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Durham University

Department of Sociology

Completed Projects

Performance Assessment and 'wicked issues': the case of inequalities

A research project of the Department of Sociology.


A National Health Service (NHS) covers the whole of Great Britain, with free care at the point of delivery. However, separate national governments in England, Scotland and Wales are now responsible for most public services, including policies and structures for the NHS. One of the major differences between these three countries is how targets and performance assessment are used by national governments to drive policy priorities. This study investigates how these differences mediate and translate into policy and practice at the local level, and the importance of local context for actioning policy. The data are primarily from a qualitative analysis of 200 interviews with key local actors in the NHS, local government and multi-agency partnerships. These were conducted in several case study localities across the three countries and in two phases in 2006 and 2008, enabling investigation of how conceptualisations changed over time, especially as new approaches to performance assessment developed and political change occurred. While governments in all three countries claimed to be prioritising health inequalities, crucial to the reality ‘on the ground’ was how performance assessment regimes used by these governments framed local perceptions and actions.


The project is funded by the following grant.

  • Performance Assessment And Wicked Issues (£256551.82 from ESRC)


The study’s research questions are:

1. How do the different approaches to performance assessment in England, Wales and Scotland shape the ‘construction’ of health inequalities by local stakeholders and how do these constructions vary with the position of stakeholders in the local policy system?

2. How does performance assessment influence local decisions about policies and programmes to tackle health inequalities, and does this change with the introduction of new performance assessment frameworks?

3. How do local constructions and decisions compare to local evidence about health inequality, performance and resources derived from statistical data and performance reviews?

4. To what extent do learning and adaptation occur as part of local strategies to tackle health inequalities and how are these affected by performance assessment requirements?

5. Does performance assessment need to be reconceptualised and reformed


Interviews and documentary analysis.


See project website (details below).

Published Results

Journal Article

  • Blackman, T., Elliot, E., Green, A. Harrington, B., Smith, K., Hunter, D., Marks, L., McKee, L. & Williams, G. (2009). Tackling health inequalities in post-devolution Britain: do targets matter? Public Administration 87(4): 762 - 778.
  • Smith, K., Hunter, D., Blackman, T., Elliott, E., Greene, A., Harrington, B., Marks, L., McKee, L. & Williams, G. (2009). Divergence or Convergence? Health Inequalities and Policy in a Devolved Britain. Critical Social Policy 29(2): 216-242.
  • Blackman, T., Harrington, B., Smith, K., Hunter, D., Marks, L., McKee, L., Greene, A., Elliott, E. & Williams, G. (2009). Health inequalities in England, Scotland and Wales: Stakeholders' accounts and policy compared. Public Health 123(1): e24-28.
  • Blackman, T., Harrington, B., Elliott, E., Greene, A., Hunter, D., Marks, L., McKee, L. & Williams, G. (2006). Performance assessment and wicked issues: the case of health inequalities. Public Policy and Administration 21(2): 66-80.


From other departments

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