A new social contract for Public Health

By David Hunter, Newcastle University; Peter Littlejohns, King’s College London; Albert Weale, University College London; Jacqueline Johnson, public health and management consultant; and Toslima Khatun, King’s College London

Air pollution is widely recognised as a serious health hazard while Covid-19 shone a spotlight on the weaknesses of the UK’s public health system

The UK is in the grip of a public health crisis. With depressing regularity, new research shows the growing deterioration of the public’s health. Improvements in life expectancy have stalled, health inequalities have widened, obesity and alcohol misuse are placing an increasing strain on health services, and air pollution is now widely recognised as a serious health hazard. While Covid-19 shone a spotlight on the weaknesses of the UK’s public health system, they had existed for some time. Indeed, as Michael Marmot has argued, most of the deterioration in health stems from 2010 and the Coalition government’s austerity policy. This resulted in cuts to public spending with local government, which is responsible for public health, suffering some of the deepest.

Despite the wealth of evidence testifying to the parlous state of public health and with many studies offering solutions that are both cost-effective and for which there is robust evidence, there remain significant political and organisational barriers to the realisation of an effective public health system. Unless these are confronted, the chances of progress are slim.

A new social contract for public health

We support the case for a new social contract in which health policy is truly public. Public health policies are often criticised by those of a neoliberal persuasion for restricting individual choice and for ‘nanny statism’. We refer to this form of liberalism as ‘vulgar individualism’. Big government and state overreach are viewed as problems which stifle personal freedom and hinder private sector growth on which the economy depends.

In fact, a much bigger problem is state underreach and a failure to take up and apply policies and policy instruments that are known to be effective in order to improve health. But as long as governments continue to subscribe to the view that the health of individuals is a matter of personal responsibility then action of the kind needed will not be forthcoming. Over the past 13 years or so, successive governments have subscribed to this view ignoring all the evidence which demonstrates the flaw at the heart of such thinking, namely, a belief that that government is best which governs least.

In place of such a stunted political ideology we propose a new social contract for public health incorporating the principles of what might be termed ‘social individualism’, that is, a commitment to using the instruments of collective political authority to create the conditions for individual choice and fulfilment.

What are the elements of the new social contract for public health?

First, and importantly, a social contract for public health would focus on prevention, reflecting the significant body of evidence demonstrating how a wide range of public health measures would prevent more serious conditions developing. But while it is easy to state all this, as indeed numerous academics and analysts have done over many years, unless political leadership is in place to confront the challenges the prospect of change happening is slim.

A particular challenge is the tension arising from the urgent driving out the important. With an NHS under extreme pressure in respect of growing waiting lists and staff shortages, for electoral and other reasons, politicians are most likely to prioritise addressing these to the exclusion of longer-term public health measures. Yet, as the Hewitt Review of Integrated Care Systems points out, ‘we have mistaken NHS policy for healthcare policy’.

Second, a new social contract requires a precautionary state, paying attention not only to known hazards but also to remote and uncertain ones. If the pandemic taught us anything, it was the need to be prepared and have sufficient resources in place to enable swift and effective action to be taken. Sadly, for a government emerging from the debacle over Brexit and trapped in a mindset of short-termism with a focus on campaigning rather than governing, adopting a policy of precaution does not come naturally.

Third, social solidarity is required in the face of health inequalities. Social individualism recognises that policies for the most vulnerable are not policies for a particular group in society, but policies for all of us when in need. What is required from public policy is the support to resilience over the life cycle.

Fourth, a new social contract requires a different approach to government and governance. In particular, addressing the short-termism that pervades our politics has to be challenged and replaced by a more sober acknowledgement of how governments need to function. A populist politics that wishes away the need for planning and relies on easy, facile slogans to attain and retain office – ‘the unbearable lightness of politics’ as the historian, Tony Judt, put it – undercuts the seriousness that is needed for effective government.

Above all, a new social contract sees a central role for an active state. To this end, we set out a manifesto to frame the approach to public health that is needed in the hope that it might inform the political debate as preparations get underway for a general election due over the next year.

A manifesto

Much that needs to be done already exists and is supported by a sound evidence base as well as by the main UK public health bodies. The Hewitt Review’s plea for priority to be given to population health matched by new investment is also worth acting on. Some measures could be swiftly adopted by a new government if it so chose. Others will take longer but making a start by implementing what be done quickly would make most sense in tackling the crisis facing public health.

Above all, regardless of the particular topic demanding attention, at the heart of public health policy is the need to work in a cross-organisational and cross-sectoral way. This will not happen without strong political leadership, but to embed a cross-government commitment to public health requires new legislation to place a duty on all government departments to respect in their policies the claims of public health. To monitor how policy is taken forward and implemented, there is a strong case for making the publication of health impact statements obligatory.

If the winds of change blowing through the country offer a turning point in the public’s health, then the incoming government has no time to lose in seizing the opportunity.

For an extended discussion of the issues raised go to our new book: Littlejohns P, Hunter DJ, Weale A, Johnson J and Khatun T (2024) Making Health Public: A Manifesto for a New Social Contract. Bristol: Policy Press

Bristol University Press | Making Health Public - A Manifesto for a New Social Contract, By Peter Littlejohns, David J. Hunter, Albert Weale, Jacqueline Johnson and Toslima Khatun

Authors

David J Hunter, Emeritus Professor of Health Policy and Management, Population Health Sciences Institute, Newcastle University

Peter Littlejohns, Emeritus Professor of Public Health, Centre for Implementation Sciences, Institute for Psychiatry, Psychology and Neurosciences, King’s College London

Albert Weale, Emeritus Professor of Political Theory and Public Policy, University College London

Jacqueline Johnson, pubic health and management consultant

Toslima Khatun, teaching fellow, King’s College London



References

The answer starts with austerity, The Guardian, 10 August

https://www.theguardian.com/commentisfree/2020/aug/10/england-worst-covid-figures-austerity-inequality

Hewitt P (2023) The Hewitt Review: An independent review of integrated care systems, GOV.UK https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1148568/the-hewitt-review.pdf

Judt T (2010) Ill Fares the Land. Harmondsworth: Penguin Books 

https://www.penguin.co.uk/books/178939/ill-fares-the-land-by-judt-tony/9780718191412 

The views and opinions expressed by the authors are those of the authors and do not necessarily reflect those of Fuse, the Centre for Translational Research in Public Health.

Image:

Image by Jacques GAIMARD from Pixabay.

Interdisciplinarity – facilitated serendipity?

Guest post by Jane Johnson, PhD student at Teesside University

With Professor Brian Caulfield booked to speak at the European Congress of the World Confederation of Physiotherapy Therapy in November on the topic of ‘the impact of interdisciplinary engagement’, and physiotherapists being encouraged to get out of discipline thinking (1), this is a topic I am coming to think about more and more, not least because my PhD involves supervisors from various fields. There is myself and the Director of Studies, both physiotherapists and from the School of Health and Social Care, a senior lecturer from the School of Computing, a professor of psychology from the School of Social Sciences, Business and Law, plus a Director of Research from the Anglo European College of Chiropractic; input has been necessary from a patenting specialist.

 Interdisciplinarity ‘…involves teams or individuals that integrate information, data, techniques, tools, perspectives, concepts, and/or theories from two or more disciplines or bodies of specialized knowledge to advance a fundamental understanding or to solve problems whose solutions are beyond the scope of a single discipline’ (3). Perhaps because it is …. ‘a term that everyone invokes and none understands’ (2) that I jumped at the chance of attending a free workshop* on this topic, welcoming the opportunity to explore how best to maximise the potential of this collaborative approach.

Asked to consider how we defined our disciplines, it was interesting to discover that whilst myself (physiotherapy), Profession Jane McNaughton (medicine), Andrew Rathbone (pharmacy) and Samuel Azubuike (public health) defined our disciplines in terms of codes of conduct and a sense of rigidity, workshop attendees from the fields of anthropology, theology, sociology, history and english defined themselves according to the methodologies they employed. This in itself was telling and got me thinking about how different disciplines understand and use common words. For example, in my own research, how physiotherapists, psychologists and those from the computing world use the word ‘functionality’ needs clarification in order for us to work together efficiently.

During the workshop we considered how disciplines linked to one another and I reflected that with respect to my own work, linkages came about in both a structured and an unstructured way: some team members were involved from the onset, others have been brought on board as the PhD has evolved. During the first nine months of this project I have come to understand that whilst one must have structure, fluidity is important too, and I am put in mind of the presentation given by Sir Ken Robinson in which he describes how life is not linear but serendipitous (4). I am a planner by nature and came home pondering how one follows a structure whilst leaving space for chance meetings. Some of the most useful contacts I have made in the first nine months of this PhD have been through attending workshops outside of my discipline. There is a need for balancing how many conferences, workshops and seminars one attends, where opportunities exist to meet people from other disciplines who may turn out to be helpful but where this is not guaranteed, against the necessity of following the designated research path. My conclusion is that there needs to be a kind of facilitated serendipity, a contradiction in terms I know.
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References

*Supported by the Welcome Trust, the workshop The Practice, Benefits and Challenges of Interdisciplinarity hosted by the Medical Humanities Department at Durham University.

(1) Hitchcock, G. (2016) ‘Physios must get out of discipline thinking’, Frontline 22, 15 June, p.8.
(2) Cited in Mansilla, V., Lamont, M. and Sato, K., 2015. Shared Cognitive–Emotional–Interactional Platforms: Markers and Conditions for Successful Interdisciplinary Collaborations. Science, Technology, & Human Values, 1-42
(3) Callard, F. and Fitzgerald, D., 2015. Rethinking interdisciplinarity across the social sciences and neurosciences. Palgrave Macmillan. P.4
(4) School of Life & Passion - Ken Robinson - POWERFUL!!
https://www.youtube.com/watch?v=nj0NXky1rh8

Learning to be a researcher

Guest post by Jane Johnson, PhD student at Teesside University

Have you ever had the experience of thrusting your hand into the air, “Oo! Oo! Pick me! Pick me!” and afterwards think, “Uh oh, why did I offer to do that?” Despite being invited to give a poster presentation at CAMSTRAND, the Complementary and Alternative Medicine Strategic Direction and Development Conference hosted by University of Warwick’s Medical School, I felt apprehensive. The topic of the conference was ‘The Application of Qualitative Methods in CAM Research’ and not only is my research mostly quantitative, I have only been doing the PhD for eight months so thought, “how on earth will I hold my own in a room of forty experienced researchers?” My intention to seek out and explore opportunities to learn and to contribute during the limited PhD time frame of 36 months had yet again left me with my hand up, and not in an air-punching Bruce Springsteen Born in the U.S.A. kind of way.

But I was glad to have been brave enough to attend because the experience was invaluable for many reasons. I heard 18 presentations and in addition to learning about the variety and content of on-going qualitative research into complementary therapies, discovered the following:

• Standing up in front of experienced researchers gave me heartburn but not heart failure.
• Even experienced researchers don’t always get their point across to the audience in the way they intend.
• Researchers are curious. They ask questions and reflect on what people say.
• For the most part, researchers want to share their experiences to help prevent other researchers making the same mistakes.
• Researchers are solution-focused. They can’t help but start questions with, “have you thought of trying…”
• Researchers like to network.
• Everyone presents their posters differently. I made a mental note to make the font size of the title of future posters even larger than PowerPoint’s recommended 24 and to use more yellow.
• Even as a novice researcher I can contribute. I helped out two attendees who were struggling to understand the concept of ‘coding’, proving that sitting in on Dr Maura Banim’s qualitative methods lessons at Teesside Uni has not been wasted on me.
• The abstract that got me accepted to CAMSTRAND will be published in The European Journal of Integrative Medicine and the discipline of having to put this together was useful.

Even when you think you are alone at a conference, there are opportunities for surprise and comradery. “Oh you’re that Jane Johnson,” said a woman noting my name badge, “I was looking at one of your books the other day in the library.” I braced myself ready to explain that I didn’t write novels featuring romance in the Moroccan desert. “Posture …something,” she said. I relaxed. “Yes,” I confirmed, “I was that Jane Johnson”, suddenly feeling an affinity for a woman I’d never met and slightly more at ease.

CAMSTRAND is an annual conference organised by the Research Council for Complementary Medicine and I look forward to attending other conferences that provide equally good opportunities for me to learn how to be a researcher.

Boring to Baywatch

Guest post by Jane Johnson, PhD Researcher at Teesside University

The title of this post is perhaps not what you’d expect to hear at an academic conference but then again not all conferences broach the tricky subject of ‘sexy communication’.

The Hoff

This month I was invited - and funded thanks to help from Teesside University and the Royal College of Chiropractors (RCC) - to present an outline of my PhD at the Researchers’ Day of the European Chiropractors’ Union (ECU) Convention in Oslo. The theme for researchers was Down from the Ivory Towers: Breaking Down the Barriers Between Research and Clinical Practice.

As a clinician-turned-researcher and someone who has sat through countless presentations by researchers, this was a theme close to my heart. It felt like a win-win because not only was the RCC getting to see where its money was being spent but - as a fledgling researcher - I gained a valuable insight into the world of research and particularly into the opportunities and challenges presented to us in disseminating what we are doing and what we discover.

President of the ECU Executive Council, Øystein Ogre opened the conference by saying that research has always been a priority for the ECU, not least because chiropractors need a sound evidence base; a concept which, as a physiotherapist, drew me to apply for the PhD on which I am now engaged.

Two speakers from whom I took home important messages were Alice Kongsted and Jørgen’s Jevne. Firstly, Alice suggested that, when presenting our message to clinicians, we should “decide on a clear message” and “drop the details”. She gave examples of PowerPoint slides where the message was unclear and the details many, contrasted to the same information presented in a pared down format. The second take home message was from Jørgen, whose claim to fame could be that he managed to get the word ‘sexy’ into a British Medical Journal publication when they published his article The Sexy Scalpel: unnecessary shoulder surgery on the rise. He said that in getting our message across to clinicians we need to be ‘message brokers’, maximising the use of social media and including images, videos, catchy quotes in our delivery.

Having previously felt anxious about presenting my own work in a highly visual and often interactive way for fear of being criticised as lacking gravitas, I suddenly felt an immense sense of relief. These were experienced researchers and skilled presenters advocating not that we dumb down the content of what we say, but that we change the way we say it. For the first time I felt like I was being given permission to present in a manner that I was drawn to even if it didn’t match the majority of presentations I have sat through. Jørgen’s said that we need make the way we communicate sexy: we need to go “from boring to Baywatch”. I may not have the skill to incorporate images of David Hasselhoff or Pamela Anderson into my slides, but I’m inspired to think more creatively about communication to clinicians.

Photo attribution: flickr.com, Geoffrey Chandler, "David Hasselhoff": https://www.flickr.com/photos/hotrodhomepage/53065807

Doing the dots

Guest post by Jane Johnson, PhD Researcher at Teesside University

“You coming over to see the New Year in?” asked my sister, munching what I imagined was a handful of salted pretzels in the shape of small Christmas trees.

“Yes if I can do your posture.”

“What’s that?”

“You know, where you stand in your underwear and I stick dots on you.”

“Sure.” She didn’t need convincing, and as a blood relative was beholden to support my requests as long as I turned up with two bottles of something excruciatingly dry with an alcohol content that prevented you from driving anything other than an electronic wheelchair within the next 24 hours.

“Is she doing me?” said a voice in the background, my mum, no doubt trying to find when Downton Abbey was on. Not having had a TV for the last 10 years, period dramas pass me by unless any of the characters have interesting postural faults, not the kind of thing usually reported on in the review section of The Telegraph.

“Mum says are you doing her too?”

“Happy to. Don’t drink anything ‘til I’m done though, ok?”

“Don’t drink anything, it’s New Year’s Eve!?”

“I know. Postural sway. I need to minimize it.”

Many therapists believe there is a link between posture and pain. Postural assessment is carried out in order to help with diagnosis, inform treatment plans and monitor postural change. Most therapists do this with visual assessment alone, the inter-rater reliability (degree of agreement among raters) of which is poor, and despite reasonable intra-rater reliability (degree of agreement among repeated administrations of a test by a single rater), it's unlikely a therapist can visually detect what could be a clinically significant minor change in posture. For many years researchers have been looking into ways to measure posture more accurately and more reliably than with visual assessment alone. This is where my research comes in. Whilst there are ways to do this in research settings, there are none that are yet viable for practicing clinicians to use in situ. My PhD involves the development of a postural assessment app from existing software which has already been validated for use on a PC, which was initially designed for use with patients with scoliosis.

Mum stood first, fresh from a bath and eager for me to finish so she could cover herself in moisturizer. “No you can’t put it on,” I said sternly as she sat in a bathrobe snacking on savories from small china bowls, “otherwise my dots won’t stick.” I agreed she could keep her socks on. She was 80 after all. My sister was next. I only had to admonish for laughing during the procedure.

Once the self-adhesive dots have been applied to specific anatomical landmarks, software can be used to calculate the angles between the dots from photographs. The angles that are calculated describe different types of posture in different parts of the body, more so in the spine. There are other apps on the market but it is not known how reliable these are. Unlike these commercial apps, the purpose of my PhD is to create an app for data collection. It will be used in year three of the project by chiropractors, to record the posture of their patients with back and neck symptoms. Use by chiropractors is important because the project is joint-funded by the Royal College of Chiropractors and Teesside University. The patients of participating chiropractors already complete a validated Patient Reported Outcomes Measures questionnaire. Combining this data with the additional photographic posture data, we will hopefully identify whether postural change occurs as a result of chiropractic intervention and whether there is a relationship between posture and pain (symptoms). In the future we hope we can identify whether any postures increase the likelihood of a subject developing back or neck pain, and whether changing back or neck posture reduces symptoms. If we can do this, we can then advise people proactively and reduce their likelihood of developing symptoms in the first place.

With my sister and mum in their New Year’s Eve underwear I worked consistently, palpating the required anatomical points, peeling off and applying green dots to them. The initial satisfaction of fixing self-adhesive dots to skin wore thin after an hour. I took the 12 photographs knowing that photographs taken by candlelight would not be of publishable quality but were adequate for my purpose, which was simply to have some images with which to practice using the software. “Can we drink now?” asked mum and my sister together? “You can drink now,” I said.