Lessons for health strategies in Europe: The evaluation of a national health strategy in England

Objectives: To determine the impact of the national health strategyfor England, ‘Health of the Nation’ (HOTN) at thelocal level; the mechanisms by which this was achieved; andto provide lessons for the new strategy, ‘Saving lives:our healthier nation’. Design: Case studies. Semi-structuredInterviews with key actors across a range of organisations (n=133),analysis of documents (n=189), and analysis of expenditure forthe period 1991/1992 – 1996/1997. Setting: Eight randomlyselected English health authorities. Main outcome measures:Perceptions and documentary evidence of the impact of HOTN onlocal policy and changes In expenditure. Results: Three modelsof implementation were Identified: strategies based directlyon HOTN; HOTN plus additional elements (‘HOTN plus’);and strategies under another label such as healthy cities orurban regeneration. There was clear commitment to Intersectoralwork and some support for joint appointments of directors ofpublic health by health and local authorities. HOTN was seenas failing to address underlying determinants of health, reducingcredibility with key partners. Views were divided on whetherto adopt a population- or disease-based model. Consistency incentral government policies and communication of the strategywere criticised. HOTN was universally perceived as increasinghealth promotion activities, particularly in the key areas.HOTN received few mentions in corporate contracts and generalpractice reports. Expenditure on health promotion activitiesIncreased slightly then declined, and HOTN appears to have hadonly limited influence on resource allocation. Conclusions:Central government, In England, should enable rather than prescribestrategy implementation. It should ensure appropriate structuresare in place and that national polices are consistent with thestrategy. There is a debate about where the responsibility forhealth strategy should lie, whether with the NHS or local authorities.The new strategy should address different audiences: local government;the NHS; the voluntary sector; the private sector; and the public.One model is the matrix approach of the European Commissionhealth promotion programme. HOTN failed to engage three groups:the public, primary care, and the private sector. This studyhas important implications for the monitoring of the new strategy.It needs to be firmly embedded in the work of those who mustimplement it. It should be incorporated into the NHS performancemanagement framework. The current financial reporting mechanismspreclude monitoring expenditure on a health strategy. Ring-fencingsome resources for the new strategy should be considered, ifonly to give it the high priority it requires. This study, bothin terms of the methods used to evaluate the strategy and thelessons learned, could be used by other European countries developingand evaluating their own health strategies.