Who Cares about the Department of Health Responsibility Deal?

My instinctive reaction to the Responsibility Deal brought in by Andrew Lansley was to be against it – believing it to be window dressing to cover up the fact that the Department of Health had little intention of using legislative and policy muscle to force the private sector to damage health less and promote it more.

I have nothing against collaborations with private sector organisations, those of us who work at a local level know that local authorities and other local statutory bodies cannot legislate. They rely on influence, negotiation and collaboration to achieve change. Structures like Local Strategic Partnerships were examples of attempts to achieve strategic collaborations for the good of communities – and Health and Wellbeing Boards will have similar ambitions.

I am also not in favour of creating laws to achieve change if this can be achieved through other means. So it is important to judge the Responsibility Deal on its own terms – on what it has achieved.

Three ways to assess the Responsibility Deal.

• Strategic – focussed on priority areas
• System level impact
• Accountable to the public

Strategic Focus

The Responsibility Deal focusses on the following areas.

Alcohol – primarily about information and also trying to increase the availablity of lower alochol drinks.

Food – primarily about information, reducing salt, reducing transfats, availablity of lower calorie and healthier food.

Health at Work – primarily about supporting those with chronic conditions to stay in employment, quality of occupational health services, accountability for sickness levels, food for staff, stop smoking services, staff health checks, mental heath workplace adjustments

Physical Activity – enabling phsyical activity in communities, promoting active travel, increasing physical activity in the workplace, tackling barriers to participation by the most inactive.

These areas bear little relation to the more coherent model proposed by Duncan Selbie Head of Public Health England which I referenced in an earlier post.

As the above table shows the Responsibility Deal is focussed almost exclusively on Health Behaviours – aside from a small amount of activity on workplace health, it largely ignores the areas that have the greatest impact on health.

Impact

Ownership

The most recent update (July 2012) tells us that there are 390 partners – I reckon this probably now stands at about 450. This means that the responsibility deal has been gathering partners at a rate of approximately 6 a week – I don’t know if this is good or not.

The update also notes that 75% are private sector organisations. So just under 300 are from the private sector.

According to the governments own statistics there are 4.5m enterprises who employ over 23m people; of these 99.2% are small enterprises employing less than 49 employees. 6,320 employ more than 250 employees; 30,475 employ between 50 – 249.

It is clear that the Responsibility Deal has barely scratched the surface in terms of connecting with the private sector.

Where it does better is when it is working in environments that are dominated by very few companies – such as food retail where the ‘big 4’ control about 75% of the market.

I have already indicated that it is very hard to understand the degree of impact because the way in which the information is presented means that it is not possible to get a feeling for the system level impact of the various pledges.

Outputs

The Responsibility deal has got some traction – for example the Food and Drink Federation Annual Review for 2011 which was published in April 2012 devotes a page to the deal and they have also supported production of the Workplace Wellbeing Toolkit – which has an introduction by Dame Carol Black.

Outcomes

This is where I really start to struggle. For example in July 2012 Dr Susan Jebb who is chair of the food network states that “the average amount of salt we’re eating in England has declined by .5g a day between 2008 and 2011. It shows clearly that the huge effort by the food industry to reformulate products to reduce salt is paying off”. I’ve no problem with any of that – except that the time period and all these gains were made before the Responsibility Deal was even established!

I suspect that many companies who have a high public profile were already very involved in this agenda well before the Responsibility Deal – for example Tesco tell us that since 2006 they have removed 3,000 tonnes of salt from their range.

It does claim to have made progress in areas such as providing information to the public through labelling – but I am unclear how much additional progress has actually been caused by the Responsibility Deal itself.

There are 27 responsibility deal pledges in total some of the more popular ones – particular around alcohol and food can have 80 or more signatories signing up and committing to report.

Weaker pledges where sign up and commitment to report is poor include:

• Awareness of alcohol units off and on trades – just over 40 companies
• Alcohol Unit Reduction – just over 30 companies
• Calorie Reduction – 21 companies
• Salt Reduction Training and Kitchen Practice (Catering) 8 companies
• Salt Catering – reformulation of products – 7
• Smoking Cessation – 26 of which 14 are not for profit organisations
• Staff Health Checks – 34 of which 15 are not for profits
• Mental Health workplace adjustments – 5 of which 2 are not for profits
• Physical Activity Inclusion – 54 of which 24 are not for profits 

Frankly some of these figures are damning. Particularly those on mental health workplace adjustments. These are measures of corporate irresponsibility – or the irrelevance of the initiative or pledges.

Accountability

Page 6 of the launch document states that

“monitoring progress is key to establishing accountability by confirming the actions that organisations have pledged to take have been completed. Similarly evaluation has an important role to play in showing the public and other interested parties, as well as the partners themselves the impact of the Deal in changing behaviours and improving health outcomes.”

I can’t disagree with any of the above. The problem is that the way the information is presented and the spin that is put on it means that it is not possible to meet this ambition.

The June 2012 update states that “the Responsibility Deal has moved further and faster than could have been achieved through the regulatory route”. I can see no evidence for this. For example the update tells us that 47 partners have signed up to provide simple and consistent information for the On Trade and that together they control 19,500 premises – sounds impressive – however, there are almost 120,000 licensed on trade premises in England and Wales – I am not convinced that signing up  about a quarter of companies is moving “further and faster.”

Unfortunately the way the data is presented – non contextualised information; individual company information in separate spreadsheets and little aggregated data means that it is not possible to make a judgement about impact and performance

Lessons

Positives

• Some key industry bodies do seem to have bought in to the Responsibility Deal
• Many major companies do seem to be members
• Some useful tools have been produced by the industry
• There is the potential for dialogue with industry

Negatives

• Many high profile companies were already engaged in this work before the Responsibility Deal was created and the added value is unconvincing
• The number of organisations involved is very small
• The degree of buy in on important but difficult areas such as mental health at work, staff health checks and inclusion is embarrasingly poor
• It is very hard to hold the Responsibilty Deal partners and the Department of Health to account because information is presented in such a poor way and when summarised it is often ‘spun’ to give as positive picture as possible.
• The focus is not strategic – with an emphasis on food and alcohol. There is a failure to engage wider sectors such as finance or housing – to encourage them to take action to improve health

What do you think?