Performance for health
Authors: Yvonne Doyle, Sadru Kheraj, Mark Ashworth
Journal: Journal of the Royal Society of Medicine (2005)

In November 2004 the UK Government published a White Paper about health in England.1 Behind it lies the notion that, in general, consumers wish to make their own choices for health but that they need help in coping with adverse factors—such as the relentless ploys of the food industry to fatten us up and the lack of affordable and safe ways to take regular exercise. Children in particular need protection from unscrupulous marketing and from the hazards posed by individuals who smoke in their presence. There is renewed emphasis on reducing obesity, sexual ill health, smoking and stress at work. Proposals that caught the headlines are for a new cadre of personal trainers accredited by the National Health Service, four hundred new sports academies and a ban by 2008 on smoking in premises that sell food.

This White Paper differs from any previous document in purporting to give public health back to the public. However, there are limits to consumerism in health; 5.2 million people lack basic literacy skills and two-thirds of people from ethnic minorities live in the 88 most deprived areas of the country. The White Paper addresses these potential gaps by designating a group of spearhead communities, among the most deprived areas, which will receive special funding and attention to work in whatever public, private and voluntary partnerships are necessary to improve health and quality of life for their residents. The locations are already well known because they show remarkable consistency in their adverse health profiles. Our own area is an example. In the deprived populations of the inner city along the River Thames, people have triple the odds of dying earlier than those in middle-class suburbia. If they survive, they have double the odds of living with disability. There are eight stops between Westminster and Canning Town on the London Underground. By the end of the journey, life expectancy in the resident population has fallen by 6 years.2 On almost every other health indicator known, people in such areas fare poorly—despite the efforts of professionals and policy-makers to improve matters with targeted local programmes and catch-up campaigns for screening and immunization. For years Government has been funding initiatives across the public sector to draw in the wider contributors to health.3 What will it take for these populations to ‘choose health’, and for the NHS to perform as well on health as it has on healthcare? We might learn from what has been tried already.

A population characterized by systematic deprivation, absorbed in day-to-day survival and unkeen on officialdom, is not easily engaged. A first step is to secure local political commitment to common objectives, and this itself is a time-consuming and complex task. The outcomes sought, such as improved life expectancy, educational achievement or crime reduction, are at least mid-term achievements. ‘Health action zones’, devised for this purpose, launched a multiplicity of initiatives but often failed to establish the necessary roots in these communities; a project-based, short-term mentality prevailed and even the corporate knowledge generated from these projects was dissipated in a wave of system reorganization. Despite the large sums spent on the programmes themselves and their evaluation we are not much the wiser about what makes a difference and why.4

More controversially, successive governments have moved to influence the behaviour of professionals towards the preventive services by setting targets—for instance, concerning smoking cessation. On this matter we have learnt a great deal, because of the close relation of smoking cessation programmes to the performance rating of primary care trusts; failure to achieve targets means loss of star ratings ando therefore attracts the attention of senior managers and politicians. The path to the desired prize is strewn with obstacles. The outcome depends on access to the service, the confidence of practitioners to intervene in the face of patient indifference or hostility, the organization of the service and the efficiency of data transfer, and the relationship with and back-up from the local NHS. Some fortunate places can get through all of these pinch points. Public health leaders in these areas talk of having begun relationships as long ago as ten years with the many practitioners and agencies who contribute to the complex business of health. Another key to success is the presence of highly effective individuals in critical enabling roles.

The current emphasis on preventive targets raises strong emotions not only among clinicians but even among public health professionals. Many public health workers based in primary care trusts frankly object to putting intense pressure on the service for interventions that ultimately depend on behaviour changes in the lower income third of the population. Mobility of up to 30% annually, poor achievement in education and employment, chaos through crime and substance misuse and cultural indifference to the concept of health defy attempts to build community capacity and prevent individual ill-health. From early social marketing for health in south-east London, our impression is that substantial numbers do not identify with the concept of future risk. Moreover, the professionals who might exert leverage via primary health—the general practitioners and nurses—do not champion or even ‘own’ the targets, so that accountability and delivery are uncoupled. Some, indeed, have ethical objections to the linking of clinical practice with remuneration for hitting targets.5

Critical examination of ‘performance for health’, including achievement of targets, exposes some uncomfortable findings. Examples are the modest outputs achieved for apparently large amounts of effort and money and the variations in performance between populations with similar levels of deprivation.1 It is tempting to ascribe poor results to the nature of the populations, but to what degree do we have our own house in order within the public services? Traditionally we have addressed population health in the same manner as the control of epidemics. However, the analogy is false: we can compel people to change their activities in order to prevent the spread of infection but we cannot force them to change their behaviour and protect themselves against chronic disease.1,6 For success with the latter we need a good understanding of the values and aspirations (or lack of them) of the individuals and groups behind the epidemiology—and the know-how and ways into this may not reside within the National Health Service.7 We should work alongside people and not do things for or to them. Could we be offering services that are more in tune with people’s lives—for example, through workplaces, shopping centres, pharmacies, churches and clubs? Schools are obvious locations and ‘healthy schools’ programmes are widespread; yet experience in some parts of England has been discouraging. The relationship between education and health services is decidedly distant—education has different targets and no particular interest in ‘taking on’ health. The White Paper offers people a range of choices including personal help and health records in their own internet slot. With personal computer-linked records and an enhanced nurse practitioner cadre in the community, they might then have access to preventive, diagnostic and treatment services without necessarily going via a general practitioner. The White Paper opens up possibilities for different types of partnership with individuals, communities, providers of care and social marketers. One result might be the emergence of local champions for health who would engage the population and lead a demand for more responsive and accessible preventive services. What about chronic disease? The omens here are good. The new UK-wide contract for general practitioners, relating remuneration to quality of care, should be beneficial not only to vulnerable individuals but also to the public health. Early onset and high prevalence of severe chronic disease is closely linked to health inequalities. The information generated by this contract will offer strong incentives to good performance—not least by allowing comparisons.

Performance for health, particularly from the NHS and local government, will need to sharpen. When the NHS announced an intention to modernize its accident and emergency and elective services there were cries from within that the ambitious targets were completely unrealistic. But the critics have been proved wrong. As with healthcare so, perhaps, with public health. By combined application of targets, performance development and culture changes, the preventive and health-promoting services could be nudged past a frontier that has long seemed impassable.