Feature

Don’t run from the politics

With public health finally pushed to the top of the policy agenda, arguing for ‘keeping politics out of public health’ misses the point, says Alastair McCapra. Instead, the politicians should be fully engaged

There are strange stirrings in the murky world of public health politics. The Nuffield Trust published a report last year calling for a new public health commission, modelled on the Food Standards Agency.

‘Political ideology still informs the values that guide government – such as, in this case, a concern with the health and well-being of the people. We are, however, in an era where an evidence-based rather than an ideological approach seems the most appropriate method of policy formulation,’ it said.¹

That other great proponent of the end of ideology, the Conservative Party, also seems keen to remove public health from the direct political control of ministers. In a 2003 consultation paper, it too proposed an independent public health commissioner, reporting not to government but directly to Parliament.

When people talk about ‘getting the politicians out of’ something and ‘leaving it to the professionals’, alarm bells start to ring. But in a field where ‘evidence-based policy making’ is now an article of faith, this case has a certain compelling logic. In public health terms, however, what could it possibly mean?

The argument for evidence-based policy making is fine as long as someone is collecting the evidence. But decisions about whether or not to collect evidence, and what to collect evidence of, are political. We cannot assume that ‘the truth is out there’ and speaks for itself.

And once you have the evidence, what do you do with it? Impose a fat tax? Enforce doctor-patient contracts on obese people? Or — as Mrs Thatcher famously did with the 1980 Black Report — simply ignore it?

One of the reasons public health has resurfaced on the mainstream political agenda is because the Blair government took a political decision to prioritise it, a political decision to create the post of public health minister and a political decision to investigate and act on health inequalities.

Those who argue for a depoliticised public health service are thus in the odd position of being able to argue their case precisely because a politicised public health environment gives them a platform to do so.

Current debates on the future of public health generally agree on the need to move beyond the confines of the ‘national sickness service’ and engage workers in diverse fields such as environmental health, occupational health, education, town planning and catering.

The more the debate advances, the wider the horizons of public health seem to become. As these horizons stretch ever further from the NHS, we enter a troubled realm in which ‘the personal is political’. This encompasses lifestyle issues, engrained habits and practices, societal norms about food and leisure, how we work and where we live, questions about a free market economy, consumerism, individual freedoms, the marketing of fantasies and anxieties, and the creation of desires.

As the government is finding out, making significant improvements in public health will require it to act in new ways. If it is to act as a real driver for change it is going to have to look beyond traditional health promotion activities and get to grips with, for example, how food is produced, packaged, retailed and advertised. It remains to be seen whether it will have the courage to ‘be at its boldest’.

The vista before us is not just one of irksome ‘health inequalities’ that have to be ‘tackled’ so we can all get back to the normal business of post-industrial capitalism. Our entire contemporary culture makes both a fetish and a problem out of health; there is almost no aspect of our culture that public health activists would consider to lie outside their realm.

If we agree that this broad, non-clinical terrain is the arena on which the framework of a new public health system is to be built, the notion of an objective, dispassionate and non-political public health activity dissolves into a technocratic fantasy. Public health can only become more political, not less. Essentially, we are looking at a revival of what was called, in the 1970s, community health.

Focused on primary care, emphasising community engagement, energetic in its experimentation and no respecter of traditional professional demarcations, the community health movement was quickly aborted in the UK first by the IMF loan, and then by the election of the Thatcher government. But in the current political climate, its revival seems more possible than at any point in the last quarter century.

In his recent Treasury review of the public financing of health, Derek Wanless set out a ‘fully engaged scenario’ in which people live longer and spend a smaller proportion of their lives in ill health. This scenario, he says, will come about as we generate ‘a dramatic improvement in public engagement, driven by widespread access to information.’²

Clearly this ‘fully engaged scenario’ will not come about as a result of turning the NHS into what it is not. The ‘national sickness service’ cannot be turned into the ‘national well-being service’ because a high-level model of public health suggests this would be more desirable.

Aside from anything else, all the signs are that we are going to continue to need a large and robust ‘national sickness service’ for quite some time to come. Parts of the NHS may be gradually adapted to a new configuration emphasising health promotion and protection, but overall the NHS, though an important part of the transformation, will not be the major vehicle for change towards a new kind of public health.

Rather, the key early catalyst will be to ‘fully engage’ people outside the NHS so that the transformations will be genuinely broad-based, multidisciplinary and focused on the needs of citizens who are not already sick.

In short, there will not be much mileage in setting new ‘stretching targets’ for GPs to undertake health promotion work as well as managing their existing caseloads. It would be far more productive to continue breaking down the iron wall between health and social care; to ensure that environmental health and occupational health professionals are given a central role; and that NGOs and volunteer organisations are involved so that the whole ‘fully engaged’ scenario does not turn into another internal management restructuring exercise for the NHS.

So how would these reforms dovetail with a ‘depoliticising’ agenda? The call for depoliticisation comes from exhausted professionals who are fed up with government targets and want to be left alone. It is easy to sympathise with this, but it simply is not possible to engineer a major change in orientation of the nation’s health services by publishing a wish-list and leaving everyone to get on with it.

People who support the ‘fully engaged’ scenario need to accept that change of this order of magnitude will only come when full engagement is harnessed to a strong central driver for change — the alternative is just drift and piecemeal reform.

Likewise, it makes good sense to be ‘evidence-based’ if your public health work is dominated by the prevention of communicable diseases. But much of the excitement about current health debates is not about ‘evidence’ but about the political decisions that need to be made to act on that evidence.

Should advertising of all foodstuffs to children be banned? Should smoking be banned in public places? How far will people tolerate – or possibly even welcome – interventions by the state or health professionals in how they live their lives?

Wanless’s summary puts public health at the top of the political agenda, at the point where government, health professionals, corporations, campaigners and ordinary citizens engage with each other. Public health cannot possibly be ‘above politics’. It has to be fought for, and politics is the arena within which that fight will have to be won.