Memorandum by the Health Development Agency
(HDA) (WP 35)
1. SUMMARY OF
THE EVIDENCE
1.1 This memorandum presents the views of
the Health Development Agency (HDA) on the issues raised by the
terms of reference of the Health Committee's inquiry. We look
at the Government's public health goals in light of the new white
paper, Choosing Health—Making healthy choices easier,
and discuss the difficulty of assessing the likely impact
of the complex and ambitious programme it proposes. We then consider
appropriateness, effectiveness and value for money in relation
first to proposals on specific interventions and second to proposals
on the public health infrastructure. We use the recommendations
of the Wanless review and the HDA's recommendations to the consultation
on the white paper as assessment criteria. The key points from
our memorandum are as follows
1.2 The white paper proposals should be
seen in the context of targets for other government departments
that contribute to public health goals, particularly the sub-set
of public service agreements (PSAs) defined as "floor targets"
for neighbourhood renewal and social inclusion. It is welcome
that PSAs for the Department of Health and the rest of government
increasingly contain an inequalities dimension.
1.3 There are around 170 commitments in
the white paper, including a large number of initiatives which
pre-date it. This makes it difficult to assess the plausibility
of this complex and ambitious programme, particularly in the absence
of important evidence—the white paper delivery plan.
1.4 With certain caveats, we regard the
white paper proposals as an appropriate response to the Wanless
review. They represent an evidence-informed approach, which is
likely to be effective if vigorously and efficiently implemented,
and so should help reduce certain demands on the NHS.
1.5 The proposals on smoking, obesity, diet
and nutrition, exercise, sensible drinking, sexual health, mental
health—the white paper's overarching priorities—are
informed by evidence. Crosscutting proposals on, for example,
action in settings such as schools, enhancing services for children
and families, an integrated approach to social marketing of health,
and re-orientating the NHS towards prevention should help in implementing
these priorities.
1.6 The creation of the National Institute
for Health and Clinical Evidence (NICE) will speed up the flow
of evidence on the cost-effectiveness of specific public health
interventions.
1.7 The white paper delivery plan should
include the development of a macro-level framework, building on
the Wanless model, for assessing progress towards full engagement
and testing assumptions about the impact of the white paper as
a whole on health spending, using as it does so the evidence of
NICE and others.
1.8 Broadly, the white paper responds in
some degree to all of Wanless's concerns about the public health
infrastructure, particularly those to do with evidence gaps, promoting
local partnerships, workforce capacity and capability, and the
theme of individual engagement in health. It also gives a high
priority to tackling obesity, a particular Wanless concern.
1.9 The white paper demonstrates a continuing
commitment to tackling health inequalities, particularly in its
concern that disadvantaged groups should be supported in making
healthy lifestyle choices. However, it is essential that the social
distribution of the impact of both national campaigns and local
programmes—such as personal health trainers—is carefully
monitored so that they can be modified if they are not reaching
disadvantaged groups.
1.10 The proposal to include health in regulatory
impact assessment would be strengthened if the distribution of
health costs and benefits across the socio-economic spectrum were
included in the analysis.
1.11 Neither the new NHS standards and planning
framework nor PSAs of other government departments contain targets
that adequately reflect the white paper priorities on diet and
nutrition, physical activity, alcohol, and sexual health. It is
essential that the promised six-monthly progress reports include
timely data on indicators concerned with these priorities.
1.12 The annual Chief Executive's report
to the NHS should report on progress on the NHS as a good corporate
citizen and as a healthy workplace, subjects it has not so far
covered.
2. ABOUT THE
HDA
2.1 The Health Development Agency (HDA)
is the national authority on what works to improve people's health
and to reduce health inequalities. We work in partnership across
sectors to support informed decision making at all levels and
the development of effective practice.
2.2 The HDA came into being in 2000 to support
the aim of the white paper, Saving Lives. Our Healthier Nation,
of improving the health of everyone, particularly the worst
off, taking into account the social, economic and environmental
factors affecting health (Department of Health 1999). The HDA's
role is to:
— gather evidence of what works;
— advise on good practice;
— support all those working to improve
the public's health.
2.3 The recent public health white paper,
Choosing Health—Making healthy choices easier, announced
that the functions of the HDA would be transferred to the National
Institute for Clinical Excellence (NICE) to form a new body with
a wider focus on both care and health—the National Institute
for Health and Clinical Excellence—within which there would
be a Centre for Public Health Excellence.
3. WILL THE
WHITE PAPER
PROPOSALS ENABLE
THE GOVERNMENT
TO ACHIEVE
ITS PUBLIC
HEALTH GOALS?
3.1 Broadly, the Government's public health
goals are to improve the health of the population and reduce health
inequalities. The white paper Saving Lives—Our Healthier
Nation (Department of Health 1999) set national targets for
cancer, coronary heart disease, accidents and mental health. The
NHS Plan (Department of Health 2000) announced that there
would be national health inequalities targets. These were specified
in Tackling Health Inequalities—A programme for action
(Department of Health 2003). The current expression of these
priorities and targets for the Department of Health and the NHS
is the standards and planning framework for the period 2005-06—2007-08,
National Standards, Local Action (Department of Health
2004a), which exactly reflects the Department of Health's public
service agreement (PSA) from the 2004 round of the spending review
(HM Treasury 2004).
3.2 The white paper proposals should be
seen in the context of targets for other government departments
that contribute to public health goals, particularly the sub-set
of PSAs defined as "floor targets" for neighbourhood
renewal and social inclusion, which deal with broader determinants
of health. It's noteworthy, and welcome, that PSAs for the Department
of Health and the rest of government increasingly contain an inequalities
dimension. For example, the targets for reducing mortality rates
from heart disease and stroke and from cancer in the Department
of Health's PSA require not just progress for the population as
a whole but also a reduction in the inequalities gap between the
most deprived areas and the population as a whole (Department
of Health 2004a). Similarly, "floor targets" on education,
housing, worklessness, crime, and liveability now more explicitly
require a narrowing of the gap in outcomes between the most deprived
neighbourhoods and the rest of the country (Office of the Deputy
Prime Minister 2004).
3.3 The white paper proposals are underpinned
by the following principles:
— Informed choice: people should
be supported in making healthier choices for themselves, though
their health should be protected from the actions of others, and
the particular needs of the young should be recognised.
— Personalisation: support has
to be tailored to the "realities of individual lives"
in order to be effective in tackling health inequalities.
— Working together: partnerships
in communities must complement the actions of government and individuals.
3.4 More specifically, the proposals focus
on certain overarching priorities. These are expressed as follows
in the executive summary of the white paper (though not so explicitly
in the white paper itself):
— Reducing the number of people who
smoke.
— Reducing obesity and improving diet
and nutrition.
— Encouraging and supporting sensible
drinking.
— Improving sexual health.
— Improving mental health. (HM Government
and Department of Health 2004).
3.5 There are around 170 commitments in
the white paper, many of which are multi-faceted. Furthermore,
they include a large number of initiatives, particularly from
other government departments, which pre-date the white paper—for
example, the chapter on "Children and Young People—starting
on the right path" draws heavily on the recently announced
children's NSF, and NHS performance management arrangements were
published in July 2004. It is proper that the white paper should
bring together, give coherence, and, in many instances, propose
enhancements to existing initiatives. However, the problem of
deciding what is in the white paper box and what in some other
policy box adds further to the difficulty of assessing the plausibility
of a complex and ambitious programme, particularly in the absence
of important evidence—namely the white paper delivery plan,
due in February. The quality of this plan will be an important
success factor.
3.6 The white paper was in large part a
response to the Wanless report's analysis of what would be required
to attain the "fully engaged scenario" of high NHS productivity
and high levels of individual involvement in health (Wanless et
al 2004). In the following section we therefore treat the
Wanless recommendations as criteria for considering the plausibility
of the white paper's proposals. We also relate the proposals to
the recommendations in the HDA's submission to the consultation
on the white paper (HDA 2004), which themselves built on recommendations
to the Wanless review (HDA 2003).
3.7 The HDA's overall view is that, with
certain caveats, the white paper proposals are an appropriate
response to Wanless, and that they represent an evidence-informed
approach, which is likely to be effective if vigorously and efficiently
implemented, and so should help reduce certain demands on the
NHS.
4. ARE THE
WHITE PAPER
PROPOSALS APPROPRIATE,
WILL THEY
BE EFFECTIVE
AND DO
THEY REPRESENT
VALUE FOR
MONEY?
4.1 Appropriateness, effectiveness and value
for money are inter-related. In this section we discuss whether
the specific health interventions proposed in the white paper
are appropriate and likely to achieve their intended aims and
be value for money. In the next section we consider whether proposals
are relevant to acknowledged deficiencies in the public health
infrastructure or delivery system.
4.2 We have assumed that the more a proposed
intervention is informed by evidence, the more likely it is to
be effective. As noted above, the white paper proposes a complex
array of often inter-connected interventions, which makes assessment
of the extent of support provided by evidence more difficult.
In addition, Wanless rightly supported innovative approaches so
long as they were properly evaluated. Almost by definition, such
approaches will be less evidence-based, or less likely to be based
on the most scientifically rigorous evidence.
4.3 Below, we comment on whether proposals
relating to the white paper's overarching priorities are evidence-based
by reference to the interventions recommended in the HDA's consultation
response (HDA 2004)—see Annex 2. We assume effective implementation
through the delivery plan.
4.4 Smoking: We consider that the various
proposals on reducing smoking are informed by evidence and add
up to a comprehensive approach, though attention should be paid
to the issue of effective targeting of the more disadvantaged
sections of the community. The issue of the rate of progress in
banning smoking in workplaces has been much debated; the white
paper is pointing the right direction.
4.5 Obesity, diet and nutrition: We consider
that the proposals on obesity, diet and nutrition, which include
those on physical activity, are generally informed by evidence
and are comprehensive. We welcome the proposal to develop a "care
pathway" for obesity and the acknowledgement of work by NICE
and the HDA. However, we are concerned that there may be some
duplication of effort, as clarification of the obesity care pathway
is one of the expected outcomes of the NICE/HDA work.
4.6 Exercise/physical activity: The HDA
recommendations put a more specific emphasis than the white paper
on the importance of walking: interventions that encourage walking
and do not require attendance at a facility are the most likely
to lead to sustainable increases in overall physical activity.
However, we welcome proposals to improve green and public spaces,
thereby creating safe walking environments, and to achieve shifts
in transport mode, including to walking. The evidence, including
that from HDA-supported work with older people by the Healthy
Communities Collaborative, suggests that roles such as health
trainers could be important in promoting physical activity. It
also suggests that self-monitoring is an attribute of effective
interventions, something which the distribution of pedometers
could support.
4.7 Sensible drinking: The evidence supports
the proposals on brief interventions, although the HDA recommended
that brief interventions in primary care should recur as part
of routine clinical management of patients—particularly
women—who are reducing their alcohol intake. The HDA also
recommended that, intensive, high quality training for people
serving alcohol should be developed, in partnership with the alcohol
industry and local authorities. This was not picked up in the
white paper, though it is relevant to the problem of binge drinking
and thus to the very recent proposals on responsible drinking
(Home Office 2005). We hope it becomes part of government discussions
with the industry.
4.8 Sexual health: We welcome the proposals
on funding and service modernisation to tackle the high rate of
STIs as an important step towards the provision of effective services.
The aims should be to create an integrated approach to the prevention
of STIs in which interventions are tailored and targeted to specific
groups, delivered by specialist services, and emphasise training
in personal skills. The evidence supports the proposals to make
sexual health services, including information, more accessible
to young people.
4.9 Mental health: Many of the proposals could
be expected to contribute to improved mental health, whether support
services for parents and families, action in schools through the
Healthy Schools programme, local community programmes aimed at
creating a less stressful physical and social environment, and
programmes to improve the physical health of people with poor
mental health.
4.10 There are crosscutting proposals in
the white paper which should be important in implementing work
on these priorities—for example, those that:
— emphasise the importance of action
in settings, particularly schools and the workplace, including
NHS workplaces. Such action is well supported by the evidence.
— enhance services for children and
families reflect evidence findings about the importance of interventions
at this early stage of the life course.
— create an integrated approach to
the social marketing of health in relation to all the overarching
priorities, including the provision of accessible, personalised
information and other services to those newly motivated to choose
a healthier lifestyle.
— reorientate the NHS towards prevention,
including a comprehensive and integrated prevention framework
across all the NSFs.
4.11 The Wanless review presented a strong
economic case for the fully engaged scenario. The white paper
recognises and proposes solutions to the problem of lack of evidence
about cost-effectiveness. Highly significant among these solutions
is the creation of the National Institute for Health and Clinical
Excellence. NICE will speed up the flow of evidence on the cost-effectiveness
of specific public health interventions. However, there also needs
to be a macro-level framework, building on the Wanless model,
for assessing progress towards full engagement and testing assumptions
about the impact of the white paper as a whole on health spending,
using as it does so the evidence of NICE and others. The development
of such a framework should be part of the white paper delivery
plan.
5. DO THE
NECESSARY PUBLIC
HEALTH INFRASTRUCTURE
AND MECHANISMS
EXIST TO
ENSURE THAT
PROPOSALS WILL
BE IMPLEMENTED
AND GOALS
ACHIEVED?
5.1 The Wanless review highlighted many
deficiencies in the public health infrastructure and made numerous
recommendations under the following headings: delivery of public
health; case studies of the most important public health issues;
public health evidence; investing in public health; roles and
responsibilities; and government levers.
5.2 The white paper itself identifies the
main areas of this infrastructure or delivery system as:
— evidence and information;
— workforce capacity and capability;
— systems for local delivery;
— the accountabilities of the Department
of Health and the rest of central government.
5.3 The table in Annex 1 lists examples
of proposals that relate to key Wanless recommendations. Broadly,
we consider that the white paper responds in some degree to all
of Wanless's concerns, particularly those to do with evidence
gaps, promoting local partnerships, workforce capacity and capability,
and the theme of individual engagement in health. It also gives
a high priority to tackling obesity, a particular Wanless concern.
5.4 On the central Wanless theme of engagement,
the consultation on the white paper was itself noteworthy in stimulating
a high level of public interest. The Department of Health is to
be commended for its efforts to encourage comment. The proposals
on "Health in the consumer society" (chapter 2) seem
to be a more than adequate response to the Wanless recommendations,
setting out as they do a social marketing strategy for health
that seeks to integrate efforts to:
— Stimulate demand—for example,
through national campaigns on sexual health, obesity, smoking
and alcohol that provide clear messages and are sensitive to the
way people live their lives.
— Provide trustworthy, accessible information,
whether on products, such as food and tobacco and alcohol products,
or through new national and local information services—for
example, Health Direct.
— Put in place local supply of the
healthy option—supportive and personalised local services
(such as NHS health trainers) or easily accessible healthier products.
— Ensure a local environment that makes
healthy choices easier—for example, healthy schools and
well-ordered and stable communities where there is good access
to services, clear leadership, social cohesion, and partnerships
among local government, the NHS, the voluntary sector, community
organisations and business.
5.5 In its response to the white paper consultation
(see Annex 2) the HDA was particularly concerned that the white
paper should:
— maintain the momentum created by
the programme for action on health inequalities (Department of
Health 2003);
— take a "social gradient"
approach to tackling health inequalities—by ensuring that
interventions were directed at people below the middle of the
socio-economic spectrum as well as the most socially disadvantaged;
— recognise that interventions—including
those aimed at enhancing public engagement—needed to be
targeted and tailored if they were to be effective in meeting
the needs of the most disadvantaged segments of the population;
— recognise that policies aimed at
influencing the underlying determinants—including existing
policies—should be screened for their impact on health inequalities.
5.6 We consider that the white paper demonstrates
a continuing commitment to tackling health inequalities, particularly
in its concern that disadvantaged groups should be supported in
making healthy lifestyle choices. We welcome the fact that local
information and personal support services are to be tailored to
meet varying needs and that new or enhanced services, such as
Skilled for Health programmes, NHS health trainers, personal health
guides, and "choose and book" Stop Smoking Services,
are to be rolled out in the most disadvantaged areas first—specifically,
the "spearhead group" of local authorities and PCTs
(Department of Health 2004b). We welcome also the recognition
that the national social marketing strategy should use a variety
of routes to reach its target audiences and frame its messages
to speak to its audiences' health concerns.
5.7 These provide safeguards against the
risk that the social marketing strategy could widen health inequalities
by stimulating a stronger demand for healthy choices among the
better off than among those at the lower end of the socio-economic
spectrum. Nonetheless, it is essential that the social distribution
of the impact of national campaigns is carefully monitored so
that they can be modified if they are missing their targets. Similarly,
evaluations of new interventions—such as NHS health trainers—should
focus on effective practice in reaching the most disadvantaged
groups, something that is not automatically guaranteed by rolling
them out first in the most deprived areas. At the same time, PCTs
will want to use health equity audit techniques to check that
disadvantaged groups are benefiting from all programmes, including
the services of a "health-promoting NHS" (chapter 6).
5.8 The white paper commitment to build
health into all future legislation by including health in regulatory
impact assessment appears to relate to the HDA's recommendation
on the need to screen policies for their impact on health inequalities
(and the similar recommendation in the Wanless report). We assume
that the intention is to factor health costs and benefits into
options appraisals in the development of new policies. We suggest
that this proposal would be strengthened if the distribution of
health costs and benefits across the socio-economic spectrum were
included in the analysis.
5.9 The HDA was also concerned about the
lack of a coherent approach to performance managing action on
public health, so we welcome the proposals on strengthening and
co-ordinating the components of the performance management system—ie
incentives (including targets), standards, developmental support,
performance monitoring, and regulation—and on aligning the
performance management systems of the NHS and local government
so as to enable closer partnership working locally. For example,
it will be important that the public health guidance issued by
NICE is given the same status, by ministers, as its current clinical
practice guidance, and that the same effort is put into monitoring
its implementation, by the Healthcare Commission, in the NHS and
by the Audit Commission in local authorities.
5.10 With regard to incentives, we particularly
welcome the introduction of an inequalities dimension into most
of the Department of Health's PSA targets, and thus into the standards
and planning framework for the next three years, and the greater
emphasis than before on narrowing the gap in outcomes in floor
targets for other government departments (Office of the Deputy
Prime Minister 2004).
5.11 Targets are an effective way of getting
services to take priorities seriously (see, for example, Audit
Commission 2003). Yet neither the new NHS standards and planning
framework nor PSAs of other government departments contain targets
that adequately reflect the white paper priorities on diet and
nutrition, physical activity, alcohol, and sexual health:
— There are shared PSA targets on sport
in schools and in the community, but sport can only make a relatively
small contribution to levels of physical activity in the population.
— Physical activity and diet are such
important risk factors for a range of health outcomes that they
need to be monitored independently of the shared PSA target on
obesity.
— There is a target for teenage conceptions
but not sexually transmitted infections (STIs).
5.12 This is why it is important that the
six-monthly progress reports promised in the white paper on key
indicators for targets that relate directly to improving health
include timely data on indicators concerned with diet and nutrition,
physical activity, alcohol, and STIs. There are a number of relevant
sources of data, such as the Health Survey for England, the Transport
Trends survey, the National Diet and Nutrition Survey, and the
routine statistics on STIs collected by the Health Protection
Agency. We would expect the use and, where necessary, enhancement
of surveys such as these to be considered as part of the white
paper delivery plan.
5.13 We welcome the new Health Poverty Index
visualisation tool, which, among other things, gives PCTs and
their local authority partners baseline data on diet, physical
activity and alcohol for their area (see www.hpi.org.uk). It should
support them in setting targets for action on these topics and
may counteract tendencies, which the new standards and planning
framework does not discourage, to concentrate on what they imagine
to be the quicker wins of the treatment and secondary prevention
options rather than primary prevention approaches.
5.14 The remaining HDA recommendations called
for a national workforce development strategy, national leadership
on making the NHS a "good corporate citizen", the NHS
to become an exemplary "healthy workplace"; and action
to make the NHS smoke-free. The white paper meets all these recommendations.
The inclusion of good corporate citizenship and the NHS as a healthy
workplace among the themes that the Healthcare Commission proposes
to cover in assessing healthcare organisations' compliance with
standards is a very welcome prompt to action by the NHS (Healthcare
Commission 2004). The Healthcare Commission can maintain a national
overview of these themes by periodically examining them in its
annual State of Healthcare Report. The HDA also recommended that
the annual Chief Executive's report to the NHS should report on
progress on these themes—they have not so far been covered.
January 2005
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