HEALTH PROMOTION
2
© Oxford University Presi 1988
A healthy city strategy three years on—the case of
Oxford City Council*
PHIL FRYER
Health Liaison Officer, Oxford City Environmental Health Department, Oxford, United Kingdom
SUMMARY
There has been a rapid growth in Healthy Cities
project initiatives in the United Kingdom since 1984.
In the first instance, local authorities in cities such as
Sheffield, Lambeth, Leeds, and Manchester renewed
their interest in public health, joined later by a wave of
activity under the World Health Organization Healthy
Cities umbrella. The initiative of Oxford City Council
dates back to 1984. Since that time the Council has
developed and implemented a local authority health
strategy spanning personal, social and environmental
health issues. In conjunction with community physi-
cians, the Council is undertaking a continuing health
audit of its services. It has launched major initiatives
on the prevention of coronary heart disease, AIDS
awareness, heating and home safety, and the health of
GETTING STARTED
A growing band of local authorities—including
those in Sheffield, Lambeth, Leeds, Manchester,
Greenwich and Waltham Forest—are talcing
major initiatives in public health. Oxford's
involvement began in 1984 when the local
Labour Party, dissatisfied with an unresponsive
health authority and yet another round of cuts
and closures, committed itself to advancing the
city's health in the broadest sense. This initiative
has now taken the form of developing a city
health strategy in conjunction with other bodies
and the community at large. The primary aim of
the strategy is to offset health inequalities in
Oxford, and the key to the strategy lies in many
local authority responsibilities for such things as
• This article was prepared for the 2nd International
Conference on Health Promotion: Healthy Public
Policy, held 5-9 April 1988 in Adelaide, South
Australia.
Vol 3, No.
Printed in Great Britain
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people from ethnic minority groups. Each of these
programmes is intersectoral and developed in associ-
ation with local communities and the voluntary sector.
A network of health groups has been established to
support and develop the work. This article outlines the
origins, development, and potential future of the
Oxford city health strategy, the difficulties encoun-
tered, and how problems have been overcome. The
philosophy of the initiative to date has been activist
rather than theoretical. The aim remains to act now in
the interest of the city's health, with local communities,
the voluntary sector, and the many local groups and
individuals who have enthusiastically risen to the
challenge of health for all.
housing, planning, recreation and environmental
health. The second strand of the strategy is to
develop a radical programme of community
involvement in public health stretching across
a wide range of issues including food policies,
smoking prevention, occupational health, recre-
ation and exercise, AIDS prevention, cervical
cancer, and health information and research.
The evolution of the health strategy over the
past three years has led to a number of reorgan-
izations and developments in the city Labour
Party as well as in the local authority. Political
commitment to public health is a necessary pre-
condition for unlocking funds and officers' time
for a health strategy. The political commitment
of the Oxford Labour Party was secured through
a number of factors. First, the health trade
unions lobbied the Labour Party from November
1983 until a political commitment to form a
Health Liaison Committee was extracted in May
213
214 P. FRYER
1984. Second, activists pushed hard to establish
a health working party within the city Labour
Party. This working party acted and continues to
act as a pressure group for public health within
the Party. Among its achievements is the pub-
lication of a policy document on health in the city
and the formation of the Health and Environ-
mental Control Committee in May 1985 through
merging the traditional Environmental Health
Committee with the new Health Liaison Com-
mittee (formed in May 1984). The city now has
a single committee to oversee health matters in
the Council. Agenda items range from healthy
eating and community fitness, radiation monit-
oring and acid rain to cervical cancer and AIDS.
Personal, social and environmental health issues
are part and parcel of this Committee's agenda.
Such has been the power of this new agenda for
public health that all parties' agreement has been
secured for the major initiatives taking place in
the city.
ORGANIZING A STRUCTURE
Once the political base was secured, the major
protagonists of the city health lobby set about
reorganizing the Environmental Health Depart-
ment to secure the structure best suited to the
new priorities. The new Health and Environ-
mental Control Committee required an integra-
tion of the health promotion and liaison role into
traditional environmental health. The liaison
role began life in the Department of Planning,
Estates and Architecture. The transfer of the role
to Environmental Health has helped to secure the
rapid development of health promotion functions
on the foundation of traditional work such as
food inspection, pollution control, occupational
health and housing. The Health Liaison and Pro-
motion Section is part of the Division of Com-
mercial and Industrial Health. It contains a
Health Liaison Officer, an AIDS Liaison Officer,
a Home Safety Officer and two part-time com-
munity health workers. The placing of the Section
in the Department has led to a series of bids for
new staff that place officers with a health promo-
tion role in traditional sections. Hence, a com-
munity dietician now works in the Food Hygiene
Section. She is building on the food inspection
work in developing a healthy eating programme
for the city. An Energy and Heating Officer has
been placed in the Housing Section to develop a
programme to arrest the unnecessary ill health
and deaths associated with inadequate heating.
Most recently a Community Fitness Officer began
work in the Occupational Health Section offering
services to employers in the city.
Concomitant with this structural change was a
change of ethos and a new team spirit. Traditional
environmental health lived in the shadow of med-
ical practitioners. The new public health strategy
has provided a vigorous platform fulfilling some
of the frustrated ambitions of the Environmental
Health Officers to take on new and exciting
work. The recruitment of new officers has aided
this process since the new recruits have shown
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evidence of experience in community activism
and community skills.
ENLISTING COUNCIL DEPARTMENTS—
FROM INVOLVEMENT TO HEALTH AUDIT
To secure the change of ethos in the Council as a
whole, the city has set up a network of health
working groups. This began with the formation
of the City Health Working Group in July 1985.
This group is comprised of representatives of
each of the Council's Departments: Housing;
City Engineers and Recreation; Planning, Estates
and Architecture; Environmental Health; Per-
sonnel; City Secretaries and Solicitors; and City
Treasury. It also includes representatives of both
statutory and voluntary health bodies in Oxford.
The first major task of the group was to formu-
late the health strategy that became Council
policy in January 1986. The second task has
proved to be more difficult. Each Council
department was asked to produce health targets.
The purpose of the exercise was to direct work
towards the overall goals of the strategy. To
accomplish this task it has proved necessary to
set up an additional group—the local authority
health audit group. As a result, over 100 targets
have been developed by the seven departments
and work is currently being undertaken with
community physicians to refine and improve the
targets before their publication in the near
future. Such targets focus on the numbers of
places with a smoke-free atmosphere in the city,
the completion of an emissions inventory, safe
routes to school for children, and the extension
and improvement of health screening at work.
The Planning, Estates and Architecture Depart-
ment took up the challenge of health data and
looked at the feasibility of developing a health
database for the city. A by-product of this work

has been the ranking of neighbourhoods in an
index of deprivation using class indicators such as
housing and employment. This ranking directed
the attention of the health strategy to the social
geography of ill health, which mirrored that of
social class.
The Engineers and Recreation Department has
advanced the health strategy through develop-
ing projects for safe routes to school and safe
cycle routes, and through a rapidly developing
community fitness programme. With 250 staff
engaged in recreation and leisure centres, the
foundation for health initiatives is strong. A
health and recreation group was set up to
examine a number of possible projects. Two
fitness testing systems were purchased and are
now in use in the community, offering a test, a
computer read-out on an exercise programme
geared to an individual's level of fitness, and
additional health promotion information on diet
and smoking prevention. A health training pro-
gramme for recreation workers is being put
together on the basis of the use of the system.
Plans exist for a community health bus to be
used in the testing programme.
The City Council employs 1300 people, which
gives it the opportunity of pioneering a model
occupational health policy. Already a smoke-free
atmosphere has been established in offices and
workplaces. Courses to help people stop smoking
are planned. The project for the prevention of
heart attack and stroke is to advise the city on its
health screening programme. The idea is to
develop the policy and then extend it to trade
unions and employers in the city. An important
by-product of the process is to inform the work-
force of the aims and objectives of the healthy
strategy and Healthy Oxford 2000 Campaign.
Bit by bit the various parts of the city bureau-
cracy are being enlisted into the health initiative.
The existence of a Healthy Oxford 2000 Cam-
paign Fund of £24 000 has aided this develop-
ment by priming the pump for joint projects.
The Fund can be used by any department or
community group falling within the target areas
of the Campaign. Most recently the local author-
ity health audit group has recommended that all
departments of the Council develop their own
health strategies, and that targets be appended to
these strategies. To provide a focus for the next
round of target-setting the following "runners"
have been identified for the exercise: smoking,
alcohol, exercise, healthy eating, stress and
HEALTHY CITY STRATEGY—OXFORD 215
AIDS. Progress towards the targets will be
reviewed every six months.
INVOLVING THE COMMUNITY-
NEIGHBOURHOOD WORK
The Healthy Oxford 2000 Campaign was
launched by the city in November 1986, inspired
by the World Health Organization (WHO)
Healthy Cities project. The campaign outlines
25 target areas for work in the city. A health
newsletter was distributed to every household in
the city as a form of public consultation. The
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newsletter, which will be continued and pub-
lished quarterly, concentrated on eight spearhead
projects on: heating, home safety, ethnic minor-
ities, screening for cervical cancer, AIDS pre-
vention, healthy food, community fitness and
smoking prevention. Early responses suggest
widespread interest and a desire on the part of
organizations and individuals in the city to
participate in the Campaign. Aid to the value of
£20 000 has been earmarked to encourage com-
munity participation. This fund is being used
to engage voluntary organizations in a joint
planning exercise around the concerns of the
25 target areas. The members of the city's health
committee meet with the 30-40 funded groups to
negotiate a health contract—a mutual under-
standing of how city and voluntary organizations
are going to work together over the coming year.
The health contract system has greatly improved
the performance of both the Council and the
voluntary sector in focusing on achievable targets
in the campaign; good examples of such targeting
include the setting up of a "cold-line" by Age
Concern—a joint measure aimed at reducing
cold-related illnesses—and the financing of a
healthy eating guide prepared by the Oxford
Vegetarians.
Neighbourhood work has been steadily devel-
oping. The city and the Oxfordshire Health
Authority have a joint programme of neighbour-
hood health events organized in conjunction with
local schools and community organizations. A
"heart-fit" project is about to be launched. It will
include a basic health check, a fitness test and a
health knowledge assessment. The follow-up will
have two parts. First, smoking cessation, weight
reduction and other personal services will be
offered. Second, social and environmental
services will be offered in the form of a home
safety and home heating visit and a check on
216 P. FRYER
the use of welfare benefits. The integration of
personal and environmental health issues is one
of the manifest advantages of advancing health
promotion in the Environmental Health Depart-
ment. Our latest idea in this regard is to build
up a series of self-sufficient health promotion
modules that are capable of being offered in
many contexts, either separately or together (see
Fig. 1). Each of these modules is interdisciplin-
ary and involves the voluntary sector. Each can
be offered in a health centre, by a general practi-
tioner or in a community setting. Collectively
they can be promoted as local or city-wide health
events.
Hetlthy Oxford 2000 Exhibition
Neighbourhood health ft
regutention check card
Pobhoty,
Refemjs from
prirauy ore, etc
Fig. 1: Healthy Oxford 2000—neighbourhood health
fit check scheme
The modules will be integrated into the existing
programme of city-wide events that are based
around the town hall, the city's open market and
its public buildings. Openings f or health pro-
motion include the use of stalls and public space
and exhibitions. The idea is to be as opportunistic
as possible in exploring for health the multi-
faceted setting of a local council.
INVOLVING THE COMMUNITY
On 13 October 1987, the city and the Oxfordshire
Health Authority, jointly with the health educa-
tion authority, facilitated the signing of 13 health
contracts with employers in the city. Among the
companies signing were the following: Austin
Rover, Unipart, Oxford United Football Club,
British Telecom, Oxford Polytechnic, Oxford
and Swindon Co-operative Society and of course
the City Council and Oxfordshire Health Au-
thority. Collectively these companies employ
41 000 workers in Oxford and its surroundings.
The health contract stipulates a number of
conditions for employers to fulfil in improving
the health of their workforces and aiding health
promotion in general. A follow-up "heart-fit"
package is being prepared by the City Council
and the Oxfordshire Health Authority to help
employers act on their public statements of
commitment. The package includes health and
fitness testing, health knowledge assessment,
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workshops and consultancy on key campaign
issues such as eating, smoking, alcohol, exercise
and stress. It is hoped to integrate the industrial
with the community side of the health promotion
package by setting the "magic" target of 2000
heart-fit tests by April 1989—1000 at work and
1000 in the community.
CASE STUDIES—THE EXAMPLE OF AIDS
The most contentious and yet most influential
initiative the city has yet undertaken was the
appointment of the first AIDS Liaison Officer in
the United Kingdom. This post is jointly funded
by the Council and the Oxfordshire Health Au-
thority, but based in the Environmental Health
Department. The city has developed an AIDS
strategy that includes action on public cam-
paigns, the promotion of condom use, and needle
exchange. A mobile exhibition is now in use and
work against AIDS is being spurred on by an
intersectoral strategy encompassing health,
housing, social services, community nursing and
the voluntary sector.
The city pioneered the post on the basis of a
projection of premature deaths from AIDS made
as part of a community health profile. Action on
AIDS became the major priority of the health
strategy once it was revealed that the disease
would become the major cause of premature
deaths (those in people under 65 years of age) in
the city within five years. The demand on the
post has been so great that the city has helped to
fund, through a health contract, a development
worker for the voluntary group OXAIDS. A
third worker has now been appointed by the
Health Authority to prepare people in primary
care and community nursing for the care of
patients with HIV-related illnesses. The AIDS
initiative has set a pattern emulated by parallel

projects on food, heating and home safety, and
community fitness. The pattern is the following:
• the joint recognition of a problem by the
Council and the Health Authority
• the formation of joint working group(s)
• the appointment of an officer
• the joint grounding and supervision of related
projects.
This process of joint work is not without its
fair share of conflict, professional jealousy and
personality difficulties. It has proved, however,
far more advantageous to all parties than each
going off and doing its own thing. Arguments
and criticism are aired to the mutual benefit of
professionals and the community. Only rarely in
the course of three years has it proved impossible
for one side or the other to climb out of the
trench of perceived professional self-interest in
the interest of the greater good.
TOWARDS STRATEGIC PLANNING WITH
THE HEALTH AUTHORITY
The expansion of interdisciplinary forums,
sponsored by the City Council with the Health
Authority, led inevitably to the formation of a
strategic planning group, meeting each month,
for healthy city initiatives in Oxford. This group
is comprised of the Assistant General Manager
of the Health Authority, the District Medical
Officer of Health, the Director of the Health
Unit, the Assistant Director of Nursing Services
(Oxford area) and the city's Environmental
Health Officer and his team. The group's chair
changes each year and is shared by the Medical
Officer of Health and city Environmental Health
Officer. Mutual criticism and health advocacy is
encouraged since both sides fear the cosiness of a
"bilateral corporatism" could blunt the cutting
edge of public health advocacy. The Mediqal
Officer criticizes housing, recreation and plan-
ning in the interests of public health and is
criticized in turn on improvements in screening
services, consumer awareness and, of course,
health promotion services. In general, however,
criticism is a spur towards more systematic
collaboration on the key issues in the health of
the city.
HEALTHY CITY STRATEGY—OXFORD 217
HEALTHY CITIES—NATIONAL ISSUES
The vitality of the new public health in the United
Kingdom, centred in local authorities, stems
from the fact that the initiative has developed
outside medical control. It is a municipal and
community model subject to local democratic
control. Work with the Health Authority and
especially community medicine, however, means
the lay public health model is supplemented and
supported by skilled physicians and epidemi-
ologists. The result is the benefits of a non-
medical and a medical model working hand in
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hand; partnership is the key concept. Every day
the new class of officers dealing with the public
health in cities, whether in newly founded health
units or in environmental health departments,
meets its medical counterpart as an equal. It is
hoped that the Acheson Enquiry into the future
of community medicine will glean some insights
into alternative models by looking at the Oxford
experience.
The city is collating and preparing abstracts of
its health strategies. They are to be presented to
councillors as a city health policy. In the mean-
time, a two-day training package for other cities
in the United Kingdom has been created with the
Health Education Council, to spread the Oxford
method of work as rapidly as possible.
Progress on advancing the strategy is reported
regularly to the recently formed national organ-
ization of health committees. A division of
labour is beginning to emerge between cities
participating in this network. The WHO Healthy
Cities project has added a welcome spur to the
new public health in the United Kingdom, as well
as an international dimension.
Although it is recognized that the solutions to
major public health problems (such as structural
unemployment, the size and distribution of
incomes, and agricultural policy) do not lie, for
the most part, in the hands of local government,
conviction is growing that local authorities can
play an effective role in advancing public health
in their localities—a role that they can strengthen
by joining together to influence the national and
international agendas for public health in the late
1980s and the 1990s.
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