House of Commons - Public Health

Public Health - Health Committee Contents

4 The national policy dimension

270. The Government sees local initiatives and devolved budgets as the key to improving the health of the population, rather than "Whitehall diktat",[469] and its "broad intention" is "for health improvement to be devolved to a local level".[470] However, it does acknowledge that there is an important national policy dimension to health improvement. This, however, will not focus on "nannying about the way people should live".[471] Rather, it will be based on:

strengthening self-esteem, confidence and personal responsibility;
positively promoting 'healthier' behaviours and lifestyles; and
adapting the environment to make healthy choices easier.[472]

271. A crucial objective of health improvement policy is to reduce the longstanding and stark health inequalities in England. A major review of the most effective evidence-based strategies for doing so was conducted by a team under the leadership of Professor Sir Michael Marmot. In its report, published in February 2010, the Marmot Review Team confirmed the extent of health inequalities and found a "social gradient" in health (meaning that "the lower a person's social position, the worse his or her health"). It recommended action to reduce the gradient by seeking to improve health throughout society "but with a scale and intensity that is proportionate to the level of disadvantage" (an approach it called "proportionate universalism"). Since health inequalities resulted from social inequalities, action was needed "across all the social determinants of health". The review also recommended the adoption of the "life course approach" to improving public health.[473]

272. Six specific policy objectives were recommended:

Give every child the best start in life
Enable all children, young people and adults to maximise their capabilities and have control over their lives
Create fair employment and good work for all
Ensure healthy standard of living for all
Create and develop healthy and sustainable places and communities
Strengthen the role and impact of ill health prevention[474]

273. The Government stated that Healthy Lives, Healthy People was its response to the Marmot Review.[475] It pledged in that White Paper to apply proportionate universalism, by improving the health of all whilst "improving the health of the poorest, fastest";[476] and to take the life course approach, addressing "the wider factors that affect people at different stages and key transition points in their lives".[477]

274. While these commitments have been strongly welcomed, there is still some scepticism as to whether Healthy Lives, Healthy People constitutes an adequate response to the Marmot Review. Members of the Review Team told us they were particularly concerned that Healthy Lives, Healthy People only picked up five of the six domains of recommendations from the Marmot Review - being silent on the need to "Ensure a healthy standard of living for all", which:

involves establishing a Minimum Income for Healthy Living, and proposes an overhaul of the tax and benefit system, to ensure that the system as a whole is progressive and avoids financial "cliff-edges" between employment and unemployment wherever possible.[478]

Professor Hunter told us that he found Healthy Lives, Healthy People "Underwhelming" as a response to Marmot, since the Government's policy was essentially focused on:

individual lifestyle behaviour change and that is not really what Marmot was saying in his six areas of policy priorities, all of which seem to be about tackling the upstream social determinants of health. There is a role for lifestyle and behaviour change in the mix, but to see that as a centrepiece of changing people's lifestyles flies in the face of the evidence. The evidence doesn't exist to back that up.[479]

275. In its approach to health improvement, the Government makes much of the idea (developed by the Nuffield Council on Bioethics) of a "ladder of intervention". This is based on the recognition that, in dealing with particular lifestyle-related public health issues, a range of policy options, on an escalating scale of intrusiveness, is available.[480] Healthy Lives, Healthy People states that:

Where the case for central action is justified, the Government will aim to use the least intrusive approach necessary to achieve the desired effect. We will in particular seek to use approaches that focus on enabling and guiding people's choices wherever possible.[481]

This favoured approach it refers to as "nudging people in the right direction rather than banning or significantly restricting their choices", using "the latest techniques of behavioural science".[482]

276. The Government is pursuing this approach in tackling a range of social issues (including ones relating to public health). A Behavioural Insights Team has been set up in the Cabinet Office to develop policy in this regard, using the "MINDSPACE" framework developed by the Institute for Government.[483] Dr David Halpern, Head of the Team, indicated that there was an evidence base for nudging, but it was generic, with little relating specifically to health:

There are two kinds of evidence […] There is a very wide evidence base from many areas […] partly, our role is to look at what works in another area and say, "Would it work in health?" If you move to health, more specifically, then you get to a smaller field of evidence […] [T]here is a fair amount of evidence. It is particularly strong when you look in other areas. When you apply it specifically to health, or any given issue, of course the field becomes smaller.

Consequently, work in this field was "very empirical", involving "trials" to "find out whether or not it works in the field".[484]

277. From other sources, we heard forthright scepticism about nudging as a public health intervention. Professor Hunter was "disturbed at the shift [by the Government] from being a nanny to being a nudger". While interventions that involved the Government "shoving people" (such as the ban on smoking in enclosed public places) were demonstrably effective, nudging, which was ill-defined ("a very flaky, slippery term"), was little supported by evidence. He referred to us the conclusions along these lines drawn by the Behaviour and Health Research Unit at Cambridge University, as recently reported in the British Medical Journal.[485] The recent report from the House of Lords Science and Technology Committee has since confirmed how thin the evidence base for nudging is, as well as the unevenness of evidence between different fields of behaviour change.[486]

278. We also heard that "the evidence base supports measures which stop or re-engineer potentially harmful modern marketing nudges", rather than trying to nudge in the opposite direction.[487] We were further told that "Upstream whole system measures", such as the smoking ban, could address factors that made "positive health behaviours and healthy choices more difficult" for many people, as well as protecting vulnerable groups whose choices are limited, such as children. Such measures had proven both effective and cost effective; and they had been shown to address health inequalities.[488] A drawback of nudging as an approach, on the other hand, was that it actually risked widening health inequalities, being most likely to influence those who already had the best health and least likely to influence those with the poorest health.[489]

279. Complementing the Government's adoption of the ladder of intervention and its preference for nudging is its intention that it "will aim to make voluntary approaches work before resorting to regulation".[490] Thus the intention is to ascend the rungs of the ladder step by step, advancing towards a more interventionist approach to each public health issue only when a less interventionist approach has been tried and has not succeeded. This is, of course, not simply an issue of public health policy. In a free society the burden of proof should always remain firmly on any advocate of regulation to show that restraint of freedom is necessary to secure a desirable social gain and that the restraint is in proportion to the gain.

280. A key vehicle for the Government's escalator approach is the Public Health Responsibility Deal, whereby:

the Government will aim to base these approaches on voluntary agreements with business and other partners, rather than resorting to regulation or top-down lectures […] if these partnership approaches fail to work, the Government will consider the case for 'moving up' the intervention ladder where necessary.[491]

The Deal, which was launched in March 2011, has core commitments and specific pledges (which include deadlines for implementation) covering: Alcohol; Food; Health at work; and Physical activity. (The tobacco industry was specifically excluded from the Deal, on the grounds that there is no safe level of consumption of tobacco - in contrast to the products of the food and alcohol industries.) All the pledges are underpinned by the threat of mandatory regulation by the Government if they are not abided by. They have been developed by five networks (made up of partners from industry, the voluntary sector and the public health field), with one each corresponding to the four commitments and groups of pledges, and a fifth relating specifically to Behaviour Change.

281. We heard that, just prior to the launch of the Deal, six leading health organisations (including the Royal College of Physicians) had refused to sign up to it. They had done so because of serious reservations about the proposed alcohol commitment ("We will foster a culture of responsible drinking, which will help people to drink within guidelines") and associated pledges. They were specifically concerned that:

there was inadequate recognition of the need to reduce alcohol-related harm;
the pledges were "not specific or measurable and do not state what would be evidence of success";
the pledges were those favoured by the alcohol industry, rather than health bodies;
the focus was on unevidenced interventions, while ignoring issues such as "availability or promotion of alcohol";
there was a lack of an evidence based "cross-departmental strategy" on alcohol; and
there was no indication of alternative actions if the pledges did not reduce alcohol-related harm.[492]

282. Professor Sir Ian Gilmore, Chair of the Alcohol Health Alliance (one of the bodies that refused to sign up to the Deal), explained that the alcohol industry's "paradigm" was that "alcohol is a normal product, but a few people misuse it. Therefore, we should target that small number of people and let everyone else get on with life and take personal responsibility". By contrast, the public health "paradigm" was that alcohol was no "ordinary commodity" but "a drug of dependence" that, while it should remain legal, needed to be controlled. Professor Gilmore argued that measures were needed to counter "the 24 hour, 7-7 exposure to alcohol marketing, alcohol sales and the cheap prices" which constituted an "alcogenic" environment, leading to widespread misuse of alcohol which caused significant harm to health within the population. The necessary measures included both a nudging approach and, at the same time, "firmer measures".[493] A key such measure was a statutory minimum price per unit for alcohol, which was supported by a sound evidence base.[494] Professor Gilmore stressed that he did not reject the idea of the Deal, nor was he suggesting that the specific issue of pricing could have been addressed through the Public Health Responsibility Deal.[495] The problem with the Deal was that it reflected the industry's approach and did not take account of that advocated by the public health representatives.

283. Mark Baird, for the alcohol company Diageo, replied that the Deal was about more than just nudging, citing as an example his company's pledge to fund the training of 10,000 midwives to enable them to pass on information about the dangers of drinking in pregnancy. He stressed that the Government had done something to tackle the issue of pricing, without going as far as introducing a minimum price per unit (the evidence base for the effectiveness of which he disputed); and that a cross-Government alcohol strategy was due later in the year.[496]

284. An important issue regarding the Deal is that of the actual mechanisms for determining that an approach has failed and it is time to move up a rung to a more interventionist one. The Minister told us:

If you look at what is going on in the Responsibility Deal, we are looking at how we monitor and evaluate and the timescale on that. I think we have to have yearly ones, although we would be looking at possibly interim ones as well in some areas. We have to see an impact quite soon, and I think all those involved—and it goes much wider than industry—are very aware of that. In a way, the regulatory route is a sword of Damocles.[497]

CONCLUSIONS AND RECOMMENDATIONS

285. We welcome the Government's acceptance of the Marmot Review principles of "proportionate universalism" and the "life course approach". However, we are unclear why the Government only endorsed five of the six policy objectives outlined by Marmot. Ministers have recognized the importance of the social determinants of health, and committed themselves to address health inequalities, so it is not obvious why Healthy Lives, Healthy People did not explicitly endorse the importance to public health of securing a healthy standard of living for all.

286. We regard the idea of the "ladder of intervention" as no more than a restatement of a principle that is fundamental to a free society.

287. Against this background we do not oppose the exploration of innovative techniques such as "nudging", where it can be shown, following proper evaluation, to be an effective way of delivering policy objectives. The Committee were, however, unconvinced that the new Responsibility Deal will be effective in resolving issues such as obesity and alcohol abuse and expect the Department of Health to set out clearly how progress will be monitored and tougher regulation applied if necessary. Partnership with commercial organisations has a place in health improvement. However, those with a financial interest must not be allowed to set the agenda for health improvement. The Government cannot avoid its responsibility for constantly reassessing the effectiveness of its policy in delivering its public health objectives.

469 Department of Health, Healthy Lives, Healthy People, November 2010, p 2 Back

470 Ev 168 Back

471 Department of Health, Healthy Lives, Healthy People, November 2010, p 2 Back

472 Ibid., para 2.31 Back

473 Fair Society, Healthy Lives: The Marmot Review - Executive Summary, February 2010, p 9 Back

474 Loc. cit. Back

475 Department of Health, Healthy Lives, Healthy People, November 2010, para 3.1 Back

476 Ibid., para 4.1 Back

477 Ibid., para 3.1 Back

478 Ev 154 Back

479 Q 36 Back

480 www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_122249 Back