Derek Wanless
Securing good health for the whole population [2004]
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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)