Should a stark example of the impact of inequality be needed, look at health status and life expectancy. If everyone over 30 without a degree had their death rate reduced to that of people with degrees, there would be over 200,000 fewer premature deaths each year. This finding, in last year’s Marmot review of health inequalities, illustrated the report’s core message: “Inequalities are a matter of life and death, of health and sickness, of well-being and misery.”
Should a stark example of the impact of inequality be needed, look at health status and life expectancy. If everyone over 30 without a degree had their death rate reduced to that of people with degrees, there would be more than 200,000 fewer premature deaths each year. This finding, in last year’s Marmot review of health inequalities, illustrated the report’s core message:
“Inequalities are a matter of life and death, of health and sickness, of well-being and misery.”
So a new white paper on health is significant, against a background of a seven year difference in average life expectancy between the poorest and most affluent regions – an inequality greater than at any point since the 1920s.
The white paper, Healthy Lives, Health People, contains familiar themes for the coalition: reduce the role of government, devolve responsibility to localities, and publish data on outcomes as part of local accountability:
“… it is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live.”
Commentators have been quick to note, however:
“… public health measures [that] have made undeniable and significant impacts include: seatbelt laws, drink-driving laws, the smoking ban.”
Health Lives, Healthy People has the Andrew Lansley hallmarks of a bold vision but is thin on detail. That detail will be strongly influenced by the food and drink industry, as documented in a Guardian investigation last month.
This highlighted that representatives of the major food and drink companies had been working with Lansley on his approach to public health policy since 2009, and are now integral to his policy machinery at the Department of Health, drafting policy recommendations for civil servants, in reversal of normal government process.
As a result, the white paper emphasis is on voluntary agreements, building on “nudge” theory; called the
“Public Health Responsibility Deal… [it] will aim to base these approaches on voluntary agreements with business and other partners, rather than resorting to regulation or top-down lectures.”
Public health experts remain concerned. Dr Vivienne Nathanson, of the British Medical Association, commented:
“If people live in an environment where they are surrounded by fast-food advertising and glamorous alcohol marketing, nudging will have a limited effect.”
The white paper proposes that responsibility for public health is transferred to local authorities in April 2013. Public health outcomes are to be measured and published alongside NHS and social care outcomes. Sceptics may wonder how improving outvomes will be encouraged, and there is reference to a health premium to incentivise improvement, but no further details.
The reality is that improving public health requires a concerted effort across agencies, as Marmot describes:
“Taking action to reduce inequalities in health does not require a separate health agenda, but action across the whole of society.”
The white paper does, though, acknowledge this:
“Healthcare services have been estimated to contribute only a third of the improvements we could make in life expectancy – changing people’s lifestyles and removing health inequalities contribute the remaining two thirds. Many of the biggest future threats to health, such as diabetes and obesity, are related to public health.”
This is where joined up government – local and national, with support of civil society – is put to the test, and in the coalition’s case the inconsistencies are already evident; for example, the white paper proposes that council areas with the highest levels of obesity, alcoholism and other symptoms of poor and excessive diet will get the most money from a ring-fenced budget to pursue their public health goals.
Yet this is against a background of major cuts in benefits and in local authority spending falling disproportionately on poorer areas with the greatest health need. Local government minister Bob O’ Neill has admitted that:
“Those in greatest need ultimately bear the burden of paying off the debt.”
Another topical example is the white paper’s referral to vouchers for healthy living and walk-to-school incentives, whilst the coalition proposes to scrap the successful and established School Sports Partnerships initiative.
Meanwhile, expert opinion remains sceptical about the white paper’s approach. Professor Ian Gilmore, chairman of the alcohol committee of the Royal College of Physicians, called the government’s measures “window-dressing”, adding that it “looks less like the ‘big society’ and more like big business”.
While Tim Lang, professor of food policy at City University London, concluded:
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“The term nudge is in fashion, but no substitute for public policy. There is a danger that the nudge will become a fudge.”