Abstract Health promotion specialists and health promotion services within the health service have been .... compatible with the related drive for evidence-based health care and therefore this study ..... hard to get away from that'. Non-HPSs did ...
Sociology of Health & Illness Vol. 19 No. 1 1997 ISSN 0141-9889 pp. 23^7
If health promotion is everybody's business what is the fate of the health promotion specialist? Sarah Nettleton^ and Roger Burrows^ ' Department of Social Policy and Social Work, University of York ^ Centre for Housing Policy, University of York
Abstract Health promotion specialists and health promotion services within the health service have been neglected by policy makers and medical sociologists. This is perhaps surprising, given the high profile of health promotion on the health policy agenda. This paper presents the findings of an exploratory sociological study into the nature and fimction of health promotion services within the 'reformed' British National Health Service. The analysis draws on qualitative interviews with health promotion specialists, directors of public health and other health workers whose work involves the promotion of health. The paper argues that health promotion services do not fit easily into the purchaser provider divide and that they have experienced considerable organisational change and uncertainty. Four factors have further compounded this lack of fit: a lack of consensus as to what health promotion specialists work should be about; a lack of any secure knowledge base; prevailing images of health promotion and of health promotion specialists; and feelings of vulnerability about the future of health promotion. Furthermore, health promotion specialists are finding it difficult to shed their principles and values and take on the dominant enterprise culture which is characteristic of the new public management. The paper concludes by suggesting three further reasons why health promotion specialists have been marginalised: their insecure occupational status which in turn is linked to a lack of jurisdiction associated with the content of their work; the contradictions which are inherent in the knowledge base of health promotion, and the increasing application of 'modernist' evaluative frameworks, derived from economics, to health promotion interventions.
O Blackwell Publishers Ltd/Editorial Board 1997. Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 lJF, UK and 238 Main Street, Cambridge, MA 02142, USA.
24 Sarah Nettleton and Roger Burrows Keywords: health promotion, internal market, NHS, England, managerialism, professionalism. Introduction
There is now a considerable medical sociology literature on prevention and health promotion. This can be grouped into at least four categories. First, that which has critically reviewed the developments in health promotion policy over the last decade (Davies 1984, Calnan 1991, Graham 1990, Mills 1993, Williams et al. 1991, 1993). Second, that which has sought to develop a sociology of health promotion (Bunton et al. 1995, Lupton 1995). Third, that which has formed part of what is now a veritable industry of study into lay understandings of health with a view to contributing to more effective health promotion practice (Blaxter 1990, Davison et al. 1991). Finally, there have been studies of health promotion within primary health care settings (Russell 1995, Taylor and Bloor 1994) and, in particular, concerning the perceptions that general practitioners have of prevention (Calnan et al. 1986, Williams and Calnan 1994). What is noticeably absent from this literature is any research which has examined the activities of health promotion services within the health service, in particular the role and function of health promotion specialists (HPSs). This lack of attention within the medical sociology literature mirrors their absence from the official policy documentation. HPSs and services are not mentioned within any of the reports on managing the new National Health Service (NHS) nor, more saliently perhaps, they are hardly ever discussed in any of the now voluminous Health of the Nation documentation. This paper makes a start in attempting to rectify this situation by reporting on an exploratory study into the nature and function of health promotion services within the 'reformed' NHS. The main aim of the study is to try and gain an understanding of the nature of the contemporary work of HPSs and how this has been shaped or infiuenced by the creation of the internal market. The two dimensions, as we shall see throughout the paper are, in fact, inseparable. There are a number of barriers to the development and implementation of health promotion services and these are grounded, to a significant extent, in the organisational settings and organisational culture in which they are located. The paper will therefore sketch out the current organisational context in which health promotion services are located within the NHS. A fundamental aspect of the reforms is that services are located in either purchaser or provider settings. Concomitant with this, is the drive to ensure that services are purchased and provided on the basis of rational decision making which, in turn, is increasingly founded on evidence of effectiveness and value for money. This paper will therefore highlight some of the difficulties associated with fitting health promotion services into either O Blackwell Publishers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 25 purchaser or provider settings, or both. Four factors are then identified which work against HPSs conforming to the ideal model of the intemal market and delivering an 'effective service': a lack of consensus as to what HPSs should do; a lack of any secure health promotion knowledge base; prevailing images of both health promotion and of HPSs; and a sense of uncertainty, and in many cases feelings of vulnerability, about the fate of health promotion services. Although HPSs have clearly been marginalised because they do not readily 'fit' into the intemal market, we suggest that this has been compounded by three further factors. First, by drawing on Abbott's (1988) notion of professional 'jurisdiction', we suggest that HPSs are disadvantaged because they have no definitive skills, core tasks or fundamental abstract knowledge which might contribute to the fomiation and maintenance of a clear occupational boundary. Second, health promotion discourse is characterised by a series of political and theoretical tensions which mitigate against the fomiation of a clear paradigm, the development of which might help to cohere a disparate occupational group. Third, an elective affinity can be identified between the discourse of health economics and the 'contract culture' within which health promotion has to operate. The specification of contracts for health promotion services within the intemal market increasingly requires such services to rearticulate what they do in temis of a vocabulary which largely derives from health economics (Burrows 1996). The focus of this study is important for three reasons. First, it throws light on an occupational group who have hitherto been neglected within medical sociology. Second, if the research on health beliefs and the effectiveness of various approaches to health promotion are to be translated into action there is a need to have an appreciation of the organisational contexts where it might be used - an aspect of medical sociology which Hunter (1990) correctly argues is significantly underdeveloped. Third, and as we have already indicated, health promotion services do not readily fit into the divide between purchaser and provider, nor is their work readily compatible with the related drive for evidence-based health care and therefore this study provides an illustration of the gap between the ideal model of the intemal market and the messy reality of its implementation. The "reforms' of the National Health Service
The Internal market It is not our intention here to provide a detailed review of the NHS reforms as this has been discussed extensively elsewhere (for example, Spurgeon 1993, Ham 1992, Klein 1995). However, for the purposes of this discussion it is worth drawing attention to some of their key features. The reforms initiated by the White Paper Working for Patients e Blackwell PubUshers Ltd/Editorial Board 1997
26 Sarah Nettleton and Roger Burrows (Department of Health 1989) and the subsequent NHS and Community Care Act, 1990 created an internal market within the health service. This involved splitting the former district health authorities, which had previously provided health care services, into purchaser and provider units. When provider units were separated from health authorities they established themselves as trusts who became free to operate as non-profit organisations, independent of health authority control. The former health authorities, initially at least, formed the main purchasers who were able to 'buy' or 'conunission' services from the trusts or, if they wished, from any other 'provider' of health care. The idea was that trusts would compete for contracts from the purchasers who were funded on a weighted capitation basis. Trusts could also negotiate contracts with General Practice (GP) fundholders, the other key players within the internal market, who, as purchasers, could buy services from a range of providers. Purchasing authorities are encouraged to 'buy' services on the basis of the findings of their local health needs assessments and their local health strategy which, in turn, is designed to optimise health gain. Purchasers are also charged with the responsibility of ensuring that services delivered by providers are effective, efficient and appropriate. Thus, contracts with providers should be monitored to ensure that they are delivering the services they said they would deliver. The contract is therefore pivotal to the internal market, the idea is that through its formation and negotiation purchasers will rationally decide, on the basis of needs assessments, what to buy on behalf of their populations and that they will be able to agree costs, outcomes, indicators of quality and measures of performance. This new 'contract culture' is compatible with the other key change in the UK health service, the development of a new style of management. New managerialism
The so-called 'new public management' or 'new managerialism' within the health service refers to the displacement of diplomatic consensus management and administration with a more dynamic style of 'strong' management derived from models of private sector management which emphasise 'accountability, results, competition and efficiency' (Gray and Jenkins 1993: 12). The introduction of new management styles within the NHS pre-dated the 'reforms' and were implemented following the Griffiths Inquiry (DHSS 1983). 'General managers' were to be responsible and accountable for semi-autonomous units. Griffiths maintained that strong management and a private sector ethos would both 'stimulate initiative, urgency and vitality' and ensure 'a constant search for change and cost improvement' (DHSS 1983: 12). The creation of the NHS internal market has further facilitated the perpetuation of this style of management. Indeed, there is a congruence between the concerns of an organisational culture dominated by 'the contract' and the concerns of new public management. In particular, there is an emphasis on performance measure© Blackwell Publishers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 27 ment, defining goals, setting targets, evaluating outputs rather than inputs and ensuring ever greater 'value for money'. Such a change in practice is invariably associated with cultural shifts which pertain to how people think about and promote themselves. Within this environment it is important to be seen to be enterprising, rational, flexible and innovative. As far as those working within health promotion are concerned, these are the skills required by HPSs when they are promoting health. However, as we discuss below, such attributes are not necessarily compatible with their notions of the health promotion function within the NHS. The key features of the internal market and of the new managerialism are often, as we shall see, incompatible with much health promotion practice and philosophy. The study
The exploratory study reported here was carried out in six (former district) health authorities in England which were selected from within one newly merged region. The areas selected were based on 'old' district health authorities each of which originally had a Health Promotion Unit. Because each area is unique, no more detail is given so as to ensure confidentiality and the anonymity of reporting. However, areas selected were diverse and represented a mix of dense urban populations, rural communities, areas of high levels of material deprivation, areas with high levels of environmental pollution and localities which are relatively affluent. In each area the manager of the health promotion unit within a health authority, or the health authority health promotion advisor, was contacted and interviewed. Within these health authorities if health promotion services where purchased from health promotion units which were located within provider settings the managers of these units were also interviewed. The methodological logistics of the research were made more complex by the fact that many informants were either in new posts, about to change their post, or were not sure where they would be by the following year. Such problems were further compounded by the fact that many of the HPSs contacted where nervous about their involvement with any research because they articulated feelings of vulnerability about their future and their relationships with other relevant stakeholders. In total, twenty-four interviews were carried out. Of these, twelve qualitative semi-structured interviews were with HPSs. The directors of public health in five of the six areas were interviewed (with just one refusing to participate). Three health service managers to whom the HPSs were clearly accountable were also interviewed in provider settings where the provider was a trust. In addition, four further interviews were carried out with workers whose function involved either the promotion of health such as a Health for All Co-ordinator, and clinical managers within © Blackwell Publishers Ltd/Editorial Board 1997
28 Sarah Nettleton and Roger Burrows primary care. The interviews were all tape recorded and, because of the exploratory nature of the research, were transcribed in full. The interview data were analysed with two main purposes in mind, first, to establish a descriptive picture of the organisational features and tasks of HPSs and second, to explore the meanings and understandings of actors in order to gain a fuller appreciation of organisational cultures and practices. A range of documentary sources were also examined such as annual reports of directors of public health, health strategy documents, organisational reviews, organisational charts, newsletters, and health promotion contracts. Health promotion services and the internal market
The creation of a market necessitates the location of services on either side of the purchaser provider split, and any attempt to straddle the divide would invariably be difficult. Such a requirement presents conceptual and practical challenges to many groups within the NHS (Flynn et al. 1995); however, some services clearly fit into either side of the market more easily than others. For example, a surgeon provides a service directly to the public usually in a clinical setting. HPSs, on the other hand, carry out functions that could be considered as both purchasing and providing. For example, they have traditionally been involved in activities such as health needs assessment; developing 'bottom up' community health development programmes; and initiating and developing alliances with agencies and organisations beyond the NHS. The Health Education Authority (HEA) funded a review of organisational 'options' for health promotion services which argued that it was imperative for these services to clarify their activities in relation to the market 'divide' (Smith 1993). The Society of Health Education and Promotion Specialists (SHEPS 1994) recognised this problem and outlined what it considered to be both purchaser and provider tasks. The document articulated the hope that the NHS Executive would respond to this and provide national guidelines. However, no such direction has been forthcoming. The boundaries between purchasing and providing functions are still not at all obvious and are therefore being negotiated locally. As Smith (1993: 10) put it: 'there is no common or agreed way in which purchasing and providing are being introduced into health promotion'. The organisational arrangements for health promotion services are, to say the least, diverse (Nettleton and Burrows 1997). Prior to the reforms, health promotion units were located within district health authorities. However, they have not automatically remained part of the newly formed purchasing agencies. Two surveys of health promotion units within the NHS carried out in 1993 (Adams 1993, Jones et al. 1995) found that they were variously located on either side of the internal market. With the polit© Blackwell Publishers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 29 ical imperative to 'slim down' purchasing authorities there has been a trend towards locating health promotion within provider settings. Each district has developed its own arrangements and so there is now considerable diversity across the coimtry. Furthermore, there are also significant differences in the quantity of resources being allocated to health promotion services ranging from £0.38 per head of population served to £5.15 per head, with no obvious reason for the disparity based upon population base or social need (French and Hilditch 1995). These organisational changes have often been protracted and exacting for those involved. The recent organisational history of local health promotion services was discussed with the HPSs many of whom reported that they had been involved hi extensive, and sometimes repeated, reviews of their services. They displayed a frustration at not being able to implement the organisational option favoured by those working within health promotion, and also voiced concern that current organisational 'solutions' did not provide the best means of developing health promotion services. Some however, although they had undergone reviews and change, felt that their current organisational arrangements were favourable. As we shall discuss below, the extent to which organisational arrangements were considered to be satisfactory was largely a function of how health promotion activities were seen to 'fit' within the context of 'host' organisations. This was, in turn, related to differing perceptions of the purpose and content of the work of HPSs.
Health promotion specialists as both purchasers and providers
Amongst our informants some argued that HPSs were most obviously purchasers, others that they were most clearly providers and others that they should most obviously be both. Amongst the HPSs themselves there was a unanimous view that there should be a HPS input into purchasing. From their point of view (and this was a view articulated by some, but not all of the directors of public health) the specialist input was considered to be vital for three main reasons. First, for their contribution to health needs assessment, in that they can complement 'medical' or 'epidemiological' views of this with an alternative or more holistic approach. Second, for their work on the development of the local health strategy, in that one of the core skills of HPSs was said to be their ability to take a strategic view, which is further informed by their extensive contact with a multiplicity of agencies and organisations. Third, their presence is important, given the general lack of understanding throughout the health service as to what health promotion is. HPSs, therefore, argue that they facilitate the conomissioning process in general and also contribute to the contracting process more specifically, both in relation to the contracting of specialist health promotion services and in overseeing the health promotion aspect of other contracts. © Blackwell Publishers Ltd/Editorial Board 1997
30 Sarah Nettleton and Roger Burrows A national level survey reveals that the presence and contribution of HPSs within purchasing varies (Jones et al. 1995). In some authorities we studied there were as many as three specialists and their profile and input in the organisation appeared to be high. In one area there were no fulltime specialists and in yet another area a specialist based in a provider setting was contracted back for a number of hours per week to the purchasers. Presence within the purchasing setting however does not necessarily result in an effective input, indeed a study by Whitelaw (1994) found that specialists within purchasing settings felt that they were systematically marginalised. The specialist's input has of course to be developed and negotiated because, as we have seen, there has been no guidance, nor historical precedence, as to what the HPSs' function should be. For example, one director of public health (DPH) was not at all confident that they had a vital contribution within purchasing: What I think is more difficult is what the role of a health promotion specialist input is at purchaser level, because I think that is much more difficult and I think that certainly a lot of health authorities over the last couple of years or so - and certainly this one - have been having difficulties in trying to establish what he, or she, or they, do (DPH 1:1) By contrast another director of public health felt that the HPS input into their organisation was invaluable and obvious: There is no-one else who takes a kind of overview of those parts of health promotion that aren't strictly medical. And there's no-one but them, really, to work on the ground with other agencies - in a structural sense (DPH 3:1) HPSs in provider settings also emphasised the importance of having a health promotion input into purchasing, and some felt that this was where all the specialists should ideally be based. As this HPS in a trust setting put it: To be brutally honest, I think that health promotion services with purchaser/provider splits just don't work. My guess is that health promotion is probably best served by being part of the health function of the purchaser, my reason for saying that is that I think that the services we provide are not necessarily direct provider services to the public. What we do is to provide, if you like, development services for providers which is something that I think could fit within the role of the purchasing authority (HPS 4:1) Indeed, one of the recurrent themes throughout the interviews with HPSs is that specialists do not 'do' health promotion, rather they 'enable', 'support' and 'facilitate' others to do it (we return to this point below). This © Blackwell Publishers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 31 may partly explain why so many HPSs have felt uncomfortable with the move to provider settings. Relationships between those HPSs who had moved either side of the market divide ranged from good to overtly antagonistic. Many were characterised by at least some level of tension, and clearly they now had different perspectives and interests. As a HPS in a purchaser setting described: I think it is negotiated, I mean in the sense that it is a fairly difRcult relationship - purchaser and provider. I thought it would work locally because the operational manager of the health promotion service and I were colleagues and actually personal friends, and we thought we could hack this and we weren't going to fall out, but it hasn't worked like that, and there seems to be a tension between purchaser and provider (HPS 1:2) Those areas where both the purchaser and the provider described the relationship more favourably were also those where the demarcation between the purchasing and providing functions had been not only established, but perhaps most importantly, accepted and even supported by the HPSs on the provider side. The presence of HPSs in purchasing does not necessarily mean that the fate of specialists in provider settings is any more secure. Smith (1993: 9) makes the point that, within purchasing, HPSs have to take a view that distances them from the interests of specialist providers and, ironically perhaps, the more integrated they are into the commissioning authority and the more autonomy they have, the more likely is this shift of perspective to take place. As a specialist in purchasing, with a long history of working in health promotion within the NHS, pointed out, within the market place it was not inevitable that health promotion provision would be commissioned from HPSs: I think there is a possibility that, with the purchaser provider split, purchasers may commission the health promotion from organisations other than specialist health promotion units, and the trouble is that specialist health promotion units tend to have a sort of pink fit, and throw their hands in the air and say, 'no you can't', when the answer is 'yes we can' and I think probably will. Not this year, and probably not the next, but at some point we are going to be expected to put stuff up for open tender, and that will be projects initially, and I think that we have got to do that, if only to let the health promotion specialists demonstrate that they are the best (HPS 2:2). Such tensions are associated with the ethos of new managerialism and the contract culture described above. When negotiating contracts there is a drive to demonstrate value-for-money and to include systems for e Blackwell Publishers Ltd/Editorial Board 1997
32 Sarah Nettleton and Roger Burrows monitoring activities. HPSs therefore can no longer be 'free spirits' (a term used by a number of our informants when describing HPSs) but they have to conform to the values and practices of the 'new' NHS and evidence based health care. Demonstrating that the work of HPSs is 'the best' is of course riddled with difficulties, and in fact another feature of health promotion discourse is the debate about the lack of any secure knowledge and evidence-base for health promotion activities. The knowledge and evidence base of health promotion
As we have suggested, a key rationale for the introduction of the intemal market was that the NHS could become a needs led rather than a demand led service. Priorities are to be based on health needs assessments; interventions are to be evidence based and should be evaluated, and evaluations should measure outcomes as well as process. Taking a rational and evidence based approach when developing priorities, interventions and outcomes is inherently difficult in any area of health care and the creation of a clear knowledge base is still being undertaken. However, it is especially difficult for health promotion services as there is a notorious lack of watertight evidence about the effectiveness of interventions and a general lack of consensus about suitable outcomes (Burrows et al. 1995). Setting priorities Ideally, within the intemal market, purchasers will determine their priorities on the basis of health needs assessments in conjunction with the development of a local health strategy. This should form the basis of contracts with providers. However the identification of priorities is invariably not quite so straightforward, and they seem to be shaped by a number of factors. The Health of the Nation was cited by all our informants as one of the main ways that priorities were selected. Indeed, concem was often expressed that the 'Health of the Nation' and 'Health Promotion' were coming to be seen as synonymous. The key areas in the Health of the Nation were used to determine the main areas of work, and then epidemiological data could be used to assess the extent to which the Health of the Nation targets were being met locally. Health needs assessments were therefore often carried out within this policy context. In some areas there were attempts to supplement this with more community orientated, qualitative forms of needs assessments. As one director of public health talking about developing priorities explained: Its mainly epidemiological data, but it is also to do with community involvement in that we have got a really quite sophisticated method I think of consulting the community, both through organisations like the O Blackwell Publishers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 33 community health council - we also run focus groups across the population (DPH 3:1). In other areas however this approach was regarded as 'too difficult' and therefore not really feasible. Political factors were also cited as being an important determinant of priorities. The view of one HPS based in purchasing, who said that 'decisions are made and priorities are set that are outside our control', was echoed by others. A number of directors of public health also reported that priorities could be contingent on 'whatever the current Secretary of State felt on the day about x, y and z' (DPH 5:1). This, in turn, was also related to a third factor which contributed to priority setting - that of the media. As another director of public health explained: DPH . . . but of course in a health service, priorities aren't always what the local priorities are - priorities come from political priorities, from outside. We don't have a great number of mentally disorderly offenders who kill and who wander in the streets. SN That's a priority? DPH Yes. SN So do you feel obliged to be seen to be doing something about an issue like that even though it's not your priority? DPH I don't feel that we are, we have to [. . .] Well, strategies have to take account of what the politicians want, because you've got to be pragmatic, you've got to say 'yes we're doing this', these are the success markers, because health authorities are monitored by the regional offices. It's tick in the box stuff. If you are not doing it, then people lose their jobs (DPH 4:1). In sum, the setting of priorities for health promotion is shaped by a number of factors and appears to be more a case of (to use a term of one of our informants) 'juggling' between a range of demands. No clear model for prioritisation seems to exist, as both a director of public health and a HPS put it (coincidentally using exactly the same words!) 'It just isn't that sophisticated yet'. The problem is not just one of setting priorities, however, because even if a rational method were to be established it is not evident how this could be translated into the contracting process. The link between needs assessment, priority setting and contracting was acknowledged to be a problem in all areas but was especially problematic, to quote one director of public health, 'in terms of something as nebulous as health promotion'. This 'link' may be critical to the fate of health promotion services, as the intemal market in concert with limited resources, means that priority setting is becoming (again to use the terminology of our informants): 'more explicit', 'more overt' and, ironically, 'more political'. e Blackwell PubUshers Ltd/Editorial Board 1997
34 Sarah Nettleton and Roger Burrows
Interventions and outcomes Mindful of these developments those involved with the development of health promotion services are concerned to demonstrate that their interventions are either based on evidence of effectiveness or are evaluated, or both. The lack of evidence for the efficacy of health promotion work was universally cited as the main difficulty for health promotion. This has been intensified by the development of a managerial culture which, in theory at least, is orientated towards effective and appropriate interventions. The problem appears to be fourfold. First there is no consensus as to what outcome measures are. As a HPS put it 'in fact there's really very few nationally agreed outcome measures, if any, for health promotion activity.' This is because it is so 'long term' s/he continued: The difficulty is that the way in which clinical effectiveness is being measured or looked at is linked back into research and development and people running controlled trials and everything being scientifically based, and all the rest of it, which is fine for an intervention that has a short term outcome. But I'm trying to argue that health promotion is not so much intervention as an investment and it should be looked at almost in parallel to the money market where you put something in and you don't see very much coming back for some considerable time, but you can see where you've put it and you can see things beginning to happen, but you're not going to actually get your return for some period of time, which is longer than a Financial Year (HPS 2:2). Whether this argument will succeed, however, remains to be seen. Some key actors, such as a director of public health in another area, presented a contrary view to this one: I think, even I, allegedly an advocate of health promotion, have to really start to raise a lot of questions now about is it doing any good? And I know that answer - you get the usual stuff trotted out - you've got to wait 20 years, all the rest of it - but that line has been pushed for a number of years now and frankly you can only say that so many times (DPH 5:1). Another director of public health expressed the view that HPSs were not equipped with the appropriate skills and knowledge adequately to deal with evidence-based practice: One hopes they are drawing on some evidence, but first of all, remember, that they haven't been evidence trained; second, that evidence is pretty weak; third, there has been until recently relatively little attempt to getting evidence together on anything in clinical practice, so why should health promotion be any worse off than the obstetricians with © Blackwell Publishers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 35 the Cochrane database which has taken such a long time to get out? (DPH 1:1). The lack of consensus about outcomes means that monitoring and evaluation is often based on process measures which might not ultimately be so convincing in the bid for resources which requires evidence of effectiveness. As a HPS within a purchasing setting explained: You can't measure in terms of ultimate outcomes, but I think what you have to say to health promotion people is [. . .] Why are you doing that; why are you training school nurses to do smoking - well because if we train school nurses they will have the skills and then they use it in schools, then they teach the kids. So you are looking at process and somewhere down the process you will be able to say if I train 15 school nurses then they will interact with 1500 children and, of those 1500 children, we would expect six per cent to smoke, and it may be that if those children are already smokers, which is quite likely, we may actually change their behaviour. / would be dubious about putting behaviour changes in, but you can do attitudinal changes (HPS 4:2 our emphasis). Thus monitoring and evaluation tend to be orientated towards process measures within contracts. For example, contracts are often negotiated on the basis of a 'currency' such as service delivery days whereby HPSs within provider settings are contracted to allocate so many days to certain types of work. Informants also pointed out that even if there were definitive outcomes - such as behaviour changes - it was not always clear that this was the direct, or indeed even an indirect, result of the health promotion intervention. Thus there is a third problem which HPSs are especially conscious of; they are encouraged to demonstrate effectiveness and yet any real outcomes can never be linked to their input. There is no (to use a new public management term) 'ownership' of efficacy. In a contemporary consumer culture so dominated by images of youthfulness and healthy lifestyles the independent effects of health promotion activities per se, if they exist, are often impossible to disentangle from more general social and behavioural changes (Bunton and Burrows 1995): We are asking health promotion to operate at standards which certainly aren't expected of anything else. Who evaluates what health visitors do? But we have to do it. If there are behaviour changes people say, 'well that's not health promotion, that's something else, that was the John Cleese advert on the telly', and you say, 'well actually, that is all part of health promotion.' 'Ah! but you didn't do it.' It is this ownership of the change people seem to want. They want to believe it is @ Blackwell Publishers Ltd/Editorial Board 1997
36 Sarah Nettleton and Roger Burrows you and only you that create that change and it can't be (HPS 1:2 our emphasis). That HPSs feel that they are being subjected to exacting standards relates to a fourth issue which they have to address and this is the fact that they are working within a field which is perceived to be vague and 'woolly'. Images of health promotion specialists
A nimiber of authors have observed how everyone loves to hate health promotion (Davison and Davey Smith 1995). For example, when arguing that health visitors should be the cornerstone of health promotion activity David Stone, the Director of the Paediatric Epidemiology and Community Health Unit at Glasgow University, offers a dim view of HPSs when he writes: The hiring of inexperienced and semi-skilled youngsters to spread tendentious health promotion messages to a bemused and sceptical public will soon be a thing of the past. Professional journals are already loudly trumpeting the virtues of evidence-based practice and the concept will cause some soul searching within the newly established, and still precarious, health promotion empires up and down the land' (Stone 1996: 29). Yen has commented that: '[H]ealth promotion is the angora sweater of the health service; it's soft and fluffy and it gets right up your nose' (see Bunton 1992). The fact that health promotion has a negative image was something that was not lost on the HPSs. In fact echoing Yen's comment a HPS lamented: 'Health promotion is just like soft pink fluffy clouds; it's hard to get away from that'. Non-HPSs did describe health promotion work as being synonymous with health education. For example, a Health for All Co-ordinator in one area was insistent that none of her work had anything to do with health promotion. She described how her contact with health promotion services was limited because she was more orientated towards community development work. The health promotion services would only be involved in any of her activities if there was a need to have an information based education dimension to a larger project. Health promotion services were equated therefore with the provision of information, developing leaflets and giving advice. The clinical coordinators working within primary care settings also saw the function of HPSs as supplying materials such as leaflets and videos. However, this is an image which HPSs themselves, and some (but not all) directors of public health are trying to get away from. © Blackwell Publishers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 37 HPSs articulated the view that there was a mismatch between what they did and what people think they should do. Essentially HPSs are keen to point out that they are 'enablers' and 'facilitators'; they argue that they make it possible for others to 'do' health promotion, they do not 'do' it themselves. As a HPS in purchasing noted 'I didn't want to see them do any direct work with the public at all and that was one of the areas of contention'. Rather, she continued, the HPSs should be enabling others 'to recognise and make the most effective use of opportunities to introduce health'. Keen to mark out their role HPSs distinguish themselves from 'health promoters': In the field, in probably a vain attempt to get other people to see what health promotion is about, we've tended to differentiate between a health promoter who is really a field worker who works with the patients or clients or, perhaps, the public, someone who has the promotion of health as all or part of their job [. . .] In my view, a HPS is a different animal - they do nothing else but health promotion, but the way in which we do it is that we carry out. . . these words 'enabling', 'coordinating', 'supporting' [. . .] And so a specialist is someone who is supporting these other health promoters so that we don't do, or we do very little, work directly with the public - it's extremely limited. But most of what we do is actually with other professionals - 'supporting', 'enabling', 'advising', 'coordinating', 'networking', 'liaising', all of those kind of words come into it (HPS 2:2). Not everyone, however, is convinced. For example, one director of public health would prefer them to keep to what they were 'good at': I have to be honest with you . . . I know you and I have talked about health promotion specialists . . . this is a relatively new term. When they were part of my outfit, when I was here [some] years ago, when they were part of the original authority, we don't want to get too bogged down in titles, but these were health promotion officers, they did a damn good job, got on with it and so on. Now this kind of health promotion specialist type of thing is something that has come relatively recently and . . . has added to the confusion (DPH 1:1). To try and shed the health promotion image some units (none of those reported in our study) have renamed themselves Health Development units. One unit we studied did however consider it: When you talk about health promotion, a lot of people think that it means leaflets and balloons and telling people - it might mean some of that, but it means so many things and I think it's just too . . . [sic] What we decided to do was that we wanted to be called health C Blackwell Publishers Ltd/Editorial Boaid 1997
38 Sarah Nettleton and Roger Burrows development unit and our role was to support health development [. . .] it wasn't something that people could automatically make assumptions about (HPS 6:1). In sum, HPSs are trying to articulate what they do. Whilst everyone should to some extent be 'doing' health promotion, their 'specialist' skill is to ensure that they are able to do it. If they are to survive, HPSs argue that they would need to orchestrate their management image more effectively: We've got to beflexibleand adaptable. I think we've got to be diplomatic and I don't think we're always that - we seem to be brown rice and lefties who nobody wants to talk to. There is that image, whether we like it or agree with it or not, that we are seen as a highlyprincipled group of people who will not shift and I don't think that's good for us. We might have expertise, but if we can't influence with that expertise what's the point in having it? So I think people need to be able to influence, negotiate, work in this new NHS culture around competition and be analytical and have organisational skills, communication skills (HPS 6:1). Similarly another HPS argued. We operate in the Health Service and we'll not be taken seriously if we're seen running around in Jesus sandals with ethnic gowns on, talking about empowering people - we will not be taken seriously. As soon as I got my MSc in health promotion there were doors opened in the health authority that were never open before and I had [a high status clinical degree]. I think that if you want to be taken seriously, if you want to get money given to you for whatever, then you've got to be in there, you've got to go to the Board with a good suit on, decent hairdo and talk professional language (HPS 2:2) In short, there is an incongruence between dominant cultural beliefs and the practices of HPSs, and the culture of the new public sector managerialism.' Principle, values and 'political correctness' are not considered to be compatible with rational decision making which is presumed to be based on objective assessments of priorities and effectiveness. One manager of a large health promotion unit within a provider setting (who said that she was new to the fleld and could not claim to be a 'health promotion specialist'), articulated this clash of cultures. She commented that when she was amongst some HPSs there was a feeling that her views or approaches were regarded by others as not being sufficiently 'principled' or 'politically correct.' She also commented that as the staff within her unit were coming to accept the new ways of working they too were find© Blackwell Publishers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 39 ing that their own world views were sometimes at odds with those of their colleagues. They had adopted the features of new managerialism. This has, perhaps, made it more difficult for some of their number to come to terms with, what Rose (1992) has usefully termed, the 'governance of the enterprising self - the self-conscious formation and refiexive monitoring of a new habitus demanded by the new managerialism, the 'good suit, decent hairdo and . . . professional language' of the above quote. Many of the observations we have made about the status of health promotion within the NHS are understandable in terms of this clashing of cultures as some of the established assumptions, principles and practices of HPSs are forced to operate in a climate where business-like discourses have come to dominate (Kelly 1991). A conmion theme which recurred throughout a number of interviews was the idea that HPSs are of variable quality. As one director of public health expressed it: I think there's a problem - the problem is that the specialists are of variable quality. That's a problem of our old clinicians, isn't it? But [. . .] the health promotion specialists seem to vary between those who are able to take out a campaigning message, but who also have an understanding about how to undertake the social engineering to be effective; and frankly those who just chum out leafiets and don't attempt to take the broad strategic view that looks at healthier lives as well as the Health Service (DPH 4:1). Such comments were sometimes made by HPSs themselves. Certainly they are a diverse group and come from a wide range of backgrounds. Furthermore, some HPSs appeared to have embraced the reforms more readily than others and argued that the only way forward was to work within the arrangements of the new structures rather than bed down and try to oppose them.
Uncertainty about the fate of health promotion specialists
From our interviews with HPSs it was clear that morale was low amongst the profession; this was also a finding of earlier studies (Smith 1993, Adams 1993). This is perhaps inevitable given the rate of change over recent years, and is a feature of other groups within the NHS. This anxiety is compounded by a sense of uncertainty about the future. As we have seen, health promotion tasks may not inevitably be contracted to specialist services and health promotion appears to be 'everybody's business' except that of HPSs. For example, the health promotion component of primary health care professional work has received much attention in recent years (Yen 1995, DoH 1993, Williams et al. 1993). In fact, there is O Blackwell Publishers Ltd/Editorial Board 1997
40 Sarah Nettleton and Roger Burrows a logic to the idea that if health promotion were to form a part of all contracts then the need for specialists could become redundant. Two imponderables in particular were often highlighted as being potential 'threats' to their future. One was a concern that where health promotion services were located within trusts they might find themselves being 'dictated' to by a trust management, and being made to do tasks which were felt to be at odds with health promotion philosophy. Furthermore, if there were to be financial 'cuts', managers of health promotion units felt that they would be easy targets. Clearly this is an uncertainty, as many trusts are in a state of organisational flux. On the other hand, the trust can, and - in some cases reported to us - does, act as an ally to health promotion units who have a 'difficult' relationship with purchasers. A second uncertainty was the extent to which GPs would shape the future of health promotion services. The conmaent that 'health promotion is like a four letter word to GPs' was made by a number of our informants from a range of settings. Yet resources for health promotion within GP settings are greater than those going to health promotion services within the NHS. This, a director of public health pointed out, may well be a major obstacle for health promotion authorities who want to adopt a broader more 'public health perspective': Remember that you are going to run into this ridiculous situation where health promotion and primary care has been completely bounced by the GP Contract where health promotion is a very mechanistic approach. That has all got to be unpicked - the politics of it as well as the practice of it. And for me that's the area where health strategy and health promotion needs to get going (DPH 5:1). The specialist input within purchasing could have a clear role hfere, to ensure the strategic and co-ordinated approach of health promotion within primary care (Russell, 1995:51-2). However, GPs were reported as often being antagonistic about the fact that health authorities were putting any resources into health promotion services at all (see also the case reported by Bunce (1996) on GP attitudes to public health interventions more generally). Another concern was that as health promotion is now being channelled through primary care settings it is not clear to what extent GPs would recognise and support what HPSs could offer. As a HPS in purchasing refiected: If you think about it, a total fundholder is supposed to be purchasing absolutely everything, so if he [sic] feels that he needs so many sessions from a chiropodist, or from a dietician, or from a physio, or from an aromatherapist, or whatever, he can use his funds to buy those in for his patients. Now whether he recognises that HPSs have particular skills that they could offer to the primary health care team to enable them to perform to a higher standard, or to an all-embracing standard © Blackwell Publistiers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 41 that would recognise the health needs of the whole practice population, I don't think they've got hold of that yet; health promotion generally to most GPs is about various bands^, and it is about the patients they see on the other side of their desk (HPS 5:1). Another specialist commented how a colleague had said that in the current climate a priority should be that they 'must sell' health promotion to GPs. She retorted 'What! Sell health promotion! We can't even give it away'. As GP fundholders and GP total fundholders come to play an increasingly significant role in shaping the internal market this matter will take on an even greater salience. Discussion
Our task here has been neither to defend nor criticise health promotion services but rather to try and understand their current place within the NHS. Like everyone within the health service they are having to respond to radically different organisational structures and culture. There are however a nimiber of features that make the situation of HPSs unique. First, their raison d'etre for promoting the health of the population is high on the policy agenda, and yet they are not. Health promotion policies completely ignore the role of HPSs and, although the health promotion aspect of the work of public health consultants has received a mention (Abrams Report 1993), policies have predominantly been orientated towards primary health care. Second, there is no guidance to support the 'evolution' of health promotion within the internal market and so organisational arrangements have had to be negotiated locally. This process has been compounded by the fact that health promotion services do not easily fit wholly into either purchaser or provider functions. Third, the instabilities and uncertainties which are invariably associated with organisational change are intensified by the fact that health promotion has an image of being vague, woolly and ineffective. The image and lack of an evidence base for health promotion are fundamentally interrelated as they tend to feed off each other: the lack of evidence base leads to a poor image; a poor image means that the spotlight is on demonstrative effectiveness. This probably presents one of the main challenges for health promotion and, given the state of research on the effectiveness of health promotion (NHS Centre for Reviews and Dissemination 1995), it is not clear how it will come out of this impasse. Of course, HPSs are likely to be worse off than, say, obstetricians because they do not have the same amount of status and quantity of resources, nor as we saw above do they 'own' many of their interventions. Fourth, the core tasks and skills, which HPSs claim they can offer, such as 'enabling', 'facilitating', 'acting as change agents', 'negotiating', O BlackweU Publishers Ltd/Editorial Board 1997
42 Sarah Nettleton and Roger Burrows and so on, are not amenable to a market environment which wants to identify what it is getting for its money. Such things are also not easy to measure and they do not rest easily with the cycle of purchasing, contracting and providing. Somewhat ironically perhaps, those very skills, which HPSs claim to have, ought to form the basis of the reformed health service which is based, in theory, not on bureaucratic hierarchies but on relationships and contracts. However, when it comes to promoting health promotion services these skills have not been sufficient to overcome the barriers and difficulties discussed here and HPSs are certainly not uniformly confident about their fate. Health promotion discourse has a politically high profile and yet HPSs have been left out 'in the cold'. This presents a puzzle which begs sociological explanation. A fairly pragmatic response to this puzzle would be that as an occupational group HPSs are small in number and are therefore politically of little consequence. However, recent sociological thinking also offers some explanations. There are three interrelated sociological arguments which may help us to make more sense of this conundrum. These revolve around issues of: occupational credibility and legitimacy; the nature of health promotion knowledge; and the incongruence between health promotion practice and the techniques of 'modernist' evaluations of health care dominated by health economics. We shall briefly discuss each of these. In his analysis of professions Abbott (1988) has argued that the content of the work of professions should always provide the initial point of departure for analysis. It is difficult to discern any work, skills or tasks which are unique to HPSs. The skills which they profess of enabling, negotiating and communicating are tasks which could, arguably, be developed by any occupational group. In fact, HPSs themselves work at equipping other health professionals with these very skills. The work of HPSs is, then, in many respects 'all form and no content'. More importantly, from Abbott's perspective, they do not possess any abstract or esoteric knowledge which accompanies their work content, what Abbott labels 'jurisdiction'. Abbott writes: . . . only a knowledge system governed by abstractions can redefine its problems and tasks, defend them from interlopers, and seize new problems - as medicine has recently seized alcoholism, mental illness, hyperactivity in children, obesity, and numerous other things. Abstraction enables survival in the competitive system of professions' (Abbott 1988:9). Indeed, some professional groups such as GPs (Davies 1984) and practice nurses (Allen 1996) have 'seized' health promotion in ways which have enhanced their status. HPSs however do not have any jurisdiction over their work content and very often rely, as we have seen, on the © Blackwell Publishers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 43 abstract knowledge base of other professional and occupational groups. Not surprisingly then, one HPS playfully said during interview that 'I did once try and argue that public health was part of health promotion but that didn't get very far.' Abbott conceptualises the professional system as one which involves the ceaseless struggle over the definition of jurisdiction of tasks which require expertise - the problem for HPSs is that they have no such concrete and tangible tasks nor a definitive expertise of any given 'object of knowledge'. This presents a further related problem for HPSs. Because they possess no definitive or discemable object of knowledge, they have no discemable client group over and above the population as a whole. They do not have a fundamental knowledge of a particular object, in contrast to say medical practitioners who have an esoteric knowledge of how the body works. Foucauldian analyses of the emergence of specific professional groups or sub-specialists have drawn attention to the way in which their formation is linked to the creation of a specific object, be it the body (Armstrong 1983) or part of the body (Nettleton 1992). HPSs do of course claim to focus on health but this remains a relatively nebulous concept and the knowledge and practices which are associated with it are riddled with tensions. The discourse of health promotion is characterised by a series of philosophical and ideological tensions or dilemmas. It is also criticised by those on the political Left and those on the political Right. A number of questions are continually debated within the health promotion discourse: Is it individualistic or structural in its approach? Is it 'top-down' or is it 'bottom up'? Is it authoritarian or liberal? Is it premised on a biomedical or a holistic socio-environmental model of health? A particularly obvious example of these tensions is the fact that health promotion discourse claims to provide an alternative to the biomedical approach to disease prevention, and yet at the same time biomedicine is seen to provide the starting point of many health promotion activities. It could be, therefore, that the organisational tensions described in this study are simply manifestations of these more profound philosophical contradictions which have been acknowledged within the medical sociology literature (cf McQueen 1989, Kelly and Charlton 1995, Davison and Davey Smith 1995). The discourse of health promotion therefore contains no underlying logic or coherence and its activities and theories draw from a range of paradigms and disciplines (Bunton and MacDonald, 1992). Although, on some occasions, this disciplinary diversity may be articulated as a strength, within the context of the current organisational changes it can easily be viewed as a weakness. Perhaps not surprisingly, given the current vogue for the terminology, the philosophical ambiguities in health promotion have been described in terms of tensions between modernist and postmodernist discourses (Kelly and Charlton 1995, Prior 1995). However, any ambiguities that health @ Blackwell PublUhcrs Ltd/Editorial Board 1997
44 Sarah Nettleton and Roger Burrows promotion discourses contain are unlikely to be tolerated by the strongly modernist frame of health economics that is coming to dominate evaluations of health care (Burrows et al. 1995, Craig and Walker 1996). In essence, much health promotion activity appears unable to conform to the evaluative frameworks demanded by health economics (Tolly 1993). To the extent that the conceptual repertoire provided by health economics continues to have an elective affinity with the organisational changes invoked by the 'reforms' the position of health promotion will be eroded. Although health promotion may attempt to rearticixlate what it does in terms of the vocabulary of health economics it is unlikely to succeed in the race for resources against those areas of health care better able to demonstrate clear measurability and efficacy.
HPSs and health promotion services within the health service have been neglected by policy makers and medical sociologists. This is perhaps surprising given the high profile that has been given to health promotion policies and activities during the last decade. Given this high profile, one might expect HPSs to be feeling confident about their role and function and secure about their future within the NHS. However, our research suggests that this is not the case; in fact many HPSs are feeling insecure and vulnerable as to what the future may hold for them. We have suggested that this may be due to the fact that there are a number of features about health promotion, which inevitably means that they will find it difficult to carve out their niche within the reformed NHS, since this is dominated by a contract culture and a drive for evidenced based health care. In practice, we have seen that in the fields of health promotion and public health, attempts to develop priorities based on need and cost-effective, evidenced based interventions are mediated by various political factors. Ironically, the promotional culture which is developing in the NHS is one largely antithetical to HPSs. We have suggested that their status and image is further undermined because they lack any degree of jurisdiction over their work which in turn undermines their occupational credibility and legitimacy (Abbott 1988). The knowledge that is associated with the discourse of health promotion is characterised by tensions and diversity and is not linked to any discrete 'object'. Given this, we conclude that unless HPSs are able to adapt to the ways and means of the internal market, to develop a more coherent and abstracted knowledge base and devise a strategic response to the requirements of evidence based health care there is a possibility that health promotion will soon become everyone's business except that of the specialists in health promotion. Address for correspondence: Sarah Nettleton, Department of Social Policy and Social Work, University of York, Heslington, York, YOl 5DD. O Blackwell PubUshers Ltd/Editorial Board 1997
Health promotion and the health promotion specialist 45 Acknowledgement The research reported here was funded by the NufBeld Foundation. We are grateful for the comments made by Simon Williams and the editors of this journal on the first draft of this paper.
Notes 1 The need to he 'flexihle' is, of course, not unique to health promotion within the NHS hut is part of a far wider discursive shift evident in a range of spheres. For an excellent analysis of this phenomena see Martin (1995). 2 For further details of the funding of health promotion and the handing systems within general practice see Yen (1995). This system is currently heing revised hy the NHS Executive.
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