Memorandum by the London School of Hygiene
and Tropical Medicine (WP 22)
We welcome the increased focus on public health
reflected in the White Paper—"Choosing Health: Making
healthy choices easier", from the Department of Health for
England. Nevertheless, we believe that there are a number of opportunities
to improve health that are not adequately addressed by the White
Paper.
As an academic institution our contributions
to UK public health include: improving the evidence base underlying
health policies; strengthening capacity to address research questions;
ensuring that research evidence is appropriately used to influence
policy and practice and training the public health workforce.
We believe that there are important philosophical
questions about the balance between individual choice and government
action that first need to be resolved in order to develop coherent
and effective national policies to improve public health.[59]
In the introduction to the document, the Health Secretary makes
the point that "people can not be instructed to follow a
healthy lifestyle in a democratic society". However, the
White Paper also points out that expenditure on marketing by the
food industry, much of it promoting products that are high in
fat, sugar and salt, is one hundred times greater than what is
spent by the Government to promote healthy eating.
This highlights the asymmetry of information
to which the public is exposed. If unhealthy eating is to be reduced
additional steps will need to be taken but this will require that
there is clarity about precisely what the role of government should
be. Behaviour change is a complex process and it seems unlikely
that the labelling of food alone will promote the necessary changes.
It also remains to be seen whether the voluntary codes to regulate
the promotion of food to children will work. There are a number
of examples where the evidence from research indicates that personal
choice alone cannot deliver the potential health benefits and
where greater Government action is necessary. These include the
fortification of food with folic acid and increasing the rate
of progress on reduction of the salt content of foods.
In our view the Government has yet to make the
case for what we believe to be necessary actions, although we
recognise that this would require that it faces down potential
criticisms of "nanny statism", a course that may risk
adverse comments by some sections of the media.
We also have concerns that the primary care
trusts which have the biggest challenges in terms of reducing
health inequalities are currently under-funded against their weighted
capitation target. There is a pressing need to match the stated
intentions of the Government with the resources being made available.
The White Paper presents a range of case studies
outlining apparently successful initiatives to improve health
but insufficient information is given to determine whether they
have had the desired impact and whether they are likely to be
generalisable. It is only through undertaking rigorous research
that we can have confidence that the policies will have the desired
affect. Although expansion of training in public health is mentioned
there is nothing on developing capacity in academic public health.
The proposed increase in research funding is welcome but there
is a need to develop a multi-disciplinary research environment
that will make it possible to address complex issues surrounding
improvements in public health.
It will also be important to develop capacity
to facilitate the translation of research into policy and practice
including that from other countries. This might be undertaken
for example by the development of centres of excellence focusing
on synthesizing and promoting the uptake of research in areas
such as nutrition, alcohol, or tobacco policy. The Research Assessment
Exercise must recognise appropriately those researchers who focus
on topics that are policy relevant and the impact of research
on policy and practice should be assessed in a transparent and
reproducible fashion by the relevant sub panels, namely those
on epidemiology and public health and health services research.
There also needs to be a greater receptivity
by the NHS to introducing innovations on an experimental basis,
where possible using randomised designs in order to compare intervention
and control groups. Currently, pressures to demonstrate action
and lack of research capacity often combine to result in a failure
to evaluate innovations. This in turn leads to a waste of resources
and an inability to learn reproducible lessons about successes
and failures which can then be shared more widely within the NHS.
Unfortunately bureaucratic obstacles to research,
particularly in the processes of ethical approval and research
governance are making it increasingly difficult to undertake many
studies that can provide the evidence to underpin public health
policy and practice. A recent example from researchers at LSHTM
concerned a study on weight management for the reduction of obesity
which necessitated contacting 77 PCTs around the country. The
researchers encountered different procedures for obtaining approval
from research governance leads in PCTs including a diversity of
application forms and inconsistent requirements for honorary NHS
contracts for research staff.
Finally, because many determinants of health
are outside the control of the Department of Health, we would
like to see a public health research agenda that spans Government
Departments encompassing sectors such as transport, housing, criminal
justice, education and social policy. This will necessitate
the development of collaboration between public health academics
and researchers from other sectors and will need to be driven
by new funding mechanisms and high level support across Government.
These comments are not the official policy of
LSHTM but represent the views of a number of senior academic staff
in public health.
January 2005
59 McKee M, Raine R Choosing Health: first choose
your philosophy Lancet 2005; 365; 369-371. Back
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