A Review of the Health of the Nation White of 1992 - Research Paper Example

A review of the Health of the Nation White Paper of 1992 I. Introduction According to the Universities of Leeds & Glamorgan and the London School ofHygiene & Tropical Medicine (1999: p. 1) The Health of the Nation (HOTN) was the cornerstone of the policies on health of England from 1992 to 1997 and was especially important because it is the FIRST "explicit attempt" by the UK government to provide a "strategic approach" to promoting health among UKs population. The focus of the HOTN was coronary heart disease and stroke, cancer, mental illness, HIV/AIDS and sexual health, and accidents. Each concern has a statement of main objectives and the five concerns have twenty-seven targets. Because the HOTN was a first attempt to explicitly articulate the key policy on health or health strategy, the HOTN was received well by UKs population. In general, the public saw the HOTN as a strategy that attempts to increase prevention in its key health concerns and "alliance work" with concerned groups. "The HOTN failed over its five year lifespan to increase its full potential and was handicapped by numerous flaws of both conceptual and process-type nature" (pp. 1). HOTN influenced the other policy documents of UK, peaking in 1993, but by 1997, the influence of HOTN over local policy became very little. Unfortunately, the HOTN was considered as an initiative that was deficient on commitment and ownership across government departments. Respondents interviewed expressed that while central government initiative over policy is desired and necessary to avoid inter-agency conflicts, for success there must be shared ownership over the policy at all levels. A sense or feeling of joint or shared ownership over strategy was not provided by the HOTN. Winyard (1999) has declared HOTN as a policy assessed by England. In a summary paper for Securing good health for the whole population: Final report, Derek Wanless said (February 2004, p. 2) that public health policy of England from 1976 to 2003 evolved in the following manner: The "Black Report" of 1980 advocated a total approach to health covering the underlying causes for the health conditions. The report recommended an overhaul of activities and distribution of resources. The World Health Organization document of 1985, Health for All by Year 2000, produced 38 health targets. However, even up to 1992, the UK government was resistant to the document and to health targeting in general. The Health of the Nation of 1992 has targets for five groups of medical conditions but was "largely silent on the impact of poverty and inequalities". The Independent Inquiry into Inequalities in Health Report (1998) identified three principles that are believed to be crucial in health: 1) health policies should be assessed based on their impact on inequalities; 2) priority should be given to families with children; and 3) action must be taken to reduce income inequalities and living standards of poor households to improve health. However, there are sectors of UK society that consider the recommendations as vague, uncosted, non-prioritized, and essentially unable to establish a link between health inequalities and wealth. Smoking Kills (1998) focused on smoking and its effects on the young, pregnant women, and health in general. From the policy paper, public health strategies were developed around drug-use, teen-age pregnancy, and sexual health/HIV. Saving Lives: Our Healthier Nation (1999) gave importance to health inequalities and pointed out that the condition of health depends also on economic and social conditions as well as the environment. There are also targets covering the concerns of The Health of our Nation (1992) but the emphasis covered increasing life expectancy, number of illness in ones life, and improving the health of those worst off in society. The 1999 document, however, was criticized for overemphasis on mortality rates in expressing targets and for prioritizing specific diseases rather than the wider public health concerns, inadequacy of implementation planning, and several vague areas. The National Health Service Plan for England (2000) placed targets to reduce mortality figures for major killers by 2010. The National Service Framework (1998) placed standards on health care. The NFS (1998) covered caner, paediatric intensive care, mental health, coronary heart disease, diseases of the elderly, diabetes, and other conditions. However, critics remarked that the NFS lack information on costs of interventions that will enable judgements on health priorities. Tackling Health Inequalities: Cross-Cutting Review (2002) studied health inequalities to develop strategies for health service delivery. However, expressed only a single target for reducing inequality: reduce inequalities in health by 10% through reduction in infant mortality and increase in life expectancy at birth. Wanless Report (2002) assessed the resources required to provide high quality health care system until 2022 and highlighted the benefits of longer-term strategy for health. Programme for Action (2003) listed government policies rather than constructed a strategic look on how to reduce income inequality. In other words, although the Health of the Nation 1992 was the first EXPLICIT policy of the UK on health, earlier policy documents preceded the 1992 document. Adoption of the earlier documents may be classified as implicit rather than explicit. After the Wanless Assessment of 2004, Englands newer health policy document includes Health Challenge England 2006, Health Inequalities 2008, and Blacks Working for a Healthier Tomorrow (2008). Other Department of Health publications that are contributing to the shaping of health policy include Hospital, public health medicine and community health services, medical and dental staff in England: 1992-2002 (2003), Choosing health? A consultation on action to improve peoples health (2004), Health challenge England---next steps for choosing health (2006), Health inequalities: progress and next steps (2008), and Human rights in healthcare: A short introduction (2008). The titles of the publications provide evidence that inequality is being addressed in health policy. However, the point remains whether the concern is being addressed adequately and correctly. Thus, this provides a direction for our assessments in the years to come. Perhaps, one concern that should be expressed in Englands health policy in the immediate term is the role of environment of health and the link between a good environment and a better health. Of course, this does mean that England should reduce its concerns for equity in health. On the contrary, to the usual notions of social equity, we add another: intergenerational equity. 1. As to why the Health of the Nation document of 1992 failed to identify equity as an important variable affecting health is something that needs deeper analysis. This is because as early as 1986, the World Health Education has already identified social equity as an important variable that can affect health. More than seeing the role of social variables on health, the Ottawa WHO (1986) conference has already identified the role of the environment for health. This even before the ideas of sustainable development, environment, and climate change were popular. The Ottawa document (1986, p.1) even emphasized that "political, economic, social cultural, environmental, behavioural, and biological factors can favour health or be harmful to it. Thus, if the Ottawa 1986 document was used by the Health of the Nation of 1992, many of its shortcomings could have been avoided. The Ottawa 1986 World Health Organization declaration could have been a very important document that could have guided health policy. Among the points raised by the Ottawa 1986 declaration (pp. 2-4): 1. Build public health policy with stakeholders and be reminded that health promotion requires diverse but complementary approaches. Following this point of the Ottawa 1986 declaration could have resulted into a health program that is integrated and that which is owned by stakeholders. 2. Create supportive environment for health by linking health policies with other policies. Following this point of the Ottawa document can lead to multiple and complementary programs for health rather than singular and unlinked health programs. 3. Strengthen community action for health. Following this point of the Ottawa 1986 document could have led to a health policy that involves communities and not merely the central leadership. This could have inspired stakeholders to work with central health authorities for health. 4. Develop personal skills for health, particularly through health education, information, and enhancing life skills for all. Following this point of the Ottawa 1986 declaration could have led into a health policy that would not lead to dependence on doctors and health empowerment of citizens. Many illnesses need not take place if citizens are empowered, educated, and informed. 5. Reorient health services in that it becomes a shared responsibility among individuals, community groups, health professionals, health service institutions, and government. If this point of the Ottawa 1986 document was followed, the Health of the Nation document of 1992 could not have been a document that lacks a sense or feeling of ownership among stakeholders. 6. Build of equality of partnership for health. This call of the Ottawa 1986 WHO document reflects the need for gender and social equality in partnership. Following this call of the 1986 Ottawa document could have led into health programs that enjoy broad support not only among the central government offices but also in the local health offices and communities as well. 7. Counteract the pressures towards harmful products, resource depletion, unhealthy living conditions and environments, and bad nutrition. Putting an emphasis into this point from the Ottawa 1986 document into the Health of the Nation 1992 document could have made England a model of health policy. As early as the 1986, the Ottawa document was a shining light for health policy that is useful for several decades. The Ottawa 1986 document was precedent in the concern for the environment and on the impact of environment on health. II. "Health of the Nation White Paper of 1992" and Context Most like the prevailing view in economics has been influencing health policy. How policies are shaped is determined largely by theories being used by policy makers in developing policy. Lepper & McAndrew (2008: pp. 43-50) discuss the schools of thought dominating the economics of well-being. However, the enumerations therein emphasized on the notions of the economics of well-being. For example, the emphasis of the Lepper & MacAndrew material (2008) focuses on whether affluence is really highly correlated with the feeling of well-being and whether we can construct a national rather than an individual notion of well-being. It is the opinion of the writer of this paper that largely, health policy is being influenced by the economists notion of how public services can be delivered efficiently. For example, it is a mainstream thinking in economics that for efficiency, public services should be available consistent with societys willingness to pay, particularly in the sum of members of society to pay for the public services. Many economists also believe that privatization or the partnership of the government with groups organized for profit will lead to the best arrangements for health. There are also economists who believe that inequality will disappear over time as the economy grows and that economies need only to emphasize on growth because inequality will be reduced as society becomes prosperous. Unfortunately, this does not seem to be being realized in England. It is now the 21st century but a significant part of the population belongs to what are considered poverty levels. Further, supposing inequality can really be reduced over time as the nation achieves prosperity, the need to address the health needs of the deprived sections of the British population. We cannot say that the British society is healthy if there is a section, especially if the size of that section is significant, that is below health standards that can be considered as decent. Further, if the disease involved are infectious. An infected Britton can lead to an infected British population. III. Effects, impact, and lessons According to the Universities of Leeds & Glamorgan and the London School of Hygiene & Tropical Medicine (1999: pp. 1-3): The HOTN or Health of the Nation White Paper of 1992 did not fundamentally improve the perspective and behaviour of health authorities. Further, the HOTN did not change the "context within which dialogue between health purchasers and providers and other partner took place". The HOTN document did not cause reforms in investment priorities. Nevertheless, HOTN was seen to have a potential to lead to joint action. Yet, the money allocated by local health authorities for "alliances" or joint undertakings were from £2,000 to £200,000, usually closer to £2,000. This reflects how joint undertakings or "alliances" were valued by local health authorities. Local authorities saw the HOTN to be dominated by a "disease-based approach" or an approach that tends to address diseases rather than focusing on building healthy bodies among UKs population. Local authorities tended to stress on primary health care. The HOTN document has no tangible impact on primary care practitioners. While targeting at the national level was welcome by local authorities, the HOTN document did not inspire local health targeting. The HOTN lacked a focus on institutional development or developing institutional capacities to address health concerns. Strengthening institutional capacities, including local institutional capacities, to meet health concerns was a priority that was not addressed by the HOTN. According to the Universities of Leeds & Glamorgan and the London School of Hygiene & Tropical Medicine, the key lessons provided by the experience of the United Kingdom with the HOTN are as follows (1999: pp. 3-4): Promote both integrated central leadership and "committed local ownership" over health policy. Government must deliver unambiguous and consistent "corporate" signals and ensure ownership of strategy across departments and localities. New initiatives must have an integrated framework that addresses as well the underlying determinants of a health concern or disease. Shared ownership must mean vertically and horizontally meaning from top to bottom of the leadership, across areas, and across departments or organizations. Central government must lead in ensuring that agency objectives, expectations, tasks, and responsibilities are spelled out. For success, health programs must embody joint leadership between central and local authorities. Further, given health objectives, central leadership must encourage broad range of programmes at the local level to meet the health objectives. There is a need to require that local authorities develop local strategies and targets, with a timetable, and with a broad participation of interest groups, including the voluntary groups. Both central and local authorities must hold interest groups responsible for their contributions, covering targets and process. A better health strategy must involve not only measures of target outcomes but also measures of process. Health programs must involve all key stakeholders, including the voluntary sectors. Further, the Universities of Leeds & Glamorgan and the London School of Hygiene & Tropical Medicine (1999, p. 4) believe that the following must be re-examined or considered: Whether suicide rates or feeling of well-being should be the appropriate targets or stress Targeting based on evidence Mechanisms for dissemination of evidence Local targeting based on evidence New approaches to health program implementation Strengthening public health information and intelligence activities Meanwhile, let us identify some of the positive impacts that MAY be attributable to the Health of our Nation White Paper of 1992. Figure 1 indicates decreasing ratio of doctors in training to consultants. Figure 1 can be interpreted positively in that it indicates that skilled doctors are staffing the British hospitals. During the years 1992 to 1997 when the Health of the Nation White Paper of 1992 was the operating strategy, the ratio consistently decreased. At the same time, however, that the White Paper was responsible for the decrease of the ratio during 1992 to 1997 cannot really be established because the ratio appears to be really decreasing over time. Figure 1. Ratio of doctors in training to consultants Source: DOH-UK 2003 Figure 1 Figure 2 and Figure 3 shows the distribution of hospital staff across gender and rank in 1992 and compared in 2002. Figure 1 and 2 indicates that gender participation in health concerns has improved. However, whether this can attributed to the 1992 document cannot be established. Figure 2. Hospital staff by gender and grade in 1992 Source: DOH-UK 2003 Figure 3b Figure 3. Hospital staff by gender and grade in 2002 Source: DOH-UK 2003 Figure 3a Figure 4 illustrates the progression of suicide rates from 1960 to 1997. The figure suggests that the 1992 Health of the Nation document could have contributed to the arrest of the increase of the suicide rates among males. For females, however, suicide rates have been decreasing since the 1980 and may not be attributable to policy. Figure 4. Suicide rate 1960 to 1997, males and females Source: McClure 2000: p. 64 Figure 1 On the weakness side, Table 1 indicates that the 1992 health policy may have been instrumental in increasing the growth in hospital between 1992 to 1997. This is because the growth rate for 1997 to 2002 at 2.9% is higher than the hospital growth rate of 2.7% between 1992 and 2002. Table 1. Hospital staff and average change VI. Way forward in health policy One of the various ways to advance Britains health policy is in the area of increasing social spending and the share of health in spending. Table 2 shows that the United Kingdom is in somewhere in the middle when compared to Canada, United States, and Sweden in terms of social spending as a percentage of gross national product. At the same time, Table 2 clearly shows that the United Kingdom is at the bottom with regard to spending for health. Table 2. Social spending as percentage of the gross domestic product (GDP) Source: Bryant & Raphael 2005, p. 17, citing OECD (2003) Figure 5 indicates the range of collaboration of government with the private sector in health service delivery. However, we need to review privatization would really lead to an improvement in health services. So far studies on the effects of privatization on improving health service delivery indicates mixed results: some are successful and some are not. Thus, it may be wrong to anchor health service delivery on privatization. Figure 5. Range of collaboration for public service delivery Source: Prefontaine et al. (2000, p. 8) Figure 6 shows a model of collaboration for public service delivery and it might be useful to review the model whether it can advance the health services of the United Kingdom. Figures 6 highlights the role of the political and social environment, institutional factors, and other variables that can determine whether collaboration would likely be successful. Figure 6. Collaboration for public service delivery Source: Prefontaine et al. (2000, p. 9) Finally, Figure 7 highlights the role of strategy in health service delivery. Perhaps, we can learn form the experience of other countries, even if they are developing countries, with regard to health service delivery, especially as an international organization, the World Health Organization is at the forefront. Figure 7. Models, strategies, and resources Source: World Health Organization, 2002, p. 41 Reference List Baquet, C., Carter-Pokras, O., and Bengen-Seltzer, B., 2004. Healthcare disparities and models for change. The American Journal of Managed-Care, 10, SP5-SP11. Black, D. C., 2008. Working for a healthier tomorrow. London: The Stationery Office. Bryant, T. & Raphael, D. 2005. Politics, public policy, population and health in the United Kingdom. In The experience of health in an unequal society. London: UK Health Watch. Buck, D, Godfrey, C., & Morgan, A., 1996. Performance indicators and health promotion targets. Discussion Paper 150. The University of York: Centre for Health Economics. Department of Health (DOH)-UK, 2003. Hospital, public health medicine and community health services, medical and dental staff in England: 1992-2002. London: Department of Health. Department of Health (DOH)-UK, 2004. Choosing health? A consultation on action to improve peoples health. London: Department of Health. Department of Health (DOH)-UK. 2006. Health challenge England---next steps for choosing health. London: HM Government. Department of Health (DOH)-UK 2008a. Health inequalities: progress and next steps. London: Department of Health. Department of Health (DOH)-UK 2008b. Health profile of England 2008. London: Department of Health. Department of Health (DOH)-UK 2008c. Human rights in healthcare: A short introduction. London: Department of Health. European Social Charter Secretariat, 2009. The right to health and the European social charter. Hamptom, J., 1993. The health of the nations research and development. British Medical Journal, 307 (July), pp. 78-79. Gray, S., Pilkington, P., & Pencheon, D., 2006. Public health in the UK: Success or failure. Journal of the Royal Society of Medicine, 99, pp. 107-111. Lalonde, M. 1981. A new perspective on the health of Canadians.(original edition: April 1974). Ottawa: Government of Canada. Lepper, J. & McAndrew, S., 2008. Development in the economics of well-being. Treasury Economic Working Paper No. 4. London: HM Treasury. McClure, G., 2000. Changes in suicide in England and Whales, 1960-1997. British Journal of Psychiatry, 176, pp. 64-67. OECD, 2003. Society at a glance: OECD social indicators. Paris: Organization for Economic Cooperation and Development (OECD). Ottawa Charter for Health Promotion, 1986. Result of the First International Conference on Health Promotion, Ottawa, Ontario, Canada, 17-21 November. Jointly sponsored by the Canadian Public Health Association, Health and Welfare Canada, and the World Health Organization. Politics of Health Group, UK Health Watch, 2005. The experience of health in an unequal society. London: UK Health Watch. Prefontaine, L., Ricard, L., Sicotte, H., Turcotte, D., & Dawes, S., 2000. New models of collaboration for public service delivery. ________: Pivot and Cefrio. Ray, S., 2005. The NHS as part of global health. In The experience of health in an unequal society. London: UK Health Watch. Royal College of Nursing, u.d. Real choice in health service. An RCN discussion document. Sales, A., Smith, J., Curran, G., and Kochevar, L., 2006. Models, strategies, and tools: Theory in implementing evidence-based findings into health care. Journal of General Intern Medicine, 21, S43-49. UN High Commissioner for Human Rights and WHO, 2002. The right to health. Factsheet No. 31. Universities of Leeds & Glamorgan and the London School of Hygiene & Tropical Medicine, 1999. The health of the nation --- a policy assessed. London: The Stationery Office. Wanless, D., 2004a. Summary Paper for Securing good health for the whole population: Final Report. London: Royal College of General Practioners. Wanless, D., 2004b. Securing good health for the whole population: Final Report. London: Royal College of General Practioners. Wanless, D., 2002 (April). Securing our future health: Taking a long-term view. Final report to the HM Treasury. London: The Public Enquiry Unit. Wanless, D., 2001. Securing our future health: Taking a long-term view. Interim Final report to the HM Treasury. London: The Public Enquiry Unit. World Health Organization, 1998. Health promotion glossary. Geneva: World Health Organization. World Health Organization. 2002. Infectious disease report. Geneva: World Health Organization. Winyard, G., 1999. The health of the nation: a policy assessed. A memorandum (Winyard is Director of Health Services and NHS Executive). UK Department of Health: Research and Development Division. Read More