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Secretary of State for Health's speech to the UK Faculty of Public Health Conference - 'A new approach to public health'

  • Last modified date:
    7 December 2010
Health Secretary Andrew Lansley

Thank you for the opportunity to be with you again. 

Thank you Alun [Maryon-Davis], on the last day that you are president for the work you have done to put the case for public health forward. 

Lindsey [Davies] led on protection against pandemic flu. 

We should never underestimate the threat of novel infections. 

As lectures were given about the eradication of infectious diseases such as polio, HIV was just emerging. It is a constant threat we must guard against. 

The experience of H1N1 has given the public the feeling, ‘they said it would be bad and it wasn’t’. When a leading expert described H5N1, he said he’d never seen one so dangerous. 

We should not let our guard down. We, in this country, can lead international preparedness.

After some six and a half years as Shadow Secretary of State it’s clear to me that we have much to be proud of in how we provide healthcare in this country. But it’s also clear to me that for too long our approach has been seriously out of balance. The emphasis we put on protecting from risk and treating illness, is not matched by the emphasis we put on preventing illness in the first place.
 
So often the treatment that is delivered in the NHS is compromised by patients’ poor diet, lack of exercise, and alcohol or drug abuse or use of tobacco. 

Britain now has the highest obesity rates in Europe, we have among the worst rates of sexually transmitted infection, and we are seeing rising rates of alcohol and drug problems.

Even smoking, which has declined for decades, remains stubbornly high and still claims over 80,000 lives a year. Nearly a quarter of the deaths in this country each year result, at least in part, from the consequences of unhealthy lifestyles.
 
Recognising the additional demands facing the NHS in the coming decades – an increasing and ageing population, costly advances in treatments and rising expectations – we simply can’t go on like this. 

To have a fighting chance of meeting new demand in the years ahead, we have to get to grips with the real drivers of demand on our NHS now.

Improving public health is something that need to take seriously at all levels – nationally, locally, and as individuals.

But in recent years – and despite your best efforts in the Faculty and elsewhere – political leadership has been nowhere to be found. And we’ve seen the impact. Public health staffing has been cut, short term initiatives have come and gone with little evaluation of what works, and public health budgets have been raided to offset short-term financial pressures.  This is not something that happens every year.  It happened in 2005/6 and it was the wrong decision.

Meanwhile, many of our greatest public health problems have escalated.

In place of leadership, we’ve had initiatives.

Initiatives without evidence, without evaluation, without coordination and, most of all, without awareness of the cultural need to change behaviour.

Behaviour change is the great challenge for public health – but too often it has been ignored.

Take alcohol – where the lack of national leadership can be seen in the sharply rising effects of alcohol consumption, and the pattern of alcohol consumption. Alcohol strategies have failed to go much beyond the public order issue.  The approach has been confined to supply, with little impact on demand.

Public health efforts, which only try to control supply, will fail. We have to impact on demand. That means we have to change behaviour, and change people’s relationships with each other and with drugs, alcohol, tobacco and food.

And where behaviour change has been the aim of recent initiatives, the outcomes have been patchy at best.

It seems to me that awareness campaigns have too often sent the wrong messages – when they’re screaming at you to drink less, many people are just having their behaviour reinforced – the message doesn’t come out as ‘drink less’ but as ‘everyone drinks, so don’t worry about it’. It tells people that the norm in society is misuse of alcohol.

How often have all of us been frustrated by a system which ‘does’ alcohol, drugs, smoking cessation, STIs, and obesity, but doesn’t seem to get it that there may be an underlying reason, or a set of factors, why our young people develop a dependent or distorted relationship with drugs, alcohol, tobacco, food or sexual relationships in the first place.


Common factors like dysfunctional families, poverty, worklessness, weak family and community structures, lack of good parenting, or mental illness are all identifiable causes. But, most of all, I would argue that the reason underlying all of this, especially amongst young people, is a lack of self-esteem.

Just as leadership drives organisational success, so self-esteem drives personal fulfilment.

That is why, contrary to the media reporting, I applauded Jamie Oliver’s initiative on school dinners and when he went to Rotherham – because Jamie ‘got it’.

He got that it’s not just about a witch hunt against saturated fats, salt and sugars. It’s about creating a better understanding of, and relationship with, good food and diet. And even more, it’s about self-confidence – it’s about building self-esteem. 

When you watch the programmes – and I did watch them - they were about building self-esteem, not just about what went into the food and how you cook it.

The problem was the government’s response. Instead of working with families to engage them with the idea of building a good diet together, with food they enjoy, the bureaucracy took it over and they came up with a series of rules for what was permissible in school meals.

The fact is, you can’t legislate for self-esteem from Westminster. We can’t pass the Elimination of Obesity Act 2010. Turning Jamie’s campaign into a list of how often you can offer chips – whilst not rationing roast potatoes cooked in oil – doesn’t do the job.

In complex policy areas like this it has become clear that government cannot simply ‘deliver’ key policy outcomes to a disengaged and passive public. We cannot solve complex problems on our own – everyone has a role to play.

So how do we do that?

I freely admit that none of us have all the answers.

But, it’s clear that we have to find a new approach – to think new thoughts. We need a paradigm shift.

The reforms we are bringing in will empower you – the professionals – to commission services that work – to apply the best technology and the best new insights of social psychology and behavioural economics to achieve real improvements in public health. 

The latest academic research in these fields is suggesting new ways of helping people to change their behaviour, and achieve what we all want to achieve. 

Studies has shown that social norms are much more important than policymakers have traditionally assumed.  People are deeply influenced by the behaviour of those around them – and public policy should reflect that.

Nicholas Christakis, who is a Professor of Medical Sociology at Harvard, puts it like this – ‘There is a kind of social contagion [with obesity], a kind of social domino effect. Suzy makes Betty eat poorly. And then Betty makes Jane eat poorly. And Jane makes Ann eat poorly. Suzy does not know Jane or Ann, but Suzy’s behavior and actions are influencing the interaction between Jane and Ann.’ You will be tested on this as you leave!

He found that if a friend becomes obese your chances of becoming obese increase by more than half – and with close, mutual friends, if one becomes obese the chances of the other following suit are even higher.

That’s pretty striking. If we can find a way to harness the intensive influence that people have on each other through social networks or social media, then we’d really be on to something. 

We should be learning the lessons of what’s worked in this country and around the world.

There are numerous examples of how technology can be used as a cheap, effective tool for promoting public health. Research from the US has found that pedometer users increased their physical activity by over 25%.

Smarter incentives have also been shown to be an effective way of encouraging people to adopt healthier lifestyles, particularly for disadvantaged groups.

And we need to be smarter about how information is presented to ensure that messages really hit home.

Researchers at UCL have found that telling smokers their ‘lung age’ makes them more likely to quit smoking.

And advertising social norms can snap people out of the fantasy that their drinking, smoking or eating habits are the same as everyone else’s. 

Of course this is just scratching the surface – there is a proliferation of innovative ideas out there for you to draw on. We need to find out what those ideas are and how we can define the evidence base for what will work as part of a broader strategy.

And I talk about strategy for a reason.

For too long our approach to public health has been fragmented and complex but not effective.

So we want to free the system up – to work with you as the champions of public health, to create a framework which empowers people to make the changes that will really make a difference in their lives.

Working with communities and schools to develop young people’s confidence and self-esteem. Empowering them to take better decisions when young, so that they enjoy greater health and well-being though life.

So that we reduce alcohol and drug abuse, not because we tell people to do it, but because people are in control and less dependent.

So that young people see drug use and binge drinking not as a sign of being adult but as evidence of their immaturity.

So that peer pressure and expectations drive greater responsibility.

And the majority of young people who don’t take illegal drugs and do not get blind drunk on a Friday night are celebrated.

This, more than anything, is why we need to empower all of you.

This is why we need genuinely local strategies, based in neighbourhoods, schools and families.

This is why we need to throw off the old ways and start seeing people and families as a whole, using local voluntary and charitable organisations much more, cutting across boundaries, encouraging innovation, using the power of new technologies and new media, joining up professions and budgets and putting the people – not the system – at the heart of the strategy. Making us all accountable for results, not just processes.

And this cannot happen through top-down national schemes. We – that is the government – can supply resources, ideas, evidence, we can create identity for the public health strategy, but we cannot expect a national strategy to deliver everything.

We need to build responsibility and innovation in local communities if we are to deliver.

So my vision is for a new Public Health Service which rebalances our approach to health, ensuring we continue to respond effectively to public health emergencies and carry out the vital role of protecting the nation’s health – while also drawing together all the elements we need for preventative action for health improvement – national leadership and strategy, local leadership and delivery and, above-all, a new sense of community and social responsibility.

Now, to prepare the ground for this new Public Health Service, first we must establish a national strategy to secure a professional, unified and efficient approach to achieve measurable improvements in public health and effective protection from public health threats. A strategy that delivers the focus, resources and infrastructure that we need.

From my personal point of view, I am already the Secretary of State for Public Health. And we are very clear that, as a Department, we are more focussed on public health and that will be my personal ambition.

And because the determinants of health extend far and wide, we will lead a cross-government strategy to tackle the drivers of demand on the NHS and to make Britain a healthier nation – breaking down the longstanding barriers that have prevented progress in the past.

That’s why the Prime Minister has approved the establishment of a Cabinet Sub-Committee on Public Health, which I shall chair. In this way we will develop a strategy which not only recognises the wider determinants of health, but is equipped within government to tackle them in order to improve our health outcomes – bringing the range of potential benefits that I’ve been describing.

We will set clear outcomes and measures to judge progress alongside NHS and social care outcomes for which my Department is responsible.

We will strengthen the role of local government in improving public health, improving local accountability and rewarding the progress that communities make.

And we will create a new ring-fenced public health budget – giving confidence that in the teeth of the debt crisis we inherited, we nonetheless achieve the improvement of health outcomes, that we seek and that we also reduce the dreadful scale of health inequality we inherited.

It’s no secret that the causes of ill health are rooted in local issues such as poor housing, poor quality education, worklessness and family breakdown.

So, alongside a new national strategy, the second thing we need is renewed local leadership. We need to empower local communities to identify their own needs and provide rigorous solutions that work for their specific circumstances.

The Public Health Service will provide strong local leadership, supported by resources devoted to tackling those cross-cutting causes of ill-health. And through public health budgets, we will create local public health budgets to support local strategies and leadership.

Leadership, from local authorities working together with their public health partners, through the critical role of Directors of Public Health, will have the resources and the authority to make preventative interventions to improve the health of their communities. 

They will develop strong local strategies to deliver health and well-being in individuals, families and communities.

And just as the national strategy must extend across and beyond government, so local government must do exactly the same thing including all local partners.

We will not be dictating the ‘how’ when it comes to achieving better public health outcomes.  But we will be very clear about the ‘what’ – what we want to measure and achieve.

This could include: increases in life expectancy, reduction of inequality in life expectancy, decreases in infant mortality, improved immunisation rates, reduced childhood obesity, fewer alcohol-related admissions to hospital, and improvement in take-up of physical activity. One of the critical measures of success must be a demonstrable reduction in health inequalities in local areas.

These are the kind of measures on which we will consult. And we will promote the use and collection of evidence so we build a stronger picture of what works.  

We will be clear about what we want to achieve but not tell people how to do it.

The funding and the freedoms that I’ve talked about will only be sustainable if they are followed by greater evidence of success – through payments to match results.  We can have a health service that reduces inequalities in public health.

This is how the Public Health Service will work to improve the health of the poorest fastest.  

We know that deprived communities have some of the worst and most entrenched public health problems.

So I do want to build on the findings of Sir Michael Marmot’s review, and the six policy objectives he proposes. In the ways I’ve described today, we’re giving you new tools to tackle the problems he identified – to form new partnerships across different disciplines, and to target those determinants of poor health in ways that fit local circumstances.

Central to this is the new ‘Health Premium’ which will support local strategies which deliver measurable results – and on which we’ll consult this year.
In the past the system has rewarded poor outcomes. We will start with a system that recognises deprivation and then rewards improvement.

The third and, most important, factor for the Public Health Service is individual engagement and responsibility.

By many measures, Britain has become one of the least cohesive and most socially divided countries in Europe. 

Failings in civic, community and family life have gone hand in hand with a decline in social and individual responsibility. The negative impact on our health and wellbeing is serious. 

For public health reform any success will have to begin to reverse this decline in responsibility.

The temptation in the past has been to intervene – but no government campaign or programme can force people to make healthy choices.

I looked at yesterday’s Daily Mail and while there were nine pages on politics, there were thirteen pages on health. 

There is no lack of desire for people to be healthy, our job should be to provide the right information, to create the right environment, to incentivise healthy options and build social momentum behind behaviour change in the ways I have already described.

Nudging individuals in the right direction.  Encouraging positive choices. Not lecturing or nannying. But making people feel empowered.

Part of this is bringing government and business together to promote innovation in thinking and practice. So we will build on the ideas and expertise from our Public Health Commission, and the Coalition for Better Health, to create a new ‘responsibility deal’, built on social responsibility, not state regulation. 

And this is everyone’s business – there is a distinctive role for all of us to achieve the positive change we need. 

Change4Life is an example of this. I have been impressed how much it has achieved to date – I’ve talked to many of you about my support for it, particularly the way it has brought som many people together - healthcare professionals, teachers, charities, businesses, and the thousands of volunteers who have added their support.

But, again, we need a new approach. We have to make Change4life less a government campaign, more a social movement. Less paid for by government, more backed by business. Less about costly advertising, more about supporting family and individual responses.

There has been a change of Government and there will now be a change of approach. We will be progressively scaling back the amount of taxpayers’ money spent on Change4Life and asking others, including the charities ,the commercial sector and local authorities, to fill the gap. 

While government pump-primed the brand, we will now withdraw the primer and engage others to share in making Change4Life really work – and we will focus on extending its reach and effectiveness, especially in social media.

There is no point backing local strategies if the government is prescriptive.  Change4Life can be used by everybody to deliver their public health campaigns.

To date, industry has made ‘in kind’ contributions. I will now be pressing them to provide actual funding behind the campaign. And they need to do more. If we are to reverse the trends in obesity, the commercial sector needs to change their business practices, including how they promote their brands and product reformulation.

That is why I see our new approach as a partnership – access to the Change4life brand, alongside the Responsibility Deal; with an expectation of non-regulatory approaches.  We will work with partners in Change4life to give people better information in less prescriptive ways.

I will also consider extending the Change4Life partnership to the drinks industry, who also have a major further role to play in promoting healthier lifestyles.  Change4life is not just about obesity and physical activity but other ways to be healthy.


We also need to be smarter about how we engage with people. Over the next year, we will test new and innovative ways to incentivise healthier lifestyles, created with local communities and evaluated using a mix of academic and commercial sector techniques.

Our new approach across public health services, must meet tougher tests of evidence and evaluation – demonstrating delivery of results.

We will not retreat from our determination to prevent rising ill-health in the future – equally, we must not waste a penny of desperately scarce public money today.

The Coalition Government’s commitment to our health services is in the circumstances remarkable – we are not going to make the nation’s health the price of paying down the nation’s debt.

Alcohol misuse costs society over £17 billion each year and obesity much the same figure. If we ignore these issues, not only will we have to carry on paying for that failure, but we will also have to live with the consequences in worse educational outcomes, higher crime, poorer quality of life for everyone – and we will put the economic recovery at risk.

Healthy individuals are more productive and more able to contribute to long-term growth. As the Royal Sanitary Commission noted in 1871: ‘public health is public wealth’.
 
We can make a very strong case for the cost-effectiveness of investment in health, in health promotion and the prevention of illness.

But in the past these investments have rarely – too rarely – been accompanied by a rigorous evaluation of what works.  The idea that spending on prevention is more cost-effective than spending on treatment is not a hard and fast rule.  We have to show where it is true, how it is true and why it is true.

In the current fiscal climate we have to see a new standard of evidence.

We must only support effective interventions that deliver proven benefits. We must be certain that every penny invested will achieve better health outcomes.

To conclude, later this year, we will publish a White Paper on public health setting out exactly how the Public Health Service will work – and I want to invite all of you to participate in its development.

I want to consult with you about how we will develop this policy.

Notwithstanding financial difficulties, we can create something better.

My vision is of public health as a movement, owned by everyone, for everyone’s benefit. A movement which unites those who have been trying to prevent ill health with those responsible for treating it. A movement which not only transforms the way we deliver public health, but also revolutionises the way we think about it.

So I want to enlist your help: to work hand-in-hand with colleagues across local government and the NHS; to inspire, challenge and lead others; to deliver better health for the nation; to ensure that progress on local health outcomes is maintained; to support communities and empower individuals; to change the way people think about public health.

And as we collectively rise to this challenge you’ll have our support – I’ve set out today how we’re supporting you with ring-fenced funding, incentives and greater control.

I’ve set out my approach structurally, financially, philosophically.

We have the chance for the first time in this country, to create a unified, coherent and effective public health strategy – with the Public Health Service at its heart – guided by a national vision, lead by local expertise, driven by evidence – and founded on social responsibility.

With your help, we can make that vision a reality.

Thank you.

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