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BMJ No 7130 Volume 316
News Saturday 14 February 1998
Britain's new health policy recognises poverty as major cause of illness
| A holistic approach to public health that identifies poverty as a main cause of illness is being adopted by the British government, which issued two green papers for England and Scotland: Our Healthier Nationand Working Together for a Healthier Scotland.
These papers mark a major difference in health policy between the Labour government and its Conservative predecessor by acknowledging that the root causes of ill health are mostly social, economic, and environmental and require policies that target help at those who are worst off. |  | |
| Action to tackle poor housing is promised Photo: PENNY TWEEDIE/PANOS PICTURES |
Concerted action is promised across government departments to tackle poor housing, low wages, unemployment, crime, and air pollution.
The twin objectives are to improve the health of the population as a whole by lengthening people's lives and increasing the number of years they spend free of illness, and to improve the health of those who are worst off in society and narrow the health gap between rich and poor.
England
For England there are to be specific 12 year targets to reduce the number of deaths in four priority areas: heart disease and stroke; accidents; cancer; and mental health. These targets supersede the 27 targets in the former Health of the Nation programme. The smaller number of national targets will be supplemented by setting local priorities to reflect the health problems of different communities. Action will also focus on schools, workplaces, and neighbourhoods.
Between the extremes of blaming individuals for poor health or introducing a "nanny state," the government's third way is a national contract through local health improvement programmes and healthy living centres funded by proceeds from the national lottery. The strategy will be overseen by the minister for public health, Tessa Jowell, and a special Cabinet committee.
The health secretary, Frank Dobson, told the House of Commons that far too many people are falling ill more often and dying sooner than they should. He added: "There are huge inequalities in our society. Poor people are ill more often and die sooner. And that's the greatest inequality of them all - the inequality between the living and the dead."
He accused the Conservative government of concentrating on making people change their personal lifestyle but ignoring causes of ill health beyond their control, as highlighted in the suppressed Black report on poverty and health in 1980, which Mr Dobson honoured. He cited government plans for a national minimum wage, welfare to work reform, a crackdown on crime, new housing, food safety, tobacco advertising, and reducing traffic pollution as part of a comprehensive health improvement policy.
The green paper states that many of the 90,000 deaths in people aged under 65 could be prevented. Losing a job doubles the chances of a middle aged man dying within five years. The poorest in society are hit harder than the well off by most major causes of death. In the past poor health was put down to bad luck or unhealthy behaviour, and the social dimension was neglected. Recognising the social causes of ill health, the government states: "Connected problems require joined-up solutions. Tackling inequalities generally is the best means of tackling health inequalities in particular."
Action will be through the health improvement programmes of health authorities which, combined with the government's role, will form a concerted national programme to be in place by April 1999. The government intends to place on local authorities a new duty to promote the economic, social, and environmental wellbeing of people in their areas, in partnership with local people, business, and voluntary organisations.
An early white paper on tobacco policy and a study on poverty headed by Sir Donald Acheson will inform the government's final conclusions.
Rabbi Julia Neuberger, chief executive of the King's Fund, welcomed the green paper but said that the plans do not go far enough in tackling inequalities. "We do have to measure progress in reducing inequalities, otherwise there is a danger that no one will take responsibility and be held to account."
The Public Health Alliance said that the green paper was strong on analysis but weak on strategy. The chairman of the alliance, Dr David Player, said: "So far the green paper has ducked the key issue of setting targets to reduce inequalities, and there are very few proposals for action by the Treasury."
The Liberal Democrats said that the new targets ignored two real public health problems - smoking among young people and teenage pregnancies. The Conservatives meanwhile criticised Labour for dropping the targets on AIDS.
Stephen Thornton, chief executive of the NHS Confederation, said it was difficult to invest in the long term when there were short term service pressures. "If we are to develop a long term strategy for health we will need to target services at individuals and communities whose health is poorest," he said. "That will require some tough choices."
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Scotland
Scotland's green paper reflects the worse state of health there, where a middle aged man is four times more likely to die than in England. The Scottish paper does not set specific targets for health outcomes. These will follow after the consultation period. In addition to the areas covered in the English paper there will be targets to reduce teenage pregnancy and improve dental health to protect children's teeth.
Lifestyle targets will be proposed for smoking, alcohol misuse, eating for health, and physical activity. Views are sought on whether targets should be set in mental health, HIV/AIDS, and drug misuse. Domestic violence and infectious disease - mainly tuberculosis - are highlighted as health problems. Directors of public health are envisaged to have a key role in formulating local programmes in Scotland.
The closing date for responses to both the green papers is 30 April. Green papers for Wales and Northern Ireland are due shortly. Our Healthier Nationand Working Together for a Healthier Scotlandare available from the Stationery Office, price £10.30 and £7.50 respectively.
Jack Warden
London
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