Summary:
7 ROLES AND
RESPONSIBILITIES
[Government
intervention guidelines:]
7.59 It is important
that any government intervention is well managed, to
protect against an inappropriate infringement of
liberty or unintended consequences. To assist in the
development of targeted interventions that increase
both health and welfare, the following principles are
suggested for adoption by government.
1. Interventions
should tackle public health objectives and the
causes of any decision-making failures as
directly as possible;
2. Interventions
should be evidence-based, though the lack of
conclusive evidence should not, where there is
serious risk to the nation’s health, block
action proportionate to that risk;
3. The total
costs of an intervention to the government and
society must be kept to a minimum and be less
than the expected benefits over the life of the
policy; interventions should be prioritised to
select those which represent best value;
4. The
distributional effects of any programme of
interventions should be acceptable (aligned with
societal equity objectives); and
5. The right of
the individual to choose their own lifestyle must
be balanced against any adverse impacts those
choices have on the quality of life of others.
[Individual
responsibility & rights:]
7.3 Individuals are,
and must remain, primarily responsible for decisions
about their and their children’s personal health
and lifestyle. Individuals must be free to make their
own choices about their own lifestyles.
7.4 If government or
other bodies do intervene, it is essential that
social welfare is improved and that personal freedoms
are respected.
7.43 Individuals are
primarily responsible for their own health and
lifestyles. As discussed in the analysis above, they
are generally best able to make these decisions as:
- they know more
about their personal preferences and
situation and generally are the best judge of
their own health and happiness; and
- any
intervention into an individual’s
lifestyle can raise legitimate questions of
personal freedom.
[Self-harm v harm to
others:]
Incomplete appraisal
of costs and benefits
7.16 The full costs
and benefits should include all those that affect the
individual, and those that the individual creates for
others by his or her action.
7.45 The forthcoming
consultation ahead of the White Paper is a good
opportunity to engage the population on the issue of
their own health and the balance between an
individual’s ‘right to choose’ and the
impact that individual behaviour has on the wellbeing
of others. In particular, the consultation should
consider the acceptability of different ways of
tackling smoking.
7.58 Beyond this,
government also has a responsibility to assess the
social and economic failures described above, to
judge whether and to what extent it should intervene
further, in order to improve social welfare and
population health, while balancing individual freedom
and individual responsibility for behaviours that
affect the health of others.
7.59 - 5. The right
of the individual to choose their own lifestyle must
be balanced against any adverse impacts those choices
have on the quality of life of others.
[Social attitudes
– discrimination, risk perception:]
7.25 Social context
can have a powerful influence on individuals’
decisions. A person’s tastes and attitudes
– which form the basis of how individuals value
the benefits and costs of an action – are
shaped, in part, by environment. The effect of the
family and social environment on children is
particularly strong. Peer approval (or disapproval)
can also have a profound effect.
7.26 Where decisions
are made in an environment where unhealthy lifestyles
are prevalent, it can be difficult for individuals to
choose healthy options. Their tastes and attitudes
will be shaped so that unhealthy choices will be seen
as preferable. Shifts away from the social norm carry
the additional costs of potential disapproval.
[Education not
legislation:]
7.29 Influencing
and, over time, changing social attitudes to health
and lifestyles is likely to be much more effective in
the long run than a punitive approach that does not
also aim for a change in attitude. Laws and
regulations not accompanied by public support incur
high enforcement costs, and could jeopardise the
development of a consensus for future public health
measures.
[Reduce
discrimination & social exclusion:]
7.33 …
interventions to encourage greater equity in society
also need to be considered.
8 GOVERNMENT LEVERS
[Policy conflict
& transparency:]
8.5 The policy
objectives must be considered, as these will affect
the selection of the type of lever used and the
degree to which government is prepared to intervene.
Political judgment must be used to resolve
conflicting objectives. These conflicts need to be
recognised and investigated, and any judgments should
be explicitly and transparently made.
8.7 Where regulation
is enacted, it is important that it is both efficient
and respects civil liberties.
[Information &
tax for healthier alternatives:]
8.13 In addition to
public health campaigns, health professionals have a
role in ensuring that citizens are more fully
informed about … alternative, less harmful,
products and lifestyle choices they could make.
8.17 Taxes should
therefore provide incentives for consumers either to
lower consumption or to switch to less damaging
products, thereby reducing demand for harmful goods
to the socially optimal level. Furthermore, the
suppliers of harmful products will have an incentive
to produce less damaging goods, either through
switching product mixes or investing in new
technology.
Details:
7 ROLES AND
RESPONSIBILITIES
Summary and
Implications
people need to be
supported to make better decisions about their own
health and welfare because there are widespread,
systematic barriers to decision making. People have
limited and often conflicting information on healthy
lifestyle choices, they differ in their ability to
understand and interpret the consequences of their
actions and there are not always mechanisms which
encourage individuals to take full account of the
wider social costs of their decisions (such as second
hand smoke).
Engrained
social attitudes are not always conducive to
individuals pursuing healthy lifestyles.
Consequently,
the following principles are suggested for adoption
by government:
1.
Interventions should tackle public health
objectives and the causes of any decision-making
failures as directly as possible;
2.
Interventions should be evidence-based, though
the lack of conclusive evidence should not, where
there is serious risk to the nation’s
health, block action proportionate to that risk;
3.
The total costs of an intervention to the
government and society must be kept to a minimum
and be less than the expected benefits over the
life of the policy: interventions should be
prioritised to select those which represent best
value;
4.
The distributional effects of any programme of
interventions should be acceptable; and
5.
The right of the individual to choose their own
lifestyle must be balanced against any adverse
impacts those choices have on the quality of life
of others.
7.2
Population health improvements will derive from
individual decisions to stop smoking, to eat more
healthily, to drink alcohol moderately, to take more
exercise, and to avoid unnecessary risks.
7.3
Individuals are, and must remain, primarily
responsible for decisions about their and their
children’s personal health and lifestyle.
Individuals must be free to make their own choices
about their own lifestyles.
...
people differ significantly in their preferences and
their situations in life. But this does not remove
the duties on government and many organisations in
society, including businesses, to help individuals
make better decisions about their health and welfare.
Significant failures in how decisions are made can
lead to individuals inadvertently making choices that
are bad for both themselves and society.
7.4
If government or other bodies do intervene, it is
essential that social welfare is improved and that
personal freedoms are respected.
7.5
….for
good decisions to be made both for the individual and
for society as a whole, it is important that:
- the
individual is fully informed about all
possible options, and their consequences;
- the
individual is forced to take all the
consequences of a decision (including those
that affect others) into account;
- the
social context within which individuals make
decisions is conducive to making good
choices; and
- opportunities
exist for individuals to engage fully in the
management of their health and general
welfare, regardless of their background and
circumstances.
Box
7.1 Risk
An
example of where risk is poorly understood is
addiction. People underestimate the level of
addictiveness of cigarettes and therefore the risk of
addiction. This is seen in young people who smoke
believing that they will be able to give up smoking
at any time without difficulty, which is rarely true.
Box 7.2 Time
preference
In health and health
care, costs and benefits often do not occur at the
same time. For example, the pain and risk of an
operation must be paid before a patient benefits from
improved health; conversely, smoking may be enjoyable
initially, but poor health, and a premature death, is
more likely to result eventually. As a result, many
academics analyse health as an investment and not a
consumption decision [3].
7.8 This section
examines the types of failures that afflict decisions
about preventative health and health care. These are:
information
failures;
incomplete
appraisal of costs and benefits;
social context
failures; and
health
inequalities.
7.9 For people to be
fully informed, they need access to the most accurate
information, the time and willingness to assimilate
it, and the ability to understand and weigh up the
risks involved with potentially harmful goods,
behaviours and activities.
7.13 various
analyses of human behaviour indicate that people have
a set of in-built rules that subconsciously guide
their choices, which would need to be accurate for
good health outcomes to result.
7.14 In summary,
through having insufficient information or receiving
conflicting messages, and through misunderstanding
information about health, individuals may not manage
effectively their own health and health care.
7.15 There is no
single easily accessible source of advice for
interested or confused individuals. It is recommended
that this be considered in the Department of
Health’s review of arm’s length bodies.
Incomplete
appraisal of costs and benefits
7.16
The full costs and benefits should include all those
that affect the individual, and those that the
individual creates for others by his or her action.
Externalities
7.17 Externalities
are costs or benefits associated with the consumption
of a good or service that accrue to society in
general but are not borne by the consumer. As the
costs or benefits are not borne by the individuals,
they are not automatically considered and consumption
levels can be higher or lower than is beneficial to
society as a whole. Annex E discusses the theory
underpinning externalities in more detail. For public
health, the effect of externalities is that
individuals may only take into account what happens
to them as a result of behaviours, and not think of
the wider social impact of their choices.
7.18 Externalities
can be either positive or negative. Positive
externalities exist when the actions of an individual
have benefits to society separate from the benefits
they experience directly. Examples include
vaccination programmes where there are benefits to
one person from another person being vaccinated (see
below).
7.19 Negative
externalities exist when the actions of an individual
have a negative impact on society, separately from
the negative impacts the person experiences
individually. Examples of negative externalities
include:
lower
productivity at work related to health problems
(when not reflected in employees own earnings);
the total
disease costs (including pain and discomfort and
the cost of early death) from smoking-related
diseases in passive smokers;
irritation or
distress to the public (such as smoky rooms or
alcohol-related anti-social behaviour or crime);
the total cost
of deaths and injuries arising from accidents or
crime induced by alcohol.
7.20
For example, when people smoke, they might consider
the price of cigarettes, and the risk of poor health,
as the main costs to them. But they will not
necessarily consider all the impacts of smoking, such
as the risks for passive smokers. The presence of
significant externalities has often provided the
justification for government intervention in other
fields (such as the environment).
[5]
The external costs of a passive smoker are greater
than those for the smoker, as the pain and the lost
productivity arising from the disease are included.
For the smoker, these costs still exist, but they are
internal. When deciding to smoke, the smoker would
normally take account of his or her personal costs,
including the increased risk of disease. However, the
smoker does not bear the personal costs of the
passive smoker; they are external costs. Appendix E
discusses the distinctions between internal and
external costs in more detail.
Capacity
7.24
Finally, some individuals will always need support to
take good decisions.
Those
suffering high levels of stress and older children
who are not yet fully responsible are also
vulnerable, and may engage in unhealthy behaviours
knowingly as coping mechanisms or due to a lack of
engagement with the health system and the broader
public health agenda, so facilitation is required to
increase the chances of individuals choosing
healthier behaviours.
Box
7.3 Intervention in Children’s Eating Behaviour
Issues
surrounding rights and responsibilities in health are
brought to the fore when discussing children. Either
in economic terms (as consumers) or in social terms
(as dependants), children are greatly affected by the
decisions of others. A key question is therefore
‘who is responsible for children’s
health?’
Social
context failures
Social
context
7.25
Social context can have a powerful influence on
individuals’ decisions. A person’s tastes
and attitudes – which form the basis of how
individuals value the benefits and costs of an action
– are shaped, in part, by environment. The
effect of the family and social environment on
children is particularly strong. Peer approval (or
disapproval) can also have a profound effect.
7.26
Where decisions are made in an environment where
unhealthy lifestyles are prevalent, it can be
difficult for individuals to choose healthy options.
Their tastes and attitudes will be shaped so that
unhealthy choices will be seen as preferable. Shifts
away from the social norm carry the additional costs
of potential disapproval.
Framing
healthy choices
7.27
On the other hand, where healthy lifestyles are more
common, it is much easier for individuals to choose
healthy options. Both their tastes and the social
norms will tend to encourage better choices.
Furthermore, if a healthy lifestyle is also seen as
enjoyable, individuals will not need to trade-off
their long-term health against their short-term
enjoyment.
7.28
Government action, for example in legislating or
providing information, can change widely held social
norms and values, which determine the nature of our
social welfare in public health. Education can
influence not just underlying values, but also,
indirectly, tastes in demand for goods and services.
For example, attitudes have changed significantly
following the introduction of laws prohibiting drink
driving, coupled with associated information
campaigns. Another illustration is milk, where
information provided about the benefits of drinking
lower-fat skimmed or semiskimmed milk instead of
whole fat milk coupled with no price differences,
slowly changed attitudes and behaviour over time (see
chart 7.1). This principle could be applied to areas
such as alcohol, where public information levels and
social attitudes currently differ from public health
goals and what the evidence base indicates is
healthy.
7.29
Influencing and, over time, changing social attitudes
to health and lifestyles is likely to be much more
effective in the long run than a punitive approach
that does not also aim for a change in attitude. Laws
and regulations not accompanied by public support
incur high enforcement costs, and could jeopardise
the development of a consensus for future public
health measures.
Addiction
7.30 Addiction
usually refers to the physiological condition where
consumption of a product becomes habitual and any
reduction in consumption causes adverse withdrawal
symptoms. It is often cited as an additional failure;
it could be argued that addicts are simply
irrational. However, research indicates that
addiction can be explained on a rational basis.
Individuals assess the enjoyment or benefit of
starting or continuing to use an addictive good
against the corresponding costs of not starting or
giving up, in the same way as for other goods and
services. Like other goods and services, costs and
benefits are often expressed in terms of social norms
– peer pressure, perhaps, versus parental
disapproval, in the case of a teenager deciding
whether or not to smoke.
7.31 For adults,
other dimensions of context such as solidarity or
social capital from a smoking community are an
additional incentive to unhealthy action. Whether or
not a ‘failure’ in a rational sense,
addiction has a profound effect on the
individual’s health (in some cases devastating),
and drives much of the external costs of alcohol and
drug abuse and smoking. Its influence therefore must
be recognised and the need for action must be taken
into account. Addiction obviously has implications
for policies aimed at curbing unhealthy lifestyles.
It is more difficult to wean someone from a harmful,
addictive product than from one that is merely
harmful.
Health inequalities
7.32
Interventions to tackle market failures could also
potentially have a positive contribution to play in
reducing health inequalities.
7.33
As our society places significant value on social
solidarity and supports actions to reduce inequity,
interventions to encourage greater equity in society
also need to be considered. Effectively, society has
decided that it is willing to sacrifice some of its
total welfare to improve the distribution of this
welfare amongst its individuals.
ROLES
IN SOCIETY
Individuals
7.43
Individuals are primarily responsible for their own
health and lifestyles. As discussed in the analysis
above, they are generally best able to make these
decisions as:
- they
know more about their personal preferences
and situation and generally are the best
judge of their own health and happiness; and
- any
intervention into an individual’s
lifestyle can raise legitimate questions of
personal freedom.
7.45
The forthcoming consultation ahead of the White Paper
is a good opportunity to engage the population on the
issue of their own health and the balance between an
individual’s ‘right to choose’ and the
impact that individual behaviour has on the wellbeing
of others. In particular, the consultation should
consider the acceptability of different ways of
tackling smoking.
PRIVATE
SECTOR
7.47
The private sector, among other responsibilities, has
a duty to provide clear, consistent and relevant
communication on issues of safety, the health impacts
of products and details of the contents of their
products.
THE
ROLE OF GOVERNMENT
7.57
However, there are clear areas where government could
contribute more to improving public health. In
particular, it should ensure that evidence is
collected and analysed on a timely basis and that
comprehensible information is provided to the public.
It should identify where the evidence base requires
improvement. It needs to research its success in
community awareness and in stimulating action, and
should promulgate successful examples of
interventions.
7.58
Beyond this, government also has a responsibility to
assess the social and economic failures described
above, to judge whether and to what extent it should
intervene further, in order to improve social welfare
and population health, while balancing individual
freedom and individual responsibility for behaviours
that affect the health of others.
Policy
principles
7.59
It is important that any government intervention is
well managed, to protect against an inappropriate
infringement of liberty or unintended consequences.
To assist in the development of targeted
interventions that increase both health and welfare,
the following principles are suggested for adoption
by government.
1.
Interventions should tackle public health
objectives and the causes of any decision-making
failures as directly as possible;
2.
Interventions should be evidence-based, though
the lack of conclusive evidence should not, where
there is serious risk to the nation’s
health, block action proportionate to that risk;
3.
The total costs of an intervention to the
government and society must be kept to a minimum
and be less than the expected benefits over the
life of the policy; interventions should be
prioritised to select those which represent best
value;
4.
The distributional effects of any programme of
interventions should be acceptable (aligned with
societal equity objectives); and
5.
The right of the individual to choose their own
lifestyle must be balanced against any adverse
impacts those choices have on the quality of life
of others.
7.60 It is also
important that these principles are supplemented by
good practice.
Three
recommendations for government are immediately
relevant and important:
- advice should
be made freely available in forms, languages,
media and locations easily accessible by all;
- periodic
communication about the state of public
health at national and local levels should be
available to encourage the involvement of
individuals and organisations; and
- feedback should
be sought regularly from the population
indicating the degree of awareness about
information and the acceptability of state
interventions.
8 GOVERNMENT LEVERS
HEALTH POLICY
OBJECTIVES
8.3 Within health
policy, there are a number of possible objectives to
increase social welfare, including to:
- increase the
health of society;
- reduce health
inequalities in society; and
- increase the
efficiency of the NHS.
8.5 The policy
objectives must be considered, as these will affect
the selection of the type of lever used and the
degree to which government is prepared to intervene.
Political judgment must be used to resolve
conflicting objectives. These conflicts need to be
recognised and investigated, and any judgments should
be explicitly and transparently made.
8.7 Policy must be
practically implemented without violating other
government objectives. There may be cases where there
are practical constraints to their use and the
regulatory approach may have to be used as an
alternative. Where regulation is enacted, it is
important that it is both efficient and respects
civil liberties.
8.10 The remainder
of this chapter discusses each of the main economic
levers available to government: taxation, subsidies
and service provision, providing information, and
regulation. All but regulation have the power of
choice in the hands of the consumer, but seek to help
them make better choices by correcting market
failure. It assesses how suitable these are in the
context of public health, and discusses the design
issues relevant to each, providing examples where
appropriate.
POLICY INSTRUMENTS
Information
8.13 In addition to
public health campaigns, health professionals have a
role in ensuring that citizens are more fully
informed about: the effects on their health of their
current lifestyles; of particular risks that they
face; and alternative, less harmful, products and
lifestyle choices they could make.
Taxes
8.16 Taxes can
influence people’s buying decisions, while still
allowing individuals to decide whether and how much
to consume. In particular, taxes are generally the
most efficient way of correcting negative
externalities in economic terms. By setting the tax
at the level of the externality, and raising the
prices of goods, individuals are forced to take into
account wider social costs in deciding whether and
how much to consume, given their available resources.
8.17 Taxes should
therefore provide incentives for consumers either to
lower consumption or to switch to less damaging
products, thereby reducing demand for harmful goods
to the socially optimal level [3]. Furthermore, the
suppliers of harmful products will have an incentive
to produce less damaging goods, either through
switching product mixes or investing in new
technology.
8.18 When setting
the rate of a tax, the level of the externality is
important (see box 8.1). Economic theory indicates
that the tax should be set at the value of the
externality (the underlying principles are discussed
in more detail in Annex E), as:
- consumers will
be fully charged for the costs to the rest of
society that they are causing; and
- their
consumption will fall to a level that causes
the greatest increase in the overall welfare
of society.
[3] A level of
consumption that is socially optimal is where the net
benefits lost by the consumer are greater than those
gained by the rest of society if reduced further. An
optimal level is often not zero.
8.20 Some goods have
negative externalities that extend beyond health
costs and must also be considered when setting a tax.
For example, not only is alcohol abuse linked to poor
health, but it can also have wider consequences
– with links to the social and personal costs of
crime, disorder and various anti-social behaviours.
8.22 Where greater
falls in consumption will result in further
improvement in health outcomes, it is often argued
that taxes should be set at a rate above the external
cost. However, while there can be more gains to
population health, the fall in the individual’s
utility is likely to be higher. From an economic
perspective, it could be argued that higher levels of
tax (over and above the cost of the externality)
would reduce the welfare of society. Consumers may
therefore claim that they are being forced to pay
more than the additional costs they cause.
8.24 If government
chooses to tax above the external cost, it should be
explicit about its intentions. It should set out
explicitly why and how higher tax rates will improve
public health, and overall social welfare in the long
run; and it should always consider the limits to
government intervention discussed below.
Box 8.2 Demand
inelasticity: the effect of taxes and subsidies
Taxes and subsidies
encourage changes in the behaviour of consumers by
changing the price of a good. By increasing the
price, taxes generally lead to a reduction in the
demand for a good, while subsidies reduce prices and
increase demand. One policy option when confronted
with an inelastic good is to develop strategies that
increase its elasticity. For example, cigarettes tend
to be inelastic as smokers are addicted to nicotine.
By providing a substitute in the form of nicotine
replacement therapy, smokers should be more likely to
quit, increasing the elasticity of cigarettes and the
effectiveness of taxing tobacco [7].
8.25 The Government
can decide that for some goods, there is no
appropriate level of consumption due to the harm that
is inflicted either to the individual or others. In
these cases, a tax policy is unlikely to be
effective, as it will not result in a zero level of
consumption, and it is usually more efficient to
regulate and ban a product.
[6] A corollary is
that taxing inelastic goods is more effective when
the objective is to raise revenue as opposed to
changing buying behaviour. When taxes are levied on
elastic goods, the reduction in demand reduces the
potential revenue that can be collected. Because the
demand for inelastic goods remains relatively
unchanged, revenue will be higher. It is therefore no
surprise that customs taxes are levied on goods with
inelastic demand – tobacco, alcohol and fuel.
[7] Another factor
reducing the effectiveness of taxing tobacco is the
tax avoidance either through legal cross-border
shopping or illegal smuggling. Action to reduce
smuggling can improve the effectiveness of tax in
reducing smoking as well as boosting the tax revenue
to the Government.
8.28 There is a wide
range of other issues to consider when designing a
tax system, including:
- Should the
consumption or the production of a good be
taxed?
- Should the
product or the unhealthy ingredient be taxed?
- How should the
tax be calculated – as a percentage of
sale price, a flat rate based on the volume
sold, or in some other way?
Regulation and
deregulation
8.34 While the
policy levers above rely on influencing an
individual’s behaviour through either providing
information or varying a good’s price,
regulation explicitly directs behaviour. Though this
approach is less flexible, as there is less freedom
for people to choose their level of consumption, it
can be used when:
- a tax, subsidy
or information policy mechanism cannot be
practically implemented or costs too much; or
- a specific
level of consumption is required – for
example, society has decided that no level of
consumption of a good is acceptable or the
costs of the externality are vast; or
- to reinforce
the provision of information or promote a
change in attitude, as discussed earlier.
8.35 Regulation can
be a more cost-effective means of correcting a market
failure. There is no transparent cost on the consumer
of a tax11, and the Government can avoid implementing
a new revenue collection scheme. However, there can
be hidden costs that must be identified when a
regulation is considered, such as the compliance
costs of industry [12] and the reduction in enjoyment
or utility for the consumer.
8.36 As well as
determining whether new regulation would benefit
society through a regulatory impact assessment, the
Government again needs to consider how such a
regulation will affect civil liberties (discussed in
more detail below). The use of voluntary codes does
allow this problem to be tempered, but these codes
may not go as far as required and can be difficult to
enforce.
8.37 In addition to
the immediate protection afforded from regulations,
they can also be used to lead to a change in taste
and attitudes. In a case such as the use of seat
belts (see box 8.6), regulation followed after a
period of encouragement to comply, which began to
shift attitudes. Regulation further promoted a change
in attitude, such that society no longer sees the
change as an imposition.
[11] At a society
level, a tax is not a cost as the revenue raised can
be recycled in the economy and either used by
Government to fund services or returned to society by
reducing other taxes, though this does not reduce its
negative impact on consumers. The cost at society
level is the cost of administration.
Box 8.6 UK Safety
belt legislation
Before UK safety
belt legislation was passed in 1983, only a minority
of drivers wore safety belts. Virtually immediately
afterwards, the vast majority complied and continue
to do so. The Department for Transport estimates that
the wearing of seat belts in the front seat saves
over 2,200 lives every year. By contrast, the take up
of rear seat belt wearing has been slower; but steady
progress has been made since 1996.
8.38 New laws or
regulation can have an impact on motivations for
behaviour change. The banning of smoking in public
places, for example across all of California, has
been linked to real falls in smoking. The forthcoming
legislation to make almost all public places and
workplaces entirely smoke free in Ireland will
provide further data. If successfully implemented,
smoking there in public areas, such as bars and
clubs, which importantly are also working
environments for many, will no longer be the social
norm. That in turn is likely to affect the wider
acceptability of smoking among young people. The
importance of social approval varies with different
behaviours. Changes in social norms can help break
addictions, as can pharmacological treatments.
Tackling both the social context and the
individual’s own behaviour (including addiction)
may therefore achieve much more than dealing with
these separately. Co-ordinated strategies are
generally more likely to be cost-effective and result
in better outcomes.
8.39 Regulations
used to lead, or reflect, social trends tend to be
much more successful than those that go against the
grain. People are much more likely to abide by such
restrictions, whereas laws are difficult to enforce
if there is no such widespread acceptance.
Furthermore, if attitudes move against a behaviour
such as drink-driving, disapproval from one’s
peers can often be a more powerful restraint than the
fear of being caught.
Voluntary Agreements
8.40 Partnership
approaches have developed in public health that
encourage individuals to take on more responsibility
for behavioural change. GP-patient contracts are an
example of this. They outline the respective
responsibilities of obese and overweight patients and
their doctors in achieving weight loss. An additional
benefit of such agreements is that they may help to
build a broader social consensus about healthy
lifestyles and behaviours.
LIMITS TO GOVERNMENT
INTERVENTION
8.42 Interventions
to improve public health have the potential to reduce
significantly personal freedoms. This is most clear
when government acts explicitly to prevent or
restrict individuals from behaving in certain ways,
or from consuming particular goods.
8.43 In general, if
the freedom to be curtailed or limited is a
significant one and valued highly by the individual,
the state would need strong reasons to impose its
will over the individual on public health grounds.
Usually, there should at least be a strong consensus,
preferably public but certainly professional, that
the public health measure is necessary to prevent
harm to others. Government can of course legitimately
intervene when one person’s freedom to act would
infringe others’ human rights – for
example, a person with a highly infectious disease
may need to be quarantined without consent. In other
cases, however, the mere fact of social or
professional consensus may not provide sufficient
justification for action.
8.44 Ideally,
individual consent provides the strongest foundation
for government action. However, in cases where it is
only the individual’s health that is at issue,
the question of intervention without consent poses
challenges. Nevertheless, there are examples where
such measures have been enacted and have become
accepted (see box 8.6 on safety belts). First,
individuals may already prefer not to be free to
choose, and may accept restrictions. Second, they may
come to accept the reasons behind the restrictions
and no longer see them as an imposition.
Nevertheless, it is important to recognise that
measures should be justifiable in the public interest
and to individuals as a reasonable restriction of
their freedom.
8.45 In some cases,
public attitudes may be initially hostile, but also
may reasonably be expected to change over time once a
health measure has been introduced. However, such a
change can never be guaranteed, and decisions should
be reviewed to ensure that a reasonable consensus has
developed.
Measures may need to
be modified or withdrawn as a consequence, and
government should be prepared to accept this as part
of the policy development process.
9 RECOMMENDATIONS
The welcome
announcement of the forthcoming consultation period
and of a Public Health White Paper suggests that the
conclusions and recommendations of this Review will
be addressed by government. The 21 main specific
recommendations are listed in this chapter.
It is also
recommended that all new public health policy should
be considered against a "checklist" before
implementation to assist in the development of
targeted interventions that increase both health and
welfare. The following principles are suggested for
adoption by government:
- Interventions
should tackle public health objectives and
the causes of any decision-making failures as
directly as possible;
- Interventions
should be evidence-based, though the lack of
conclusive evidence should not, where there
is serious risk to the nation’s health,
block action proportionate to that risk;
- The total costs
of an intervention to the Government and
society must be kept to a minimum and be less
than the expected benefits over the life of
the policy: interventions should be
prioritised to select those which represent
best value;
- The
distributional effects of any programme of
interventions should be acceptable; and
- The right of
the individual to choose their own lifestyle
must be balanced against any adverse impacts
those choices have on the quality of life of
others.
9.2 The Government
should set a clear national framework of objectives
for all the key risk factors such as smoking and
obesity.
9.5 The Government
should seek advice about what quantified objectives
it should set for progress in tackling all major
determinants of health and health inequalities. The
process should involve consultation, and quantified
objectives should be subdivided where appropriate to
cover important subgroups, particularly those key to
achieving objectives to reduce health inequalities.
It may be appropriate to set figures for three years
and seven years ahead and they should be reassessed
regularly. (Paragraph 4.3)
9.7 A consistent
framework (such as the methodology developed by NICE)
should be used to evaluate the cost-effectiveness of
interventions and initiatives across both health care
and public health. (Paragraphs 3.96 and 6.42)
9.9 As recommended
in Securing Our Future Health, future National
Service Frameworks (NSFs) should be fully costed to
incorporate detailed information about the
cost-effectiveness of interventions. Where changes in
lifestyle have a potential impact across more than
one NSF, these should be taken fully into account in
assessing cost-effectiveness. Comprehensive research
programmes should be established for future NSFs,
which enable them to be reviewed and continually
updated in the light of the emerging evidence.
(Paragraph 6.80)
9.10 Work being
carried out to refine productivity measures in health
services should ensure that productivity measures
move away from narrow definitions of output to
overall measures of health outcomes, and allow
comparisons of effectiveness of prevention and cure.
(Paragraph 1.29)
[1] Tax and the
Environment: Using Economic Instruments, HM Treasury,
2002
Review of arm’s
length bodies
9.11 The forthcoming
Department of Health review of arm’s length
bodies should ensure that the gaps in activity
identified here are filled. Responsibilities should
be assigned for:
- developing the
cost-effectiveness evidence base on public
health (Paragraph 5.44);
- researching the
practical effectiveness of current activities
and interpreting findings for future
implementation (Paragraph 5.44);
- the educational
role, previously played by the Health
Education Authority (HEA), at a time when
full engagement requires the public and the
health workforce to have more support. There
is no single easily accessible source of
advice for interested or confused individuals
(Paragraph 7.15);
- reassessing
periodically our national objectives for all
major determinants of health and health
inequalities (Paragraph 4.3); and
- the regulation
of nicotine and tobacco (Paragraph 4.26).
9.12 The efforts of
arm’s length bodies should be co-ordinated at a
local level (for example, the Health Development
Agency, Public Health Observatories and the Health
Protection Agency) and their relationships with PCTs
should be examined by the review. (Paragraph 5.11)
Research and
evaluation programmes
9.13 A commitment of
adequate resources for monitoring and feedback should
be an integral part of the planning of any national
programme of action to tackle the key determinants of
health. (Paragraph 3.97)
9.14 An experiment
should be established across primary care to assess
the benefits of additional resource in information
systems, in monitoring risk, and in services. It
would also produce evidence about the effectiveness
of information to assist personalised risk management
and disease prevalence in local populations. The
experiment should be directed towards areas of
inequality, given that access to services there is a
crucial issue, which must be resolved. (Paragraph
3.136)
9.15 The roles of
the various research bodies in relation to public
health, and how they best work together to identify
and address gaps in public health research, to ensure
the structured and coherent development of the public
health research requirements of England should be
defined as part of an overall public health research
strategy. The Chancellor recently announced that a
long-term plan for science funding would be a central
feature of the 2004 Spending Review2. Work on this
should consider public health research capacity, and
the links between academics and deliverers of public
health. (Paragraph 5.55)
Full Engagement
9.18 The forthcoming
consultation ahead of the White Paper is a good
opportunity to engage the population on the issue of
their own health and the balance between an
individual’s ‘right to choose’ and the
impact that individual behaviour has on the wellbeing
of others. In particular, the consultation should
consider the acceptability of different ways of
tackling smoking. (Paragraph 7.45)
9.21 Feedback should
be sought regularly from the population and important
subgroups to provide an indication of their degree of
awareness of issues and of the current best advice,
as well as the acceptability to them of possibly
controversial state interventions. (Paragraph 7.60)
Structure and Roles
9.22 CHAI should
develop a robust mechanism for the performance
assessment of the public health role of PCTs and
SHAs, drawing on lessons learned from the Regional
Public Health Indicators, the NatPact PCT competency
framework (see box 3.21) and the evaluation of
current practice within SHAs in relation to the
performance management of PCTs. (Paragraph 3.52)
9.23 A strategic
plan at national level should be produced to
implement a coordinated approach to developing the
public health workforce. It is important that the
competencies required to play new roles (for example,
smoking cessation officers) are identified. This
strategy should build on current activities but in
particular, the potential contribution of the
‘wider’ public health workforce must be
fully realised and the skills and capacity of the
Specialist and practitioner workforce to engage with
this wider public health community must be
strengthened. (Paragraph 3.125)