Do health improvement priorities reflect the national priorities in the Saving Lives: our healthier nation white paper? Do they provide evidence of health needs assessment, public consultation and accessibility, partnership working, and target-setting for measurable improvements?
In analysing 36 1999-2000 programmes to identify how they met key criteria, we found that national priorities were well represented, but that detailed evidence of how those priorities had been decided and would be pursued was far from complete.
HImPs produced in 1999-2000 were not expected to be comprehensive, but were simply the start of a rolling threeyear programme of development.What signs of improvement should we be looking for in the revised HImPs which are beginning to emerge?
Government guidance in 1998 stated a range of requirements for HImPs.
They should:
set a strategic framework for action on national and local priorities, setting targets and milestones for measurable improvement;
include needs assessment and resource mapping;
include local joint investment plans and a service and financial framework;
include an account of the nature and extent of past and future involvement of other stakeholders in preparing the HImP;
be made w idely avai lable in accessible forms.
In the first year of preparing HImPs, HAs understandably experienced difficulties in meeting these varied requirements quickly.Difficulties included:
engaging primary care groups and GPs during their 'shadow'year; policy overload and the pace of change;
different understandings of what health improvement means to different stakeholders; the challenge of partnership working; resource constraints; ensuring effective public involvement and accountability; the problems posed by different planning cycles in the NHS and local government; and the problem of how to measure progress in improving health.
Health improvement goals are inevitably long term, but progress needs to be measurable in the medium term.
We scrutinised a sample of 36 HImPs published in April 1999, using a structured analytic framework based on key features of the guidance provided to HAs. The 36 HImPs analysed represent about three-quarters of those relating to PCGs included in the national survey of PCGs being carried out by the National Primary Care Research and Development Centre and the King's Fund.We looked for evidence of local commitment to:
national and local priorities for health improvement;
public consultation;
partnership working;
a strategy driven by identified health needs;
effective implementation of the strategy.
There are, of course, many limitations to documentary analysis.Nevertheless, the documents represent the principal public statements of HAs'policies and strategies for the local NHS.HImPs can at the least be regarded as declarations of intent, a public avowal of commitment to certain values and objectives.
Categorisation Our rule for categorising priorities was that none should be coded more than once, and priority areas which were logically included in others should be omitted.For example, in the case of a HImP which prioritised either menta l hea lth or chi ldren and adolescent serv ices or both, we did not include a hybrid code such as child and adolescent mental health.However, if neither of the broader areas had been prioritised, the more focused priority was included.
One HImP had set no priorities at all, on the grounds that not enough work had been done locally to produce a definitive list.Another had only set four.Both were explicit that future HImPs would include more priorities, and that the process of defining these was identified and already underway.
The total number of priorities set was 457, a mean of 13 per HImP.Twelve HImPs had between six and 10 priorities,17 had between 11 and 20, and five had more than 20.The highest number was 28: arguably, very large numbers of priorities make it harder for local organisations to focus their efforts.
The most commonly mentioned priorities are shown in table 1.Table 2 sets out priorities by category.
Twenty-nine of the HImPs analysed recorded some consultation with the public, including the following representative groups and organisations: community health councils (23); local health-related groups (19);
carers'groups (13), other community groups (20).Only two mentioned practice-based patient groups.
Whether patients and community groups would be able to understand some of the resulting documents may be doubted: only 13 provided a glossary.The sheer length of some of the documents might put offmany people.
A key aspect of HImPs is that HAs should have consulted widely with local partner agencies in drawing them up, and that such agencies should be committed to delivering the programmes.Most (33) mentioned a range of partner organisations.Thirteen simply provided a list, whereas the remainder (20) gave some indication of the roles and responsibilities which partner agencies had agreed to take on.Most HImPs gave details of other joint work with local authorities (29), or with local NHS trusts (22), and referred to other local strategic/planning documents in some detail (26).Nineteen referred to the joint investment plans drawn up with local authorities.This is a surprisingly low figure, since they have been required for some time.
About half of the HImPs (19) mentioned PCGs' priorities.Only nine included details of PCGs'primary care investment plans.Details ofmany PCGs'priorities and investment plans were not available in time to be included in the HImP.PCGs only existed in shadow form as the first HImPs were being drawn up.
But the fact that nearly half of the HImPs did not refer to local PCG priorities suggests that some HAs were slow to acknowledge the importance of PCGs in the new NHS.
Making it happen We looked for evidence on how the priorities would be delivered.Had resources been identified for health improvement work? HAs were required to refer to service and financial frameworks in the HImP: 29 did,20 in some detail and nine only briefly.Twenty-one included some financial information.
We also looked for evidence relating to the monitoring of performance.Only seven HImPs included any measurable targets (for example, mortality and morbidity statistics):
other HImPs had milestones such as 'working group to report by April 2000'.
There is no doubt that the four national priorities set in Saving Lives have been taken on board by HAs in setting the strategic framework for local NHS activity.What is less clear is how these priorities will be pursued. In assessing the next round of HImPs, now being published, we hope to see:
continued evidence of public consultation;
clearer commitments by stakeholders to specific work programmes;
a central place for PCGs;
more detailed health needs assessment and resourcemapping data;
specific targets for measurable improvements.
We also recommend that HAs should prepare and disseminate user-friendly summaries as well as full technical documents.
Key points
An analysis of 36 health authorities' health improvement programmes found they reflected national priorities well.
The average number of priorities was 13, with coronary heart disease/stroke, mental health and cancer being the most common.
One plan set no priorities.
Most programmes included some consultation with the public.
Only seven HImPs included measurable targets.
Many plans were written in a way which would make them difficult for the public to understand.Only 13 provided a glossary.
REFERENCES
1 Health Improvement Programmes: planning for better health and better health care. HSC 1998/167.NHS Executive.
2 Arora S, Davies A, Thompson S. Developing health improvement programmes: challenges for a new millennium.J of Interprofessional Care 2000; 14 (1): 9-18.
3 Carruthers I, Shapiro J, Knight T. Improving HImPs: the early lessons .Birmingham: health services management centre, 1999. Stephen Abbott is project officer and Steve Gillam is programme director, primary care programme, the King's Fund.
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