Select Committee on Health Appendices to the Minutes of Evidence


Joint Memorandum by Dr Naomi Fulop and Julian Elston, London School of Hygiene and Tropical Medicine (PH 69)

  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.


  1.1  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 Health.

  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 departments.

  1.4  If public health is to have a really high profile, the Minister for Public Health should be a cabinet minister.


  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 authorities.

  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 of health.


  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 (HImPs).

  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 local solutions.

  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.


  4.1  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 Nation—a 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.

July 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 level

  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 greatly—but 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 system.

  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 implementation.

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.

  Resources—lack 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 promotion activities.

  Organisational structures—at 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 partnership—perceived 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).

  Commitment—data 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.

  Demographic characteristics—divisions 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 features—political 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 strategy.

    (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 be encouraged.

    (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.

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