Select Committee on Health Second Report

Public Health and the Individual

51. We have described how an individual's health is affected by a number of factors (fixed, socio-economic, lifestyle). Individuals can also do a lot of things themselves to improve their health and are the 'targets' for health promotion activity. However, people do not live in isolation from their society and the decisions they make are often the product of a number of influences.

52. As we have seen, health inequalities have, over recent decades, actually been growing despite the fact that overall, people of all social classes have greater wealth. As the wealth of the poor has increased, it would seem logical to assume that their health too would have improved. This has happened, but the health of the poor has improved much more slowly than that of the better off. In attempting to answer the question why this has happened, Sir Michael Marmot and others have, since 1967, undertaken a wide-ranging and comprehensive series of studies of health in the civil service, the so-called Whitehall Study. Three such projects have been undertaken. The very precisely measurable hierarchy that obtains in Whitehall - where jobs are ascribed grades in relation to their seniority - allowed Sir Michael's team to establish the relationship between an individual's conception of his or her own status and their health and well being. The British civil service excluded both the richest and the poorest in society, allowing the researchers to focus on the impact of the social gradient. In oral evidence, Sir Michael himself summarized the results of the studies:

"We have been studying civil servants for the better part of three decades, the Whitehall studies, and in the first Whitehall study we showed this social gradient very clearly. For people who are not poor in any usual sense of the word where you are in the hierarchy was intimately related to mortality and coronary heart disease, from cancers related to smoking, cancers not related to smoking, accidents and other causes of death and so to all causes."[57]

53. The Second Whitehall Study set out to establish "the association between adverse psychosocial characteristics at work and risk of coronary heart disease among male and female civil servants".[58] It attempted to explore in greater depth the factors underlying the disparities in health and concluded that "people who had low control over their work environment had higher risk of coronary heart disease than people who had high control over their work environment".[59] This study concluded that, compared with men in the highest civil service grade men, in the lowest grade were more than 2.5 times more likely to die of a heart attack. Only about 25% of this increased risk could be accounted for by conventional risk factors, such as cholesterol, blood pressure and smoking. The rest of the risk seems to be attributable to low control in the work environment. Sir Michael told us that his team were now "looking at the issue of how much control people have outside work" and had found that low status women, women who tell us that they have no control at home" suffered "a dramatically increased risk of depression, subsequently". Sir Michael's overall conclusion was that "people who feel that they do not control life circumstances are at risk of mental illness, depression, but they are also at risk of physical illness".[60]

54. Research elsewhere also substantiates these findings. Studies carried out in Sweden have established that individuals in demanding jobs who see themselves as having poor control over their work "have a much higher incidence of coronary heart disease symptoms than people in demanding jobs who believe they have good control". It is now clear that this feeling of lack of control has a direct physiological impact.[61]

55. To take the example of smoking, this type of research has illuminated some of the factors influencing health inequalities. Sir Donald Acheson noted that: "the degree of dependency, and addiction, to 20 cigarettes a day increases as you go down the social spectrum. The less well off have more difficulty in quitting. There are either higher nicotine levels in their blood, perhaps due to the way they smoke, but it may also be the way they feel about their life".[62] Sir Michael Marmot suggested that the social gradient was a result of something other than ignorance of risk:

"that something else is intimately related to where people are in the social gradient. That may affect smoking, it may affect diet, it may affect exercise but it may also affect the degree of security people feel, how much hope people have for the future, whether they feel that life is working in their favour or against them. This may sound airy fairy, but we have evidence that those things are important for health and they follow a social gradient."

Sir Michael cited research into the time budgets of single mothers conducted by Hilary Graham. Smoking rates are extremely high amongst this group of society but Hilary Graham's research established that these women devoted almost all of their time and money to other people such as their children or partners:

"The only thing they did for themselves was smoke. The only money they spent on themselves was for tobacco and the only time out in the week virtually that they had for themselves was when they had a cigarette."

Sir Michael argued that people in these circumstances were "discounting the future extremely".[63]


56. One of the factors we noted in our assessment of the range of Government initiatives was a feeling reported that individuals were not sufficiently engaged in shaping their own health or that of their community. Yet, as the Whitehall Studies and other research has shown, it is vital that individuals feel they are empowered. Our concerns in this area were mirrored by Dr Donnelly of the Association of Directors of Public Health who told us:

"The single most important thing that in my personal view we have got to achieve is that we have to start returning to individuals some kind of feeling of autonomy over their own health."[64]

Professor Jennie Popay of the University of Leeds said that in her view "involving people who live in the places where the initiatives are being rolled out seems to me to be the key to sustaining the benefit of them".[65] She believed that too little energy had been directed at engaging the "lay public" in health improvement projects.[66] At present she felt that the communities potentially affected by interventions were only involved "at the margin". She also pointed out that not enough had been heard of "the voices of the people we are talking about" and that little research had been undertaken in particular of children's experiences of their social environment.[67] This echoes a point made by the NSPCC who commented: "It would be interesting to know how many health action zones and other such programmes have genuinely consulted with children and young people as part of their development and implementation process".[68] The RCN gave a concrete example of this absence of participation, when they drew attention to the "distinct lack of public involvement" in the development of the Health Improvement Programmes.[69] They called for specific guidance from Government in this area. John Goalby, a voluntary sector participant in the Walsall West Health Action Zone, working on behalf of a local residents' association, told us that his HAZ had found engagement of the community "one of the greatest difficulties".[70] Naomi Fulop and Julian Easton's research found that fewer than a third of HAZs had addressed the issue of consultation with users and carers in a strategic manner.[71]

57. We think it is crucial that the voices of those intended to benefit from interventions are acknowledged and that they feel some sense of ownership in the projects. At the moment, the impression is of grandiose schemes being foisted on to communities. The most effective interventions that we witnessed took their strength from local leadership, responsiveness to local need, and local involvement and participation at every level. Given the evidence we received relating to the general lack of involvement of lay individuals in, for example, the Health Action Zones and Health Improvement Programmes, we believe it is essential that Government takes action and makes it a condition of further funding that there is clear feedback and input from those individuals intended to benefit from public health projects, including children. We are not convinced that any wider sense of "ownership" has yet been established. It seems to us particularly regrettable that area-based initiatives have often failed to engage the communities they aim to serve.


58. Health promotion seeks to involve individuals in improving their own health. According to the World Health Organisation, health promotion is " the process of enabling people to increase control over, and to improve their health".[72] The means by which Government can achieve this are debatable. Professor Macintyre told us that "most of the evidence suggests that simply telling people what the risks are is not enough to change behaviour".[73] Professor Richard Wilkinson of Sussex University also pointed out that any resources devoted by Government to getting across healthy lifestyle messages were likely to be totally outmatched by commercial interests seeking to put across different messages. He referred to evidence on public perceptions of sugar, looking at both the health education aspects and industry advertising:

"On balance ... the overwhelming message was that sugar is good for you - Mars Bars 'help you work, rest and play.'"[74]

59. In the course of our recent report on the tobacco industry we unearthed copious evidence from advertising agencies working for the major tobacco companies. This demonstrated how tobacco marketing ruthlessly and efficiently targeted particular sections of society, notably younger people and the poor. Companies even manipulated the pack colour and design to convey subliminal messages, so that the gold packaging of Benson and Hedges exploited a sense of glamour and sophistication, whilst the soft purples and whites of Silk Cut packaging hinted at an implied health benefit from its "low" tar. We concluded that those responsible for health education could learn much from the social marketing techniques of the tobacco companies.[75]


60. In April 2000, following proposals set out in Saving Lives, the Government set up the Health Development Agency (HDA). It is a Special Health Authority whose purpose is "to establish what works in public health and to help others turn that evidence into effective national, regional and local action".[76] It is tasked to maintain an up to date "map" of the evidence base for public health improvement, to commission and evaluate research in areas where "action programmes are required to improve health and tackle inequality", to advise on the setting of standards for public health planning and practice and to build up the "skills and capacity of those working to improve the public health".[77]

61. The HDA will have almost a third fewer employees than its predecessor body, the Health Education Authority (HEA), and is no longer directly responsible for health promotion activity. This has led to suggestions in some quarters that the transition from HEA to HDA has been merely a "cost-cutting exercise".[78] In fact, the public education function of the old HEA has, at present, been transferred to a new body, Health Promotion England (HPE), which was established at the same time as the HDA. HPE has initially been contracted to work in the following areas: alcohol, children and families, drugs, immunisation, sexual health and older people, and also to update and provide publications from its predecessor body.[79] HPE's initial contract runs until the end of March 2001.

62. The precise status of Health Promotion England seems to us unclear. The nature of its short term contract, its relationship to its predecessor body and its means of liaison with the Health Development Agency (HDA) all seem too opaque. We are not convinced that this body has the direction, energy or resources to make a real difference. We would urge the Government to make clear its plans for the future of health education.

63. Clearly it is too early for us to pronounce on the effectiveness of the HDA and of HPE. Several witnesses did, however, register concerns and we would like to record these as a future marker. The Chartered Institute of Public Health pointed out that the lack of formal links with counterpart organizations in Scotland, Wales and Northern Ireland did not suggest Government was well co-ordinated in this area.[80] The BMA suggested that the HDA could be the public health counterpart to the National Institute for Clinical Excellence, but required far more support from DoH and better links with academic networks for primary care and environmental sciences. They also drew attention to a potential difficulty for a body tasked with establishing the evidence base for public health: "The agency also needs to be given the opportunity to research developments and initiatives which cannot be evaluated in the short term, for example the long term effects of health education and prevention".[81] The King's Fund was concerned that the HDA was barely mentioned in the NHS Plan. They contended that its role remained unclear, its budget had been severely reduced and it was apparently not due to receive any new money. They also queried whether the HDA should remain within the DoH or be funded by several departments and work across Government from within the Cabinet Office. However they welcomed the fact that the HDA has established a number of regional posts and that a number of these were located in Government Regional Offices and Regional Development Agencies.[82] The National Heart Forum thought that the HDA was ideally placed to look at the non-health determinants of health but was concerned that the HDA's budget was insufficient. They estimated it would require an annual budget increase of £10 million to allow it to carry out training and development.

64. We asked Professor Richard Parish, the Chief Executive of the HDA, whether he felt that his organization was sufficiently well funded for the extremely wide-ranging task it had been given. He told us that he was satisfied with funding levels for the first year of operation but would be seeking further funding in three areas: additional skills relating to workforce planning and information technology to help in the development of a National Electronic Library for Public Health; commissioning research to fill the gaps in the evidence base; and development resources to pump prime initiatives in the field "to provide the necessary resources that will have a practical impact for people working either in general practice or as a health visitor in the field, someone working in a local authority, in a leisure centre or whatever". He estimated that a further £20 million would be needed to achieve these goals.[83]

65. We were impressed by the evidence given by those representing the HDA. We would be disturbed if this new organization was not properly resourced. We are anxious to ensure that the HDA will have the resources to be able to assess 'bottom up' projects. We also recommend that its funding should be ring-fenced and kept apart from mainstream health funding so that its independence in offering objective advice on 'what works' in health is not compromised. Establishing 'what works' in public health will ultimately yield value for money savings.

57   Q109. Back

58   Bosma H, Marmot MG, Nicholson AG, Brunner E, Stansfeld A, "Low job control and risk of coronary heart disease in Whitehall II (prospective cohort study)", BMJ 1997, 314:558-65. Back

59   Q109. Back

60   Q109. Back

61   Karasek R and Theorell T, Health Work: Stress, Productivity, and the Reconstruction of Working Life, 1990, cited in Frank J W and Mustard J F "The Determinants of Health from a Historical Perspective", Daedalus, 123 No. 4. Back

62   Q120. Back

63   Q124. Back

64   Q243. Back

65   Q171. Back

66   Ev., p.90. Back

67   Q177. Back

68   Ev., p.418. Back

69   Ev., p.215. Back

70   Q524. Back

71   Ev., p.480. Dr Fulop and Mr Elson of the London School of Hygiene and Tropical Medicine were commissioned by the DoH to evaluate The Health of the NationBack

72   Cited in PH37 (not printed). Back

73   Q191. Back

74   Q193. Back

75   Second Report from the Health Committee, Session 1999-2000, The Tobacco Industry and the Health Risks of Smoking, (HC27), p. lvi. Back

76   Ev., p.130. Back

77   Ev., p.130 and DoH website. Back

78   Ev., p.439. Back

79   Ev., p.498. Back

80   Ev., p.390. Back

81   Ev., p.207. Back

82   Ev., p.475. Back

83   QQ299-300. Back

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