No one can disagree that the Government failed to optimise its communication strategy for its health reforms to date. It has the chance to redeem itself by pursuing a strong and high profile strategy on public health. It should go further and make this an issue not just about the NHS, but about the British economy, another area where a convincing narrative is seemingly elusive.
The Coalition’s focus on public health, in the Health Lives, Healthy People White Paper is very welcome and the urgency for such a focus is clear.
One of the biggest threats to modern industrial societies is the relative unhealthiness of their populations. In short, longer life expectancies without a corresponding improvement in quality of life will dilute prosperity through ever increasing social security payments and reduced productivity. This is magnified by the evolution away from closely integrated families and communities; a trend that has required the state to take on more of a de facto duty of care for the vulnerable.
The White Paper highlights that an estimated £100billion is lost to the economy through poor health. Making even a start in reducing this impact would be an impressive growth strategy by itself.
The burden of poor health falls heavily on the least well off in society. As the Marmot Review concludes, poor health is a social justice issue and recent research by the King’s Fund has shown the devastating impact of clusters of unhealthy behaviour, something recent Governments have failed to adequately tackle. The inter-relation between poor health and low incomes shows that a more nuanced approach that moves beyond the last Government’s focus on welfare transfers is necessary to tackle the underlying causes of social inequality. This will require a wider cultural shift, a change in narrative from the Government and a new ethos of social responsibility from across the economy. It should be strongly asserted, for example, that strong economic growth doesn’t come from a trickle down approach, but should be bottom up.
These wider social and economic consequences of poor health should also not detract from the central problem; millions of people continue to suffer long term illness and poor health and all too often die prematurely.
In the narrower world of health policy, the recession has prompted a situation where healthcare spending remains stable, but demand for health services is expanding inexorably. The Nuffield Trust has painted a gloomy picture of future prospects for NHS funding. Without radical changes, the next ten years will require either unheard of improvements in productivity, unpalatable deep cuts to other public services or even more politically explosive moves to reduce the extent of free at the point of use health services. The only other viable alternative is to stifle and eventually reverse the spiralling level of demand for such services.
Such a multifaceted and long term problem presents a number of practical and institutional problems for public and private sectors. Even if there is the will to find a solution, it would involve not only the cooperation, but the integration of the healthcare, education and welfare systems, not to mention business and employment policy. A significant shift in policy might not show significant outcomes for many years, requiring an approach quite different from the short term target driven preoccupation of politics and the media.
A more intractable problem is that ultimately the success of any policy in this area relies on personal and family responsibility. As the White Paper has identified, Whitehall diktat and bureaucracy led nannying don’t work in improving individual behaviour yet without intervention of some sort, breaking the vicious circle of poor quality of life will be an uphill struggle. Anything from appeals to patriotic imperatives to a reinvigoration of community to improve social norms probably go beyond the realm of policy but should fit into a narrative for the future of British society that aspirant political leaders would do well to invest in.
Providing the infrastructure on which such a cultural shift can be based is something good policy can take forward. At both local and national level there will need to be an unprecedented level of integration, not just in structure, but also ethos, to overcome institutional inertia.
The key, though, will be local delivery. At present there is minimal scope for integrating these disparate services on long term strategic issues and indeed, their main concern is often to report to Whitehall departments rather than local communities. It will not simply be a case of devolving power and budgets to local communities, but giving them an appropriate framework to develop services that are really outcome focussed. The debate over what shape services take must focus on both the negatives and the positives; it must consider how to reduce poor health but also look at how to improve the quality of life overall in the context of enabling greater participation in society and increasing prosperity.
This should go far beyond the happiness agenda that has emerged and become the forefront of politicians striving for a fairer society. It should evolve into a narrative focused not predominantly on social mobility-the idea that people should be able to do better than their parents-but on social equality, the idea that everyone should have the opportunity to develop to their full potential. Progress over recent decades has meant that just about everyone has experienced an objective improvement in living conditions to their parents but this has all too often come at the price of massive inequality, which contributes heavily to the poor outcomes highlighted by the King’s Fund and other, and arguably hinders a more prosperous economy overall.
Government will have to approach the problem of an overburdened health system at some point. Doing so sooner will be better and will avoid some very unpalatable choices further down the line. That such an approach can be linked to a human capital narrative of reigniting the economy must surely make developing such an approach irresistible.
Tom Smith is Director of Liberal Insight