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

Objectives: To determine the impact of the national health strategy for England, 'Health of the Nation' (HOTN) at the local level; the mechanisms by which this was achieved; and to provide lessons for the new strategy, 'Saving lives: our healthier nation'. Design: Case studies. Semi-structured interviews with key actors across a range of organisations (n=133), analysis of documents (n=189), and analysis of expenditure for the period 1991/1992 1996/1997. Setting: Eight randomly selected English health authorities. Main outcome measures: Perceptions and documentary evidence of the impact of HOTN on local policy and changes in expenditure. Results: Three models of implementation were identified: strategies based directly on HOTN; HOTN plus additional elements ('HOTN plus'); and strategies under another label such as healthy cities or urban regeneration. There was clear commitment to intersectoral work and some support for joint appointments of directors of public health by health and local authorities. HOTN was seen as failing to address underlying determinants of health, reducing credibility with key partners. Views were divided on whether to adopt a population- or disease- based model. Consistency in central government policies and communication of the strategy were criticised. HOTN was universally perceived as increasing health promotion activities, particularly in the key areas. HOTN received few mentions in corporate contracts and general practice reports. Expenditure on health promotion activities increased slightly then declined, and HOTN appears to have had only limited influence on resource allocation. Conclusions: Central government, in England, should enable rather than prescribe strategy implementation. It should ensure appropriate structures are in place and that national polices are consistent with the strategy. There is a debate about where the responsibility for health 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 Commission health promotion programme. HOTN failed to engage three groups: the public, primary care, and the private sector. This study has important implications for the monitoring of the new strategy. It needs to be firmly embedded in the work of those who must implement it. It should be incorporated into the NHS performance management framework. The current financial reporting mechanisms preclude monitoring expenditure on a health strategy. Ring-fencing some resources for the new strategy should be considered, if only to give it the high priority it requires. This study, both in terms of the methods used to evaluate the strategy and the lessons learned, could be used by other European countries developing and evaluating their own health strategies.