RHP&EO is the electronic journal of the International Union for Health Promotion and Education

Integrating health sector action on the social and economic determinants of health

The UK Response Under New Labour

Dominic Harrison
Health Promotion General Manager,
North West Lancashire Health Promotion Unit, Sharoe Green Hospital, Preston England

Summary

The investments of health care system resources in Europe are less efficient, effective and ethical than they might be because they are not focussed on the determinants of population health.

Section 1 of this paper reviews some key issues of relevance to this claim and examines:

• Why healthcare systems do not produce health
• The determinants of population health and the contribution of social capital.

 Section 2 of this paper reviews:

• Emerging perspectives and evidence for effective action on health determinants
• Health Investment & UK health system reforms (under the new Labour government)

Section 1

Why healthcare systems do not produce health

Recent reviews of both European and international health care reform agree on at least four areas of challenge that will drive health policy and management towards the next millennium. WHO (1997) , Seedhouse D (1995) , Williams R. (1995)

• The challenge to contain health sector costs.
• The challenge to increase the population health outcomes from health sector investment.
• The challenge to ensure that access to health is based on values of solidarity, inclusion and equity.
• The challenge to involve increasingly empowered health consumers.

These pressures are pragmatically and fiscally determined - healthcare budgets are rising inexorably throughout the industrialized world yet there is little evidence of corresponding population health improvement. In fact there is considerable evidence demonstrating that contemporary paradigms of health care resource investment are allocatively inefficient, financially unsustainable and, in many respects , unethical.

Health care systems in industrialized societies do not produce health.

Most people are kept healthy or made ill where they live, work and play – long before they have contact with the health care system. A review of UK experience illustrates the problem.

The graph (click to see) shows the standardised Mortality Ratio (S.M.R) for preventable mortality (deaths of people under 65 years) from all causes in England and Wales from 1841 to 1985. What it demonstrates is that substantial population health improvement was achieved between 1875 and the early 1930s. DoH (1991)

However, the introduction of the hospital focused NHS in 1948 (the dotted line) not only failed to make a significant impact on population health improvement but actually seemed to be associated with a slowing down of the rate of reductions in preventable death already achieved.

Death rates are not a good measure of population health status, but they are an ‘inverse indicator’ largely immune from cultural bias. In aggregate at least, healthy people are least likely to die early.

There are a number of reasons for the failure of the NHS to make any impact on population health status:

• Population based social policy changes rather than individual medical interventions brought about most of the health improvements achieved between 1841 and 1935. Improved housing, safe clean accessible water, better nutrition, better family planning and more disposable income were key factors. Improvements in medical science played a very minor role. Despite this, at the inception of the NHS, over 90% of the health care budget were dedicated to the health care of individuals.
• Health sector investment after 1948 was not made in improving environments conducive to health but was rather focused on dealing with the negative consequences of illness in individuals. At a whole system level, the NHS failed to invest resources where existing evidence showed most health improvements had been obtained.
• Such investment as has been made in health care and hospitals has been demonstrated to be less efficient, effective and scientifically rigorous than was often assumed. Studies in North America and the UK show that only about 20% of health care interventions have been proven as beneficial or useful by the standards of a double blind clinical trial. Riley et al (1995) , Brook RH and Lohr K.N. (1985) .
• Furthermore 70% of all medical and health care is for preventable conditions. NHSE (1994). Of the remaining health care intervention that has both been proved useful and is dealing with non preventable disease, a considerable amount is technically but not allocatively efficient in it’s application of resources. This means that, although existing intervention may bring some benefit to the patient, other interventions e.g. by less qualified staff or treatment on an out patient basis may bring equal or improved benefit for less resources Roberts (1995) . Similarly even greater benefit could be brought about by earlier intervention, associated with reduced cost and increased health gain outcomes.
• Even when specific disease groups are reviewed evidence of substantial success is hard to find. Mental health services psychiatric interventions demonstrate particular problems: ".doubts arise out of the failure of psychiatry to demonstrate that it can treat according to a set of stated objectives , and can reasonably define the likely outcome of its interventions within a predicted timescale . What we do know is that the relapse and readmission rate of around 73% appears inordinately high...."Olsen R (1992)
• Even where the most invasive clinical interventions are practised, the value of a very large percentage of very expensive healthcare service intervention remains obscure. A report published in February 1995 noted for instance that five out of the 10 most frequently performed operations in the United Kingdom had no proved benefit. Towle A (1998).
• Inappropriate amounts of healthcare system resources are spent on over medicalisation of normal human conditions. A review of the top ten causes of NHS expenditure (analysed by ICD 9 group) in 1989/90 in the UK NHS shows that normal pregnancy and delivery is number 7 in the league table , consuming 3.9% of the total NHS budget. (A large portion of this money is spent on the provision of services by medical and nursing staff whose expertise is in abnormal pregnancy)! Smee (1995)

The World Bank, reviewing the relationship between national health expenditures and population health outcomes in 1993 stated: " At any level of (population) income and education, higher health spending should yield better health, all else being equal, But there is no evidence of such a relation" World Bank (1993).

The fact that international health sector investment is unrelated to population health outcomes is not perhaps surprising. The US Surgeon General, May A. (1996) addressing this issue, has listed the general causes of premature death and disability (and thus avoidable health sector cost) as:

• 10 per cent due to inadequate access to medical care.
• 20 per cent genetic.
• 20 per cent due to environmental factors.
• 50 per cent due to 'behavioral and lifestyle' factors .

Despite this evidence of the poor outcomes of health sector spending, and the emerging evidence about the determinants of population health from around the world, resource investment for health is overwhelmingly dedicated to treatment and care of prevalent disease in individuals, within the health sector itself. Resources are focussed only on the small percentage of the population who are ill at any one time, to the exclusion of those who certainly will be ill if preventive action is not taken.

This is not just a UK problem but is also a cultural problem for all industrialized nations .

The ‘cultural framing’ of health need in industrial societies has the effect of allowing a potentially preventable incidence of ill health to arise in the whole population as a result of unmet need for preventative interventions. A recent review of health sector investment in the UK concluded that less than 1% of the UK NHS budget is spent on formal health promotion. Limb M (1996) Furthermore, much of this resource is spent on clinical prevention – aimed at influencing high risk behavior in individuals, Rose (1993) – rather than population based prevention, targeted at modifying the determinants of population health.

The determinants of population health and the contribution of social capital

As Blane et al (1996) argue, "There is a growing recognition that the most powerful determinants of health in contemporary populations are to be found in social, economic and cultural circumstances."

Population Health Determinants

For many years traditional public health approaches, have focused analysis and prescription for effective action to improve health on disease orientated risk factor epidemiology. This sought to know about the social, behavioural and biomedical causes of disease. Recent work over the past ten years (Evans R ,1994, Marmot ,1993, 1996 Syme, 1996 Hertzman ,1996, Wilkinson, 1996, Brunner, 1993, 1996) has been highlighting the inadequacy of this foundation for policy and action in the promotion of health. Syme (1996) asks, "How is it possible that after 50 years of massive effort, all of the risk factors we know about, combined, account for less than half of the disease that occurs? Is it possible that we have somehow missed one or two crucial risk factors?" (p21) He suggests that about 60% of preventable morbidity and mortality are located neither within individual sovereignty nor the domains of individual behaviour, lifestyle or 'risk' but within social organisation. Marmot (1996) has shown how control and autonomy are crucial determinants of health often more powerful in explanatory value than smoking and Wilkinson (1996) has shown how inequality itself rather than poverty per se may be a major cause of preventable morbidity and mortality in most industrialised societies. Antonovsky (1996) has reminded us that disease oriented risk factor epidemiology is only half the story. We know the biomedical causes of why 40 % of people smoking 20 cigarettes a day may die early - we do not know the bio/ psycho/ social reasons why 60% do not - we have no real epidemiology of health (salutogenesis).

Even within a narrow biomedical model there is now convincing evidence to discredit the received wisdom on which most individual, behaviour change focussed, health promotion / education has been undertaken. This is not to say it was not effective, just that it was largely irrelevant and certainly an inefficient use of very scarce specialist resources.

Syme(1996) and others suggest there is an urgent need for a paradigm shift in the conceptual framework and problem solving strategies for public health. This must recognise that most health risk and most determinants of health are systemic located within complex, dynamic and interactive social relationships which themselves are determined by social institutions and organisations including families, communities, workplaces - indeed the healthcare system itself. Such a change of paradigm requires population health to be seen not as the 'additive' outcome of the application of health care resources but as an integrative social product arising from the impact of social systems on individuals, communities and societies. Determinants of population health are mediated through social systems but are determined by social relationships within those systems. This understanding has enormous implications for the efficacy effectiveness and efficiency of health investment and the search for an evidence based health promotion within social systems.

Social Capital

Particularly important to the future health and social welfare of the whole local population (not just those who are ill today) is the development of ‘Social and Organisational Capital for health’

‘Social Capital’ has been formally defined as " those features of social organisation, such as networks, norms, and trust, that facilitate co-ordination and co-operation for mutual benefit’ (Putnam 1993). Institutional (or organisational) performance (or development) has been defined as " how responsive representative government is to its constituents and its efficiency in conducting the publics business. In practice this is composed of measures of the policy process and internal operations , the content of policy decisions, and the capacity to carry out policy" Hertzman (1996)

This concept is linked to that of ‘civic society’. Civic societies are those "which value solidarity, civic participation, and integrity; and where social and political networks are organised horizontally, not hierarchically " Putnam et al (1993).

Collectively social and organisational capital and the construction of civic society is seen as an area of social development widely neglected by monetarist approaches to economic and social development in the west and by state capitalist systems in the east. The consequence for both has been a rapid reduction in the quality of life, a decimation of the ‘co-operative economy’ (what we do for each other without the exchange of money such as childrearing, self help, organising community events etc.) , and these factors in turn are major sources of loss of social cohesion, ‘public life in public space’, crime and health status in communities. Most importantly, Putnam et al (1993) in a study of the impact of Italian Regional Government (introduced in 1970) has established a number of measurable constructs for institutional performance and civic society which show close correlation’s between infant and child mortality and social capital - the higher the indicators of social capital the lower the mortality. The relationship is striking but does seem to disappear by mid-life for reasons that are not fully as yet understood.

Addressing this emerging area of social policy in The Guardian 1997, Geoff Mulligan , a Director of the thinktank Demos said in an article "On The Brink Of A Real Society" said , ...some of the structures that would make sense for a more community orientated government.....will require a greater use of commitments. This may mean asking parents to commit to helping with homework; it may mean encouraging households to separate waste for recycling; it may mean following the Dutch model of agreeing a covenant of environmental targets between business and government, whereby business is left to determine how each target is met. Add these together and it is possible to see a radically new way of governing, one that puts the emphasis on prevention not cure, looking at problems in the round rather than slicing them up, and seeing society as a web of commitments rather than contracts. Such a programme would draw on the seismic shift from the "me" to the "we" and turn it into new architectures and tools for government"

Effectiveness of Community Based Health Promotion

The analysis outlined above and its implications are being addressed in health policy at international levels.

Developing a community infrastructure for health can have a significant impact on environmental, behavioral and lifestyle factors. The creation of new ‘social systems for health’ within the community has been identified by Grossmann and Scala (1994) at Vienna University as a major new area for health promotion development within ‘settings’, with a vast potential for population health status improvement.

This wealth and health creating power of community is well illustrated in Lima’s largest squatter settlement Villa El Salvador. This demonstrates the links between social, health and environmental action to improve the wellbeing of the community. A large area of state owned desert land has, over a period of 15 years , been transformed into a thriving, self-governing community of 300,000 people. At the heart of the development has been CUAVES (the Self - Management Urban Community of Villa El Salvador) , Villa’s own community organisation. The organisations democratic structure gives representation to each block and a vast network of women’s groups, through which citizens have planted 500,000 trees and built 26 schools, 150 day centres and 300 community kitchens. Training and education has reduced illiteracy to 3% and infant mortality to 40% below the national average. This is despite the fact that one third of the residents live on lower-than subsistence incomes, compared with only 10% in Lima as a whole. Ekins P (1994)

Integrating Action on Health Determinants into Health Care Systems

The major determinants of population health status are outside the domain of health care itself; so a key strategy for change must involve refocusing health care system resources to ‘do the right things right’. This analysis is, incidentally, also true for crime and the criminal justice system, - i.e. more spending on police and prisons does not impact the rate of crime. (This may be a new public sector paradigm.)

The problem does not allow for easy solutions.

Certainly the evidence to support this change is voluminous but , it seems that evidence is not what drives change in social systems. It has been suggested for instance that only about 1% of the evidence already available on effective healthcare interventions themselves has ever been used as a basis for routinised healthcare practice or the purchasing of health services . (ECHHO ,1997). Given this disappointing figure , it is unlikely that evidence relating to reinvesting on determinants will impact on practice . Indeed Weiss C H (1991) convincingly demonstrates that there is evidence to show that research has 'very little' impact at all on any public policy. (Caplan ,1977; Bulmer 1978;Weiss with Bucuvalas, 1980; Alkin et al 1979; Deitchman, 1976; Dockrell 1982; Knorr ,1977; Rich, 1977; Leff 1985). She argues that research rarely determines policy, rather it tends to be used to illuminate the consequences or support the advocacy of decisions already made on the basis of custom and practice , values or interests. With this in mind it may be useful to reflect on whose interests are and are not served by a refocusing of health system resources on the determinants of health.

Section 2

Emerging perspectives and evidence for effective action on health determinants

1) Health promotion and health investment as integrative not additive strategies.

It sometimes seems that whilst everyone knows what they are busy about in healthcare systems , what they are busy for is easily overlooked. Primary healthcare teams, health authorities and NHS Trusts in the UK spend 7% of UK GDP on health, but their annual reports would not look any different were all the patients to have died .

Such reports always focus on health services provided rather than health outcomes achieved.

Evidence based healthcare has enjoyed unparalleled prominence as the awnser to these problems but the approach has generally overlooked the key issue of allocative efficiency and has thus ignored evidence relating to health investment choices and health promotion.

In fact evidence based health care , and evidence based health promotion / investment might best be seen as distant subjects in search of separate objects. Evidence based healthcare might ask "What is the most efficient and effective (least cost greatest outcome) intervention that can be undertaken with this group or to this patient, that will restore or maintain health ?" Evidence based health promotion and health investment should be asking " What are the determinants of this populations health status and what are the most effective and efficient interventions to protect and improve it?"

Ironically , the most frequently asked question of health promotion or health investment by all these agencies is - "does it improve health?" But planned health promotion interventions in the UK for instance enjoy budgets of less than 1% of the total UK total spend on health . (Limb, 1996) . With such levels of investment it is inconceivable that they could be anything other than largely irrelevant to population health, except perhaps on a political and symbolic level . Yet researchers undertaking so called 'effectiveness reviews of health promotion' employed by the Health Education Authority, York University and the International Union of Health Promotion and Education (IUHPE) earnestly search for evidence of effectiveness solely within that 1%, as if it might make a difference whatever the awnser was.

Their mistake is to view health promotion and health investment as additive activities - something undertaken in a long list of activities along with all other health service related activity. In fact health investment and health promotion are integrative concepts . They arise out of the whole of social organization , the total impact of social systems on individuals. Health investment and promotion arise as a consequence of the impact of housing, nutrition, transport and income policies etc. of nation states. It is changing these social systems to integrate health objectives which is the goal of health development and promotion. Maintaining health damaging social systems then purchasing marginal health promotion programs 'in addition' to ameliorate their effects simply misses the point.

The implication is that beyond minor infrastructure costs , a great deal of health investment and health promotion might be achieved without any financial resources at all.

What is needed is the commitment, collaboration and participation of non health care sectors; as well as a high level of advocacy and change management skills in the health sector, not large new commitments of GDP for health.

2) Re defining the theory of purpose of healthcare systems - particularly hospitals.

The UK NHS has recognized its unifying goal is to improve the health for all of the population.( NHSE,1996) , but its constituent parts are not yet orientated to this 'theory of purpose'.

The international movement for Health Promoting Hospitals (HPH) has been developing practical change strategies for increasing the allocative efficiency of hospitals and health care organisations within a number of pilot hospitals, NHS Trusts and Ambulance service providers in Europe within a systems approach.

A key principle of the organisational development strategy for HPH is to involve all stakeholders in incremental practice based learning for health promotion and a refocusing towards the determinants of health.

The overall vision for the health care system is to move practice north or west on the diagram below. Most health sector investment is currently within the quadrant focussing on treatment of the individual. The overall strategic vision is to move health system investment towards prevention within the whole population. For health care staff , this inevitably implies earlier more cost effective interventions (associated with increased health outcomes and reduced cost). It also necessarily involves increased focus on health determinants including action on community participation and integration of the health care system within the community.

Adapted from HEA (1996)

It is possible to see changes as suggested above as part of a broader emergence of a Theory 1 and Theory 2 view of the "theory of purpose" of healthcare systems. This has a particular impact on the role and function of hospitals which consume between 35-65% of all European Healthcare system resources.

Theory 2 :

• Is health gain and public health focussed from a broader Stakeholder perspective.
• Increases the allocative efficiency of existing health system investment.
• Concentrates on early intervention & networking outside the healthcare system - focussing on determinants of health.
• Creates new social capital for population health, based on new social relationships within the healthcare system, involving communities individuals and other social systems.
• Sees change as occurring from within the system
• Sees quality and outcome as the principal focus of a development, rather than 'judgement' focused strategy. It believes in evolutionary change in health care systems.
• Is an evidence based strategy for structural change towards health determinants in healthcare systems.

The contrast between theory 1 and theory 2 views of the role of hospitals within the healthcare system can be summarized as follows:

3) Transforming Management and Leadership Styles in health systems.

 Increasingly , within the European public sector , traditional assumptions about the nature of leadership and management are shifting to take account of new demands. European social systems and organisations are largely rooted in 19th century approaches to problems . They were established to deal with the issues of their time. These were vertical social systems amenable to management through command and control systems. However, most contemporary problems are horizontal , requiring action across many social systems. This requires the development of virtual organisations developed collaboratively within and between traditional social systems. It requires innovative problem solving and management styles that allow ascendancy to networking and trust rather than command and control.

An illustrative example of this issue in practice is road traffic accidents a Europe - wide principal cause of early death amongst people under 30 . Most European countries control the determinants of accidents through vertical social systems . These can be defined as : Transport policy (Department of . Transport) , Community driving standards (community), traffic control measures such as speed bumps (Local Authorities) ), road safety education (Department of Education) , accident and emergency services (Department of Health). Resolving the problem of road traffic accidents to children requires action across all these agencies through the creation of a new problem solving structure.

The skills to manage such changes in social problem solving require a clear paradigm shift in understandings of authority. New paradigm management is largely sapiential (to do with wisdom ) and is knowledge based . Clearly some management functions will remain as positional in nature but this is not going to be the major skill for future management effectiveness in European healthcare systems. The model illustrated (click to see), Douglas (1996), outlines the key dimensions of authority in management and leadership. Action on health determinants within the healthcare system requires the development of skills in sapiential and knowledge-based authority.

4) Moving healthcare from markets to networks : Changing the social system of healthcare relations to improve effectiveness and efficiency.

Ferlie E. and Pettigrew A. (1996) of the Warwick University Business School Centre for Corporate Strategy and Change recently undertook a survey of the organizational responses of the NHS to its emergent performance challenges.

Defining the three archetypal forms of organization as hierarchies, markets and networks, they gave a powerful analysis of the need for the NHS to complete the existing transition into a network-based organization. They argue " the network perspective re directs our attention away from formal structure and policy to the importance of patterns of social relationships within organizations, including (perhaps especially) informal ties. It conceptualizes market processes in highly relational and socially embedded terms. Concepts of trust, reciprocity and reputation move centre stage. They argue that the challenge to improve health rather than simply provide better, or more, health services will require increased interagency co-operation which can only be achieved by agents competent in networking skills. This will require a move to win-win negotiation and abandonment of coercive and manipulative relationships enforced by externally determined performance indicators. Networking competencies need to rest within the organizational and clinical domains of hospitals and health care systems as a whole , as well as at managerial levels.

Furthermore, networks are polycentric and diffuse rather than centralized in their character . It may be that this process will allow for the effective development of a Stakeholder culture for performance measurement to emerge, with subjective patient defined health status outcomes commanding as much attention as technically determined clinical measures.

The debate about organisational structures and culture is still only just emerging despite relevant data existing for some time. These issues have profound implications for hospital performance management and the achievement of health outcomes focussed on determinants of health. Aiken, Smith and Lake (1994) found that magnet hospitals (characterised by attributes deemed desirable to nurses and which were conducive to better patient care) had lower mortality than matched hospitals. This confirms earlier work by Zimmerman, Shortell and Rousseau et. al. (1993) in intensive care units, that a patient centred culture, strong medical and nursing leadership with good communication between these groups, and an open approach to conflict resolution and problem solving are associated with positive patient outcome.

5) Re -defining stakeholders in the "whole system" for transformation of healthcare systems

Viewed as a whole system, the heath sector has a range of stakeholders available as allies for change. All of these will need to engaged if a refocusing towards health determinants and health promotion is to be achieved. Change management for health within the healthcare system has to come from every strategic level - it will not be successful either top down or bottom up - all levers need to be activated.

The intervention levels, strategic tools and strategic activity for change within the UK NHS, for instance can be defined as:

Too often change management for health has been seen as either a senior management function to do with 'systems' only or an educational process delivered at the practitioner level of intervention. These are only some of the levers a truly effective strategy for change could pull.

6) The development of new economic analysis (including economy efficiency, effectiveness, value for money and cost benefit analysis)

A key tool for change has been the development of technical analytical tools that can expose the problems of, and needs for, health care reform from an economic perspective . Thus, focussing action on the concept of 'population health gain' has proved a useful mediation strategy, challenging the vested interests of clinical medicine from whom resources must be diverted if increased allocative efficiency is to be achieved.

The term ‘health gain’ was probably first used in the UK in a paper by the Welsh Health Planning Forum. Welsh Office NHS Directorate. (1989)

In 1990 the Welsh Office had begun to publish protocols for investment in health gain focusing on health strategy, cost effectiveness, evidence based intervention, contracting, rationing / disinvestment and outcome assessment.

By 1991 Professor Jan Blanpain, Director of the WHO Collaborative Centre for European Health Policy proclaimed the 1990’s as the ‘decade of health gain’. Felvus (1992).

The specific meaning or definition of health gain has been subject to much debate. Griffiths (1992) suggests that although there seems to be a ‘broad consensus over the value and location of the concept it is "probably best left broad because there is endless room for argument at the detailed level

By 1992 the concept of health gain began to be widely used in relation to international debate about improving health. The problem with securing consensus on its meaning is that its exposition depends on definitions of health and health is a ‘contested concept’ Gallie (1956).

One widely used and simple definition of health gain is " a measurable improvement in health status, in an individual or population, attributable to earlier intervention" Brambleby (1995)

A more comprehensive definition might be:

"Health gain can be defined as the cost effective, positive, planned and measurable health outcome arising from the application of health care resources upon an individual or community, or the social product of health arising from the impact of social systems on communities." Harrison et al. (1996)

More recently health gain seems to have become closely linked with concepts of ‘health improvement’, ‘health development’ and 'health investment'.

The parameters of health gain usually require a consideration of:

• Efficiency (technical and allocative).
• Effectiveness.(cost )
• Outcomes assessment.
• Evidence based intervention / decision making.
• Public participation / values.
• Health needs assessment.
• Rationing and funding debates.
• Resource allocation.
• Development of measurement and procedural tools (protocols, technical assessment, databases)
• Models of health / health development.
• Strategies for organisational change.
• Consideration of population versus individual healthcare investment.
• Population focussed health promotion.

7) Health Investment and health career analysis

 A key determinant of both cost and price in health sector spending is health need. The UK NHS, in an act of admirable tautology , defines health need as the ability to benefit from health related interventions.

In the UK, purchasers of health services almost universally frame this need as the ability to benefit from clinical intervention in the treatment of disease. This allows a potentially preventable incidence of ill health (and thus avoidable cost) to arise in the whole population as a result of unmet need for preventative interventions.

Furthermore, the focus of contemporary cultural perspectives on health care firmly places judgements of effectiveness in the domain of future contingent outcomes assessed following a single point of intervention on an individual person within a defined clinical setting. Consequently, effectiveness reviews of those interventions most likely to reduce deaths from heart disease result in a list of clinically framed interventions at an individual level - many showing post coronary rehabilitation coming out on top as the most effective!!

However a health career analysis of known principal population risk factors tells a different story. The main population risk factors are not within the domain of clinical intervention and are to do with population based health determinants.

In exposing the inappropriate and ineffective investments of health care systems , it can be useful to create a Health Career Analysis for a particular disease group. The health career analysis is an analytical tool for making a holistic assessment of all the evidence of preventable causes (or determinants) of any particular disease.

Method

• Review all available literature. This should include traditional clinical sources such as Mediline , Silver Platter etc., but should also include searches in different literatures e.g. environmental science, political science etc. You may also wish to include patient perceptions of causes in your analysis as well as advocacy groups on the Internet.
• Order the 'causes' into domains . For coronary heart disease for instance, this may be most appropriately conceived of in terms of socio cultural factors, psychosocial factors , and behavioral / clinical factors.
• Where interventions of known effect are available, these should be listed at an age specific point. Where there are known causes of the disease but no known effective preventative interventions these should be discussed by the planning group taking account of the Taxonomy of Outcomes in Health Promotion . It is very important not to exclude known causes because they are assumed to be 'just how things are'.
• It should be remembered that using a socio-ecological or population model of health implies the use of quite different methodologies from clinical practice. For instance a small shift in the exposure to determinants of heart disease in a whole population may not save a specific patient from a particular illness event. It may however reduce the number of such events in a community with high prevalence. The method or strategy for achieving this will probably be advocacy related on a bio/psycho/social model of health determinants.

The following analysis lists the main known causes of preventable death from CHD in the UK population listed from birth to death (assuming death from CHD at aged 60). It is an outline analysis only. What it demonstrates is that the health care system invests its resources for this disease:

• only at the end of the health career (where intervention is least likely to be effective).
• only at the end of the health career where most costs and least health outcomes can be expected.
• only in consequences of illness rather than determinants of health
• largely in behavioral / clinical intervention in individual patients rather than broader social system intervention in relation to population health determinants.

Coronary Heart Disease: Outline Health Career Analysis

Interventions earlier in health careers will inevitably evolve to re-focus healthcare staff time on domains of effect outside behavioural / clinical settings and onto determinants of population health.

8) Develop the Publics role as Co-Producer of health - a resolution to the cost containment dilemma ?

 The concept of resources for health in the late 19th century , where social action was a major contributor to population health improvement through public health measures led by social reformers, has become corrupted by neo-classical concepts of wealth to such an extent that we are now experiencing a so-called cost containment dilemma in all European healthcare systems.

Thompson (1997) makes an important contribution to this debate:

" ..the message is that when patients judgements of care are seen to have an integral part to play in the care strategy, they will demand action from the providers of care, in the same way that clinical and organisational audit are currently beginning to do. For this to happen it is necessary to accord equal status to patients as a Stakeholder group ....I would argue that the notion of treating patients as consumers or customers, far from being empowering, actually uses neo-classical discourse to place patients in a position of being able to only chose from a limited range of services over which they have no say. A more liberating model would place patients in the role of health producers, who on occasions require assistance in meeting their needs through co-operative working with health professionals, or what has been labelled a co-production model , or collaborative autonomy"

This view has profound implications for how health system resources are conceptualised in the future. As with the theory of purpose of healthcare systems above it is possible to see an emerging theory 1 and theory 2 of cost containment summarised below.

Increasing resources for health through different models of health related interventions has wide implications for action on health determinants. These need further exploration.

Health Investment & UK Health System Reforms

1) NHS: The new labour project in health and social welfare reform.

From May 1997 the UK has had a (New) Labour government who have brought significant changes to the UK health care system. Politically, this government is more broadly aligned with the social democrat traditions of Europe than the (old) labour party , but has borrowed much of the style and philosophical approaches to government of the US Clinton administration drawing heavily on concepts of communitarianism.

A central project within policy making in health and social welfare reform is the concept of the 'third way'. This is meant to signal a move away from old model of state centralist 'top down' solutions to social problems on the one hand and the Thatcherist 'Social Darwinist' free market philosophy on the other. This latter, significantly widened inequalities in health and economic welfare over the period of conservative government from 1979 - 1997.

The 'third way' concept is best understood as a new 'social contract' in which the state takes responsibility for the key role in providing a framework for economic and social development , (and social welfare) but requires from the community a new level of public participation and social responsibility in all aspects of public life. In the health and social welfare system this has focussed on developing good social 'governance' and community based 'social capital'.

2) NHS: Mission and principles.

The NHS defines its mission as "to secure through the resources available the greatest possible improvement in the physical and mental health of the people of England by promoting health, preventing ill health, diagnosing and treating injury and disease and caring for those with long term illness and disability who require the services of the NHS".

The principles on which the NHS was founded in 1948 were :

• The NHS provides comprehensive care for the promotion of health, prevention of illness and treatment of disease.
• Everyone in the UK has the right to use it
• Care is provided according to peoples clinical need - not their ability to pay.

3) NHS: Finance and service structure.

The budget for the NHS in Britain was approximately £42 billion pounds in 1996/7 representing about 7% of the nations Gross Domestic Product . The service is funded through a mixture of national insurance and general taxation and administered by the Department of Health , through the NHS Management Executive. The NHS Management Executive has a national office in Leeds in the north of England , and functions in England through eight regional offices . The NHS in Scotland, Wales and Northern Ireland is managed through their respective government offices (the Welsh Office, the Scottish Office etc.) .

The NHS provides primary care through family doctors (GPs), opticians, dentists and other healthcare professionals; secondary care through hospitals and ambulance services and tertiary care through specialist hospitals treating particular types of illness such as cancer. At the same time the NHS works with local Social Services Departments to provide community care.

4) NHS: Management and control systems.

Finance and priority setting is highly centralised though some attempts have been made in recent reforms to pass accountability for decision making to local Health Authority and General Practice / primary health care teams.

Each year financial allocations and ‘priority and planning guidance’ is sent through the government controlled Regional NHS Executive Offices. They then define regionally focused Corporate Contracts for Health Authorities who in turn translate these priorities into contracts with local Hospital , Community Service or Ambulance Trusts as well as those for General Practices (primary health care teams).

At a local level of approximately 500,000 population , Health Authorities are purchasers of services and Trusts and General Practices (primary health care teams) are providers.

5) NHS: Use of services.

Nine out of ten people who use the NHS are seen in the community - usually through their GP. In 1993 there were 26,000 GPs in England , most working in group practices and supported by a healthcare team of practice nurses and other support staff. Typically a GP has a ‘list’ of 1,900 patients, though in areas of poverty lists are often much larger.

Some 280 major district hospitals in England provide a range of services from accident and emergency to maternity to care of elderly people. Hospitals range in size from large institutions to smaller community hospitals. Bed numbers are falling dramatically as a result of technological and practice changes driven by cost containment measures and efforts to improve outcomes.

Between 1982 and 1992 for example , the number of beds available for all clinical specialisms fell from 348,000 to 231,000 while the number of patients treated rose by more than a third. Central to changes in practice is the move towards multidisciplinary teams, and a wider understanding of the concept of clinical authority. All hospital staff - doctors nurses and other support staff now work increasingly together to provide a continuum of care.

Leeds is a typical metropolitan area with a population of 724,000. NHS services provided to this community are: 406 GPs in 133 practices, 29 of whom train new GPs, 294 dentists in 158 surgeries,153 pharmacies,171 opticians, 6 general hospitals employing 841 medical and dental staff, 3791 nurses and 691 other medical professionals, 4 psychiatric hospitals and over 60 community health centres and clinics.

6) NHS: Specialist health promotion infrastructure.

The cornerstone of local health Promotion work is the Specialist Health Promotion Services. These employ postgraduate trained health promotion specialists who facilitate health education and health promotion programmes and organisational development for health both within and outside the healthcare sector.

Whilst health education and promotion remain a small but growing part of total NHS business, financial allocation for specialist health promotion services make up less than 1% of the NHS total budget. In 1996 explicitly allocated NHS resources for health promotion and education was accounted for by: £3m for a Health Of the Nation Unit in the Department of health, £42M for the English Health Education Authority and national other national programmes, £90m Specialist Health Promotion Units in Health Authorities and Trusts, and £76 M payments for general practice based primary health care health promotion functions.

 7) NHS: Health care reform from 1997.

Since the spring of 1997 a rapid programme of structural and policy reform has taken place. These reforms will radically change the value base and direction of national health policy.

The changes can be classified as :

• Changes to national health strategy
• Changes to national health services
• New Systems and Structures for Health Investment / Improvement.

Changes to National Health Strategy.

A revised national health strategy DoH (1998) Our Healthier Nation has been published replacing the DoH (1992) 'Health of the Nation' document.

Four clear elements of the strategy include:

• Developing health promoting settings or environments
• National and local disease prevention targets
• Integrated Health Promoting Action
• The 'Contract for Health'

Health Promoting 'Settings' (or environments).

The strategy focuses on four 'settings' for action on creating health promoting environments

• Communities
• Workplaces
• Schools
• Health care systems

Disease Prevention Targets

The new strategy DoH (1998) 'Our Healthier Nation' identifies a number of disease prevention targets for

• Heart disease and stroke
• Cancer
• Accidents
• Mental health

Health Authorities are also encouraged to set local targets e.g. on reducing unwanted teenage pregnancies.

Integrated Health Promoting Action

The strategy will focus action more on the determinants of those diseases from a social and environmental perspective (rather than simply from that of individual behavior change).

There is a clear focus on integrated action on the determinants of health and on health promotion as a sound economic investment. Integrated action , i.e. health promoting policy action by non health departments is required in relation to :

• Poverty, inequality and social exclusion
• Employment policy
• Housing
• Air Quality
• Water quality
• The social environment (community development)
• Nutrition policy
• Tobacco and alcohol advertising and availability
• Sexual health
• Drugs
• Education policy
• Transport policy
• Social Services

The Contract for Health

The key strategic instrument of the strategy is presented as the Contract for Health. This is a political and practical concept . The strategy says :

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Last modified: December 23, 2001

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