Dr Julia Segar was one of those out in force during Manchester Policy Week to hear Durham University’s Professor David Hunter and Manchester’s own Professor Steve Harrison ponder whether optimism or pessimism should prevail in the light of recent changes to the way public health is organised.
The recent healthcare reforms have seen public health move from the NHS to local government and Prof Hunter began his lecture with a brief history of the topic, tracking its movements in and out of local government.
During the period 1974 to 2013, public health was the responsibility of the NHS with a distinctly clinical and biomedical focus to the work. With the advent of New Labour in 1997 and subsequent publications of the Wanless Reports and the Marmot Review there was a growing recognition that health and wealth are inseparable.
Public Health is inextricably linked to social and political issues and Prof Hunter declared himself to be an optimist about the move of public health into local government.
‘Nudge’ or ‘shove’? This is a persistent tension in approaches to public health issues. The current concern around the health implications of lifestyle issues such as obesity, alcohol consumption and smoking has given rise to debates over the merits of ‘nudge’ policies or ‘shove’ policies. Nudge policies are designed to get individuals to change (e.g. placing fruit at eye level in cafeterias while placing unhealthy snacks on high shelves).
Shove policies, on the other hand, entail government action, such as the ban on smoking in public places. These approaches are clearly linked to the ideology and politics of the government of the day.
Critics of nudge for individual choice are sceptical about the role of big business, doubting, for instance, that fast food companies will make meaningful voluntary changes to the way they market their products. Critics of shove policies accuse governments of creating a nanny state which doesn’t trust its citizens with choices about personal lifestyle issues.
So while the smoking ban has undeniably been a success for public health, further big ‘shove’ policies such as plain packaging for cigarettes and minimum unit pricing on alcohol are clearly off the agenda for the current government.
Nevertheless Prof Hunter believes that the move of public health to local government has the potential to transform the way that it is conceived and delivered. He contended that local government is the natural home of public health and feels hopeful that a more social and less biomedical approach could ensue.
Prof Harrison countered with a more pessimistic view of the reforms, worrying that the move to local government may just result in diffusion of responsibility and of blame.
He pointed out that the smoking ban had only been possible because passive smokers are victims who are not smokers. Other attempts at big public health initiatives run into the prevailing ideas about personal responsibility.
Prof Harrison left us with the question about the role of the state in public health and the social and political obstacles that lie in the path of progress.