Interview

Improving health by any means possible

Britain’s first minister for public health, Tessa Jowell, spoke exclusively to healthmatters on the government’s strategy for public health

After a prolonged gestation the publication in February of Labour’s public health green paper, Our healthier nation, gave the government an opportunity to set out at length its thinking on public health issues. Labour’s manifesto promise to replace the disease-oriented and lifestyle-focused Health of the Nation strategy of the last government with its own more broadly based approach was widely welcomed by public health campaigners, who have been impatiently awaiting the result.

But while some critics have described the green paper as ‘long on diagnosis but short on prescription’, minister for public health Tessa Jowell told healthmatters that it demonstrated the government’s ‘determination to tackle root causes of ill-health, to tackle health inequality and to drive up standards of health enjoyed by people up and down the country’.

And, in the light of criticism that a target to reduce inequality is absent from the strategy, she signalled a willingness to consider whatever was necessary, including national or local inequality targets, to reduce the gap between the health of rich and poor.

Tessa Jowell is Labour’s first appointment as minister for public health, a post which it created on coming to power last May. With a background in social work, Ms Jowell spent 12 years as assistant director of the mental health charity MIND, and a further five running community care programmes, before becoming MP for Dulwich, south London, in 1992.

She regards Our healthier nation as a clear break with past thinking on public health strategy, which has tended to polarise debate between those who regard it as something done for the population by government, and those who see it as a matter of individual behaviour and choice.

‘I think that what we’re seeking to do is to establish a “third way” which recognises that there is a role for government — that no government involvement in public health will mean no improvement in health — but that government can’t do everything and that what we are looking for is the correct balance between government action, local action and personal responsibility,’ she says.

She places great emphasis on tackling the ‘root causes of ill health’, an emphasis reflected in the green paper’s discussion of the impact of poverty, unemployment, unsafe environments, poor housing and fear of crime on people’s health. And she admits that she is a pragmatist when it comes to setting targets for health improvement.

‘Quite frankly, I will do by way of target setting what needs to be done in order to stop people dying needlessly from conditions that can be prevented,’ she says, pointing out that target setting is ‘a mixture of science and judgement’.

But the reduction of the Health of the Nation’s plethora of targets to the four proposed in the green paper – on heart disease and stroke, cancer, accidents and mental health – has raised some eyebrows among public health specialists. Shouldn’t there be more? What about all the other preventable causes of ill health?

‘Targets are important in terms of benchmarking progress but what’s much important is harnessing resources at government, local action and personal level in a combined effort,’ she responds.

And a target for reduction in health inequalities? ‘Donald Acheson is looking specifically at the scientific evidence in relation to inequality, and what interventions by government may have an impact in reducing inequality. Now if that’s helped by having a national target in relation to inequality then I’m happy to consider that.’

The minister is clearly a pragmatist when it comes to policy, and is keen that her health strategy should result in concrete actions rather than theoretical arguments. ‘I don’t want this to become a theological debate,’ she warns. ‘This has got to be a practical programme for action. If local inequality targets help that, then of course we would want to apply them.’

She is also upbeat when it comes to the progress the government has made so far on key public health initiatives, holding up the Food Standards Agency and the European agreement on phasing out tobacco advertising and sponsorship as evidence of Labour’s determination to take public health seriously.

A Europe-wide ‘common position’ has now been achieved between health ministers, and Ms Jowell expects a ‘comprehensive framework’ for banning tobacco advertising to be in place within a few months. But, as everyone remembers, the government’s handling of the tobacco issue was far from straightforward.

In November 1997 it was clearly intending to exempt Formula One racing from a tobacco sponsorship ban, a position which was eventually revised in the wake of public outcry following revelations of a £1m donation by Formula One head Bernie Ecclestone to Labour’s election campaign. Wasn’t that episode something of a setback?

‘No, I don’t think that was a public health setback. I think that was much more to do with the way in which the issue was presented,’ says Ms Jowell firmly. ‘What was never in doubt was our determination to ban tobacco advertising.’

‘What was reflected during that time, from the public health point of view, was the difficulty of introducing a ban on sponsorship that would not jeopardise the sports which are currently heavily dependent on tobacco sponsorship, and what we have secured is a framework which different member states may chose to implement at different speeds.’

‘If you look back over all the correspondence and discussions that the Secretary of State and I have had since taking office, the overriding concern has been how to wean sport off the very high level of dependence that it has established, to find replacement sponsors without jeopardising the sporting events that people love to watch.’

‘Sport is popular, but so too is the government’s measure to reduce the number of children who take up smoking and to reduce tobacco advertising — but what we wouldn’t want to have to test is the popularity of our moves in relation to smoking if people suddenly saw their favourite sporting events disappear.’

Perhaps, though, in the light of that episode, thinking on public health issues has not permeated as widely through the government as health ministers would like to believe. One long-standing goal of public health campaigners has been to see the health impact of policies taken as seriously by, for example, the Department of Environment, Transport and the Regions or by the Ministry of Agriculture (MAFF) as they are by the Department of Health. Nine months into the job, how successful has the public health minister been in gaining inter-departmental commitment to public health policy?

‘Right across the range there are areas in which the public health agenda is being connected to other parts of the government,’ says Ms Jowell, pointing to recent examples such as the Food Standards Agency (a joint initiative of the DoH and MAFF), the health in schools and health in workplaces initiatives (with the DfEE) and work on air quality (with DETR).

‘I think it’s likely that at the end of five, six or seven years we’ll look back and see that improvements in health and reduced inequality were brought about more by the government’s raw determination to tackle inequality and social exclusion, more by our commitment to welfare reform than by any specific health intervention.’

But she recognises too that there is a long road ahead, and we are not yet very far down it. ‘You have to remember, that despite all the work that was done by hero and heroine innovators up and down the country through developing healthy alliances, there is not a cross-government public health infrastructure – we are creating it.’

And, perhaps unusually for a politician, her commitment to the task of improving public health, and her willingness to use whatever is to hand to secure such improvement, come across as strong and genuine. ‘We are determined to achieve the objectives that we have set for improving health and reducing inequality and we will do those by any means available to us’.