Is it time for the government to follow the lead of many of its citizens – and adopt some new year’s resolutions of its own when it comes to health?
There’s clearly a need for some new thinking by government as it faces yet another NHS winter crisis.
At the risk of stating the obvious, we need:
- To address the root causes of ill-health, like our current obesogenic environment and high levels of social inequality.
- A true National HEALTH Service – which gives higher priority to stopping people falling ill in the first place, rather than simply waiting until they fall ill and then trying to treat them.
- To recruit and importantly RETAIN health professionals – and ensure they have the training and the skills to encourage health, not simply treat illness.
- To provide practical carrot and stick incentives for businesses to produce goods and services which are good for our health and for employers to ensure healthy working environments.
- Central and local government to lead by example – including considering the health implications of ALL their policies and ensuring they too provide healthy work places.
So, taking each in turn, we recommend these New Year’s Resolutions for government.
1. To address the root causes of ill-health
1.1 Consider what action is needed in relation to fast food, takeaways and home delivery (on which UK consumers currently spend £30 billion p.a.) – to complement existing action on sugary drinks.
1.2. Consider how to make physical activity at school a varied, fun and enjoyable experience, as an integral part of the learning environment – to build a commitment to physical activity that can be sustained into and rekindled in adult life.
1.3. A simpler, fairer tax system, where the amount of tax you pay doesn’t depend on whether or not you can afford expensive tax avoidance advice – to reduce the social inequality that fuels health inequality.
1.4. Many more affordable homes to buy and rent, by enabling Local Authorities and Housing Associations to contribute more, encouraging more factory-built homes (to avoid weather delays during construction) and reducing commuting costs to better connect affordable housing and employment.
1.5. Actively encouraging and supporting volunteering, both to increase support for those in need and for the mental and physical health benefits experienced by those volunteering.
1.6. Objectively review changes and initiatives which have taken place within the health, benefits, education and care systems, to see which have reduced health and social inequalities and which haven’t.
2. To create a true National HEALTH Service
2.1. Ensure Clinical Commissioning Groups (CCGs) commission health improvement, not just the treatment of accident and illness – with a particular focus on the importance of the early years for long term physical and mental health.
2.2. Ensure NHS Trusts report on the action they have taken to improve health, over and above the treatment of accident and illness, in their Annual Reports.
2.3. Find ways to fast track career progression for health professionals who are actively engaged in health improvement – to encourage a move away from paying lip service to the importance of prevention to making this a reality.
3. To recruit and importantly RETAIN health professionals with the right skills
3.1. Write off student loan debts for doctors and nurses who complete five years continuous full-time employment with the NHS, to help reverse:
- the one third fall in applications for nursing courses since bursaries were replaced by student loans in 2017.
- the 13% fall in applications to medical school since tuition fees rose to £9,000 p.a. in 2012.
3.2. Set up a task force, led by someone like Dr Sarah Wollaston MP (Chair of the Health and Social Care Committee) to consider how to make the NHS an employer that qualified health professionals actively wish to continue working in – to avoid the record number of health professionals currently leaving the NHS (resulting in 41,000 nursing and midwifery vacancies currently; and only half of doctors completing their first two years of on the job training now going on to NHS training to become a specialist or GP, down from 71% in 2011).
3.3. Modernise the medical school and nursing curriculum, and Continuing Professional Development (CPD) post qualification, to include a significant focus on preventative health – including providing health professionals with the knowledge, skills and expertise to help their patients adopt healthier lifestyles and the potential of initiatives such as GP-based social prescribing and the hospital-based Ottawa Model of Smoking Cessation.
4. To provide practical carrot and stick incentives for businesses to produce goods and services which are good for our health and for employers to ensure healthy working environments - recognising that voluntary approaches have failed to achieve the progress needed and that financial incentives or regulatory action are now needed:
4.1 Start with clear regulation to limit the mass production of food high in sugar, salt and saturated fat, as recommended by the British Retail Consortium – and make R & D corporation tax relief only available to food and drink companies undertaking R & D to develop healthier products.
4.2. Ban added sugar in baby and infant formula, to avoid ‘hooking’ children on sweet tasting products, as recommended by the UK’s Chief Medical Officer.
4.3. Provide tax or other financial incentives to organisations which secure Health at Work accreditation and/or financially incentivize Investors in People to add a new indicator to IIP accreditation i.e. supporting the physical and mental health of employees (to reach the thousands of employers nationally with IIP accreditation – employing around a third of the UK’s workforce.)
5. Central and local government to lead by example:
5.1. Reverse the cuts in public health funding, the front line when it comes to preventing illness, and then increase funding for public health annually, in line with RPI inflation.
5.2. Agree a mechanism to ensure that the health implications of all government policies are seriously considered, including those for transport, housing, education, the environment, agriculture, business, energy, work and industrial strategy.
5.3. Seek appropriate Health at Work accreditation for all central and local government organisations and their component parts (including hospitals and schools).
Our guiding principle is that prevention is better than cure. So when the government launched its ‘Prevention is better than cure’ vision paper recently we were keen to see what it had to say.
A worthy aim
The government aims to improve healthy life expectancy by at least 5 extra years, by 2035, and to close the gap between the richest and poorest – something we can all support.
Strong on analysis
Much of the analysis is spot-on. Here are some examples:
Prevention means stopping problems from arising in the first place; focusing on keeping people healthy, not just treating them when they become ill.
We need to see a greater investment in prevention - to support people to live longer, healthier and more independent lives, and help to guarantee our health and social care services for the long-term.
There is a role for government to create the environment that makes healthy choices as easy as possible, and to address the conditions that lead to poor health. This could be through laws, regulations and incentives
Prevention is crucial to the work of the NHS. But, for too long the health and social care system has talked about the need to refocus its energy away from treating illness and towards preventing illness, without this translating into practical action.
When it comes to prevention, we all have a role to play: individuals, families, communities, employers, charities, the NHS, social care, and local and national government.
The paper recognises the importance for health of things like not smoking, eating a healthy diet and being physically active. It also usefully takes a more holistic approach to health. For instance, it recognises the importance of the early years of life for long term health, the need to combat loneliness and to encourage mental health, that the way jobs are designed has implications for both physical and mental health, and the importance of living in safe, well-designed, connected and healthy neighbourhoods.
So, we’d give the government’s vision 10/10 for analysis. What about implementation?
Weaker on implementation
The paper does sketch out government initiatives to tackle some of the issues identified. These include the 2017 NHS Health and Wellbeing incentive scheme for NHS staff, the 2018 Childhood obesity plan for action chapter 2, and the Cycling and Walking Investment Strategy (with £1.2 billion of funding from 2016 – 2021).
However, in general, implementation is the paper’s weak point. We’d score it 3/10. Here’s why:
Too little too late
The government says that by 2028, 75% of cancers should be diagnosed at stages one and two. It doesn’t indicate how this will be achieved or why we have to wait so long. We have known for years that the UK has lower cancer survival rates than many other European countries – indeed the NHS has had a Cancer Plan in place since 2000. Why is it taking so long to address the problem?
Again, the government’s response to air pollution caused by traffic (and the health risks this generates) is to end the sale of new diesel and petrol cars and vans by 2040. That’s 22 years away. Assuming that new vehicles purchased in 2040 will have at least ten years further life, that’s another 32 years of traffic pollution!
Pass the parcel
This is a recurring theme. For instance:
- The government says it has given local authorities the lead responsibility for improving health locally. What it doesn’t mention is that it has halved its funding for local authorities since 2010. As a result, 80% of local authorities have reduced their public health budgets in 2018. And there was no mention of public health in the Chancellor’s November 2018 budget.
- The government says more employers should help improve the health of their staff and the nation – but gives no idea as to how they will be incentivized to achieve this.
Not addressing the adverse impact of previous government policies
Many of the government’s health ambitions require the UK to have enough trained and committed health professionals. Yet constant reorganisations of the NHS, public sector pay caps and the unpopular junior doctors’ contract have eroded morale and resulted in recruitment and retention problems. According to the British Medical Association:
- The number of applications to UK medical schools has decreased for three years in a row.
- Applications for the first year of doctors’ training following medical school are also down.
- Only half of doctors completing their first two years of on the job training are now going on to NHS training to become a specialist or GP (down from 71% in 2011).
As already identified, the government is also not facing up to the public health implications of halving its funding to the organisations it has tasked with promoting health locally (i.e. local authorities, to whom the government passed public health responsibility from the NHS in 2013).
Not addressing built in inertia
The government recognises that the NHS has been paying lip service to prevention but not taking it seriously in practice. However, it suggests no practical strategies to change this. For example, there is:
- No mention of any changes to the education and professional development of health professionals to give higher priority to prevention.
- No mention of any changes to health career paths to raise the status of preventative health and encourage more able and committed health professionals to make this their first choice.
- No mention of any changes to the way health funding is allocated by Clinical Commissioning Groups to give higher priority to prevention (a local CCG spends nearly £250 million a year but there is no mention in its Annual Report of how much of this, if any, was spent on preventative health).
In 2019 the government plans to put forward a Green Paper to follow up this initial vision paper. This will be a good opportunity to move from theory to practice, in particular to address the weaknesses we have identified. We very much hope the government will take advantage of this opportunity, so that prevention truly begins to be taken more seriously.
In an ideal world each of us would consistently make informed decisions in the best long-term interests of ourselves and those we love. And in an ideal world, the wise choices would always be the easy ones.
Or, if we chose to put our long-term health, wealth and happiness at risk we would accept personal responsibility for the consequences. For example, if we insisted on chain smoking, binge-drinking, drug taking or over-indulging in junk food we would arrange private health insurance, so that any health problems arising would not end up being a burden on our families and the NHS.
In practice, we don’t live in an ideal world and sometimes a government has to step in to protect the most vulnerable, especially children. However, when government does take action it risks being accused of acting like a ‘Nanny State’ – in particular in certain sections of the press. There’s even now an annual Nanny State Index, which currently ranks the UK as the worst place in Europe for smokers. So whenever I see the term being used I ask myself these questions:
1. Will the action taken save lives? From the introduction of compulsory car seat belts to the ban on smoking in public places (each opposed at the time as Nanny State-ism) the answer has nearly always been yes. And the tragedy of Grenfell Tower illustrated clearly what can happen when Health and Safety isn’t taken seriously.
2. How much real choice do people have in practice? If you live in a deprived area, with betting shops and fast food outlets on every corner, do you really have the same choices as someone living in an area with a plentiful supply of gyms and farmers’ markets?
3. Who benefits financially from ‘choices’ like smoking, alcohol, junk food and gambling? If the beneficiaries are big businesses looking to boost executive pay and shareholder returns while government is prepared to accept a loss of tax revenue in the interests of public health, I think I know which I would trust to have the public’s true interests at heart.
4. How intellectually consistent are the opponents of public health initiatives? Usually the apparent proponents of individual freedom tend to employ arguments that favour commercial interests rather than personal freedom per se. For example, how many columnists who rail against government infringing personal liberty in the UK go on to argue for the legalisation of drugs, brothels or the right to bear arms? If defending personal freedoms was their real goal, surely their arguments wouldn’t be so selective.
This doesn’t mean we should accept government proposals unquestioningly and it doesn’t mean we should adopt a puritanical ‘killjoy’ mentality, becoming in effect health fundamentalists. That's why, here at Health Action Campaign, we've been researching what options are available to food companies who want to reduce levels of sugar and salt in their products, without using artifical alternatives and without compromising the taste for consumers. And Public Health England has published research indicating that e-cigarettes are 95% less harmful than smoking.
However, it is reasonable to expect government to level the playing field, particularly for the most vulnerable. We know for instance that childhood obesity levels are twice as high in deprived areas. And people in deprived areas typically die younger and after more years of poor health.
If the choice is between saving people’s lives and protecting their health on the one hand or being accused of being a supporter of the Nanny State on the other, I know which I’d choose.
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