Working towards “health in all policies” at a national level

The World Health Organization has challenged governments to adopt the principle of “health in all policies” to tackle the social determinants of health and health inequalities.1 However, policy making is complex, especially across multiple government departments, which makes implementing such an approach challenging. The Welsh government is consulting on whether and how to introduce this principle, asking whether there is a “need for a public health bill to place statutory duties on bodies to consider public health issues.”2

The strategy proposed in the Welsh green paper echoes Geoffrey Rose’s famous conclusion that to improve the health of a nation the “only acceptable answer, is the mass strategy, whose aim is to shift the whole population’s distribution of the risk variable.”3 The mass strategy proposed is healthier public policy in multiple areas, including education, social care, housing, transport, and urban planning. With life expectancy in Wales lower than in England and health inequalities within Wales increasing, this offers the possibility that Wales’s first public health bill will rise to WHO’s radical challenge for a health in all policies approach to tackling social determinants of health.

If Wales establishes a statutory duty on non-health policy makers to improve health at a national level it will lead the way in the United Kingdom and internationally. The Welsh government could look towards South Australia, where the state government introduced a model of health in all policies in 2007.4 High level political commitment, dedicated resources, and expert advice provided the impetus, and a socioecological “health lens” tool was developed that is now applied to all state policies to ensure that population level health is promoted strategically alongside economic growth.4 Although some countries have adopted cross government health targets, no national government has yet implemented a statutory health in all policies process such as that proposed by the Welsh government.

The health lens approach is a five stage collaborative process, whereby public health staff support other government departments and agencies to develop healthier policies through engagement with stakeholders, evidence gathering to assess health impacts, generation of joint policy recommendations, “navigation” through the policy making process, and evaluation.5 In South Australia this has complemented prevention activities that focus on children and young people, whose lives are shaped by multiple non-health policies.4 If adopted nationally in Wales, this approach would ensure that all future education policies support health and wellbeing—for example, by preventing reforms that allow playing fields to be sold off. More broadly, the use of the socioecological health lens would ensure that policy makers consider how secondary schools may inadvertently increase psychological health problems during adolescence.6

Geoff Mulgan, who advised former UK Prime Minister Tony Blair on public policy and joined up government, recommends cross cutting budgets and policy teams underpinned by strong networks to ensure “systems thinking and, hopefully, a reduction of unintended consequences [without] excessive bureaucracy and transaction costs.”7 The South Australian model provides a template for a public health policy team to work across Welsh government to “health proof” all future policies from an early stage in their development and according to the best available evidence. This would mean all policies would be subjected to a rigorous prospective health impact assessment, rather than retrospective assessments that have limited scope for national level health improvement or policy reform.

According to Mulgan, new training programmes and professional roles are also likely to be key to putting the principle of health in all policies into action across the policy making agenda.7 The Welsh government’s Public Policy Institute, which is being launched in 2013, aims to facilitate training and new partnerships, including those between policy makers and public health professionals. Appointing health improvement advisers in all seven Welsh government directorates could help to ensure that health is fully integrated across government and that policy initiatives with harmful effects on health are avoided.8

Public policy making across sectors in this context would still be a challenging prospect, even with more joined up government, because it requires all departments and agencies to be explicitly health centred for the first time. To use the example of education policy again, schools’ core business is to promote students’ learning (not health) and recent education policies that focus on promoting attainment though targets and greater inspection have probably limited schools’ capacity and motivation to promote health.9 However, one major strength of the health lens process is that, by engaging stakeholders at the start of the process,5 public health policy teams can work collaboratively with the education sector and “sell” them the wider benefits that promoting student health will have on behaviour and learning in schools.

Evaluating the results is another challenge, although innovative “policy trials” have already been used by the Welsh government to examine the health effects of the national exercise referral scheme and free breakfasts in primary schools.10 11 These could be replicated in other policy areas, such as secondary and higher education, housing, and transport, to study and optimise new national policies and examine their impact on health. Wales is also strongly placed in terms of national level data linkage facilities, which are needed to support effective horizontal health governance.7 The new Centre for Improving Population Health through E-Health Research (CIPHer), based in Swansea, could also monitor and evaluate the impact of policies on health.

Of course, complementary multi-level behavioural interventions will continue to be relevant alongside greater policy level action, especially for vulnerable populations who may benefit least from some healthy public policy reforms.12 A statutory health in all policies approach in Wales would also not tackle income inequality directly, but it might mitigate some of the societal harms arising from it. As such, the Welsh green paper opens the door to a far more radical approach than the “nudge” inspired English public health strategy.13 Doing nothing is still an option at this stage, but the Welsh government should ask itself not whether it can afford to take health concerns into account across all policy areas, but rather whether it can afford not to.