Thursday, 2 December 2010

"Healthy Lives, Healthy People" - welcome to the land of nudge, to Lansley's Brave New World


I have been reading “Healthy Lives, Healthy People”, the Government’s ‘strategy for public health in England. And a fine read it is too, reflecting as we might expect the current obsession with ‘behavioural science’ and the nudging of people into making the right ‘lifestyle choices. Mind you some of those ‘nudges’ are more akin to a robust shoulder charge than a gentle shove!

As you know, dear reader, I am not enamoured of this approach to public health. Indeed, the entire conception of ‘public health’ has moved from ensuring a safe environment to influencing individual choices – up to and including bans. However, this little piece isn’t about all that – although my observations are pertinent to that aspect of debate. It's more about missing the point!

The most striking thing about “Healthy Lives, Healthy People” isn’t just the dominating obsession with smoking (a word that appears on nearly every page) but with a recurring observation about the ‘causes’ poor health:

“People living in the poorest areas will, on average, die 7 years earlier than people living in richer areas and spend up to 17 more years living with poor health. They have higher rates of mental illness; of harm from alcohol, drugs and smoking; and of childhood emotional and behavioural problems.”

Not exactly a surprise really. So why, instead of targeting our efforts at the ultimate cause of health inequality – poverty – do we concentrate instead on whether people make the right or wrong lifestyle choices?

People living in these places have a pretty low quality of life – to put it bluntly, their lives are crap. And they know it so they indulge – booze, smoking, drugs, reality telly, McDonalds, fizzy drinks, chocolate bars plus, of course, sex. Plenty of sex.

Using these cosy middle-class nudges to change behaviour is an insult when we leave them in poor housing, we fail to educate their children adequately and we provide a debilitating drip feed of benefits. So you take the nice stuff away, the things that make the crap life a little more tolerable – either by manipulating the price or through bans and controls – and these people will live a few years longer. Another couple of years living in a damp council flat or worse being spoon-fed in some tatty old people’s home. Now that really is something to look forward to!

And yes, my Conservative friends, pretending that it isn’t poverty causing the problem is just as bad as moralising about people’s behaviour. Here are some samples from “Healthy Lives, Healthy People”:

“Rates (of maternal depression) are nearly twice as high among mothers living in poverty and three times as high for teenage mothers.”

“Smoking rates during pregnancy are much higher among lower socio-economic groups and teenage mothers.”

“Rates (of childhood obesity) are higher among some black and minority ethnic
(BME) communities and in lower socioeconomic groups.”

“There is evidence that mental ill health disproportionately impacts on people from the black and minority communities, the homeless and other socially excluded groups.”

I could go on with quote after quote – being poor is a disaster for your health. But out masters see it as a matter of persuasion rather than of action to reduce levels of poverty:

“The latest insights from behavioural science need to be harnessed to help and guide people’s everyday decisions…”

All a bit, ‘Brave New World’ it seems to me. And it gets worse:

“At the same time, we do not have total control over our lives or the circumstances in which we live. A wide range of factors constrain and influence what we do, both positively and negatively.”

So my choice to drink or abstain, to smoke or moan endless about its smell or to eat a great big, fat, juicy burger with loads of chips and not a lettuce – these choices aren’t made by me but by a set of environmental influences. I am entirely a victim of advertising! Not only wrong – and dangerously wrong – but irresponsible and immoral to boot.

The report on public health makes just one brief mention of housing, ignores the importing of diseases like TB and says nothing about wider environmental contributors to disease and ill-health. Although reference is made to how those in work have better health outcomes (duh?), the authors seem more concerned with time off work through ‘smoking-related’ or ‘alcohol-related’ problems than in getting those poor – and more likely to be sick – people back into work.

It seems to me that directing the £4bn spent on 'public health' into making houses drier and warmer, helping people get into work, providing community mental health support, and giving people some practical independent living skills - budgeting, cleanliness, cooking and so on - would be of more value to both the health of the nation and wider society than all the smoking cessation clinics, 'alcohol strategies' and obesity campaigns put together.



Mike Chitty said...

Good post Simon. The futility of trying to deal with symptoms rather than causes. The wider determinants of health are an inconvenient truth to many health professionals who argue for and win resources to achieve goals that are essentially outside of their influence.
Your reinvestment of the £4bn makes a lot of sense, but I would argue that you have missed the potential for investing in 'psychological regeneration' - giving people the skills and habits that they need to develop a sense of agency and power in shaping their own lives.

Chaloner said...

Interesting post. good to see ideology put aside for what should be common sense.

One addition to this argument, which you might find a step too far, is embedding public health promotion into existing organisation.

I am writing a post at the moment, based on some work I did around alcohol licensing. Id be interested in seeing more work to mandate local community pillars such as licensing forums to act in the interests of public health, as opposed to serving only an administrative function.

Still developing my ideas around this, but I feel that public health could be made into a core function across a range of existing local governance structures.