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More questions than answers

Steve Iliffe casts an eye over the government’s ‘consultative document for health in England’ — and finds it long on optimism, but short on detail

The latest government consultative document (’green paper’), The Health of the Nation, is the first concrete example of new-style, citizen-friendly Conservatism. It proposes a range of targets for health services to aim at, just as the World Health Organisation’s programme Health for All by the year 2000 did, back in 1978.

The differences between the two programmes are great, however, with the British government coming off second best. Selective in its use of evidence, The Health of the Nation chooses new targets that focus on individual lifestyles, rather than the WHO’s targets, which are based on ideas of equity, community development, environmental protection and better living conditions for people. There is little sign that the government is prepared to tackle the greatest cause of inequality in health — poverty.

The government’s aims are modest and may be difficult to assess. Much of the programme reflects health promotion activities that are already underway, or at least at the active planning stage, and there is little that is truly innovative in the document. Some of the health problems targeted, like heart disease and stroke, are already changing for the better and further improvements will be difficult to distinguish from the existing trend.

Health promotion at individual level is presented with a large dose of official optimism. The question of whether existing health promotion programmes like Look after your heart are effective is not discussed, even though there are good reasons for doubting that they have much impact.

Even if health promotion works, it is not clear from The Health of the Nation how health authorities will set targets, choose how to allocate money between health promotion and medical care, and measure the outcome. Extra money would certainly be needed, but there is no sign of it coming.

Even the proposed ‘national advisory group’ that will co-ordinate national target setting and advise the government is left without clear powers. Will it be able to stimulate ‘healthy policies’ in other government departments and ministries — like transport — and will it have the authority to ensure that programmes and policies are developed in a concerted way across ministerial boundaries? ‘The Health of the Nation’ is unhelpful here, as we might expect from a government that steals good ideas, only to devalue them.

The lesson of the hospital trusts is that when problems arise in local health services the government denies responsibility. If health authorities cannot reach targets and provide care for an ailing, poor community on their cash-limited budget, that will be presented as a failure of management, not a failure of government responsibility.