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Context In 2004, the English Public Health White Paper Choosing Health introduced 'health trainers' as new members of the National Health Service (NHS) workforce. Health trainers would offer one-to-one peer-support to anyone who wished to adopt and maintain a healthier lifestyle. Choosing Health implicitly envisaged health trainers working in community settings in order to engage 'hard-to-reach' individuals and other groups who often have the poorest health but who engage the least with traditional health promotion and other NHS services. Methods During longitudinal case studies of 6 local health trainer services, we conducted in-depth interviews with key stakeholders and analyzed service activity data. Findings Rather than an unproblematic and stable implementation of community-focused services according to the vision in Choosing Health, we observed substantial shifts in the case studies' configuration and delivery as the services embedded themselves in the local NHS systems. To explain these observations, we drew on a recently proposed conceptual framework to examine and understand the adoption and diffusion of innovations in health care systems. Conclusions The health trainer services have become more 'medicalized' over time, and in doing so, the original theory underpinning the program has been threatened. The paradox is that policymakers and practitioners recognize the need to have a different service model for traditional NHS services if they want hard-to-reach populations to engage in preventive actions as a first step to redress health inequalities. The long-term sustainability of any new service model, however, depends on its aligning with the established medical system's (ie, the NHS's) characteristics. [ABSTRACT FROM AUTHOR]

Issue Addressed: Australian efforts to tackle the burden from chronic diseases through prevention have included numerous strategies, committees, policies and programs. This research reflects on this changing landscape, with focus on the most recent, and most significant, investment and subsequent disinvestment in preventive health, the National Partnership Agreement on Preventive Health (NPAPH). The purpose is to better understand the place of the NPAPH in Australia's prevention landscape, explore views from senior health department personnel on the NPAPH and identify lessons for the future.Methods: Individual and small group semi-structured interviews were undertaken with 19 senior public health managers and program implementation staff from State and Territory health departments across Australia. A grounded theory approach was used to generate themes relevant to the research.Results: Participants reflected positively on the NPAPH, mostly that it established a strong platform for the national roll out of programs supporting healthy lifestyles, it created core infrastructure that elevated the rigour and sophistication of prevention activities and it was achieving or on the way to achieving its desired outputs. However, despite promising potential, governance arrangements over chronic disease prevention were not clearer either throughout or post the NPAPH. While partnerships between State and Territory governments, as well as with other sectors, were seen as a strength of the NPAPH, many viewed the role of the Commonwealth in the NPAPH as limited to funding.Conclusion: Longer term investment in, and leadership for, chronic disease prevention is necessary. The NPAPH built on positive reforms at the time, creating opportunities for implementing programs at scale, building workforce capacity and improving evaluations. Early termination of the NPAPH meant potential return on investment was unrealised, new partnerships could not always be sustained and the prevention workforce was again under threat. Furthermore, responsibility for prevention, which was never clear, became even more opaque. SO WHAT?: The NPAPH, as a national initiative for achieving improvements to the prevention of chronic disease, was a welcome investment. Disinvestment in the NPAPH, as well as other promising reforms of the time, led to a loss of credibility in outcomes focussed funding collaborations as well as missed opportunities for the future health and wellbeing of the Australian population. Australia needs a recommitment at all levels of government to investment and action in prevention and a restoration of funding in prevention commensurate with the size of the health burden. [ABSTRACT FROM AUTHOR]