Public Service Agreement targets:
a gendered analysis
Sarah Payne and Sarah Ayres
with Paul Burton, Ray Forrest and Eva Lloyd
School for Policy Studies, University of Bristol
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
 Equal Opportunities Commission 2006
First published Autumn 2006
ISBN 1 84206 182 8
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CONTENTS
EXECUTIVE SUMMARY
iii
1
INTRODUCTION
1
2
METHODOLOGY
3
3
GOVERNMENTAL FRAMEWORK
4
4
DETAILED ANALYSIS OF PUBLIC SERVICE AGREEMENTS
IN THREE DEPARTMENTS
5
5
OFFICE OF THE DEPUTY PRIME MINISTER
5.1
An overview
5.2
ODPM PSA 1 - Neighbourhood renewal: Floor Target 10 Worklessness
5.3
ODPM PSA 5 - Affordable housing
7
10
6
DEPARTMENT FOR EDUCATION AND SKILLS
6.1
An overview
6.2
DfES PSA 4 - Obesity
6.3
DfES PSA 5 - Looked after children
13
13
14
16
7
DEPARTMENT OF HEALTH
7.1
An overview
7.2
DH PSA 7 - Patient experience
7.3
DH PSA 8 - Vulnerable older people
20
20
20
24
8
CONCLUSIONS
27
REFERENCES
6
6
28
i
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
EXECUTIVE SUMMARY
EXECUTIVE SUMMARY
OVERVIEW
In April 2007 a new gender equality duty (GED) will require public authorities to pay
attention to gender equality in all their functions, including policy design and
performance measures. This means that service providers and public sector
employers will have to design services and employment with the different needs of
women and men in mind. Public authorities will be expected to set gender equality
objectives and take action to achieve them.
Public Service Agreements (PSAs) are three year agreements between government
departments and the Treasury, setting out departmental targets as part of the
Spending Review. This report analyses the 2004 PSAs in three government
departments – the Office of the Deputy Prime Minister (ODPM) (now the Department
for Communities and Local Government (DCLG1)), the Department for Education and
Skills (DfES), and the Department of Health (DH). It explores the extent to which
PSAs are gendered, the availability of gender disaggregated data used to monitor
PSAs in these departments and the possible impact of taking a gendered approach
to the targets.
FINDINGS
Gender sensitive policy is likely to increase policy effectiveness by targeting
resources more efficiently and tailoring service delivery to the specific needs of the
population. Targeting resources in a gender sensitive way can lead to short and long
term efficiency gains. For example, a gendered policy to stop individuals smoking is
more effective in the short term as it takes account of different social behaviours of
men and women. This also leads to longer term efficiency gains for the NHS due to a
reduction in tobacco related illness.
Many government policies and targets are cross-cutting. Therefore, efficiency gains
in one department may lead to improvements in other departments’ performance
against their targets.
Addressing complex social and economic problems is hugely challenging, requiring
an increasingly nuanced and sophisticated approach to public policy management. A
gender disaggregated approach would help provide the detail required to make more
informed decisions about multifaceted policy issues. Despite this, none of the PSAs
1
Reference to the ODPM is retained in this report, as Government communications on
existing PSA targets still refer to that department.
iii
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
in the departments studied take account of gender other than those relating to
conception and teenage pregnancy.
There are significant differences between Government departments in their ability
and willingness to respond to gender issues, in terms of their expertise, available
data and personnel. Recognising the gender implications of policies is not always a
top priority.
Research shows that the evidence base and information available for monitoring
PSAs is often weak. Less than half of the data for indicators used to monitor progress
towards PSA targets are gender disaggregated, although figures vary between
departments and policy areas. With some of the PSAs, gender specific targets and
gender disaggregated data would not be appropriate.
Although gender has a very low profile in the PSAs explored, ethnicity features at
times. This suggests that the public sector duty on race equality has had some
impact, indicating the possibility of change with regards to the gender duty.
A detailed analysis of six PSA targets (two in each department) suggests a gender
disaggregated approach to the design, monitoring and evaluation of PSAs could
improve departmental performance against these targets and provide other efficiency
gains, as illustrated below.
Worklessness (ODPM)
There are important gender differences in the proportions of women and men who
are not in employment and the reasons they are unable or unwilling to enter
employment. Three-quarters of participants in the New Deal for Young People are
male whereas the target group for the New Deal for Lone Parents (NDLP) is
predominately female. Women of working age are more likely than men to care for a
family member and the effect of partnership and of a dependent child on women's
employment patterns varies greatly between ethnic groups. Women are at higher risk
of developing mental health problems, particularly depression and anxiety, which
affects their ability to work. A gendered approach, which takes account of the
different needs of women and men, could result in efficiency gains both from
reductions in state benefits and in demand for other public services. More detailed
indicators and gendered policy interventions (such as the NDLP) would help to
achieve the level of sophistication required to improve performance against this
challenging target.
iv
EXECUTIVE SUMMARY
Affordable housing (ODPM)
Gender differences in income mean there are significant differences between women
and men with regard to their opportunities for affordable housing. A higher proportion
of single men than single women are owner-occupiers and women on low incomes,
lone parents in particular, are marginalised from renting or purchasing homes in high
cost areas. Attention to the different housing needs of women and men in different
parts of the country could help the department to achieve this target. A gendered
approach to the supply of affordable housing could also help the government to meet
targets in other key areas, such as crime and health because of linkages between
these and domestic violence, inadequate or inappropriate housing.
Obesity (DfES)
There are gender differences in the causes of obesity, how it is tackled and how
accurately it is measured. In 2004, 16 per cent of boys and 12 per cent of girls aged
2-10 were obese, and 14 per cent of children overweight. For the 11-15 year old age
group, more girls than boys were obese and overweight. The success of
interventions such as school-based exercise and diet programmes differ, as girls and
boys respond to different types of exercise and prefer different food. A number of
efficiency gains in the short and long term could be made by taking a gendered
approach to obesity, particularly by focusing on gender differences in key underlying
factors and suitable interventions.
Looked after children (DfES)
There is a gender gap in achievement at all Key Stages in the school population and
the educational performance of looked after children is well below the average for all
children, but there are no gendered data on attainment available for this group. While
overall outcomes for looked after children in general are poor, outcomes for girls tend
to be worse. Levels of mental illness are high for both girls and boys in this
population, who face different types of mental health problems. One in seven girls is
already pregnant or a mother when leaving care and the risk of teenage pregnancy is
associated with many of the factors also associated with being in care. Taking
account of gender differences in educational attainment and in improving outcomes
by designing interventions that are directly applicable for girls and boys could have
both short and long term benefits. These include a reduction in under-age
conceptions, health improvements (particularly for girls), and a reduction in the
proportion of children who end up outside of education, employment or training.
Vulnerable older people (DH)
One of the main differences between the sexes is life expectancy. Women live longer
than men, on average, with the result that more of the old and very old are women.
More women live alone and women are also more vulnerable to poverty and
v
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
deprivation than men, for a variety of reasons. There are differences in their use of
both statutory and private home care services. It is essential to understand the
differences between women and men in factors affecting their ability to sustain
independent living and the level of services they require, in order to determine how
well services meet need and which groups will benefit from policies designed to
support them.
Patient experience (DH)
An improvement in patient satisfaction can lead to better health outcomes and so
improve morbidity and mortality rates. Existing gender disaggregated data are very
limited but suggest that women and men have different perceptions of their health
service experience and that levels of satisfaction differ. The picture which emerges is
mixed and stresses the need for a more consistent approach to data collection in
order to understand the reasons behind these responses. Women are known to
place a higher value on privacy, including being cared for on a single sex ward and
having a carer of the same sex. Service providers need to know what the differences
are between women and men in detail if they are to improve patient satisfaction, and
to understand the reasons behind these responses.
Conclusion
These PSAs were analysed in order to demonstrate the potential for gender analysis
across the PSA process as a whole and are indicative of what can be achieved. This
study suggests that where a gendered approach is adopted, targets are more likely
to be achieved and resources more effectively targeted, benefiting all those
concerned.
vi
INTRODUCTION
1
INTRODUCTION
This report explores the availability of, and need for, gender disaggregated data in
the assessment of Public Service Agreements (PSAs). From April 2007 a new
gender equality duty will require all public authorities to pay due regard to the need to
promote gender equality and eliminate discrimination in the delivery of services and
in employment. This duty will require public sector organisations to pay attention to
gender equality in all their functions, including policy design and performance
measures. This means that service providers and public sector employers will have
to design services and employment with the different needs of women and men in
mind. It should generate policy making and services that are sensitive to gender
difference. The Gender Equality Duty is part of the larger Equality Act (2006) that
established the Commission for Equality and Human Rights (CEHR), and is due to
become law in April 2007.
PSAs are three year agreements between government departments and the
Treasury, setting out departmental targets as part of the Spending Review. Financial
incentives are in place for departments who reach their targets. The PSAs set in the
2004 Spending Review for three departments - the Office of the Deputy Prime
Minister (ODPM)2, the Department for Education and Skills (DfES), and the
Department of Health (DH) are analysed here. The report focuses on the gender
dimensions of these PSAs and the availability of gender disaggregated data which
would help the departments’ response to the public sector duty on gender to be
evaluated. Identifying the gender implications of PSA targets in all areas of policy is
central to the public sector duty on gender equality, but there are other reasons why
it is useful to do this. Policy and provision which is gender blind can obscure the
specific needs of women or men, resulting in the inefficient use of resources and
suboptimal outcomes for individuals. Gender sensitive policy which takes account of
the role played by gender in shaping needs and experiences of public services is
more likely to deliver greater policy effectiveness and improve performance against
PSA targets. However, at present neither the PSA targets, nor measurement of
progress toward targets, are gendered. A second related point is that many of the
performance measures including PSAs are cross-departmental and, as a result,
greater disaggregation of data carries added value for other departments.
Despite this clear rationale, there remain significant administrative barriers to gender
analysis in policy making. Although the 2002 Spending Review made a commitment
2
Now the Department for Communities and Local Government (DCLG). Reference to the
ODPM is retained in this report, as Government communications on existing PSA targets still
refer to that department. See p.7 for further information.
1
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
to
website
reporting
on
departmental
PSAs
(http://www.hmtreasury.gov.uk/performance/index.cfm) the data reported are not gender
disaggregated - for example, for the Department for Work and Pensions commitment
to reduce pensioner poverty, figures are provided for all pensioner households.
However, there are important differences between older women and older men in
their risk of poverty, their reliance on state benefit and in the kinds of intervention
which might help reduce poverty. Another issue relates to the complexity of the
datasets used. Many PSAs are monitored by inter-linked datasets, creating problems
in terms of linking populations where statistics are collected in a different time frame
or in a different way. Where these data are not disaggregated by gender, finding
alternatives may prove more problematic. It is also worth noting the timeframe and
difficulty involved in making a case for change in how performance is measured:
Persuading the DH [Department of Health] or AC [Audit Commission] to
revise an indicator to make it more meaningful can take years … Given
the diversity of recording systems and cultures in which recording is taking
place, it will take time for new indicators to ‘bed down’ and become part of
the culture of management and professional practice.
(Miller, 2001: 15)
Nonetheless, despite these hurdles, changes in setting and measuring performance
targets are possible. This report focuses on gender rather than the other public
sector duties on race and disability. It is worth noting, however, that the Technical
Notes (TNs) which support the PSAs comment on ethnicity but not gender, probably
due to the earlier implementation of the public sector duty on race equality (in 2001).
This provides an important indication of how far and in what ways PSAs might be
able to incorporate the new gender duty in the future. For example, some of the
targets in relation to ethnicity are about narrowing the gap between ethnic groups,
and this approach could be extended to boys/girls and men/women in a number of
PSAs. Having said that, more emphasis on the race duty requirements may be
necessary as the PSAs themselves are largely neutral in terms of ethnicity.
The remainder of this report offers a brief account of methods used, an overview of
PSAs, followed by a more detailed analysis of the PSAs in three departments,
highlighting the case for gender disaggregation by an in-depth study of six PSA
targets and the data they rely on.
2
METHODOLOGY
2
METHODOLOGY
The study consisted of a review of the data used to measure performance against
PSA targets in three departments - the ODPM, DfES and DH. The analysis focused
on the value of national statistics in terms of specific PSAs, gaps in this data and
alternative gender specific statistics.
The work was conducted in five key stages. First, the 2004 PSAs were identified for
each of the three departments. Second, the technical notes relating to each of the
PSAs and the 2005 Departmental Annual and Spring Reports were used to identify
the indicators of success and the datasets used by departments to measure
performance against PSA targets. Third, the researchers undertook a gender
analysis of the data to:
1.
Ascertain whether the performance measures used by departments are gender
disaggregated;
2.
Consider whether alternative datasets exist that might facilitate a gender
analysis;
3.
Comment on the rationale for generating gender disaggregated datasets if
these are not available;
4.
Comment on the rationale for incorporating a gender dimension to PSAs and/or
performance indicators.
Fourth, two PSAs from each of the three departments were selected for a more
thorough examination. Examples were selected that offered a potentially interesting
angle in demonstrating the added value of a gender analysis. Finally, key comments
and observations that have arisen during the research process were noted. These
are presented in the conclusions.
3
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
3
GOVERNMENTAL FRAMEWORK
There are global and EU commitments to gender mainstreaming but the response in
the UK has been relatively slow. Nonetheless, gender equity is not new to
government departments, including the Treasury, and in recent years a number of
initiatives focusing on gendered aspects of policy and service delivery have been
developed. For example, in July 2004 the Treasury published ‘Gender Analysis of
Expenditure Project’ (HM Treasury and DTI, 2004). The project looked at examples
across different policy areas where a gender analysis might improve policy
effectiveness. The work was said to have informed the 2004 Spending Review
process but the specifics on precisely how remain unclear. Indeed, while the
Treasury has expressed an interest in gender issues, a lack of human resources
(time and expertise) within the department limits its ability to address the issue
comprehensibly. Moreover, it has been suggested that Treasury groups (e.g.
Poverty, Education) are viewed as highly variable in how they are equipped to deal
with gender issues.
There are also significant differences between departments in their ability and
willingness to respond to gender issues. ‘Gender impact assessments’ have been
adopted with very different rates and with differing levels of enthusiasm. Likewise,
gender ‘focal points’ have been set up in each department since 1997 but the
positions are not full time, there is minimal expertise and recognising the gender
implications of policy does not always feature as a top priority. The Policy Appraisal
for Equal Treatment guidelines were drafted within the WEU to set out in simple
terms the process civil servants should follow to ensure sensitivity to gender.
However, these guidelines have yet to have significant impact (Veitch, 2005).
A more persuasive mechanism is undoubtedly the Gender Equality PSA (DTI PSA 9)
that came into force in 2003 (http://www.dti.gov.uk/about/strategy-objectives/PSATargets/page14321.html). It is intended to be the most powerful tool the WEU has
produced as departments are required to report publicly on the sub-targets contained
within it. As part of the PSA, the DTI has an objective to raise gender equality across
a range of indicators, including women’s representation on public boards and equal
pay, by 2006. However, if the duty on gender equality is to be effective, all
departments will need to formulate a strategy while cross-department activities will
need to clarify where the responsibility lies. The Treasury and the PSA system
represent a powerful mechanism that shapes future departmental and policy
trajectories. The Treasury’s support and commitment is, therefore, viewed as vital in
promoting the gender equality duty across government.
4
DETAILED ANALYSIS OF PSA TARGETS IN THREE DEPARTMENTS
It should be added that the Gender PSA itself is limited to certain targets and does
not represent a comprehensive approach to gender across the whole PSA
(Comprehensive Spending Review) process. Departmental PSAs are intended to
form a core element of the government’s ‘joined-up’ agenda, i.e. more partnership
working between departments, joint budgeting arrangements, and more staff rotation.
The PSA system was designed to bring all of central government under a systemwide performance regime to reduce fragmentation and to bring increased
transparency, accountability and information to the public about performance in
service delivery. Demonstrating performance against PSAs to citizens and users was
intended to be a core objective of the PSA system.
5
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
4
DETAILED ANALYSIS OF PUBLIC SERVICE AGREEMENTS IN
THREE DEPARTMENTS
How can a gender analysis help to improve departmental performance against
PSAs?

First, a greater awareness and understanding of gender differentials would
facilitate meeting the PSA target itself. Where there are differences between
women and men, policies which do not take account of these are unlikely to be
successful. Thus, an appreciation of these differences allows gender sensitive
policy to be developed and improves chances of success.

Second, a gender disaggregated approach to policy can result in efficiency
gains. Targeting resources in a gender sensitive way allows better use of
resources and better use of public money in the short and long term.

Third, the inter-relationship between departmental PSAs and other targets also
means that efficiency gains of gender disaggregation in one department may
accrue to other departments, improving performance against related targets.

Fourth, the public sector duty on gender equality requires departments to
demonstrate how they have considered the gender implications of policy
formation and delivery and that their work is commensurate with this duty.
Analysis of the 2004 Public Service Agreements for specific departments, however,
reveals a wide variation in the availability of data disaggregated by gender. The
following sections present an analysis of the 2004 PSAs for each department
(ODPM, DfES and DH). In each section a brief overview of the department’s PSAs is
provided. This sets out the range of policy issues addressed by the department and
the number of instances where gender disaggregated data are both required and
made available. This is followed by a detailed analysis of two PSAs from each
department. These detailed examples were selected on the basis of their significance
in the overall delivery of welfare. None of the targets chosen mention gender and
they provide a way of drawing some conclusions about PSAs in terms of the
incoming public sector duty on gender equality and the case that may be made for
both gender specific PSA targets and gender disaggregated data. Further analysis of
the gendered implications of the 2004 Public Service Agreements for these
departments can be found at http://www.eoc.org.uk/Default.aspx?page=15570.
6
OFFICE OF THE DEPUTY PRIME MINISTER
5
OFFICE OF THE DEPUTY PRIME MINISTER
5.1
An overview
The 2004 PSAs for the ODPM cover a range of issues including tackling deprivation
and social exclusion (neighbourhood renewal), improving regional economic
performance, reducing accidental fire-related deaths, improving the performance of
local government, providing decent and affordable housing, land use planning and
liveability (i.e. promoting cleaner, safer and greener public spaces). On 5 th May 2006
a new government department, the Department for Communities and Local
Government (DCLG) was created, taking the majority of the ODPM's responsibilities
and some from the Home Office. Its remit is to promote community cohesion and
equality, and to take responsibility for housing, urban regeneration, planning and
local government. However, reference to the ODPM is retained in this report, as
government communications on existing PSA targets still refer to that department.
ODPM’s Neighbourhood Renewal PSA (PSA1) is unique in that it involves working
with other departments across government to narrow the gap between deprived
neighbourhoods and the rest of the country. Progress in meeting this target will be
measured by tracking improvements in deprived areas on six indicators covering
health, education, crime, worklessness, housing and liveability outcomes. These
indicators have been derived from those underpinning national PSA floor targets on
key public service areas. ODPM also has a joint PSA with HM Treasury and the DTI
to boost regional economic performance and reduce the persistent gap in growth
rates between regions (PSA2).
In 2004 ODPM was set eight PSAs, which include 35 indicators on which the
department’s performance will be judged. Of these 35 indicators, gender
disaggregation could be seen as unnecessary in 19 instances. For example, there is
no rationale for gender disaggregated data in relation to improving the efficiency of
the planning system (PSA6) or reducing economic disparities between England’s
regions (PSA2). The remaining 16 indicators would benefit from gender
disaggregated data, although the case is far stronger for some than others. For
example, there is arguably a stronger case for undertaking a gendered analysis of
the department’s policy on social housing than on its policy to reduce accidental
deaths by fire, due to the significantly higher proportion of people affected by this
policy and, hence, the increased efficiency gains to be derived.
Of the 16 indicators where gender disaggregated data are essential, such data are
only available in seven cases. There are, therefore, nine cases where data are not
gender disaggregated but where a gender analysis would help to improve
performance against key targets. The data relating to the department’s
7
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
neighbourhood renewal floor targets on health, education, worklessness and crime
are gender disaggregated. In contrast, gender disaggregated data are not available,
for example, for the PSAs relating to decent and affordable homes and liveability.
Incorporating a gendered perspective into these indicators could help focus
resources more effectively, leading to more effective policy making and delivery.
The two PSA targets selected for more detailed analysis relate to the ODPM’s
neighbourhood renewal floor target on worklessness (joint with HMT and DWP) and
to affordable housing.
5.2
ODPM PSA 1 - Neighbourhood renewal: Floor Target 10 - Worklessness
Target
Tackle social exclusion and deliver neighbourhood renewal, working with
departments to help them meet their PSA floor targets, in particular narrowing the
gap in health, education, crime, worklessness, housing and liveability outcomes
between the most deprived areas and the rest of England, with measurable
improvement by 2010.
Floor Targets (joint with HMT and DWP)
As part of the wider objective of full employment in every region, over the three years
to Spring 2008, and taking account of the economic cycle:
1.
Demonstrate progress on increasing the employment rate (joint HMT);
2.
Increase the employment rates of disadvantaged groups (lone parents, ethnic
minorities, people aged 50 and over, those with the lowest qualifications and
those living in the local authority wards with the poorest initial labour market
position); and
3.
Significantly reduce the difference between the employment rates of the
disadvantaged groups and the overall rate (joint DWP).
Geographical areas
Wards located in Local Authority Districts in receipt of neighbourhood renewal funds
that are also those wards with the worst labour market position. These target wards
will be selected using Labour Force Survey (LFS) data and data on receipt of key
benefits (e.g. Jobseeker's Allowance, Income Support, Incapacity Benefit and Severe
Disablement Allowance).
8
OFFICE OF THE DEPUTY PRIME MINISTER
Context
The Government is committed to tackling worklessness, particularly amongst
vulnerable groups. As part of its strategy to tackle poverty and social exclusion the
Government is committed to:

Building an active welfare state that makes work pay and work possible.

Encouraging lifelong learning to ensure that people have the skills and
education to play an active part in the modern labour market.

Providing support for those most at risk from discrimination and disadvantage.
Indicators to be used
For those living in the Local Authority wards with the worst labour market position
that are also located within Local Authority Districts in receipt of Neighbourhood
Renewal Fund (NRF), significantly improve their overall employment rate, and reduce
the difference between their employment rate and the overall employment rate for
England.
Sources of data identified in Technical Notes are the Labour Force Survey (LFS)
(data for employment rates by group and for lone parents from LFS household data),
and ‘Assessments of the economic cycle’ produced and published by HMT.
Gender analysis of the PSA and commentary
There are important gender differences in the proportions of women and men who
are not in employment and the reasons they are unable or unwilling to enter
employment.

Nearly three-quarters of participants in the New Deal for Young People (NDYP)
are male (Dorsett, 2004) although they constitute fewer than two-thirds of those
eligible for the scheme. A gendered analysis would highlight that women are
underrepresented in this scheme and would help to direct resources and effort
more effectively to those in need, as it has with the ongoing success in helping
lone mothers back to work. This may be attributed, at least in part, to the New
Deal for Lone Parents (NDLP) scheme, a voluntary programme aimed at lone
parents who are not working or who are working fewer than 16 hours a week.
The target group is predominately female (90 per cent) and serves to
demonstrate what might be achieved by incorporating a gendered analysis into
policy making and delivery (HM Treasury and DTI, 2004).
9
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS

The effect of partnership and of a dependent child on women’s employment
patterns varies greatly between ethnic groups (Lindley and Dale, 2004). A
higher proportion of Black Caribbean women work full-time in comparison with
White women, they are also more likely to work full-time when their children are
young. In contrast, Pakistani and Bangladeshi women have the lowest levels of
economic activity and this is true for women with a partner and not just mothers
with young children. Policies reflecting these gender and cultural distinctions
could help increase paid work among women and lone parents from all ethnic
communities. As neighbourhood renewal areas have relatively high proportions
of lone parents and ethnic minority groupings, such an approach would be
advantageous.

Women of working age are more likely than men to care for a family member
(Babb, 2006) and to be classed as economically inactive, even though they
undertake considerable care duties. A gender analysis could help to present
data that better reflects the working commitments (paid and unpaid) of men and
women and help target those with dependants who are currently unable to
(re)enter the workplace.

Women are at higher risk of developing mental health problems, particularly
depression and anxiety, which may act as a barrier to their employment
(Lennon et al., 2001). A gendered performance indicator as part of the New
Deal for the Disabled would help to target resources more effectively at
vulnerable women with specific health needs. Such an approach would also
have beneficial impacts in terms of improving public health and could result in
efficiency gains both from reductions in state unemployment benefits and
reduced demand on health services.
While some of these differences are often reflected in specific policies – as
mentioned above, the New Deal for Lone Parents (Dewson, 2005) focuses largely on
the needs of women - gender is not referred to in the key indicators. Employment
data are, however, gender disaggregated and provide an opportunity to plan, monitor
and evaluate progress on this target in a more comprehensive way. They provide
comprehensive statistics on ethnicity and disability that might be used to enrich a
gendered analysis. Moreover, the ONS has commissioned a series of reports that
provide a detailed description of the different working trends of men and women. In
particular, recent analysis of changes between 1991 and 2001 showed differing
activity behaviours for women with and without dependent children. They
demonstrate that the continued rises in female activity rates during the 1990s were
driven by the choices and behaviours of women with dependent children (Lindsay,
2004).
10
OFFICE OF THE DEPUTY PRIME MINISTER
The government has begun to take account of the different employment needs of
men and women. Apart from the NDLP, other schemes include:

New Deal for the Disabled



New Deal for Partners (to aid the partners of benefit claimants back to work)
New Deal for Young People (16-25 year olds)
New Deal 25+ (over 25 years of age)


New Deal 50+ (over 50 years of age) (Dewson, 2005)
New Deal Areas

Local Action Teams

Employment Zones
Evidence suggests, however, that these schemes are less effective at tackling
worklessness in the most deprived areas (SEU, 2004). This is hugely complex and
there is a need for more focused planning in terms of helping vulnerable people with
specific health, cultural and social needs. More detailed performance indicators
aimed at, for example, women and men from certain ethnic groups or women with
specific health needs would help to achieve the level of policy sophistication required
to improve performance against this challenging target. In addition, an understanding
of diversity within groups is invaluable: cross referencing data on gender with
ethnicity provides a greater insight into the social and cultural trends affecting women
and men and patterns of work.
5.3
ODPM PSA 5 - Affordable housing
Target
Achieve a better balance between housing availability and the demand for housing,
including improving affordability, in all English regions while protecting valuable
countryside around our towns, cities and in the green belt and the sustainability of
towns and cities.
Context
A fundamental principle of the Government’s Sustainable Communities Plan (ODPM,
2003) is that everyone should have the opportunity of a decent home at a price they
can afford, in a place in which they want to live and work. Following the Barker
Review (Barker, 2004), there is a government drive to make provision for affordable
housing to meet the needs of key workers and low income households, particularly in
the South East and Eastern regions of England where demand is highest. Affordable
housing can be classified as social housing at typically low, sub-market rents and can
also include other forms of sub-market housing such as intermediate rent (above
social rent, but below market rent) and low cost home ownership schemes such as
shared ownership
11
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
Indicators to be used
1.
Numbers of regional long-term vacant dwellings as a percentage of the overall
regional stock for the North West, North East and Yorkshire and Humber region.
2.
Number of local authorities where house prices are significantly lower than
comparable national levels.
3.
Numbers of statutory homeless households with children in temporary
accommodation.
4.
Long term trends in the ratio of lower quartile house prices to lower quartile
earnings in all English regions.
5.
Annual net additions to the dwelling stock in the South East, East and London
regions.
Sources of data identified in Technical Notes are Local Authority Housing Investment
Strategies, Land Registry data, Local Authority Housing Statistics, Land Registry
data and New Earnings Survey, and ODPM Housing Statistics.
Gender analysis of the PSA and commentary
Gender differences in income mean there are significant differences between men
and women with regards to their opportunities for affordable housing, particularly for
single women and lone parents, 90 per cent of whom are women.

A higher proportion of single men than single women are owner-occupiers (54
and 40 per cent, respectively), pointing to the differences in earnings and
purchase opportunities between the sexes. Data on house price/earnings ratio
are gender disaggregated, providing scope to plan, monitor and evaluate
progress on supporting women to own their own homes. A gendered analysis
could help the department to improve performance against this target by
informing future decisions about the location and type of new housing being
built, and whether this meets the needs of the wider population.

Women on low incomes and lone parents are marginalised from renting or
purchasing homes in high-cost areas. This affects both urban and rural
communities, depending on location. The General Household Survey indicates
that lone-parent families (most usually women) are three times more likely to
live in rented accommodation than other families, with only 37 per cent owning
their home, compared to 78 per cent for other families.3 There are further
differences by ethnicity, with a disproportionate use of social housing among
lone parent Afro-Caribbean households. It might be advantageous to have an
indicator which tracks the access of lone parents and low-income women to
3
http://www.statistics.gov.uk/ssd/surveys/general_household_survey.asp
12
OFFICE OF THE DEPUTY PRIME MINISTER
new housing developments, to ensure that they are not squeezed out of the
renting or property markets in certain areas. Supporting lone parents to own
their own homes could result in efficiency gains as a result of lower demands on
social housing.
Affordable housing specifically allocated to women could help to enable women to
leave violent relationships, reducing levels of domestic violence and homelessness.
Supplying adequate housing that is both suitable and affordable could help provide
choices to vulnerable women and their dependents. Alongside this, consideration of
the specifications for new housing developments (e.g. well lit walkways, access to
services, secure gardens etc.) could take account of the different preferences made
by men and women when considering renting or buying. Attention to the type of
affordable housing might also help to improve performance against other government
targets, such as the Home Office’s PSA on reducing crime and the fear of crime, the
Department for Environment, Food and Rural Affairs’ PSA on providing rural
services, or the ODPM’s own target on liveability. Moreover, efficiency gains might be
gleaned from a reduced demand on social housing, protective shelters and police
and health resources.
Affordable housing also has implications for the supply of key workers in the public
sector, for example, teachers and nurses, the majority of whom are women. The NHS
is the biggest employer in the country, with women occupying over 70 per cent of its
workforce. In addition to medical staff, a high proportion of these women occupy
essential but low paid positions, such as hospital cleaning or catering. Providing
affordable housing to women who work in the public sector could help to secure the
supply of public workers possibly resulting in efficiency gains due to a reduction in
the use of short-term contract staff and reduced levels of staff turnover. This scenario
is perhaps most pertinent in the South East, where the demand for public sector
workers is highest but where affordable housing is severely limited (GLA, 2001).
Thus, if the emphasis is on supplying homes for the population as a whole, these
factors need to be considered. Attention to the different housing needs of women and
men in different parts of the country would help the department to achieve this target.
Moreover, a gendered approach to the supply of affordable housing could help the
government meet targets in other key areas, such as crime and health, resulting in
short and long term efficiency gains due to a reduced demand on public services.
13
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
6
DEPARTMENT FOR EDUCATION AND SKILLS
6.1
An overview
The 2004 PSAs for the DfES cover a range of concerns, including child development
(improvement in Foundation Stage Profile scores, performance in Key Stage tests,
GCSEs and post-16 progress), inequalities (greater improvement in more deprived
areas), school attendance, the health of children (obesity, exercise, under-18
conception rate), engagement of young people with training, education or paid work,
life-long learning and skills development and the availability of childcare. Some of
these PSAs either explicitly or implicitly connect with PSAs in other departments. For
example the DfES target to increase the availability of childcare relates directly to the
Department of Work and Pensions’ PSAs around participation in paid work.
In 2004 the DfES was set 14 PSAs which include 25 indicators with which the
department’s achievement would be assessed. Of these 25 indicators, gender
disaggregation is inappropriate or unnecessary in seven instances, leaving 18 where
gender disaggregated data might be important in assessing how well the DfES is
meeting the gender equality duty or in helping to build an effective strategy for
meeting the target. Of the 18 indicators where gender disaggregated data are
essential, such data are only available in 11 cases. There are, therefore, seven
indicators where data are not gender disaggregated. On the whole, data on the
development and educational performance of children are well disaggregated, while
data on health related issues are only partly disaggregated, and data on truancy are
not.
This lack of disaggregated data in some areas of DfES activity is important in a
number of respects but particularly in terms of the department’s ability to achieve
their targets. Both authorised and unauthorised absences from school, for example,
are associated with poorer performance in key stage exams but the impact varies for
girls and boys. Girls have lower levels of overall attendance than boys - primarily
because girls have more authorised absences while levels of unauthorised absence
are similar for girls and boys. However, the impact of unauthorised absence appears
to be greater for boys in terms of educational achievement (Morris and Rutt, 2004)
which suggests gendered strategies relating to absence might have particular
implications for PSAs relating to pupil attainment.
The two PSAs selected for more detailed analysis relate to obesity and to the
educational achievement of looked after children.
14
DEPARTMENT FOR EDUCATION AND SKILLS
6.2
DfES PSA 4 - Obesity
Target
Halt the year-on-year rise in obesity in under 11s by 2010 (joint target with the DH
and the Department for Culture, Media and Sport (DCMS)).
Context
Obesity among children is increasing rapidly, on a global basis as well as nationally.
Obesity in childhood is associated with increased risks of a number of health
conditions including heart disease, type 2 diabetes, high blood pressure and reduced
immunity. Childhood obesity increases health care costs, affects educational
opportunities and poses the threat of adulthood obesity which carries additional longterm health risks. There is an urgent need for effective public health strategies to
reduce the prevalence of childhood obesity and combat the educational and health
costs both for individuals and for services. The focus on childhood obesity also
reflects research suggesting that obesity prevention may be easier with children than
adults, while reducing obesity in childhood brings longer-term benefits for health and
reduces future welfare costs. The immediate risk factors for childhood obesity include
sedentary lifestyle combined with excess food intake and/or inappropriate diet.
However, research into childhood obesity has suggested that there is insufficient
understanding of the more specific causes behind these factors - the ‘obesogenic
environment’ (Doak et al., 2006).
Indicators to be used
No significant change in prevalence of obesity measured by BMI - children above the
95th percentile of the 1990 reference curve defined as obese.
Sources of data identified in Technical Notes are the Annual Health Survey for
England and the Department of Health’s ‘Obesity Among Children Under 11 19932005’, published April 2005 (http://www.dh.gov.uk/PublicationsAndStatistics).
Gender analysis of the PSA target and commentary
There are important gender differences in the causes of obesity, how it is tackled and
how accurately it is measured for girls and boys.

In 2004, 16 per cent of boys and 12 per cent of girls aged 2-10 were obese, and
14 per cent of girls and boys were overweight. For children aged 11-15 (who
are not included in the PSA target), more girls than boys are obese and more
girls are overweight. The overall trend in obesity and overweight over time is
upward, especially for obesity, and the rise has been greatest among younger
boys. A detailed appreciation of gendered differences in obesity and the
underlying factors would enable those organisations responsible for delivering
15
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
on this target to focus resources more appropriately and devise gender
sensitive strategies.

There are gender differences in the success of interventions such as schoolbased exercise and diet programmes to tackle childhood overweight and
obesity (Doak et al., 2006). These differences relate particularly to the role
played in interventions by physical activity and what kind of activity is used.
Boys are more likely to engage in vigorous physical activity than girls during
school breaks, for example (Verstraete et al., 2006), while gender specific
interventions such as dance-based projects may be more effective for girls than
boys (Doak et al., 2006). Prevention strategies that are gender aware may offer
additional benefits in terms of, for example, girls’ mental health and self-esteem,
and may help to improve women’s health in later life.

Obesity is affected by eating habits and diet and gendered dimensions of food
intake and choice are important in this PSA target. Both children and
adolescents eat low amounts of fruit and vegetables, but slightly more boys
than girls eat no fruit and vegetables, while a greater proportion of boys’ diets is
made up of protein-dense food. The gap is widest in early adolescence, aged
11-13 in particular. The food choices of boys may be stimulated by their greater
levels of physical activity, but such choices have consequences for their longterm health as well as their weight. Tackling diet effectively is important in
childhood obesity and offers further gains in terms of reducing male mortality in
adulthood due to the association between diet and mortality.
Data on obesity in children mostly uses Body Mass Index (BMI) figures. This index is
based on a height to weight ratio, but has been criticised as a poor indicator of
overweight in children, in particular compared with a composite use of BMI together
with fat distribution or waist circumference (Nicholls and Viner, 2006). While girls and
boys are assessed on the basis of sex-specific tables, for both girls and boys the cutoff point used to indicate whether a child is classified as obese is the 95 th percentile
point. However, differences between girls and boys in their development, particularly
around puberty, challenge the accuracy of this measure. For example, there is a
tendency for weight to ‘spike’ before growth spurts for both girls and boys but this
rapid increase in weight is more pronounced for prepubescent girls. This should be
considered alongside the increased risks among girls of anorexia and bulimia
(Nicholls and Viner, 2006), which mean that weight increases have implications for
girls’ emotional well being, self-esteem and their risk of long-term eating disorders.
Approaches to measuring weight gain and strategies to support pre-pubescent girls
need to take account of the full range of gender differences in weight and eating
problems.
16
DEPARTMENT FOR EDUCATION AND SKILLS
The PSA’s technical note states that delivery of this joint PSA target will be supported
by a range of programmes including:

The joint DfES and DCMS ‘PE, School Sport and Club Links’ project which
seeks to increase the percentage of school children who spend a minimum of
two hours each week on high quality PE and school sport within and beyond
the curriculum.

The joint DfES and DH ‘National Healthy Schools’ Programme which seeks to
promote a whole school approach to healthy living.

The joint DfES and DH ‘Food in Schools’ Programme which seeks to promote
a whole school approach to a range of food issues.
It is crucial that the gender differences inherent within these programmes are
recognised and acted upon to ensure they have a positive effect on childhood obesity
and overweight. A number of efficiency gains in the long and short term may be
realised through taking a gendered approach to obesity, particularly by focusing on
gender differences in key underlying factors and in suitable interventions.
6.3
DfES PSA 5 - Looked after children
Target
Narrow the gap in educational achievement between looked after children and that of
their peers, and improve their educational support and the stability of their lives so
that by 2008, 80 per cent of children under 16 who have been looked after for 2.5 or
more years will have been living in the same placement for at least two years, or are
placed for adoption.
Context
The health and well-being of looked after children have been the focus of
government policy for some time. The Green Paper ‘Every Child Matters’ (DfES,
2003) and the following programme committed the government to improvements in
the outcome for this group of children. The 2005 White Paper ‘Higher Standards,
Better Schools for All’ also identified looked-after children as a particularly
disadvantaged group and promised consultation on new proposals to tackle
educational outcomes for looked-after children.
An estimated 90,000 children pass through the care system each year, with up to
60,000 children in care at any given time (see http://www.everychildmatters.gov.uk).
The PSA referring to looked-after children, however, focuses on children looked after
for at least 12 months, of whom there were 45,000 in 2004 (DfES, 2005). Most of
these children are of school age, and around a quarter have Statements of Special
Educational Need. Statistics show that the educational performance of these looked17
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
after children is below average at each Key Stage: 54 per cent of looked after
children achieved level 2 or above in English at Key Stage 1, for example, compared
with 85 per cent of all children (DfES, 2005). Similar differences persist in Key Stages
2 and 3 and at GCSE level, and looked after children are less likely to undertake
further qualifications or go into higher education than their peers.
Indicators to be used
1.
Percentage of children aged 11, looked after for at least 12 months, who obtain
level 4 in Key Stage 2 English and Maths.
2.
Percentage of young people looked after for at least 12 months, who reach
school leaving age without having sat a GCSE equivalent exam.
3.
Percentage of young people, looked after for at least 12 months and in year 11,
who achieve five or more GCSEs graded A*-C or equivalent.
Sources of data identified in Technical Notes are SSDA903 data collection, which
collects individual child level information on children in care for the year to 31 March,
and DfES ‘Outcome Indicators for Looked After Children’, (http://www.dfes.gov.uk).
Gender analysis of the PSA and commentary
There are wide differences between looked after children and the general population
of children in terms of both educational achievement and other measures of health
and well-being.

There is a considerable gender gap in achievement at all Key Stages in the
wider school population but data used in the assessment of this PSA, for each
indicator, are not disaggregated by gender, despite the huge disparity in
achievement noted above, under Context. So there are no gendered data
available on attainment. Overall, 54 per cent of looked after children are male
which, in general, reflects the sex ratio of the general population for this age
group. But 70 per cent of unaccompanied asylum seeking children are male,
suggesting that a specific set of needs will arise for this group. Paying specific
attention to gender differences in the outcomes of looked after children - both
educational achievement and length of placement - would highlight gender
specific needs of girls and boys within this sub-group.

While outcomes for looked after children in general are poor, outcomes for girls
tend to be worse (Daniel et al., 2005) which is significantly different compared
with the population as a whole. Levels of mental illness are high for both girls
and boys in this population, following their experiences leading up to the
placement and to their family background, often compounded by the care
18
DEPARTMENT FOR EDUCATION AND SKILLS
system itself (Meltzer et al., 2003; Richardson, 2002). However, there are also
differences between boys and girls in the kinds of mental health problems
experienced and in the age groups affected (Meltzer et al., 2003). Overall boys
are more at risk of mental disorder, but this reflects the higher rates of mental illhealth among younger age groups, while in older age groups girls' and boys’
rates of disorder are similar. Emotional disorders decrease with age in boys but
not in girls, while conduct disorders are higher among boys in the older age
groups (11-15 year olds). This can be attributed, in part, to differences in
externalising and internalising behaviours, as girls as more likely to adopt the
latter. Again, while self-harm is higher among looked-after children and
adolescents, girls appear to be at greater risk than boys (Polnay and Ward,
2000). As above, taking a gendered approach could lead to improved outcomes
for looked after young people, particularly in terms of mental health.

Research also suggests that care leavers do not feel adequately informed about
sexual health, contraception, healthy living, and emotional development
(Richardson, 2002; DH, 2002) and 1 in 7 girls is either pregnant or already a
mother when leaving care (Polnay and Ward, 2000). The risk of teenage
pregnancy is associated with many of the factors also associated with being in
care: experiences of deprivation, educational difficulties and low educational
attainment, poor self esteem and experiences of sexual abuse (SCIE, 2005). In
addition, looked after children are more likely to begin sexual intercourse at an
earlier age than their peers and this is also associated with increased levels of
teenage pregnancy. Support for all looked after children in terms of
contraception and sexual health is important, but taking account of gender
differences in educational achievement may be particularly significant in
reducing the risk of unplanned pregnancies among looked after girls.
These gender differences in the problems experienced by looked after children and
factors affecting outcomes suggest an urgent need for gender disaggregated data in
this area. There is no obvious reason why these data could not be collected.
Alternative data sources on gender distribution of educational outcomes among
looked-after children are not available. A gendered approach could help the DfES
meet its targets by designing interventions that are directly applicable to girls or boys.
Long term benefits could include reductions in under age conceptions, reductions in
the proportion of looked after children who end up not in employment, education or
training, and health gains among girls, in particular, due to the inter-relationship
between self-esteem, educational achievement and social inclusion. Changing
current outcomes of looked after children has tremendous potential to reduce their
risk of exclusion and worklessness in later life and, for girls, early motherhood and
self-harm.
19
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
7
DEPARTMENT OF HEALTH
7.1
An overview
There are eight 2004 PSAs for the DH, focusing on the health of the population (adult
and infant mortality and life expectancy), health behaviours (smoking, obesity, drug
use), inequalities in health, patient experience and the care of vulnerable groups. The
DH was also given four standards to achieve and maintain, relating to access to
primary and emergency care. The eight PSA targets included 20 indicators to
measure performance. Of these 20 indicators, gender disaggregated data might be
seen as inappropriate in two cases, leaving 18 where it is necessary. Data
associated with eight of these indicators are routinely available in a gender
disaggregated form, with the remaining 10 indicators not reported separately for
women and men. Statistics on health - including mortality data and life expectancy are largely disaggregated, as are figures for health behaviour. However, data on
health service use are less routinely disaggregated. For example, some of the figures
relating to problem drug use are available separately but not all of them, while most
of the data on other kinds of service use are not.
7.2
DH PSA 8 - Vulnerable older people
Target
Improve the quality of life and independence of vulnerable older people by supporting
them to live in their own homes where possible by:

Increasing the proportion of older people being supported to live in their own
home by 1per cent annually in 2007 and 2008; and

Increasing by 2008, the proportion of those supported intensively to live at
home to 34 per cent of the total of those being supported at home or in
residential care.
Context
Supporting vulnerable older people at home has been the focus of policy for some
time, including the National Service Framework for Older People, the introduction of
telecare and the Partnerships for Older People Projects (POPP) currently being
piloted. The recent Wanless report (2006) supports the idea of caring for older people
in their own home but highlights the shortcomings of current funding and the
increasing demand for such care that can be expected in the future.
Indicators to be used
Intensive home care as a proportion of intensive home and residential care. The
source of data identified in Technical Notes is the Community Care Statistics 2003-
20
DEPARTMENT OF HEALTH
2004 ‘Referrals, Assessments and Packages of Care for adults’ (RAP) – data found
at www.dh.gov.uk . Data are not disaggregated by gender.
Gender analysis of the PSA and commentary
There are important gender differences within the older population in terms of their
levels of vulnerability, their health, their needs, their material circumstances and the
availability of support from family, relatives and neighbours, all of which may affect
the extent to which independent living is possible, as well as their need for services.

One of the main differences between women and men is life expectancy.
Women live longer than men, on average, which means that more of the old
and very old are female. Women are also more likely to be without the help of a
spouse. In every age group over 65 there are more women than men, but the
percentage increases from 52 per cent among those aged 65-69 to 72 per cent
among those aged 85 and over (Soule et al., 2005, supporting data). More
women live alone than men and slightly more live with their children. In terms of
their health status, women over 75 are more likely than men of the same age to
report their health as poor and to describe themselves as suffering from a
limiting long standing illness. (However, in younger age groups there are fewer
differences and between 60 and 64 more men report poor health.) Similarly,
more older women describe themselves has having difficulties in performing
activities of daily living (ADL). More women than men also live in residential
care, reflecting their greater longevity (a higher proportion of 85+ live in
residential care), their lack of alternative carers and also their poorer health
(Soule et al., 2005). A gendered analysis would help in the planning and
delivery of services and lead to a greater understanding of what interventions
are required to enable older people to remain in their own homes. This could
lead to potential efficiency gains, particularly in the savings made through
reductions in residential care needs of this group.

In older age groups, women are more vulnerable to poverty and deprivation
than men for a number of reasons. In particular, women receive lower pensions
on average than men as a result of lower lifetime earnings due to lower pay and
time spent out of the labour market in caring responsibilities. In addition, for
current female pensioners, the ability to opt out of the State Earnings
Retirement Pension has left many women reliant on lower state benefits. This
leaves many older women at risk of poverty. The report 'Focus on Older People'
(Soule et al., 2005), for example, highlighted the fact that while single male
pensioners are more likely to be among the top 20 per cent of households in
terms of income than the bottom fifth, the reverse is true for single female
pensioners. Identifying the most vulnerable older people in terms of resources
21
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
through a gender analysis of the data will assist those who are in most need
and improve their chances of retaining their independence.

There are differences between women and men in their use of both statutory
and private home care services (Soule et al., 2005; Stoddart, 2002). In recent
years the percentage of people using statutory home care services has fallen,
alongside an increase in the numbers using private home care services.
However, women are consistently more likely to be in receipt of home care
services of both kinds (Soule et al., 2005). More women over 65 than men in
this age group use both Local Authority and private home help services, meals
on wheels and are visited by district nurses or health visitors. A key benefit of a
gender disaggregated approach to this PSA is through the more precise
identification of what is needed in order that resources may be targeted more
appropriately.
The data identified by the Technical report for Referrals, Assessments and Packages
of Care (RAP) are disaggregated by ethnicity, reflecting the longer standing public
sector duty in relation to ethnic minority groups. However, disaggregated data are not
available for men and women, and the pro-formas used to collect statistics from
Councils with Social Services Responsibilities do not ask for returns broken down by
gender. As with other PSAs, the data used to assess progress towards the target
also have a range of other uses. RAP data are used in the monitoring of targets laid
out in the NHS Plan, the Carers Act, Fair Access to Care, and in a number of
performance measures including the Best Value initiative and the Social Services
Performance Assessment Framework. This is important in terms of recommendations
on the disaggregation of data in that additional users would also benefit in the context
of the incoming public sector duty on gender equality.
Gendered differences in the health experiences and the needs of the older
population suggest that this data should be disaggregated in order to monitor
progress towards the PSA in a way which is commensurate with the public sector
duty on gender equity. Alternative sources of data include statistics on receipt of
home care and private care, and on residence in communal establishments, but
these do not simply reflect levels of need. In addition, such measures do not capture
intensive home care which is most likely to maintain independence.
Finally, it is important to consider ways in which the quality and appropriateness of
such care might be measured in a gender specific way. A number of researchers in
this field have observed that there is little robust evidence relating use of services to
need, or breaking down different kinds of need in more detail. Given the differences
between women and men in demographic, financial and health circumstances, data
22
DEPARTMENT OF HEALTH
on quality and appropriateness of care also need to be gender disaggregated. The
differences between women and men in factors affecting their ability to sustain
independent living and the level of services which they may require, are important in
determining how well services meet need and which groups will benefit from policies
designed to support vulnerable older people.
7.3
DH PSA 7 - Patient experience
Target
Secure sustained national improvements in NHS patient experience by 2008, as
measured by independently validated surveys, ensuring that individuals are fully
involved in decisions about their healthcare, including choice of provider.
Context
Improving patient care and satisfaction with NHS services are central to the DH’s
agenda. Survey data to assess satisfaction are collected at trust level. Surveys cover
patients’ perceptions of the services they have received, and these data are used in
national reports on patient experience in relation to specific aspects of care - mental
health services, primary care and accident and emergency care, for example. The
data have also been analysed to explore variations between sub-groups including
men and women. Consumer evaluations of health care are widely seen as important,
not just in the UK but elsewhere - partly in response to quality assurance objectives
but also because the experiences of health services can affect health outcomes
(Crow et al., 2002). The PSA also is a response to public disquiet over what has
sometimes been described as the ‘postcode lottery’ and patients' rights to choose
their health care provider.
Indicators to be used
1.
Access and waiting
2.
Safe, high quality, co-ordinated care
3.
Better information, more choice
4.
Building closer relationships
5.
Clean, friendly, comfortable place to be
The source of data identified in Technical Notes is a series of National Patient
Surveys at: http://www.healthcarecommission.org.uk/NationalFindings/fs/en
Gender analysis of the PSA and commentary
There are significant differences between women and men in terms of their health
status and their use of services (Doyal et al. 2003). Research suggests the existence
of a gender gap in their expectations of care as well as in satisfaction (Beattie et al.,
23
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
2005; Wilde Larson et al., 2005), but there is little gender disaggregation of variables
in the main surveys used to assess this target.

Improvements in patient satisfaction can lead to better health outcomes and
so improve morbidity and mortality rates, yet existing gender disaggregated
data which examine satisfaction are very limited. What there is suggests that
women and men have different perceptions of their health service experiences
and that levels of satisfaction differ. The picture which emerges is mixed and
stresses the need for a more consistent approach to data collection in order to
understand the reasons behind these responses and develop means of
improving patients' experiences. Overall, gender differences in level of
satisfaction are inconsistent and while at times women are more satisfied,
other research has suggested the opposite (Crow et al., 2002). The 2005
Survey on Primary Care Trusts reports data for women and men together and
it is only in the multivariate analysis of surveys published in 2003-04 that
gender is dealt with consistently. This study found some variation between
women and men: men responded more favourably than women overall, and
gender explained part of the variation in answers to questions on ‘safe, high
quality, co-ordinated care’ (the 'co-ordination’ dimension) and a small part of
the variation in questions on environment and information.

Measurements of patient experience and satisfaction suffer a number of
difficulties. Evaluation of services is subjective and personal, reflecting
individual expectations, prior experience and history. Differences between
people may reflect different ideals or different knowledge; older people, for
example, are more likely to report high levels of satisfaction with their care
which may reflect lower levels of expectation. People with poor physical or
mental health are more likely to report low levels of satisfaction, whereas
people who experience positive health improvements are, perhaps not
surprisingly, more likely to report satisfaction with all aspects of services. Intergroup variations, such as those between women and men, may reflect gender
differences in expectation or in health status or in changes to health status, for
example, and this affects the findings of patient surveys. Developing
innovative and accurate measures of patient satisfaction and collecting the
necessary data are essential if this target is to be met.

It was noted above that improving patient satisfaction may lead to better health
outcomes. Women place a higher value on privacy, including being cared for
in a single sex rather than mixed sex ward and having a carer of the same sex
(Bach and Wikblad, 1998). In mental health services, in particular, women
prefer single sex accommodation and there is evidence that being on a mixed
24
DEPARTMENT OF HEALTH
sex ward can adversely affect the recovery of female patients (Wood and
Pistrang, 2004). Although there is a commitment to returning to single sex
sleeping accommodation in mental health services, this is not yet in place in all
areas, and in-patients continue to share daytime facilities. Ensuring that
gender is considered and patients' experiences and concerns acted upon
could lead to improved satisfaction with services, and ultimately, to
improvements in health.

The needs of women and men may be met differently in some clinical areas.
For example, gender differences in coronary heart disease (in symptoms,
assessment, intervention and rehabilitation) suggest that services may not
meet their needs equally (see Doyal et al., 2003). However, while women
report wanting more information than men following a coronary event, they
also receive less information than men (Stewart et al., 2004). Again, only by
taking account of gender in both the target and the supporting data can these
issues truly be addressed and improvements made.

Women and men see different aspects of the care they receive as more or
less important, with issues related to information, continuity of care and health
professionals being more important to women than men. If women are more
interested in shared decision making and involvement in their health care than
men, then achieving this PSA may require a targeted approach which
increases men’s participation in health decisions as well as improving the
experience of such shared decision making and involvement for both women
and men.
The five dimensions of patient care used in the assessment of this PSA are derived
from the 2003/04 programme of surveys carried out by the Healthcare Commission
and used in the 2005 analysis of variation within the national surveys. They follow an
earlier set of seven dimensions that included respect and dignity as a separate
domain. There is little gender disaggregation of variables in the surveys, for example,
in the 2004/5 Survey of Out-Patient Departments responses are not disaggregated
by gender, although gender differences in patient experience are possible and would
be important. The 2004 Survey on Coronary Heart Disease reports little gender
disaggregated data though where figures are available, women are more likely to
report negatively regarding care. The conclusion suggests there were gender and
ethnicity differences in access to rehabilitation but it is not clear whether women or
men were more likely to get rehabilitation. Findings from one interesting question on
patients’ use of mixed-sex rehabilitation services are not reported separately. The
2005 survey of stroke patients’ experiences also found that overall men reported
experiences more positively than women but as responses are not broken down by
25
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
sex, we do not know why. For example, were there differences between women and
men in whether they were treated in a stroke ward as opposed to a general ward?
What were the differences in the constituent parts which made up the overall score?
Was there a gender gap in the information women and men felt they received or in
how doctors and nursing staff treated them, or delays in diagnosis?
Table 1 is based on merged responses to groups of questions in the original surveys
about patient satisfaction and show the mixed nature of responses. Gender
disaggregated data are available intermittently, however, if available more
comprehensively they could shed further light on the underlying reasons for gender
differences in satisfaction. For example, in the survey of mental health users,
differences between women and men in their answers to such questions as having a
say in decisions about medication, being offered counselling, being treated with
respect and dignity, or feeling listened to by health care professionals, need to be
explored if policies to improve patient experience are to be successful.
Table 1
Who was more dissatisfied – women or men?
Dimensions
Adult
inpatient
survey
Young
patient
survey
Ambulance
user
survey
Mental
health
user
survey
Primary
care
trusts
survey
Access
W ***
-
M
W
W ***
Coordination
W ***
W ***
W ***
M
M ***
Information
W ***
W ***
W
M ***
M ***
Relationships
W
W ***
M
M
W ***
Environment
W ***
W ***
W
n/a
W ***
Note: Based on regression coefficients for each survey.
W = more women dissatisfied, M = more men dissatisfied, *** p<0.001
Source: Healthcare Commission (2005)
These differences illustrate why a gender disaggregated approach is essential if this
PSA is to achieve improvement in patient satisfaction. The first step is to collect data
routinely by gender, so that differences between the experiences and perceptions of
women and men can be analysed and acted upon. Without knowing what the
differences are or understanding the reasons behind those differences, this target is
unlikely to be achieved.
26
CONCLUSION
8
CONCLUSION
Gender sensitive policy is likely to increase policy effectiveness by targeting
resources more efficiently and tailoring service delivery to the specific needs of the
population. Targeting resources in a gender sensitive way can lead to short and long
term efficiency gains. For example, a gendered policy to stop individuals smoking is
more effective in the short term as it takes account of different social behaviours of
men and women. This also leads to longer term efficiency gains for the NHS due to a
reduction in tobacco related illness.
Where a gendered approach is adopted, this research suggests that targets are more
likely to be achieved and resources more effectively targeted, benefiting all those
concerned. But in order to take a gendered approached, gender disaggregated data
are necessary. While some of the datasets did report data separately for women and
men, many did not. Instilling a gendered approach to policy making across Whitehall
will be challenging, but is essential.
There are a number of important contextual issues that might influence the potential
for change. For example, there is currently a major drive to improve data and
government statistics and this includes recognition of the need for gender
disaggregated data. Second, there is a strong emphasis at the centre on promoting
excellence and innovation in policy making. Finally, it is necessary to consider the
multi-level nature of governance and policy making in the UK. PSA targets are
filtered down to the regional and local tiers and across to non-departmental public
bodies. Given the rigidity of Whitehall decision making, focusing attention on
influencing targets and/or service delivery at a sub-national level could prove just as
fruitful.
27
PUBLIC SERVICE AGREEMENT TARGETS: A GENDERED ANALYSIS
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