Is it nudge or fudge? Your verdict on Andrew Lansley’s public health white paper Healthy Lives, Healthy People: our strategy for public health in England launched in Wandsworth on Tuesday, ultimately depends on your philosophical stance about what’s desirable – and possible – when it comes to improving the health and the health-related behaviours of individuals and groups. But one thing is certain, Mr Lansley’s proposals cast the net wide, draw in issues of undeniable importance and deserve a good hearing.
Driving over the cliff is not attractive
As a health promotion specialist, I am prepared to take the white paper at face value. After all, if this approach does not succeed in helping to stem the tide of (mainly) lifestyle related health deficits and widening health inequalities, then we are rapidly approaching a tipping point of unaffordable demands on our healthcare system and everything related to it regardless of who the commissioners are. If we go over a cliff, it matters little if GPs, PCTs, Local Authorities or Uncle Tom Cobley are in the driving seat. Public health failure means we pass the point of no return.
At the weekend, Andrew Marr wondered “how will this government persuade us to drink less, stop smoking and eat our greens – and actually why should they?” In reply, Mr Lansley said his proposals spread across government and indeed beyond government “to ensure we really impact on the determinants of health.” Why? Because, he continued, “many of the poorest need the greatest support; health inequalities are too wide, we need to deliver improvements in lives of the poorest fastest.”
That is the right vision if we are going to address health issues which have their genesis in employment, housing, environment and education but which present to an NHS which can do little to address their causes. As Mr Lansley told Andrew Marr: “It comes down to responsibility; we need to support people to be responsible.”
Radical shift promised – is it deliverable?
Healthy Lives, Healthy People promises “a radical shift in the way we tackle public health challenges.” Does it deliver a policy of that magnitude? At 100 pages, 107 footnotes, and partnered with a 64 page evidence review – a publication in its own right Our Health and Wellbeing Today with 227 references – this is a heavyweight effort. And don’t forget an impact assessment of 156 pages.
And this isn’t the end of the policy train either. The white paper promises a flood of related documents next year covering health visitors, mental health, tobacco control, the public health “responsibility deal” with industry, obesity, physical activity, social marketing, sexual health, teenage pregnancy, and pandemic flu – not forgetting health protection, emergency preparedness and response. Whew.
Mr Lansley’s introduction makes his approach clear. His biggest concerns are the predisposing factors and consequences of obesity, sexually transmitted infections, drug and alcohol use, and smoking. But nannying and diktat are out. Instead this will be a new approach “that empowers individuals to make healthy choices and gives communities the tools to address their own, particular needs.” Local government will have the “freedom, responsibility and funding” to innovate and improve local public health and local people will be the judge of their efforts.
Moving Marmot forward
The white paper strategy takes as its point of departure Michael Marmot’s seminal review of health inequalities in England, Fair Society, Healthy Lives (February 2010) with its emphasis on early years development and education.
The big issue will be resources of course – money and people. Mr Lansley says public health money (likely to be around a modest £4bn of the £100bn+ the NHS spends annually) will be ringfenced within the NHS. The new Public Health England service based in local authorities and led by Directors of Public Health will be the shock troops against health inequalities working in partnership with public, private and third sector bodies. And there will be a “health premium” incentive to reward efforts to improve good outcomes that address health inequalities It is to be a grand coalition to improve local health, but one can already hear town hall voices saying the cash won’t be enough and it should be theirs anyway. Perhaps they have a point; only time will tell.
Fine words are one thing, legislation is another and we shall now have to wait until early 2011 for the long promised Health and Social Care Bill which will bring all of this into reality (including the switch on of Public Health England from 2012). In the meantime, I urge you to read Mr Lansley’s White Paper and reflect on the challenges and opportunities it creates. These initiatives depending as they do on people making personal commitments to change are a challenge to a public sector more comfortable with redesigning structures and managing inputs and process and commissioning services than it is with delivering outcomes that add value. This new commitment to delivery is impossible without the consent and commitment of the public.
Perhaps the final words – at this stage at least – should be Professor Marmot’s welcoming Mr Lansley’s white paper:
“I am particularly pleased to see the clear recognition that health is determined by wider social influences, and that these have an effect throughout our lives – right from the start. It clearly makes the abolition of child poverty, early years development and education, good working conditions, healthy and sustainable communities, and good conditions for older people a centre part of a strategy for reducing health inequalities. ‘Nudges’ will, however, only encourage individuals to exercise responsibility for their actions if they are combined with wider social programmes, regulation and a focus on equity from the outset.’
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