Who holds responsibility for public health?
CancerWatch campaigns for better public health in order to reduce the incidence of cancer, and thereby reduce the misery of the 146,000 cases of cancer (40% of the total) that are believed to be avoidable each year. As any campaigner for better public health knows, an important aspect of a health campaign lies in discerning who holds responsibility for it in order that those entrusted with responsibility can be made to accept it and be made accountable for it.
Let us trace the responsibility for public health in the UK over the last twenty years. Seminal to the battle for improving public health were the Wanless Reports of 2002 “Securing our future health” and in 2004 “Securing good health for the whole population”. These reports were commissioned by H.M. Treasury and were carried out in order to determine the long term resource requirements of the National Health Service. They acknowledged that poor public health was likely to put significant pressure on NHS budgets and was thus considered a financial and economic problem. The reports emphasised the long term financial benefits of improving public health. These reports formed a catalyst for a number of House of Commons select committees and other bodies to report on public health.
In the case of obesity, for example, a number of reports ensued, followed by a government White Paper which clearly identified obesity as a public health priority and enabled comprehensive and wide ranging recommendations to be made. At this point obesity was identified not just a financial problem but clearly as a health problem as well.
As such, responsibility for obesity could be shared between the state and the population. Policy was thus directed to help people choose better lifestyles, and various “shared responsibility” papers followed to exhort the population to live healthier lifestyles.
But then Tony Blair, the then Prime Minister, spoke of the obesity epidemic as the result of millions of individual decisions. Other politicians followed suite, and thus the obesity epidemic finally became a personal problem and the responsibility of individuals, not of the state. Obesity finally became the individual’s fault and therefore, only the individual could correct it. So, like magic, the politicians absolved themselves of responsibility. And that, with the important exception of childhood obesity, has been the situation ever since.
Identifying where responsibility lies is important, as it informs us about the tools that can be used to remedy the problem. For example, if obesity is a public problem then legislation can authorise public health interventions into private life in the same way that legislation is used to enable interventions for the control of communicable disease.
In government policy papers there has been little reference to legislation as a public health tool. Policy predicated on individual responsibility and choice does not leave much room for regulation and compulsion in its armoury. They forget that much is dependent on the regulatory and legislative environment — labelling, social media, and advertising to mention just a few.
Legislation is not a magic wand, but well constructed regulations can:
- Impose enforceable duties on bodies which are in a position to improve the health environment;
- Provide powers (such as licensing, taxation, inspection) which give some leverage in ensuring that stakeholders recognise responsibilities
- Set norms to influence public opinion
The only institution that can pass laws in this country is Parliament, (although local government can play a subsidiary role), so if the government refuses to take responsibility, legislation, a major tool to control improve public health, is lost from the public health armoury.
In 2012 the Government’s refusal to take responsibility for public health was made explicit when it passed responsibility for public health to local government under the 2012 Health and Social Security Act. It is very difficult to see what tools local government has at its disposal to deliver meaningful improvements in public health. Local authorities can build cycle lanes, but it has been pointed out that the real solution to obesity is about consuming fewer calories, and taking more exercise has only a limited effect. Local authorities can and do run the smoking cessation services, but again, these have limited effect. They control licencing for alcohol premises but that has never reduced alcohol consumption, and is more about law and order issues.
This is not to say that national government has completely absolved itself of responsibility for public health. For example, its excellent Child Obesity Programme is well respected; unfortunately the average age of a child is nine, the average age at which an individual is diagnosed with bowel cancer (for which obesity is a major risk factor) is age about 70, so we have some 60 years to wait to see if the programme is genuinely effective.
CancerWatch believes central government should take more responsibility for public health. Currently the government spends almost £150bn on the NHS (fundamentally a sickness service) each year, but delivers only £3bn a year to local government as the public health grant to deliver public health for the nation. CancerWatch respectfully suggests that refusal to take responsibility for public health by central government may account for why an advanced industrial nation like the UK seems to be getting sicker and sicker and is increasingly overburdening the NHS, when a greater acceptance of responsibility by central government might make us healthier and healthier.