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Andrew Lansley: No excuses, no nannying

In a speech to Reform, Andrew Lansley said:

"Thank-you for being here this morning.

Thank-you, especially, to Reform for arranging this opportunity. Even if Reform and I don't always see eye-to-eye on the future funding of healthcare, I have a great respect for the quality of the research and thinking they are doing on healthcare.

It is helping us to think hard about how we can secure the future of our healthcare.

That is my starting point today.

Although the health debate seems obsessively to be about the National Health Service, the principal determinants of health lie outside the NHS.

Poverty, housing, environment, employment, family and heredity are all potentially more significant determinants of health than the local capacity of the NHS.

So it is surprising, to say the least, that the principal policy response of the Government in recent years to continuing disparities in health outcomes has been to skew the distribution of NHS resources.

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

Resource allocation within the NHS (the review of which should have been published last year and wasn't; and then in July, but wasn't) has put measures of deprivation (income support and attendance allowance) up alongside age as a determinant of health need, leading to corresponding greater resources for poorer areas and less for areas that are less deprived and more elderly. This is despite age being a more significant determinant of relative burden of disease. 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.

Such a strategy would at least have more sense if the way resources were deployed within the NHS, led, in deprived areas, to additional spending on primary and secondary prevention of disease.

I asked the House of Commons library to examine the (2006-7) data for spending on the Healthy Individuals Programme. They report that spending by spend by Spearhead PCTs is not statistically significantly greater than non-Spearhead PCTs. And our investment in public health is only two-thirds of the OECD average proportion of public health spending.

We therefore have a huge postcode lottery in access to NHS services, but we don't have the resources needed behind public health measures in the most deprived areas.

In an NHS of rising resources, public health services have been a Cinderella service, first to be cut when deficits hit, the victim of every reorganisation and constantly pushed to the back of priority lists. The number of public health staff is not a sufficient indicator of public health service standards, but it is significant that they have decreased by 5 per cent since 1997.

So, my purpose today is to describe how we intend to improve the nation's health, and in doing so, also to improve the health of the poorest, fastest.

It is something of a cliché now to say that public health, has become an issue less of public health and more of personal lifestyle. The big essential health gains have been made - clean water, Clean Air Acts, slum clearance. It is argued that we are confronting less the diseases of poverty and more the diseases of affluence.

But is the cliché right?

Environmental health is still important. Banning smoking in public places is undoubtedly the most significant public health measure of the last decade and it is very much an issue of environment, not just lifestyle.

And how far is obesity, for example, a disease of affluence - hardly, given that the rich are often thinner than the poor. It is perhaps more accurate to say that obesity is a disease of development. Within developed and developing countries, culture and class often have quite distinct impacts and old patterns of poor health re-emerge in new forms. The Foresight Report considered it possible that, by 2050, 15 per cent of women aged 20-60 in Social Class I would be obese but over 60 per cent of women in Social Class V.

So, some of the 'old' public health issues persist, in the sense that deprivation and poor health outcomes are still linked. But the issues of lifestyle factors goes wider and creates new threats.

Nor have some of the traditional challenges for public health services abated as we might have expected.

A medical student thirty years ago would have been taught about infectious diseases, but in the context of the progressive eradication and control of such diseases.

But nature has an unnerving way of fighting back. Who thirty years ago would have predicted the new pandemic of HIV/AIDs? Or the emergence of SARs? Or the re-emergence of TB in developed countries? Or the spread of West Nile virus? Or the scale of the threat should the H5N1 virus become capable of human to human transmission?

I have spent over four years continuously arguing for us to be world leaders in preparation for a pandemic influenza. Britain is now among the better prepared nations but still needs to do more, including further research and development work into new vaccine technologies.

Seen over the longer-term, our public health record has been remarkable. Average life-expectancy has risen by around three to four months for each year, for decades. Infant mortality has fallen to five per 1,000 live births.

We should not, however, underestimate two key problems we must now confront.

First, persistent inequalities. The gap between richest and poorest in terms of life expectancy and infant mortality has grown in the last decade. Like the reduction of poverty, we must judge our policies by how well they reach the poorest in society, not just the average.

Secondly, we have to ensure that we put life in our years, not just years on our life.

Extended life expectancy, if it also means increased morbidity in old age, spells economic and social catastrophe. Yet that is exactly the risk. It is a commonplace assertion that the next generation may, because of obesity and a sedentary lifestyle, be the first for over a century to have a shorter life expectancy than their parents.

Is this right?

The Government's Actuary Department currently predicts that life expectancy will rise over the next 50 years by around six years for men and five years for women.

Rising obesity, on average, would reduce this increase in average life expectancy across the population by only about a year.

The real risk, in addition to the major loss of life expectancy for the severely obese, is that people live longer with long-term ill health. The nature of this problem was rather well illustrated just last week in research published by the Peninsula Medical School.

It showed that although overweight people in younger and middle age run a risk of premature mortality, among older people only the severely obese have a higher risk of dying, but all older people who are overweight are at significantly increased risk of developing problems with mobility and carrying out everyday tasks.

If this happens, the £7 billion current cost of overweight and obesity will rise dramatically. (Foresight say 6-fold by 2050)

Which prompts one observation about the way in which we respond to the challenge of rising obesity.

It is not just an issue about children today and in the future. Everyone who will be 65 or more in 2050 is already over the age of 23. If we are going to defuse the time-bomb of obesity-related ill-health, we must change the behaviour of adults today, as well as our children.

Behavioural change is the challenge now.

In a speech he made two years ago, Tony Blair accepted the proposition that 'public health' had now really become about healthy living; that the traditional paternalistic state of the past must be replaced by an enabling state, one which encompasses the individual, creating partnerships, providing information, enabling choice, supporting decisions.

I agree with him. He was right to say it, but Labour in Government has not even delivered on the modest proposals he set out then.

He called it the 'Small Change, Big Difference' campaign. But nothing changed and there was no difference, a £13,000 PR campaign, a book of case-studies and that was it. Look at the "Small Change, Big Difference" website - last entry May 2007. In a Government obsessed with top-down targets and initiatives, why has public health dropped off the agenda?

The targets for reducing health inequalities and reducing childhood obesity exist, but will be missed. The initiatives drift. Why? Because this is a Government even more obsessed with the short-term when what public health requires is a commitment to action now, and real follow-through even if the benefits accrue over the longer-term.

In our consultation on public health last year, we set out the structural and funding issues, to give us the necessary long-term framework. We consulted on three key proposals:

One: 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.

Two: Separate public health budgets. They would be allocated separately from NHS service budgets. They would be geared also to evidence of local participation and support, not least through Local Area Agreements, and they would be geared to supporting interventions which work, assessed through research and evaluation.

We want an evidence-based policy, and funding which supports success.

Based on this, we will ensure that public health resources are available to support long-term action, even increasing as a proportion of overall healthcare budgets, and not siphoned off.

Three: Directors of Public Health, jointly appointed by PCTs and Local Authorities, should not be within the PCT, but have a clear remit of their own. Not 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.

I am pleased to confirm that our consultation secured overwhelming support for these proposals.

There are two respects in which respondents particularly wanted us to go further.

Locally, the importance of a Local Authority's input to the public health agenda needs to be further enhanced.

'Knowing your public' and 'joining-up local initiatives' were regarded as essential and neither were easily achieved in a highly medicalised model of public health interventions. So we will require that the public health activity directly respond to Local Authorities and local communities in the Local Area Agreement, and that the Director reports not only to the CMO, but also to a local board drawn from the PCT and Local Authority.

Second, there is a strong call for an independent national commission capable of investigating, taking evidence on public health issues and making recommendations.

It was argued by some that it should be an independent Parliamentary body and I will ask my colleagues in this context to consider this.

This will strengthen the public health infrastructure greatly. But the key issues are less about structure and more about how to achieve results.

The Foresight Report on Obesity illustrated very well the complexity of factors which contribute to what they describe as an 'obesogenic' environment.

Much as I have the greatest respect for the quality of the research in Foresight, I think the "messaging" was wrong.

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.

This is in the context of human beings whose biology has not evolved from our forebears, who were usually hungry.

So, we have plenty of stimuli to respond to food; few which act to constrain us; and very little scarcity of food to hold us back.

I understand why this is characterised by Foresight as: "the current prevalence of obesity in the UK populations is primarily caused by people's latent biological susceptibility interacting with a changing environment that includes more sedentary lifestyles and increased dietary abundance".

But this, while no doubt accurate as a description, is counter-productive as a message.

Tell people that biology and the environment causes obesity and they are offered the one thing we have to avoid: an excuse.

As it is, people who see more overweight people around them may themselves be more likely to gain weight.[1] Young people who think many of their friends binge-drink are more likely to do so themselves. Girls who think their peers engage in early sex are more likely to do so themselves. Peer pressure and social norms are powerful influences on behaviour. They are also classic excuses for risky and damaging behaviour.

That doesn't mean I want to ignore the environmental factors. On the contrary, we have to deal with them, actively and urgently. But I do feel, strongly, that as we do so, we should also focus on how people can and should take responsibility for their lifestyle and health.

We can and want to remove the excuses by providing an improved environment but it is no substitute for discipline and self-esteem. People need to know that the buck stops with them. They can't shuffle off the responsibility.

This sounds hard but it need not be.

Britain has many people who are dissatisfied with their weight and with their lack of physical activity. They worry about their health and the future. They want it to be different.

'No excuses' is empowering. It means it really is down to each one of us - and we can make it happen.

Nor is this simply about telling people what to do.

Tackling the environment, should not be a licence to lecture people, telling them that they have no excuse not to exercise, or to eat their fruit and vegetables.

Nannying - at least among adults - is likely to be counter-productive.

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. Providing information and example is empowering, lecturing people is not. Supportive rôle models and positive social norms is motivating and empowering, not a drag.

So, there should be excuses, and no nannying.

But is it all different for children? Surely we don't expect them to be responsible in the same way as adults, nor do we think that all 'nannying' is inappropriate. It is different for children, but let us be clear. If we change the environment for children - better school food, more school sport, more community sport, more information and awareness of the risks associated with poor diet, smoking, drugs and unprotected and early sex - do we automatically change behaviour?

No. I think it is clear that changing these factors will not be enough. I am convinced that we have to empower young people as well as adults.

Even with children we need more of a 'Mary Poppins' than a 'Miss Trunchbull'.

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.

Every child needs as many of these as we can possibly give them. You can get on without one or two of these, but it's very hard to do so without any.

Public policy can't create all of these - but we can help - and we will.

From a better start, with more support for families bringing baby home for the first time, through encouraging marriage, to parental choice and incentives for more good schools, support for voluntary and faith-based groups building community cohesion, through to citizens' community service, in all these and other ways we will provide leadership and support.

For teenagers, I believe we also have to think specifically how we can deploy leadership, rôle models and social marketing approaches, not just to warn teenagers about the harm they can do through risky behaviour, but the positive empowerment they can achieve by choosing healthy living.

One key message we learnt from bringing stakeholders on all sides of the obesity debate together at our 'Lazytown' summit, with 'Sportacus' (aka Magnus Scheving in February), was that we must not constantly talk about tackling obesity and warning people about the negative consequences of obesity - instead we must be positive - positive about the fun and benefits to be had from healthy living.

Where 'Lazytown' is going with the pre-teens, we need also to go with the teenagers. This is not something a Department of Public Health can do 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.

We will look at the best practice already underway in local areas, including the 'Make Space for Health' pilot schemes, but we will ensure that there is local ownership and delivery, drawing on national initiatives, whether on families and schools, in enhanced lottery funding (following our National Lottery Independence Bill), for community sport or our nationally-funded information and social marketing campaigns.

As part of the national framework, too, we need to ensure that the corporate responsibility of business, and the ability of businesses to contribute to the promotion of healthier living, is fully and successfully engaged.

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. 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.

I am today making a number of policy proposals. Responding to these, I hope business will see the way forward clearly in partnership with the next Conservative Government. I even hope it will stimulate action now by Labour in their remaining months.

Either way, I know that business wants and needs a lead and a clear way forward.

Let me tell you, in brief, what my proposals for the Responsibility Deal are:

1. We will support EU proposals for a mandatory GDA-based front of pack food labelling.

We will not add UK regulation to this. Additional traffic-light or colour-coded information will be voluntary. Conservatives in Government will give backing for public awareness of GDAs and how they can be used to build a better diet and support enhanced nutritional information and awareness. We will focus on delivering an improved diet, not a narrow focus based on a fear of 'junk foods'. Government promotion and FSA promotion of 'traffic light' labelling will stop. For four years, I have argued for a GDA-based system. The Government's obsession with a traffic light system has blocked progress. Why on earth have consumers no single system to help them? Why can they see taxpayer-funded traffic light adverts on the side of a bus, and then not find them in their shop? Why push a system that only tells people a fraction of what they need to know?

Let me quickly list the other key proposals:

2. Industry-led reformulation initiatives and reduction of portion sizes.

3. Proportionate regulation on advertising and positive campaigns from the industry and government to promote better diets.

4. A combined business and Government social responsibility campaign to promote healthy living, including the use of rôle models, community engagement and positive peer pressure.

5. A new focus on public health through Local Area Agreements, incorporating direct local business involvement in campaigns to promote exercise, community sport and healthy lifestyles.

6. A responsible drinking campaign matched by community action projects to address drug abuse, STIs and alcohol abuse, using a proportion of drinks industry advertising budgets and supported by the Government.

7. Community Alcohol Partnerships, based on the successful example from St. Neots in Cambridgeshire.

8. Clear labelling on alcoholic drinks and a push for the standardisation of labelling where necessary at a European level.

9. Incentives and a local structure, through business organisations, for SMEs to improve the health of their employees, working with business organisations, "NHS Plus" and the Fitness Industry Association.

10. An 'Investor in Health' accreditation scheme

alongside 'Investors in People'.

These are ten substantial proposals: combining action by Government and responses by business. They will create real opportunities for substantial local action as well, involving local government.

Let me sum up.

We now have clear plans for building a stronger public health infrastructure. A cross-Government focus on public health will be reflected in the responsibilities of the Department of Public Health and with separate public health funding to give focus and delivery.

Recognising that some traditional public health tasks and threats remain, we will also lead a new public health strategy responding to new public health challenges caused by lifestyle and behaviour changes.

We will take action to ensure people have the opportunities, information and incentives towards healthy living. No excuses.

We will empower people and local communities, and work in partnership with business, Local Government, communities and families to deliver on a healthy living agenda - in schools, workplaces, local clubs and through NHS services. Legislation will be a last resort. Leadership, information, incentives and empowerment will be characteristic of our approach - no nannying.

We will work with all age groups, but particularly recognise how vital it is that our young people have are empowered with the self-esteem to make confident decisions for themselves and are empowered to make their own decisions.

They may be the right or they may be the wrong decisions. But if we get it right, as parents and as a society, increasingly they will make the right choices.

We all have a choice.

We can make it a real choice.

We can lead healthier lives.

And a healthier society will be the result."

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