MEMORANDUM BY THE HEALTH DEVELOPMENT AGENCY
(PH 31)
SUMMARY AND
RECOMMENDATIONS
Current public health policy is based on a broad
consensus that social, economic and other factors have a strong
influence on health and health inequalities.
Many organisations have responsibility for public
health, including central government, public bodies, executive
agencies, regional organisations, local authorities and the voluntary
and private sectors, as well as the NHS.
The Acheson report recommends a broad range
of "upstream" and "downstream" policies to
tackle inequalities in health.
The HDA believes that any policy or combination
of policies that has an impact on health determinants is a public
health policy, regardless of which government department it emerges
from.
It is too early to say whether or not current
public health policy is reducing health inequalities. The question
should be whether an appropriate model of public health is in
place, supported by adequate policies, processes and monitoring
systems, and whether the focus is on improving health outcomes
and tackling health inequalities.
Current policy is rooted in an evidence-based
model, but more needs to be done to clarify how policies relate
to each other and how they are implemented in the context of the
Acheson recommendations.
There should be a sharper focus on the health
of children and families.
Implementation of health impact assessments
of policies (including health inequalities impact assessments)
would both improve policies and help with their evaluation.
Processes are being established to increase
the likelihood that policies will succeed. However, "initiative
overload" and structural barriers hinder effective local
delivery.
There needs to be greater investment in establishing
and maintaining an evidence base of what works, and in sharing
knowledge.
Process indicators are needed to monitor
Saving Lives. There should be inequalities targets, with interim
milestones and appropriate process indicators.
Local delivery of public health policies can
be improved by:
— Better local co-ordination—health
improvement programmes (HimPs) and community plans should be integrated.
— A clear funding stream within mainstream
budgets to support partnership-based public health programmes,
particularly those that tackle health inequalities.
— Professional development programmes
focused on partnership working.
— Local integration of performance
management arrangements.
— An efficient infrastructure for sharing
knowledge.
Public health leaders, like leaders in other
parts of the public sector, need new skills. There should be a
national public sector leadership programme.
The HDA's job is to establish what works in
public health and to help others turn that evidence into effective
national, regional and local action. It views health development
as the process of continuous, progressive improvement of the health
status of individuals and groups in the population. The HDA will
provide robust evidence-based advice to government while making
sure that it is in tune with the concerns and needs of local organisations.
1. THE HEALTH
DEVELOPMENT AGENCY
1.1 The Health Development Agency (HDA)
is a special health authority that was set up in April 2000. Its
remit is to improve the health of people in England—in particular,
to reduce inequalities in health between those who are well off
and those on low incomes or reliant on state benefits. It achieves
this by:
— working with key statutory and non-statutory
organisations at national, regional and local level;
— finding out what works and maintaining
this evidence base;
— turning the evidence into action
by building up the skills and capacity of those working to improve
the public's health;
— advising on the setting of standards
for public health planning and practice.
2. WHAT IS
PUBLIC HEALTH?
2.1 The HDA defines public health as "the
science and art of preventing disease, prolonging life and promoting
health through the organised efforts of society."1
2.2 Research indicates that many factors
affect a population's health—and health inequalities within
it. It has been estimated that over 70 per cent of what determines
people's health lies outside the domain of health services and
in their demographic, social, economic and environmental conditions.
2.3 This evidence matches public perceptions
of what constitutes health and of the causes of ill health, as
illustrated by recent HDA research.3 Respondents mentioned
low income, working hours and conditions, unemployment, housing
and the physical environment, lack of access to a range of services,
crime, the burden of family and caring responsibilitie, social
isolation, and racism as barriers to health. Their comments show
how these external factors shaped their attitudes to eating, physical
activity, and to habits such as smoking, drinking and drug-taking.
2.4 These views of health and its determinants
inform the Government's public health White Paper Saving Lives:
Our Healthier Nation.4 The public health Green
Paper5 depicted the factors affecting health in the
following way:
| Fixed | Social and economic
| Environment | Lifestyle
| Access to services |
Genes
Sex
Ageing | Poverty
Employment
Social exclusion
| Air quality
Housing
Water quality
Social environment
| Diet
Physical Activity
Smoking
Alcohol
Sexual behaviour
Drugs
| Education
NHS
Social services
Transport
Leisure
|
2.5 The appointment in 1997 of the first ever Minister
for Public Health with the task of ensuring co-ordination of cross-Government
policies that have an impact on health demonstrated this shift
in thinking.
3. WHO IS
INVOLVED IN
PUBLIC HEALTH?
3.1 Many organisations have a responsibility for public
health. These include central government, public bodies, executive
agencies, regional organisations, local authorities and the voluntary
and private sectors, as well as the NHS.
3.2 Local organisations exercise that responsibility
in various ways. Some, for example, protect the public health
by monitoring environmental hazards or managing infectious diseases.
Some work with communities to identify and meet their health needs.
Some work on specific health compaigns or with small groups, run
specialist services such as smoking cessation clinics, or develop
local partnerships to reduce health inequalities.
3.3 Local government makes a major contribution to improving
the health and well being of local communities. For example, social
services departments protect and support young people, older people
and families. Environmental health departments deal with noisy
neighbours and water pollution, as well as monitoring air quality
and ensuring the food we eat is safe. Many local education authorities
are working with the their health authorities to set up Healthy
School programmes. Other departments work to improve the quality
of local housing, promote community development or support urban
regeneration. With new duties to promote social and economic regeneration,
local authorities are likely to make an even bigger contribution
to public health in the future.
3.4 Employers can contribute by changing management practices
and improving conditions so as to create a healthy workplace.
3.5 The job of central government and its regional arms
(and, indeed, the HDA) is to ensure policy is "joined up",
that policies have a positive impact on health, and that there
is a national infrastructure (including the right mix and number
of appropriately qualified professionals) to achieve public health
goals.
4. INEQUALITIES IN
HEALTH
4.1 The Government intended Saving Lives to be
a response to the findings of the independent inquiry into inequalities
in health, chaired by Sir Donald Acheson, which had reported in
1998.6 An important focus was on local partnerships—particularly
health improvement programmes (HimPs) and the new primary care
groups and trusts—and how they would tackle health inequalities.
4.2 The Acheson report recommended both "upstream"
policies (ie policies likely to have a wide range of consequences,
including benefits to health) and "downstream" policies—ones
that have a narrower range of benefits and are more explicitly
targeted on health.
4.3 It recommended three crucial steps, which the HDA
strongly endorses:
— All policies likely to have an impact on health
should be evaluated in terms of their impact on health inequalities.
— A high priority should be given to the health
of families with children.
— Further steps should be taken to reduce income
inequalities and improve the living standards of poor households.
5. THE IMPACT
OF CURRENT
POLICY ON
HEALTH INEQUALITIES
5.1 The HDA believes that any policy or combination of
policies that has an impact on health determinants is a public
health policy, regardless of which Government department it emerges
from. An assessment of the effectiveness of public health policy
in tackling health inequalities should, therefore, take account
of the impact of both upstream and downstream policies, as defined
by Acheson.
5.2 An obvious problem is that it is too early to say
whether current policy is reducing health inequalities—its
effect will not by fully apparent for many years. In any case,
in many areas—housing, for example—a decision on policy
is yet to be made, while in others—such as transport and
neighbourhood renewal—implementation is at an early stage.
5.3 It is more relevant to ask whether:
— Policies are based on an appropriate model of
public health.
— Policies are based on evidence and focused on
outcomes.
— Processes to achieve change are in place.
— Systems to monitor progress are adequate.
— There is sufficient flexibility to make changes
in the light of the evidence on progress.
The model of public health
5.4 We fully endorse the approach to public health set
out in current policy, but believe that the inter-relationship
of several major strands of Government policy needs to be made
much clearer. For example, there are the neighbourhood renewal
strategy, Sure Start, the various zone-based initiatives, as well
as planning mechanisms such as HimPs, community plans and regional
development strategies. Each has its own goals and targets and
measures of success. People need to be able to understand the
relationships among them (and the links between goals to do with
economic success, social regeneration, eliminating child poverty,
sustainable development, quality of life, well being and health).
Evidence-based policies
5.5 In its response to the Acheson report, the government
gave examples of how it was putting policies in place in all the
recommended areas.7 Health impact assessments of policies
(including the impact on health inequalities as recommended by
Acheson) are likely both to improve policies and aid policy evaluation,
so the HDA welcomes the intention set out in Saving Lives
to introduce such assessments.
5.6 The recent Government commitment to eliminate child
poverty, along with other initiatives, has raised the profile
of policy on children and families. However, given that Acheson
saw the health of families with children as such a high priority,
we believe there should be a sharper focus on this group.
Processes to achieve change
5.7 Policies will not succeed without the necessary processes
(ie structures, systems and people) to take them forward. It is
possible to draw some tentative conclusions about whether or not
these processes are in place by using success criteria from an
assessment commissioned by the Department of Health in 1997 of
the previous public health strategy, The Health of the Nation.
That report8 concluded that success for the new strategy
was more likely if there was:
— Integrated central leadership and committed local
ownership.
— Sustained local intersectoral partnerships.
— A high priority placed on developing the evidence
base for both target setting and other implementation activities.
— A requirement for substantial performance management,
including robust accountability arrangements, particularly at
local level.
5.8 Integrated central leadership . . .: Partnership,
integrated planning and co-ordinated implementation have been
essential "process" objectives of all Government policy.
Within central government a variety of mechanisms is promoting
a joined-up approach. These include the comprehensive spending
review and public service agreements, cross-departmental co-ordination
units, Ministerial responsibility for cross-cutting themes (including
the Minister for Public Health), impact assessment in policy making,
and the development of common approaches to improving performance.
5.9 Moreover, the Government is now strengthening ministerial
and Whitehall co-ordination of policy initiatives and of Government
Offices in the regions. This is a response to the findings of
a recent Cabinet Office report9 that there were too
many initiatives, causing confusion, not enough co-ordination,
and too much time spent on negotiating the system, rather than
delivering.
5.10 . . . and committed local ownership: The
Government is urging or requiring regional and local agencies
to plan and work together, whether within planning mechanisms
for all authorities, such as health improvement programmes (HimPs)
and community plans, or through targeted regeneration and social
inclusion initiatives, such as health action zones (HAZs) and
the neighbourhood renewal strategy. It needs to avoid adding to
the "initiative overload" and fragmentation identified
in the Cabinet Office report.
5.11 Sustained local intersectoral partnerships:
There are several barriers to effective local service delivery—see
also section 6 below—but the forthcoming NHS national plan
may propose some solutions.
5.12 A high priority placed on developing the evidence
base for both target setting and other implementation activities:
The Government has a strong commitment to evidence-based policy
making. Examples include the creation of the HDA with its remit
to build and disseminate the public health evidence base and promote
health development (see section 8 below); the establishment of
public health observatories; and the ongoing programme of national
service frameworks. However, there needs to be greater investment
in the evidence base and in sharing knowledge, so that mainstream
programmes, such as HimPs, can quickly absorb the learning from
pilot programmes, such as health action zones.
5.13 A requirement for substantial performance management,
particularly at local level: There are performance assessment
frameworks for the NHS and local government. However, development
work needs to be done to integrate these frameworks. (See also
section 6 below).
Monitoring progress and flexibility
5.14 Evaluation methods for complex and inter-related
policies—such as those on public health—are still
in their infancy. The previous strategy had a mix of final outcome
targets and risk factor targets, which served as intermediate
outcomes. However, it did not propose any process indicators by
which progress could also be judged.
5.15 The targets in Saving Lives are to be achieved
in 10 years, with interim milestones by 2005. The White Paper
does not make any proposals for assessing in other ways whether
or not policies are succeeding. However, the national contracts
in the four priority areas (cancer, coronary heart disease and
stroke, accidents and mental illness) contain many ideas that
could be translated into process indicators. These could monitor
change in risk factors, the development of the public health infrastructure
or national and local partnerships, and trends in major public
health-related policies, such as those on employment, social security,
transport and the environment. We believe there should be national
inequalities targets, but, similarly, there should be interim
milestones and appropriate process indicators.
6. THE INTER-OPERATION
OF LOCAL,
INITIATIVES, PLANNING
MECHANISMS AND
PRIMARY CARE
ARRANGEMENTS
The background
6.1 Many initiatives are tackling social exclusion and inequalities
(including health inequalities) and promoting regeneration and
well being in areas of significant deprivation. All bear more
or less directly on public health. Some are based on areas—for
example, Health Action Zones (HAZs), Employment Zones, Education
Action Zones, the New Deal for Communities. Sure Start and Sure
Start Plus for teenage parents. HAZs are noteworthy in that they
provide the opportunity for local partnerships to find new ways
of addressing the determinants of health, in line with the new
public health thinking discussed in section 2 above.
6.2 Some of these area-based initiatives are pilot schemes
(for example, Better Government for Older People, New Commitment
to Regeneration, the Drug Treatment and Testing Pilots, and Personal
Medical Services Pilots). Others, such as the Healthy School Standard
and health living centres are development programmes. The former
involves health authorities and LEAs working together to support
schools in their efforts to become healthier places for working
and learning. The latter are programmes of activities, rather
than centres or buildings, that help people of all ages to improve
their physical and mental health.
6.3 At the same time, the Government has introduced important
new mechanisms for regional and local strategic planning, and
introduced primary care groups (PCGs) and primary care trusts
(PCTs).
6.4 Regional Development Agencies (RDAs) now lead on
regional social and economic regeneration strategies and work
closely with Government Offices and other regional arms of Government,
including NHS Regional Offices. Health improvement programmes
(HimPs) are the local plans for improving health and health services
and reducing inequalities in health. Health authorities take the
strategic lead, but HimPs are partnership ventures with local
authorities and other local agencies. Health authorities, along
with PCGs and PCTs and responsible for carrying out the plan.
6.5 The Local Government Bill places a duty on local
authorities, as part of Best Value, to prepare a community strategy
or plan to promote the economic, environmental and social well
being of the people who live and work in their area.
6.6 Increasingly, PCGs and PCTs will lead in the commissioning
of NHS services, including public health services. During 2000-01,
approximately 80 per cent of PCGs will have responsibility for
60 per cent of the local commissioning budget. This proportion
will increase in later years. PCTs hold the budget for the majority
of health services and have the freedom to introduce new models
of service provision and new arrangements for funding public health
activities.
Local delivery arrangements—issues and challenges
6.7 The HDA has been particularly interested in the role
of HimPs and how they can learn from the HAZs. Our view of local
delivery arrangements is based on evidence from a number of studies,
including our own reviews of HimPs and reviews by organisations
such as the Nuffield Institute and the King's Fund. We also draw
on our experience of co-ordinating the Healthy School Standard
programme and working with the NHS Executive and the national
HAZ evaluation team in capturing an disseminating the learning
from HAZs, including managing the HAZ website (www.haznet.org.uk).
6.8 HimPs are a positive development for health improvement
planning. However, they need to focus more specifically on reducing
inequalities and tackling the wider determinants of health.
6.9 HimPs and community planning are clearly parallel
processes. Community plans could have a much greater impact than
HimPs on the health of the population, as they will directly tackle
many of the wider determinants of health (such as housing, education,
transport and the local environment). The two planning processes
need to be fully integrated.
6.10 Many HimPs have already started to link with local
authority plans, although in most cases this consists of a preliminary
map of related plans. HAZs have produced a framework that supports
planning links across sectors. This needs to be shared more widely.
6.11 Experience so far shows that public involvement
in HimPs, particularly that of minority ethnic groups, has been
hard to achieve. In many areas, with no additional resources,
community health councils have facilitated consultation and developed
links with voluntary and community groups. HimPs need to learn
from HAZs, where local authorities and health authorities are
working together to involve the local community. They can also
learn from healthy living centres, which have needed community
participation to meet funding criteria.
6.12 If HimPs are to be more than old-style NHS purchasing
plans, mainstream funding will need to be channelled into health
improvement. It is not yet possible to assess the resourcing of
public health priorities within HimPs. It is clear, however, that
if public health is to be brought in from the margins it must
appear in mainstream budgets, perhaps through the creation of
a funding stream shared between health and local authorities.
6.13 HimPs herald a new needs-based approach to resource
allocation that should mean inequalities can be better addressed.
Nevertheless, PCGs may only be able to take on their public health
responsibilities once they evolve into PCTs, when they can exert
greater control over the commissioning function. PCTs will have
a wider network of working relationships and the potential to
develop outreach and other innovative services. Primary care funding
will also need to shift from a capitation basis to a needs-based
formula.
6.14 Performance management of the public health aspects
of HimPs is in its infancy. There has been little progress in
joining up NHS and local authority performance management. HimPs
should again learn from HAZs, where partners use a ten-point Development
and Performance Framework in their reports to Ministers, NHS Regional
Offices and the NHS Executive. The framework covers issues such
as service improvement, partnership, leadership and governance,
community participation and staff involvement.
6.15 Early HimPs have not yet defined targets, milestones
or methods of monitoring progress. In contrast, HAZs have been
under continual pressure to demonstrate success. A range of health
and social indicators is needed—to measure process as well
as outcomes. Many of these indicators already exist, but they
have not always been shared across professional, organisational
and departmental boundaries. The process of identifying and agreeing
local indicators, as well as sharing the data to support them,
has started in a number of HAZ areas.
6.16 As trailblazers, HAZs are developing a wealth of
learning but more effort is needed to apply this learning to HimPS.
The HAZ and HimP central teams in the NHS Executive are starting
to work together more closely, but they will support from other
national organisations, such as the Local Government Association,
the Improvement and Development Agency (IDeA) and the Health Development
Agency, and from national networks such as UK Health for All.
Some ways forward
6.17 The effectiveness of activities to improve local
co-ordination and delivery will depend very much on the context
crested by central government. It has accepted the recommendations
of the Cabinet Office report, so it is highly likely that co-ordination
of policy in Whitehall and the Government Offices will improve.
The latter will work more closely with the NHS Regional Offices
and Regional Development Agencies, which should lead to better
regional and local integration of policies on health, public health,
and on social and economic regeneration.
6.18 Given this context, we recommend action in the following
related areas:
— Local Co-ordination: HimPs and community
plans need to be integrated. The two planning cycles need to be
harmonised and the lack of coterminosity of local and health authority
areas needs resolving.
— Funding: Health improvement funding within
mainstream budgets should be earmarked to support joint public
health programmes, particularly those that tackle health inequalities.
Public health should not have to depend on funding from marginal
initiatives.
— Targets and monitoring: Local agencies
need help defining targets and milestones, and monitoring progress.
A range of social indicators is needed to support the development
of shared indicators.
— Professional development and leadership:
Partnership working requires new skills and competencies at all
levels. Appropriate professional development programmes are essential.
These should include opportunities for professionals and communities
to increase capacity and skills to deliver joined up approaches
to health improvement.
— Performance management and accountability:
Arrangements in health and local authorities need to be brought
together so that they place value on achieving shared goals and
joint working.
— Sharing knowledge: It is essential that
learning from HAZs and other pilot initiatives be absorbed by
HimPs and community plans, and vice versa. Similarly, HimPs need
their own networks to share research and practice. The HDA has
an important part to play in these processes.
7. PUBLIC HEALTH
LEADERSHIP
7.1 It follows from the new thinking about multi-disciplinary
and intersectoral approaches that public health leaders, such
as directors of public health, will need the ability to create:
— Effective mechanisms for joint working with partner
organisations.
— An organisational commitment to involve other
sectors and encourage participation by the public, communities
and users of services.
— New organisational forms that support new approaches
to public health.
— A focus on outcomes and effectiveness.
— Authority and credibility beyond the boundaries
of the NHS.
7.2 The implication is that public health leaders (and
leaders in other parts of the public sector) need certain generic
skills. The HDA believes there is a case for a national public
sector leadership programme. Such a programme would be in accord
with what the evidence tells us about the benefits of system-wide
solutions to public health problems. A national programme would
also avoid duplication of effort; break down some of the barriers
between public sector organisations; promote better communication
and more sharing within the public sector; and facilitate the
development and transfer of skills within the public sector.
8. ROLE OF
THE HEALTH
DEVELOPMENT AGENCY
8.1 The Heath Development Agency (HDA) was announced
in Saving Lives, and was established by statutory instrument on
14 January 2000. The Agency assumed its full responsibilities
on 1 April 2000, following the demise of the Health Education
Authority, and was formally launched by the Minister for Public
Health on 2 June 2000.
8.2 The HDA's purpose is to establish what works in public
health and to help others turn that evidence into effective national,
regional and local action. We see health development as the process
of continuous, progressive improvement of the health status of
individuals and groups in the population.10 The HDA
will provide robust evidence-based advice to Government while
making sure that it is in tune with the concerns and needs of
local organisations.
8.3 The HDA has been seen as the public health equivalent
of the National Institute for Clinical Excellence (NICE). This
journalistic shorthand disguises important differences between
the two organisations. NICE is concerned with treatment, the HDA
with health development. NICE works within the NHS, whereas the
HDA will have to demonstrate that it has a "joined up"
approach by working with a range of organisations both within
the outside the NHS. Moreover, the HDA's approach will be based
on evidence about processes that are effective in bringing about
change.
8.4 We will have to form partnerships with the NHS locally,
local authorities, NHS Regional Offices, Government Offices and
Regional Development Agencies, as well Learning and Skills Councils,
universities and further education colleges.
8.5 In addition to regional and local involvement, the
HDA will co-operate with several Government departments, including
the DETR, DfEE, DTI, MAFF and the Treasury, as well as the Department
of Health. We will also have to work with a range of public, private
and voluntary sector bodies, particularly agencies such as the
Audit Commission and the Improvement and Development Agency (IDeA).
8.6 As part of local support, the HDA will develop a
network of regional posts located either in NHS Regional Offices,
public health observatories or Regional Development Agencies,
depending on each region's circumstances. These posts will contribute
to the development of action zones. HimPs, the implementation
of national service frameworks, and the development of public
health observatories, and help to co-ordinate action across sectors.
Research and Development
8.7 The HDA will collate and disseminate evidence to
improve the quality of public health work via Evidence Base 2000,
a database driven website. All our websites and databases will
be linked to those of the public health observatories to ensure
a co-ordinated approach to information dissemination, and we will
support the new National Electronic Library for Health (NeLH).
In addition, we will maintain the Our Healthier Nation website
on behalf of the Department of Health (www.ohn.gov.uk). More specifically,
we will provide resources on issues such as HIV and AIDS.
8.8 In its information strategy the HDA will take account
of the fact that not all professionals have ready access to internet-based
resources.
Developing Standards
8.9 As part of the move towards better quality in public
health, the HDA will work with other agencies to develop standards
of good practice. Apart from providing advice to support policy
development, we will be concerned with standards for programmes,
initiatives and planning mechanisms such as workplace health;
healthy schools; community-based coronary heart disease prevention,
cancer risk reduction, dietary improvement, mental health promotion,
HIV/AIDS prevention and immunisation; HAZs; HimPs; regeneration;
housing and transport; and for measures to eliminate inequalities
in access to services.
8.10 Standards for professionals who play a public health
role—such as non-medical public health and health promotion
specialists, public health medicine, health visitors and practice
nurses, school nurses, occupational health nurses, environmental
health officers, and PSHE teachers—are the domain of the
professional bodies which accredit training and register practitioners.
However, the HDA will have a role in providing evidence and advice.
Audit and review
8.11 A system for audit and review is needed to ensure
standards of good practice are implemented. Although the HDA itself
will not carry out such activities, we will explore the possibility
of using a peer review approach. The intention would be to use
reviewers/auditors drawn from a similar area of work or geographical
location, thus ensuring that they have a clear understanding of
the work under review.
Implementing change
8.12 In reviewing the evidence of effectiveness and as
part of the process of disseminating good practice, the HDA will
develop guidance, protocols, and toolkits designed to accelerate
implementation. In particular, we will focus on health improvement
planning; the implementation of national service frameworks; HAZ
development; and the public health role of primary care groups
and primary care trusts.
8.13 The HDA will also use its evidence base to develop
guidelines for local monitoring and evaluation, particularly in
relation to HimPs. These would not only be used locally but be
incorporated into the performance management arrangements adopted
by NHS Regional Offices.
Conclusion
8.14 To sum up, the HDA has a clear role in promoting
good practice in public health through a process with the following
elements:
— Collating the evidence base.
— Disseminating the evidence and encouraging uptake.
— Working with others to develop standards.
— Encouraging audit and review.
— Identifying public health workforce requirements.
— Professional development.
— Providing guidance on public health programmes.
— Producing frameworks for performance monitoring
and evaluation.
8.15 The HDA is in its first year, but we believe that
we have an important part to play in improving the public health
and in supporting any action resulting from the recommendations
in this memorandum.
July 2000
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