David Oliver: Is Sajid Javid putting political ideology before prevention?

Politicians and their parties obviously embrace ideology, but problems as serious as preventable disease and health inequalities require proper solutions based on expertise and evidence, not on political biases. On 8 March the secretary of state for health and social care, Sajid Javid, set out his vision for NHS reform.1 His three stated priorities were prevention, personalisation, and performance.

In the same speech, however, he stated that “public health and economic freedom are mutually reinforcing,” called for “freedom from an overbearing state,” and used the government’s term “health disparities” to describe what the public health community has long called “health inequalities.”2

Despite his reincarnation as a champion of the NHS, Javid is on record as a devotee of the ultra-libertarian Ayn Rand.3 Only last year, with the pandemic still raging, he voiced opposition to health protection measures by saying that the people should not be “cowering before covid”4—a phrase drawing on Rand’s writing.

After a burst of state interventionism during the pandemic the Conservative Party is now quickly rowing back towards small state, libertarian ideas. No 10’s new chief of staff, Steve Barclay, spoke in February of “cutting back the size of the state” as a priority.5 Andrew Griffith, minister for policy, argued for a smaller, less activist state.6 But with specific regard to tackling preventable ill health and inequalities, public policy initiatives are essential, and partisan ideology won’t cut it.

From 2010, long before the covid pandemic, the government had cut the public health grant, which fell by a quarter from 2015 to 2021.7 It had reduced support grants for local government and thus a range of wider supportive and preventive services and wider determinants of health. The Institute for Fiscal Studies found that local authorities in the most deprived areas had been hit hardest.8 This government has presided over an era of growing socioeconomic inequalities and policy initiatives on welfare that have left vulnerable groups worse off.

It had also ducked big policy interventions—on food pricing and regulation, sugar, alcohol pricing, affordable housing, and transport—in favour of a more permissive attitude influenced by industry and ideology and focusing on individual responsibility and choice, not the wider structural determinants of ill health. The Marmot update in 2020 showed that inequalities had worsened since the seminal 2010 report.9

Meanwhile, the much trailed wider government plan for “levelling up” set out by Michael Gove contains an interesting set of ambitions and metrics for progress, but it has been criticised for offering far too little state investment to back any meaningful actions.

The Health Foundation published a major report in February on key steps to tackle smoking, poor diet, obesity, physical inactivity, and harmful alcohol use. It also called for major investment, and, yes, state intervention, to tackle these determinants head on and create a healthier socioeconomic environment.10

This is what a serious commitment to prevention looks like. In his speech Javid alluded to improving healthy life expectancy and tackling preventable deaths from cardiovascular disease, but he gave no detail on the “how.” He also flagged the ongoing “landmark government reviews to tackle health disparities.”

But the devil will be in the detail of what these ongoing reviews recommend. Any interventions will also rest on the real power given to the new Office for Health Improvement and Disparities and on the seriousness of any commitment to ensure that health and prevention run through every public policy. Since 2010 a series of government reports and plans have emphasised prevention over service provision, with similar rhetoric. They have fallen well short of consistent, evidence based, and well funded action.1112

I hope that Javid’s ambition and rhetoric are backed by meaningful solutions. But I suspect that his own small state libertarian ideology and that of his party, as well as the influence of industry lobbyists, will mean that the priorities are once again not met.