Feature

Tough on the causes of ill-health?

Despite a good start, Labour now seems to be confusing health with healthcare, argue Ruth Barnes and Alex Scott-Samuel

Health policy before New Labour

The well-known 1947 WHO definition of health as ‘a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’ was always more symbolic than realistic. Who can claim that they have not only avoided disease but have achieved a state of complete well-being?

Yet the principle underpinning it still has resonance. It has long been understood that health, well-being and quality of life are influenced by a wide range of individual, social and environmental factors as well as by heredity, lifestyle ‘choices’ and health care. But health means different things to different people and the way we define it influences our response to it.

Successive UK governments have adopted a narrow definition of health, based on a medical model and using health as shorthand for health care. When the NHS was established in 1948 it was assumed that an injection of resources and, more importantly, the creation of a health service accessible to the whole population, free at the point of delivery, would lead to a ‘mopping up’ of ill-health so that we could all live healthier ever after.

As we know, this assumption proved to be wrong and, despite the early successes of the NHS and its admirable intentions, it quickly became clear that increasing the supply of care both increased demand and revealed high levels of previously hidden need.

In the 1980s, the Thatcher government’s response to what was (misleadingly) presented as spiralling expenditure on health services was to introduce a system of business oriented general management devised by the chief executive of Sainsbury’s.

This was followed in 1990 by the introduction of health care contracts and the separation of ‘purchasers’ from ‘providers’ – despite the findings of a government-commissioned global review of models of health care delivery, which emphasised the problems created by confusing cost-cutting with efficiency and choice with equity.

For many who lived through this period, the WHO’s Health for All policy represented a single voice of sane authority, confirming that health issues could not be tackled simply through health care.

When the Major government finally got the message and produced the Health of the Nation strategy in 1992, its acknowledgement of the wider determinants of health was at best sketchy; inequalities were famously re-branded as ‘variations’ and there was no recognition of their origins in deep-rooted inequities in physical, social and economic environments.

Health policy after Blair

With the election of New Labour in 1997 came a sense that at last these wider health determinants were being addressed through the government’s commitment to social inclusion and the direction of public funds to tackling inequalities in disadvantaged areas through initiatives such as the New Deal for Communities, Sure Start and the Neighbourhood Renewal Fund.

Could it be true that the spirit of Labour’s famous slogan ‘tough on crime, tough on the causes of crime’ was actually being applied to addressing the causes of ill-health? Or were the new ‘public health medicines’ merely the prescriptions of spin doctors?

Sadly, the latter increasingly appears to be the case. Despite the apparent emphasis on reviewing and developing the evidence base for public health action (‘what counts is what works’), many major government initiatives can best be described as ‘policy-based evidence-making’ — where the adoption of a value-driven policy is followed by the creation of ‘evidence’ to support it.

A typical example is the private finance initiative: expensive loans are raised from the private sector to build inadequate hospitals and schools, so the chancellor can balance his books. High quality research exposing this ploy is aggressively rejected and sycophants are wheeled out in its defence.

Another topical example is the Treasury’s cross-cutting spending review, which was supposed to examine the potential impact on health inequalities of all government spending.

Despite its impressive remit, the review and the action programme that followed somehow forgot to examine the Treasury’s own macroeconomic policies. Nor did it assess government policies on globalisation, defence, foreign affairs, gender inequity and other important causes of health inequalities.

And more recently, the Number 10 Policy Unit is providing a home to academic spin doctors who are prepared to assert that introducing a ‘choice’ of private sector health care providers into the NHS will somehow reduce health inequalities. Such views can and should be challenged, but serious debate about how power and ideology influence people’s health has been lacking.

So, with this as the background, the Politics of Health Group (PoHG) was recently established as a dynamic, inclusive left-of-centre group committed to discussing and understanding issues relating to the impact of politics on health, and to advocacy and campaigning around them.

PoHG already has an active email discussion group and has published an online discussion paper. A steering group meets regularly to plan further developments. Why not join us?

The PoHG discussion paper Towards a New Politics of Health by Clare Bambra, Debbie Fox and Alex Scott-Samuel can be downloaded from http://www.liv.ac.uk/PublicHealth/Publications/publications01.html