Moving upstream or muddying the waters? Incentives for managing for health

The objective of this study was to identify factors influencing the capacity of NHS managers to 'manage for health'.

Semi-structured interviews (32) were carried out over the telephone or face to face with national stakeholders (15) and NHS senior managers (17) from four Strategic Health Authorities (SHAs) and five Primary Care Trusts (PCTs) in England. Interviews were transcribed and a qualitative analysis carried out.

The current system of targets and incentives prioritised access to acute services, public health skills were too thinly spread, baseline data were inadequate, decision-making for public health investment was fragmented and evidence for effective interventions was scanty. Health improvement targets should be plausible, longer term and locally owned, but key factors in creating a proactive public health organisation were a strong public health ethos, and effective management and leadership skills. Strengthening the NHS's role in managing for health was welcomed, but enthusiasm was tempered by concurrent NHS policy initiatives and incentives pulling in opposing directions.

Key NHS policy initiatives have been developed in isolation from each other. While their combined effect remains unpredictable, they may serve to threaten the welcome shift towards managing for health improvement.