Public Health Possibilities

Public Health

The Labour Party Health Policy Commission will be turning its attention to Public Health over the next few months – after three years when the operation of the NHS crowded out discussion about health.

What follows is not intended to be a policy proposal, but a list of issues which the SHA may wish to put on the table for discussion.

Economic Equality

Richard Wilkinson has been telling us for many year that economic inequality, not poverty, is the key to health inequality.  Everyone in the Labour Party has read the Spirit Level and said how wonderful it is, but shied away from its implications.  The evidence is pretty clear that increases in average income much above £6500 per year have little impact on health outcomes.  So what makes a difference is actually the difference between the income of the poor and the income of the rich.  Economic growth, to which almost all politicians, of all parties, are wedded, will not help.  Indeed more growth of the kind which the UK has had over the last 30 years, which has largely gone into the pockets of the top 1% will probably be harmful.

But if tackling the rich is beyond us we might get further with low pay. Campaigns around the Living Wage have had political success and there is evidence that the Living Wage has a positive impact on the psychological wellbeing of low-wage service sector employees. It may also have a positive impact on public expenditure, as the beneficiaries of such a campaign are largely dependent on means-tested benefits – a subsidy to low paying employers.

Social Cohesion

Reducing  economic inequality may be too politically difficult to tackle head on.  Michael Marmot’s  Review of Social Determinants of Health and the Health Divide provides guidance on what is possible and what works. As he says “Health ministers clearly have a role in ensuring universal access to high-quality health services, but they also have a leadership role in advancing the case that health is an outcome of policies pursued in other arenas.” The same is true of local leaders, and we can look to local authorities, now responsible for public health, to consider the health impact of all their policies.

Many deprived communities are at the receiving end of a lot of expensive public services  from which they often get little benefit.  Empowering communities to take control of public services can be shown to have a very positive impact on health, and on a load of other indicators of disadvantage.

Marmot’s Key issues in understanding and promoting health equity
  • A social gradient in health exists (ie, health is progressively better the higher the socioeconomic position of people and communities). It is important to design policies that act across the whole gradient, as well as addressing those at the bottom of the social gradient and who are most vulnerable. To achieve both these objectives, we propose policies that are universal but with attention and intensity that is proportionate to need.
  • We must address the social determinants of health, such as the conditions in which people are born, grow, live, work, and age—these components are key determinants of health equity. These conditions of daily life are, in turn, influenced by structural drivers: economic arrangements, distribution of power, gender equity, policy frameworks, and the values of society.
  • Advantages and disadvantages in health and its social determinnats accumulate over the life course. This process begins with pregnancy and early child development and continues with school, the transition to working life, employment, and working conditions, and circumstances affecting older people.
  • Processes of exclusion should be addressed rather than focusing simply on addressing the characteristics of excluded groups. This approach has much potential when addressing the social and health problems of Roma and irregular migrants as well as those who suffer from less extreme forms of exclusion and dip in and out of vulnerable contexts.
  • Develop strategies and actions based on the resilience, capabilities, and strengths of individuals and communities. The hazards and risks they are exposed to need to be addressed.
  • Much focus has been, and will continue to be, on equity within generations. The perspectives of sustainable development and the importance of social inequity affecting future generations means that intergenerational equity must be emphasised and the effect of actions and policies for inequities on future generations should be considered and action taken to reduce potential adverse effects.
  • All the social determinants of health can affect genders differently. In addition to biological sex differences, fundamental social differences exist in the way women and men are treated and the assets and resilience they possess. In all societies, these gender relations affect health to varying degrees and should shape actions taken to reduce inequities.

This government’s policies have been pretty much the opposite of what Marmot recommends.  We have a sustained campaign of vilification of the poor and disadvantaged.  Poor people with large families are traduced rather than supported.

Early Years

Marmot’s  highest priority is to “ensure a good start to life for every child. This requires, as a minimum, adequate social and health protection for women, mothers-to-be, and young families and making significant progress towards a universal, high-quality, affordable early years education and child-care system.”  Labour’s Surestart project addressed this issue, but has largely been unravelled by the coalition government.  Midwives and health visitors are still in short supply and having great difficulty in keeping up with increases in the birth rate.

Alcohol consumption

Unit Pricing of alcohol is still a live issue.  One we should support. But there are other issues which could be tackled.  Irresponsible marketing of alcohol primarily by supermarkets is widespread.  Nobody is ever prosecuted for selling alcohol to people who are drunk, but thousands of such offences take place every weekend.  It wouldn’t be difficult to track down offenders by starting with their victims in the local Accident and Emergency Department any Friday night.


The European Union harmonised framework for tobacco sales should be very helpful, although it will take several years to take effect. A measure which is within the control of national governments is the age at which purchase or consumption of tobacco is permitted, and that might be an issue we could raise. I f the age was raised to 21 it might make it easier to stop children taking up the habit . The age was last raised in 2007. There are signs that the take up of smoking cessation programmes is falling off.  This may be associated with the rise of Ecigs – which may reach people who were not reached by traditional public health.   There is considerable anxiety in the public health community about Ecigs, but it seems clear that whatever their dangers they are several orders of magnitude less harmful than tobacco.


As with smoking and alcohol the government is unwilling to confront the businesses who make money out of selling unhealthy stuff.  Furthermore unhealthy food is subsidised by the Common Agricultural Policy.  Apart from a reduction in the consumption of sugar and fat, which might be effected by taxation the main issue is lack of exercise.  Cars and televisions are the main enemies. But the population is very attached to them. Getting them on their bikes may be difficult. But other coutries have done better than we have.  Sustained policies to encourage walking and cycling are effective. Not only do they increase exercise levels but they also improve air quality and reduce carbon emissions.  Public authorities, including NHS bodies, are big providers of catering, and often whet they provide is not very healthy.


There is a gradient in the provision of decent health services. The Inverse Care Law has not been repealed, though the last government did tackle some of the problems. Probably the worst problem is the poor quality of primary care in many deprived areas.  Dental health and sexual health services are also much worse in deprived communities.

Behavioural Public Policy

The main attraction of the  behavioural approach among public policy makers is its potential usefulness in informing the design of effective, and yet inexpensive, policy.   interventions.  Among politicians there isn’t much disagreement about the goals of public health policy as far as changing behaviour is concerned.  The problem is the means of doing it.  Bans are ineffective and taxation is unpopular.  For Labour there is an additional difficulty in that taxation of unhealthy behaviour hits the poor much harder than the rich.  The unit pricing of alcohol won’t have much effect on people who don’t drink White Cider.