BMJ  2004;329:1247-1248 (27 November), doi:10.1136/bmj.329.7477.1247

Editorial

The white paper on public health

Is promising, but has some blind spots, which must be tackled

The white paper Choosing Health: making healthy choices easier lays out the government's approach to tackling a broad range of public health challenges from smoking, obesity, and drinking to mental and sexual health.¹ Positive aspects, such as signposting foods to indicate their fat, salt, and sugar contents have quite rightly been welcomed. Limitations, including the ironic coupling of the emphasis on individual choice with a failure to tackle secondhand smoke, are being highlighted by the relevant expert groups. The public are developing an awareness of the relevance of these public health issues in their lives, thanks in part to the substantial media coverage of the report's contents and of stakeholders' responses. At least these problems are beginning to get a thorough public airing, which must be a step in the right direction for further policy change. However, to maximise the benefits of such a substantial switch towards prevention, as urged by Wanless,² three fundamental blind spots need to be considered.

The first exemplifies a historical failure to match rhetoric with action. The report promises to help local health services deal with inequalities: "We are giving primary care trusts the means to tackle health inequalities and improve health through funding to give greater priority to areas of high health need..." This implies recognition of the need to provide greater resources to those primary care trusts in most need in order to move disadvantaged people up to the level of advantaged people.³ However, the promise rings hollow for many primary care trusts serving deprived communities. The government has set inequalities targets for these primary care trusts requiring them to improve the health of their populations faster than the average for the United Kingdom.⁴ Many of these are already struggling because they have not even received the funding they are due according to the government's own calculations of their requirements.⁵ In northeast London, for example, all four of the primary care trusts defined as being in the government's "spearhead group" (which means they have the worst health and deprivation indices), are currently under-funded to a total of over £80m ($149m; 114m) against their weighted capitation target.

The second blind spot is an inability to work through the consequences of worrying about being labelled as a nanny state. As a result, the recommendations on banning smoking are inconsistent and may actually increase health inequalities due to differential uptake by people across the socioeconomic divide.⁶ Encouraging smoking cessation on an individual level is one thing, but allowing smoking in pubs that do not serve prepared food undermines this effort. It is precisely people who visit pubs where food is not served who are in most need of protection from the effects of secondhand smoke. In this way the white paper fails to address the inequalities that purport to be the driving force behind it.

The third blind spot is the government's reluctance to take its own medicine. That decisions should be informed by robust research evidence is becoming embedded across the health service, and the white paper does pay some attention to the need to use evidence based interventions. A pity then that such emphasis is placed on individualistic interventions such as the provision of educational materials, when it is well established that information alone does not entice people to change behaviour. Nor will the provision of fruit for your lunch box alter eating habits so long as healthy eating is perceived to be posh.⁷ That the government persists in believing that it is as simple as that is disappointing. Improving public health is about changing behaviour. We need an in-depth understanding of the personal values, beliefs, preferences, and aspirations that drive behaviours in different social groups. Only then can we begin to design interventions to modify deep seated cultural norms and to challenge ingrained ambivalence. Changing behaviour will require the implementation of comprehensive structural, environmental, and economic interventions. For example, the report has nothing about using the taxation system to increase the minimum weekly income for healthy living,⁸ or for increasing taxes on tobacco, which are known to have the greatest effects on smoking levels of young people.⁹

The white paper does signal a seminal moment in terms of attention to public health and could have a profound impact. But the government must consider its blind spots and show a commitment to tackle complex environmental and personal barriers to behaviour change if it is to fulfil its pledge to make healthy choices easier.

Department of Public Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT (Rosalind.raine{at}lshtm.ac.uk)

Department of Public Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT

North East London Strategic Health Authority, 81 Commercial Road, London E1 1RD

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Competing interests: None declared.

References

1. Department of Health. Choosing Health: making healthier choices easier. London: Department of Health, 2004. www.dh.gov.uk/PublicationsAndStatistics/Publications/P ublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4094550&chk=aN5Cor (accessed 22 Nov 2004).
2. Wanless D. Securing our future health: taking a long-term view. Final report. London: HM Treasury, 2002.
3. Mooney G. Vertical equity in health care resource allocation. Health Care Anal 2000;8: 203-15.[CrossRef][ISI][Medline]
4. Department of Health. National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/06-2007/08. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicy AndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4086057&chk=ypFWoL (accessed 22 Nov 2004).
5. Healthcare Commission. State of health care report. London: Healthcare Commisson, 2004.
6. Arblaster L, Lambert M, Entwistle V, Forster M, Fullerton D, Sheldon T, Watt I. A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health. J Health Serv Res Policy 1996;1: 93-103.[Medline]
7. Ward L. Children teased and bullied at school over healthy food choices. Guardian 2004 November 9. http://www.guardian.co.uk/uk_news/story/0,,1346429,00.html (accessed 18 Nov 2004).
8. Morris JN. Commentary: Minimum incomes for health living: then, now and tomorrow? Int J Epidemiol 2003;32: 498-9.[Free Full Text]
9. Townsend J. Policies to halve smoking deaths. Addiction 1993;88: 43-52.[CrossRef]

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