This article discusses a comparative study of how local actors tackle health inequalities in England, Scotland and Wales. The main method used in this study was a thematic analysis of 200 interview transcripts. Its focus was on how health inequalities are framed for intervention by performance assessment systems and the challenge for these systems that their nature as a ‘wicked issue’ presents. The three different national contexts are described, including organizational structures and the use of targets, and the difficulty of making evaluative comparisons is considered. Reflecting on results from the study, it is concluded that both divergence and convergence in themes across the three countries reveal narrative patterns that draw on discourses rather than evidence. The nature of national performance audit regimes appears to play an important part in shaping these discourses, which are themselves evolving, partly in interaction with local feedback.