Feature

Bound, gagged and blindfolded

Britain’s health promotion movement has caused increasing embarrassment to the government. Now its sturdy independence is under threat, warn Jane West and Liz Jones

Britain’s health promotion movement is under attack. At a time when the white paper on the NHS is proposing a more ‘businesslike’ health service, which will increasingly see money following sick patients, rather than being channelled into promoting good health, the government has launched a second, more blunt attack on the country’s health promotion organisations. These agencies and organisations have caused it consternation on two counts.

They have been attempting to involve local communities in determining their own healthcare needs — something vital to health education — and they have begun to illustrate the link between poverty, poor housing and bad health. The government response has been swift and direct.

In April, Health Minister David Mellor ordered the Health Education Authority to ‘reconsider the concept of community development work’ and he warned the organisation instead to focus its future work on a few mass media advertising campaigns.

Scottish Health Minister Michael Forsyth has announced management consultants are to ‘review’ health education in Scotland. His move follows reports of Scottish Office concern over research which inconveniently continues to link ill health with poverty.

And in Wales the Health Promotion Authority has been beleaguered by attempts to cut its budget and question its plans for the future.

The establishment of a link between poor social conditions and ill health would shatter the government’s justification- for trying to force all responsibility for heath back onto the individual. It would also expose the total inadequacy of the government’s emphasis on street poster advertising rather than a proper programme of preventative healthcare.

So worried is the government at the long-term implication of community development, it has placed under threat the ‘sturdy independence’ of the HEA, promised to the organisation by former health and social services secretary Norman Fowler on its establishment in 1987.

After the annual ministerial review of the HEA in February, Mr. Mellor wrote to chair Sir Donald Maitland in April warning that the authority ‘needed to work fully with government policies’. The letter continued: ‘I suggest that to be more effective the authority needed to focus more on the major health issues rather than attempt to undertake every aspect of health education.

‘I expressed my concern about authority’s tendency to undertake a large number of small projects over a wide range of activity’.

HEA chief executive Dr Spencer Hagard has denied that the government has attempted to restrict the HEA’s and he claims the future of community development is safe.

But the HEA response to Mr Mellor, attempting to justify the need for community development, apparently had to be redrafted 12 times before it was submitted. The final version is understood to narrow considerably the role of community work — already the smallest department at the HEA.

And it is said that all reference to the World Health Organisation’s Health For All programme was struck from the document. The three words ‘health for all’ are now reported be out of bounds in the HEA offices.

Staff are unclear whether they can even continue to work within the HFA framework. They fear it is deemed ‘too political’.

Yet the vast majority of health promotion workers agree that working with local people — empowering communities — is a vital element of health education.

Advertising campaigns explaining the major risks to health are an important complement to that work. But mass media campaigns on their own have been shown to be totally ineffective in changing behaviour.

In Scotland the review announced by Mr. Forsyth will cover not only the Scottish Health Education Group (SHEG) which is Scotland’s equivalent of the HEA, but also the health promotion departments run by health boards and voluntary agencies such as Action on Smoking and Health (ASH) which are funded to carry out health education.

Much of the work carried out by Scottish health education officers is grounded in the principle — which has mostly gone unchallenged so far in Scotland — that poverty and unemployment are major contributors to ill health. Health workers in Scotland now fear their independence is under threat. One health education worker said that they looked at England and at the government’s interference with the HEA and ‘shuddered’.

Members of the new Public Health Alliance launched in Scotland in June are worried the Forsyth review will back the government’s ‘victim-blaming’ approach to health education.

This fear is supported by reporters of Scottish Office displeasure at the publication of research demonstrating the links between damp housing and poor health, particularly among children (see News in focus)

One of the researchers involved, Sonia Hunt, decided not to renew her contact with the research unit in health and behaviour change at Edinburgh University, which is partly funded by the Scottish Office. It did not want to see any more such research and, furthermore, it wished to view any other material before publication.

Meanwhile, staff morale at both SHEG and the HEA continues to spiral downwards. Turnover at both organisations is high — as much as 220 per cent at SHEG since 1985. Yet health inequalities in the UK continue to widen.

The latest government statistics show men in social class V are now 2.3 times more likely to die before retirement age than those in class 1 (Population Trends 56, OPCS).

The government’s unpublished report to the WHO this year shows that infant mortality varies from 7.2 in social class I to 11.2 in social class V.

The concerns are serious. If staff continue to leave the HEA because they feel their work is being undermined, they will gradually be replaced by people more committed to the mass advertising campaigns favoured by the government.

The longer term and more diffuse strategies directed at reducing inequalities in health will be quietly dropped and Health For All by the year 2000 will be simply a dream that might have been.

The future good health of the UK depends on dedicated and impartial health education workers at local and national level, who do not feel constrained by political interference.

It is crucial that they continue to work closely with communities in order to establish the communities’ priorities for health.

Researchers must be free to continue to publish material that builds up a true picture of the nation’s health and the causes of ill health — regardless of the embarrassment to this or any future government. And the HEA must be allowed to take a lead in the battle to promote health by reducing inequalities in society, instead of simply offering glib health education advice which only serves to increase the ‘victims’ guilt.