Five hits, five misses: public and population health and the main party manifestos

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Reading manifestos is a double-edged pleasure for a policy wonk, hoping to find evidence of ‘their stuff’ while fearing its absence. The lot of a public health policy wonk is a particularly trying one because we need to look more widely, beyond the NHS (and sometimes social care) sections, to get a sense of how policies might have an impact on the population’s health.

Having done that, here are my five hits and five misses in the three main parties’ tomes.

  • Both Labour and the Liberal Democrats have committed to putting the public health grant on a firmer footing, with the Liberal Democrats ‘reversing the cuts’ and Labour committing to ‘more than £1billion’ (as we and The Health Foundation have called for), in contrast the Conservatives are silent. This would be money well spent in terms of improving health outcomes. Labour also say they will reverse the broader cuts to local government funding, with the Liberal Democrats promising a ‘real increase’: a boost to the many services and functions – such as housing, economic development and transport – that are vital for population health and have suffered cuts over the austerity years.
  • Both Labour and the Liberal Democrats commit to a ‘health in all policies’ approach, actioned in Labour’s case through a ‘Future Generations Act’ similar to that in Wales, and in the Liberal Democrats’ through a national wellbeing strategy modelled on New Zealand’s approach. If implemented, these could be the manifesto commitments that have the biggest effect on population health in the long term.
  • All the parties recognise that ‘a public health approach’ (addressing and preventing the causes of poor outcomes, as well as treating and tackling the consequences) is critical to success on some major complex social issues that have an impact on health. For example, all three parties commit to some action on gambling; Labour will take a broader approach across areas including drugs and alcohol, and the Liberal Democrats commit to action on violence and drug legalisation.
  • On the wider determinants of health, two areas stand out: housing and climate change. On housing, the Conservatives see this primarily, though not solely, through the lens of supporting home ownership, while the other parties take a broader perspective including committing to greater social housing, reform of the private rented sector and addressing fuel poverty. Climate change looms large across all three manifestos including commitments to move towards a net zero-carbon economy, more electric vehicles and significant investment in the ‘green economy’.
  • And now a personal favourite. Tucked away in the Liberal Democrats’ manifesto is a commitment to mandatory implementation of NICE public health recommendations, levelling the playing field between public health and drug treatment and other health technologies. Frankly, it’s bizarre that this is not already the case, given most of the many public health interventions assessed by NICE turn out to be net cost saving or highly cost effective.

So, five good commitments for public and population health, although there could, of course, have been more. But here, in my view, are five missed opportunities.

  • None of the parties commits to an explicit cross-government health inequalities policy, which we and others have called for. Without this, it will be harder to ensure that any proposals will work for those in our society with the worst health outcomes. As a second best, any ‘health in all policies’ approach will need to have an explicit health inequalities aspect so that it narrows rather than widens health inequalities gaps.
  • All three manifestos talk about more local control over decisions or devolution within England. The Conservatives offer few details but commit to publishing a new White Paper on devolution in England. The Liberal Democrats are more explicit and will give local areas more powers to take control over services, such as housing and skills, and develop new income sources and revenue-raising powers. Labour’s main approach is through regional investment and re-establishing government offices for the regions. The missed opportunity here is that none of the manifestos explain or develop the case for how these moves could support the coordination of policies across sectors for health. In fact, in England, there is a quiet revolution on this happening, led most obviously in Greater Manchester; the manifestos could have been much clearer in how their policies would support and shape this work.
  • While the manifestos compete on how much parties will spend on the NHS (no bad thing in itself), they lack imagination in recognising that this money could effectively be used three times over for improving health: directly through treatment; more broadly for prevention; and – an area where there is huge potential – how the NHS spends, employs and works with others as a key institution in local areas, in other words, the role of the NHS as an economic agent. While the NHS long term plan and some innovative NHS bodies have started to recognise this, the manifestos have missed a trick in not developing ideas further.
  • There is too little on tobacco use in the manifestos. Labour say they will introduce a new tobacco control plan and the Liberal Democrats will introduce a levy on tobacco companies. There is also silence on e-cigarettes, either for or against from all three parties. When tobacco still kills close to 80,000 people every year in England and the government’s Tobacco Control Plan argues that it is responsible for around half of health inequalities in life expectancy, the manifestos should have said more.
  • Finally, the Conservative manifesto is the least detailed and, therefore, comes across as the weakest of the three. Charitably, this might be explained by the fact that the prevention ‘Green Paper’ is under review following consultation. The manifesto commits to ‘a long-term strategy to empower people with lifestyle related conditions to live healthier lives’ – a narrow form of wording that doesn’t recognise the wider factors, beyond the role of individuals themselves, that influence health. The manifesto was an opportunity to lay out a convincing and compelling plan for meeting the government’s own commitment of five years more healthy-life expectancy for the population by 2035 while narrowing inequalities in health. In doing that, it could have drawn on the work already undertaken for the ‘Green Paper’ and related consultation responses. It is to be hoped that this work remains behind the scenes, and that the lack of content is a result of the wider lack of detail across the manifesto and not a lack of ideas or commitment.

If, for some strange reason, the above hasn’t whetted your appetite for reading the manifestos cover to cover, then do the second best thing and take a look at our handy guide to the main commitment on health and care across the three main manifestos or listen to our latest podcast where we discuss the main elements and differences between the parties in more detail.

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