Promoting Health: Politics and Practice

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Edited by: Lee Adams, Mary Amos & James Munro

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    Dedication

    To Godfrey William French, my beloved father who died at 38 years. (Lee Adams)

    For Zeke, Jasmine and Toby my grandchildren, in the hope that they grow up in healthy communities. (Mary Amos)

    To Mum and Dad, with thanks. (James Munro)

    Foreword

    Whenever politicians stand back and ask what needs to be done to improve the nation's health, each incoming health minister is struck anew by a simple fact well known to all health practitioners: prevention is better and cheaper than cure. The building of sewers did more in history and does more now in the Third World than the building of high tech hospitals, with more health gain and better value for every pound spent. The most cursory glance at the statistics shows every new health minister that poverty is what drags down NHS outcome figures more than anything else. Excess infant deaths, lung cancer, obesity, heart disease, early death and high child accident rates are all the direct results of a poor and poorly educated population. Even Conservative health ministers admitted this was the undeniable truth.

    But once ensconced at the controls of the NHS, the daily rapacious demands of the existing health system sweep all before it. The press, patients and voters demand more beds, shorter waiting lists, more high tech operations and more expensive drugs: each may offer a proven health improvement for the patient, but a relatively small one for the money spent. Trying to wrench money out of the acute sector and spend it instead in the community has confounded ministers of all parties, over many years. After all, even now it remains almost impossible to stop very expensive NHS acute beds being ‘blocked’ by elderly patients for lack of finding them a care home place in the community, even though it is in everyone's interests to get the patient moved. So consider how much more difficult it is to move sizeable sums away from the acute sector and into community-oriented health promotion and disease prevention programmes.

    Labour's solution has been to try to do both. In recent high spending years it has been possible to pledge larger than ever sums to the NHS, and at the same time to direct more money towards alleviating poverty than any government since Attlee. Tony Blair has personally made two key pledges: to match average EU spending levels on health by 2006, and to abolish – yes, abolish – all child poverty by 2020. Both of these will be phenomenally difficult to achieve. At least he did not make Bevan's mistake at the founding of the NHS and assume that higher spending on poverty and health in the short run must lead to less demand eventually, since a healthier and better-off population should need less health care. The history of the past 50 years shows, alas, that the richer and healthier the population grows, the greater the demands become for acute health services too – a puzzling and irritating fact. Those in greatest need tend to be not only poor but also patient and passive, while the more affluent become less patient and more demanding on services.

    Within the health service itself, under Labour there has been virtually no serious shift of resources from treatment to prevention. Health Action Zones, designed to nurture prevention schemes in poor areas, are a very small add-on. The post of Public Health Minister has actually been demoted a rung since Tessa Jowell was first appointed. Instead, the real initiatives likely to produce a long-term health gain have come from the Treasury, where Chancellor Gordon Brown's best monument so far has been to direct most available funds towards the poorest. As a result of the Working Families Tax Credit, Child Tax Credit, much higher Child Benefit and a 70 per cent rise in Income Support for children of unemployed parents, the poorest two deciles were some 10 per cent better off by the 2001 election, while the top decile was just a shade worse off as a result of tax and benefit changes. The New Deal for Communities and other regeneration schemes, alongside programmes such as Sure Start and Early Excellence Centres, are attempting to head off disadvantage from the cradle.

    But at the same time the divide between richest and poorest still grew in Labour's first term, as it always does in boom times when incomes at the top soar away. Around the world the countries with the sharpest rich-poor gap are the ones with the worst health outcomes. There will come a time when the Labour government will have to admit that it matters – but they have not done so yet. Channelling available extra resources towards the poorest may simply not be enough to meet both the Prime Minister's tough targets, without redistribution from the top as well.

    In this wide-ranging book, its authors take a radical look at what public health and health promotion should mean in the broadest social and political context. Too often, narrow definitions of health promotion have resulted in nothing more than exhorting the poor not to smoke or eat fried Mars bars. Here, the real causes and effects of social exclusion are analysed, with new ideas of what social inclusion could and should mean for health and well-being. Everything from the importance of public services and the sense of ownership of those services, to protecting the ecosystem, impacts on public health. Many of the ideas here broadly run with the grain of much thinking among ministers but this should act as a sharp reminder that the Prime Minister's goals are unlikely to be met on the government's present political trajectory.

    Polly Toynbee The Guardian August 2001

    Notes on Contributors

    Lee Adams has worked in health promotion in the NHS for 26 years, currently as director of the Wakefield health action zone and visiting professor of public health at Sheffield Hallam University. She is also a member of the management boards of the Centre for Public Services and of Public Arts.

    Pete Alcock is professor of social policy and administration and head of the Department of Social Policy and Social Work at the University of Birmingham. He is the author of Social Policy in Britain and Understanding Poverty (both Palgrave) and a number of other books and articles in the social policy field.

    Mary Amos is co-ordinator of healthy city work at Portsmouth City Council. She worked in health education and promotion in the NHS for 15 years, and more recently directed the masters course in health promotion at Sheffield Hallam University.

    Marian Barnes is reader and director of social research in the Department of Social Policy and Social Work, University of Birmingham. She has a particular interest in collective action among users/survivors of mental health services, older people and other service users.

    Alan Beattie has been involved in health education and public health for 25 years, in academic and community settings, and is currently professor of health promotion at St Martin's College Lancaster.

    Simon Bullock works as a researcher for Friends of the Earth, on the links between environmental and social issues.

    Fiona Campbell is co-ordinator of the Democratic Health Network at the Local Government Information Unit and a member of Oxfam's governing body. She is interested in the role of local government in reducing health inequalities and in issues of democracy and accountability in health under globalization.

    Martin Caraher is reader in food and social policy in the Centre for Food Policy at Thames Valley University. He has research interests in the role of community groups in food policy, health promotion in prisons, and the development of public health capacity among professions allied to medicine.

    Frances Cunning is director of social and community development at Sheffield health authority.

    Maria Duggan is an independent research and policy analyst in public health, and was previously director of policy at the Association for Public Health. She has published widely on health inequalities.

    Judith Emanuel is a lecturer in education for primary health care at the University of Manchester, and currently runs a masters programme in Zambia.

    Jeff French is director of policy and planning at the Health Development Agency having worked in the health development field for over twenty years. He has a long-standing interest in the history of public health and health promotion.

    Mark Gamsu is Sheffield Healthy City co-ordinator. Previously working with the public sector tenants' movement in London, he has worked in Sheffield for 12 years, as a trainer, housing service manager and social services planner.

    Lorraine Gradwell is chief executive of Breakthrough UK, and a deputy chair of the Greater Manchester Coalition of Disabled People. She has a long history of involvement in the disabled peoples' movement, and worked for a spell as coordinator of ‘Healthy Manchester 2000’.

    Sue Greig is Health Improvement Manager for South East Sheffield Primary Care Trust (from November 2001 Senior Lecturer Public Health, Sheffield Hallam University). She is interested in practice which connects tackling health inequalities with sustainable development.

    Maddy Halliday is currently Director Scotland and UK development for the Mental Health Foundation and is also Scottish chair of the UK Public Health Association. She gained extensive experience of Health For All initiatives as coordinator of Glasgow Healthy City Partnership and Healthy Sheffield.

    Deborah Harkins is a public health specialist at Wigan and Bolton Health Authority.

    Sue Laughlin is currently Women's Health Coordinator with Greater Glasgow Health Board where she has responsibility for supporting the implementation of the Glasgow Women's Health Policy as it applies to the health service in Glasgow. She is also the co-ordinator of the Glasgow WHO Collaborating Centre for Women's Health.

    James Munro is a health services researcher at the Medical Care Research Unit, Sheffield University, and founder editor of Health Matters magazine, an independent quarterly on health care and public health policy issues.

    Neil Parry is project worker for Sheffield East End Quality Of Life Initiative interested in sustainable community development.

    James Petts worked in agriculture and the food industry for over ten years in areas of production, distribution, manufacturing and retail. Since joining Sustain, he has been working on a variety of projects in the areas of urban agriculture, food strategy, local food initiatives, and food poverty.

    Geof Rayner is currently chair of the UK Public Health Association and visiting fellow at the centre for food policy, Thames Valley University. He has previously worked for a variety of organizations, including the NHS, local authorities, universities in Britain and America, and WHO.

    Hilary Russell is deputy director of the European Institute for Urban Affairs at Liverpool John Moores University. She has extensive experience of evaluating partnership approaches to regeneration and has a special interest in community participation.

    Eurig Scandrett has worked in ecological research and adult and community education. He is currently head of community action at Friends of the Earth Scotland, and associate lecturer in environmental policy with the Open University.

    Charles Secrett is one of Britain's leading environmentalists. He is executive director of Friends of the Earth and has written extensively on a wide range of environmental issues.

    Martine Standish currently works in social and community development in public health at Sheffield health authority, and comes from a background in voluntary sector and social work.

    Melissa Stead is senior research officer at Sheffield Hallam University.

    Ruth Sutherland is director of the Community Development and Health Network for Northern Ireland. She has worked in and alongside health and social services in both statutory and voluntary/community sector roles for over twenty years.

    Charles Webster is a fellow of All Souls College, Oxford. He writes on the history of health care in the twentieth century.

    Dexter Whitfield is founder of the Centre for Public Services, which has worked for almost 30 years with public bodies, trade unions and community organizations to develop strategies for improving public services and the welfare state. His latest book is Public Services or Corporate Welfare: Rethinking the Nation State in the Global Economy (Pluto, 2001).

  • Conclusion

    What are the biggest threats to health we face? While much effort by health promoters and public health specialists is directed at trying to change lifestyles' or prevent particular diseases or their complications, there are bigger issues at stake. It is not just that health is ‘more than the absence of disease’, but that a prerequisite for both health and disease is our survival – and ensuring that will be one of the greatest challenges of the coming century. We believe that the major and persisting threats to health, in our ‘modern’ world, are human conflict, environmental degradation, increasing political and material inequality within and between nations, and the marketization or privatization of public services. In the face of such challenges, public health strategies which are disease- or behaviour-focused will no longer do the trick – if they ever did.

    The Health For All declaration has long noted that peace is a prerequisite for health. Despite so many images and reports over the past decade from the ‘trouble spots’ of the world – the Middle East, the Balkans, South East Asia, even Northern Ireland – and the involvement of our own governments in many of these conflicts, it still seems too easy to forget this fundamental point. The necessity for peace should at least remind us, had we forgotten, of the close relationship between politics and health.

    The survival of our fragile eco-system will also be a pressing concern for the century ahead. Human activity – much of it transnational corporate activity – is already causing global climate change. We can expect an increased frequency of severe weather events, rising sea levels, changed food growing conditions, spreading insect-borne diseases and mass migration of populations. In addition, the continuing economic concentration of such ‘industries’ as farming leads to immediate environmental costs through the increasing use of heavy freight transport to move goods long distances, increasing congestion and the demand for yet more roads. Everywhere that environmental damage and upheaval occur, whether the result of global forces or of local economic activity, the poorest will suffer first and most directly, while the better off try – but will ultimately fail – to avoid the impact. It is clear that environmental justice, alongside social justice, must now become a strong demand for public health promoters.

    The widening income inequality of the past two decades, especially in the UK and the USA, has rightly become a focus for research and policy debate by many concerned about public health. As has been noted throughout this book, increasing material inequality threatens not only the health of the poor, but the health of all, and is also associated with crime and social unrest within countries, and migration between them. Yet we are also seeing growing inequality in political power in the UK, with centralization of government control over public services, erosion of local democratic accountability, the ‘quangoization’ of the state, and the increasing influence of profit-making corporate interests in many areas of public life. Meanwhile, internationally the growth of corporate power means that many nations – even developed nations – find themselves trading with companies economically bigger and more powerful than they are.

    In such a global context, it is no surprise to find many governments, including the UK government, encouraging an increasing role for unaccountable, commercial organizations in both the provision and financing of public services. The health arguments not simply for public services such as health care, education and transport, but also for their public ownership, have been discussed earlier in this book. Once privatized, services – such as the rail network – are difficult to take back into public ownership, even in the presence of strong public support. Despite the lack of evidence of any benefit following from the market reforms of the health service in 1991, or of the supposed greater efficiency of private hospitals over their public counterparts, current policy supports a continued gradual shift of ownership of hospitals and primary care facilities to the private sector together with pressure to make greater use of for-profit providers in many areas of care, such as elective surgery and long-term care.

    If these are the most potent challenges to health, what are the greatest obstacles to those working, locally or nationally, for health improvement? The first is the generally unsupportive, or even hostile, policy climate for health. Too often, health is seen as a luxury which should only be considered after other, ‘more important’ objectives have been assured, such as attracting inward investment locally or increasing GDP nationally. Health is a ‘soft’, unmeasurable benefit which must come second to hard outcomes such as economic growth, turnover or service delivery. Assessing the health impact of social or economic regeneration schemes may be seen as an obstacle, rather than the whole point of the activity. Even within the health service, which is where the majority of public health promotion professionals work, the idea of public health is poorly understood, with doctors still thinking in terms of preventing infections and managers in terms of meeting coronary heart disease targets. The idea of improving health through democracy, participation, equality or accountability is barely grasped.

    One related issue is that of professional division and isolation. Different understandings of health and how to promote it have resulted in competing and sometimes mutually suspicious professional groups who expend much effort in taking up self-justificatory postures. At the same time, there are many other groups of workers – often in local authority settings – who understand that the work they do, for example in housing, town planning, or consumer protection, has health implications but they lack expertise or access to advice on integrating a health dimension into their work. A strong, coherent and broad-based body of professionals is required who are available to national, regional and local policymakers and service providers – and also to the communities they serve – and who can advise on the health implications of policy issues and help in taking practical action for health.

    Such thoughts raise questions about what public health promotion is, and could be. As neither policy-makers nor direct service providers, health promoters of all kinds tend to sit uncomfortably between these poles, nudging the machinery of the local state and local services in the direction of a more positive health impact. This position seems inherently ambiguous, lacking in formal power or authority but working, at best, through influence, advice and persuasion. It is both ‘in and against’ the state. The continuing, largely theoretical, debate about the independence of the annual reports of directors of public health demonstrates the political tensions which inevitably result from such a position. Although improving health will remain a political project with the tensions and conflicts that entails, the current marginal position of the public health agenda in the NHS and local authorities is by no means inevitable. It is possible to imagine organizations in which, for example, public health equity is taken seriously as a central task, and audited as rigorously and as regularly as the financial position. But for this to occur, the health of communities and populations would have to be high profile issues at national and local level, and of course this is currently not the case.

    The ambiguity in the nature of public health promotion is also apparent in the debate over the role of ‘evidence’ in improving health. Local people with concerns over health issues, for example, the dangers of waste dumping, industrial emissions or traffic volumes, often find themselves ignored because public authorities are reluctant to act in the absence of any evidence that health is being harmed. Similarly, health promoters face difficulties in justifying approaches such as community development without evidence of the ‘effectiveness’ of their methods. Often, public authorities will make the crude judgement that the lack of any evidence of effect is simply the same as evidence of a lack of effect. Even where evidence is available, it frequently proves to be the ‘wrong type’ – occupying a different evidential paradigm to that of the decision-maker – and is unable to support the argument either way. If promoting health is primarily a technical task, then of course robust, good quality evidence seems to be essential. However, many of the changes argued for in this book are primarily about the distribution of power and resources, rather than about particular technical interventions. To the extent that these are seen as simply the means to the end of better health, then it is reasonable to demand evidence to support them. But if, for example, local democracy, public accountability, a clean and pleasant environment or accessible services are seen as good in themselves, as worth having even without any consequent measurable health benefits, then the need for evidence is much less obvious.

    In this book, many authors have described the importance of local strategies and projects to promote health and reduce inequality in very practical ways. From anti-poverty projects to food co-operatives, and from benefits advice to community development projects, there is clearly much scope for action which can bring real improvements to the lives of local people and can also help to highlight local needs which would otherwise remain invisible. There remains a question, however, over how far such local action can ultimately overcome, rather than simply ameliorate, the major threats to health which we have discussed above.

    Can local action ever lead to structural changes which reduce threats to health? By themselves, local projects will produce only local effects, but shared more widely they may inspire others to do something similar – and many people doing similar things in their own localities is social change, albeit in a small way. National or international changes in policy require lobbying, either alone or, better, in alliances with others. Despite the very many people involved in health-related initiatives, a strong public health movement has not yet emerged (though the UK Public Health Association may yet fill this role). Although there are very many single issue campaigns which have a clear relevance to public health, for example, on food, air quality, child poverty, housing, transport, and so on, we have lacked a broad-based movement with a clear understanding of how health is enhanced or damaged and which is able to put forward a wide range of demands for specific policies which will improve health. Instead, the pressure for change has very often been left to individual consumers or consumerist lobby groups which have had some notable successes in particular areas, such as GM food retailing. Public health advocates would do well to study the tactics of consumer organizations, community activists and environmentalists, and learn from their successes.

    ‘Consumer consciousness’, however, will not help when it comes to securing policies to reduce widening material inequality, protect the ecosystem from further harm or ensure effective and accessible public services. To make progress on the big issues we need to promote a radical vision of a society far more equal, more sustainable and more healthy than our own – and existing public health and health promotion professionals cannot do this in isolation. Far broader alliances – particularly with environmentalists, anti-poverty workers, trade unionists and campaigners for open and accountable government – are needed to create and support such a vision. We hope that, in this book, we have demonstrated that it is both necessary, and possible, for public health promoters to move beyond their traditional ways of working and to engage with others to this end.

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