What did the Labour government promise?
The Labour government's White Paper on public health,
Saving Lives: Our healthier nation, set far-reaching disease-based targets, and promised a new cross-government approach to health, housing, employment and the environment. It emphasised preventative measures, as well improving health care for those who were already ill.
The 2000 NHS Plan saw the government turn its attention to a major reform of the NHS, following a period of what was felt by many to be sustained underinvestment. But public health came back on the agenda with the Treasury's two reports on the future of the NHS by Derek Wanless, which concluded that better public health measures could improve population health and play a significant role in determining the future demand for – and costs of – health care.
In November 2004, the government's White Paper,
Choosing Health: Making healthier choices easier, focused much more on how individuals might be better motivated to improve their health. The main levers were envisaged as: informed choice for individuals through better information; personalised support to make healthier choices easier, especially for people in deprived areas; and government-led partnerships with stakeholders, including industry.
What structures did the government put in place?
Critics continue to argue that public health is still too focused on the NHS. But a range of structural changes have been introduced that run in a different direction.
At a national level, for the first time, the responsibility for improving health has become a cross-cutting theme across government policy, rather than the sole responsibility of the Department of Health. The government appointed a Minister for Public Health, and required that assessments of the impact of wider policies on health ('health impact assessments') would become part of the regulatory framework.
Regional directors of public health now sit in regional government offices, and are required to liaise with other departments on employment, transport, environment and urban regeneration issues.
The government also developed the 'corporate citizenship' role of the NHS – new social responsibilities for the impact of how it recruits staff, procures goods and services, and creates new buildings.
At a local level, primary care trusts (PCTs) now have directors of public health, some of whom are joint appointments with local authorities. PCTs and local authorities in deprived areas are expected to develop Local Strategic Partnerships and in future, Local Area Agreements, which set local priorities and targets to improve health and the physical and social environment.
To improve public health intelligence, the government set up nine Public Health Observatories, and a Health Development Agency (recently incorporated into the National Institute of Clinical Excellence).
What targets did it set?
The government pledged to improve population health by increasing the length of people's lives, and years spent free from illness, improving the health of the worst off and narrowing the health gap.
By 2010, it aims to have reduced death rates from cancer by a fifth, from coronary heart disease and stroke by two fifths, from accidents by a fifth, and from suicide by a fifth. In 2004, it added a target to halt the rise in obesity among children by 2010.
What impacts have government policies had on public health?
On average, life expectancy and healthy life expectancy both increased between 1997 and 2001(see below).
Expectancy at birth of years lived in good or fairly good general health: 1981–1999
But these trends cannot be attributed solely to government policy, as life expectancy for all groups have been increasing steadily over a period of time, regardless of which party has been in government.
Moreover, these extra years are not necessarily lived in good health, as healthy life expectancy has increased differently in different social groups, and people in social class 1 can now expect to live longer than those in social class 5.
Deaths from cancer and accidents have halved since the 1970s, and death rates from cancer and suicides have also fallen.
However, the government has been slow to act on obesity. From the late 1980s onwards, obesity rates rose from just under 10 per cent of the population in the mid-1970s to nearly 25 per cent in 2000.
What challenges exist in terms of people's lifestyles?
The government has emphasised preventative measures that reduce risk factors for cancer and coronary heart disease (such as reducing smoking and drinking, and improving diet and exercise). It has set targets for reducing smoking and fitness, but not alcohol consumption.
On smoking, it aimed to reduce the number of people in the population smoking from 26 to 21 per or less by 2010. It pledged to increase tax on cigarettes and ban advertising, pledges that it has kept.
But it decided against a complete ban on smoking in public places, for which it has been heavily criticised. The proportion of the population smoking has remained fairly stable for the past decade, though the trend is an overall decline.
The Government allocated £214 million for smoking cessation services until 2006, and claims that over 200,000 people have stopped smoking as a result of its programme. However, 'quit' figures refer to people who say they are not smoking after four weeks, and the evidence suggests that only a minority go on to give up permanently.
It also pledged to promote sensible drinking through education and awareness programmes; treatment for people with alcohol dependency; and work with the alcohol industry to develop a voluntary social responsibility charter. It has been criticised for focusing on individuals' drinking habits, rather than measures of proven effectiveness such as increasing taxes on alcohol, or restricting licensing hours and banning advertising.
Average alcohol consumption is still below government limits but significant segments of the population drink above these limits. Women, 16 to 24 year olds, and teenagers are all now drinking more. Alcohol-related illnesses and deaths are also on the increase, with alcohol-related injuries and disease costing the NHS about £1.7 billion a year.
What about people’s diets?
The government promised to educate people about healthier diets, improve access to healthy food for people in deprived areas, and develop nutritional standards for school meals. In the 2000 NHS Plan, it promised a national school fruit scheme by 2004. Its 'five-a-day' campaign aims to boost awareness of the importance of consuming enough fruit and vegetables, but assessments to date suggest this has increased awareness, not consumption.
By November 2004, the School Fruit and Vegetable Scheme reached two million four to six year olds, who received a piece of fresh fruit or vegetable every day. Evaluations suggest that a quarter of children and their families ate more fruit at home after their school joined the scheme, and parental awareness of diet had increased.
Under public pressure, the government has also allocated more money to school meals, but has not agreed to new nutritional standards.
What about exercise?
The government is encouraging people to increase their fitness levels, especially by cycling, walking or sports activities.
It inherited a national target to quadruple the number of cycling journeys by 2012, but instead decided to give local authorities responsibility for setting their own targets. Local authorities claim to have created 6,000 kilometres of new cycle routes between 2001 and 2004. Despite this, statistics show that fewer people now cycle or take part in physical activity, excluding walking.
The Department for Culture, Media and Sport has been asked to increase take-up of sporting activities by 5–16 year olds from 25 per cent in 2002, to 75 per cent 2006, largely through a minimum of two hours a week on PE and school sport. 62 per cent of children now meet this target.
GPs also now offer exercise on prescription for people with health problems, ranging from obesity to depression that can be alleviated by exercise.
What does the future hold?
It is too early to tell whether the government's renewed focus public health will translate into widespread lifestyle changes and consequent better health, but some fear that its focus on personal choice may deflect attention from importance of wider socio-economic and environmental factors in determining population health.
