Working towards “health in all policies” at a national levelBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1096 (Published 18 February 2013) Cite this as: BMJ 2013;346:f1096
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If the mean moves, the tail will follow
Adam Fletcher’s editorial “Working towards ‘health in all policies’ at a national level” refers to “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’ ”.1
At that time Nicholl argued that it is not always possible to distinguish the unusual values of a population variable due to biological variation from those due to disease.2
Pointing out that Rose and Day had said it was a hypothesis to be tested, I asked whether reducing population means would reduce the prevalence of ‘deviants’ or whether the distribution curve would become skewed or even bimodal? I gave examples of bimodal population distributions that had been uncovered.3
The issue was discussed further in the same column in some detail by Davies and Sitas, who had begun the correspondence by drawing attention to Rose and Day’s hypothesis.4
1. BMJ 2013;346:f1096.
2. Nicholl J. The mean predicts the number of deviants (Letter). BMJ 1990;302:1393.
3. Ingle RF. If the mean moves, the tail will follow (Letter). S Afr Med J 1993;83:142.
4. Davies JCA, Sitas F. If the mean moves, the tail will follow (Opinion). S Afr Med J 1992;82:76-77.
Competing interests: No competing interests
We were gratified to read Adam Fletcher’s editorial in last week’s BMJ (18th February), and we fully support his arguments for a ‘health in all policies’ approach in Wales. The South Australian ‘model’ to which he refers may offer interesting lessons, but it is important to recognise that the consultation on a public health bill in Wales is the latest stage in a long process of public health policy development, the history of which has been recently documented 1. In this context we were surprised to see no reference in Fletcher’s editorial to the key position of health in all policies from the first months of the Welsh Assembly’s existence. The approach promulgated in the first green paper of the new Assembly, ‘Better Health, Better Wales’ 2 was centrally concerned with ‘a new approach which recognises and addresses the factors which impact on health’, and put in place, for example, a health impact assessment support unit which has been working since that time to sharpen the ‘health lens’ of non-health policy sectors. Subsequent documents such as ‘Well Being in Wales’ 3 and ‘Our Healthy Future’ 4 continued this development.
We have to agree that the challenge for health improvement in Wales is greater than in most other parts of the UK, so the government initiative to consult on a major policy for health improvement is indeed welcome. Some three years ago, the Welsh Government set up the Public Health Wales NHS Trust with an overall remit to develop programmes in both Health Protection and Health Improvement, so an arm for providing support for a radical step-change in policy is already in place. The Trust already provides a range of detailed health indicators through the Public Health Wales Observatory, which would form a key support for an evaluation strategy which, as Fletcher points out, would be so essential to such an initiative.
In short, the innovative consultation on a public health bill is a development of an approach to health which has existed in Wales for some time, and marks out some key differences from the English situation.
1 Michael P, Thompson S. Public Health in Wales (c1800 – 2012). Welsh Government, 2012
2 Secretary of State for Wales, Better Health Better Wales: a green paper. 1998. www.wales.nhs.uk/publications/greenpaper98_e.pdf
3 Office of the Chief Medical Officer. Wellbeing in Wales Welsh Assembly Government 2002. www.wales.nhs.uk/documents/file1-full-doc-e.pdf
4 Our Healthy Future http://wales.gov.uk/topics/health/ocmo/healthy/;jsessionid=2F689E7F5C34E...
Competing interests: Prof Sir Mansel Aylward is Chair, and the other authors are Non-Executive Directors of Public Health Wales NHS Trust.