NATIONAL AUDIT OFFICE qe REPORT BY THE COMPTROLLER AND AUDITOR GENERAL Health of the Nation: A Progress Report HC 656 Session 1995-96 5 14 August 1996 | NATIONAL AUDIT OFFICE REPORT BY THE COMPTROLLER AND AUDITOR GENERAL Health of the Nation: A Progress Report ORDERED BY THE HOUSE OF COMMONS TO BE PRINTED 22 JULY 1996 19 SEP 1996. LONDON: HMSO HC 656 Session 1995-96 Published 14 August 1996 £8.95 Health of the Nation: A Progress Report This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act. John Bourn National Audit Office Comptroller and Auditor General 28 June 1996 The Comptroller and Auditor General is the head of the National Audit Office employing some 750 staff. He, and the NAO, are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies have used their resources. Health of the Nation: A Progress Report Contents Page Preface 1 Part 1: Strategy and development Development of the Health of the Nation strategy 2 Health of the Nation: targets 4 Progress towards the targets ~ Areas where progress is limited 8 Conclusions and recommendations 9 Part 2: Progress towards targets 11 Bibliography 44 | - Ps ar Bow : yal wh 4~ 4 bui d S> 2> 078 - ' p f ’ r } 7 1 i« j ‘ ae , ; ' { LF i és ta Tear mt is | ae eee) ee > Saji “se it, 7 7 mi o ‘ ; ye iaieeily Rhy ele 1 * ae 94 40 ‘ by Oe f - ; : Health of the Nation: A Progress Report Preface The government's Health of the Nation strategy, led and co-ordinated by the Department of Health, is the central plank of government policy on health in England and forms the main context for the planning of services provided by the NHS into the next millennium!. This report describes the background to the development of the Health of the Nation Strategy, providing an overview of progress towards the targets adopted as part of the initiative. It does not examine wider issues, such as what benefits have been gained at what cost. The Health of the Nation is a wide-ranging strategy which aims to put health and health promotion on everyone’s agenda. The strategy is set against the background of a continuing overall improvement in England’s general state of health. It emphasises disease prevention and health promotion as ways in which even greater improvements in health can be secured, while acknowledging that further improvements in treatment, care and rehabilitation remain essential. The strategy emphasises the role of joint working, for example between government departments, local authorities and voluntary organisations. Within its five key areas there are 27 specific, quantified targets designed as tools to focus effort and to provide a measure to indicate progress. This report concentrates on progress towards those 27 targets. 1 Priorities and Planning Guidance 1996-97; Department of Health, 1995 Health of the Nation: A Progress Report Part 1: Strategy and development Development of the Health of the Nation strategy 1 In 1991 the government published a Green Paper, The Health of the Nation” which set out a strategic approach to improving the health of the people of England. Drawing on the work of the World Health Organisation’s Health for All strategy and on ideas from other countries, the Green Paper suggested that improvements in the nation’s health could be brought about by health promotion and disease prevention rather than solely through improvements in healthcare services. It proposed the establishment of a co-ordinated strategy for public health, which would aim to improve the health of the nation. 2 The Health of the Nation White Paper which followed in July 1992 developed this into an ambitious strategy for improving the health of the population. To focus attention where it was most needed and where it would deliver the best return, the strategy identified five key areas of ill-health. Those five areas were chosen because: e they were major causes of premature death or avoidable ill-health; e they were ones where effective interventions should be possible offering significant scope for improvement in health; e it was possible to set objectives and targets in the areas and monitor progress towards them. The five key areas and their main objectives are listed in Table 1. The key areas, the main objectives, and their associated targets, are tools for achieving the wider strategic aim of the Health of the Nation. The strategy also identifies a number of settings such as schools, homes and workplaces where health promotion could be focused to good effect and emphasises the value of joint working; for 2 Details of publications are given in the Bibliography at the end of the report Health of the Nation: A Progress Report Table 1: Health of the Nation key areas and main objectives A Coronary heart disease and stroke To reduce the level of ill-health and death caused by coronary heart disease and stroke and the risk factors associated with:them. Cancer To reduce death and ill health from breast cancer, lung cancer, cervical cancer and skin cancer. Mental illness To reduce ill health and death caused by mental illness. HIV/AIDs and sexual health To reduce the incidence of HIV infection and sexually transmitted diseases; to provide effective diagnosis and treatment for HIV and STDs; to provide effective family planning services and to reduce the number of unwanted pregnancies. E Accidents To reduce ill health, disability and death caused by accidents. Source: based on Health of the Nation pp 47, 67, 83, 94, 104 example, between the Health Education Authority, the media, employers and employees. The strategy aims to put health onto everyone’s agenda by extending recognition of the wide range of influences on health and widespread responsibility for taking account of health. In each key area, the Department of Health set out action plans and proposals for meeting the targets they had set including co-ordinating action by other government departments, as many target areas impact on more than one government department. The Department also established a framework for monitoring and reviewing progress towards the targets. As part of the monitoring process, the Department has produced two progress reports: One Year On ... in 1993 and Fit for the Future in 1995. The Health of Nation initiative was paralleled in Wales, with the publication of The Strategic Intent and Direction in 1991; in Scotland by Health Education in Scotland: A National Policy Statement, published in 1991 and followed by Scotland’s Health: A Challenge to Us All published in 1992 and in Northern Ireland by A Regional Strategy for Northern Ireland Health and Personal Social Services ins1.99Z. Improving health through Health of the Nation has been a key strategic goal for the NHS since the launch of the White Paper in 1992 and has been highlighted in successive NHS Priorities and Planning Guidance. The strategy has influenced health authorities’ plans to purchase health care to meet needs of local people, and is reflected in local programmes carried out by hospitals, community health units and primary health care teams. The White Paper stated that Regional Health Authorities would encourage District and Family Health Service Authorities to shift the focus towards health promotion, including changing the balance of resources as necessary. Joint working with local authorities, Health of the Nation: A Progress Report voluntary bodies, schools and others has also provided additional resource in terms of expertise and access to target audiences but this cannot be quantified in financial terms. Health of the Nation: targets The Health of the Nation White Paper identified a range of targets for the reduction of death and ill health in the key areas. The Department of Health monitors progress towards these targets through a variety of indicators, some of which directly reflect the primary targets themselves, and also through a range of supplementary indicators, including for example, the take up or coverage rates for screening for cervical or breast cancer. Table 2 lists the targets set out in the White Paper in 1992. Appropriate indicators for monitoring progress were specified in the White Paper and set out in more detail in Specification of National Indicators published in 1992. Baselines were set for each indicator against which progress is monitored by the Department. For most indicators the baseline year chosen was 1990. The target dates were chosen to reflect the time needed before any change would be observable, though in some cases; for example, smoking among 11-15 year olds (B9), there were pre-existing targets. Full details are given in Part 2. Progress towards the targets Table 3 on page 6 provides an overview of the progress of the Health of the Nation strategy, by summarising the information available for each target set out in Part 2 of this report. Assessing whether or not progress is being made towards the target is a complex task which should be approached cautiously. For some targets trends are not clear, or little historical data are available or the target date is further into the future, making assessment difficult. Key points e Many targets show encouraging progress Table 3 shows good progress towards many of the Health of the Nation targets on present trends. e .Progress towards some targets cannot be monitored at present Table 3 shows that it is not yet possible to monitor progress towards targets C1 and C3. This limits assessment of progress in the key area of mental illness, where only one indicator, the death rate from suicide, can currently be monitored. However,