01 SEP 2016

Public Health is in Crisis

I wrote the following article for The Guardian

In her first speech as Prime Minister, Theresa May promised to tackle the nine-year gap in life expectancy between rich and poor, placing this at the top of her list of burning injustices. This yawning inequality has defeated successive governments, and the gap is even wider between rich and poor for years lived in good health. Closing it will require action across areas such as poverty, housing and education, as well as those more conventionally thought of as affecting health. May will need to start early and look far beyond the short-term political cycle for results.

Public health seldom makes headlines. We tend not to recognise, let alone thank it for preventing disease or life-changing accidents, despite public health measures transforming our life expectancy. We are more likely to focus on and appreciate the specialists who treat a condition than to complain about the absence of the expertise or policy that could have helped to prevent it.

The childhood obesity strategy was the first test of the government's determination to take action on health inequality. It was greeted with near-universal dismay because of the wasted opportunities to make a difference. Whole sections from earlier drafts, covering promotions and advertising, were conspicuously erased and reformulation yet again left to ineffective voluntary agreements. The final paragraph sums up the tone that it will be "respecting consumer choice, economic realities and, ultimately, our need to eat". This crass statement entirely misses the point; of course children need to eat, but the childhood obesity strategy needed to make sure that they benefitted from a better diet.

Five years ago, amid the huge controversy surrounding the Health and Social Care Act, one proposal received a cautious welcome: the transfer of responsibility for public health from the NHS to local authorities. It was felt that local authorities could make a greater difference to the health and wellbeing of their communities if the right expertise, powers and funding were based there rather than within a health service more focused on treatment than prevention of disease. In a report published today, the Commons health select committee has looked at those changes and made a number of recommendations about how public health could be strengthened to make sure that it has the tools to do the job. These will be key to helping to narrow health inequalities.

The chief executive of the NHS, Simon Stevens, has rightly called for a "radical upgrade" in public health and prevention, not only for the benefits to health but because it will be essential to reducing future demand for health services. The future financial sustainability of the NHS depends on the prevention of more expensive long-term conditions. This was not the time to undercut the role of public health with budget reductions, including in-year cuts. Witnesses before the committee described their extreme frustration at these decisions, which they described as "irrational" given the current focus on reducing demand.

While local authority public health teams are doing their best to cope with funding cuts, the potential impact of this was clear, and unsurprising – figures from a survey conducted by the Association of Directors of Public Health show that large proportions of local authories are already having to reduce a wide range of different public health services.

Perhaps more surprising was that we heard from witnesses – both from local authorities and from NHS organisations – a sense that prevention is no longer seen as the responsibility of people practising in the NHS. While local authorities now hold the ring for funding and co-ordinating public health and preventative work across their local area, every NHS professional has the potential to advance the prevention agenda in every patient appointment they carry out – but they will also need the time and space to do so. It is also a shame that those messages on improving health will continue to be drowned out by the unfettered advertising and promotion of junk food and alcohol.

While the local mechanisms are in place to embed health in all policy decisions, this will not succeed without stronger, more joined-up action at a national level. At a time of budget cuts it is more important than ever that local authorities have the levers to make a difference. Unfortunately, they have their hands tied when it comes to negotiating with business interests even where the health of local communities is at stake. The government could and should introduce health as a material consideration in planning and licensing to allow proportionate action to develop healthier communities, homes and workplaces.

I hope that the government will prioritise health inequality, but the early signs are not encouraging. If future policy is to be judged by the childhood obesity "plan", we can expect little real progress. Tackling health inequality requires far more than warm words on education and personal responsibility.

5 comments

Supporting the EU, now writing letter for the Guardian. It's hard not to see this bitter article as sour grapes at May's failure to promote Sarah.
- George, Paignton

Really George? Of course, one can read the article anyway they choose, but it would appear that you started off with a formed opinion, rather than concluding one having read the article and seeing that what Sarah is saying, is the absolute truth. Excellent Sarah, and thank you for standing strong.
- David M.

On the contrary. I have followed Sarah's conduct closely, and have formed the view that she is comfortable neither as an MP or a Conservative. I will continue to contribute to local press on the subject. I know an awful lot of Conservative voters in the constituency who feel the same. Her nanny ways seem to me at odds with the values of a country where subjects make their own choices and take responsibility for them. These are Tory values and seem alien to Sarah. She seems to think that "respecting consumer choice" is crass, and seems to favour the kind of minimum pricing strategies for alcohol that are so offensive in a free society (I see the SNP like this too, which speaks volumes about where she is on the political spectrum). Her inability to accept that there will always be a gap in life expectancy between the rich and the poor (for so many reasons there isn't space to write about...suffice to say that we have a public health service that is free at the point of delivery, so I feel rather less responsible for it than Nanny Sarah seems to want me to) is the kind of political naivety that would have worried me about someone who only became a Tory at 44. Her letter today regarding the apparent lack of funds in the NHS...when this is demonstrably not true...is the standard response of the Left when reform is just too difficult for the kind of vested interests that Sarah is actually a part of. More money is always the remedy they seek. I have a number of other problems with our MP, and have little confidence in her. Labelling decent Christian people (including a former Archbishop of Canterbury) bigots before the last election, simply because they didn't agree with her view at the time on Gay Marriage. Her volte face on the EU Referendum (going in moments from describing "the threadbare deal" attained by Cameron, our "powerlessness" in Europe, and saying our national interest lay outside the EU...to "the prime minister has returned with a threadbare deal that has highlighted our powerlessness to effect institutional change" and that "the balance of our national interest now lies outside the EU", to switching to back the Remain due to her apparent failure to understand the difference between a net and a gross contribution). Praising the SNP Health Service when it has failed by any measure. Indeed even her Twitter feed seems to praise Nicola Sturgeon, Anna Soubry and Emily Thornberry. Dear oh dear. It would be better for all that Conservative members in the constituency get the vote they were denied by David Cameron before 2010 and could elect an a candidate seems to be more in tune with fairly basic and sensible Tory values. It won't be Sarah Wollaston.
- George, Paignton

Hi! Not sure how to start this as the end-point is fixing the economy, but this is surely what you mean by closing gaps on health and income etc? Miliband and Balls joined with your former prime minister and coalition in writing the banks out of the narrative of the economic hardship of middle and lower income earners. Corbyn's business and regional banks put idiots who mean well in charge or put public finance into the hands of bankers who already operate massive frauds. It is extremely easy to simply arrange the tax and regulatory system so that banks investing in the real economy is in the banks' own best interests. Imagine if in 2008 "we" had said to the bankers, "Your top-rate of income tax is now set at ten times the percentage unemployment rate, and this will be set monthly with ONS labour market statistics. Additionally the bank-levy total will be the cost to the State of paying Jobseekers Allowance; this total to be divided among the banks pro-rata with the how the bank-levy is calculated". With 8.3% peak unemployment this would have set bankers' top-rate income tax at 83%; the total raised by the bank-levy doesn't matter, just note that unemployment benefit will not cost the State anything ever again; obviously other benefits aren't funded this way - yet. Any economist will tell you that getting SMEs access to honestly priced finance will kickstart the whole economy, and also that Brexit means that UK internal markets are even more important than ever. So that's not just inequalities sorted, but also Brexit made easy. The only people against this idea are ... well you can work that out. See here for a "FAQ": http://bailoutswindle.com/QuestionsProtestationsAnswered.html
- Harry Alffa

I would say that is surprising ro read Sarah's article since Sarah voted to reduce human rights, to reduce pensions and disability by £30 per week claiming it is better spent elsewhere, and that probably nobody else outside officialdom will agree with her. Now she wants to waste 65 billions each year exiting the EU just in exchange rates, pay 7% of our budget on nuclear rearmament and "defence", (far more than the EU "cost" us although they give us 50 % of ALL their grants) because of Brexit, and we will lose our pensions which are at the moment being removed from index linking to pay for Brexit and really bad financial managing by the government. Millions affected by Brexit were not given a vote, we are charging £1050 if their children want British passports whilst we are selling EU passports to commondwealth citizens as long as they have the money = so they see the benefit of the EU. Sarah is now disenfranchising us by saying she will vote for Article 50 for "democracy"!!! If you really want to go against our wishes, Sarah, resign and stand in a by-election. That is because she wants to be a fat cat Tory politician and not face an election or apologise for making the mistake and not going on with the suicide of Brexit. Why is Brixham is "Totnes" anyway and not Torbay? We do not want fishermen AND farmers wanting out of the EU but wanting us to pay their grants for them. We want compensation from them.
- siv white

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