Feature

Securing the people’s health

Donald Reid spells out what Labour must do to tackle our urgent public health problems

How much energy can we expect the new government to devote to the promotion of the public’s health? At first glance, the national state of health seems far from critical — the last 18 years have seen steady increases in average life expectancy, for example. But beneath the surface, there are serious problems to be faced.

Of these, health inequality is by far the most important issue, as the previous government acknowledged with its curiously titled report Variations in health. This assembled powerful evidence of the growth in health inequality, while from other sources came the even more alarming information that the health of some groups is actually declining, giving rise to Third World health standards in places.

These findings reflect socio-economic changes in society, with the gap between rich and poor steadily widening since 1979. And, as the recent King’s Fund report on the state of inner city general practices in London has shown,¹ the inverse care law still applies — those most in need of treatment get the worst services.

So the crisis in Britain’s health is not about averages, but about extremes. The single most important remedy is to tackle poverty, starting with a coherent national strategy to reduce income and related inequality. National progress towards this goal should be measured against a clear index of inequality.

Health strategy must be adapted accordingly, starting with a major overhaul of the Health of the Nation, with the targets reoriented towards reducing health inequality rather than simply risk factors or diseases.

The health of young people merits special concern, with a decline in mental health, increased drug taking and smoking rates up to 90 per cent among some vulnerable groups. Since all of these are related to long term youth unemployment, money invested in providing jobs for the young should pay a significant return in better health in the long run.

The same applies to housing improvements, where the effects of unhealthy housing may cost the NHS up to £1bn annually. Increasing taxes on the use of private transport would also produce a range of benefits. If the funds were invested in public transport, both car use and pollution-related respiratory illness would fall, and there would be less need to drive more main roads through the middle of established communities, which leads to fragmentation and social isolation.²

Better public transport would also mean fewer ‘food deserts’ in poorer areas, created by local food shops closing the face of competition from out-of-town supermarkets. Not surprisingly, food deserts go hand in hand with unhealthy diets — so reinforcing the link between deprivation and ill health. Reduced car use will obviously contribute to a more sustainable environment which, after inequalities, is probably the second great public health concern of our time.

The government’s commitment to an independent national Food Safety Agency will hopefully help to restore public confidence in our BSE and E. coli infected food chain. But the Food Safety Agency should also form the advance guard for a broader ‘national office for public health’, reporting to Parliament on the health impact of government policies. It would have the power to require each ministry to produce health impact statements of its policies for public scrutiny, and would work closely with the Environment Agency to ensure that health and environmental policies are fully compatible.

The last major problem in public health concerns the question of co-ordination and leadership, both nationally and locally. In addition to a minister for public health we need a Cabinet-level appointment to co-ordinate the cross-government policies required to reduce inequality and improve health on a sustainable basis.

The same applies at local level, where the problems are even greater. Who is really watching over our health locally — as opposed to providing our health care — when NHS directors of public health (DPHs) find themselves spending up to 80 per cent of their time on treatment issues? And local authorities, who have by far the greatest potential influence over our health, have lacked strategic public health direction since the transfer of Medical Officers of Health to the NHS in 1974.

Worse, they have no statutory responsibility for health apart from the enforcement of environmental health regulations. Either DPHs need to be set free from their increasing entanglement with healthcare, or local authorities need to be monitoring the health of their populations. A thorough investigation is required if we are to regain strategic leadership and co-ordination at local level.³

In conclusion, the key priorities for the new government are to reduce health inequalities by narrowing differentials in income, healthcare, housing, and employment — all on an environmentally sustainable basis. New national health strategies are required to reflect these goals, supported by better mechanisms for co-ordination and the creation of an independent watchdog agency.

While we should all welcome the appointment of a minister for public health, the delivery of an agenda as radical as this will require the concentrated efforts of the entire government. How far this will happen depends on the extent to which they agree with the Roman orator Cicero that ‘the health of the people is the highest law’.