For all the talk of pressures on the NHS from a failure to stem demand caused by lifestyle factors, politicians find it difficult to prioritise public health.
The default position, especially at election time, is to confine the discourse to a narrow fixation on the NHS and the usual mix of investing in more doctors, nurses, beds and buildings. Public health might be accorded a brief supporting role when it comes to the party manifestos but only after the serious business around money and organisational reform has been given centre stage. How to end the path dependency which prevails, whereby what we have always done continues to be what we do, is the challenge.
NHS England’s Five Year Forward View published last October is a brave attempt to break the mould. It argued that the sustainability of the NHS depended on a “radical upgrade in prevention and public health”. It put the failure to achieve such an upgrade squarely on the NHS for not heeding earlier warnings and taking prevention seriously.
This is not empty rhetoric. The NHS chief executive, Simon Stevens, is a true convert to the cause. How many of his predecessors, or indeed any NHS manager anywhere, would be able to hold forth on public health in a 40-minute lecture as he did at Durham University last December?
If the forward view believes the NHS is on the hook for its failure to take prevention seriously, it is just as clear on what needs to be done to reverse the situation. But little of this thinking is evident in the pre-election jousting among the parties. Instead, the battle lines are drawn over who is prepared to put the most funding into the NHS and employ the most doctors and nurses.
Huge spending on cures
As the former cabinet secretary, Gus O’Donnell, argued in Society Guardian recently, there is an urgent need for the next spending review to reprioritise spending. He noted that the “massive health budget involves enormous spending on cures and a tiny proportion on changing behaviours to prevent problems”.
The first part of this statement is quite correct if not new – some 4% of the NHS budget goes to prevention although in England this responsibility now lies with local government. Pleas to reprioritise spending have been frequent but insufficient to puncture the current idea that what the NHS needs is more investment in cures and care rather than prevention.
Where many would take issue with O’Donnell is over his second statement concerning changing behaviours. He wants to see “behavioural units in every department”. But where is the evidence that such units, or the sort of new behavioural economics they subscribe to – the so-called “nudge architecture” to encourage people to lead healthier lives by taking actions to, well, nudge them into healthier lifestyles – actually works?
We need shove not nudge
The evidence suggests that in tackling complex, wicked problems to which there is no easy or single solution the mix of policy responses has to include interventions that tackle the root causes of the problems rather than their symptoms. This means not so much nudging people but shoving them into healthier lifestyles through regulation and taxation.
That, of course, leaves politicians uneasy about being seen as killjoys and cheerleaders for the “nanny state”.
It is all too easy for governments to succumb to the phenomenon of “lifestyle drift”. They may acknowledge the social determinants of health but end up tackling them through interventions aimed at individual lifestyles.
Vague and dispiriting promises
That does not mean governments never act against their self-interest – notable examples include the ban on smoking in public places and, more recently, the coalition government’s decision to introduce plain packaging for cigarettes.
But smoking may be seen as a special case. When it comes to alcohol, food and fizzy drinks the issues become trickier. And yet government action is still required. The government’s Foresight 2007 report on obesity argued that simply pointing the finger at individuals and encouraging them to change their behaviours would not suffice. Obesity is a societal problem and demands societal solutions.
During the election there has been remarkably little discussion of these complex social problems and the appropriate policy response to them. The party manifestos regurgitate easy platitudes about, in the Conservative’s case, taking action to reduce childhood obesity by promoting clear food information. In Labour’s case, it is about setting maximum permitted levels of sugar, salt and fat in foods marketed to children. The Liberal Democrats want to restrict the marketing of junk food to children.
What is dispiriting about the list of vague promises is that none of them is new and previous governments have either failed to act on them or their feeble efforts have been ineffective. If they had worked, the same set of measures would not be repeated at each election.
So while O’Donnell is right about the need for a “totemic gesture” to send out a clear message about spending on prevention, and Stevens is right about the failure of the NHS to seize the public health agenda, it would seem that our political leaders still need persuading that such a major shift in health policy is urgently needed.