Health promotion in local government: a British experience.

Historically, the development of health promotion work in Britain centred largely upon the activities of elected local authorities. From the mid-nineteenth century onwards, these authorities were primarily responsible both for major interventions in the physical environment, such as improved housing and sanitation, and for the development of community-based preventive and primary care services, such as ante-natal care, health-visiting and district nursing. The importance attached to such work was underlined by the statutory requirement that local authorities should appoint a Medical Officer of Health who could not be dismissed without specific Ministerial approval. Yet in recent decades, this long-standing tradition has been undermined, with both public health doctors and the community health services being displaced from their historical local authority base and placed instead within the the National Health Service, where they are substantially outnumbered by their hospital-based colleagues. As a result, a major political and administrative focus for developing public health approaches has largely disappeared. This loss of a health focus has become a matter of concern to a growing number of local authorities in Britain; a concern which reflects their public health tradition and newer policy issues and approaches which began to affect British local authorities from the late 1970s onwards. This paper considers the example of one such authority, the London Borough of Greenwich, where the author was employed during the early 1980s. In particular, it examines the political and practical problems faced when attempting a systematic review of the authority's role and potential for promoting health through its policies on housing. In the light of this experience, some tentative suggestions are made about the kinds of structures which will be needed if local authorities are to revitalise their public health tradition in a political and economic climate hostile even to existing levels of State intervention.     

Health promotion in local government: A British experience

Historically, the development of health promotion work in Britaincentred largely upon the activities of elected local authorities.From the mid-nineteenth century onwards, these authorities wereprimarily responsible both for major interventions in the physicalenvironment, such as improved housing and sanitation, and forthe development of community-based preventive and primary careservices, such as ante-natal care, health-visiting and districtnursing. The importance attached to such work was underlinedby the statutory requirement that local authorities should appointa Medical Officer of Health who could not be dismissed withoutspecific Ministerial approval. Yet in recent decades, this long-standingtradition has been undermined, with both public health doctorsand the community health services being displaced from theirhistorical local authority base and placed instead within thethe National Health Service, where they are substantially outnumberedby their hospital-based colleagues. As a result, a major politicaland administrative focus for developing public health approacheshas largely disappeared. This loss of a health focus has become a matter of concern toa growing number of local authorities in Britain; a concernwhich reflects their public health tradition and newer policyissues and approaches which began to affect British local authoritiesfrom the late 1970s onwards. This paper considers the exampleof one such authority, the London Borough of Greenwich, wherethe author was employed during the early 1980s. In particular,it examines the political and practical problems faced whenattempting a systematic review of the authority's role and potentialfor promoting health through its policies on housing. In thelight of this experience, some tentative suggestions are madeabout the kinds of structures which will be needed if localauthorities are to revitalise their public health traditionin a political and economic climate hostile even to existinglevels of State intervention.     

A partial solution: a local mental health authority for the UK

BACKGROUND: the structural problems of the mental health system in the UK have been analyzed by a number of authors over the past several years as the "reforms" of the health and social service systems have continued (Kavanagh and Knapp, 1995; Mechanic, 1995). In a recent article, Hadley and Goldman (1995) suggest that one possible solution to some of these issues may be the creation of a local mental health authority. Such an authority would consolidate the funding, authority and responsibility in a single entity. We believe this model, which is typical of many local public mental health systems in the US, is at least part of the solution to the current problem of financial and service fragmentation of the current system in the UK. The numerous "reforms" of the health and social service systems (which include the Community Care Act, the development of the Internal Market, GP fundholding and the purchaser-provider split) were not designed for the care of the mentally ill (Han, 1996). These policy changes in the design of health and social services have created a complicated and difficult context in which services must be delivered. Too many agencies play a significant role in the delivery and management of mental health services. Health authorities, social service agencies and GP fundholders are direct and indirect funders of the system while community care trusts, social service agencies and GPs are service providers (Hadley, 1996a). RESULTS AND A PROPOSAL: We believe that the development of local mental health authorities may be part of the solution to the structural and economic problems of the current system in the UK. It is not the answer to limited resources or limited skills, but can create a new structure, which will permit and encourage the cooperation and innovation that is now possible only with unusual effort. Local mental health authorities have a number of crucial characteristics, but, most importantly, they refocus the system on the provision of care to the seriously mentally ill. This is the expressed priority of government, advocates and providers, alike.These new entities could be created at either the purchaser or provider level or, as exists in a number of jurisdictions in the US, at both levels, where a single purchaser may be responsible for multiple consolidated providers. This combination is now the emerging model for innovative services in the US. In the UK, the development of a local mental health authority at the purchaser and/or provider level might be relatively simple. Although the creation of a statutory authority would require primary legislation and is therefore probably not a short-term solution, there appears to be a variety of administrative options that would have the same effect. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The creation of a local mental health authority may be a necessary first step towards the development of a coordinated and comprehensive system of care. It seems likely that there is currently more "political" support for the development of a purchaser model but the development of a sophisticated purchsaer is also likely to take considerable time and effort. Although all the structural and policy problems of the mental health system in the UK will not all be solved by local mental health authorities, they may be beneficial if responsibility for mental illness care is to be centralized and fragmentation is to be reduced. Without making structural changes, the best efforts by clinicians, policymakers and managers are most likely to be in vain. Without a clear point of ultimate purchasing and service responsibility, the fragmentation and inefficiency of the current system will remain (Hadley et al., 1996).     

Community participation and citizenship in British health care planning: narratives of power and involvement in the changing welfare state

This article considers changing conceptions of local citizenship with particular reference to the idea of 'community participation' in the planning of state health care within Britain. The aim is to gauge the extent to which a political rhetoric of community participation in the 1990s constituted an attempt to redefine the relationship between health authorities (responsible for planning and prioritising services) and local communities. Data from aninvestigation encompassing 75 interviews is used to chart the manner in which health authority managers have re-articulated and given substance to the rhetoric of participation. The analysis appears to confirm a 'democratic deficit' with regard to decision-making in health care planning but there is a significant qualification. A process of 'professionalisation' and the growth of 'active management' (rather than 'active citizenship') may in part be off-setting the democratic deficit. This process is however highly contingent upon developments in health service policy and organisation.     

Movement and change: independent sector domiciliary care providers between 1995 and 1999

Promoting the development of a flourishing independent sector alongside good quality public services was a key objective of the community care reforms of the last decade. This paper charts some of the ways the independent domiciliary care sector is changing, as local authorities shift the balance of their provision toward independent sector providers and away from a reliance on in-house services. Two surveys of independent domiciliary care providers were carried out in 1995 and 1999. The aims of the studies were to describe the main features of provider organisations, such as size of business, client group and funding sources; to examine the nature of provider motivations and their past and future plans; to consider how local authorities manage the supply side of social care markets; and to examine the effects on providers of the development of the mixed economy. The first survey in 1995 was conducted in eight local authority areas, which by 1999 had increased to 11 because of the creation of three new unitary authorities. The findings are based on 261 postal surveys together with 111 interviews between the two studies. The research illustrates a domiciliary care market that is still relatively young with many small but growing businesses. There are considerable differences in the split between in-house and independent sector services in individual authorities and a common perception among independent providers that in-house services receive favourable treatment and conditions. Spot or call-off contracts continue to be the most common form of contract although there are moves toward greater levels of guaranteed service and more sophisticated patterns of contracting arrangements. There remains an ongoing need to share information between local authorities and independent providers so that good working relationships can develop with proven and competent providers.     

Budget-makers and health care systems

Health programs are shaped by the decisions made in budget processes, so how budget-makers view health programs is an important part of making health policy. Budgeting in any country involves its own policy community, with key players including budgeting professionals and political authorities. This article reviews the typical pressures on and attitudes of these actors when they address health policy choices. The worldview of budget professionals includes attitudes that are congenial to particular policy perspectives, such as the desire to select packages of programs that maximize population health. The pressures on political authorities, however, are very different: most importantly, public demand for health care services is stronger than for virtually any other government activity. The norms and procedures of budgeting also tend to discourage adoption of some of the more enthusiastically promoted health policy reforms. Therefore talk about rationalizing systems is not matched by action; and action is better explained by the need to minimize blame. The budget-maker's perspective provides insight about key controversies in healthcare policy such as decentralization, competition, health service systems as opposed to health insurance systems, and dedicated vs. general revenue finance. It also explains the frequency of various “gaming” behaviors.     

The impact of competition among health care financing authorities on market yields and issuer interest expenses

The main source of capital for non-for-profit health care organizations is tax-exempt municipal bonds. The tax-exempt nature of this debt requires that they be issued through financing authorities, which are run by, or affiliated with, state or local government agencies. In some states, all tax-exempt health care bonds must be issued through a single financing authority, but in other states the issuing health care organization has a choice of multiple authorities. Using a Herfindahl index of issuer concentration, prior research has found that greater competition among authorities results in lower interest costs to the issuing health care organization. We pick up where this earlier study left off, examining the links between authority competition, the interest expenses to the issuer, and the yield to the market investor. Although our analysis of all hospital bonds issued between 1994 and 2002 corroborates earlier findings with regard to interest expenses to the issuing health care organization, we also find market yield is lower for statewide authorities where issuer concentration is lower. Thus, authority competition is good from the issuers' point of view, but holds no favor in the investors' eyes. On the other hand, the lower market yield associated with statewide authorities does not make its way down to the issuer in the form of lower interest costs. To help sort through this paradox, we explore our findings through interviews of executives in state issuing authorities.     

Facing the cuts: a health authority's experience of rate-capping.

Health and social services in Britain are both publicly funded, but health care is provided centrally by the National Health Service while social services are provided by local government. Central government has sought to limit overall public spending by limiting the income of local authorities from rates (property taxes)--a policy known as rate-capping. In the face of this policy, one inner London local authority was forced to cut its social services budget in 1988/89 by 17%. We have compared the actual social service reductions with the perceptions, expressed in semi-structured interviews, of 69 health and social services staff. There was a perceived deterioration in social service provision, and indicators were suggested which would help health service staff to monitor these changes. There were also recent and more long-standing difficulties of communication between the two services, which limited joint working. The increasing emphasis on community care requires health authorities to cooperate more closely with social services at the local level.     

INGO在缅甸特区政府卫生责任倡导中的作用

由于特殊的历史和政治原因，缅甸特区政府一直以来忽略了老百姓的健康问题或者无力做更多的投入，而国际非政府组织（INGO）在推动和倡导当地政府承担更多的民众健康责任方面起到了很大的作用。以无国界卫生（英国）组织在缅甸的卫生项目为例，在提升政府卫生意识、支持INGO卫生工作，建立面向民众的卫生服务与管理体系，提高特区自我卫生管理能力，支持特区开发卫生发展规划和加强特区政府与中方联控项目合作等六个方面，促进了特区政府增加卫生投入提升其对民众健康责任承担。     

Quality standards for health care delivery and management in publicly oriented health services

In 1999, the multidisciplinary Tavistock group prepared a generic statement of ethical principles to govern health care systems. This paper elaborates on these principles in two directions. First, it develops a set of quality standards, based on ethical principles, intended to regulate health care delivery and service management. Second, it focuses them on 'publicly oriented' (not necessarily governmental) as opposed to 'for profit' (not necessarily private) services. We propose ten principles or quality standards for these services, part of which relate to the individual patients, others to the community. They are political as well as technical, and can be used to inspire health policies, contracts issued by governments, and identification of partners by aid agencies. We analyse their application in key areas of health care by publicly oriented and for-profit health care organizations standards in developing countries, and conclude that the latter are unlikely to adopt the proposed standards. We further elaborate on the implications of the standards for publicly oriented services, focusing on care delivery and patient-centred care, family and community medicine, services management and disease control. Using these criteria for a renewed compact between authorities, health professionals and communities may help to motivate health professionals by bridging the gap between their professional and social-political identity.     

Viewpoint: public versus private health care delivery: beyond the slogans

In most settings, a 'public' health service refers to a service which belongs to the state. The term 'private' is used when health care is delivered by individuals and/or institutions not administered by the state. In this paper it is argued that such a distinction, which is based on the institutional or administrative identity of the health care provider, is not adequate because it takes for granted that the nature of this identity automatically determines the nature of the service delivered to the population. A different frame of classification between public and private health services is proposed: one which is based on the purpose the health service pursues and on the outputs it yields. A set of five operational criteria to distinguish between health services guided by a public or private purpose is presented. This alternative classification is discussed in relation to a variety of existing situations in sub-Saharan Africa (Mali, Uganda, Zimbabwe). It is hoped that it can be used as a tool in the hands of the health planner in order to bring more rationality in the current altercation between the public and the private health care sector.     

Community-based adolescent health services in Israel: from theory to practice

Despite their engagement in health-risk behaviors and their health-related concerns, adolescents have the lowest rate of health service utilization of any age group. Time constraints during routine medical encounters generally leave little opportunity for professional screening for health-risk behaviors or for discussing psychosocial problems. In addition, providers express low levels of perceived competency in areas such as sexuality, eating disorders or drug abuse. To address these needs, a walk-in Adolescent Health Service was established by the Sheba Medical Center to provide diagnosis and short-term treatment for individual adolescents, as well as counseling and support for local care providers. A three-way model of cooperation and partnership was developed and implemented. A professional and financial partnership with local authorities were established to help define the particular needs of the community's youth and to improve the ability to reach youth with special health needs. The partnership along with the main medical provider (Kupat Holim Clalit) helped define local health needs, served as a referral source of patients with unmet health needs, and improved the continuity of care. The regional medical center (Sheba Medical Center) provided supervision and consultation for the medical staff of the service, as well as a referral center for patients. It was emphasized that the service staff was intended as a professional source for the primary physician and should not be considered a rival. The core staff included a specialist in adolescent medicine, gynecologist, mental health specialist and social worker. A structured intake procedure was developed for assessing health concerns and problems of adolescents in the context of a community clinic. Findings from the first years of services showed that the first 547 female adolescents demonstrated that a majority of adolescents presented with primary complaints of a somatic nature, while one third were diagnosed with psychosocial problems and one-fifth with a sexuality-related problem. A considerable percentage of those diagnosed with psychosocial or sexuality-related problems had not stated these issues as their "reason for encounter". This additional increment probably represents the contribution of the Health Concern Checklist (HCC), in which the adolescent was asked to mark each item for which she had concerns or would like to receive further information. The HCC can help primary care physicians as well as adolescent medical specialists approach the teenage patient and initiate productive communication. A practical approach to confidential health care for adolescents: The issue of confidentiality has not been sufficiently clarified by Israeli law or by the medical community. The need for confidentiality was strongly felt in the adolescent health service. A policy which provides all adolescents with the opportunity to meet with a physician and receive health guidance or advice at least once, even without parental knowledge or consent, was formulated and implemented. If parental consent was not feasible, the minor was allowed to give informed consent for medical and psychosocial care for himself/herself, with certain limitations.     

Public health, private concern: The organizational development of public health in the Netherlands at the beginning of the twentieth century

This article outlines an important period in the developmentof public health in the Netherlands. It starts with the developmentof a more active government policy, in the middle of the centuryand ends with the political decision to develop a public healthsystem, based on private initiatives and funded by the centralgovernment and local authorities. In 1933 this decision wasmade implicitly. In that year a Health Services Bill was rejected,in which the suggestion was made that municipal health servicesshould be established. To understand this development, the roleof both the central government and local authorities is sketched,as well as that of private organizations. In parallel with theincreased Involvement of governments, private initiatives developed.Cross societies are considered crucial in this development.It was not until the second decade of this century that it becameclear which way the Dutch health care system would develop.Private organizations were insecure about their role and governmentinstitutions were thought to be inadequate and expensive. Thedebate on the Health Services Bill illustrates this. The periodin which this bill was discussed can be seen as a decisive onefor the field of public health in the Netherlands.     

Comprehensive care: building community alliances for care of people with HIV/AIDS

In this article we suggest that optimal care for people livingwith HIV/AIDS calls for a multidisciplinary and multisectoralapproach, which can be achieved with cooperation between thestatutory and non-statutory service systems. AIDS has both directlyand indirectly focused attention on the limitations of the servicesavailable in our communities, including those provided by theprimary and secondary health sector. However, non-statutorycommunity-based organizations have been providing vital servicesof information, counselling and care, relying on a steady streamof unpaid labour. Community control over its health care systemand environment should be encouraged and local authorities shouldacknowledge the resources provided by non-statutory bodies,supporting such groups both morally and financially. Using theHealthy Cities project network as a framework, we recommendestablishing working relationships to enhance service integration.The creation of service alliances is intended to facilitatecontinuity of care by establishing links within local governmentagencies, and the priority of the alliance should be to developa realistic, comprehensive service plan involving all interestedparties.     

Priority setting in health authorities: a novel approach to a historical activity

As resources in health care are scarce, health authorities and other health organizations are charged with determining how best to spend limited resources. While a number of formal approaches to priority setting within health authorities have been used internationally, there has been limited success with such activity, particularly across major service portfolios. This participatory action research project instituted a novel priority setting framework, coined macro-marginal analysis (MMA), in a fully integrated urban health region in Alberta, Canada. The focus of MMA is on identifying areas for service growth and areas for resource release, then determining, based on pre-defined, locally generated criteria, if actual shifts or re-allocation of resources should occur. For fiscal year 2002/03, the Calgary Health Region identified over 40 M dollars in resource releases (approximately 3% of the total budget), which were made available for servicing the deficit, and more importantly for our purposes, re-investing in service growth areas. The MMA framework is pragmatic in nature and has the ability to incorporate relevant evidence directly into the decision-making process. This work constitutes a significant advancement in health economics, and responds where previous priority setting approaches have failed in that it allows decision-makers to achieve genuine re-allocation of resources with the aim of improving population health or better meeting other important criteria.     

Who can you trust? Credibility assessment in online health forums

As the cost of health care rises governments everywhere are examining how on-line services can replace or augment face-to-face services. Consequently, many health bodies are establishing on-line health forums where patients can share ideas with, or solicit information from, both other patients and health professionals. In the wake of this trend, many on-line forums have arisen which do not have the imprimatur of official government services but are run and managed by private individuals sharing experiences outside of the patient-clinician channel. This phenomenon creates risks and challenges for users who need to evaluate the credibility of unknown and often anonymous contributors to these forums. This paper examines how users assess the credibility of the information in these forums. Five criteria were discovered in the first stage of the work. We then quantitatively tested the relationship between those criteria based on two types of information. Our analysis shows that different criteria are used by participants in online health forums for scientific information and experiential information. We used these novel findings to develop a model for how information credibility is assessed in online health forums. These findings provide important lessons for health promotion bodies considering how to encourage the sharing of valuable health information on-line as well as guidelines for improved tools for health self-management.     

Involving disabled and chronically ill children and young people in health service development

AIM: To investigate the extent and nature of involvement of physically disabled or chronically ill children and young people in local health service development. METHODS: A postal survey of all health authorities (n = 99) and NHS Trusts (n = 410) in England. RESULTS: Seventy-six per cent of health authorities and 59% of Trusts responded. Twenty-seven initiatives involving chronically ill or disabled children and young people in consultation regarding service development were identified. Over half of these were carried out in partnership between health services and other agencies, usually local authorities and/or voluntary organizations. A variety of methods was used for consultation, including child-friendly methods such as drawing, drama and making a video. Seventeen initiatives reported that children's involvement had resulted in service changes, but only 11 went beyond consultation to involve children and young people in decision making about service development. Only a third of the organizations had someone with designated responsibility for children's involvement. DISCUSSION: The involvement of this group of children and young people in service development in the NHS is at an early stage. The failure of policy documents on user involvement to identify children and young people as a group for whom methods of consultation need to be developed, and the lack of people with designated responsibility for developing children's involvement may be a reason for slow progress in this area. The initiatives identified show that such involvement is possible and can have a positive impact on services.