This tremendous breadth also shows why it can be so hard to get a grip on public health, and particularly inequalities. Not only are inequalities pervasive, they are varied in their causes – both ultimate and proximate – and there is no single, correct way to measure, assess, or reduce them. All of this can lead to an understandable frustration at the lack of progress, a casting around for scapegoats, and a political schism on what to do to address them.
But in my view these blogs, and the reactions to them, can point us in the right direction. In particular, we need to realise that inequalities affects us all (as the Marmot Review showed), as does Alastair Campbell in his blog on mental health, we can all suffer, regardless of our position in society. But we also know that many mental health problems are closely associated with the tough economic times that we are in. Governments should therefore accept they have real responsibilities to shelter and support our health and wellbeing as they design their economic and public policies. That's why I – like many others – see the scrapping of the sub-Committee on Public Health as the wrong decision. Getting health into all policies – and taking account of the effects – will be more difficult without it.
But David Halpern's blog on the potential for nudge shows how government departments and agencies have the power to massively improve our health and wellbeing by also encouraging small and easy changes – if only they would take the time to think differently. Nudge clearly has the potential to improve inequalities in health, but so have many other well-meaning policies that have just ended up exacerbating them. It would be great to see an analysis of the impact of David Halpern's unit in the areas they are working on with the Department of Health and beyond.
And, as Gabriel Scally argues, it is not only governments who should be responsible for thinking differently – acting on the big and the small levers, and supporting us as individuals. The NHS is one of the largest employers in the world with massive economic power; its workforce, if mobilised, can bring about huge amounts of change. That's why it’s good to be reminded of, and recognise, the Institute for Health Equity’s upcoming work with the medical royal colleges, BMA and many others to deepen and develop the NHS's role in tackling the wider determinants of health.
I think we can bring about most change first and foremost as principled pragmatists: taking, testing and evaluating ideas from wherever they come – be they from the right or the left – and from structural and regulatory solutions through to nudging. The existing science can to some extent help us sift and sort the things that are most likely to work in particular situations – but we need to become much better at generating, testing and sharing good, practice-based evidence. We also need to be braver about stopping what doesn’t work and spreading what does quickly and systematically. This would be a good place for Public Health England to begin when it takes up its critical role in April.