Tackling health inequalities : what do senior managers think

Objective: To describe how New South Wales (NSW) Area Health Service Chief Executive Officers (CEOs) understood concepts of equity in the development of NSW Health's Equity Statement; CEO knowledge and interpretation of a given concept being one aspect of developing policy.

Design and Setting: This paper describes the process through which NSW Area Health Service CEOs were involved in developing the Equity Statement, specifically:

1. Briefings with individual CEOs on key issues and identification of possible difficulties and potential 'equity champions'.
2. A two-hour workshop to explore ('pre-mortem') why the proposed statement might fail.
3. CEO involvement in identifying strategies that promoted equity already operating locally.
4. C onsultations with selected individuals about the draft recommendations.
5. Feedback to CEOs.

The article provides a case study of consultative policy making by illustrating how participant knowledge can both inform and be strengthened by involvement in the policy development process.

Results: There was a high level of awareness among CEOs of health inequalities and an acceptance of their responsibility to address them. They saw three main ways of doing this: a) equity of resource allocation for health service delivery within and between regions; b) equity of access to health services based on need; and c) equity of health outcomes. CEOs felt that making the health system accountable for health outcomes would provide pressure for system-wide resource allocation changes. They recognised that factors substantially impacting on health outcomes were outside the control of the health system. Furthermore, finding a balance to which they could be held accountable was difficult. All CEOs saw ensuring needs-based access to services as a key area where they could potentially have an impact; and they specifically saw challenges in a conflict between equity and efficiency, marginalisation of special treatment for disadvantaged people, balancing investment in rescue services and prevention/early intervention, and developing a rational health financing system. The resulting policy has been broadly embedded within the NSW health system with strong local support.

Conclusion: The NSW Health and Equity policy was embedded because CEO leadership and acceptance of the policy enhanced local ownership.