So whose business is public health?BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6743 (Published 23 November 2010) Cite this as: BMJ 2010;341:c6743
- Nigel Hawkes, freelance journalist, London
To listen to some critics, the UK coalition government’s plans for public health are a betrayal of Judas-like proportions. My local paper, in southeast London, managed to see Tory wickedness even in the abolition of free swimming in the local pool. Since when, I’m tempted to ask, has free swimming been every English person’s birthright and its denial a sickening hammer blow to public health?
That is not to say that the plans of England’s health secretary, Andrew Lansley, are beyond criticism, though it is hard to know precisely what they are before the public health white paper is published. But this has in no way deterred those who want to persuade us that the health secretary has sold his soul to the food and drinks industry, giving them the right to determine what his policy will be.
Whatever it is, it can hardly be less effective than Labour’s performance in government between 1997 and 2010. For an entertaining read I commend the evidence taken on 14 September this year by the House of Commons Committee on Public Accounts, investigating the failure to narrow health inequalities over this period (BMJ 2010; 341:c5103, doi:10.1136/bmj.c5103). The committee, chaired by Labour’s Margaret Hodge, gored and tossed the witnesses from the Department of Health for England with an almost bloodthirsty zeal. “Claptrap” was among the kinder words she used.
What got the committee’s blood up was the gap between rhetoric and action. The need to put health inequalities at the heart of policy was announced in 1997, yet it took nine years, until 2006, until it actually became a priority. Why? Because, explained the hapless Richard Douglas, interim permanent secretary at the health department, it took that long to develop an evidence base.
Once this was developed, the conclusion was that three major interventions—lowering cholesterol concentrations, lowering blood pressure, and smoking cessation—were the priorities. (You could have learnt that by asking Google, one committee member unkindly interjected.) Implementing these in a coherent way would have cost £24m (€28m; $38m) in the “spearhead” primary care trusts (those with the greatest inequalities) out of a total budget for these trusts of £3.9bn, National Audit Office figures show.
Yet in these spearhead trusts the gap in life expectancy has widened by 7% for men and 14% for women since 1995-7. Only in some trusts in London was this target, later abandoned, likely to be met, and the witnesses could not tell the committee why London had apparently succeeded where all others had failed. So, even when their policies worked they didn’t know why. They thought it probably had more to do with changing populations than with any policy that had been implemented.
It is easy to mock, and some might argue that Labour’s policies will have long term benefits. That is possible, if we exclude the ones that are now forgotten, such as health action zones (the big idea of 1997) and healthy living centres, launched in 1999 with £280m arm-twisted out of the National Lottery. The final report on this enterprise concluded that it had achieved all that it set out to do: promoting good health, reducing health inequalities, and improving the health of the worst-off people. It would be nice to know where.
There was no end to these good ideas. The healthy living initiative (2007) focused on families with children aged under 11, while Change4Life (2008) aimed to encourage a healthy diet and an active life by using social marketing tools. Mr Lansley has said that he approves of Change4Life but won’t be giving it any more money. It will be up to industry, which was already heavily involved, to provide the funds if the programme is to continue.
Why did Labour’s initiatives fail? It wasn’t out of bad intentions or misplaced aims. The plans may have been too ambitious, given the limited leverage available to government to influence people’s behaviour. The problem with well meant advice—which is what a lot of it amounted to—is that those who listen are not necessarily those who ought to hear. Public spending on poster, television, and cinema campaigns rose 30-fold under Labour, reaching nearly £60m in 2009-10. But drinking levels barely changed, the incidence of sexually transmitted diseases rose, and smoking fell at a slower rate than it had before. Fruit consumption rose by a whisper, but vegetable consumption fell. At the 2010 election Labour claimed credit for the single most effective public health initiative of its tenure, the banning of smoking in public places—even though this was pushed through in the teeth of opposition from the then health secretary.
Given this record, it is hard to deny Mr Lansley a bit of leeway to do things differently. He has promised a ringfenced budget for public health, which is to be welcomed. He also plans to devolve its running to local authorities, which may not prove such a good idea. He has certainly taken advice from food and soft drink companies, rather than demonising them. Should we be scandalised by this, as some people apparently are? It depends entirely what emerges, but the involvement of industry should not have come as a surprise to anybody, as he launched such “responsibility deals” with them when still in opposition.
A dyed in the wool Tory, which Mr Lansley isn’t, would say it’s none of his business how much people choose to drink or what they prefer to eat. These are personal decisions that, like the choice of what to read or watch on television, are not the business of anybody else, least of all government. The chances of him saying that are nil. But it would be refreshing if somebody did.
Cite this as: BMJ 2010;341:c6743