"The health of thr nation" - an economic economic perspective on target setting

1. The development of a strategy based on all aspects of health, not just health care provision, is to be welcomed as it is the emphasis on the outcomes, rather than the process, of implementing health policy. Health strategies can be designed to set policy agendas, to foster inter-departmental co-operation or to provide detailed targets for implementation. In addressing all of these potentially conflicting purposes, there is a danger that, through over ambition the strategy will ultimately fail to achieve any of them satisfactorily. 2. It is proposed in the Health of the Nation that the strategy should concentrate initially on a limited range of target areas. A comprehensive analysis of all possible target areas is required for the selection process making use of criteria that are explicit and widely accepted. 3. In the identification of target areas for health gain, the model of prevention of ill-health which is implicit in the strategy places great emphasis on individual behaviour and pays too little attention to the role of social processes. 4. Two important criteria are absent from those used to select target areas in the strategy: equity and cost-effectiveness. There may also be over emphasis on measurability of targets in the criteria included. Using the criteria stated in the Green Paper, many more plausible areas for targeting could be included and it is unclear how those chosen were selected. Addition of the equity and cost effectiveness criteria would add further possible target areas. 5. The detailed targets suggested in the strategy are not convincing because of the limited evidence to support term. This is not helped by the lack of transparency in the process by which targets are derived. The target measures used show a mixture of outcomes, intermediate outputs and inputs. Some of these are inappropriate and may produce perverse behaviour if implemented. The selection of very few target areas is sensible and lessons can be learnt about detailed target setting in these areas before the scope of the strategy is extended. 6. Achieving major changes in policy direction is very difficult if new resources are not made available. The strategy is based on an assumption that no existing NHS activities will be stopped, and research indicates that health promotion work is unlikely to result in short term financial savings. It is difficult to see how change can be achieved without a specific injection of new resources. 7. The extent of new resource requirements is difficult to estimate because of a lack of cost data. A programme aimed at achieving the smoking target would cost about £20-30 million per year. Achieving the CABG target in one region alone would cost £1.6-£2.4 million per year plus up to £6 million capital spending. Broad estimates of this kind are, however, not available for other potential target areas. 8. The strategy recognises the important influences on health of factors beyond the control of the Department of Health and the NHS, and emphasises the need for coordinated policies on health across a broad range of government departments. 9. Effective coordination of policy will require collaboration between agencies implementing policy as well as the central government departments formulating policy. No mechanisms for such local coordination are described in the Green Paper. 10. Past experience has shown that successful coordination of policy with non health departments and agencies is more likely to be achieved if health objectives are complementary to other departments’ main objectives; if health policies do not threaten the economic interests of organisations sponsored by other departments, and if health policies are supported by external bodies such as the European Community. 11. More research is needed to establish the health benefits achievable through control of risk factors if other departments and agencies are to be persuaded to give control of such risk factors a high priority in their programmes. 12. One way forward is for district health authorities to be required to set local targets and to identify the contribution of non NHS agencies to achieving these. Regional health authorities will have a pivotal role in monitoring the performance of districts, evaluating the relevance of national priorities to local situations, improving the coordination between health and non-health agencies and influencing the development of the strategy at a national level.