Public health and private choice - thoughts on a consultation

This afternoon I attended a Public Health Consultation event organised (because I insisted) to allow Bradford councillors to have some input into the PCT/Council response to the Public Health White Paper. Obviously our input was constrained by time but we managed to comment at length on:

Domains and Indicators from Healthy Lives, Healthy People: Transparency in Outcomes: Proposals for a Public Health Outcomes Framework

And:

Commissioning and funding from Healthy Lives Healthy People: Consultation on the funding and commissioning routes for public health

In this discussion we looked at the different “measures” that might be applied to the assessment of public health effectiveness and hence the likelihood of Bradford Council receiving the “Health Premium” promised to Councils meeting targets. In listening to this – and looking at the targets – it struck me that there is an interesting and important discussion to be had as to what we actually mean by the term “public health”.

What seems clear to me is that the domain of public health – our concern to do something about external and environmental factors contributing to disease and ill-health – has expanded to encompass things that are not external to individual choice. Hence the ‘new’ definition from the Faculty of Public Health:

“The science and art of promoting and protecting health and well-being, preventing ill health and prolonging life through the organised efforts of society.”

Public health is no longer concerned with externalities – with sanitation, with poor housing, with air pollution, with clean water – but with lifestyle choices deemed by “society” to be wrong. And the justification for this action is all couched in generic health outcomes, chiefly in “life expectancy” and “healthy life expectancy”.  Because, for example, reducing smoking is seen as improving overall “life expectancy” it becomes justified even though such interventions are not in areas of ‘public goods’.

Underlying this argument is the nature of the deal between the individual and the state – whether that deal in a collective or individual arrangement, between the ‘civic’ and the ‘personal’. And, most commonly, the argument is couched in terms of selfishness – my drinking, smoking or fatness means a greater burden on the NHS and less resource available to treat the illnesses of good people who eschew such a decadent lifestyle.

If however – as I believe is the case – my relationship with the state is a personal one, then this argument is false. I pay taxes, duties and other imposts in return for the state’s protection. And that protection applies to me personally not to me as part of a collective. My lifestyle choices – smoking, drinking, eating burgers, sky-diving, potholing, and so forth – are not a matter of public concern. Therefore public health cannot – as its proponents now argue – extend to controlling lifestyle choices but must be limited to public goods and to the impact of public services on health.

Nevertheless, the consultation paper on “proposed indicators” contains nine targets directly linked to levels of smoking, drinking or eating yet just two relating directly to housing. Yet housing conditions – damp, drafts, poor heating – are very significant factors in ill-health, arguably more significant that smoking, drinking or obesity. Add to this the incidence of ill-health linked to long-term unemployment and poverty and it is clear to me that the directing of around 60% of public health budgets to booze, fags and burgers is wholly misplaced – even if we accept the argument that there is a need to develop responses to these “problems”.

In the end, the experts – those nannying fussbuckets of the Faculty of Public Health – will win the day and the funding will go to continue the current strategy. And this is despite all the evidence that this strategy is failing to deal with the problem it intends to deal with (too much drinking, smoking and burger-eating). At the meeting I pointed out that reports of liver disease had risen during a time when the consumption of alcohol was falling – the answer to this conundrum is that the problem drinkers are drinking more ergo more liver disease!  I’m not sure that I believe this – the problem may relate more to the increase in drinking during the 1980s and the lag in presentation for liver conditions.

While I enjoyed the meeting and made a substantial and, hopefully, substantive contribution, I expect that we will end up with a centrally directed, nannying (or should I say nudging) approach focused – to the exclusion of almost everything else – on the poor lifestyle choices that some people make. And it won’t work – the single mum on the sixth floor of a council block will still want cheap stimuli, the little cheers and buzzes that get her through an otherwise crap life. Which means she’ll carry on smoking, drinking, enjoying sex, eating crisps or chocolate and watching telly – those things are her pleasures and telling her it’s bad for her won’t change a thing.

 If you want to change her outlook – or the outlook of a million or so other folk – you have to change economic prospects, improve the housing and clean up the locality. And all the public health fussbucketry won’t achieve any of that, will it?

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