Memorandum by the UK Public Health Association
(UKPHA) (WP 105)
EXECUTIVE SUMMARY
We welcome the white paper for its commitment
to action to improve health and to avoid the fate of previous
attempts to do so. There are positive aspects of the proposals
which we fully support. However, we believe the White Paper will
only "make a real difference" as it intends if a number
of serious weaknesses are addressed as its implementation proceeds.
The UKPHA is a multidisciplinary membership
organisation, whose members share a common commitment to promoting
the public's health. We assess the White Paper against each of
the UKPHA's key priorities.
Combating health inequalities
— There should be a refocusing on addressing
underlying health determinants, with stronger measures put forward
to lift people out of poverty.
— Implementing a strategy to address
mental health problems should be made an integral part of the
Government's aim to tackle inequalities in health.
— There should be a recognition that
choice is a spurious, and largely irrelevant, concept in public
health and that health education will make a negligible, and possibly
harmful, difference to health status and inequalities.
— Efforts should be made to act on
best evidence, to make better use of current staff and resources,
and to make creative connections across issues and government
departments, seeking cost effective win-win solutions to health
inequalities.
Promoting sustainable development
— There must be central Government
leadership and integral local authority involvement to sustain
improvements.
— Changes to the workforce should learn
from, and build on, other recent and current work.
— public sector workplaces should be
examples of "healthy" environments.
— initiatives should be properly piloted
and evaluated before being adopted nationally.
— The training and capacity building
essential for partnership working should be identified as a specific
auditable requirement within the public sector.
Challenging anti health forces
— The Government needs to play industry
at its own game, and adopt a sophisticated level of social marketing.
— Legislation should be introduced
to control advertising to children.
— The smoking ban should be applied
to all work places, so that all hospitality industry employees
are equally protected from the harmful actions of others.
— Education in schools should be planned
with positive health in mind and in particular school meals should
be regulated for health.
For all our misgivings and concerns, there is
much to welcome and be positive about in the White Paper. It signals
a reassuring shift in focus towards greater health promotion and
protection by the health services. There are a number of proposals
that could have a positive health impact.
CHOOSING HEALTH
OR LOSING
HEALTH?
A response from the UK Public Health Association
to the White Paper "Choosing Health—making healthy
choices easier"
Persistent socio-economic inequalities in the
UK, combined with a greater severity of market failures affecting
lower socio-economic groups, seem to have contributed to significant
inequalities in health outcomes which, unless tackled, will present
a significant barrier to many in society becoming "fully
engaged".
Derek
Wanless (2004) "Securing Good health for the Whole Population"
INTRODUCTION
The UK Public Health Association welcomes the
White Paper for its commitment to action to improve health and
avoid the fate of previous unsuccessful initiatives. It puts good
health centre stage in regard to the policy agenda and begins
to address some of the barriers which hamper individual health
and well-being. To that extent it offers real opportunities for
a significant change of direction in the management and delivery
of health promotion and health, as distinct from health care,
services. However, our response considers whether the White Paper
will in practice "make a real difference" as it intends.
Will it help achieve the "fully engaged scenario" to
which the government is committed? We conclude that the hope must
be that it will, but only if a number of serious weaknesses are
addressed as its implementation proceeds.
Three principles underpin the public health
White Paper, Choosing Health: Making healthier choices easier:
Though important, we doubt whether they are
the most critical issues in addressing the poor state of the public's
health and the widening health gap.
The UKPHA is a multidisciplinary membership
organisation, whose members share a common commitment to promoting
the public's health. Its three key priorities are:
— combating health inequalities;
— promoting sustainable development;
— challenging anti health forces.
We assess the White Paper against each of these
priorities.
COMBATING HEALTH
INEQUALITIES
White Paper recognition of health inequalities
We welcome the White Paper's acknowledgement
of the "need to focus specifically on tackling inequalities
in health". This is in line with a clear commitment made
by the Government since coming to power in 1997 in a number of
reports and policy statements culminating in the Department of
Health's 2003 report, Tackling Health Inequalities: A Programme
for Action. We would regard tackling inequalities a more important
principle than promoting informed choice and are disappointed
that it is not cited as such by the White Paper.
Tackling health inequalities by promoting choice
In contrast to these earlier reports, which
emphasised the importance of the wider social and structural determinants
of health, the Government's approach to tackling health inequalities
has shifted—and, in our view, in the wrong direction. The
White Paper aims to reduce health inequalities, not by tackling
the wider determinants, but by promoting choice. While accepting
that "such inequalities are not acceptable", it states:
"Our fundamental aim must be to create a society where more
people, particularly those in disadvantaged groups or areas, are
encouraged and enabled to make healthier choices".
The relevance of choice in public health
We welcome the recognition given in the white
paper to the legitimate role of government in creating healthier
environments and shifting social norms in order to support individuals
and protect the health of vulnerable groups. However, we fundamentally
disagree with the portrayal of personal choice as the key issue
for improved public health and the focus within the white paper
on individuals as consumers, and not as citizens.
What does choice mean in public health? Public
health is principally about organising society for the good of
the population's health; at this level of concern, it is no more
a matter of individual choice than the weather.
Many individuals cannot choose whether or not
they have sufficient income to live in warm safe housing and eat
healthy food. They cannot choose to walk or cycle when both pedestrian
and cycle routes are often neither safe nor pleasant and dominated
by the needs of the car. Those who suffer the worst health inequalities
cannot choose to enjoy the benefits of local safe green spaces
to pursue healthy outdoor activities or to breathe clean fresh
air.
Even when choice can be exercised, consumer
decisions are profoundly affected and influenced by the powerful
and all pervasive impact of the advertising and promotional activities
of the food and drink industry, which is driven by the need to
increase sales and maximize shareholder value rather than to promote
the public's health.
Other Government interventions on inequalities
The Government's progress on improving social
justice, defined as "a fair distribution of advantages across
society", leaves much to be desired. The pro-New Labour think
tank, IPPR[190],
reports a mixed picture in its recent social justice audit. The
economy has grown, the nation is healthier, living longer, and
experiencing less crime than a decade ago. But inequalities in
disposable income have slightly increased since 1997, wealth distribution
has continued to get more unequal in the last decade, the rich
have continued to get richer, progress on the gender pay gap has
been slight, intergenerational social mobility appears to have
declined, the poorest people continue to be more likely to suffer
from crime, and deprived communities suffer the worst effects
of environmental degradation.
Although the UK has moved from its ignominious
position of having the worst child poverty in the EU, to being
rated 11th out of 15, it is, as the IPPR reports, still the case
that in 2001, 23% of children in Britain were living in households
earning below 60% of median income, compared with just 5% in Denmark.
Furthermore, the alleviation of poverty should target not only
children but also pensioners, and childless, lowly paid adults.
Populism rather than good governance
The public consultation preceding the White
Paper has been selectively drawn upon to support the Government's
stance. On close inspection, the outcomes of some questions contradict
the outcomes of others (eg compare: "Three quarters of respondents
. . . agreed that the Government should prevent people from doing
things that put the health of others at risk" with the contradictory
statement: "only 20% of people choose `no smoking allowed
anywhere' [in pubs]"). The Government's partial smoking ban
carries out the wishes expressed in the second statement, but
overrules the view expressed in the first. The Government appears
to have opted for the route that it perceives will attract less
negative "nanny state" press coverage. It has put media
advantage before good governance.
Old fashioned health education
We question whether this is in fact a public
health White Paper at all in the widest sense of the term.
It smacks of an old fashioned, medically dominated, health education
approach that fell into disrepute some years ago because it has
been seen to be completely ineffective. In 1976 a similar policy
document "Prevention and Health—Everybody's Business"[191]
(subtitled a Reassessment of Public and Personal Health) was published
based on the principle that "we need to interest individuals,
communities and society as a whole in the idea that prevention
is better than cure" The failure of Preventing Health to
bring about the changes, both within the NHS and society in general,
necessary to achieve the improved personal and public health it
claimed to seek has never been fully investigated or learnt from
and yet here we are again going over similar ground. Choosing
Health puts most of the responsibility onto the individual, whilst,
paradoxically, recognising that many disadvantaged individuals
cannot respond positively to health education messages, because
of circumstances beyond their control. The White Paper is not
aiming to change their circumstances, but to help them cope better
with their continuing disadvantage through a mix of education,
advice, and personal support in order (hopefully) to make informed
lifestyle choices.
Although social marketing is referred to, and
is an important strategy for promoting health in the 21st Century,
to be effective it must promote a concept of public and individual
health which is perceived and developed as an overall state of
well-being and a balancing of the physical, emotional and spiritual.
There is a real danger that health will be marketed and defined
in terms of personal fitness, body imagery, and individual achievement.
Mental health
There is some limited reference to mental health
in Choosing Health but little action proposed. This is despite
the fact that the UK is a signatory to the WHO European Declaration
on Mental Health and Action Plan. This was signed by all 52 member
states at an historic meeting in Helsinki in mid-January 2005.[192]
Mental health is an overarching issue connected to, and affected
by, inequalities, and which is linked with all four of the major
problems identified in the White Paper: obesity, sexual health,
smoking and alcohol. A White Paper aiming to make a fundamental
improvement to the nation's health should be setting out plans
to address mental health problems, particularly as experienced
by people in economically disadvantaged groups. Prof Richard Layard,
Co-Director of the Centre for Economic Performance at the London
School of Economics, has commented that if you wish to see an
improvement in health and well being—and consequently people's
ability to exercise more choice and control over their lives—society
will need to invest heavily in mental health services.[193]
The UKPHA recommends that:
— There should be a refocusing on addressing
underlying health determinants, with stronger measures put forward
to lift people out of poverty.
— Implementing a strategy to address
mental health problems should be made an integral part of the
Government's aim to tackle inequalities in health.
— There should be a recognition that
choice is a spurious, and largely irrelevant, concept in public
health, and that whilst the UKPHA would not disagree with the
possible marginal positive effects of many of the measures proposed,
we maintain that both the available evidence and experience show
unequivocally that health education will make a negligible, and
possibly harmful, difference to health status and inequalities.
— Efforts should be made to act on
best evidence, to make better use of current staff and resources,
and to make creative connections across issues and government
departments, seeking cost effective win-win solutions to health
inequalities. We cite, as an example, the tackling of fuel poverty.
Through effective, subsidised and easily available insulation
schemes the burden of ill health is reduced on those living in
cold damp homes, their disposable income is increased and their
quality of life improved. Simultaneously carbon emissions are
reduced and long term financial benefits accrue to the Treasury
through the reduction in costs to the NHS of treating the ill-health
resulting from living in cold damp homes.
PROMOTING SUSTAINABLE
DEVELOPMENT
The principle of working in partnership to make
health everybody's business is supported as this is essential
to achieve UKPHA's commitment to sustainable development. Again,
we would have preferred to see partnership working as a major
principle in the White Paper. The basis of the UKPHA's commitment
to promoting sustainable development is a recognition that good
health is dependent upon achieving the social economic and environmental
conditions which support healthy lifestyles. This has been acknowledged
by the commitment of successive UK governments (in 1992 and again
in 1997) to implementing Agenda 21, the UN Action Plan for sustainable
development agreed at the Rio Earth Summit and by the World Health
Organisation through the Healthy Cities initiative.
Sustainable development is an essential precursor
for the achievement of good public health. As the 21st Century
unfolds, it is clear that unsustainable development, resulting
in environmental pollution and climate change, poses significant
threats to the public's health. Toxic residues, polluted air and
waterways as well as the changed disease patterns and extreme
events associated with climate change are factors which have been
given scant attention in the White Paper.
The Government should recognise that the health
education measures put forward in Choosing Health will
have little or no effect without a concerted effort to arrest
the ever increasing degradation of the environment.
It verges on the naïve to talk of encouraging
individuals and communities to enhance their health by becoming
more active when the environment and infrastructure within which
they live their daily lives offers no accessible, affordable and
convenient public transport system and very little high quality
outdoor space, in which physical activity or community interaction
can naturally take place.
Given the significant interconnection of polices
aimed at the promotion of the public's health, and those which
are aimed at achieving sustainable development, we believe Choosing
Health is too focused on the Department of Health and NHS
as the primary locus of activity and drivers for change. The White
Paper does not unequivocally assert that the state of the nation's
health is dependent upon cross governmental joined up working
which provides the context within which healthy choices can be
made. A failure to address wider governmental responsibilities
reinforces both a narrow view of health and the prevailing fragmentation
of policy agendas and silo thinking.
Real opportunities exist both to re-invigorate
neighbourhoods and communities and to plan and develop new communities
which are sustainable and health promoting. The new Spearhead
Initiative and urban development programmes, such as the Thames
Gateway, must be based on creating sustainable neighbourhoods
and communities where the social, economic and environmental fabric
supports and promotes health and well-being.
Need for leadership at Government level
To make the White Paper vision a sustainable
reality, there has to be leadership from Government. This cannot
effectively come from the Department of Health. Its culture and
ethos are so interwoven with the NHS and its fate, that to expect
the mindset to switch from health care to health on the scale
required is asking a great deal. Since previous attempts have
not succeeded, if history is any guide then it is unlikely that
the future will be so different without a different approach.
What is needed is a paradigm shift through the creation of a wholly
new "Landmark" cross governmental coordinating function
to arch across departmental and ministerial silos in a way which
allows public health to become a defining issue of our time.
Cabinet Minister
We believe there is a case for relocating the
public health ministerial portfolio from the Department of Health
to the Cabinet Office, thereby reflecting its cross-governmental
nature. Regrettably, the White Paper has missed an opportunity
to re-energise this post and remove it from the shadow of the
NHS.
The CMO role
To support the Minister of Public Health in
the Cabinet Office, we propose a system of dual accountability
for the CMO so that the post's clinical responsibilities remain
located in the Department of Health, with accountability to the
Health Secretary, while its health responsibilities move to the
Cabinet Office, to support the Minister for Public Health and
be accountable to her or him. But this is only one possible option
for a new approach. We think the time is right to consider the
CMO's public health responsibilities in the light of the range
and scope of challenges ahead. We therefore propose an independent
review of the CMO's public health role and function, including
an exploration of alternative ways of organizing the function
and its responsibilities.
Local authorities and community development underplayed
The impact of local authority services is greatly
underplayed in the White Paper, despite the fact that local government
may be regarded as the natural leader for public health. Local
authorities control the majority of the services and environmental
factors that affect people's day to day lives. Indeed within Agenda
21, chapter 28, it is acknowledged that "As the level of
governance closest to the people, local authorities play a critical
role in educating, mobilising and responding to the public to
promote sustainable development".
Branding the White Paper as a Department of
Health/NHS production risks alienating local government because
it is regarded, and tends to see itself, as the junior partner
to the NHS. Unfortunately, the White Paper simply reaffirms the
power imbalance that has undermined rational argument of the location
of public health since 1974 when the public health function was
removed from local government and transferred to the NHS. We do
not favour further organisational restructuring but do believe
local government should at a minimum get equal billing with the
NHS for its contribution to improving health and tackling health
inequalities.
Community development has a track record of
success in empowering communities, and, thereby, individuals,
and a strategic approach to health promotion recognises this.
With the focus in the White Paper predominantly on individuals
this may prove to be ineffective without the concomitant development
and strengthening of community confidence and action.
Capacity and capability of the workforce
Choosing Health makes reference to new
tasks for the public health workforce and, in Annex B, sets out
the detail on roles, training and competence. We agree that it
is desirable to review the workforce deployment, to reconsider
what new skills are needed, and to make optimum use of what already
exists.
Particular mention is made of the importance
of partnership working and yet throughout the public sector there
has been no real attempt made to tackle the cultural and inter-professional
adjustments required to ensure effective partnership working.
Despite the research evidence on what makes for effective partnerships,
it does not appear to have been drawn upon to take forward the
thinking on the subject or to modify practice. Too often partnerships
are arbitrarily drawn together either as a response to a government
edict or in the pursuit of partnership funding and the key players
are either unable or unwilling genuinely to become more than the
sum of their parts. Not only are these partnerships often ineffective
when occurring between professionals, they can also be ineffectual
and inappropriate when operating at the community level. Currently
the Audit Commission undertakes a limited role in assessing the
evidence and effectiveness of partnership working within organisational
structures. There is however little to indicate that the training
and capacity building essential for the development of "fruitful"
partnerships is identified as a specific requirement within public
sector organisational management systems.
New categories and definitions of the workforce
In an era when the need for evidence based policy
and practice is recognised as being of paramount importance in
public health interventions it is curious to see the proposal
for the introduction of Health Trainers contained in the White
Paper. We are not convinced that the proposal is either desirable
or has been sufficiently thought through. The case for their introduction
needs to be demonstrated. We have serious misgivings about their
role and responsibilities, insofar as these are described in the
White Paper. Health trainers run the risk that, far from strengthening
the public health workforce, they could paradoxically weaken it
by creating another professional grouping with skills and boundaries
to be developed and managed thereby adding to the already considerable
and complex partnership challenge. We are not convinced of the
need for such an army of helpers drawn from the community nor
do we think a demand for this sort of intervention exists on a
sufficient scale to warrant such an initiative. The idea may symbolise
government's desire to be seen to be doing something but we think
it is a costly distraction with minimal value. We question whether
their introduction will give added value above strengthening the
role of, say school nurses and health visitors, and promoting
a true community development approach to these existing professionals'
work. This would, of course, require attention to be given to
their falling numbers, low morale and recruitment difficulties
currently exacerbated by changes in training and the closure of
the health visiting register.
Given the experience of health promotion within
PCTs, we question whether it is realistic to expect PCTs to have
the time, skills, or motivation to undertake the tasks envisaged
in the White Paper. Again, we urge the involvement of local authorities
and suggest that many of the initiatives contained in the White
Paper might best be led from a local authority base or by a joint
local authority/NHS team.
We are surprised that the term "Community
Matrons" is used (will male incumbents be so called?) given
that "nannying" is out of fashion. Is there not an inconsistency
here? When the term Matron was in widespread use in the first
half of the last century, it referred exclusively to hospital
posts. There is a danger that its use in this context suggests
a wish to bring institutional values to the community, which rather
contradicts the idea of personalising services.
We further suggest that careful thought be given
to the scope of the school nurse posts, and urge that expectations
of what is achievable should be realistic and should be seen as
part of an integrated public health workforce.
A healthy public sector
We welcome the specific mention of the NHS implementing
good public health policies within its own organisation. However,
we are concerned that the opportunity has not been taken to apply
the same policies to all public sector workplaces.
Piloting before plunging
Choosing Health proposes and refers to
many initiatives currently running or about to be set up. We hope
that current pilots, such as the "Spearhead PCTs", will
be evaluated before decisions are taken on whether to mainstream
them, and that new concepts, floated in the White Paper, such
as Health Trainers, will be piloted before being rolled out nationally.
UKPHA recommends that:
— There is a need for central Government
leadership and integral local authority involvement if these proposals
are to be realised and sustained.
— Overall public health must be distinguished
from health improvement; the responsibility for the public's health
should be removed from the silo of the NHS to a cross-governmental
cabinet level sphere of influence and operation.
— Changes to the workforce should learn
from, and build on, other recent and current work, especially
with regard to health promotion.
— All public sector workplaces should
be examples of "healthy" environments.
— Initiatives should be properly piloted
and evaluated before being adopted nationally.
— The training and capacity building
essential for the partnership working which will underpin the
successful implementation of the White Paper should be identified
as a specific auditable requirement within public sector organisational
management systems.
— Public health should be recognized
as a natural consequence of health promoting social, environmental
and economic conditions and should therefore be a central integrating
function of the government's new Sustainable Development Strategy.
CHALLENGING ANTI-HEALTH
FORCES
Social marketing
We agree with the White Paper's statement on
the need for creative social marketing techniques in promoting
health. Whilst welcoming the co-operation of industry, as in the
case of the Portman Group, we caution against assuming that it
is always best for industry to be a partner especially where successful
intervention will inevitably run counter to short-term commercial
interests. And where Government and industry do collaborate, the
Government should be in the driving seat.
We note that the Department of Health intends
to appoint an independent body to implement its marketing strategy.
We suggest that this will be most effective if it is independent
of industry and adopts the same sophisticated marketing techniques
that are successful in industry.
We suggest that there would be widespread support
for this, and cite the recent call from Alcohol Concern (www.hda.nhs.uk)
for Government to fund television and other advertising on excessive
drinking.
There is a dichotomy here in approaches to marketing.
When the Government seeks to influence people's behaviour, it
is called nannying, but when big business does it, it is dressed
up as offering choice. The consequence of this is firstly, a failure
to properly regulate, or to protect and promote the public's health
and secondly, the extension of the potential scope for market,
and public, exploitation by industry.
Regulation
Curbing the relentless and sophisticated marketing
of foods high in salt, fat and sugar to children is the single,
immediate step that the government should take to protect children
from unhealthy eating patterns. It is disappointing therefore
that we must spend the next three years watching the inevitable
failure of voluntary controls before the government is willing
to introduce the necessary statutory legislation.
The proposals for smoking restrictions in workplaces
and enclosed public places are a significant step forward for
public health. We welcome the ban, but are seriously concerned
that the anomalous exemption of some pubs and clubs will leave
bar staff working in those premises unprotected from the health
hazards of second hand smoke. This could also result in health
inequalities being widened, as smoking only pubs will tend to
be predominantly located in poor areas. We question the long time
scale for the implementation of the proposals and strongly urge
government to strengthen the restrictions to achieve a comprehensive
ban in the shortest possible time.
It is also a matter of concern as to how the
partial ban will be enforced, whether the responsibility will
be passed to local councils and whether they will be given the
necessary resources. Similarly, we would like to see a commitment
to a tobacco control and prevention programme of the kind developed
in California which aims to denormalise the acceptability of tobacco
use in communities through a comprehensive programme of measures
and education which includes revealing and countering the influence
of the tobacco industry. We note the initiative in the North East
of England to establish a Tobacco Control Office which draws on
the Californian experience.
We welcome the move to revise school meal standards,
and express the hope that this will result in unequivocal regulation
which ensures that all pupils are provided with healthy food and
drink at school. Ensuring that education is planned with positive
health in mind will require co-operation between Government departments
at the highest level to ensure a curriculum which not only develops
healthy lifestyle choices from the earliest age but which inculcates
a sophisticated understanding of the consumer society within which
those choices operate, including the role, methods and influence
of the advertising industry.
UKPHA recommends that:
— For health messages to be successfully
delivered, the Government needs to play industry at its own game,
and adopt a sophisticated level of social marketing.
— Legislation should be introduced
to control advertising to children.
— The smoking ban should be applied
to all work places, so that all hospitality industry employees—who
are typically on low pay, and so may be starting from a disadvantaged
health standpoint—are equally protected from the harmful
actions of others.
— Education in schools should be planned
with positive health in mind and in particular school meals should
be regulated for health.
CONCLUSION
Will Choosing Health "make a real
difference" as is hoped and intended? Will it help the nation
to be, in Derek Wanless's famous phrase, more "fully engaged"?
For all our misgivings and concerns, there is
much to welcome and be positive about in the White Paper. It signals
a reassuring shift in focus towards greater health promotion and
protection by the health services. There are a number of proposals
that could have a positive health impact, including the planned
Local Area Agreements, greater co-operation between agencies,
projects to increase physical activity, the partial smoking ban,
standards for food in the public sector, the initiatives to make
better use of professionals such as dentists and pharmacists,
the focus on occupational health, the gearing up of the workforce,
the approach to social marketing, and food labelling changes.
But to ensure that these improvements are sustainable and effective,
the government must provide sound leadership from within the Cabinet;
apply principles of good governance rather than rule by inconsistent
opinion polls and focus groups; it must also bring local authorities
in as equal partners as a matter or some urgency if local government
is not to be marginalised; build on existing workforce insights
and conclusions, when developing new workforce initiatives; pilot
and evaluate initiatives before extending them; grasp the principles
of social marketing and take a strong lead on advertising to children
and imposing a total smoking ban in work places, through legislation.
It is said that the White Paper marks the end
of the beginning and that the journey to a state of improved health
will proceed in myriad ways which cannot be entirely foreseen
or predicted. We agree. But we regret that the White Paper is
not more bullish about the enormity of the challenges ahead and
about the actions needed to tackle them effectively. Sadly, too
many punches are pulled to give confidence that the Government
does really mean business this time round.
190 The State of the Nation-An Audit of Social
Injustice, The Institute for Public Policy Research, London,
2004. Back
191
Prevention and Health: Everybody's Business. A Reassessment of
Public and Personal Health. A Consultative Document prepared jointly
by the Health Departments of Great Britain and Northern Ireland.
London; HMSO. Back
192
World Health Organisation European Ministerial Conference on
Mental Health, 12-14 January 2005, Helsinki. Declaration on
Mental Health Policy and Action Plan on Mental Health Policy. Back
193
Richard Layard "Happiness and Public Policy" Sustainable
Development Commission Workshop, HM Treasury, 5 October 2004. Back
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