Big Lottery Fund Policy Commentary Issue 1 Learning from Healthy Living Centres: The changing policy context
Healthy Living Centres: The changing policy context Stock code BIG-PC1-HLC Print Photography Peter Devlin, Alan Fletcher, Gail Blackwood Further copies available from: Email general.enquiries@biglotteryfund.org.uk Phone 0845 4 10 20 30 Textphone 0845 6 02 16 59 Our website www.biglotteryfund.org.uk Accessibility Also available upon request in other formats including large print. Our equality principles, mission and values We are committed to bringing real improvements to communities and the lives of people most in need. To find out more about our equality principles, mission and values, visit our website. We care about the environment The Big Lottery Fund seeks to minimise its negative environmental impact and only uses proper sustainable resources. Big Lottery Fund, December 2007 2
Introduction The Healthy Living Centres (HLC) programme was established in the late 1990s, with 352 grants worth 280 million being awarded by the then New Opportunities Fund (subsequently the Big Lottery Fund) across the UK between 1999 and 2002. Since the programme was launched, major changes to the health policy environment have had a great influence on the programme and its projects. These changes have included political devolution, changes in public health agendas and priorities and new institutional structures. The programme has been evaluated by the Big Lottery Fund, and the reports are available to download from our website. We asked David Hunter, Professor of Public Health and Management at the Wolfson Research Institute, Durham University, to write this article. The views it contains are his own. We hope that it will promote discussion on the changing public health policy context and the role of local community initiatives in helping people to enjoy improved health and well-being. Sarah Mistry Head of Evaluation & Research 3
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Looking back: changing approaches to health The purpose of this commentary is threefold: to review the broad health policy context across the UK and its growing divergence postdevolution; to identify significant policy shifts over the past decade or so since Healthy Living Centres (HLCs) first came into existence; and to assess what, if any, lessons HLCs may hold for future policy. HLCs, a key New Labour initiative during its first term in government, were funded by the New Opportunities Fund (which merged with the Community Fund to become the Big Lottery Fund). They were the product of a new government impatient to improve the public s health and, perhaps of greater significance, tackle widening health inequalities. Under the former Conservative government, health inequalities were not widely debated and little action was taken to address them. The prevailing view was that poverty was largely self-inflicted. With the arrival of New Labour in 1997 the climate changed almost overnight. The sense of urgency was palpable with the appointment of the first ever Minister for Public Health heralding a new era for public health policy and providing a focus for it in central government. Not only did health inequalities become more widely discussed but considerable energy was expended in the pursuit of novel policy responses which would make a real impact on them. HLCs and Health Action Zones were products of this search. During Labour s first term in office, there was a belief and confidence in the ability of government to bring about real change in health, and not only health care, and to make significant inroads into widening inequalities. There was an enthusiasm to embrace new and innovative solutions and to learn from their experience. Evidencebased policy was to the fore and the mantra was what worked was what mattered. HLCs were exemplars of this new confidence and determination. Enlightened and innovative government action, it was believed, could make a real 5
difference to the lives not only of individuals but to impoverished communities. HLCs were perceived as an intervention designed to tackle both the social determinants and the behavioural issues affecting individuals lifestyles although, as the evaluation report shows, the attempt to balance these twin objectives was not without its tensions. For all the government s enthusiasm for new pioneering initiatives, it was at the same time keen to see quick results. However, this sense of urgency was at odds with the fact that changing population health after decades of neglect would not only require significant resources both financial and human but also time to make a difference. Not only was the government in a hurry, it was keen to reshape society according to its lights, and wary of any perceived negative consequences. This resulted in a sometimes oppressive commandand-control managerial style that was out of place with initiatives like HLCs that were intended to be customised to their contexts and 6 meet the particular needs of their local users and communities. Constant changes in policy almost as ends in themselves became the hallmark of New Labour in its second and third terms. As one commentator put it: New Labour has behaved like consumers of policy, abandoning them as though they have no value once they exist 1. This restlessness has been more apparent in England than in the devolved arrangements taking shape in Wales, Scotland and, more recently, Northern Ireland. Indeed, a significant feature of health policy in the UK is the growing divergence evident within the four countries. Whereas in England the government s focus around 2000 shifted from health to health care and issues like waiting lists, access to beds, and balancing the books consumed its attention, Wales and Scotland sought to give a higher priority to health improvement and narrowing the health gap. There was also a desire to see health improvement as part of a broader social justice agenda. Initiatives like HLCs therefore attracted much
interest in both countries and received considerable additional support. Another marked difference was that by 2003, the Government in England had begun to embrace market-style thinking and neoliberal principles that stressed individual lifestyle issues and underplayed the socio-economic structural determinants of health and the role of government in tackling them. Such a shift was manifest in the second English public health white paper, Choosing Health, published in 2004. It received further endorsement in July 2006 in a major speech on public health delivered by the former Prime Minister, Tony Blair, in which he referred to the new challenges facing society whether from smoking, poor diet, alcohol misuse, or sexual behaviour. He claimed that our public health problems are not, strictly speaking, public health questions at all. They are questions of individual lifestyle 2. Such a view marked a decisive shift in thinking and could be contrasted with the focus on social 7
8 determinants underpinning earlier health policy in which HLCs were viewed as promoting health in its broadest sense and developing communities to enable them to overcome their poor health. In contrast, Wales and Scotland have resisted following a similar direction. Wales in particular is much more concerned with giving the public voice rather than choice in respect of its future health 3. The differences have manifested themselves in other ways, too. Whereas in England and Scotland, the NHS is largely regarded as the lead agency for public health, local government occupies a more prominent position in Wales. Moreover, while the focus on individual lifestyles and health promotion is strong in England, elsewhere there is greater emphasis on community development and engagement. This is especially notable in Northern Ireland which has a long tradition of support for community initiatives. All governments in the UK are struggling with how best to respond to the wicked problems posed by the public health challenges they confront 4. Despite the rhetoric about the importance of partnership working and integrated policy and delivery systems, for the most part government functions remain firmly silo-based and vertically organised, trends that have been reinforced by a target-driven culture that is evident across the UK but especially in England. For complex interventions like HLCs, aimed at improving health in its broadest sense and which cut across departmental responsibilities, such an environment is dysfunctional and inhibiting. It also makes partnership working especially perilous, as does the constant restructuring which has been a notable feature of the NHS in England, though to a lesser degree in the rest of the UK, since 1997. Where programmes like HLCs, which straddle several departments, belong when departmentalitis is rife is a key factor in their perceived value and success.
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Looking forward: what can HLCs offer? If, on reflection, the problems HLCs were established to address are as prevalent now as then, what of the future? As noted above, the policy context has shifted from an upstream focus, where it was seen as entirely appropriate to intervene early to prevent the onset of health problems and to keep people healthy in their communities, to a more downstream emphasis on prescribing individual, secondary prevention treatments such as statins. The belief that it is possible to address ill-health in a community through changing how its members conceive of their health has given way to a more instrumental approach which once again puts the NHS in the lead thereby potentially eclipsing more broad based interventions like HLCs aimed at tackling some of the longer standing causes of health inequalities. While the policy shift is most marked in England, none of the other countries making up the UK are likely entirely to escape it. Following the election of new governments in Wales and Scotland in May 2007, it remains to be seen whether the rather different emphasis in Wales, Scotland and Northern Ireland noted earlier can survive and, indeed, be developed further. Early indications are that it will and in Scotland the Scottish Government departmental structures and ministerial portfolios have been reorganised to strengthen the government s commitment to health improvement and wellbeing and to ensure that cross-cutting issues are given higher priority. This follows a review of the Executive which concluded that its leadership needs to respond with passion, pace and drive to address problems and to drive cross-cutting policy 5. In Wales, the Chief Medical Officer commissioned a review of the public health function. Following ministerial consideration of the review s recommendations, work is underway to design a unified public health system for Wales. A new health strategy is also in preparation and there are signs that a concern with the socio-economic structural determinants of health remains alive in Wales if not in England. In Northern Ireland, the Health and Social Services Boards have not only 11
shown interest in sustaining the work of HLCs but are providing tangible support to ensure this happens. Finally, HLCs have much to contribute to the renewed emphasis across the UK on devolved responsibility, and on encouraging greater diversity in provision by encouraging and unleashing the talents of social entrepreneurs and local communities. Social enterprises are also being actively encouraged to provide services in new and non-traditional ways. Opportunities exist to encourage initiatives in the third sector that match the best of the achievements of HLCs. Indeed, the evaluation reports provide advice and offer a number of important lessons which prospective social enterprises would be wise to heed. Social enterprises at their best provide good examples of how communities can take control of their health and actively engage in building better lives for themselves and those lacking the means to do so. However, there are also risks in assuming that the third sector can take on significant new 12 service delivery functions with the requisite capacity and leadership 6. The evaluation of HLCs holds important lessons in these areas. Whatever happens in future, there is a need for greater clarity of leadership and direction from the centre which applies across the UK though perhaps especially to England. A critical capability review of the Department of Health concludes that the Department too often operates as a collection of silos, and corporate governance structures are not as effective as they need to be 7. There is also an absence of a clear articulation of the way forward for the health and well-being agenda. To achieve this requires more vigorous and committed cross-government and cross-sector working. Although Wales and Scotland are grappling with similar issues and may, as noted, be making swifter progress in addressing them, there remain concerns that health policy is too fragmented across government both vertically and horizontally and that talking the talk has yet to be matched by walking the talk.
Key learning points In conclusion, the evaluation of HLCs repays careful study as it offers many important insights and learning points for policy-makers and managers. Four merit highlighting here and, possibly to varying degrees, apply across the UK. First, for community-based initiatives to take root effectively, the need for building capacity within communities must be addressed. Second is the importance of getting people to take on leadership roles, the difficulty in doing so, and the need for leadership development to be acknowledged and supported. Third, the issue of partnership working remains a vexed one. The evaluation of HLCs showed that managing effective and sustainable partnerships proved difficult. It was not helped by constant reorganisation, especially of the NHS in England. Although HLCs might have been reasonably stable, many of those organisations they sought to work with experienced constant organisational churn. Finally, the issue of resources was a constant source of concern. Short-term funding was a serious problem and it goes far beyond HLCs. While a few successful HLCs succeeded in developing viable social enterprise models, most require significant external support in order to continue. None of these learning points is new but in my view, all bear repeating. Unless they are heeded and are able to influence and shape future policy and practice in a way that may lead to better, more robust and sustainable solutions to complex social and health challenges then we will not achieve the step change in health improvement and narrowing the health gap that is called for. David J Hunter Professor of Health Policy and Management, Centre for Public Policy and Health, Wolfson Research Institute, Durham University. November 2007 13
References 1 Sennett R (2006) The Culture of the New Capitalism, London: Yale University Press. 2 Blair T (2006) Speech on Healthy Lifestyles. 26 July, Nottingham. www. pm.gov.uk 3 Beecham J (2006) Beyond Boundaries: review of local service delivery (Beecham report). Cardiff: Welsh Assembly Government. 4 Rittel H and Webber M (1973) Dilemmas in a general theory of planning, Policy Sciences 4: 155-169. 5 Scottish Executive (2006) Taking Stock Review: Fit for the Future. Edinburgh: Scottish Executive. 6 Marks L and Hunter DJ (2007) Social Enterprises and the NHS: changing patterns of ownership and accountability. London: UNISON. 7 Cabinet Office (2007) Capability Review of the Department of Health. London: Capability Reviews Team. 14
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