Political posturing on public health – Health Policy Today, 27th August 2008

Today’s headlines in advance of Andrew Lansley’s speech on obesity were along the lines of ‘Conservatives say there is no excuse for being fat’,  but this masks a deeper political point.

In a wide-ranging speech, Lansley sought to put clear blue water between Conservative and Labour approaches.  The problem is that the speech is being interpreted as a little too close to business interests.

QUESTIONING SPENDING ON INEQUALITIES

The speech began with questions about the way NHS money is distributed around different parts of the NHS.  Lansley accused the Government of skewing spending, and of targeting money at deprived areas - wrongly.

“If spending on healthcare alone determined health outcomes, Glasgow would be the healthiest place in Britain and Wokingham the least healthy”.

Lansley argues that the spending on public health in deprived areas is not "significantly greater" than in non-deprived areas.  The logic of his argument is that extra money is going on treating problems rather than alleviating them. In his view spending should be weighted towards age, closely related to chronic disease, rather than according to measures of deprivation.

Lansley says, “there is a fundamental flaw in this; it treats the differences in health outcomes as if they were all the result of differences in access to NHS services.”  Lansley notes that public health involves a wider remit than the national health service and that the trend to obesity is growing.

BEHAVIOURAL CHANGE IS THE CHALLENGE NOW

Lansley said he understood the problem as a phenomenon of the developed and developing work. “I understand that we have many influences which make it easier to become overweight: less physical work, greater access to motorised transport, abundant cheaper food - at least until last year - and more energy-dense foods. “  He suggested we had inherited the habits of people that were always hungry and we had to change.

“Behavioural change is the challenge now”, he said.  This won’t be achieved by forcing change upon people.  Individuals must instead be empowered to change.  

“If we are realistic about the impact of social norms and peer influence in affecting behaviour, we must also realise that we should not be 'nannying' people.”  This sentence could have been said by Alan Johnson.  In fact, Johnson said something very similar, at the beginning of August, in a speech to the Fabian Society.

Like Alan Johnson, Andrew Lansley is also interested in the potential of nudging rather than nannying: “providing information and example is empowering, lecturing people is not.”   The following words are less likely to have been said by a Labour politician.  Lansley praised, “supportive role models and positive social norms” as “motivating and empowering, not a drag”.  This was said in response to Johnson accusing Lansley, during his speech to the Fabians, as ‘hectoring people rather than helping them’

HOW WOULD THIS CONSERVATIVE PHILOSOPHY SHOW ITSELF IN GOVERNMENT?

Andrew Lansley would take public health out of the Department of Health.  He would create “a Secretary of State for Public Health, leading a Department no longer seeking to interfere in the day-to-day management of the NHS, with an enhanced Chief Medical Officer's Department, leading a public health drive across Government”.

This independence would be reflected in local areas.  Directors of Public Health “should not be within the PCT, but have a clear remit of their own.”  They should not be “the Medical Director of the PCT, but an independent advisor who uses evidence-based methods when deciding how to manage public health budgets, leading population-based commissioning strategies and informing local priorities.”

JOINED UP GOVERNMENT POLICY?

Lansley’s speech touched on a range of areas.  It will not only be for the NHS to support healthy behaviour.

Promoting the family will improve individual behaviour, he also suggested.  “Responsibility, like many things in life, is best learned young. Responsibility like most things in life is best learned in your family. So we need a strategy which recognises not only that we must provide children with more and better opportunities, information and direction, but also that we must seek both to strengthen families and their potential for positive influence, and the self-esteem of young people themselves. “

“I believe young people are not just blank canvasses on which colours are daubed by TV or the internet, and where the loudest voices win, but that they are capable of making positive decisions. To do so however, young people need the confidence and self-esteem that comes with a secure background, loving parents, a caring family, good friends, a close community and an ambitious and supportive school.”

Lansley said these things cannot be done by the Department of Health, alone.  “We will work closely with Michael Gove and his team on children, schools and families, and Jeremy Hunt and Hugh Robertson on sport and improving physical activity, to ensure that the opportunities for living a healthier lifestyle are there for teenagers, as we seek to motivate them to make positive choices.”

POLITICAL CAPITAL

Ann Keen, the Labour MP and Government Health minister, said: "Once again the Tories offer lots of warm words but with very little policy substance. The Tories are using individual responsibility as an excuse for their lack of effective policies in this area.

“Everyone believes that individual responsibility matters. But the Tories are using individual responsibility as an excuse for their lack of effective policies in this area.”

Is she right?

At a time when the two parties have quite similar policies on how to reform the health service, today’s speech offered an opportunity to set out a different political approach.  If anything, the speech seemed designed to set out an alternative philosophy.

Lansley’s speech tried to tap into a changing social mindset – with the balance shifting from collective to individual perspectives.  His speech trumpeted classic Conservative themes of individual responsibility and families.

The analysis also reflects a trend noted in the recent Social Attitudes Survey by Peter Taylor-Gooby, a professor of social policy at Kent University.  He finds that although levels of concern about poverty are staying roughly level, there is a declining view that it is the business of government to step into deal with problems.

The Tory stance contrasts with recent ministerial warnings of impending legislation if more is not done by retailers, alcohol producers and pubs to tackle binge drinking.

The part of the speech that has so far attracted most attention from political analysts is the prominent role given to business.

A KEY ROLE FOR THE ROLE OF THE BUSINESS COMMUNITY

A lot of the actions that were outlined by Andrew Lansley involve close liaison with business.

“Earlier this year, the Conservative Party set out the concept of a 'Responsibility Deal' - of how, instead of the constant and escalating resort to legislation and regulation and public sector intervention, we should instead enter into a non-bureaucratic partnership with the business community, together to tackle key challenges in society.  Today, I propose that our second 'Responsibility Deal' should be on public health.”

What did this mean?

“I have invited Dave Lewis, Chairman of Unilever UK, to chair a working group of business representatives, voluntary groups and experts. Together, we will invite views on these proposals and hammer out the detail of the Deal.”

Lansley promised ‘industry-led reformulation initiatives and reduction of portion sizes’ as well as ‘proportionate regulation on advertising and positive campaigns from the industry and government to promote better diets”.  Furthermore, there will be “a combined business and Government social responsibility campaign to promote healthy living, including the use of role models, community engagement and positive peer pressure”.

Like the Conservatives, Unilever oppose the government led traffic-lights scheme and instead support the “guideline daily amounts” scheme.  They Conservatives backed European proposals for mandatory GDA labelling.  

As the FT says, the opposition party will risk accusations of caving in to corporate influence . As the Daily Mail pointed out, Unilever are behind Findus ready meals and Walls ice cream.

The strongest attack came from the Evening Standard website today.

‘Mr Lansley has announced that Unilver boss Dave Lewis is to chair a new Tory working group on the problem. Unilever is - alongside Kraft and others - the biggest critic of the traffic light system, claiming that it would "demonise" many of its brands. The Tories are also to oppose a ban on junk food ads, while Baroness Buscombe (chief executive of the Advertising Association) is also on their new group.’

‘This all sounds a bit like the old Tory party of vested interests, rather than the new one. It was none other than D Cameron who told his party conference "we must stand up to big business when it's in the interests of Britain". From chocolate oranges to too-sexy children's clothes, the leader has made social responsibility his watchword.’

REACTIONS TO THE SPEECH

Following his speech, facing questions about the business connections in their plan, Andrew Lansley was on TV defending his links to Unilever.  "Who better to work with than one of Britain’s leading food manufacturers?... Business is not trying to make people fat - business is trying sell good food products”.

The BMA also attacked the plan this afternoon.  Dr Peter Maguire deputy chair of the BMA’s Board of Science said: "It is disappointing that the Conservatives' plan to abandon the traffic light food labelling system. It is a simple system that allows people to make healthier choices by reducing foods from their shopping baskets that are predominantly red. It is unrealistic to expect people to weigh up the differences in percentages between products using the daily guideline amounts system during their weekly shop."

The Conservative’s plan to seize the initiative today may just have backfired.