Policy submission on Public Health

SHA Policy document agreed by  Central Council January  2014

 1. Purpose

1.1. This paper has been agreed by Central Council for submission to the Labour Party and used elsewhere to inform debate on this important topic.

1.2 .The paper is deliberately short. Its draws heavily upon the more detailed paper prepared by Dr Tony Jewell some months ago which was discussed by Central Council and which found broad acceptance.  It deliberately does not deal with the specific issue of where, structurally / organisationally, public health should sit in relation to the NHS, or national, devolved, or  local government.

2. Approach

2.1. The approach taken in this paper is to draw out from Dr Jewell’s work a limited number of broader policy areas to which an incoming Labour government, or other well crafted policy approaches, should give attention. The key message taken from Tony Jewell’s work is that securing better health status for the people of the UK requires co-ordinated government action across a range of government activity.  For reasons set out briefly below the key areas of government policy relate to:

• economic and industrial policy
• defence and foreign policy
• education and research and development
• social policy, including the benefits system and housing.

2.2. The paper also expands upon extant SHA policy relating to the positioning of the public health function within both central and local government

3. Public health challenges 

3.1. The key aim of a health care system (working with others) is to raise the health status of the people it serves. Put simply, ever improving health status requires the population as a whole to not only live longer but to enjoy more years of quality life.

3.2. The key challenges facing those keen to improve the health and well being of the public relate to:

• understanding the main threats to the health and well being of  individuals and communities, in terms of both physical and mental health  – ensuring that the wider determinants of health status are understood and that Government (with many others) takes action to impact positively upon those determinants –  especially in the first of the four stages described below
• ensuring that the four stages of health care (prevention, diagnosis, treatment and after care) are delivered dynamically by the complete and ever evolving  care system as present and  forecast needs of the population change and as new service  responses arise in all four stages
• understanding what can be effective in preventing communicable disease(s) and the many other conditions that could be prevented or ameliorated
• for health care specifically, diagnosing quickly and accurately conditions that require a good response (from the NHS or others); giving that response through timely and evidence -based interventions; and delivering compassionate ongoing rehabilitative / longer term care for those for whom “cure” is not possible.

3.3. The skills available from Public Health practitioners also include: specific analytical abilities to aid a consideration of the cost effectiveness of different care options; the gathering and interpretation of international evidence about best practice in diagnosis and treatment; the use of epidemiological data as a predictive tool for planning purposes, and an ability to understand research methods so that data on health outcomes and care processes can be given proper weight. This is especially important when “evidence” is placed in the public domain (or withheld) by those with a vested interest in gaining access to public funds for their commercial ventures.

4. Public Health and Labour Policy

The health (and social care) field is vast and it is not proposed to address all, or even most, of this topic in terms of the advice given to the Labour Party (and other readers) about its policy towards Public Health. Rather, this section concentrates on a few areas of policy where government as a whole can make a difference. These are briefly listed below. They deliberately go beyond areas that are to be found in more traditional commentaries on public health.

4.1. Economic, Social, and Industrial Policy

4.1.1. There is good evidence that good levels of health and well being are closely related to low levels of inequality of income and wealth[1]. Differentials are more important than absolute levels of wealth. The Labour Party should consider legislating for a legally enforceable maximum income differential in much, if not all, of the economy – for example  no more that a twenty fold differential between the lowest and highest paid employee.

4.1.2 Thus a key plank in any policy towards improving the health of the public must be to reverse the obscene rise in income inequality in the UK that has occurred in the 21st century. Economic, social, and industrial policy must therefore address the means by which national wealth is more fairly divided – not only between the interests of labour and capital, or owners managers and workers, but also between different parts of the UK, different generations, and different social groups.

4.1.3. The concentration of the financial sector and other activities in the London area has increased the imbalance  of the national economy, contributed to widening geographical inequalities of wealth. Commercial and industrial policy – including key infrastructure investments – must be seen against this backcloth. Labour’s industrial policy should re-balance both the geographical and sectoral imbalances within the UK economy. Its financial policies should ensure that a government owned UK investment bank is created and the investment and retail financial sectors are  more clearly delineated.

4.1.4. The role of trade unions, and the legal framework relating  to industrial relations both need to be re calibrated in order that the current imbalance between the influence of the  employed and the employer can be corrected[2].

Labour should reform the legal framework within which collective bargaining occurs – both at national and international level – to achieve this objective. Further, industrial democracy within the Boardroom is necessary.  Labour should use  corporate taxation policy and Government support to industry and commerce to reward companies that embrace co-operative working arrangements with their workforce. For example, there is much evidence to support the view that mental well being is higher among those who have some control over their working environment and working  day.

4.1.5. Put another way, good health stems in no small measure from a sense of security -security (and safety ) at work, security of income and security of housing and neighbourhood. Policies must build trust and reciprocity. To this might be added the security of fair and affordable access to the system of justice for both civil and criminal law.

4.2. Defence and Foreign Policy

There is emerging evidence  of adverse impacts upon the health of  the population  arise from aspects of defence and foreign policy.

4.2.1. Defence

4.2.1.1.Recent conflicts in Iraq and Afghanistan have directly impacted upon the physical and emotional health of military personnel and their families. Although the number of years of life lost through post war conflicts has been relatively small[3], the impact on morbidity arising from the numbers of physically disabled service men and women and from those suffering from stress related conditions is significant. Related issues of alcohol and substance misuse, and homelessness and family breakdown are increasingly reported as resulting from the stressful nature of military service.

4.2.1.2. Labour should ensure that:

• the likely health impact upon service personnel and their families of any conflict is taken into account when  considering the use of  military force and the nature of that use[4]
• the post conflict care of servicemen and their families is planned for and fully resourced from the defence budget
• the NHS is fully prepared- at all levels – to recognise the signs of ill health arising from military service and to provide an adequate response.

4.2.2. Foreign policy

4.2.2.1. Challenges to high levels of health status can increasingly arise from factors external to the UK. These include the ongoing need to control or contain contagious diseases now more easily transported around the world, and the need to reduce the number of “failed states” that give rise to increasing numbers of refugees forced to seek safety in other countries – including the UK.

4.2.2.2. Labour should see part of its foreign and aid policy in the light of the contribution it can make to protecting the health status of the UK.

4.3. Education Policy and research       

4.3.1. There is much evidence that the early years experiences of children are crucial to their future good health. Education policy should encompass aspects of lifestyle –  including both children, actual, and prospective parents. Good health education should be strengthened as part of the curriculum, with parents and families encouraged to participate.

4.3.2. The health care sector relies heavily upon publicly funded research  and upon publicly supported students. In terms of research, Labour should operate a strategic health research programme concentrating upon selected areas where the UK  has good existing infrastructure. Expert advice on these areas should be sought from those Universities already working in life sciences but genetics, nanotechnology and robotic /distant care delivery are possible areas.

4.3.3. To maintain an adequate skilled workforce, Labour should introduce NHS bursaries to support students undertaking health related studies, in return for which successful students would work in the NHS for a period of years.

4.4. Other social policy – housing and benefits and climate change

4.4.1. The current dearth of affordable housing, and housing policies which:

• increase the transient nature of neighbourhoods
• increasingly segregate people of different backgrounds and income levels
• lead to shortages of adequate housing
• create fragile tenancies or other tenure

should be systematically reviewed so that communities have a chance to develop and become more self- supporting. Market solutions have patently failed to meet need. Labour should give local authorities the lead role in creating social and affordable housing. Land identified for housing but not being developed, should attract high tax rates to encourage its immediate use.

4.4.2. Labour should commit now to commissioning further research on the impact upon mental health of recent benefit changes and the “spare room tax”. In particular, suicide rates and hospital admission rates among those receiving (and losing)such benefits should be studied.

4.4.3. Climate change gives rise to several public health challenges. These

include the likelihood of hot summers and colder winters that bring health challenges especially for the elderly in terms of keeping cool in the former and warm in the latter.

4.5. The issue of choice

4.5.1.Much of the discourse around the health promotion dimension of public health relates to the notions of “choice” and lifestyles.

4.5.2. Most would agree that a free society should seek to educate it citizens about the risks and benefits of differing lifestyles. It is less clear to what extent the state should tolerate an informed  choice of lifestyle that knowingly imposes a cost upon society as a whole.  Neither is it clear to what extent “choices of lifestyle” can be properly made as opposed to being likely outcomes from family or community circumstances. Just as the determinants of health are rooted in a complex web of social and economic factors, so too are the factors that impinge upon many of the choices that individuals make.

4.5.3. The history of Bevan’s NHS – drawn from the 19th century Miners clubs – relied in part upon the club itself, in effect, agreeing what levels of cover were to be available, and to who. There were accepted, and less accepted, norms of behaviour. This approach has been absorbed into the NHS to a considerable degree; for example it is accepted that the predictable week end football and rugby injuries should be treated on the NHS, that terminations of pregnancy should also provided to a high level whereas, by contrast, assisted conception  is heavily restricted. It is thus an imperfect political process that shapes what a publicly  funded NHS is there to do. Put another way, “need” is only partly a clinical issue –  it is also a political construct.

4.5.4. There would seem to be three possible ways of addressing the issue of the role of the state (the club) in responding to the health impacts of “unhealthy lifestyles”, where the evidence of likely future harm is strong. The first is to signal very clearly that treatment needs arising directly from lifestyles that are “chosen” will not be provided freely by the NHS. The second is to “tax” such behaviours both to seek to deter or minimise them and to raise funds for the likely care. The third is to accept that, broadly, such lifestyles are within the accepted range and any costs should be collectively borne.

4.5.5. This paper proposes only that the SHA should do further work on this specific topic and ascertain where Labour’s thinking has got to in this regard. Some behaviours may be more amenable to being changed as individuals grow older and, perhaps, experience new lifestyles in adulthood. The balance of different types of persuasion and coercion may differ where, for example, smoking, diet, exercise and  alcohol issues arise.

5. The  role of the Public Health profession                             

5.1. The public health profession has a huge role to play in identifying the causes of poor mental and physical health (across the four stages of a care system described in 3.2.), in using evidence to inform the public and in challenging the political system to either act on these or justify inaction.

5.2. The current location of public health within the different NHS architectures of the UK is, for a short while, a given; this paper does not address the different topic of where the public health function should sit – and what it should do.  It is suggested that the location chosen should underpin the role and values of the public health function set out in this paper.

5.3. Certain requirements should be met and Labour should commit to these. First, the public health function should be seen as a national resource (with its devolved elements) charged with speaking truth unto power without hindrance. Second, its arguments should evidence based and its time horizons should look across the coming generations. Third, its remit should cover the effectiveness of the whole care system and the impact of wider government policy upon health status.

5.4. Labour should commit  to supporting the vision for public health described above. Senior Public Health leaders – at both local and national level –   should be required to provide annual reports to local authorities, health boards, and national and devolved Parliaments / Assemblies that report on health status at different levels of populations and which identify evidence based means of improving them. The reports should also chart progress with meeting longer term health challenges – for example the  probable diminution in the effectiveness of the current range of antibiotics and the long term trends in illness patterns. Such reports should be “protected” by law as public documents – standing or falling on the evidence adduced and the professional standing of the authors. Their potential to challenge vested interests should be explicitly recognised.

6.Conclusion

The health and well being of the UK population has many facets and there is a long and proud history in the UK of public health practitioners from many disciplines) exploring the  causes of ill health and lobbying for measures which reduce ill health and remove the causes.

This paper has taken the work of Dr Tony Jewell – which fully summarises the role of public health – and deliberately concentrates upon the wider work of Government and its impact upon public health.     .