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Promoting health improvement and tackling health inequalities: Local authorities perspectives - Evaluation of a pack for trainers

3. Post - training findings

This chapter is based upon the findings from the questionnaire returnsfrom the seven test sites and the one-to-one interviews in the four test siteswhich took place, following training delivery in each local area. Unlike the focus group results, where foursets of findings were produced, the post-training one-to-one findings consistof 16 separate sets of findings. Assuch, the second part of this chapter has been structured by highlighting thekey themes which emerged across these sets of findings. In order to provideclear connection and comparisons to the pre-training findings, thepost-training findings have been grouped in the following way:

• issueswhich remained significant at both pre and post-training stages
• issuesat pre-training stage which were not found at post-training stage
• newissues which emerged at post-training stage

3.1 Summary of the key issues at post-training stage

The results which follow summarise all key issues which were capturedat post-training stage, through both the questionnaire and one-to-one interviews:

• akey theme running through responses was that some general 'tweaking' would berequired to the pack but that it was a very effective starting point, providinga good base of information and activities for introducing and developing the HIagenda in the local setting. It wasalso felt that a level of local flexibility will always be required to get thebest results. This will includeadapting timings, ordering the sequence of events, flexibility around how longis spent on each individual activity and the provision of local examples andanecdotes
• onlyone local authority delivered the training to two separate groupings while theothers delivered to only one group
• thetraining was targeted at a predominantly senior audience across local settings,although some participants across settings spanned a strategic and operationalrole context
• therewas a mix of views from trainers regarding the 'pitching' of materials,including views that it was at the right level, too simplistic and toochallenging. This relates to thedifferent sessions and how different participants related to the variousactivities
• overall,views on the effectiveness of the pack were very positive, through its generaldirection and quality of materials. Itwas felt that the pack should be reorganised to group activities and theirassociated guidance together. Thereshould be less detail on the transparencies and more consideration of thelikely energy of the group over the day will be necessary in terms of how muchinformation should be included. Theguidance in its current format was felt to be a bit didactic / prescriptive /inflexible. However, for the purpose ofthe pilot process, this was necessary. Flexibility is desired for the future
• adaptationsrequired were felt to be relatively subtle. Some trainers wish to include different health models, local statistics,the use of powerpoint (instead of transparencies), some changes to timings andthe actual presentation of the transparencies / powerpoint (not content). The pm session of 'Challenges andOpportunities' might already be covered through the earlier sessions. In which case, trainers might wish toconsider summarising this session and build on any further areas for development
• howthe training will be integrated into wider training provision is an area whichis still a bit unclear in most local areas. There are some plans to make thetraining part of wider corporate training induction or mainstreamed into thecorporate training programme. Again,the 'proximity' of the lead trainers / HI officers to senior level corporatesupport was deemed to be necessary to progressing the training in this way.There were also some suggestions of making the training part of a widerprogramme for Councillors. This willrequire senior, internal support as well as perhaps guidance from COSLA withregard to how to make the training sustainable. It was also felt that 'train the trainer' support would benecessary, given the particular mix of skills and experience required of thistype of training delivery
• seniorand / or strategic planning support will be necessary to secure the future ofthe training internally, together with a HI officer 'presence' in providingeither guidance and support or direct 'hands-on' support to the delivery of thetraining (although this will have resource implications, especially in light ofthe wider strategic role of HI officers)
• 'What Is Health?' - the pre-coursequestionnaire could be adapted to encourage participants to prioritiseactivities. Information relating towhat the local authority / service areas already do in line with HI could belinked to the last session of the day to provide more impetus. This could be designed for easy completionin a grid response format. Design couldalso include asking participants about their role - if any - in working on theJHIP. This questionnaire was largely not considered to be an effective'ice-breaker' but a warm-up activity would be needed, in order to encourage amore interactive format from the beginning of the day. Many participants were felt to be reluctantto discuss views at an early stage and it was felt that this might be overcomeby introducing some early warm-up activities
• 'Overheard on the Bus' - there were mixedviews, here, with some sense that more clarity of the purpose of this sessionis required as well as offering trainer prompts to support this earlyparticipant-led session. Reluctance to engage at this stage could have beenrelated to ineffective warm-up activities. The impersonal nature of this exercise was felt to be a positive issueas participants need not feel exposed about expressing their own personal viewsbut rather focus on those of others
• 'Brief History of Public Health' - some mixedviews but a general feeling that this session needs to be shortened, with someof the surplus information provided as a separate handout. This would be made clearer by a strongeremphasis on the learning points which were felt to be a bit ambiguous. Because this session is quite presenter-led,it will be important to ensure that it is not 'too dry'. This could be addressed by shortening thesession, transferring some of the detail onto a separate handout and providinglocal examples
• 'Approaches to Health: Medical and Social' -very mixed views, here. It was felt tooffer clear guidance and was relatively easy to deliver where the links couldbe made obviously to 'Overheard on the Bus'. This session seemed to work lesswell with more operationally-focused staff, where more time was required tocover the complexities. It was alsofelt to be important to ensure that that the session does not lose focus andattempts t o draw conclusions that the medical model is 'bad' and the socialmodel is 'good', or vice-versa. Thissession requires to focus on generating awareness of the two models.
• 'What Influences Health in Your LocalAuthority?' - the guidance was felt to be unclear, here, and the scoringcomplicated. Some trainers appeared tobe unclear as to the purpose of the session. Handout two requires to be changed to remove the reference to tobaccoadvertising, which is now obsolete
• OttawaCharter sessions - these were generally positive sessions if a littlecomplicated and perhaps better suited to more senior audiences. The wider resonance of the Charter to localuse, beyond the health improvement agenda, is something which could beemphasised. There was some feeling thatextra time might be required to prepare this session but that the benefits wouldbe in the support and structure of delivery. For the Food Programme example, more background is required and / or awider range of examples used. ThePhysical Activity example was felt to work quite well but was challenging. It also required quite a bit of trainersupport. It will be important fortrainers to emphasise that the focus of the exercise is based on localauthority activity and not national initiatives or their own, personal issues.This will depend on the strategic ability of the group.
• 'Car Park' activity - this was felt to begood fun and energising after lunch, with clear links to healthinequalities. There was a suggestionthat the 'characters' might be updated and reviewed and an indoors formatshould be considered, since it will not always be possible to undertake outdoors. By plotting the 'results' on grid paper,this would offer a strong focus for the follow-up discussion exercise, ratherthan trying to come together and re-trace their steps
• statisticalevidence session - this was felt to be quite a 'dry' session and could beimproved by shortening to only the very necessary details and including localstatistics (which can be taken from the NHS Health Scotland web-site), as wellas statistics from Europe and high performing countries, as a focus fordiscussion. Clarity of objectives wasalso felt to be lacking, resulting in less focused prompting by sometrainers. There were felt to be sometyping errors on the associated overhead. Finally, it was requested that the North Karelia experience could beadded to provide more focus to this session. However, a cautionary note is required, here, regarding the overallobjective of this session. The key learning outcome relates to engendering anunderstanding with participants that statistics are often used for differentpurposes and are subject to different interpretations. As such, it might be confusing to use anextensive range of statistical sets, where participants might become focused onthe statistics themselves, rather than the process of use and interpretation
• measuringdeprivation - objectives were felt to be unclear concerning whether thissession was about the statistics themselves or the tools to measure andinterpret these. This session couldalso explore how such tools support policy making and linkages to the socialmodel and health inequalities. There was felt to be generally limiteddiscussion during this session, suggesting that trainers should focus on thekey learning outcomes and adapt the discussion to participants' needs
• groupdebate - this was felt to be good for re-energising the group and generatingfocused discussion (coming in the middle of the afternoon). Trainer preparation is required to prepareand structure the session and consider timings and the rules and format fordebating. The pack should also include ideas of how to support both argumentsif the group is short on ideas. Thedebating format should be flexible to accommodate needs - e.g. using only twodebaters while the others ask questions and then vote, or get participants tostay in 'character' from the Car Park exercise and to work through the debateon this basis
• roleof LA - felt to be a very good exercise for information sharing and providingreassurance to participants that many areas are already being exploredlocally. Clarity of objectives of thissession is essential and objectives will change depending on the level ofparticipants. For example, some lessstrategic groupings might be expected to 'list' key local activity associated withthe HI agenda while more strategic groupings might be expected to move beyondthis to exploring future plans and added value in partnership working. Since this session is a crucial part to thewhole day, enough time needs to be allocated to exploring views and developingthoughts. This will also go some way todetermining whether participants reach a satisfactory conclusion from thissession, and so work towards finishing the day on a positive, confident andforward-looking note. Trainers mightrequire to offer prompts in order to encourage focused thinking and to checkknowledge and understanding
• roleof LA in partnership working - some trainers felt that this had already beencovered in the previous session and was therefore superfluous. The last twosessions - in particular - will require quite specific objectives, depending onthe groups participating, in order to end on the right note and with the keymessages. This will be challenging dueto the complexity of this session together with participants already feelingquite tired by this stage. Somesuggestions for change here included linking this session to the first amsession to review how views and ideas might have developed over the course ofthe day. Using 'post-its' to gather anddisplay ideas was also felt to offer a clear focus, especially since thesecould be moved around to accommodate new ideas and views. One trainer suggested that a handout wasmissing from this session, in line with what had been described in the pack. In providing a focus for further action, itwas suggested that participants could be given a basic version of a healthimpact assessment. As well as beingguided as to its purpose, use and benefits, they could be asked to use theseback in their service areas to provide a baseline and focus for wider action. Since undertaking the research, it has beenrevealed that health impact assessments are being dealt with in the HI agendathrough an evaluation module. Therefore, in the interests of ensuring that a fuller understanding ofits objectives and application can be achieved at local level, it has beendecided not to include this area in the training pack for this project, but toleave all references to this for the evaluation module
• aimsand learning points - some confusion existed among trainers as to whetherlearning points could be more usefully defined as learning outcomes. These werefelt to require more definition and clarity and could perhaps be included inthe presentation to alert participants to intended outcomes
• facilitatorguidance - this was felt to be generally very helpful, but that its currentposition in the pack does not give it enough prominence. As such, it was felt to be somewhat lackingin coherence, due to its lack of integration in the pack with the rest of theassociated material (as detailed earlier in the report)
• transparencies- the content of these was thought to be of a very high quality, but there wassome feeling that the detail on some transparencies will be required to beshortened and to be presented in powerpoint format
• facilitatorbackground notes - in line with pack reorganisation, these could be improved.There was also some feeling that guidance was somewhat inconsistent in itsavailability across all sessions. Thesessions on inequalities were felt to require clearer guidance by way ofintegrating these sessions and so emphasising the key learning points. Despite the detail in the background notesthere was some feeling that this might not prepare trainers for participants' questions. This is whereHI knowledge is essential and could not be addressed by someonewithout an HI background
• handouts- as noted earlier, local statistics and other, additional material from thetransparencies could be transferred onto handouts
• readinglists - it was suggested that it is perhaps unrealistic to expect that a non-HItrainer would read all materials on the reading list, in addition to thecontent of the pack. This could be off-putting and daunting. There was also some lack of clarityregarding what participants should be encouraged to read prior to attending thetraining. The pack proposes that participants could be asked to make themselves familiar with the COSLAdocuments, in order to provide a basic level of grounding, prior to attendance.However, there was some confusion regarding what was requested for participantpre-course reading and post-course reading. This will require to be made clearer in the pack It was also notclear if participants would actually read the suggested pre-course, backgroundreading before attending the training.

3.2 Issues which remained significant at both pre- and post- training stages

Almost all of the issues identified bytrainers at pre-training stage remained significant following trainingdelivery. Some of these issues wereexpanded upon, to provide new insights and these have been listed in section3.4 below. The key issues whichremained the same related to:

• aparticular skills 'mix' is required of this type of training delivery, inrelation to facilitation skills, knowledge and understanding of the HI agendaand wider 'insider knowledge' of the culture and structures at a local level,as well as a clear grasp of the Community Planning agenda at national and locallevels
• theneed to reorganise the structure of the training pack and to simplify some ofthe language on the transparencies and in the handouts
• adequateinformation in the pack regarding the policy context of HI and references
• theneed for sufficient time to plan and prepare the Ottawa Charter session, inorder to provide clear direction and information to participants
• thepack contains very relevant aims but the learning outcomes need to be moreclearly defined, particularly for the discussion and debating activities. For example, where the pack states 'ask thegroup to discuss, there needs to more direction provided to trainers of whatthey should expect from participants. This issue perhaps stems from the terminology used in the pack, where'learning points' is used instead of 'learning outcomes'. As such, there might have been a tendencyfro trainers to confuse the training process with results
• theobjectives of the last session require careful consideration and should takeaccount of the abilities of the group. Whilst more operationally-focusedparticipants might be more comfortable in 'listing' activities, morestrategically-oriented participants need to move beyond this to consider whatshould be happening next at a local level
• somediscussion sessions did have to be cut short, in the interest of sticking totime, especially where there was some initial reluctance of participants toshare ideas
• thepurpose of the pre-course questionnaire remains quite unclear and requiresclearer guidance and direction. It wasnot deemed to be an effective warm-up activity and whilst it should be used atthe beginning of the day, a warm-up activity should precede it. Additional questioning and earlier return ofthe form for prior consideration by trainers, would make its use more effectiveand focused
• boththe historical development session and the Ottawa Charter sessions should beshortened, to focus on only the key points, while the remainder of the materialcould be transferred to additional handouts
• noneof the content was deemed to be too simplistic although 'What is Health?' requiresmore focused direction and objectives
• theweighting process activity attached to the 'What Influences Health in YourLocality?' session requires to be simplified through an easier and fasterscoring system and which results in a general overview of the 'top 5'priorities
• aswell as condensing the Ottawa Charter sessions, the completion of thepro-formas should focus only on the key principles and not a 'task-driven'exercise based on 'filling in the boxes'
• thetraining methods are well-balanced but there should be a slightly lesspresenter-led focus. This is likely tobe addressed by shortening some of the sessions
• theobjectives of 'Overheard on a Bus' require some clarity, as well as prompts fordirection
• oneof the key challenges of the training will be to get beyond the intellectualargument of the need for the HI agenda and to prompt action for futuredelivery. This will depend on the skills and level of the participants, as wellas the extent to which senior level support (from a corporate and / or HRperspective) for the training and the wider HI agenda exists at a locallevel. The barriers of local authoritycultures and traditions will be a key influence, here
• further,national support for the future delivery of the training will be required. Otherwise thirty two variations of the HItraining might exist with no common themes or 'core' learning points
• theco-training guidance was not found to be especially useful to the majority oftrainers, who were generally experienced in this area but will be necessary forless-experienced future trainers
• co-trainingrelationships worked very well, largely due to the time spent on planning andpreparing for training delivery in a very structured way. This was conducted through face-to-facemeetings.

3.3 Issues at the pre-training stage which were not founded at post-training stage

There were only two issues which fell into this category:

• initialconcerns by some trainers that the strategy planning session at the end of theday would be too complicated were not founded with strategic groupings, whowere clearly ready to engage in this type of discussion. However, perhaps because trainers had notexpected this, these sessions were probably not as focused as they could have been. This is an important issue as the effectivenessof this last session is likely to be the key focus for participants inassessing the overall value of the training. A lack of focus at this stagecould tarnish the reputation of the training. In contrast, less strategic groupings might not be able to address theseobjectives. If this session is felt tobe too taxing for them, this could lead to disappointment and, again, couldtarnish the reputation of the training. Trainers will require to consider theintended outcomes of this session very carefully and perhaps be prepared toadapt objectives as the day unfolds and they gain a stronger grasp of what thegroup can achieve by the end of the day. The overall energy levels of the group, at this stage, will also be akey influence
• despiteconcerns about timing and fitting everything into the day, trainers found thatit was possible to cover all areas. However, this did mean cutting short the discussion sessions and it wasfelt that a more effective approach would be to cut back on the presenter-ledsessions, as detailed earlier, and to provide more time for the discussionsessions

3.4 New issues which emerged at post-training stage

A range of issues emerged here, largely building on what had alreadybeen recorded at pre-training stage:

• trainerskills - in defining the skills and abilities which trainers require fordelivery of the HI training, it is important to determine whether the ultimateobjective of the training is to challenge or inform participants. From the detail in 3.2 and 3.3 above, thiswill largely be determined by the specific needs of the group, as well asprogress being made at a local level. It is probably true that both of these issues are relevant to thetraining objectives. Future trainersshould be made aware of this from the outset, in order to determine whethertheir skills and experience are appropriate. It is very likely that a 'train the trainers' workshop will be requiredfor future trainers, with input from the HI officers
• pre-coursereading and scene-setting - participants should be encouraged to undertakebackground reading relating to the policy context of the HI agenda (through theCOSLA papers). This should bereiterated at the introductory session, at the outset of the day. Additionally, this should be discussedwithin the wider context of the community planning agenda and the LocalGovernment Act (2003), in order that participants can place the rationale forthe training in an appropriate context and understand the 'duty' element of theHI agenda. This could be achieved through diagram representationon a transparency, with scope for local information to explain progress andplanning structures which are particular to their local setting. This could act as a very powerful pre-cursorto the training and offer a clear context for incentives to engage with thetraining. Additionally, furtherstructure to the day could be created by the inclusion of some earlytransparencies which detail both the structure of the day, the key aims andlearning points. This will provide focus and a 'framework' for working over thecourse of the day
• further'scene-setting' guidance - at the 'scene-setting' stage (or perhaps earlier inpromoting the event and 'recruiting' participants) it would be useful toreassure participants that the HI agenda is not about starting from a 'cleansheet' and adding to current workloads. The message should be emphasised that a great deal of work at a locallevel already exists and that the training provides some prompts and focus forfuture direction. This could assist inreassuring participants of the value of the training, as well as offeringincentives to attend. It will beimportant that participants do not perceive the training message as HI beingsimply 'another hat to put on', in addition to current workloads. Some local authorities are already makingprogress with the Scotland's Health at Work (SHAW) initiative. From an operational perspective of 'healthimprovement' this is a real example which participants will be able to relateto. As such, where relevant to thelocal setting, this could be discussed at the scene-setting stage. However, this is only a small part of the HIagenda and should not form the focus of the scene-setting. There was also asuggestion that if participants sign a 'confidentiality agreement' at theoutset of the training, this might set the scene for encouraging open andhonest discussion throughout the day, as well as meaningful sharing ofexperiences. Whilst this type of'scene-setting' could be helpful, a confidentially agreement might be seen tobe daunting and intimidating. It shouldbe noted that the 'open learning' style of this training event might be quitenew to some participants. This will make scene-setting all the more important
• identifyingand 'recruiting' future participants - It was also suggested by some trainersthat service directors and / or heads of service will have a key role to playin promoting the training within their service areas. Where they have personally attended the training, thispromotional message is likely to be more powerful. These groupings are probably best placed to be able to identifywho the next 'layer' of target participants should be
• barriersto understanding and engaging with the HI agenda - it was also identified bysome trainers that the 'named person' culture which often operates within thelocal authority setting could act as a barrier to wider understanding of howeveryone has a role to play in contributing to the HI agenda. Traditionally, local authority staff have'single focus jobs', whereby performance and accountability are defined throughtheir service area. The HI agendarequires that staff work across service areas for added value in servicedelivery. This 'joined-up' approach topartnership working is still quite new to the local authority setting and willpresent challenges to both participants' understanding of the HI agenda, aswell as the incentives to engage and deliver in this way. Indeed, the planning structures to how thiscan be achieved are still quite unclear at a local level
• lackof current 'how to' examples - this current lack of clarity relates to thenewness of the HI agenda and, as such, there are few examples of what otherlocal settings are currently doing which could be disseminated across localauthorities. This will, of course,change as progress is made and as experiences are captured and shared through afocused approach to networking. However,in the interim period, participants might feel uncomfortable about exploring anagenda where both processes and parameters are still unclear
• clearerstructure to the pm strategy planning sessions - the last pm sessions relatingto the role of the local authority require a structural context, whichsummarises the national and local HI context. This could be presented as a summarised version of the structuresidentified in the introductory session. There should also be scope for each local setting to include details oftheir local planning structures and progress. This could be presented in diagrammatical format linking the SocialJustice Milestones to the Community Planning and HI agenda. These sessions might also benefit from thegroup undertaking a SWOT analysis, in order to focus thinking and to moveforward from mere 'listing' of current activity
• inclusionof 'ice-breakers' - the pack should contain a range of options for trainers touse as 'ice-breaker' activities. Trainers could choose from these options, in line with participants'needs and what is likely to appeal to the group. Indeed, the effectiveness ofthe 'Overheard on the Bus' session seems to be dependent upon successfulcontext-setting through the prior session - 'What is Health?' In the absence of an ice-breaker session,followed by effective context-setting, it follows that the 'Overheard on theBus' session might fail to stimulate discussion in the way in which it isintended
• the'Car Park' activity - this activity appears to have been very successful andwas very much enjoyed by participants, by way of both an afternoon 'energiser'and challenging their own views and perceptions. As detailed earlier in this chapter, the discussion which takesplace after the activity could perhaps be more focused by mapping out 'movements'from the activity and discussing these. Also, one trainer suggested that the 'character' which a participantmight be asked to assume could present some personal discomfort. In this setting, the participant might notget as much out of the activity as intended. To address this, a few extra characters could be set aside andparticipants could be encouraged to change their character if they wish to
• proposedchanges to the 'What Influences Health in your Locality?' session - setting upthe debating activity will require an element of planning. In one of the localauthorities, participants were asked to choose their stance and, in practice,too many opted for one line of argument to the detriment of setting up a fairdebating session. It might be best toeither assign roles at the outset of the activity or encourage only a fewindividuals to take part in the debate while the others observe, ask questionsand then vote. Alternatively, there wasa suggestion that participants resume the 'character' whom they were assignedduring the car park activity and take their perceived stance during thedebate. This would make the activitymore impersonal. Importantly, it will be necessary to establish that theobjective of this session is not for the debate to be 'won' but that the valuelies in the discussion and complexities which will arise during the course ofthe debate. To this end, the actualvoting stage is much less important than the process
• trainingfollow-up - the importance of a 'Phase 2' or follow-up session was raised bymany of the trainers. This would serve a range of purposes: it would allow for reflection of the keymessages from the training; it would encourage a 'next steps' approach to HIand sustain momentum for the HI agenda; it might encourage participants toprogress their thinking from a more intangible level to a practically-focusedapproach in considering what each service area can contribute to theagenda. This follow-up session couldalso be preceded by providing participants with the outcomes of the one-daytraining session. This could be done by typing up the key outputs anddistributing these either in advance of the follow-up session or at thebeginning of the session. Trainers should bear in mind that by the last pmsessions of the training, participants' energy levels are likely to belower. As such, a follow-up sessioncould produce more focused direction and outcomes
• trainingfollow-up - at the close of the session, it was suggested by one trainer that a'post card' of the Dahlgren and Whitehead model of health could be distributedto all participants. This could act asa powerful reminder of the key messages of the training and participants couldbe encouraged to take this back to their service areas for personal use or forwider discussion with colleagues
• suggestedchanges to statistics sessions - the statistics session could be condensed notjust by removing some of the information but by presenting the key data on oneoverhead which allows for easier comparison. There was some feeling that the 'connections' between the data presentedon different transparencies might have been lost due to these being presentedin different formats
• trainingdelivery over one day or two half days - whilst most trainers felt that aone-day delivery format was the most appropriate, there was some feeling thatdelivery over two half days, within a two week period might be moreeffective. This is because of theamount of information within the training and a view that this was too much toretain in one day. This might be overcome by commencing the second half daysession with a recap of the first half day. However, the disadvantage of two half days is that it is often difficultfor staff to commit to this and some fall-out might occur with someparticipants only attending the first half day. For this reason, a one-day format appears to offer the bestapproach, but with a more considered approach to the actual amount ofinformation over the course of the day
• regularsummary sessions - in order to ensure that participants remain focusedthroughout the day, it might be useful to undertake short summary sessions ofwhat has been achieved so far, perhaps before or after break times. These could be presented on flipcharts andthrough the co-training approach, where the less 'active' trainer could takenotes of progress during each session
• updatingmaterials and sustaining the training - as well as follow-up sessions forparticipants, it will be necessary to ensure that the training content staysupdated and that experiences are shared across local settings of the trainingitself, as well as local HI activity. There will clearly be a role here fornational co-ordination and overview, as well as how HI officers and futuretrainers input to this process. (HIofficers who took on a training role for the pilot exercise were keen to ensurethat any future inputs to the training are considered within the wider contextof the HI officer role.) It has been suggested that networking activity will benecessary for this to be made sustainable. This could be achieved in a range of ways, including web-access.Sustainability will require direction,planning and resourcing, with a clear view of what the objectives are for thetraining and how this links not only to the wider HI agenda, but also to thenational Community Planning agenda. Itmight be through this route that further resourcing and dissemination of goodpractice takes place. Capacity buildingwithin the HI agenda will be largely dependent upon how such networkingprocesses are established, in line with the national context. There was someconcern expressed by trainers that the sustainability of the agenda will bestrongly related to the sustainability of the currently short-term funded HIofficer posts
• relationshipsbetween trainers and HI officers - related to the above point is the need toensure that future relationships between trainers and HI officers are clearlydefined, in order that communication takes place on a regular and systematicbasis, as opposed to ad hoc updates, where important information ismissed. Such information will includeHI updates from HI officers to trainers and training updates from trainers toHI officers
• futureevaluation of the training - building on the baseline of information generatedfrom this report will be extremely important. As such, it will be important toconsider how the training and the processes which support the training will beevaluated in the future. This isparticularly important on considering that the pilot sites for this trainingwere self-selecting and are, perhaps, not typical of how the training might bereceived across all local settings
• thetiming of the training - with forthcoming elections, there was a general viewfrom trainers that the timing of this training is extremely important. In order to raise the profile of the HIagenda and ensure that its place will become embedded in future, localactivity, it must be incorporated into service plans, as well as workingtowards mainstreaming the training through the corporate training calendar andinduction training
• roll-outof training to partners - beyond embedding the HI agenda at a local authoritylevel, it will be necessary for the other partners of the JHIP to engage in asimilar process of awareness raising. This training could provide a strong framework for taking this forwardand, as such, there was general agreement that the parameters of the HItraining should not be limited to the local authority setting
• e-enabledtraining format - as well as considering how web-access could support thesustainability of the training, this medium should also be explored for wideravailability of and access to the training. This would allow for fasterupdating of materials as well as ensuring that a larger base of participantscan engage with the training. There areimplications, here, for the training format and the relationship between thetraining objectives and the delivery formats. This might be some way off but it was suggested by one interviewee thatthe HI agenda could be at the forefront of the E-Government component of theModernising Government agenda. It isclear that considerable commitment would be required to achieve this and,whilst being an important area for consideration, the implications are beyondthe scope of this particular piece of work
• thetitle of the training - despite recognising a need to review the title of thetraining, most areas simply used the same title as the pack - 'Promoting HealthImprovement and Tackling Health Inequalities'. This was felt to be too long and there was some concern that the word'promoting' might be misleading , given the established Health Promotion roleof NHS Boards
• whathas / will the training achieve? - there was strong consensus that a great dealhas been, and will be achieved by the training. Examples include: raisingthe profile of HI at a local level; encouraging partnership working through theactual training event; gearing up and preparing for completion of and deliveryof the JHIP; providing reassurance and information of what has already beenachieved at a local level; encouraging participants to make the effective'linkages' to take forward the agenda; tackling the 'myths' which existregarding what HI is and the local authority's role in addressing the agenda.Where training has been targeted at the local HI group ( as was the case withsome of the pilot sites), this offers a new opportunity for a relativelynewly-formed group to meet outwith their normal meeting format and so worktogether in a way which might offer new insights and ideas. The last of these issues seems especiallyimportant as partnership working contexts are often difficult and challenging,partially due to the partners not knowing each other very well and beingconstrained in addressing this through the normal 'meetings' format. Indeed, itwas observed by one trainer that their local group who have met since thetraining seemed to be working together in a more relaxed and productive waythan before the training
• nextsteps for the training pack - of the four test sites who were closely consultedin this study, two appear to be ready to move forward with the training in theshort-term. The other two sites are still planning how this training will fitwith wider integration of the HI agenda. After careful consideration, it hasbeen decided that no sites should use the pack in the interim period, prior torevisions being made. There are severalreasons for this: only the pilot siteshave currently had access to the pack and, as such, it would be unfair to limitshort-term usage to only these sites; in the absence of over-arching andfinalised guidance regarding pack content and delivery, there might be atendency for local variations to be developed. Under these conditions, quality assurance will be difficult to monitor;related to this issue, there is a clear need for consistency in content anddelivery across all local authority settings - accepting that local planningstructures and mechanisms must be accounted for; in the interests of ensuringthat the pack is sufficiently robust for future sustainability, there will be aneed to provide national guidance to support local areas in achievingthis. This guidance has yet to bedeveloped and will require careful consideration of balancing local flexibilitywith overarching national support. Since the pack does not contain any majorflaws, the revisions required are of a relatively minor nature. As such, the timescales for revision shouldbe quite short
• revisingthe training pack - a few trainers suggested that it might be useful to includea trainer in the process of revising the pack. This seems important in order to retain a practical approach to makingrevisions

3.5 Key issues at post-training stage

This chapter has detailedthe results of both the post-training questionnaire returns across the sevenpilot sites and the results of the one-to-one interviews at post-training stagewith trainers and senior managers in four pilot sites. The findings very much build upon trainers'views at pre-training stage and add clearer insights for both how the trainingcontent can be improved and what might be required to make the trainingsuccessful and sustainable in the future. The key themes which have emerged can be grouped under the followingthemes:

• skills of trainers and future support for trainers
• pre-course activities for both training organisationand participants' pre-course work
• detailed changes to the training pack
• post-training activities and support to participants
• next steps in taking forward the training pack
• current challenges to successful delivery of thetraining and future sustainability