Jnl Soc. Pol.

(2012), 41, 2, 391–408 

C Cambridge University Press 2012

doi:10.1017/S0047279411000985

Policy Success and Public Health: The Case

of Public Health in England

R OB BAG G OTT

Health Policy Research Unit, De Montfort University, Leicester, LE1 9BH

email: rbaggott@dmu.ac.uk

Abstract
Like many countries, England has introduced a range of policies and strategies on public
health since the early 1990s. Using concepts drawn from the policy success and failure literature,
this article concludes that recent governments in England achieved only ‘precarious success’
in McConnell’s typology. It demonstrates, with wider significance, that success or failure is
not merely about policy achievement in programme terms, but that policy processes and
the political dimensions of policy must be included in any evaluation. It also highlights the
adversarial nature of public health policy, the subjectivity of judgments about effectiveness
and the political problems this creates for government. The article pinpoints the relevance
of public health policies for judgements about government competence, trustworthiness and
accountability. It argues that failures of public health policy, including poor evaluation and
failures to learn from experience, may be more comprehensible by adopting a political analysis
of public policy making in this field.

Introduction
Many countries now have public health strategies, typically identifying the main
causes of mortality and morbidity and how these can be reduced (see, for
example, the latest strategies of the US Federal Government (USDHHS, 2011)
and the Australian National Government (2010). A number of countries have
had strategies in place for some years. In England, for example, the Conservative
Government under John Major introduced The Health of the Nation (HOTN)
strategy in 1992 (DH, 1992). Tony Blair’s Labour Government published two
white papers on the subject: Saving Lives (DH, 1999) and Choosing Health (HM
Government/DH, 2004) and a further white paper on community health services,
Our Health, Our Care, Our Say (DH, 2006), which had important implications
for public health. These strategies have been accompanied by policies on specific
issues such as obesity, food safety, smoking, alcohol, drugs, sexual health, as well
as health inequalities, Despite all this, criticisms have persisted that government
is not doing enough to prioritise public health objectives and implement policies
(Hunter et al., 2010; Health Committee, 2009; Healthcare Commission and
Audit Commission, 2008; Baggott, 2010). Meanwhile, the current Coalition

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Government under David Cameron has brought forward a new set of policies
(DH, 2010a, 2010c, 2011a).
This article explores public health policies in England over the past two
decades and focuses upon how judgements can be made about their success or
failure. This is important not only for those interested purely in the English
case, but more generally for the analysis of public health policy and strategy
in other countries. First, though, what constitutes ‘policy success’ or ’policy
failure’? Fortunately, there is body of literature available, which sheds light on
these concepts and helps provide a framework for this analysis.
When looking at success or failure, a distinction can be made between
politics and programmes, reflected by Edelman’s (1977) observation that words
may succeed while policies fail. ‘Warm, fuzzy, ambiguous language’ (McConnell,
2010: 126) is often used by politicians and state bureaucracies to build wider
support for policies. Government may manipulate political agendas through
placebo or symbolic policies. Asymmetry between programme and political
success is therefore biased towards the latter. However, as Bovens et al. (2001)
observe, it is also possible for programmes to succeed while politics fails (that
is, policy objectives are achieved but the government continues to faces political
problems). Furthermore, McConnell (2010) identifies three dimensions of policy
success: programme success (for example, meeting stated objectives, producing
desired outcomes), process success (preserving the legitimacy of the policy process,
ensuring successful implementation) and political success (enhancing electoral
prospects or reputation of governments and leaders, controlling the policy
agenda, sustaining the broad values and direction of government).
Policy success or failure is rarely pure. In most cases, there are degrees of both.
Policy fiascos lie at the extreme negative end of the spectrum (Bovens and t’Hart,
1996). Meanwhile, McConnell identifies degrees of success ranging from ‘policy
success’ (where government achieves its aims using legitimate processes and
gathering no opposition) to ‘policy failure’ (where these goals are not achieved,
attract overwhelming opposition and use processes that are not legitimate).
However, most policies fall into the middle range categories of ‘durable success’
(falling short of aims by a modest degree), ‘conflicted success’ (success is heavily
contested) or ‘precarious success’ (operating on the edge of failure, with some
successes but major shortfalls). These five possible outcomes can occur across the
three dimensions of success as described above. McConnell thereby demonstrates
that it is possible for policies to succeed on some dimensions, but not others.
Another important consideration relates to the subjectivity of judgements
about policy success. Such judgements are linked to expectations about
government policy, which vary. Bovens and t’Hart (1996) argue that optimists,
pessimists and realists hold different views about the competence and capacity
of governments. Judgements about success or failure will reflect these broader
perspectives. In addition, there is a general acknowledgement that despite

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 public health and policy success in england 393

efforts by neo-liberal governments to reduce public expectations about state

intervention, these remain high. This is particularly relevant to public health,
where, despite complaints about the ‘nanny state’, there is a strong ethical
basis and much public support for government involvement in preventing
illness and promoting health (see Nuffield Council on Bioethics, 2007).
Furthermore, judgments concerning policy success and failure are often rooted in
economic interests. Industry, for example, often views public health interventions
differently from health professionals and campaigners. As the criteria for success
will vary according to the observer’s perspective, it has been proposed that
policies should be assessed against the criteria set by government. For example,
McConnell (2010: 39) defines policy as successful ‘insofar as it achieves the goals
that proponents set out to achieve’. As Bovens and t’Hart (1996) observe, students
of policy failure also use similar criteria. However, as many authors in the field
acknowledge, there are situations where governments do not operate with explicit
objectives, or where their ‘real’ objectives are hidden. This makes it extremely
difficult to make judgements about success and failure. Another problem is that
government objectives (explicit or hidden) change over time, making it difficult
to assess progress against moving targets.
Evaluation and the generation of evidence are crucial factors in shaping
judgements about success and failure. Evaluation is therefore ‘a political act
carried out in a political context’ (Gray and t’Hart, 1998: 9). McConnell shows
that policy-makers seek to influence evaluation, applying a range of techniques
(including a tight grip on evaluation studies, influencing media coverage of
reports, using particular language and symbolism to indicate achievement and
controlling the flow of information and evidence about policy impact). Although
‘tight grip’ strategies are the norm, policy-makers may choose a looser grip,
allowing for a more independent evaluation to strengthen legitimacy of their
policies, or to encourage criticism of existing policy to build a stronger case for
reform. Other important issues pertinent to evaluation include the timing of
evaluation and spatial factors (Bovens and t’Hart, 1996; McConnell, 2010). An
evaluation conducted at one point may suggest policy failure, at another, success.
The timing of public health policy evaluation is crucial because many initiatives
(diabetes prevention, for example) may take many years to bear fruit. Spatial
factors can also affect judgments about success and failure. If evaluations are
narrowly focused on particular outcomes, the wider costs and benefits of policy
may be missed. Public health interventions are particularly prone to this, with
the wider impact of complex community interventions often difficult to capture.
Moreover, this type of evidence is frequently given less weight than controlled
study designs (notably randomised controlled trials), which are difficult if not
impossible to use in community settings (Mackenzie et al., 2010).
Another consideration is the impact of judgements regarding success and
failure on wider issues of governance and accountability. Such judgements are

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often related to allocation of blame and responsibility and play a role in holding
governments to account. They also provide opportunities for policy learning.
For example, policy fiascos can provide a basis for understanding the pathology
of public policy, enabling similar problems to be avoided in future (Bovens and
t’Hart, 1996). McConnell, however, argues that policy-makers learn more from
success than from failure (for him, failure-based learning tends to be superficial).
Also, he notes that as powerful forces produce policy continuity, policy-makers
are more likely to build on success in an attempt to maintain current policy
trajectories. However, learning from success or failure and subsequent policy
change is not guaranteed, due to a range of constraints (ideological, psychological,
institutional, political and structural).

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

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 public health and policy success in england 395

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., 2010; Haroun, et al., 2011), 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

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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, 1998; 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

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 public health and policy success in england 397

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, 1984). 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 Govern-
ment 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,
2010) 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

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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, 2011).
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, 2009). However, the evidence that nudging improves health is
weak, especially in the absence of regulatory measures (Bonell et al., 2011).

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 public health and policy success in england 399

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, 2004; Hunter, et al., 2010, 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, 2010).
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,

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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, 2004; 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, 2004), 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., 2010; Hunter
et al., 2011). Furthermore, there was concern that accountability mechanisms were
not robust enough to ensure partners delivered on their commitments (Hunter
et al., 2011). In some local areas, a statutory system of joint strategic needs

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 public health and policy success in england 401

assessment (JSNA), introduced in 2007, encouraged closer working between NHS

and local government organisations (Hughes, 2009). 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.,
2011). 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., 2011).
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., 2011). 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 (2000), 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, 2010).
A common problem has been the under-resourcing of public health
initiatives (Wanless, 2004; 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, 2007). Government attempted to
redress the low priority of public health issues by requiring PCTs to acknowledge

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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, 2004; Hunter et al., 2010). 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, 2004). 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.

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 public health and policy success in england 403

Although many saw merit in these policies, there was concern about how
they would be implemented (Limb, 2011; Health Committee, 2011; McKee et al.,
2011). 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., 2011). 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., 2011). 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., 2011).
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

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 404 rob baggott

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),

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 public health and policy success in england 405

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, 1997), 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

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 406 rob baggott

partnership working and local implementation can build into a groundswell of

criticism about the ability of government to form and implement appropriate
policies.

Conclusions
To conclude, recent governments in England have achieved only limited success
in the field of public health policy. This is true across all three dimensions of
policy: programmes, processes and politics. A judgement of ‘precarious success’,
in McConnell’s typology, is a fair assessment of policy achievements in this field.
But this study has wider significance that goes beyond England. In seeking to
assess policies and strategies here, a number of broader points have been made
that hold lessons for those examining similar policies and strategies elsewhere.
First, that success (or failure) is not simply about the impact of policy on
outcomes but must include appraisal of policy processes and the political context.
Not only does policy need to achieve in programme terms but it must adopt
legitimate and effective processes and (from the government’s perspective at
least) be politically sound. Second, that a key issue is ‘success for whom?’ Despite
the ‘common good’ principles of public health, the adversarial nature of public
health policy must be fully acknowledged. Third, that public health policies and
strategies are related to wider issues about the competence, trustworthiness and
accountability of government. They therefore have wider political ramifications.
Finally, it must be recognised that the oft-lamented poor quality of policy
evaluation and the failures to learn from past experience should not be simply
bemoaned as irrationalities to be corrected but acknowledged as instruments of
political management. Once this is accepted, one can perhaps move on to a more
realistic debate about what governments can achieve in this policy area.

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