Select Committee on Health Memoranda


MEMORANDUM

Memorandum by the Department of Health

3.  PUBLIC HEALTH

3.1  "OUR HEALTH"

  3.1a  "What are the specific public health targets, how will they be monitored and what are the current baselines? How does the Department intend to monitor local target setting and achievement? How will it make information on local targets available to Parliament?

  1.  The White Paper, "Saving lives: Our Healthier Nation" was published on 6 July 1999. It sets new targets in four priority areas: Cancer, Coronary Heart Disease & Stroke, Accidents and Mental Health.

CANCER

Target

  The target in the White Paper is:

  To reduce the death rate from cancer amongst people under 75 years by at least a fifth by 2010—saving up to 100,000 lives in total.

Monitoring

  The data source will be Office for National Statistics (ONS) mortality statistics.

Current baselines

  The baseline for the target in the White Paper is 139.7 deaths per 100,000 population, for the three years 1995-97.

Related targets/monitoring

  Smoking—Three targets in the "Smoking Kills" White Paper:

    —  To reduce smoking among children from 13 per cent to 9 per cent or less by the year 2010; with a fall to 11 per cent by the year 2005.

    —  To reduce adult smoking in all social classes so that the overall rate falls from 28 per cent to 24 per cent or less by the year 2010; with a fall to 26 per cent by the year 2005.

    —  To reduce the percentage of women who smoke during pregnancy from 23 per cent to 15 per cent by the year 2010; with a fall to 18 per cent by the year 2005.

CORONARY HEART DISEASE & STROKE

Target

  The target in the White Paper is:

    To reduce the death rate from coronary heart disease and stroke and related diseases in people under 75 years by at least two fifths by 2010—saving up to 200,000 lives in total.

Monitoring

  The data source will be Office for National Statistics (ONS) mortality statistics.

Current baselines

  The baseline for the target in the White Paper is 139.6 deaths per 100,000 population, for the three years 1995-97.

Related targets/monitoring

  Smoking—Three targets in the "Smoking Kills" White Paper:

    —  To reduce smoking among children from 13 per cent to 9 per cent or less by the year 2010; with a fall to 11 per cent by the year 2005.

    —  To reduce adult smoking in all social classes so that the overall rate falls from 28 per cent to 24 per cent or less by the year 2010; with a fall to 26 per cent by the year 2005.

    —  To reduce the percentage of women who smoke during pregnancy from 23 per cent to 15 per cent by the year 2010; with a fall to 18 per cent by the year 2005.

  The Coronary Heart Disease National Service Framework, to be published shortly, is likely to contain related targets and monitoring arrangements.

ACCIDENTS

Target

  The target in the White Paper is:

    To reduce the death rate from accidents by at least a fifth and to reduce the rate of serious injury from accidents by at least one tenth by 2010, saving up to 12,000 lives in total.

Monitoring

  The data sources will be the Office for National Statistics (ONS) mortality statistics and inpatient data from the Hospital Episode Statistics system.

Current baselines

  The baseline for the mortality target in the White Paper is the average of the European age standardised rates for the three years 1995, 1996 and 1997. The baseline for the target in the White Paper is 16.2 deaths per 100,000 population, for the three years 1995-97.

  The baseline for the morbidity target in the White Paper is the hospital admission rates for serious injury from accidents—as defined in the White Paper—for the year 1995-96. The baseline for the target in the White Paper is 197,000 hospital admissions for the year 1995-96.

Related targets/monitoring

  Other Government Departments are setting targets relating to accident reduction—in particular, DETR will be setting targets for a reduction in road accidents as part of their Integrated Transport strategy.

MENTAL HEALTH

Target

  The target in the White Paper is:

    To reduce the death rate from suicide and undetermined injury by at least a fifth by 2010—saving up to 4,000 lives in total.

Monitoring

  The data source is Office for National Statistics (ONS) data on deaths from suicide and undetermined injury.

Current Baselines

  The baseline for the target in the White Paper is 9.1 deaths per 100,000 population, for the three years 1995-97.

Related targets/monitoring

  The Mental Health National Service Framework to be published shortly, is likely to contain related targets and monitoring arrangements.

Local Target Setting

  Health authorities, local authorities and their partner organisations should, as part of their Health Improvement Programme (HImP):

    —  reflect the national targets for each of the four OHN priority areas;

    —  agree additional targets for local priorities;

    —  agree local targets for reducing health inequalities.

  The NHS Executive Regional Offices working with Social Care Regional Offices and Government Offices for the Regions will agree and monitor these targets as part of the Health Improvement Programme process.

  The NHS Executive Regional Offices will be able to supply narrative reports of progress to summarise local situations eg "X of the region's poorest areas have set targets on smoking cessation. Activities to improve this area are . . .". NHS Executive HQ will also be able to monitor HA plans and performance in the priority areas through the use of the Common Information Core in conjunction with other data sources such as Hospital Episode Statistics (HES) and the Korner returns, and data from the Public Health Common Data Set (PHCDS).

  3.1b  Could the Department update the information given in Table 31.c on baseline performance figures for the new Health Action Zones? Could the Department provide information on the resources made available to each HAZ over the next three years? Could the Department provide a commentary on the strategy and targets of each HAZ and on how their performance will be evaluated?

Overview

  1.  HAZs have two broad objectives; to reduce health inequalities and to modernise services. Ministers have told HAZs that their programmes should address the major health and service issues they face. The first wave began implementing their programmes in January this year having been given extra time to prepare. The second wave were given the go ahead by Ministers on 12 April. There are now 26 HAZs covering about 14 million people. There will not be a third wave. Table 3.1.1 updates the information provided last year in Table 3.1.

Table 3.1.1

AGE STANDARDISED MORTALITY RATES FOR OUR HEALTHIER NATION INDICATORS, 1995-97


Rates per 100,000 Population
HAZs
Circulatory Diseases aged under 65
All Cancers aged under 65
Suicide & undetermined injury all ages

Lambeth, Southwark and Lewisham HAZ
80.36
87.02
12.90
East London & City HAZ
96.06
89.41
9.93
South and West Devon HA (Plymouth HAZ)
58.24
74.10
11.29
Bedfordshire HA (Luton HAZ)
58.97
74.30
8.30
Sandwell HAZ
93.62
90.17
6.77
South Yorkshire Coalfields HAZ:
   Doncaster HA
69.29
88.07
11.10
   Rotherham HA
73.31
86.80
7.56
   Barnsley HA
82.18
88.38
11.04
Manchester, Salford & Trafford HAZ
   Manchester HA
112.81
113.47
15.71
   Salford & Trafford HA
79.57
94.41
9.49
Bradford HAZ
79.91
81.15
8.97
Tyne and Wear HAZ:
   Newcastle and North Tyneside HA
75.92
101.74
11.16
   Gateshead and South Tyneside HA
79.21
99.79
11.33
   Sunderland HA
80.10
89.58
10.11
Northumberland HAZ
72.66
78.96
9.31
North Cumbria HAZ
63.65
82.20
10.22
Tees HAZ
84.14
96.70
10.32
Wakefield HAZ
77.72
79.67
6.81
Leeds HAZ
65.37
83.28
10.11
Hull and East Riding HAZ
62.87
86.86
8.74
Merseyside HAZ:
   Liverpool HA
107.40
108.42
10.15
   St Helens & Knowsley HA
87.22
99.32
10.15
   Wirral HA
74.86
91.83
12.79
   Sefton HA
68.48
95.20
7.48
Bury & Rochdale HAZ
89.87
91.81
9.35
Nottingham HAZ
63.13
80.97
8.17
Sheffield HAZ
68.85
83.29
7.40
Leicestershire (Leicester City HAZ)
62.45
69.77
8.17
Wolverhampton HAZ
89.37
79.52
8.42
Walsall HAZ
77.08
86.11
6.41
North Staffordshire HAZ
78.88
86.39
10.17
Cornwall & Isles of Scilly HAZ
54.13
81.77
12.19
Camden and Islington HAZ
79.16
84.91
13.42
Brent & Harrow HA (Brent HAZ)
63.80
69.36
8.53
England
63.69
79.08
9.07


Footnotes:

  1.  Data is available on a health authority basis rather than a HAZ basis. Some HAZs consist of more than one HA and others are part of a HA, where this is the case, it is indicated above.

  2.  The source of the data is the Public Health Common Data Set 1998.


HAZs
Accidents
under age 15
Accidents
aged 15-24
Accidents
aged 65 and over

Lambeth, Southwark and Lewisham HAZ
3.68
8.18
41.26
East London & City HAZ
3.65
12.85
46.04
South and West Devon HA (Plymouth HAZ)
1.24
15.35
51.57
Bedfordshire HA (Luton HAZ)
5.00
20.79
72.13
Sandwell HAZ
6.66
13.45
61.11
South Yorkshire Coalfields HAZ:
   Doncaster HA
3.87
15.82
62.12
   Rotherham HA
4.70
17.76
29.84
   Barnsley HA
5.46
21.97
31.24
Manchester, Salford & Trafford HAZ
   Manchester HA
6.44
21.83
66.11
   Salford & Trafford HA
4.89
13.05
51.07
Bradford HAZ
9.93
17.95
59.27
Tyne and Wear HAZ:
   Newcastle and North Tyneside HA
3.82
9.97
60.83
   Gateshead and South Tyneside HA
2.34
13.63
77.92
   Sunderland HA
6.49
12.47
66.06
Northumberland HAZ
4.01
16.99
70.76
North Cumbria HAZ
9.38
38.64
68.25
Tees HAZ
5.77
12.47
44.84
Wakefield HAZ
8.04
18.91
37.54
Leeds HAZ
4.56
18.89
60.83
Hull and East Riding HAZ
7.78
21.15
73.48
Merseyside HAZ:
   Liverpool HA
4.87
15.14
48.94
   St Helens & Knowsley HA
3.83
18.37
77.37
   Wirral HA
5.80
11.49
30.11
   Sefton HA
3.93
18.63
49.11
Bury & Rochdale HAZ
5.93
21.57
48.09
Nottingham HAZ
5.24
15.15
59.81
Sheffield HAZ
4.18
10.15
49.68
Leicestershire (Leicester City HAZ)
4.24
17.18
50.51
Wolverhampton HAZ
4.68
9.78
51.57
Walsall HAZ
8.26
18.47
86.64
North Staffordshire HAZ
2.62
12.16
76.41
Cornwall & Isles of Scilly HAZ
3.78
22.30
45.84
Camden and Islington HAZ
3.13
14.53
41.70
Brent & Harrow HA (Brent HAZ)
0.35
7.08
41.39
England
4.16
17.81
52.81


Footnotes:

  1.  Data is available on a health authority basis rather than a HAZ basis. Some HAZs consist of more than one HA and others are part of a HA, where this is the case, it is indicated above.

  2.  The source of the data is the Public Health Common Data Set 1998.

HAZ Strategy and Targets

  2.  For Health Action Zones the Department has adopted a bottom up process recognising that each of the HAZs have different problems that need to be addressed. The targets should address the major health and service issues they face. The Department has not specified what these should be but has specified the approach that should be taken in the programmes. We expect all HAZs to build their programmes on seven principles:

    —  equity: in resource, allocation, in reducing health inequalities and promoting equality of access to services;

    —  staff involvement;

    —  person centred services;

    —  engaging communities;

    —  an evidence based approach to service planning and delivery;

    —  partnerships/multi agency working;

    —  a whole systems approach to taking forward change engaging stakeholders across the local health and social care system.

  3.  The approach the NHS Executive has taken to target-setting within HAZs is that the HAZ targets and milestones should be regarded as an integral part of a community health improvement process:

    —  That begins with stakeholder ownership of a needs assessment and priority setting process;

    —  And perceives targets as the expected consequences within specified timescales;

    —  Of purposeful investments in processes, activities and interventions Directed at achieving strategic goals;

    —  Which may require achieving synergy arising from multiple interventions.

  4.  In each programme, there is a clear link between the issue they are intended to tackle the intervention they are taking to tackle it and the outcome they wish to see. An example of this approach from Wakefield HAZ is attached. Under each objective are a number of projects, an example of which is attached. This shows that each project within each objective has process targets that relate to outcome targets.

HAZ Performance Management

  5.  The NHS Executive has been working with DETR, GROs and SSI to develop a performance management framework, which sets out the general process the NHS Executive will take with six monthly reports to ministers on progress against plan.

  6.  Arrangements for performance management need to meet central monitoring and reporting requirements and demonstrate that HAZs are:

    —  implementing agreed plans;

    —  delivering early and sustainable successes;

    —  developing their plans, processes and capacity;

    —  achieving core objectives;

    —  demonstrating core values;

    —  meeting core requirements.

  7.  They should build on the HAZ's own arrangements for self-assessment, performance management and reporting in order to minimise bureaucracy and additional burdens. They should fit in with those for performance managing (a) health communities on the delivery of their HIMPs and (b) other area based initiatives on the delivery of their plans

Responsibilities for Performance Management

  8.  The HQ HAZ Team is responsible for reporting to Ministers, the Executive Board, HM Treasury and others on the general progress of HAZs and their use of national funds.

  9.  Regional Offices of the NHS Executive will lead the performance management and development of individual HAZ's working in partnership with RO's of the SSI/SCR, Government Offices for the Regions and increasingly other regional offices (eg Employment Service, Benefits Agency) to ensure joined up government at regional level. RO's will submit regular reports on progress and use of national funds to the HAZ Team. RO Leads will work in partnership with other regional colleagues to ensure joined up working within RO's including the linkage/integration of performance management arrangements for HAZs with those for the HIMPs

  10.  HAZs should establish clear arrangements locally for internal performance management, including the local framework, the reporting cycle and lead responsibilities for performance management.

HAZ Evaluation

  11.  In addition to performance management, HAZ included in their programmes arrangements for local evaluation. In some cases, local academic centres will undertake evaluation for particular HAZs. Regional Research & Development Directorates may also play a part in developing arrangements for local evaluation. HAZs' plans for local evaluation and their approach to target-setting will be quality assured by an independent assessor (who is also assisting them in developing targets for their plans), as well as being assessed by Regional Offices, Regional Government Offices and the Social Services Inspectorate.

  12.  A national/central evaluation programme will be run by an independent consortium of academic organisations. The evaluation will be part of the Department's Policy Research Programme, the aim of which is to provide a sound evidence base for policy formulation. The central evaluation of HAZs is therefore intended to address strategic issues of importance for central policy on HAZs and the wider policy agenda. At the same time, the central evaluators will be required to work with local evaluators to develop capacity and to share information. In addition, the overall evaluation programme will be designed to disseminate learning across HAZs at key points in the year, in order to support the development of HAZs locally. However, unlike the local evaluations, the central evaluation is not intended to provide tailored support for the specific development of individual HAZs.

  13.  Phase 1 of the central evaluation will pay particular attention to the extent and nature of partnership working and the process for selecting interventions and their associated implementation and resource strategies. Phase one is divided into two distinct areas:

    —  Developing effective partnerships: Monitoring and evaluating the process of HAZ development by mapping their activities and describing methods and arrangements for partnership working. Assessing the growth of partnerships over time, and evaluating the costs of benefits of this type of working will be a long term objective of this part of the study.

    —  Strategic monitoring: will cover monitoring resource flows, the process deliverability, impact and sustainability of the HAZ partnerships, and their effect on final health outcomes.

  14.  HAZs will be addressing different challenges in their respective areas and the central evaluation will not be covering a single defined entity. The central evaluation will instead address the wide range of issues deriving from the above criteria which will be presented in diverse ways by individual HAZs. The aim will be to produce generalisable findings, assessing processes as well as outcomes, identifying intermediate achievements, such as structural changes and new ways of working, which might be instrumental in progressing HAZs towards their major objectives.

HAZ Finance

  15.  Whilst HAZs are about bringing all the players together to find imaginative ways to make best use of existing resources through working in partnership, additional resources have also been made available. The HAZ budget is part of the Health Modernisation Fund. HAZ programme funds are intended to be used strategically to enable mainstream programmes to be refocused on the overall HAZ objectives.

  16.  In 1999-2000 the HAZ central budget will be set at the following levels:


1999-2000
£49.1m
2000-01
£66.2m
2001-02
£67.8m




  17.  In addition to this money other funding is being made available to HAZs:

    —  £30 million was targeted to the HAZs as part of the allocations circular (HSC 1998/205). This money is to be spent in support of the HAZ programmes and in the geographical area of the HAZ. The intention is to make equivalent allocations in 2000-01 and 2001-02. This money is included within HA initial cash limits and has been allocated to individual HAs within the HAZs;

    —  £10 million in 1999-2000 with the possibility of more to follow in future years to all HAZs for smoking cessation;

    —  £3.3 million to 1st wave HAZs for drugs prevention.

  18.  This would make a total of over £280 million over the CSR period.

Programme Allocations

  19.  The following tables set out the allocations for the 1st wave and 2nd wave covering the programme and development support elements.


 
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Prepared 18 October 1999