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Phase IV of the WHO European Region’s Healthy Cities Program ended in December 2008. This article presents the findings from a recently completed review of Brighton and Hove’s Healthy City Program which aimed to scope whether added value had accrued from the city’s role as a WHO Healthy City during phase IV. In contrast to most other evaluations of healthy cities, this review adopted a qualitative approach representing an appraisal of the Brighton and Hove Healthy City Program from the internal viewpoint of its local stakeholders. In addition to documentary analysis and a facilitated workshop, a series of in-depth interviews (N=27) were conducted with stakeholders from the Brighton and Hove Healthy City Partnership representing each of the sectors reflected in the Local Strategic Partnership (public, statutory, elected, community and voluntary, neighborhood and communities, business). The key findings of the review are presented in a way which reflects the three key areas of the review including (1) the healthy cities approach, (2) participation in phase IV of the WHO Healthy Cities Program, and (3) the Brighton and Hove Healthy City Partnership. These findings are discussed, and recommendations for action at local, national, and European levels are proposed. In particular, we argue that there is an urgent need to develop a suitable monitoring and evaluation system for the WHO Healthy Cities Program with appropriate indicators that are meaningful and relevant to local stakeholders. Moreover, it would be important for any such system to capitalize on the benefits that qualitative methodologies can offer alongside more traditional quantitative indicators.
By the end of 2008, it was estimated that more than half the world's population would be living in cities.1 This has major implications for population health due to the established linkages between the expansion of urban development and growing health problems (for example, substandard housing, overcrowding, air pollution, insufficient or contaminated drinking water, inadequate sanitation and solid waste disposal services, vector-borne diseases, industrial waste, increased motor vehicle traffic, stress associated with poverty and unemployment, and so on).2 The city is therefore an important setting for health promotion.
The WHO Healthy Cities Project was launched in 1987 to implement the action areas of the Ottawa Charter for Health Promotion.3 The healthy cities approach focuses on facilitating community-based health enhancing initiatives via a multisectoral approach to health in urban settings.4–6 The project has developed into a movement that rejects the “top-down” approach (the physical and social engineering solution) in favor of a new perspective on urban health problems and a focus on community-based “bottom-up” strategies to tackle public health issues.7 The healthy city focuses on action for health promotion at city level. As such, it aims to place health high on the agenda of political decision makers and key stakeholders in the cities’ health and social systems, as well as creating awareness of health among the broader population. These actions seek to reorientate public health endeavors at city level toward health promotion and prevention for example, by facilitating collaboration in the implementation of intersectoral health promotion strategies.8,9
There are over 1,200 towns and cities from over 30 countries within the WHO European region that are healthy cities and that link to one another through national, regional, thematic, and metropolitan networks. The European Healthy Cities Network consists of those cities that are more advanced in terms of their commitment to health and sustainable development and that have been formally designated to the European Healthy Cities Network on the basis of criteria that are renewed every 5 years (http://www.euro.who.int/Healthy-cities).
The European Healthy Cities Project has developed through four phases, each phase focusing particular attention on different priority themes. In addition to these specific themes, the healthy city approach emphasizes in particular the need to build strong organizational structures for health at the local level set within a broader European and international context.10 Phase I of the project (1987–1992) was devoted to planning and preparation.1 This phase consisted of a network of 35 cities and its main focus was on creating new structures to act as change agents and introducing new ways of facilitating health in cities.11 Phase II (1993–1997) was more action-oriented with a strong focus on formulating and implementing “Health for All” oriented city policies, developing city health profiles and comprehensive city health plans. Integral to phase II was the setting of explicit targets, which addressed issues such as equity and sustainable development and also established mechanisms to promote accountability for health.12 This phase essentially involved speeding up the adoption and implementation of policy at the city level, strengthening national and subnational support systems, and building strategic links with other sectors and organizations that have had a major influence on urban development.12 Phase III (1998–2002) stressed action to promote urban and global health in ways that were both innovative and sustainable. The work reflected international policy developments and built on the experiences and successes of the first two phases.13 Phase IV (2003–2008) highlighted the core developmental themes of healthy urban planning, health impact assessment, healthy ageing (HA), and physical activity/active living.14
Over the past 20 years, there has been a continuing debate regarding the most appropriate assessment methodology to monitor and evaluate the healthy cities approach in order to provide evidence that it has been effective.15 Included in this debate has been the desirability and availability of a universally accepted classification system of key indicators.16 These attempts to produce a commonly accepted approach to the assessment of healthy cities have been largely unsuccessful, mainly due to the individualized nature and stage of development of each city involved.
It has been proposed that healthy cities should not use externally defined and contrived measurements but should be assessed as a more political endeavor that has to be negotiated among the key local stakeholders involved in each healthy city.17 This is a position we agree with and indeed have adopted by conducting a qualitative appraisal of the Brighton and Hove Healthy City Program from the internal viewpoint of its stakeholders. Such a position has important benefits such as allowing the research team to explore process and the structures that support process. In doing so, we of course recognize the difficulties and challenges inherent in adopting such an approach. Individuals are often accustomed to and indeed want to see hard outcomes and tangible deliverables, especially in the short term. However, the process of making a city healthier does not lend itself to quick, easy measurable results meaning the healthy city initiative can be difficult to defend in some arenas.18
This methodological debate of course has implications for research, and in conducting our review, we embraced a qualitative research framework that would allow us to examine what was working and what was not providing both short- and long-term insights to enable the Brighton and Hove Healthy City Program to evolve. In doing so, we adopted the characteristics of a successful healthy cities project as defined initially by Tsouros to provide a useful heuristic framework for the review (see Table 1).19
Brighton & Hove is a densely populated city on the south coast of England with a resident population of over a quarter of a million people within its 222 km2. The population expands considerably particularly during the summer months when great numbers of tourist and visitors arrive. The city lies between the physical barriers of the South Downs and the sea, offering not only many benefits in terms of quality of life but also particular challenges. The city is known for its lesbian, gay, bisexual, and transgender community, estimated to be about one in six people in the city. With two universities, the city hosts approximately 32,000 students, many of whom stay on after university.
Brighton and Hove falls within the most deprived 25% of all local authorities in England. It is characterized by pockets of severe deprivation, some in areas of relative wealth. Its Reducing Inequalities Review highlighted that significant inequalities continue to exist between different areas and communities in the city.
These reflect in particular a number of major socioeconomic problems the city faces related to mental health; drug, alcohol, and substance misuse; low or no skills among sections of the population; a quarter of all children living in households with no working adults; high, static number of people claiming incapacity benefits; and high unemployment and above-average numbers of young people not in education, employment, and training.20
In order to tackle these wider determinants of health, the City of Brighton and Hove adopted the WHO Healthy Cities approach in 2001 as a way of achieving its health improvement objectives. The healthy cities setting-based model was identified as the best fit to achieve improved health and wellbeing within the cultural, social, political, and organizational context of Brighton and Hove. A Healthy City Forum was established in 2001 to oversee the achievement of health improvement objectives for the city. This was the fore-runner of the City Health Partnership (2002) which eventually became the Healthy City Partnership in 2005. This development brought together champions from each sector, who had the authority or influence to commit their organizations to joint action to improve health and reduce health inequalities within the city. Alongside these developments, in order to strengthen action on its health improvement agenda, Brighton and Hove joined phase IV of the WHO Healthy Cities Program in 2004. Phase IV was ending in 2008, and Brighton and Hove had been invited to apply to participate in phase V of the WHO Healthy Cities Program, as a formally designated WHO Healthy City. Phase V was planned to run from 2009–2013. To assist key stakeholders in this decision-making process and to optimize the future operation of the Healthy City Program, the International Health Development Research Centre (IHDRC) at the University of Brighton was commissioned in April 2008, to conduct a review to scope whether added value had accrued from the city’s role as a healthy city. The review would ensure that the decision as to whether or not to participate in phase V of the WHO program would be underpinned by evidence of effectiveness.
This paper therefore presents and discusses the key findings of the review and makes recommendations for action at local, national, and international levels. The key aims of the review were to assess:
This qualitative review consisted of two distinct and interrelated elements: first, desk-based analysis including a review of selected literature and second, in-depth qualitative research with local stakeholders from the Brighton and Hove Healthy City Partnership, including individual interviews and a half-day facilitated workshop. Prior to commencement of the review, a Project Advisory Group1 (PAG) was established to monitor progress and ensure the project’s aims were being appropriately addressed and that the review was both comprehensive and practically relevant.
Purposive sampling was used to identify and recruit participants for individual interview and to take part in the facilitated workshop. Stakeholders from each of the sectors reflected in the Local Strategic Partnership (LSP) were identified (for example—public, statutory, elected, community and voluntary, neighborhood and communities, business), and final recruitment was based on an individual’s professional role/sector and their contribution to the Brighton and Hove Healthy City Program, rather than any demographic criterion (for example—gender, age, ethnicity). Although up to 35 interviews were initially planned, only 30 suitable individuals were identified and 27 individual in-depth interviews actually completed (three individuals invited for interview did not wish to participate due to being new in post and feeling as if they did not have sufficient knowledge to participate in the review). Three of the interviews were conducted by telephone with European stakeholders, including the head of the Center for Urban Health, WHO European Office in Copenhagen; the coordinator of the healthy city program in Belfast, Northern Ireland and former chair of the WHO Healthy Cities Network Advisory Group; and the coordinator of the healthy city program in Helsingborg, Sweden. The latter two cities were selected as appropriate participants and invited to participate in the review, firstly as the coordinator of the UK national network at the time of the review (Belfast) and secondly having recently conducted a similar review of the healthy city (Helsingborg).
A qualitative review of selected literature was conducted by the IHDRC review team during the early stages of the project primarily to inform the development of the interview schedules and facilitated workshop. Published and gray literature were selected for documentary review and analysis based on a number of criteria, such as relevance to the WHO Healthy Cities approach and specifically to the city of Brighton and Hove’s local policies and practices (for example—strategies, action planning documents, policies, minutes, reports, and briefing papers). Relevant materials for inclusion were also identified with the assistance of the PAG.
All interviews took place during May and June 2008, were divided up between, and conducted by each of the three authors. A semistructured interview schedule based on key areas was developed in collaboration with the PAG (see Table 2). The interview schedule was loosely based around the questionnaire provided by WHO to all designated healthy cities at the end of phase IV, as a tool for evaluating their participation in this phase. Based on this core schedule, two slight variations were also produced for interviews with different stakeholders. The interview schedule was designed to act as more of an aide-mémoire to remind the researcher of the areas to be covered rather than as a tool to prescribe the actual list and order of questions to be asked. Therefore, in developing lists of categories and questions, the intention was to provide a framework to ensure coverage of the same kinds of questions and addressing aspects of the review, while maintaining the necessary flexibility for change should circumstances dictate.
Most interviews lasted for approximately 1 h. The purpose and process of the interview was explained, and all participants signed a consent form before being interviewed. Participants were also given an information sheet about the review.
In parallel with and in order to supplement the information provided by the interviews, a half day facilitated workshop was also held with key stakeholders from the Healthy City Partnership. The overarching aim of the event was to examine the “Health of the Healthy City Partnership”, to review the structure and working processes of the group, and to make recommendations for improved working as a team to achieve the key objectives of a WHO Healthy City. The workshop consisted of a series of small group exercises supplemented by larger plenary discussions.
All interviews were recorded, transcribed, and thematically analyzed. Notes taken by the researcher(s) were also subject to equivalent analysis where appropriate and relevant. Similarly, all generated materials produced during the facilitated workshop (for example—focus group discussions, flipcharts, discussions, etc.) were recorded and content analyzed for inclusion in the review. A coding system was devised for reporting the findings of the analysis, according to the structure of the Local Strategic Partnership (i.e., public sector, local authority, community and voluntary sector forum, and business sector; see Table 3). This enabled stakeholders to remain as anonymous as possible, while preventing the potential loss of impact, for example, where knowing the job title or association of a person may have added significant weight to a statement or quote. In terms of generating thematic codes, all three authors worked independently in the first instance to content analyze the data according to the three main sections of the review: (1) the healthy city approach—principal achievements and added value, (2) participation in phase IV of the WHO Healthy Cities Program, and (3) The Healthy City Partnership. The analytical findings from each author were then compared, and a second, third, fourth, and fifth “sweep” of the full data set was conducted by the research team in order to secure completeness of the analysis.
Ethical approval for this review was granted by the Faculty of Health and Social Science Research Ethics and Governance Committee of the University of Brighton prior to any fieldwork taking place.
The findings that follow are presented in a way which reflects the three key areas of the review: the healthy cities approach, participation in phase IV of the WHO Healthy Cities Program, and the Healthy City Partnership.13 The stakeholders’ quotes cited are indicated by the sector they represent (see Table 3).
The principal achievements and/or impacts focused on broad awareness of the WHO “badge”:
It has brought a lot of kudos and raised the profile of health issues in the city by having that stamp of WHO...that’s an achievement in itself. (CVSF 4)
This was perceived as helping to legitimize health and raise its profile across the city, facilitating political “buy-in” for the program, and increasing strategic partnership working:
It has brought to the fore health considerations in the city—certainly at a political level...it has created a high profile and has legitimatised health and wellbeing as an important issue—so health shouldn’t be seen in isolation but very much part of the wider work that the City Council does as well, in terms of education, planning, environment etc. (HS10/LA)
It’s placed health high on the agenda of the local authority in particular, and enabled us to obtain a significant level of political support. (HS9)
It also raised the profile of the city more broadly in international and European arenas, legitimatizing and endorsing the work of the Healthy City Partnership. However, some stakeholders were unable to identify key achievements of the Healthy City Program for various reasons. These included having only recently joined the partnership; a lack of clarity around objectives, targets, and key benchmarks; failure of the Healthy City Program to reflect upon and celebrate its successes; and difficulties in attributing impact or influence specifically to the program itself:
It is hard to say what has and hasn’t been achieved...It seems to be a conduit of lots of information—so probably a 2 or 3 hour meeting where lots of information is received and sometimes I am not sure—I haven’t quite worked out how that fits into some of the bigger picture work. (LA3)
An additional recurrent theme concerned the difficulties in attributing and measuring the influence and/or impact of the program given its strategic role, rather than a more service delivery focus or model of working:
It has brought key stakeholders together, it has supported collaborative thinking and planning and also service delivery. But it is sometimes difficult to say what has happened as a result of the HC and what might have happened anyway...it is a difficult thing to separate. (HS1)
In terms of what the Brighton and Hove Healthy City Program had not achieved, the need for the healthy city approach and concepts to be more widely understood, for example, through increased marketing and branding:
The induction of HC and HC concepts hasn’t been sufficiently known and understood to enable it to be embedded across all policy areas. In terms of marketing, there has been an insufficient lack of overall marketing of Brighton and Hove as a HC...you need an overall marketing strategy to go with it. (HS1)
Important achievements related to the themes of healthy urban planning (HUP) and health impact assessment (HIA) included raised awareness of the impact of urban development on health and wellbeing, embedding HUP principles and objectives into the City Council planning strategy, and enabling HIA to form a key part of council planning developments. This was achieved by delivering a series of training programs to city council planners throughout the city.
Brighton and Hove participated in three WHO Healthy City subnetworks in phase IV. The subnetworks were established to provide training and other technical guidance to cities that wished to progress their development on the core theme objectives at an advanced pace.14
The HUP core theme of the WHO Healthy Cities Program addresses both the natural environment (parks, green areas, natural pathways, etc.) and the built environment (housing, transportation, and workplaces). Urban planning can control or influence the physical and social environment of cities to promote healthy living. Brighton and Hove has been a key member of the HUP subnetwork since 2005. Analysis of the narratives provided by stakeholders in relation to this theme revealed that most interviewed felt that Brighton and Hove has made significant achievements in terms of HUP particularly with regard to raising awareness of the potential impact of urban development on health:
It’s raised awareness of the connectivity between urban planning and its impact on health and wellbeing. It’s also highlighted the impact of urban development on short and longer term health issues and outcomes and has introduced HIA application to the planning process which has been positive. (HS1)
It [HUP] has been very successful in raising awareness amongst the planning groups, that there’s more to their role than just, you know the physical layout of the city, and the physical infrastructure of the city, that they need to see how that impacts on the residents and the communities—I get the sense that Brighton is seen as having done very well in this. (BS1)
A number of stakeholders referred to the strategic and political impact of the Brighton and Hove HUP work as being important achievements. For instance, in terms of embedding HUP principles into strategies and policies and thus engaging planners and planning systems in the city council leading to the establishment of health impact assessment as a key component of council planning developments:
Embedding HUP principles and objectives into strategy in a pragmatic, feasible and achievable way. We can demonstrate that through the local development framework and its core strategy and its various development plans and supplementary documents. (HS10/LA)
...The way in which they [Healthy City Partnership] have helped to develop the local development framework for us in terms of it turning its head towards public health. It’s always difficult to know what would have happened if the Healthy City Programme didn’t exist but if you look at the difference between the local plan, as was, and the local development framework as it is emerging, then they are poles apart... (LA6)
A second major theme in response to this question related to the training of city planners around health and wellbeing which was perceived by many to be a key achievement of the HUP theme:
The joint training we have done with health and urban planners has helped to create a tangible outcome. The training programme has been implemented through the auspices of the HC, and has been excellent in terms of building those links with planners and has brought them together. (HS8/LA)
In addition, training was also perceived as being helpful in addressing the challenges of intersectoral working and more specifically tackling the wider determinants of health:
...It’s enabled us to get health training, health promotion, public health training onto the agenda of staff development for planners throughout the city. I know that quite a number of planners have been through these staff development courses and I think this has been a major benefit. In some ways it’s been a challenge breaking down the barriers that people have in their understanding about health and trying to move from health in a very medicalised or health sector narrow concept to one considering holistic health, and particularly the way the environment influences people’s health. (HS9)
Health impact assessment is a methodology (and core theme closely linked with health urban planning) which assesses the impact of various plans, programs, and projects on health and wellbeing. The objective of HIA is to advise politicians and decision makers on how to enhance beneficial effects and reduce the harmful effects of proposals or plans. Brighton and Hove has been a member of the WHO HIA subnetwork since 2006. Analysis of the narratives provided by stakeholders revealed that most interviewed felt that Brighton and Hove had made significant achievements in terms of HIA, particularly with regards raising awareness of the impact of urban development on health and wellbeing:
It has certainly raised awareness of the impact of urban development on a population’s health and wellbeing. Also the application of HIA on the built development within the city—we have had full council support for new policy requiring all major built developments to be screened for potential HIA, that is a good thing. (HS1)
Three years ago I probably wouldn’t have known what a HIA means...and now I have and I think that’s a direct result of the HC Programme. (LA2)
However, a limitation has been a lack of capacity and resources required for expansion of HIA. The nonstatutory nature of HIA has meant that its outcomes can only be advisory.
HA is an approach that switches the emphasis away from a traditional focus on health and social care services. The underpinning principle behind this theme is that actions on the wider determinants of urban living can enhance the health and independence of older people. Brighton and Hove has been involved in the WHO Healthy Ageing subnetwork since 2005.
A key theme arising from the interviews in relation to achievements in the healthy ageing core theme was that of raising awareness of older people’s health issues and establishing health ageing as a key priority for the city:
Healthy ageing has been given much greater priority and this has helped to address the previous inequality in access to services and facilities for older people. (CVSF 2)
The healthy ageing work that has been going on as well has been very important....it’s been good just to see that there is a real push in the city to help older people be as healthy as possible and to promote health, healthy living, social inclusion and all those sort of things whether it’s mental health but also physical health. (CVSF 5)
Key achievements under the HA theme included raising awareness of older people’s health issues by shifting the focus toward the wider determinants of health, to include issues such as increasing independence and social inclusion by strengthening the role of older people in decision making and incorporating consultation into strategic plans. Nevertheless, there was some difficulty in reporting achievements specifically attributable to the Healthy City Program.
Physical activity is a fundamental means of improving people's physical and mental health. It reduces the risks of many noncommunicable diseases and benefits society by increasing social interaction and community engagement. Healthy cities emphasize the importance of physical activity as part of everyday life, not as an optional extra to be added at the end of a busy day. Responses concerning this core theme’s achievements were fairly sparse and quite mixed although they still tended to follow the achievements of the other core themes such as raising awareness, increased partnership working, and the WHO Healthy City “badge” adding weight to funding bids:
...Encouraging people to enjoy open and green spaces is a very good initiative—they have health walks organised and quite a few older people I know are involved in that, so that’s been a very good initiative... also the green gyms, that’s been good. (CVSF 2)
The way we have taken this forward here—AL is part of the built environment and when we have new developments, you look at how you can promote AL, cycling, walking etc. It’s the same for HIA and HA. (HS6/LA)
As for the other core themes, there was difficulty for stakeholders in identifying tangible attribution and measurement of progress for physical activity/active living.
One of the most challenging goals of the Healthy Cities Program is to reduce health inequalities by addressing the social determinants of health, including poverty, social exclusion, and the needs of vulnerable groups.11,21
Rather than answering how the Brighton and Hove Healthy City Program had addressed health inequalities, respondents tended to discuss outcomes which related more directly to the health inequality agenda (for example, obesity and nutrition, smoking cessation, and teenage pregnancy, etc.).
We’ve addressed inequalities through health promotion, smoking cessation, teaching cooking skills...also with active living. We’ve had an active living worker first in EB4U [EAST BRIGHTON] and then we’ve spread it to the rest of the priority areas... (HS5)
...In terms of interventions—they can look at inequalities in child health which could be through the uptake of breast feeding and early nutrition , it could be through access to immunisation as well as work on stopping smoking as well...there has been some good work on that. (HS6/LA)
The Healthy City Program has helped to raise awareness of health inequalities in the city by providing a strategic focus to encourage cross-sectoral partnership working. However, a lack of understanding as to the role of the program in tackling inequalities was noted. In attempting to address the wider determinants of health, stakeholders found it difficult to make a direct causal link from specific ongoing projects and infrastructural developments to the Healthy City Program. However, it was felt that awareness had been raised on what constituted the wider determinants of health, as a direct result of the program’s work, and the long-term financial benefits of related work was recognized.
In order to ascertain the degree of added value being a WHO-designated healthy city has brought to Brighton and Hove, stakeholders were asked their views on whether they perceived the WHO Healthy Cities Network to be functioning well. Views were clearly divided over this issue. For instance, in terms of more favorable views, some stakeholders focused on the benefits gained through being part of wider national and international networks. In particular, how the network facilitated an exchange of knowledge and ideas across the participating cities, as well as leading to tangible outcomes. Furthermore, some participants felt that belonging to such networks helped to increase ambition and raise morale at a local level:
The idea that you can meet with lots of people from around the world to talk about what you’re doing and what they’re doing is a fantastic opportunity. (HS3)
There’s an element of if we’ve got something like that—membership of a wider network, both national and international, helps to drive up our own ambitions and it gives us other people to go to, other people to compare with—there can be tensions that work in a very positive way and if we can see another city that is similar to us in profile but is doing better at something, it might pull us to try and do that better. Or if we are doing particularly well at something, we can feel justly proud of our achievements. (CVSF 4)
In terms of the relationship to WHO, there were mainly negative responses from stakeholders, particularly in terms of the lack of on-going technical and practical support and advice received from the WHO Center for Urban Health (currently based at the WHO European Regional Office in Copenhagen).
I don’t think it is functioning well—it’s gone through highs and lows; highs where it has given better strategic support and guidance but those highs have been much more sporadic and over the last 2 years. The strategic support has been very disappointing, it has been minimal. (HS10/LA)
No, I don’t think it is working very well. (LA1)
...the way that the WHO is set up and managed is exceptionally poor in terms of the Healthy Cities Network. It’s not very efficient, I think it gets lots of money from lots of people, and I’m not certain what value it adds...I think the idea is fantastic, I think the way it operates is poor. (HS3)
WHO’s communication mechanisms were perceived as being inefficient, and as a result, the subnetworks had been unable to work in a cohesive and sustained way.
What hasn’t worked well is the regularity of communication from the WHO office and the lack of participation in ongoing sub-network meetings. Sub-network meetings are there to provide advanced development and progress by the cities in the delivery of the Phase 4 objectives. There has been a lack of clarity about budget allocation and just a general sense of malaise and strategic drift. They are very, very slow in getting strategic papers out to us and in the UK context, if we are to keep our politicians on board we need to be kept regularly briefed about the future direction of the Programme. (HS10/LA)
The setting of the strategic direction and the quality and regularity of communication, leadership and guidance from WHO head office, resources or the lack of them particularly administrative resources... (HS1)
In contrast, the European and UK/Ireland Healthy Cities Networks supported one another, acted as a reference point for one another, and formed a united voice to WHO as and when appropriate.
A value of the national network has been that as a UK/Ireland city we’re able to then convey things with a united voice back to the WHO, for example on the proposal for Phase V core themes etc—so I think there is a lot of value in this national network. (HS6/LA)
Lack of resources and poor management in the Copenhagen office were perceived as key factors for the lack of support. On a positive note, the technical training offered by WHO advisors has been invaluable for some Brighton and Hove officers, and the benefits of this training had been translated into practice at a local level and the skills disseminated to a wider pool of officers.
Key themes arising from Brighton and Hove’s participation in the WHO network included the kudos mentioned earlier and the knowledge exchange between cities which it has facilitated. This participation has had a positive impact on the development of policy, in particular in the areas of HUP and HIA.
The majority of stakeholders felt that as a result of being a WHO-designated healthy city, progress had been made in the areas of policy and practice in the city. This was reported to be particularly so in relation to two of the core areas of phase IV of the program: healthy urban planning and health impact assessment.
I think it did yes...made a huge amount of progress. (LA1)
Yes, particularly in HIA and HUP and around the knowledge base—there is a strong case that that it has facilitated that. (HS8/LA)
...through the focus on the key objectives, it has enabled us to advance two areas in particular, HUP and HIA to a degree and pace that we would not have done so previously. (HS10/LA)
The subnetworks have provided a forum for the exchange of knowledge, the development of tangible ideas for implementation in Brighton and Hove, and the provision of technical training. While recognizing some benefits of participating in the WHO Healthy Cities network, there was some uncertainty as to whether the progress made in policy and practice could in fact be directly attributed to WHO and the Healthy City Program or whether the work would have been achieved anyway.
Probably—I don’t know—as I said earlier, I think that Brighton and Hove would have done some of these things anyway. (HS3)
I’m not sure the actual working relationship has meant that we have done anything that we wouldn’t have done otherwise. I felt it was a motivational factor, feeling that you belonged to a programme that you have certain thing you have to achieve, that you go to a business meeting—that has been the motivation—to have a framework. (HS6/LA)
The ongoing uncertainty around the detail of phase V of the Healthy Cities Program meant that stakeholders found it difficult to make a reasoned decision as to whether Brighton and Hove should continue to participate. However, they commented on the following issues—the potential costs of their participation, WHO priorities compared with Brighton and Hove’s priorities and that there should be synergy between the two in order to justify Brighton and Hove participating in phase V. The benefits again reflected the perception that there is kudos attached to being a WHO designated city, the network’s “pool of knowledge” which would continue to be a resource for the city, and the program acting as a “vehicle” for the delivery of a broad public health agenda.
Stakeholders were asked to comment on the “health” of the Healthy City Partnership in order to explore how it could evolve to optimize the potential for health improvement and reduction in inequalities within the city. A number of key themes emerged including value of involvement, appropriate priorities, community consultation and engagement, terms of reference, membership, working practices, vision for the future, and key challenges. These themes are outlined briefly below.13
Stakeholders felt that there were clear benefits to being involved in the partnership on behalf of their organizations and/or sector. Benefits included a sense of legitimacy by the partnership for endorsing action at local level, higher visibility, facilitating intersectoral collaboration, and enabling joint working.
...it has given us a focus to move more upstream whether you see it as health promotion or public health or health improvement—it has given us a strategic focus where we are more accountable from a local partnership perspective in terms of how we spend NHS capacity and resources focussing on the wider determinants of health. (HS10/LA)
It has also confirmed that the work that was already going on in terms of the development of European and international work, particularly linked to the health and social agenda, has been valid. (HS1)
In general, stakeholders reported that the WHO Healthy Cities priorities were also the appropriate priorities for the city.
In broad terms yes the priorities are correct. I can’t think of any other areas that the Healthy City Programme as a broad programme could really concentrate on. (LA1)
...it’s good what we’ve done around urban planning...so that’s embedded in theory in the Council in terms of their planning processes. (HS3)
The four priorities in Phase IV are relevant priorities locally...HA is one where I think our systems and processes of engagement within the city were already well advanced. (HS10/LA)
Some respondents also suggested a number of other priories they felt should be addressed additionally, including mental health, substance (mis)use, and sexual health.
...from a PCT (Primary Care Trust) perspective our top priorities for health are firmly rooted in the characteristics of the local population so they are about sexual health services, mental health, health inequalities, and a range of other things... (HS2)
Sexual health issues are a big thing for us together with mental health in terms of suicide prevention... (HS8/LA)
We would like to focus on young people’s issues, substance abuse issues, alcohol and sexual health... (CVSF 6)
Stakeholders felt there was a need to consider local demographic variations across the city and to ensure that potential conflict between WHO, local, and national priorities would be addressed.
For me the priorities for East Brighton might not necessarily be the priorities for the city... (LA4)
We have to work out how we are going to manage and measure and reach performance on the 35 targets we are about to set ourselves as a local health economy and wider with our partnership group...we’ve got a national indicator set which is cross-cutting, cross organisations, we’ve got a whole health and wellbeing agenda...how are we going to marry those up without us all spending lots of time at lots of different meetings, trying more or less to measure the same thing. (LA3)
Stakeholders were asked what mechanisms were in place for the partnership to consult with the local citizens of Brighton and Hove. Interviewees reported that consultation was made using the existing mechanisms of various partners from the partnership via their own communication systems. However, most felt there were too many consultations with communities in the city and that it was necessary to work in a more joined up way with other organizations, sectors, and agencies in order to make optimum use of resources. Stakeholders felt that the partnership needed to be clear about the purpose of consultation and engagement with local communities and to ensure that the conceptual difference between the two terms was recognized.
...there is a question for us to ask ourselves...what we mean by HC work and of what we should be doing in terms of engagement with communities and for what reason...We should only be doing it if we can offer something. (HS10/LA)
I think we need to make a difference between engagement and consultation...we need to be a bit more mindful about what it is we are doing. (HS6/LA)
In general, stakeholders felt that existing communication mechanisms had not been effective and that the partnership should design and operate its own dedicated communication strategy and delivery mechanism.
Overall what we need is a strategy and then a series of delivery mechanisms to enable that to happen, not least....engagement with the local media, mass media, which would be very useful in terms of keeping HC issues on the public agenda. (HS9)
Although there was general support for the partnership’s terms of reference in their current format, most participants felt they needed to be reviewed and updated in order to evolve with the development of the partnership.
They are still very relevant, but I think there is an issue about they might need to evolve because the HCP has evolved over time. (HS10/LA)
Suggestions were made on how this could be done including references to working practices, membership, elaboration of the link to the Local Strategic Partnership, and the need for some specific and measurable objectives and targets/deliverables. Concern was expressed as to whether the partnership was sufficiently empowered to achieve the terms of reference. Additionally, there was concern regarding the implications for the Healthy City Partnership of the local government requirement to establish a health and wellbeing partnership with the health sector and other stakeholders.
I’m not sure whether the Healthy City Partnership is sufficiently empowered to deliver them [TERMS OF REFERENCE], so it is about power and influence and clout and muscle... in addition...it is tasked with coming up with a comprehensive plan for health improvement...to what extent is the Healthy City Partnership actually empowered and resourced to drive forward an action programme to equip that plan? (LA2)
Most stakeholders felt that membership of the partnership was reasonably mixed in terms of sector representation and seniority. However, many felt that there was a need for membership to be revisited in order to ensure representation from additional sectors (for example the business sector) and that appropriately senior level individuals were involved to ensure action outcomes.
it’s not clear how, in the Terms of Reference, how people are opted in or become members...I was never asked, the group were never asked to co-opt me as part of the group, so who am I accountable to and who am I representing...also, how the chair and the vice chair are nominated would be a good thing to put in, and you know how long they’re the chair for should be put in the Terms of Reference. (LA4)
Stakeholders reported wanting clarity about the recruitment of members to the Partnership, and their own role and functions within the Partnership, relating this particularly to uncertainties about accountability.
What needs to be strengthened is....what you can do as a member of the Healthy City Partnership, what membership means in terms of what responsibilities you are going to take on behalf of it. (LA2)
Stakeholders felt that the partnership was probably working as well as it could, based on the available resources and current policy context.
I think it is working as effectively and efficiently as it can within the current resources and policy contexts that we are working to locally...but I think we need to be more radical about what we can achieve... (HS10/LA)
However, there was broad agreement that it had not been working in the most effective and efficient way. Common concerns (as examples) related to the lack of capacity and resources and the lack of strategic direction.
Brighton has so many partnerships, partnership on partnership, and my question is how can we make this partnership something from which specific actions emerge and something that is...really tangible as well...It could be improved. (HS6/LA)
The simple answer is no...it could work more effectively and more efficiently if we were all more aware of where we are going as a partnership and that we were really buying into that as partners...but I think it is so big it ends up not being able to make things. (CVSF6)
Stakeholders proposed a number of ways forward to improve the effectiveness and efficiency of the partnership’s working practices including the development of a strategy and operational plan, more focused and interactive meetings, linking more explicitly to the Local Strategic Partnership, and becoming involved in commissioning.
Maybe it’s getting people on more smaller, more flexible action groups, time limited because otherwise you create silos that engage in different areas and have a task and achieve it then take it back to the group...rather than just going to meetings being bombarded with reams of paper...there’s no opportunity for me to actually sit down and network with those people. (BS2)
...to have more strategic meetings, away-days if you like, which would enable members to be consulted on a more strategic basis, a more operational basis, rather than the basis of what I would call business meetings with very tight agendas and a number of key issues which need to be reported...share their experiences on a much more productive basis...allowing members to engage more actively in decision making, particularly about resource allocation. (HS9)
There was inevitably some overlap here with other sections of the report. Most notably, interviewees reported that their vision for the future was for the partnership to function in a more strategic and collaborative way including becoming more influential and visible and being clearer about its purpose.
It [Healthy City Partnership] shouldn’t be there for the sake of being there—if it has no authority and no credibility there’s no point. It should keep going...but keep going with a purpose and the usual stuff about being able to measure the success and outcomes of what it does. (HS4)
There should be very clear, genuinely collaborative and integrated processes and action and that is where a strategy and an action plan would support that. (HS1)
This strategic shift was seen as a crucial element in the decision to join phase V of the program. Other visions for the partnership included a review of membership and working practices, being able to demonstrate “short-term wins”, and the development of an on-going comprehensive monitoring and evaluation system.
...there should be ongoing evaluation and review processes in place. (HS1)
We need to be mindful about proper evaluation and then how we take things forward, or not. (HS6/LA)
We should look for examples of what other cities are doing that we are not doing very well and seek to emulate those. We shouldn’t be just driven by looking at what problems we have...but we should be positive in our approach and look for some good examples of things that other people are doing...We should also recognise when achievements are made—It’s quite interesting that it was a struggle to say what the achievements have been of the Partnership, and maybe we are not very good at that as a partnership. (CVSF 4)
Moreover, some said that such a system could not only help the partnership to recollect its achievements but enable it to reflect on comparative work in other European cities.
Stakeholders reported that clarifying potentially competing priorities at local, national, and European level would be a key challenge for the partnership in the future.
Prioritising the priorities—whose priorities are we going to address, local priorities, city priorities, WHO priorities? Some of those will be the same, but others might be conflicting... (HS1)
...it’s important to achieve local objectives and to give them primary accountability—in some way the challenge is to use national and European objectives in a very constructive and innovative way to achieve these local objectives. (HS9)
Other challenges reported included ensuring appropriate senior members participated in the partnership and for it to address its strategic credibility and power to influence action at a local level as well as becoming embedded into the mainstream.
The key challenge is making sure that we have the right people working on the right agenda—making sure those people are senior enough to go and drive change in their organisations or who they represent. (HS8/LA)
It was felt that a key challenge for the Healthy City Partnership was to address its strategic credibility and power to influence action at a local level and that in order for the Healthy City Program to be embedded into the mainstream, stronger links would need to be made with the LSP as well as current and future local authority liaison mechanisms.
The findings and recommendations arising from this review, although focused on the city of Brighton and Hove, have wider implications for other healthy cities within the UK and internationally. These implications relate to a series of key drivers which we propose underpin the effectiveness of the healthy cities approach, as follows:
All settings-based approaches to health promotion are more effective when they receive strong support from the top of the key organizations involved at both the executive and political levels. WHO defines this as one of the key elements of action—the need for “explicit commitment at the highest level to the principles and strategies of the ‘Healthy Cities’ project”.22 This necessary high level of political commitment has been achieved for example in the city of Helsingborg, Sweden.23 One of the reasons suggested for lack of sufficient engagement in Brighton and Hove by senior politicians and executives was their lack of awareness of the core values and principles underpinning the healthy cities approach. This need for more effective marketing also could benefit from more appropriate use of evidence and effective communication of the short-term impact of healthy city interventions.
Leadership is a vital component of the infrastructure to facilitate health promotion action. Dedicated healthy city core staff resources are essential to take on this leadership role within the urban context, but it is clear from the Brighton and Hove experience that staff often work beyond capacity. This means that effort should be directed to a more equitable division of labor involving various stakeholders involved in the Healthy City Partnership taking on specific delegated leadership tasks. In addition, appropriate commitment in time and human resources should be allocated by WHO senior management to enable sufficient guidance and support from WHO technical advisers. WHO support would also be strengthened by a more regular and effective two-way communication mechanism.
There is often confusion at local level between concepts such as community consultation, participation, empowerment, development, and engagement. They are frequently left undefined or used interchangeably.24 They need to be clarified in the context of healthy cities approaches in particular in relation to differences between community consultation and active community engagement.
The community is often not as involved as could be—this concurs with White’s suggestion that while the WHO Healthy Cities Project is supposed to be based on community activity, the project and resultant initiatives are prone to being more highly correlated with top down initiatives and are thus met with mixed opinion.5 Joint ownership is a fundamental principle of the healthy cities approach and needs to be translated into its practical activities. It is accepted that a constant tension exists between the need to work at the highest executive and strategic level (top-down approach) and engaging at the same time with the community at grass roots level (bottom-up approach).
One of the most tangible benefits perceived by key stakeholders is the kudos which WHO Healthy City designation brings. A comprehensive communication strategy directed at carefully segmented target audiences needs to take advantage of this in order to raise visibility and add credibility to the healthy city program. Such target audiences would consist of citizens and communities within the city, senior politicians and senior executives from both the private as well as public and voluntary sectors. Examples of achievements under the healthy city banner should be used creatively to ensure clear attribution and provide evidence of the added value attached to the healthy city program.
It is felt essential that the Healthy City Program should develop a clear long-term strategy and shared vision for its work. It must build on existing plans and strategic documents with the aim of moving the program into the mainstream.
Therefore, linked to the above strategy is a need for a series of short-, medium-, and long-term operational plans. Linked to this strategy and operational plans is the need to build a robust ongoing monitoring and evaluation mechanism. It must also have a strong and efficient steering committee with clear terms of reference, membership criteria, and systems to facilitate effective intersectoral action and partnership working.
We recommend that similar qualitative reviews, as reported in this paper, should be carried out on a regular basis in all healthy cities to ensure they are meeting the needs of their local stakeholders, including their citizens and communities at the grass-roots level. Qualitative methodologies, such as those adopted in this review of Brighton and Hove, need to be considered alongside the more traditional quantitative methods in order to provide the rich in-depth data necessary to impact on future policy and practice. The success of this review relates partly to the adoption of a number of principles which reflect the bottom-up approach to evaluation. In particular, the involvement of key local stakeholders at all stages of the review, from the development of the questionnaires, participation in the review itself, and subsequent to the review, in taking responsibility for implementing some of the recommendations made through the newly established (as of 2009) Healthy City Strategy Phase V Working Group.
Over the last two decades, we would propose that too much emphasis has been placed on the search for a system of universal quantitative indicators alone. We suggest that, as a result, this has failed to identify and document many achievements of the health cities approach and particularly of the WHO European Healthy Cities Program.
There is a pressing need to expand this work to produce a comprehensive monitoring and evaluation system, with appropriate indicators that are meaningful and relevant to local stakeholders. This process would assist all healthy cities to more effectively and efficiently utilize their resources and achieve their objective of improving the health of their citizens.
We would like to thank the Brighton and Hove Healthy City Partnership and all of the stakeholders who took part in the review and in particular Terry Blair-Stevens for his comments on an earlier draft of this paper. We are also grateful to the Brighton and Hove City Teaching Primary Care Trust for commissioning and funding this review.
1The Project Advisory Group consisted of the Healthy City manager, the vice-chair of the Healthy City Partnership, and the IHDRC research team.
Caroline Hall, Email: firstname.lastname@example.org.
Nigel Sherriff, Email: ku.ca.nothgirb@ffirrehS.S.N.