House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Memorandum by the Academy of Medical Sciences (WP 94)

The Academy of Medical Sciences welcomes the opportunity to respond to the House of Commons Health Committee inquiry into the Government's Public Health White Paper.

INTRODUCTION

The "Choosing Health" White Paper is an important step forward as it draws attention to the significance of public health and the prevention and treatment of disease[167]. The Academy strongly supports the Government's action in making the promotion of public health a national priority.

CHOICE

At the heart of the White Paper lies a philosophical tension about the balance that should be struck between state intervention and individual freedom[168]. Such confusing messages are likely to undermine the implementation of a long-awaited UK public health strategy.

Despite its opaque philosophical foundations, informed choice is one of the core principles underpinning the new public health strategy. The White Paper proposes that Government should provide information to the public so that individuals will choose healthy practices such as taking regular exercise or avoiding smoking. However, whilst "choice" is ultimately down to personal decisions, these decisions are very much affected by the environments in which people live and work[169]. Knowledge and commitment are needed to adopt a lifestyle that differs from most of the rest of the population. For example, people in the UK have little or no control over three quarters of their salt intake as it is added during food manufacture[170]. To avoid salt, people would have to prepare their own meals and snacks from raw ingredients. This is inconvenient and time consuming. It tends to be the richer minority who more readily make such changes but this, in turn, only serves to widen health inequalities[171].

Where matters of infectious disease are concerned, an issue the White Paper considers primarily in terms of sexual health, individuals often are less able than governments to make choices.

The Academy is concerned that the White Paper moves the burden of responsibility too much toward individuals who may wish to adopt healthier lifestyles but cannot easily do so.

COLLECTIVE CHOICE

More can often be achieved through collective action than at an individual level. This should be a foundation of UK public health policy. Indeed most public health action is "hidden" in the sense that members of the public are often unaware of its existence: for example, legislation covering clean air, water, safety of buildings, transport, electrical appliances.

Many of the issues raised in the second Wanless Report, such as fragmented public health structures and the need to assess rigorously the effectiveness of public health initiatives, are not fully addressed in the White Paper[172]. Wanless recommends a more coherent approach, recognizing the constraints on individual behaviour and suggests that more can be achieved through collective action than at an individual level. The Academy of Medical Sciences report "Calling Time" provides an example, in the case of alcohol of how collective choice could control alcohol consumption and thus minimise alcohol-related harm[173].

Governments are vulnerable to the accusation that population level policy measures will promote a "nanny state", with individual responsibility removed. This unhelpful criticism obscures the all-important need for comprehensive public health programmes. The Academy believes that it is perfectly possible to implement a public health programme that reflects a "caring" state while preserving legitimate individual choices and freedoms. In most cases there is no tension between the interests of the community and the individual.

EVIDENCE-BASED PUBLIC HEALTH POLICY

Public health policy should be evidence-based. The relative gain, probability of success, and cost-effectiveness of public health policies need to be considered before implementation. For example, persuasive local initiatives like SureStart[174] tend to be expensive and have not been properly evaluated. On the other hand the value and safety of fortifying flour with folic acid to prevent the serious birth defect spina bifida has been demonstrated[175]. Sufficient political will is now required to implement this public health measure, as has been done in the USA, Canada and in over 30 other countries.

Academic institutions and researchers are currently under-utilised by policy makers and the contribution made by experts is not always valued. Despite the UK's status as a world leader in public health research, there is an acute shortfall of clinical academics specialising in public health[176]. It is important to develop academic capacity in public health so that research can be better converted into policy and practice. Additionally, the Research Assessment Exercise should value appropriately the work of researchers who focus on topics relevant to health policy. The gaps between researchers, service providers and policy-makers also need to bridged.

Despite pressure for "quick fix" solutions, public health policy should be based upon rigorous research. Some of the examples of initiatives given in the White Paper are of unproven effectiveness and there are good reasons to believe that many will have little impact on health because they do not address the underlying constraints to healthy behaviour. For example, giving out pedometers may have little impact on exercise patterns if people do not feel safe walking or cycling or the weather is cold and wet. These proposed actions require rigorous evaluation before they can be endorsed.

JOINED-UP PUBLIC HEALTH

The various public health policies set out in the White Paper do not fit together to form a comprehensive strategy. Instead they provide piecemeal solutions of unproven cost-effectiveness.

Given the appointment of a Minister for Public Health and the public health issues raised in the Chief Medical Officer's annual reports, it is surprising that the White Paper does not mention new structural developments within the Department of Health to augment its public health work or set out structures/mechanisms for interaction with other public health stakeholders[177]. Since many of the determinants of health such as education, housing and transport are beyond the traditional remit of the Department of Health, or the Primary Care Trusts that have new public health responsibilities, it is clear that any public health strategy needs to cut across Government.

Public health has many facets, creating a complexity that can lead to lack of focus and inactivity. However, the main determinants of disease, diet, smoking and infection can be, and have been, examined in detail quantitatively. These provide compelling evidence that can, and should, drive public health policy. No one could argue that the prevention of BSE is a matter of individual choice. It requires decisive and effective central action. Similarly the prevention of lung cancer, stroke, cardiovascular disease, diabetes, all of which depend to some degree upon personal choice, also require central action so that the requisite facilities and services are available to address them.

CONCLUSION

The Academy would like to emphasise that clinical medicine and public health are complementary not competitive, representing different points along a continuum from individual-centred interventions to population-wide strategies.

The Academy welcomes the contribution the White Paper makes in highlighting the importance of public health but is concerned that its emphasis on individual choice is misplaced. Over the coming months the Academy will develop a detailed vision of public health from a medical academic perspective based upon the issues raised in this response.

February 2005