Programme success and failure

As mentioned, policy evaluation is hampered by the failure of governments to specify aims. However, this has not been true of recent English public health policies. Governments have identified key aims alongside targets for the reduction of particular diseases, conditions and health risk behaviours. The Major Government set targets in its HOTN strategy, including a reduction of deaths from cancer, coronary heart disease/stroke and accidents, as well as lowering levels of smoking, alcohol consumption and obesity. Labour followed suit with a similar set of targets for reducing diseases and other conditions. It did not adopt risk factor targets in its Saving Lives white paper, but used them in specific policy areas (for example, tobacco smoking – see below), both in policy documents and in performance management processes (notably central government department public service agreements (PSAs) and NHS/local government targets and agreements).

The HOTN strategy had little impact in programme terms. Only in a minority of target areas was it possible to demonstrate good progress (NAO, 1996). In some important areas, notably women's alcohol consumption, smoking among schoolchildren and adult obesity, indicators moved in the opposite direction than that intended (DH, 1998b). The policies of the Major Government were also criticised for what they excluded. In particular, they were attacked for failing to reduce health inequalities and not addressing social, economic and environmental causes of ill health.

In some respects, Labour's public health strategies were more effective. Deaths rates (for the under seventy-fives) from heart and circulatory disease fell by over half between 1995–7 and 2008–10, exceeding the 40 per cent target set by government (DH, 2011b). The target for reducing cancer mortality rates was also met (achieving a 22 per cent reduction between 1995–7 and 2008–10, 2 per cent higher than the target). Suicide mortality rates fell by 13.4 per cent over the same period, falling short of the target of 20 per cent. The Labour Government's policies on smoking (DH, 1998a) set out targets to reduce the habit. Adult smoking rates fell from 28 per cent to 21 per cent between 1996 and 2009 (the original target of 24 per cent having been altered to 21 per cent or less of the adult population by 2010) (NHSIC, 2011c). Regular smoking (at least once a week) among children aged eleven to fifteen years fell from 13 per cent to 5 per cent between 1996 and 2010, beating the target of 9 per cent (NHSIC, 2011c). Meanwhile, accidental death rates, another target area, fell by only 3.5 per cent between 1995–7 and 2008–10, falling far short of the 20 per cent reduction envisaged (DH, 2011b). Targets for sexual health showed some improvement. Teenage pregnancy rates fell substantially, but remained short of the 50 per cent reduction set by government to be achieved by 2010 (ONS, 2011). Another target, to reduce the rate of gonorrhoea infections by 2008, was achieved, but overall levels of sexually transmitted disease rose considerably – new cases rose from 288,781 to 322,820 between 2001 and 2010 (Health Protection Agency, 2011).

Unlike its predecessor, Labour did not set a specific target for reducing adult obesity. Under Labour, adult obesity (measured by Body Mass Index) continued to rise, from 17 to 22 per cent of males and 20 per cent to 24 per cent of women between 1997 and 2009 (NHSIC, 2011a). A target was set in 2004 to halt the increase in obesity in children aged under eleven by 2010. This was achieved, the obesity rate in children in this age group fell after 2005, though remains high (at 14 per cent in 2009, three percentage points higher than when Labour took office). In 2007, a further target was set, to reduce by 2020 the proportion of children who are overweight or obese to the level in year 2000 (when 27 per cent of children aged two to fifteen fell into this category). The latest survey, relating to 2009, revealed that 30 per cent of children were overweight or obese (NHSIC, 2011a). In addition, targets were set for improvements in diet: adult daily salt intake fell, but remained considerably higher than the maximum level of 6g a day recommended by the government's nutritional advisors. Added sugar in the diet and saturated fat levels also fell, but continued to exceed the maximum recommended for the population as a whole. The percentage of the population eating the recommended five or more portions of fruit and vegetable a day increased – from 25 per cent to 28 per cent of women and from 22 per cent to 25 per cent of men between 2001 and 2009. The proportion of children's eating ‘5-a-day’ increased from 10 per cent to 21 per cent between 2001 and 2009 (NHSIC, 2011a). There was evidence of improvements in school meals (Evans et al., Reference Evans, Cleghorn, Greenwood and Cade2010; Haroun, et al., Reference Haroun, Harper, Wood and Nelson2011), but the availability of packed lunches and nearby takeaway outlets reduced the net effect of this initiative. As part of policies to reduce obesity, reduce cancers and cardiovascular disease, the government also aimed to increase physical activity. In 1997, 32 per cent of men and 21 per cent of women met government physical activity targets (twenty or more occasions of moderate or vigorous activity lasting at least thirty minutes in the past four weeks). This increased to 39 per cent and 29 per cent respectively in 2008 (NHSIC, 2011a). Objective measurements showed that adults tended to exaggerate their physical activity levels, however. Only a minority of children (32 per cent of boys and 24 per cent of girls) met their target of at least 60 minutes of physical activity a day (NHSIC, 2011a).

Although official guidance on maximum alcohol consumption levels for adults already existed (no more than three units of alcohol per day for women and four units for men) it was not until 2007 that performance indicators were introduced, in a cross-departmental PSA agreement on alcohol and drugs. Nonetheless, these were not designated as a high priority. The level of alcohol-related problems remained high and in some respects deteriorated. In England, deaths directly attributable to alcohol increased by almost a quarter between 2001 and 2008 (NHSIC, 2011b). Hospital admissions (partially and fully due to alcohol) rose from 510,800 to 1,057,000 between 2002–3 and 2009–10 (NHSIC, 2011b). In 2007, the number of adults regarded as drinking at hazardous levels (that is, bringing the risk of physical or psychological harm) remained substantial, at a third of men and 16 per cent of women (NHSIC, 2011b). In the same year 9 per cent of men were regarded as alcohol dependent, a slight fall since 2000, whereas the percentage of alcohol dependent women remained at 4 per cent. With regard to children's alcohol consumption and problems, some statistics suggested an improvement: the percentage of secondary schoolchildren who reported drinking alcohol fell (from 61 per cent to 51 per cent between 2001 and 2009) and the percentage reporting drinking weekly fell from 20 per cent to 12 per cent in the same period (NHSIC, 2011b). However, the amount consumed by those who did drink remained high at 11.6 units a week in 2009. In 2009–10, 3,700 children under sixteen were admitted to hospital in England for reasons wholly due to alcohol consumption.

Although the Labour Government highlighted health inequality as a public health issue (Acheson, Reference Acheson1998; DH, 2003), it remained a persistent problem under its tenure. After initially refusing to set national targets, in 2001 the government declared it would reduce by 10 per cent the gap in infant mortality between routine and manual socio-economic groups and the population average, and reduce by the same proportion differences in life expectancy between the most deprived local areas and the national average. These targets were to be achieved by 2010. Although the infant mortality rate among routine and manual groups improved from the baseline (1997–9), it fell less than among the population as a whole. Hence, the relative gap widened. However, in recent years the infant mortality rate has improved faster than average among routine and manual groups. The net effect of this was that by 2007–9 the gap had narrowed by 4 per cent since the baseline, an improvement but short of the target (DH, 2010b). The life expectancy gap (between poorer areas and the average) for both men and women was wider in 2008–10 than in 1995–7 (the baseline for this indicator). For men the inequality gap grew by 7 per cent and for women by 17 per cent in this period (DH, 2011c). Facing increasing criticism of its failure to reduce health inequalities (Public Accounts Committee, 2010), the Labour Government established a further review of policy (Strategic Review of Health Inequalities in England, 2010).

It is too early to begin to assess the record of the present government. However, for both previous governments, success was mixed and at best achieved ‘precarious success’ in terms of programme outcomes. Even where progress was made, for example in reducing smoking rates, cancer deaths and cardiovascular disease under Labour, there were mixed results in other areas (obesity and diet, sexual health) and significant failures in accidents, alcohol misuse and health inequalities.

Public health policy process

Critics of public health policy processes have often argued that policy formation is dominated by industries whose products are associated with ill health. In the past, the tobacco industry enjoyed enormous influence over government policy (see Taylor, Reference Taylor1984). Its position remained strong under the Major Government, reflected in that government's opposition to European Union measures to impose stronger health warnings on tobacco packaging. Although it remains powerful, the tobacco industry has been less influential over policy in recent years. The Labour Government adopted a much stronger anti-tobacco policy than its predecessor, including extending bans on advertising and sponsorship, banning smoking in certain public places and expanding smoking cessation services (DH, 1998a). However, the Ecclestone Affair (where the Blair Government was accused of weakening its tobacco sponsorship ban in return for political contributions – Rawnsley, Reference Rawnsley2010) and the decision to exempt certain licensed premises from the smoking ban, revealed that tobacco and related interests retained considerable residual influence only overcome by countervailing pressure from campaigning groups.

The food and alcohol industries have also enjoyed influence. In the Major Government era, the drinks industry secured a relaxation in the official ‘sensible drinking’ guidelines, and persuaded government not to legislate on alcopops (fruit flavoured alcoholic drinks that appealed to children and young people). The food industry prevented steps to regulate the nutritional content of food, diluted proposals to restrict advertising and successfully lobbied against high profile campaigns on healthy eating. The influence of the food and drink industries continued under the Blair Government. Industry was able to persuade government to resist adopting direct regulation and fiscal measures. Governments in their turn were happy to endorse corporate social responsibility as a main instrument of policy (for example, salt reduction in food, responsible marketing and promotion of alcoholic drinks). Labour established new fora where industries could discuss voluntary and self-regulatory measures. However, this attracted increasing criticism, particularly as a result of poor progress in some areas (for example, the labelling of alcohol products and codes of practice on alcohol sales and promotions). As with tobacco, media criticism and pressure from public health campaigners led to tougher measures − for example, restrictions on the advertising of foods high in salt, fat and sugar to children aged under sixteen, and a strengthening of school meal nutritional standards. A cross-government obesity strategy was introduced (HM Government, 2008), which strengthened coordination of policies but did not propose any radical new measures. With regard to alcohol, campaigners secured a revised alcohol strategy (HM Government, 2007 superseding PMSU, 2004), further restrictions on licensing and increased penalties for serving under-age drinkers.

The influence of economic interests was, however, reflected in the broader ethos of public health policy, which emphasised individual choice at the expense of regulation and collective action. This was explicit in the title of the 2004 White Paper, Choosing Health: Making Healthy Choices Easier (HM Government/DH, 2004). The key emphasis was upon individuals taking greater responsibility for their own health while making the environment more conducive to healthy lifestyle choices through the provision of advice, information and support. There was less emphasis on the structural, environmental and socio-economic aspects of public health.

The desire to work with the food and alcohol industry was encouraged even more by the Cameron Government. In March 2011, the government agreed ‘responsibility deals’ setting out how businesses in these areas can contribute to healthy diet, increased physical activity and responsible drinking, and asked health organisations to endorse them too (DH, 2011a). This proved controversial, and a number of public health groups boycotted the agreements (Triggle, Reference Triggle2011). Critics maintained that social responsibility commitments were no substitute for effective regulatory measures. With regard to alcohol, for example, the Cameron Government refused to adopt minimum pricing, as demanded by a range of professional groups and alcohol agencies, and instead adopted ‘below cost’ pricing rules that made little difference to the deep discounting of alcohol products by supermarkets. Statutory controls on nutritional standards and information were also rejected. The government refused to ban the use of transfats (regarded as particularly damaging to health), regulate levels of salt or require the food industry to adopt a ‘traffic light’ system of food labelling.

The Cameron Government continued its predecessor's focus on behavioural initiatives. It continued the social marketing initiative begun by the Labour Government (Change4Life), but with a greater emphasis on the role of private and voluntary sectors. The Coalition also espoused the concept of ‘nudging’ people into changing their habits. Nudging is essentially about changing the environment within which choices are made, echoing Choosing Health (Thaler and Sunstein, Reference Thaler and Sunstein2009). However, the evidence that nudging improves health is weak, especially in the absence of regulatory measures (Bonell et al., Reference Bonell, McKee, Fletcher, Wilkinson and Haines2011).

Another important aspect of the policy process was the creation of new institutions to provide public health expertise and/or regulation. In 2000, New Labour established the Food Standards Agency (FSA) with powers and duties in food safety, labelling and nutrition. This followed more than a decade of criticism of the previous Conservative Government's food policies, particularly food safety. The FSA, constituted as a non-departmental body accountable to Parliament through the Secretary of State for Health, proved a useful ally to health campaigners. It restored some confidence in food safety regulation, while pressing for a clear standardised nutritional labelling scheme, developing a nutrient profiling scheme as the basis for restrictions on food advertising to children, and implementing voluntary agreements to improve the nutritional content of food (such as salt reduction). It should be noted, however, that the Cameron Coalition Government has removed FSA responsibilities for nutrition, transferring these to the Department of Health, seen widely as a retrograde step and strengthening the influence of the food lobby.

Other institutional changes under New Labour included the establishment in 2002 of the Health Protection Agency, bringing together a number of specific health protection bodies (in areas such as communicable disease, biological and chemical hazards). The Blair Government abolished the Health Education Authority (responsible for health promotion campaigns), replacing it with the Health Development Agency (HDA) in 2000. The new body was focused on improving the effectiveness of health promotion and public health interventions, including strengthening the evidence base for policy and practice. The HDA was later abolished and its functions for reviewing and disseminating evidence incorporated within the National Institute for Health and Clinical Excellence (NICE). Despite these developments, criticism of the weak evidence base for public health policy and concerns about the organisation of public health expertise persisted (Wanless, Reference Wanless2004; Hunter, et al., Reference Hunter, Marks and Smith2010, Health Committee, 2009). The Cameron Government pledged to strengthen public health research (creating the National Institute for Health Research School for Public Health Research, for example). However, less conducive was its decision to halt work by NICE on several public health topics (Kmietowicz, Reference Kmietowicz2010).

Another common criticism of the policy process is that public health policies are poorly coordinated. The Blair Government sought to improve coordination by appointing a Minister for Public Health. Although widely welcomed, the impact of the move has been variable. Post-holders have varied in quality, commitment and political profile and the post has been downgraded (in terms of ministerial rank) on two occasions. The current postholder is a Parliamentary Under Secretary of State, the lowest rank of government minister. The Blair Government also established a cabinet committee to promote coordination between government departments involved in public health. The Major Government established a similar committee, judged as ineffective (DH, 1998b). Both the Major and the Blair Governments stated that they would use health impact assessment to ensure that policies would reflect the importance of health priorities, but this was not routinely used. Cross-departmental coordination at the national level remained a problem. The Health Committee (2009) was extremely critical of a failure of English public health strategies and in particular poor coordination across government. Prior to this, a capability review of the Department of Health was critical of its overwhelming focus on the NHS and its inability to coordinate cross-government action on health (Cabinet Office, 2007).

Criticisms of poor coordination at the national level were echoed at the local level, where there was much variation in the quality of inter-agency working (Health Committee, 2001; Wanless, Reference Wanless2004; Audit Commission, 2010; Health Committee, 2009). The Blair Government made more effort to strengthen partnership working on public health than its predecessor. It focused particularly on the relationship between local authorities and NHS bodies, setting out new duties of cooperation in 1999. While the primary focus of improvement in joint working was upon social care (Snape, Reference Snape, Snape and Taylor2004), public health issues began to rise on local partnership agendas. Local authorities became more involved in health matters. In 2000, they acquired powers to promote or improve the economic, social and environmental wellbeing of their communities, alongside a new duty to formulate community wellbeing strategies (later renamed sustainable community strategies). Local authorities became more familiar with the health agenda through their new health scrutiny role (LGIU, 2010), through participation in health projects (such Health Action Zones and healthy communities programmes), regeneration programmes, school-based initiatives and developments in children's services and through responsibilities for housing, transport and planning.

Local authorities led Local Strategic Partnerships (LSPs), established by the Blair Government to bring together local agencies such as the NHS, other local public sector agencies and the private and voluntary sectors. Local Area Agreements (LAAs), setting out area-based priorities, strategies, targets and resources on a range of issues were heralded as a further means of strengthening partnership working. LSPs and LAAs were increasingly emphasised as means by which local government's strategic leadership role could be exercised (Department of Communities and Local Government, 2006). Some local areas targeted public health problems such as alcohol misuse and obesity as part of their local partnership plans (Audit Commission, 2010). However, there was a lack of a systematic approach to partnership working in public health and little evidence that partnerships produced better health outcomes (Perkins et al., Reference Perkins, Smith, Hunter, Bambra and Joyce2010; Hunter et al., Reference Hunter, Perkins, Bambra, Marks, Hopkins and Blackman2011). Furthermore, there was concern that accountability mechanisms were not robust enough to ensure partners delivered on their commitments (Hunter et al., Reference Hunter, Perkins, Bambra, Marks, Hopkins and Blackman2011). In some local areas, a statutory system of joint strategic needs assessment (JSNA), introduced in 2007, encouraged closer working between NHS and local government organisations (Hughes, Reference Hughes2009). The appointment of joint directors of public health by local NHS bodies, primary care trusts (PCTs), and by local authorities, encouraged by the White Paper Our Health, Our Care, Our Say (DH, 2006), was acknowledged as improving partnership working (Hunter et al., Reference Hunter, Perkins, Bambra, Marks, Hopkins and Blackman2011). Even so, there was much room for enhancing further the quality of inter-agency working (LGIU, 2010). For example, it was found that despite evidence of effective partnerships at the strategic level, a disconnect between front line practitioners and senior management undermined partnership working on the ground (Hunter et al., Reference Hunter, Perkins, Bambra, Marks, Hopkins and Blackman2011).

The Healthcare Commission and Audit Commission (2008) noted that health targets were periodically altered, which caused confusion among those expected to implement them. Furthermore, central government was accused of introducing too many initiatives and targets (Hunter et al., Reference Hunter, Perkins, Bambra, Marks, Hopkins and Blackman2011). Regular restructuring of local agencies by central government further weakened local partnerships. Other problems included a lack of consistent focus on public health across the NHS, local government and other agencies, unclear responsibilities between agencies and partnership problems, and insufficient resources and incentives to generate appropriate action.

Implementation of public health policy was poor, even within the NHS. Despite the increasing attention given to public health issues by both media and the government, it was difficult to prioritise these in practice, both at national and local levels. Alan Milburn (Reference Milburn2000), then Secretary of State for Health, said that public health must be brought ‘out of the ghetto’. However, a critical House of Commons, Health Committee (2001: lxxvii) report commented that ‘for all the laudable government rhetoric . . . in the race for resources it runs the risk of trailing well behind fix and mend medical services’. The NHS Plan (DH, 2000) had earlier made several other public health commitments, including a new health inequality target, a revised sexual health strategy, schemes to encourage fruit and vegetable consumption and an expansion of existing programmes, such as Sure Start and smoking cessation services. Even so, public health was not regarded as a top priority. Indeed, The NHS Plan was formulated primarily in response to concerns about the performance of the NHS, not public health. The public health chapter of The NHS Plan for England disappointed many, particularly in contrast with Scotland and Wales, which gave such matters a much higher profile (Baggott, Reference Baggott2010).

A common problem has been the under-resourcing of public health initiatives (Wanless, Reference Wanless2004; Health Committee, 2001). Recognising that previous initiatives had failed because of this, the Blair Government allocated £1 billion to implement Choosing Health (HM Government/DH, 2004). However, these funds were raided to pay for acute services (Wanless, Reference Wanless2007). Government attempted to redress the low priority of public health issues by requiring PCTs to acknowledge the Choosing Health agenda. Another significant development was the inclusion of public health standards within Healthcare Commission's core standards from 2005, which meant that in future NHS bodies would be assessed against public health criteria. Following the replacement of Blair by Gordon Brown in 2007, the Labour Government took this a stage further, expanding the number of public health objectives included in central government PSA agreements, national NHS targets and local plans. Brown also established the Darzi Review (DH, 2008), which recommended that the NHS should focus more on prevention and health promotion, working in partnership with other bodies such as local government. The Brown Government also implemented ‘World Class Commissioning’ which involved benchmarking PCT commissioning functions against key criteria, including health improvement, reducing inequalities, public engagement, partnership working and needs assessment – all crucial to public health objectives.

However, these did not address the fundamental weakness of the public health function (Wanless, Reference Wanless2004; Hunter et al., Reference Hunter, Marks and Smith2010). Indeed, this had been further undermined by the NHS reorganisation of 2002, which replaced health authorities with smaller PCTs, fragmenting expertise and reducing capacity (Evans, Reference Evans2004). A further reorganisation, in 2006, was initially viewed more positively from a public health standpoint because it created larger PCTs with increased capacity and resulted in a greater degree of coterminosity with higher tier local authorities. Even so, the reorganisation proceeded without due consideration of the impact on public health and caused major disruption to public health functions (Health Committee, 2006). Indeed, both the 2002 and 2006 reorganisations exacerbated well-documented problems with the public health workforce, including uncertain job prospects, low morale, skill shortages and fragmentation (Healthcare Commission and Audit Commission, 2008; Faculty of Public Health, 2008).

Following a change in government in 2010, a new public health structure was proposed. Local directors of public health (DsPH)s and their teams were to be moved out of the PCTs into local authorities (those with social services responsibilities) along with key public health duties and functions. Statutory health and wellbeing boards (HWBs) were to be established at the local level to assess needs (already a statutory duty of PCTs and local authorities) and develop joint health and wellbeing strategies (JHWBS), while coordinating public health, health services and social care. A new national public health service, Public Health England (PHE), would be formed from existing institutions, including the Health Protection Agency, the National Treatment Agency for Drug Misuse, cancer registries and regional public health observatories). A ring-fenced, public health budget for the national public health service and local government public health functions would be established, with funding of local public health authorities reflecting both performance and local needs.

Although many saw merit in these policies, there was concern about how they would be implemented (Limb, Reference Limb2011; Health Committee, 2011; McKee et al., Reference McKee, Hurst, Aldridge, Raine, Mindell, Wolfe and Holland2011). For example, the rationalisation of national and regional expertise into PHE was regarded as providing a clearer national framework for public health interventions. Yet there was disquiet about its scope (what functions would be included) and lack of independence (at this stage it was proposed that PHE be situated in the Department of Health, not a separate agency). The government later conceded that these functions should be undertaken by an executive agency of the Department of Health (DH, 2011a). However, some preferred a special NHS authority for this role, believing this would further strengthen PHE's independence. The transfer of public health functions to local authorities also attracted much support in principle, but with reservations. One of the main issues was that as some public health functions (for example in relation to children's health services) would be retained by the NHS, this could lead to fragmentation (Health Committee, 2011). Another issue concerned the level of funding available to local authorities to carry out their new functions, which at the time of writing remains undecided. Concerns were expressed that funding for public health might actually be reduced, due to under-budgeting of the new local authority responsibilities and duties. Also, local authorities had an incentive, exacerbated in a period of budgetary cuts elsewhere, to redesignate existing council functions as ‘public health matters’ (McKee et al., Reference McKee, Hurst, Aldridge, Raine, Mindell, Wolfe and Holland2011). Moreover, budget cuts – in regeneration, housing, transport, social welfare services, leisure and recreational facilities for example – were likely to have an adverse effect on public health.

It was feared that the transfer of public health staff from the NHS to local government would fragment the workforce, splitting it between PHE and the local authorities (McKee et al., Reference McKee, Hurst, Aldridge, Raine, Mindell, Wolfe and Holland2011). In addition, direct employment of DsPH by local authorities was seen as a potential threat to their independence and status. There was concern that the government did not intend to require local authorities to appoint DsPH at an appropriately senior level, with direct access to senior council members and the chief executive (Health Commitee, 2011). Critics demanded safeguards on the independence of the DsPH, which government assured would be jointly appointed by local authorities and PHE. It was also made clear that local authorities could not dismiss their DsPH without first consulting the Secretary of State for Health. As a means of further strengthening independence and integration of the public health workforce, some suggested that current NHS public health staff be transferred to PHE and those with local functions (such as DsPH) seconded to local authorities (McKee et al., Reference McKee, Hurst, Aldridge, Raine, Mindell, Wolfe and Holland2011).

Partnership working was another area of uncertainty. It was unclear whether HWBs would have sufficient powers to incentivise or compel stakeholders to work together. There was also concern that NHS commissioning plans would not take JHWBS sufficiently into account. Following the 2011 NHS ‘listening exercise’, a further period of review and consultation for the government's reform plans, these provisions were strengthened. In addition to being able to refer commissioning plans back (where they were not in line with the JHWBS), it was proposed that HWBs would have greater rights of consultation on local commissioning plans and would be consulted by the national commissioning body on the efficacy of this process. In addition, duties on the new local commissioning bodies to participate in the formulation of JHWBS were strengthened, alongside new requirements to draw on public health expertise when undertaking their functions. Closer monitoring of local commissioners’ performance in relation to the preparation and delivery of JSNA and JHWBS was also proposed. Nonetheless, the NHS reforms and the public health changes were criticised for undermining public health capacity. The proposed abolition of PCTs, coupled with the transfer of budgets to local authorities, led to a reduction in public health posts in the transitional period. Likewise the regional public health observatories faced a 45 per cent cut in capacity ahead of their transfer to PHE (Health Committee, 2011).

Political success

Although the success of government strategies in public health has been limited in programme and process terms, this does necessarily mean they have been politically unsuccessful. Government may have succeeded in this regard by managing the political agenda, achieving compromise between different interests, and convincing public opinion and the media of its competence. However, public health has proved a difficult area for governments in recent years, for a number of reasons.

First, many public health issues have been controversial and prominent. The media have highlighted issues such as obesity, food safety and alcohol. Governments have sought to manage expectations and the political agenda, but their policies have often been perceived as inadequate and ministers have been forced to reissue or strengthen policies (as in the case of school food policies and smoking in public places). Worse still for government, public health issues have been highlighted in the media as indicating a fundamental lack of competence or even untrustworthiness. This happened in the case of the Major Government and food safety in the 1990s. The Blair Government faced similar accusations on alcohol misuse, smoking and obesity.

Second, interest groups in this field are vocal, well-organised and influential. But they are also divided. There is much antagonism between the commercial groups (industry) and the public health campaigning bodies (which include pressure groups, charities and professional associations). In such an adversarial policy community, it is impossible to please everyone. Industry usually opposes fiscal measures and direct regulation (unless yielding competitive advantage), preferring self-regulation and information-based policy measures (such as health education). In contrast, the public health campaigners tend to favour stronger regulatory controls. Government has tended to side with industry, adopting direct regulation as a last resort. This has caused protest from public health campaigners, who have redoubled efforts to strengthen regulation. In such a political environment, government faces difficulties in building consensus and moderating criticism of its policies. Issues are not resolved politically as dissatisfied interests continue to agitate for their preferred policies, often enlisting the support of the media, thereby maintaining the issue in the public eye.

A third problem lies in controversy surrounding the appropriate balance between state intervention and individual choice, responsibility and freedom. All recent governments (Labour, Conservative and Coalition) have been sensitive to accusations that they are introducing a ‘nanny state’. But efforts to reassure libertarians have led to concerns that the state is abdicating its responsibilities to protect health. In some cases, however, government has restricted liberties. These can be considered political successes when shown to be effective in improving public health and where public criticism and opposition of the measure has abated. Past examples include breathalyser tests for motorists, compulsory seat belts and more recently legislation on smoking in public places. On some issues, notably, government has managed this politically by allowing Members of Parliament to vote with their conscience rather than on party lines.

A fourth problem is that public health issues are often intractable, complex and difficult to resolve in the short term. This means that policy-makers find it difficult to demonstrate success. This is particularly a problem for politicians, who need to demonstrate so-called ‘quick wins’. There has been much discussion of ‘wicked issues’ (Clarke and Stewart, Reference Clarke and Stewart1997), difficult to resolve because of their multi-faceted nature, complex causation and the involvement of multiple agencies. Many public health issues fall into this category. The difficulty in making progress has tended to produce amelioration strategies. Governments seek to shift the blame on to other agencies (such as the local level agencies in the NHS and local authorities) for failing to implement policy. Another technique is to blame previous governments. Indeed, when taking office in 1997, the Labour Government commissioned a review of the HOTN strategy, enabling it to build its approach on a critique of its predecessor's approach. More usually, evaluation has either been tightly controlled to minimise criticism, not undertaken at all, or undertaken in such a way that the lessons for future policy are ambiguous. This may have satisfied a desire to cloud judgements about policy success (in programme as well as political terms). However, this has backfired to some extent by generating criticism that policies are not properly evaluated and lessons from success and failure have not been learned (Healthcare Commission and Audit Commission, 2008; Health Committee, 2009). This ultimately feeds back into questions of government competence. Similarly, persistent criticisms of partnership working and local implementation can build into a groundswell of criticism about the ability of government to form and implement appropriate policies.