Your blogger went to an interesting discussion this week about the future of public health policy in England. At stake was not the policies themselves but rather the means by which those policies might be decided.
Public health in this context means things like preventing cancer, heart disease and accidents, as opposed to drugs and surgical interventions that might be needed after cancer, heart disease or an accident have actually happened. The change in the decision-making lies in the transfer of powers from the health service to local government from April next year, which means that elected members of local authorities are going to have a role in deciding what should be done. Decisions that were previously in the hands of technical specialists are going to involve politicians, too.
And that’s important, because public health itself is increasingly political.
Its 19th century origins were wholly medical, as it was discovered what causes cholera and malaria and how to prevent them. But these days, the issues are smoking and obesity, which arise not from some microscopic infectious agent before which the public is otherwise helpless, but as a result of decisions that members of the public have themselves taken.
It is one thing to decide what’s the best way to fight malaria, when nobody actually wants malaria. It’s another thing to decide the best way to fight smoking, when people who smoke might actually want to keep doing so. These are not technical questions but political ones. (It is outside the scope of this website to discuss how smoking might be reduced, but firmly within the scope to point out the controversies that come with it.)
So, at this simple level it’s surely a good thing that public health decisions might become more politically accountable.
But a word of warning. Public health is like many other healthcare issues which require a disproportionate amount resources devoted to only a few people – think what it costs to keep someone in intensive care after an accident, for example – but those few people in this case might not be understood simply to be innocent victims.
An example cited at the meeting was the provision of sexual health screening for on-street sex workers. Such people are at greater risk of contracting sexually transmitted diseases, and if they are infected, they are a great risk of spreading such diseases further. But such people may well not be popular. For a local authority to provide such screening services might attract sex workers from neighbouring areas, whereas the local community might prefer the traffic to go the other way.
The chart here shows what people thought were the most important issues for local public health policy to deal with: the fewer people affected, the lower the priority, regardless of the seriousness of the need.
More democracy in this field requires a more mature attitude towards the needs of minorities and the causes of ill-health than is often on display in the popular media, if public health outcomes are not going to take sharp turn for the worse. But coming back to issues like obesity and smoking, dealing with them requires a more mature attitude anyway. As long as the perception is that these are things that are done to people, rather than things that people are doing to themselves, then ill-health arising from diets and lifestyles will continue to increase. The rising tide of these problems will be reversed when those who are affected feel able to take the decisions that will reverse them.
Power – and the feeling of power – needs to be put not only into the hands of elected local government but into the hands of the people themselves.