Whenever a politician utters the words ‘public health’ at the start of the day, you can guarantee that by the end of it ‘nanny state’ will be the words instead on everyone’s lips.
Launching Labour’s public health offer this week, Andy Burnham outlined that challenge from the outset, limiting the ambition of our actions to the extent that the public can stomach. How very technocratic.
We desperately need to move beyond the debate forever stuck between the patrician wagging finger and the autocratic ban. These policy announcements are a start. Outlining a raft of measures, Labour’s public health agenda could best be described as a ‘sliding scale of intervention’.
What clearly underlines Labour’s new vision for public health is the growing consensus around how society and the environment impact on our collective health. It was under Alan Johnson as health secretary that a Labour government commissioned Michael Marmot to revolutionise the way we look at public health. No surprise then that Marmot identified in his groundbreaking ‘Fair Society, Healthy Lives’ report that low skills and low pay are perhaps the biggest driver of public ill health, and that intervention at the earliest possible opportunity was the cure.
It takes a healthy household income to be able to make healthy household choices. If you are strapped for cash, you will shop where it is cheaper. If you have got a busy life juggling work and family, you will buy for convenience. If you are stressed, no one can begrudge a cigarette, the odd pint or a comfort snack. It is welcome therefore that Labour will not be signing up to levying ‘sin’ taxes on people and families making perfectly rational choices.
No clearer have we borrowed from Marmot that the introduction into the Labour lexicon of ‘proportionate universalism’, the notion that a rising tide can lift all boats, but that some boats might need more of a helping hand. Perhaps while the term itself ought to go into the same place ‘predistribution’ did, we can agree that the principle is sound. Having a job in a growing high-skilled economy is a safe bet for a healthier life.
But Marmot is a bit like marmite in many parts of the public health world, and the return of public health duties to local government is throwing up some interesting challenges. For far too long much of the public health establishment has focused, much like the rest of the NHS, on meeting ever-growing demand with ever growing supply. Clinical interventions after the fact, like healthy eating courses, fitness referrals or ‘awareness campaigns’, have characterised the weak response to date to the growing challenges of obesity, smoking and alcohol consumption.
The transition of public health to councils is making the clinical public health vanguard nervous. With the increased focus on the underlying social causes of ill health, and with councils forced to tighten their financial belts, some are turning to clever accounting. Cutting away some traditional public health services, authorities are beginning to make room within their dedicated public health grant for council services they want to protect.
While many have decried the practice as using health money to fill potholes, this behaviour is actually what is desperately needed. Forced to justify why fixing poor quality housing, delivering skills programmes and swimming pool subsidies all contribute to healthier residents amidst a range of others, councils are forced to examine the extent to which each and every service they deliver is helping support healthy people. In so doing, they are cementing into their budgets upstream investments that will pay out in the long term.
That payout is not just healthier people, but also an NHS that is not spending billions treating perfectly avoidable conditions. The arms race between political parties over which can spend more on the NHS never seems to be able to examine how we can curb the growing cost that increased demand generates, without blaming patients for getting sick and seeking out care.
Choice is exercised in context. The environment you are in will impact on your health. Your income will impact on your choices. Better regulation of the food and drinks industry, like sugar and salt capping in processed foods, teaching appropriate relationship and sex education at younger ages or levelling the playing field in advertising to stop sugar, booze and tobacco pushers out-marketing healthy lifestyle promotion, are all part of that broader goal. So too is using licensing powers and planning policy as part of a programme of building healthier communities full of healthy people.
Whether it is increasing the life chances of children from the youngest ages through Sure Start, or banning smoking in public, Labour in government demonstrated it was willing to make tough but effective decisions to raise our collective health. Bolstered by the stability that three historic terms in government provided, time was able to demonstrate interventions like Sure Start actually worked.
In a political cycle that lasts only up to four or five years, it is incredibly easy for governments and councils to consign public health onto the list of low priorities. Without an immediate return on investment we can point to on the doorstep, the politics of today often trump the policy for tomorrow.
However, as other parts of the public sector start looking towards the principles of public health in preventing and curbing demand for services, and with an NHS on its knees, holding our political nerve will soon be less a choice and more a financial necessity.