Department of Health-commissioned analysis shows that the Conservatives' Health of the Nation strategy was flawed and had minimal impact. Mark Crail examines how its little publicised findings will inform Labour policy

If politicians are defined by their policies, then it is The Health of the Nation that sums up Virginia Bottomley. Yes, it was bossy, but at the end of the day it was just trying to do what was best for people - whether they liked it or not.

Now, six years on from the launch of the first ever national public health strategy, studies by two teams of academics have concluded that it was also badly flawed, and that it failed to change what the NHS did.

Their reports, and a joint summary sent by the Department of Health to health authority chief executives last week, conclude that though The Health of the Nation had an 'important symbolic role', it failed to realise its potential.

Handicapped 'from the outset' by 'numerous flaws of both a conceptual and process-type nature', its influence was short-lived, so that by 1997, when the Conservative Party left office, 'its impact on local policy-making was negligible'.

Regarded as a DoH initiative, which reduced its impact in local government, The Health of the Nation nevertheless 'did not significantly change the perspective of HAs', had a 'slight' impact on trusts and 'did not seriously impact' on primary care.

Professor David Hunter, a co-author of the report, which was commissioned by the DoH to inform work on Our Healthier Nation , believes that no matter how seriously ministers took the policy, the message did not get through.

'The feeling was that the government didn't care because it didn't figure in the performance management system until late on, ' he says. 'Whether or not HAs did anything about it, it didn't seem to determine how they were viewed.'

Action to rectify that when the Our Healthier Nation white paper emerges in the new year figures high on Professor Hunter's list of recommendations .

His report calls for local strategies, targets and timetables, for HAs and local authorities to be held responsible for their contributions, and for Our Healthier Nation to be included in the new performance management framework.

All this, he acknowledges, may well elicit groans from HA chief executives who already have many other priorities. But he says: 'One problem with The Health of the Nation was that we didn't have chief executives who were signed up to the agenda .'

That's something Sian Griffiths, cochair of the Association for Public Health, hopes will be put right this time round.

Dr Griffiths says: 'Centrality is an important issue. Public health has to be moved to centre scene so that it is important to HAs and primary care groups. It must be important to chief executives.'

She adds that it is also important that the messages of Our Healthier Nation 'go down the different lines to local government and HAs'.

caption to come 'It has to be communicated in ways that are acceptable to the different audiences'.

Tony Hockley, adviser to health secretaries Virginia Bottomley and Stephen Dorrell from 1992 to 1997, says: 'I am sure The Health of the Nation was flawed, but we would not be where we are today if we hadn't made the mistakes of the early 1990s.

'In its day it was ground-breaking.

We had no coherent public health policy at all until The Health of the Nation , and it was widely welcomed at the time within the academic and political community.'

But he adds: 'You learn from experience. We now know much more about what is measurable and what is achievable in public health, and what is clear is that we tried to do too much too soon.'

In a book, Back on Target, published by the Social Market Foundation this week, Mr Hockley and Professor Nick Bosanquet argue that the present government should focus on the limited number of targets it has set itself.

'They have to be quite ruthless with all the interest groups who want targets on this, that and the other, ' he says.

But he argues against strong, central performance management for public health. He says: 'The Health of the Nation focused too much on government activity and was too prescriptive.

There is very little that government and public authorities can do. There is a lot more that individuals can do.'

It is a view with which Professor Hunter has some sympathy.

'Governments over-estimate the extent to which they can pull levers and make things happen, ' he says.

But he adds: 'The problem previously was that the government didn't seem to care. If this government is serious, it has to put in performance management - it is not exactly top-down, it is about getting the right measures.'

Curiously, ministers have not made a big deal of the report. Though it could clearly be presented as a condemnation of the previous government, public health minister Tessa Jowell has stayed deafeningly silent.

The DoH press office issued no press release, and could offer no more than the executive summary to journalists who discovered its existence; just one copy of the summary was sent to each HA chief executive, none to trusts.

'I would have thought that the document itself makes the point about the need to engage primary care groups and trusts, ' says Dr Griffiths. 'It is going to be important when Our Healthier Nation comes out that they see it as their business too.'

The Health of the Nation - a policy assessed .

Stationery Office.£22.50.

Pointers for the new public health strategy Greater success is likely with integrated central leadership and committed local ownership.

Government needs to:

Send out clear, consistent corporate signals.

Develop an integrated framework for its numerous initiatives.

Establish shared ownership.

Spell out what is expected of whom.

Building and sustaining partnerships and alliances is important.

There is a need for:

A matrix approach involving diseases, population groups and settings.

A development strategy for managers and practitioners.

Acknowledgement of different health and local authority cultures.

Developing the evidence base for target setting and other implementation work should be a priority.

There is a need to consider:

Development of evidence-based targets.

Local target setting.

Re-examination of the suicide target.

Improving information.

Without substantial performance management, particularly at local level, a new public health programme's chances of success will be reduced.

There is a need to:

Require the development of timetabled local targets and strategies.

Hold each group responsible for its contribution.

Embed public health in the organisational culture.

Consider regular, independent policy audits.

Consider a new role for the Health Education Author ity.

Source: The Health of the Nation - a policy assessed .