Joint Memorandum by Dr Naomi Fulop and
Julian Elston, London School of Hygiene and Tropical Medicine
We were commissioned by the Department of Health
in 1997 to evaluate the implementation of the England's first
public health strategy, the Health of the Nation1,2. Although
the remit of the committee is to examine the co-ordination between
central government, local government health authorities and PCGs/PCTs
in promotion and delivering public health, we feel that many of
the findings identified in this report are highly relevant to
the current policy context.
We are currently undertaking a study to evaluate
the role of partnership in developing and implementing local health
strategy, funded by the Research and Development Directorate of
the London Regional NHS Executive. This study is focusing on the
organisational arrangements of Health Improvement Programmes (HImPs)
and how HImPs link with other "health partnerships"
such as Health Action Zones, Healthy City/Health for All initiatives
and community plans etc,. This work includes a documentary analysis
of 50 first round HImPs (complete) 3 and a comparative case study
of four health authority areas, two with Health Action Zones.
From these two research studies, we would like
to make the following points to the Health Committee's inquiry
on public health.
1. THE ROLE
1.1 A key lesson from the evaluation of
the Health of the Nation strategy is that if the national
public health strategy is to have a high and consistent profile
in central government, as well as in the public eye, it must not
be secondary to the health services agenda. By being located in
the Department of Health, the Minister for Public Health's concerns
are marginalised by the concerns of the NHS.
1.2 This marginalisation of public health
is likely to increase once the combined posts of permanent secretary
to the Department of Health and chief executive of the NHS has
been created. We would strongly argue therefore that the Minister
for Public Health should not be based within the Department of
1.3 There is an argument that it should
be based in the Cabinet Office, particularly if this post is to
facilitate cross-departmental co-ordination of policy and ensure
that coherent and consistent policy messages are given out across
1.4 If public health is to have a really
high profile, the Minister for Public Health should be a cabinet
2. THE ROLE
2.1 The evaluation of the Health of the
Nation found support for the idea that Directors of Public
Health should be appointed jointly by local authorities and health
2.2 The survey of first round HImPs indicates
that social service departments appear to be the most frequent
local authority contributors to HImPs, with other departments
such as housing and education contributing far less. Such a joint
appointment may strengthen the work of HImPs on the wider determinants
3.1 The large number of overlapping initiatives
is confusing to organisations both within and outside the statutory
sector. The capacity of the voluntary sector to respond to all
these new initiatives has been hampered by a lack of resources.
In some areas, these have been slow in coming from the statutory
sector, especially where there are no additional partnership funds
3.2 The increased workload and duplication
has resulted in the streamlining of initial organisational arrangements.
Many inter-partnership arrangements are still evolving. However,
this streamlining process appears to be constrained by the different
performance management requirements placed on these partnerships
and the conflicting timetables for reporting progress, emanating
from different government departments. Joining-up central government
in this area would aid this process and allow for some creative
3.3 The government's focus on quick wins
in HAZs, while useful in some respects (in terms of partnership
motivation) has lead to greater emphasis on projects rather than
changes to promote long-term strategic development of inter-organisational
arrangements. Increasingly directive performance management of
HAZs from the centre may restrict local innovation.
3.4 Many of the above initiatives are required
to consult users (and carers) of services, and the voluntary sector
and the community. There is real concern about "consultation
fatigue" and a worry that these sectors will disengage from
the process, especially if these partnerships are slow to deliver
on the issues identified.
3.5 Less than a third of HImPs appear to
have addressed the issue of participation in a strategic manner.
Even then, many HImPs failed to consider the participation beyond
the HImP itself. Clearly there needs to be a more systematic approach
to participation which takes an area wide, multi-agency perspective.
Local authorities with their well and long-established mechanisms
for consultation may be best placed to oversee this role.
3.6 The Health Select Committee should consider
expanding the remit of its inquiry to consider regeneration partnerships.
In several of our case study sites, Single Regeneration Budget
bids had been developed to complement the focus of the HImP or
community plan. However, separate management arrangements for
each SRB round has resulted in further duplication of efforts
and more meetings for senior staff.
4. THE ROLE
4.1 The survey of HImPs indicated that PCG
involvement in developing the HImPs has been slow. Poor engagement
of PCGs has been related to pre-occupation with organisational
development, resource pressures and the push to PCT status.
4.2 However, current fieldwork indicates
an increasing involvement of PCGs in HImPS. This is mainly focused
around the coronary heart disease and mental health National Service
Frameworks. Involvement in work on the wider determinants of health
appears to be limited and their contacts with the community and
voluntary sectors very patchy. There is a danger that primary
care involvement in local health strategy may focus on disease
management and secondary prevention activities based around the
medical model. Opportunities for primary care to develop a broader
population perspective might be missed if their capacity to work
with other sectors is not increased through better resourcing,
or if the pace of organisational change is maintained. Making
social services the only mandatory representatives from local
government on PCGs boards may further the focus on services at
the expense of taking a population perspective.
1. Fulop N et al. "Evaluation of the
implementation of the Health of the Nation" in Department
of Health. The Health of the Nationa policy assessed.
London: Stationery Office, 1998.
2. Fulop N et al. Lessons for health strategies
in Europe: the evaluation of a national health strategy in England.
European J Public Health 2000; 10: 11-17.
3. Elston J, Fulop N. What can Health Improvement
Programmes tell us about health partnership in England? A documentary
analysis. Submitted to the Journal of Health Services Research
and Policy. 2000.
Evaluation of The Implementation of the
Health of the Nation
The Health of the Nation (HOTN) strategy for
England was launched in 1992. It focused on five key areas, setting
out overall objectives for each, with 27 individual targets monitored
by the Department of Health's Central Health Monitoring Unit.
Although there is information on progress towards meeting these
targets, the HOTN strategy has not been evaluated as a method
by which central Government influences national and local policy.
This study aims to provide a review of the HOTN
strategy which will complement current monitoring of progress.
It aims to provide an analysis of the mechanisms by which the
strategy has been implemented at the local level.
The study was undertaken in eight districts,
with one selected at random from each NHS region. The districts
selected have a fairly even distribution of structural and demographic
characteristics including the OPCS Area Classification, Jarman
scores and standardised mortality ratios (SMRs). All except one
experienced a real budgetary increase, averaging 9.7 per cent
over the study period (1991-97).
Health strategies and alliances developed by
the health authorities can be categorised as: (i) taking place
under heading other than HOTN; (ii) under the specific heading
of HOTN or; (iii) HOTN "plus", where local key areas
were added to the original five.
133 semi-structured interviews were conducted
in the eight districts covering all sectors. 152 documents were
collected. A comprehensive dataset from health authority, former
FHSA and Trust accounts, AIDS Control Act Reports and resident
population estimates were obtained for each district. Local expenditure
data were obtained to varying degrees of completeness in all but
one health authority.
How the policy was perceived
Those interviewed were clearly committed to
intersectoral work for heath improvement and interviews supported
a view that positive experience of partnership for other purposes
such as drugs action or economic regeneration were beneficial
to partnership for health improvement. There was some support
for the proposal that directors of public health be appointed
jointly by local authorities and health authorities, as an enabling
structure for Our Healthier Nation (OHN). Communication of HOTN
by the Department of Health to most potential partners for health
improvement was poor. Information about the health strategy should
be more relevant and accessible, particularly to key players outside
the health service
The present targets had little credibility,
and most of our sample would like to see the indicators changed.
Introduction of performance management of OHN in the health service
and other sectors would be seen as demonstrating top-level commitment
provided it is introduced with a sophisticated understanding of
agencies' ability to achieve performance management objectives.
Interviewees would like central government to
take a stronger role in improving health, at every level, and
to avoid conflicts between policies of different government departments.
The sample supported more resourcing for a national
strategy for health, but nearly half qualified their replies to
specify prescribed and purposeful spending to support structured
action for health improvement at the local level.
A strategy structured by a matrix approach (see
Figure 7.1) which combines diseases, settings and population groups
at its highest level could be flexible and successful in winning
the support of a wider range of partners.
Impact of HOTN
HOTN was perceived as increasing prevention
activity overall, particularly in relation to the key areas and
alliance work. In particular, HOTN was perceived as enabling health
promotion efforts to be prioritised and improve co-ordination.
There is some evidence for ownership of HOTN outside HA departments
of Public Health, particularly through purchasing plans and contracts
with providers but there are also areas where ownership appears
weaker, such as a lack of reference to HOTN in corporate contracts
and general practice reports. The impact of HOTN on key policy
documents did, however, increase over the study period, to a peak
in 1995 but then fell off.
Per capita expenditure and health promotion
expenditure as a proportion of total NHS for both "narrow"
and "broad" measures of health promotion show a slight
increase over the study period to a peak in 94-95 with a gradual
tailing off, so there is little evidence to suggest that HOTN
had anything more than a limited influence on patterns of resource
allocation at local level. Analysis of individual health authorities'
patterns of expenditure suggests that population-based health
promotion may be a "soft target" and may be reduced
to achieve savings. Expenditure on HIV/AIDS prevention activities
increased its share of total population-based health promotion
funding suggesting that some HAs are using this ring-fenced budget
to cross-subsidise other health promotion activities. This raises
the issue of the importance of ring-fenced resources in the implementation
of a national health strategy
Mechanisms for implementation developed at local
The different extent to which HOTN was used
to focus activities for health improvement and multi-sectoral
health strategies was reflected in varying management structures
for HOTN. The use of contracts to involve NHS Trusts in the implementation
of HOTN varied greatlybut there is support for integrating
OHN explicitly into new commissioning arrangements. General practitioners
tend to focus on the health promotion tasks under their contracts,
and did not give strong priority to strategic action for health
outside this framework.
HOTN appears to have stimulated and focused
multi-sectoral health strategies in some districts, while others
have been able to progress strategies without this stimulus. Health
authorities have not found it easy to involve the police and private
sector in health partnership. Police forces and some businesses
are willing to engage in partnership, but prefer working on specific
measures to less well-defined "strategic" partnerships.
Six out of eight HAs had explicitly earmarked funds for alliances;
amounts ranged from £2k to £200k, suggesting that they
were used in very different ways. Over a third of interviewees
(38 per cent) mentioned the need for a statutory framework to
allow key local participants, particularly local government, to
work multi-sectorally for health with the support of their formal
Only one HA operated a designated HOTN budget
covering all HOTN development activities. Five other HAs had allocated
partial (non-staff) budgets for development in certain key areas.
Current budgeting and financial reporting mechanisms need considerable
improvement if they are to be effective in supporting decision-making
across multiple settings and agencies. The absence of any requirement
to monitor spending on HOTN development ensured that it is impossible
to identify or compare the resources invested in the implementation
of the strategy. If current financial monitoring and budgeting
systems do not change, the same fate will inevitably befall OHN
Factors influencing implementation of HOTN
The following key factors emerged as influencing
the implementation of HOTN: lack of resources; support from central
government, organisational structures within or between organisations;
the quality of partnerships; commitment of organisations and individuals;
demographic characteristics of the local district, and LA cultural
and political factors.
Resourceslack of resources were cited
by one-third of interviewees as a barrier to implementation. This
was supported by the expenditure analysis which indicated first
that population based health promotion may be a "soft target"
and may be reduced to achieve savings, and secondly that HIV/AIDS
prevention funds were being used to cross-subsidise other health
Organisational structuresat the interface
between organisations, co-terminosity in general was perceived
as facilitating implementation of HOTN. However, at an individual
district level, unitary districts were not any less likely to
perceive structural factors as barriers to HOTN implementation.
Within HAs, organisational restructuring and staff turnover were
perceived as negatively affecting implementation. Within LAs,
where directorates worked independently of each other without
a strong corporate approach, HAs found it difficult to develop
relations across these LAs.
Quality of partnershipperceived as important
for implementation of a health strategy. Partnerships need to
be reinforced by a supportive culture and incentives for partnership
(such as those provided in SRB).
Commitmentdata indicated a range of perceived
commitment to HOTN with health promotion departments as having
the strongest commitment followed by public health departments
and HAs overall. Commitment by senior staff and key individuals
was perceived as an important facilitating factor for HOTN.
between affluent and deprived areas in their districts were identified
as influencing implementation of HOTN.
Deprivation can be seen as a factor which can
mobilise inter-sectoral action on health.
Local Authority cultural and political featurespolitical
complexion of LAs may affect implementation of HOTN, although
this was a stronger factor in some districts than in others. LAs
which had a tradition of commitment to health promotion had better
relations with their health authorities.
Impact on non-HOTN areas
Compared to the level and type of activity in
the HOTN key areas, strategic activity and activity involving
alliances and targets, or based in innovative settings is low
in our non-key areas (childhood immunisation, asthma, diabetes).
There may have been a slight increase in "HOTN-type"
activity where these areas are designated as local key areas.
Work on the non-key areas is based largely on well established
mechanisms in primary health care. These mechanisms need strategic
management that is probably best ensured at the national level.
The inherent characteristics of these three areas probably led
to the development of a different pattern of activity
Lessons learned for Our Healthier Nation
There are ten key lessons for the new health
(i) A range of models of implementation of
OHN should be supported, reflecting the different target groups.
(ii) OHN should address the underlying determinants
of health and inequalities. A matrix model has many advantages,
enabling explicit consideration of both disease and population-based
models of health.
(iii) There is an unresolved issue about
where responsibility for the strategy should rest and the placement
of the public health function should be kept under review in the
light of changes in the NHS.
(iv) Regardless of the detailed arrangements
within the NHS, communication needs to be improved to widen ownership
of OHN outside the NHS.
(v) If the momentum of the strategy is to
be sustained, it needs to be firmly embedded in a performance
management framework. This should include monitoring the process
of implementation as well as the outcome, and should enable resources
connected with the strategy to be identified, isolated and monitored.
(vi) Targets are a necessary tool for prioritisation,
but must be credible and local development of local targets should
(vii) There is a need for a statutory framework
to encourage key local agencies, particularly local government,
to work in partnerships for health. Other incentives for partnerships
should also be considered to support the commitment of individuals
and organisations necessary for implementation.
(viii) Central government has a key role
to play but it is essential that there is a consistent message
across government that is in support of OHN (need to be "on
message"). Central government should also foster the development
and dissemination of an evidence base.
(ix) It will be important to increase the
role of key stakeholders, in particular the public, the private
sector and those working in primary care.
(x) Consideration should be given to ring-fenced
funding for the implementation of OHN.