The government is in announcement mode. There is a need for rebuilding organisational infrastructure, and an opportunity for reconfiguration.
Two new initiatives have caught my eye this week- both could be helpful additions, in principle, but both seem to display the fatal weakness of this government for simple, neat solutions to complexity.
The office for health promotion was announced last week- it largely replaces the functions of public health England other than pandemic readiness (that is, pretty much everything they were doing a year ago), and promises a cross-governmental approach to improving public health. No-one in the field can realistically object so far, nor to the statement in the press release that only about 20% of health outcomes are due to the quality of healthcare received.
This latter fact is so important that we need to pause to appreciate it. We spend billions of pounds, and, as importantly, our blood and sweat, making the NHS the best service it can be, but we make, at best, a marginal difference to the health of the nation. This is as important as it is, in some senses, dispiriting.
The problem starts when the press release cites what the remaining 80% consists in: it’s our old friend lifestyle! They specifically cite diet, smoking and exercise, which is, at best, an incomplete and selective list. Firstly, it omits important determinants like poverty, poor housing, the obesogenic environment, racial disparity and unsafe working conditions. The reason is simple and quintessentially Tory: these are choices, and all people need to do is choose better for health to be revolutionised.
How do we change the way people choose? The press release is understandably short on detail, so all we have to go on is…. well, everything the Tories have ever done. Apps to encourage, patronising public health messaging and ‘awareness training’ for staff. The problem with this approach is that it doesn’t work, because it fundamentally misunderstands the nature of health choices and the determinants of health.
How does it help people to urge them to eat 5 vegetables a day when they are cooking for 5 on a single hob, and can’t afford the money or time to cook like that? To exercise regularly when they don;t feel safe outside their home? To stop smoking when they don’t see the point of deferring present pleasure for future benefit? This is the whole problem with the idea of Health Promotion- it is predicated on the idea that all people need is a bit more information and motivation, and POW! It doesn’t work like that- the problems we have in public health are so much more complex that that.
One of the best talks I’ve ever seen about childhood obesity ended with a Q&A during which the professor who was speaking said that weight reduction wasn’t, couldn’t be, the point- the point was to provide an environment to promote health, then to see what happened. This is so far from the data-driven, simplistic model that is currently being pushed, but is so much closer to the truth.
When I started in my current role at the Royal College of Paediatrics and Child Health, my title was Officer for Health Promotion. I changed it to health improvement to reflect the fact that we have moved on from urging and informing people, to looking at system approaches. I only hope the government can follow suit.
But another development suggests that they are still wedded to the simple. Speaking of which, Gavin Williamson announced (well, strictly, re-announced), a number of ‘behaviour hubs’ to spread ‘best practice’ about dealing with behaviour. From what I can see these hubs are selected on no better basis that the schools who best match the government’s Victorian notions of children ‘seen and not heard’, who have successfully rid themselves of anyone too troublesome or troubled, and who can therefore spread this zero tolerance approach so that no child with difficulties controlling emotions or behaviour will be tolerated. It’s an approach that works from the school’s perspective, but is profoundly exclusive of those with additional needs.
It is also contrary the the DfE’s own guidance on mental health and behaviour in schools, but increasingly I feel like they publish these things as a figleaf for what they actually want to get on with. In this case, once again, it’s an approach to a complex problem (and make no mistake, behaviour problems in childhood are complex) to a simple matter of wrong choices. But while adults get a cheery app, troubled kids get detention and exclusion in every sense.
It is of course an inherent characteristic of right-wing populist government to prefer simple solutions, but that doesn’t mean we don’t have a duty to try… and try…. and try.
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