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.

What does a hung parliament hold for the future of Public Health?

Posted by Fuse Senior Investigator David J Hunter, Professor of Health Policy and Management & Director, Centre for Public Policy and Health, Durham University

The June general election threw a lot of things up in the air but resolved little. We are living in a suspended state awaiting resolution of what is clearly an unstable political landscape and a government hobbled by its own tensions and contradictions. Uppermost among these is of course Brexit. This will continue to consume all of government as it has already done for much of the past year. No part of government will be left untouched by it. The upshot is that other domestic policy areas are likely to receive minimal attention. This includes public health which rarely features high on the policy agenda.

Earlier in June, the Faculty of Public Health President, John Middleton, in a British Medical Journal editorial urged the next UK government ‘to make health central to all its policies’ (BMJ 2017, 2 June doi:10.1136/bmj.j2676). He concluded that just as local government had adopted a health in all policies approach, ‘national government must now become a public health government’. There seems little chance of that happening in the current febrile political climate.

Of course one can argue the merits of putting health into all policies as distinct from putting all policies into health which might hold more appeal for those who are suspicious of, or are opposed to, health imperialism. But the central point is valid. Most, if not all, of what government does impacts on the public’s health. Indeed, much of the support for political parties calling for an end to austerity was driven by a perception that the unrelenting assault on the public realm since 2010 was having unacceptably negative consequences for people’s health and wellbeing. It’s a small consolation that what has happened in regard to widening inequalities was predicted by the public health community.

So if we cannot look to national government for public health leadership in the foreseeable future, and that seems a forlorn hope given that the former public health minister lost her seat in the election and her successor is unlikely to make an impact anytime soon, what does the immediate future hold for public health? And where is the action likely to occur?

Having a disabled or incapacitated national government may not be entirely a bad thing if it allows local government and other agencies to go about their business without being subjected to a constant outpouring of policy initiatives and ministerial announcements and directives which invariably offer only distraction.

This suggests a need for the public health community to engage more vigorously than it has done hitherto in driving the 44 Sustainability and Transformation Plans (STPs) in England. Though flawed, deeply so in some cases, and poorly communicated with minimal public engagement, STPs and related developments like Accountable Care Systems (ACSs) offer an opportunity (perhaps the only one for the time being) to put public health centre stage in developing place-based approaches to improving population health.

STPs are underpinned by the Triple Aim (Berwick et al 2008Health Affairs 27(3): 759-69) which comprises: improving population health, focusing on patient-centred care, and achieving more efficient per capita spending. STPs and many of the other health system transformation activities underway, and being actively promoted by NHS England with back-up as appropriate from Public Health England, are aimed at managing demand on health care services.

This is not a new agenda – the Wanless reports from 2002 and 2004 commissioned by the last Labour government eloquently argued the case for making the NHS a health rather than a sickness service – but the drive for a systemic transformation has perhaps never been so evident.

The opportunity to bring about a much needed shift in health policy should not be lost and public health should be at the centre of STPs. They offer the best prospect of taking on the big beasts of the acute hospital jungle and wresting resources from them to put into public health. Yet, as research being carried out by colleagues in the Centre for Public Policy and Health (CPPH) at Durham examining the public health changes introduced in 2013 demonstrates, with few exceptions Directors of Public Health in Local Government and their teams and Health and Wellbeing Boards are failing to provide the system leadership that is urgently needed1,2.

Since New Labour introduced foundation trust status for hospitals, compounded by the Coalition government’s misconceived and unnecessary Health and Social Care Act 2012, the NHS has been bedevilled by fragmentation and an ethos of competition in place of collaboration. STPs and associated reforms including ACSs are an attempt to mitigate the worst features of the various reforms since the turn of the century.

It is vital that STPs succeed and bring about the whole system, place-based approach to health and wellbeing that they promise. But we are some way from reaching that goal and the risks are considerable especially when budget cuts affecting public health make it less likely that the necessary changes can be realised.

However, we must not make too much of the budget cuts invoking them to argue that it demonstrates how misconceived it was to relocate public health to local government. Had public health remained under the NHS, it is almost certain that it would be in an even poorer state than is the case at present. Those who remember the days of PCTs will recall the frequency of raids on public health budgets to offset overspends and prop up hospitals. At least public health under local government control remains visible and there is evidence despite the impact of austerity of authorities making serious efforts to become public health organisations and take health improvement and wellbeing seriously.


References:

1. Commissioning Public Health Services - Centre for Public Policy and Health (CPPH), Durham University: https://www.dur.ac.uk/public.health/projects/current/cphs/
2. Evaluating the Leadership Role of Health and Wellbeing - Centre for Public Policy and Health (CPPH), Durham University: https://www.dur.ac.uk/public.health/projects/current/prphwbs/

Photo attribution: "Exactly." by Sam Rodgers © 2017: https://www.flickr.com/photos/samrodgers/34779376735

Public Health Post-election: What is its future?

Posted by David J Hunter, Professor of Health Policy and Management, Durham University and Fuse Deputy Director

The Conservatives’ election victory has brought both old and new faces into the ministerial team at the Department of Health. Jane Ellison returns as a junior minister and will retain the public health brief thereby bringing a degree of continuity to the post. She was growing into the post in the run-up to the election and public health insiders speak well of her.

Public Health Minister Jane Ellison

The fact there has been extensive coverage of the other ministerial appointments in health excluding hers might say a great deal not only about the place of public health in the government’s health priorities but about the level of importance the media attaches to the subject.

Clearly the funding difficulties plaguing the NHS will be uppermost in Jeremy Hunt’s (back as Secretary of State for Health) in-tray with the integrated health and social care agenda not far behind. But the new government is also committed to implementing the Five Year Forward View (5YFV) produced by the NHS Chief Executive, Simon Stevens, last October. Herein lies the hope for public health and surely the near certainty that it will occupy a high place on the government’s list of priorities.

Public health did not feature prominently in the Conservative Party’s manifesto and no major new initiatives were promised. None of the parties had much to say about public health during the campaign. And yet the new government is going to come under significant pressure to up its game over the next five years with the call for ‘a radical upgrade in prevention and public health’ featuring prominently in the 5YFV.

Not only that, but Simon Stevens rarely misses an opportunity in public to stress the importance of public health, admonishing successive governments for their failure to implement the Wanless ‘fully engaged scenario’.  Since the NHS failed to heed the warning, it ‘is on the hook for the consequences’. Wanless wanted a transformed NHS that put health and not illness first.

The 5YFV urges the NHS to redeem itself over the wasted years by becoming an advocate for ‘hard hitting action’ on avoidable lifestyle-related illnesses. Because these put added pressure on health care services, tackling them at source has to be a high priority if a universal service free to all at the point of use is to be sustained.

The latest projections from WHO published a week ago show that Europe faces an obesity crisis by 2030 and that urgent action is needed by governments. In the UK, 33% of women are forecast to be obese by 2030 compared with 26% in 2010. For men, the figures are 36% and 26% respectively. The figures are worse in some other WHO member states with only The Netherlands doing better and remaining stable.

As we know, although there is no silver bullet for tackling obesity restricting unhealthy food marketing is regarded as a key policy lever available to governments. Where this leaves the government’s responsibility deal approach to addressing key public health challenges is uncertain. Even if its critics are persuaded that it is working, the key question in the light of the WHO projections is whether it is working fast enough given the urgency of the crisis looming in under 15 years’ time.

Another key development concerns devolution within England and the Northern Powerhouse initiative. Local MP for Stockton South, James Wharton, has been made the first minister for the project. It builds on the DevoManc announcement earlier this year which put local government in charge of the NHS budget for the Greater Manchester region. Chancellor George Osborne, the architect of this experiment, in his first speech since the election will announce today similar devolved arrangements for the City regions, including Newcastle.

The move to devolve power and responsibility could have major implications for public health as local government will be able to pool budgets and adopt place-shaping policies to improve health and wellbeing and tackle the social determinants of health.

But the catch must be that these developments are occurring at a time when local government is on its knees. With no let up to austerity in sight and with further public spending cuts to come which will fall heavily on local government, the question has to be asked: is local government being set up to fail? Whatever the outcome, there will be significant implications for public health which cannot be predicted. Watch this space.