Andrew Lansley, the health secretary, recently announced the government’s plans to improve public health in the white paper, Healthy Lives, Healthy People. So what exactly is the plan? Well… it’s to “nudge” people more. They want to nudge people to make the right decisions when it comes to their health, rather than the so-called “nanny state” approach taken by Labour, where the “man in Whitehall” was telling people how to live their lives. The idea is that people can be enticed, instead of being coerced, into making better decisions. It is, of course, total nonsense.
“Nudging” is one of the government’s new buzzwords. It was made popular by Professor Richard Thaler, an adviser to David Cameron in the cabinet office’sbehavioural insight team or “nudge unit”. And, no, I am not making this up. This is the infamous, supposedly civil service, team that includes former Conservative party staffer, Anna-Maren Ashford, Cameron’s personal image consultant and head of “Brand Dave” before the election.
Labour made huge improvements in public health, but the new government’s white paper comes against a backdrop of the NHS, and indeed other healthcare systems around the world, struggling to cope with the demands of a population that is eating too much, drinking too much, smoking and not doing enough exercise. I speak from some experience, though I gave up smoking several years ago in a moment of good sense. It is curious to remember that the founding fathers of the NHS actually believed that demands on the institution would gradually decline over the years, as people were treated and made healthier and would therefore not need to use the health service as much. Instead, of course, demand rocketed as people began to live longer, as technologies and treatments improved exponentially, and as we grapple with the health problems associated with twenty first century living.
Take obesity, for example. According to the world health organisation, obesity alone is already responsible for up to 8% of health costs and 10-13% of deaths in Europe. Obesity can have a severe impact on people’s health, increasing the risk of type II diabetes (a condition once only known in adults), cancer, and heart and liver disease. It is also a significant burden on the NHS, with direct costs caused by obesity standing at around £4.2 billion a year.
Lansley and Cameron are attracted to ‘nudge theory’ for obvious reasons. It suits their ideologically-driven approach which says that the state should be rolled back, leaving individuals to fend for themselves. This can also be neatly wrapped into their “localism” approach, whereby public health (along with massive public spending cuts) is “devolved” to local authorities and left to personal responsibility.
But the problem is that, historically, nudging has never been enough. Significant improvements to public health have always required the involvement of the state, whether that has been the ban on tobacco advertising, forcing people to wear seatbelts and not drink and drive, or most recently the ban on smoking in public places. The shadow health secretary, John Healey, has also pointed out that there is nothing new to the government nudging people. Back in 2004, Labour set out the importance of incentives and individual decisions, but argued that this needed to be done alongside government action, in our own white paper on public health.
When you talk to charities, like the excellent British heart foundation, the sheer scale of concerns is alarming. In a range of policy areas – whether free school meals, school sports and playgrounds, “traffic-light” warnings on pre-packaged foods or the apparent back-pedalling on banning the display of tobacco products in shops – the truth is that the government is taking the country backwards. Over 50% of health inequalities in this country are created by tobacco use alone, and the evidence is clear that stopping point-of-sale displays of cigarettes will undoubtedly help. Cancer research UK has said that the government “has the opportunity to act with conviction and reduce the devastating impact that tobacco has on so many lives”. The legislation is ready, but Lansley is loath to commit.
Public health experts are concerned. They argue that the nudge approach is much too feeble to deal with the biggest threats to health. Dr Vivienne Nathanson, of the British medical association, has said that nudging on its own will only “have a limited effect”. Other health professionals have described it as a complete negation of responsibility by the government.
Just as troubling is the objectives of the health white paper being at odds with the government’s wider policies. Poor health is caused by a whole host of factors: poverty, lack of education, worklessness, a poor environment (especially housing) and inequality. In almost every area, the government is driving through policies that will make public health worse, not better. For example, only last week the government’s official quarterly homelessness statistics revealed that homelessness has increased significantly for the first time in seven years. From July to September this year, 11,840 applicants were accepted as homeless by local authorities, 14% higher than the same quarter in 2009. Leslie Morphy, the chief executive of the homelessness charity, crisis, has said that his “real worry is that this is just the start of something much bigger as the government’s cuts, particularly to housing benefit, kick in”.
And what about places like Barnsley, a deprived area where people’s health is worse than many other areas of the country and where the gap is still widening? The government claims that local authorities with the highest levels of poor public health will get the most money for a ring-fenced budget, but again, this does not take into account the massive cuts of 28% to local government over the next four years. Although Eric Pickles will deny this when he stands up in the House of Commons today, the cuts to local government will disproportionately hit poorer areas – like Barnsley – the most, where council tax receipts as a proportion of their budget are comparatively low, and where they disproportionately rely on central government funding.
Overall, despite all the government’s professed desire to improve public health, it is clear that their policies will do more to increase health inequalities than to reduce them. They may say that they will the end, but they simply do not will the means. The big gains made in the last decade in cancer screening, cuts in deaths from heart disease, healthy food in schools, stopping smoking, are unlikely to be continued and could well decline. What is more, it will be worse in traditionally Labour areas. No amount of nudging people along is going to change that. If the truth is that central government has effectively given up on active policies to improve public health, it will be left for local government to try and pick up the baton. And Labour local authorities in particular will need to rise to that challenge.
Michael Dugher is Labour MP for Barnsley East, a shadow defence minister and vice-chair of the all party Parliamentary group on heart disease.