Bookmarkers beware: Bookmarks to pages other than the home page may not work after we change our server in April Editor's Choice | This Week in BMJ | Press releases BMJ No 7130 Volume 316 Editorial Saturday 14 February 1998 Our healthier nation Can be achieved if the demands allow it John Gabbay See News, p 495 At last we have a national public health policy firmly based on the glaring evidence that health depends on social, economic, and environmental policies as well as on individual lifestyles and health services. The government's green paper, Our Healthier Nation(1) sets out the case for concerted action to tackle not just the causes of disease but the causes of the causes: poverty, inequalities, social exclusion, unemployment, and all the other features of the physical and social environment that converge to undermine health.(2) "Connected problems," the paper tells us, "require joined-up solutions." The joining up is to be done via a three way "contract" between central government, local services, and the individual, where each will agree to play its part in improving the country's health while reducing health inequalities. Thus, under the Minister for Public Health, government bodies in all sectors are to be driven towards policies that help improve health. Partnerships between health and local authorities will solve local problems, each partner committing themselves to appropriate targets. The public are to be given more help and information, especially in schools, workplaces, and neighbourhoods, to help individuals choose health. But will this combined approach work? Will it succeed by sweeping all public policies in the same health promoting direction, or will its very comprehensiveness pull us in too many directions at once? The answers partly depend on whether there will be genuine, cohesive commitment to the programme across Whitehall. The previous government's ambitious programme, The Health of the Nation,set out to shift the focus of the NHS from treating sickness towards promoting health.(3) Its strategy in 1992 was to set 27 targets in five areas and follow that up with a welter of initiatives to help persuade individuals to live healthier lifestyles. Whatever the arguments about the validity of such targets, by 1997 the NHS could claim that, with the help of its "healthy alliances" with local authorities and other agencies, only four targets - obesity, skin cancer, teenage smoking, and women's drinking - showed trends in the wrong direction. That programme underplayed fundamental tenets of the worldwide movement for health promotion, such as the requirement for healthy public policies and strong local community action,(4) but there remains much to build on.(5) Wisely therefore Our Healthier Nationhas strong continuities with The Health of the Nation.But we should also learn from the reasons why the earlier initiative was increasingly patchy and faltering in its progress. Two reasons have now gone: reluctance to tackle the determinants of health, and an excessive emphasis on targets that became ends in themselves. This time there is only one general outcome target in each of the four priority areas of cardiovascular disease, cancer, accidents, and mental health. Criticisms have already been voiced that these are only mortality measures and that reductions in inequalities will not be directly monitored, but such criticisms miss the point that process targets will be best agreed locally, not nationally. Recent trends in epidemiology suggest that even if the new policies have favourable results they are unlikely to show much effect by the year 2010, so intermediate targets will be needed.(6,7) Here, research and development will be vital - not only in the science and technology of health promotion but also in its organisational and behavioural aspects.(8) Of greatest concern, however, is a crucial lesson that seems not to have been learnt: unrealistic expectations must be curbed, or initiative fatigue will creep in. The ideals of The Health of the Nationfaltered because those responsible for delivering them were too hard pressed meeting the other demands of running services. While it is right that this new intitiative will shortly be complemented by others on tobacco, alcohol, drugs, and sexual health, the recent white paper has already set out a strenuous if welcome agenda for health authorities and primary care groups, central to which is the local health improvement plan.(9) Naturally, these plans will have Our Healthier Nationat their core, but is it realistic to expect them to be in place by April 1999 while their creators are also reorganising services? Time and effort will be needed at all levels for the local partnerships to work, especially when the main partners are each primarily accountable for meeting other objectives in their own sectors.(10) Public health professionals of all disciplines will, of course, carry many of the new responsibilities, and the Chief Medical Officer's imminent review of the function of public health doctors will be vital at a time when their wider role in public health has been weakened by the demands of the NHS market. Primary care groups, responsible for planning to meet the health needs of their populations, will find it hard to add yet more to the daunting list of unfamiliar responsibilities. More will be expected of local authorities, who may indeed be better placed to deal with the root causes of ill health but also need time to develop new patterns of working and enhanced skills to take some of the lead on health. Clinicians will need to ensure that the million or so people in our unhealthy nation who each day seek medical help receive consistent messages about dealing with the underlying determinants of health. But the message for government and for local organisations must be to ensure consistency in their demands of clinicians and managers and to provide earmarked resources and clear accountability for the key programmes. We want to do the job: give us the time to develop the tools. John Gabbay Professor of public health medicine Wessex Institute for Health Research and Development, University of Southampton, Southampton SO16 7PX email: jg3@soton.ac.uk References 1 Our healther nation: a contract for health. London: Stationery Office, 1998. 2 Warden J. Britain's new health policy recognises poverty as major cause of illness. BMJ 1998;316:495. 3 The health of the nation: a strategy for health in England. London: HMSO, 1992. 4 World Health Organisation. Resolution of executive board. http://www.primnet.se/public/html/nhprin/hpres98.htm 5 Health of the nation briefing pack. 2nd ed. Leeds: NHS Executive, 1997. 6 Barker D J P. Mothers, babies, and disease in later life. London: BMJ Publishing Group, 1994. 7 Kuh D, Ben-Schlomo Y, eds. A life course approach to chronic disease epidemiology: tracing the origins of ill health from early to adult life. Oxford: OUP, 1997. 8 Speller V, Learmonth A, Harrison D. The search for evidence of effective health promotion. BMJ 1997;315:361-4. 9 The new NHS. London: Department of Health, 1997. 10 Scriven A. The influence of government policy on health promotion alliances. In: Scriven A, ed. Alliances in health promotion: theory and practice. London: Macmillan, 1998. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline