How far can governments go to promote good health?
Andrew Lansley, shadow health secretary, argues it is possible for government’s to take the lead in promoting public health without telling people how to live their lives.
The simplification of food labelling and the smoking ban in public places have provoked indignation among those who see them as unnecessary incursions by the state into individual liberty. But public health policy has always witnessed such strong reactions. The rise in obesity, alcohol abuse and sexually transmitted infections are the unintended consequences of the collective actions of a host of different agents: government; businesses, communities; and individuals – and none of these agents will initially accept policy not aligning with their own profit or pleasure motives. Public health interventions therefore require a shared compromise, and reaching this compromise is a shared responsibility in which the pivotal role of government has too often been ill-defined.
Public health policy becomes accepted if it works, so the limits in which government can operate are not just subject to change but hysteretic. Measures to secure a clean water supply are today, for example, taken for granted, but when first introduced in 1854 The Times thundered that we would ‘prefer to take our chances with cholera’. So rather than prescribe the limits by which policy is constrained, the role of government should be to anticipate the policies which will work – and then build upon them.
In doing so, government must avoid ‘nannying’, which is almost always counterproductive. People loathe being told what to do. So although public health policy has three tasks, none involve coercing people into healthy living.
The first task is to create an environment in which healthy behaviours become social norms. This requires leadership. We should not forget that the iconic HIV/AIDS campaign of the 1980s was deemed distasteful by many at its beginning, but it was this leadership by government which shifted public opinion. Businesses made condoms freely available – they were demonstrated on daytime TV – and television executives broadcast scores of educational programmes. Society as a whole acted on the government’s lead, with the responsibility for tackling sexually transmitted infections shared within it. It was the model public health campaign, resulting – literally – in the decimation of many sexually transmitted infections.
The second task is to alter the payoffs to individual decision-taking so that decisions leading to ill-health tomorrow become more costly today. This too requires political nerve. The use of fiscal incentives has often been queried, with the strategy for taxing tobacco heavily originally denounced. Banning smoking in public places has also been pilloried – despite smoking per se not being banned – as nannying. However, its effect will be to render it increasingly inconvenient to smoke.
The first task is often costly for the taxpayer – at least in the short-term – because it tends to increase demand on health services. The fact that public health budgets currently reside almost exclusively in primary care trusts is a fatal system flaw: cash-strapped commissioners have virtually no incentive to pay for interventions that will cost them more in additional demand. The value of having these budgets concentrated in highly deprived areas is also yet to be proved: if anything, the most substantive public health gains are achieved through those measures which change the behaviour of the entire public – and not just those individuals at risk of most harm.
So the government’s third and final task is to design a public health infrastructure which ensures that policy levers exist to convert aims into actual results. The lack of any such infrastructure – and any elected person clearly accountable for it – explains the absence of notable public health successes in recent times. That’s why we’ve published a consultation on public health which addresses the policy infrastructure required.
Public health successes are now vital, as Derek Wanless made clear in July. At the very best, a failure to tackle preventable ill-health will be costly but, at the very worst, continuing to ignore these challenges will kill. If public health policy is tasked as above, then we will succeed in creating an environment which militates against unhealthy behaviour – but which avoids telling individuals how they should live their lives.
