a further widening of the gap, or even narrowed it, in some of these outcomes, which is an important achievement.
Finally, our study suggests that the NDC programme may have reduced some inequalities within NDC areas, with the most disadvantaged respondents within NDC areas faring better in terms of positive changes in mental health and life satisfaction than similarly disadvantaged groups in comparator areas.
Do different types of New Deal for Communities programme have different impacts?
This general picture masks some differential impacts of different types of local programmes. Type 1 local programmes (involving major redevelopment) consistently underperformed on most health and social outcomes compared with both type 2 (incremental) and type 3 (strengthening people) local programmes. Overall, type 2 local programmes were most often associated with improvements over time. Compared with type 1 areas, in type 2 areas:
social capital and smoking advantages emerged or were maintained between 2002 and 2008
respondents had a greater probability of reporting improved mental health over time
respondents without work were significantly more likely to find employment over time
hospital admission rates fell faster than in comparator areas, particularly for alcohol- and drug-related conditions, which are closely linked to mental health problems
the better performance on hospital admission rates was maintained in type 2 programme areas with very different social and economic contexts.
There is also some evidence that type 1 programmes may be associated with increased inequalities. Although less successful at reducing hospital admissions than the other types of local programmes, they appear to have performed better on these indicators in the least deprived areas.
Explaining the patterns that we have found: implications for policy and research
Our findings add to previous research showing that area-based interventions such as the NDC can have positive impacts on the health and social circumstances of residents of disadvantaged neighbourhoods. More importantly, the NDC also reduced the gap between more and less disadvantaged residents of NDC areas, and between NDC residents and those living in less disadvantaged areas of England – albeit that these effects were relatively modest, confined to a small number of health and social outcomes and not always consistent across the multiple outcomes and analytical approaches used. Impacts are most obvious for mental health improvements (a finding reinforced by the reduction in mental health hospital admissions in NDC areas that we also identified), aspects of social cohesion/capital and educational attainment.
The relatively better performance of type 2 local programmes suggests that future area-based interventions designed and delivered to achieve a better balance between redevelopment of the physical environment and investment in releasing the capacity of residents in terms of both human capital and genuine community governance could be better able to impact on a range of health and social outcomes at the same time as reducing inequalities, albeit modestly.
There is also the intriguing suggestion that 6 years into the NDC initiative, a time when political priorities were changing nationally, improvements in outcomes for disadvantaged communities began to slow. This underscores the potential health equity benefits of long-term investment in area regeneration programmes but also highlights the importance of understanding how local programmes are best enabled to weather changes in policy expectations and interests over time.
Our project has developed, and tested, more nuanced research processes, utilising secondary data sources to help tease out why some area-based investments do or do not work and in which contexts. We will be archiving material that will allow other researchers to access the data sets and variables that we have constructed to replicate the methods we have used. The findings emphasise the need for prospective evaluative studies that track both the form and the function of interventions, as well as local context. We were not funded to undertake an economic evaluation of the NDC initiative and with the data available this would not have been possible, highlighting the need for further methodological innovations in this field.
