In the next few days we are promised a new public health White Paper and I thought, before it was published, I would draw some lessons from my experience of the last one in 2004.
I am writing this before publication of the coming White Paper for two reasons,
First it is interesting to draw parallels between the experiences of getting together the political argument in the White Paper Choosing Health between February and November 2004 and the current debate in 2010.
Secondly, and more directly politically, the Government – 6 months in – have a tendency to announce all their policies as if 2010 is year zero and they are revolutionaries doing completely new things. This is followed by a short period of their trying to win an argument for revolution. Being Conservatives they then start to lose the battle for change and change their argument to say “We don’t know what all the fuss is about, this is simply a continuation of what Tony Blair was saying”.
I thought we would, before it is published, cut through some of these stages and point out what I am sure will be the continuities as well as the discontinuities. Then when it’s published I can – over the week after publication – analyse both the text and the intention. After a week or so we can then look at how the Government is trying to spin its intentions. Revolution? Continuity? Or much more likely trying and not succeeding in being either.
Nearly every aspect of public health policy and practice revolves around the politics of what we think should be the relationship between the individual and the state. Many of the public health interventions that the profession want to implement spring from a belief that the state has to intervene in individual behaviour. On many occasions this involves the law being used to intervene in that behaviour.
The profession feel that public health statistics command it to argue for these interventions. Smoking, drinking, eating are all behaviours where the statistics are clear – if we do them in the wrong way (and in the case of smoking do them at all) it causes very bad health outcomes for both the individual and the public purse.
Given the evidence is so clear the public health profession feels that it must recommend tough action on these behaviours and save lives, pain and distress.
The statistics are also clear that the ‘social determinants’ of health in terms of income, education, work and housing have a big impact on health outcomes. If you are in work, you are likely to be healthier than if you are unemployed. If you are in non-manual work you are likely to healthier than if you are in manual work. Have a degree, decent housing - all the statistics show a strong correlation with good health.
So the public health community is driven by these statistics – about which there is no dispute.
However many of them draw from the statistics a particular approach to health improvement. To change individual behaviour many of them are clear that you need to stop the ability of the individual to make bad choices by banning the things that ‘cause‘ ill health and, thereby, not allowing the individual to have a choice. So trans fats is the next substance in their sights and, whilst very few of them believe in prohibition of alcohol in the full USA 1920 style, most want some laws stopping shops and consumers from being able to buy it at certain prices.
If in argument with this you suggest that stopping choice is not the way to empower people, you are seen to be not following medical advice. In fact this is not medical advice – it is political advice from medics. Using the state to intervene either in social conditions or in individual behaviours is intrinsically about politics – even if the topic has health outcomes.
That is what makes public health so important in the politics of the country – and why it will be interesting and important to understand how the politics of the Coalition finds its politics of public health.
New Labour’s 2004 public health White Paper was a new Labour document. Its title and sub title showed that:
Choosing Health – making healthy choices easier. Working in partnership across government with people, their communities, local government, voluntary agencies and business.
The emphasis was on Government’s responsibility to help individuals and communities make the right healthy choices in their lives. With the single exception of smoking which was restricted and not banned, it was not up to Government to tell them what to do.
The foreword by Tony Blair is explicit:
“Small changes in the choices people make can make a big difference. Taken together, these changes can lead to huge improvements in health across society. But changes need to be based on choices not direction. We are clear that Government cannot and should not pretend it can ‘make’ the population healthy. But it can – and should – support people in making better choices for their health and the health of their families. It is for people to make the healthy choice if they wish to. “Choosing Health” sets out what this Government will do to help them” (Page 3)
The then Secretary of State for Health, John Reid, was more explicit about the political debate:
“In recent decades the debate about the respective role of Government, individuals, communities, industry and others in improving health has too often become bogged down in a ritual battle between two ends of a political spectrum. On the one hand, a paternalistic state is encouraged more and more to limit individual choice, constrain personal decisions and ban action that promotes unhealthy behaviour. On the other, the government is asked to stand back, leaving people’s health to whatever the hidden hand of the market and freedom of choice produces. (Page 5)
Some people in public health felt that because the Write Paper was not advocating the first then it must have been advocating the second. They rejected the fact that the White Paper was arguing for something new.
John Reid based the ‘third way’ of the White Paper on what he had heard from the public.
“First people told us that they want to take responsibility for their own health. They were clear that many choices they made – such as what to eat or drink, whether to smoke, whether to have sex and what contraception to use – were very personal issues. People did not want the Government or anyone else, to make those decisions for them
Second what they did expect was that the Government would support them in making these choices. They wanted clear and credible information, and where they wanted to make a change and found it hard to make a healthy choice, they expected to be provided with support in doing so – whether directly or through changes in the environment around them – so that it is easier to do the right thing “ (Page 5)
I have quoted the politics of the 2004 White Paper on public health because it then went on to develop policy and practice that flowed from it,
- Health trainers starting in the poorest areas.
- Much better food labelling information.
- Recognising that children did not have the same opportunities to choose.
- Developing local communities for health.
- Bringing the full force of the NHS to bear on improving health and the importance of work for health.
This week – 6 years later- we will get this new Coalition Government’s White Paper.
They too will frame their public health theory and practice within a politics.
If the spin about what they are trying to do is the same as their other announcements they will start off saying it is “revolutionary”. If they do, then my blog for one will be looking for the nature of their revolution from the past – for the discontinuities they are planning between 2004 and today.