58. Health promotion seeks to involve individuals
in improving their own health. According to the World Health Organisation,
health promotion is " the process of enabling people to increase
control over, and to improve their health".
The means by which Government can achieve this are debatable.
Professor Macintyre told us that "most of the evidence suggests
that simply telling people what the risks are is not enough to
Professor Richard Wilkinson of Sussex University also pointed
out that any resources devoted by Government to getting across
healthy lifestyle messages were likely to be totally outmatched
by commercial interests seeking to put across different messages.
He referred to evidence on public perceptions of sugar, looking
at both the health education aspects and industry advertising:
"On balance ... the overwhelming message was
that sugar is good for you - Mars Bars 'help you work, rest and
59. In the course of our recent report on the tobacco
industry we unearthed copious evidence from advertising agencies
working for the major tobacco companies. This demonstrated how
tobacco marketing ruthlessly and efficiently targeted particular
sections of society, notably younger people and the poor. Companies
even manipulated the pack colour and design to convey subliminal
messages, so that the gold packaging of Benson and Hedges exploited
a sense of glamour and sophistication, whilst the soft purples
and whites of Silk Cut packaging hinted at an implied health benefit
from its "low" tar. We concluded that those responsible
for health education could learn much from the social marketing
techniques of the tobacco companies.
60. In April 2000, following proposals set out in
Saving Lives, the Government set up the Health Development
Agency (HDA). It is a Special Health Authority whose purpose is
"to establish what works in public health and to help others
turn that evidence into effective national, regional and local
It is tasked to maintain an up to date "map" of the
evidence base for public health improvement, to commission and
evaluate research in areas where "action programmes are required
to improve health and tackle inequality", to advise on the
setting of standards for public health planning and practice and
to build up the "skills and capacity of those working to
improve the public health".
61. The HDA will have almost a third fewer employees
than its predecessor body, the Health Education Authority (HEA),
and is no longer directly responsible for health promotion activity.
This has led to suggestions in some quarters that the transition
from HEA to HDA has been merely a "cost-cutting exercise".
In fact, the public education function of the old HEA has, at
present, been transferred to a new body, Health Promotion England
(HPE), which was established at the same time as the HDA. HPE
has initially been contracted to work in the following areas:
alcohol, children and families, drugs, immunisation, sexual health
and older people, and also to update and provide publications
from its predecessor body.
HPE's initial contract runs until the end of March 2001.
62. The precise status of Health Promotion England
seems to us unclear. The nature of its short term contract,
its relationship to its predecessor body and its means of liaison
with the Health Development Agency (HDA) all seem too opaque.
We are not convinced that this body has the direction, energy
or resources to make a real difference. We would urge the Government
to make clear its plans for the future of health education.
63. Clearly it is too early for us to pronounce on
the effectiveness of the HDA and of HPE. Several witnesses did,
however, register concerns and we would like to record these as
a future marker. The Chartered Institute of Public Health pointed
out that the lack of formal links with counterpart organizations
in Scotland, Wales and Northern Ireland did not suggest Government
was well co-ordinated in this area.
The BMA suggested that the HDA could be the public health counterpart
to the National Institute for Clinical Excellence, but required
far more support from DoH and better links with academic networks
for primary care and environmental sciences. They also drew attention
to a potential difficulty for a body tasked with establishing
the evidence base for public health: "The agency also needs
to be given the opportunity to research developments and initiatives
which cannot be evaluated in the short term, for example the long
term effects of health education and prevention".
The King's Fund was concerned that the HDA was barely mentioned
in the NHS Plan. They contended that its role remained unclear,
its budget had been severely reduced and it was apparently not
due to receive any new money. They also queried whether the HDA
should remain within the DoH or be funded by several departments
and work across Government from within the Cabinet Office. However
they welcomed the fact that the HDA has established a number of
regional posts and that a number of these were located in Government
Regional Offices and Regional Development Agencies.
The National Heart Forum thought that the HDA was ideally placed
to look at the non-health determinants of health but was concerned
that the HDA's budget was insufficient. They estimated it would
require an annual budget increase of £10 million to allow
it to carry out training and development.
64. We asked Professor Richard Parish, the Chief
Executive of the HDA, whether he felt that his organization was
sufficiently well funded for the extremely wide-ranging task it
had been given. He told us that he was satisfied with funding
levels for the first year of operation but would be seeking further
funding in three areas: additional skills relating to workforce
planning and information technology to help in the development
of a National Electronic Library for Public Health; commissioning
research to fill the gaps in the evidence base; and development
resources to pump prime initiatives in the field "to provide
the necessary resources that will have a practical impact for
people working either in general practice or as a health visitor
in the field, someone working in a local authority, in a leisure
centre or whatever". He estimated that a further £20
million would be needed to achieve these goals.
65. We were impressed by the evidence given by
those representing the HDA. We would be disturbed if this new
organization was not properly resourced. We are anxious to ensure
that the HDA will have the resources to be able to assess 'bottom
up' projects. We also recommend that its funding should be ring-fenced
and kept apart from mainstream health funding so that its independence
in offering objective advice on 'what works' in health is not
compromised. Establishing 'what works' in public health will ultimately
yield value for money savings.