Conceptual diagrams in public health research.

I f neo-liberal thinking is gripping health care reform in many countries with its focus on market style competition and individual choice, a similar revolution may be underway in public health policy. The example of recent developments in England is instructive and offers a warning to other countries that are also rediscovering public health or are perhaps discovering it for the first time. Although welcome and overdue, the manner in which the (re)discovery is taking place and its implications for public health policy and practice may be less encouraging. The government published its English public health policy statement in November 2004 to general acclaim from the public health community. Indeed, the reception given to the policy proposals was perhaps a little too uncritical. This was certainly the view of the United Kingdom Public Health Association (UKPHA), which published a critical assessment of the policy statement and the political ideology underpinning it. It concluded that the policy is seriously flawed, pulls too many punches (for example, refusing to opt for a total smoking ban in public places), and is emasculated by its entanglement with the choice agenda that has little or no place in public health. In fact, far from being a progressive document that builds on the previous health policy statement, Saving Lives: Our Healthier Nation, published in 1999, the new statement, Choosing Health, displays a number of regressive features. To understand the shift from a public to a private conception of public health policy, for that is in essence what Choosing Health amounts to, it is necessary to trace its antecedents. These lie in the two seminal reports produced by Derek Wanless, the Treasury’s special adviser. 5 A former banker, he was invited to assess the pressures and challenges facing the British NHS over a 20 year period until 2022 and to give an opinion on whether a publicly funded health care system was sustainable for the duration. He concluded it would be but only if a number of things happened, among them getting a grip on demand by being less preoccupied with downstream acute care and more willing to invest in, and prioritise, upstream preventive interventions. He produced three scenarios and the most ambitious of these, the fully engaged scenario, was the one the government opted for. It did so largely because if successful it would save the NHS a significant amount of funding because the population would be both healthier and taking more responsibility for its health. Wanless developed his views on public health in his second report where he emphasised the need for the NHS to be rebalanced from a sickness to a health service. He claimed that the problem lay not in policy prescriptions but in the lack of their effective implementation over some 30 years. Political will seemed to be lacking despite good intentions and favourable rhetoric. Reflecting this weak determination to act he pointed to a public health workforce that was not fit for purpose. It lacked many of the essential skills to change individual behaviour (for example, social marketing) and was spread too thinly across multiple organisations thereby lacking capacity to make a sustained impact. In addition, the evidence base remained weak so that too little systematic evidence existed to inform policy about what worked and which interventions were cost effective. Wanless’s prescription lay principally in getting ’’a realignment of incentives in the system to focus on reducing the burden of disease and tackling the key lifestyle and environmental risks’’. The government’s response to Wanless’s second report was muted. There was evidence of some discomfort between the Treasury and Department of Health on who was in the driving seat in respect of public health issues, with the health department believing that leading on health was part of its remit and should not be usurped by the Treasury. It therefore crafted a case for giving public health a high priority on the grounds that during its first seven years or so in office the government had been obliged to sort out the NHS in respect, inter alia, of waiting lists, and poor quality in hospital and primary care services. With these issues having been brought under control, it was appropriate to turn attention to wider health issues. However, it was debatable whether the government needed another public health policy on top of the one published in 1999 after a lengthy period of public consultation on a draft version produced in 1998. There did not seem to be a self evident need, or appetite, for another policy review especially one that would take some six months to conclude after a major public consultation exercise. So what possible explanation can be given? Two reasons can be advanced. Firstly, announcing a policy review followed by a policy statement enabled the government simultaneously to show it was taking action on public health while at the same time defusing Wanless’s critique of slow progress—in effect kicking it into the long grass. Secondly, between the publication of the 1999 policy statement, Our Healthier Nation, and the arrival of the second Wanless report in early 2004, the government had set in train a ’’quiet revolution’’ in the NHS that entailed introducing market style incentives and competitive behaviour that went far beyond anything contemplated by the internal market reforms of the early 1990s. The rhetoric from 2002 was about devolution, putting power back to the frontline, reducing central control, and giving patients and public more choice. The 1999 public health statement arguably needed updating and bringing into line with the current New Labour mantra of choice and individualism combined with market style incentives to modify lifestyles. A comparison between the 1999 policy document and the 2004 updated version illustrates the different emphasis and language evident. Both documents cite the importance of individual choice and acknowledge that government has a part to play in creating the conditions in which people could lead healthier lives. But their significance is reversed. Compare what the then health ministers said in their foreword to the 1999 public health statement—‘‘Now we want to see far more attention and Government action concentrated on the things which damage people’s health which are beyond the control of the individual’’—with what the prime minister said in his foreword to the 2004 policy statement: ’’We are clear that Government cannot...pretend it can ‘make’ the population healthy. But it can—and should—support people in 1010 EDITORIALS