Office of Health Promotion a golden opportunity
This one is a short blog on some of the obvious opportunities for the Overhead Projector (as we now like to call it). This one is written by me without the help of an editor, so please excuse the shoddy spelling and grammar.
Short answer is that whilst it might not be what many in public health would have wanted, there are many opportunities and these need to be capitalised on and engineered because the opportunities wont land in anyone’s lap by magic.
What follows is a set of 20 thoughts in broad blocks
PH reform must focus on whole of PH not just H Protection
- H Improvement is muted in the overall narrative, it is all about health protection. At this time…. understandable…. But the number of deaths from tobacco alone will dwarf the number of deaths from covid, then play in booze, lack of sweat and too many pies.
Health promotion / improvement. Some have been sniffy about the name. What’s in a name.
- Whatever you want to call it…. does it matter? You will loose time, ground, friends and opportunities sweating about it. Im fairly well qualified in these matters and have no clue what distinguishes health improvement and health promotion.
- One of the “failings” (and I use that term very advisedly) was that most of their visible work on health improvement was often characterised as exhorting individuals to behave different. Thus in the public consciousness, health promotion became about “handing out leaflets” (I have stood outside Tesco handing out “eat more apples” leaflets). The more impactful stuff didn’t light the public imagination as much. This one has never been right since the birth of PHE.
Style and approach.
- Style that we might get – we might see an approach focused around Singapore style = Apps / Gamification / Individual level financial incentives (largely don’t work other than for short term behaviour shift – smoking in pregnancy for eg, rather than smoking cessation per se).
- I would push hard on an approach oriented around the commercial determinants of health agenda (ie influence of industry should be the focus rather than exhorting individuals to change their lifestyle choices). I am hearing plenty of people in positions of influence are fairly sold on this – surprisingly so.
- The obvious push back will come from BAES, HMT, poss DCMS (and the IEA), sometimes on ideological grounds, sometimes on commercial grounds sometimes on commercial grounds but dressed up in ideology. The lessons of all similar approaches – starting from tobacco control in NYC and Cal in the 80s and 90s was that industry actively support educating people and personal responsibility – one can only wonder if this is on account of the impact of this on sales (and prevalence) rather than impact on health.
- Thus the challenge will be pushing on addressing structural underlying issues / CDOH vs as opposed to individual level change (tho pushing against tide there)
- Working with industry vs govt regulation OF industry might become important. If you accept that perhaps only tobacco is inherently harmful, then the rest is about working WITH industry on a harm minimisation agenda. This is difficult though, and takes us into difficult territory.
Quickly narrative will shift to self regulation and the Responsibility Deal type of territory. The RD was / is about as useful as a chocolate fireguard (plenty of evidence on that) as industry will talk to “strong self regulation” but actually implement the least impactful (on profit) things it can get away with to stay the hand of state regulation. See what is happing in Gambling – seems a very strong influence of industry on all aspects of policy, thus relatively weak action. Difficult space this
- Currently the CMO is the lead. This CMO has been very positive on this, what if CMO changes. We don’t want to be wedded into a medical model if a new CMO is far more medical model than this one. Nothing inherently wrong with medical model, but cant be ONLY a medical model
Investment and budget
- Budget wise PHE *total budget c£1bn or £18 per person. Singapore Health Promotion budget =£42 per person.
We all want “more” public health, till it actually comes to the point of paying for it. Then we mostly choose more visible, tangible things.
Lessons from history
- Another of the “failings” is perceived “independence”. Some of the lessons from this Paul Cairney and esp some of the links – see the linked paper by John Boswell and others – blog are hugely insightful here
- Advantage of Office of HP as it is shaping up = close to politics, close to heart of govt, can do somethings more easily that you cant do it you are in the centre of govt. If you can get things to stick now, nobody is going to unravel it. it is probably important to test the boundaries. This is the single period in any of our careers that we will have MOST traction, so capitalise on it. There have been plenty of surprises of late – for example the recent announcement on junk food advertising – ‘please sir, can we have another helping of similar.
Areas of focus. Health in all policies, across whole of govt
- Do a few things rapidly and get them through, then people will coalesce around this. Look for quick wins where there is traction in lots of spaces and lots of win wins to other policy areas.
Active travel – need DfT and HMT engaged
Obesity – DCMS, DfE, HMT, other depts also, Air quality (DEFRA, DfT).
All agree on tobacco – question is of pace and how quickly to grind them down (again Defence will come from BAIS and HMT (and IEA).
Food – arguably not inherently villainous…. Thus get on side. See above tricky spaces re responsibility deal and self regulation.
Gambling. Emerging rapidly. Once in a generation opportunity to address something fairly early in lifecycle.
Poverty, debt, financial insecurity. Relatively fallow ground from a health in all policies perspective. Lots of obvious targets and involvement from nearly every govt dept. Classic and truly wicked issue.
Alcohol – go for PH as licencing objective, promoting low and no alc sector
On Health in All Policies per se
- Worth putting a bit more emphasis on the role of local gov and other gov depts. Landing the narrative that health improvement is something more than / beyond focus on individuals. Articulate the H Imp role of many other gov depts / big systems – education, welfare and benefits, housing, economic policy, transport, leisure
- Something about learning from where it has worked well. I have done a fair few blogs on that. SA and Cal both written great how to manuals. GLA currently got a review going. Paul Cairney’s most recent blog on health in all policies also great, I was particularly strug=ck by the 7 point playbook (lessons to avoid needing to relearn) and the notion of political vs technical exercise. Very helpful and thought provoking.
How will we know it is working
- Getting the cross govt governance right. What sort of gov policy needed across depts, oriented around outcomes. Health is one of those tricky things where the consequences of getting it wrong are weighted in esp DHSC, but also DWP and Local Govt social care, but the seeds of success sprawl across govt and well beyond govt.
- Learning from what was the Cross Govt pub h committee that was established then fizzled out within the ?early Blair govt was the level of senior leadership that attended. Started with SoS level then was delegated down and became civil servant.
I read that ministers lost interest on account of 1) being fickle … some of this stuff is quite intractable and slow burn stuff 2) didn’t want to be personally involved in difficult political stuff thus delegated.
- At local level, HWBBs have existed since 2013. The David Hunter et al review of Health and Well Being Boards is one place to start, Shared Intelligence have done, in my view, the best reviews of HWBBs for the LGA and how they have developed over the years, in particular look at the July 19 report
- Accountability. Maybe something about setting up a 2 way conversation with govt on accountability. A once a year exercise? With SoS from number of gov depts and Perm Sec…. what have YOU done in YOUR department to positively pivot more health out of policy areas YOU are responsible for. Obviously then there is the very tricky business of joined up approaches across lots of govt depts.
- We all want metrics. Metrics of system shift rather than the minute details of things within a system. Worth noting here that lots of this already exists in various spaces. Key challenge is one of accelerating forward trajectory and the pivot points. Might be good to explore metrics that can best articulate progress toward pivot points
So, 20 thoughts in themes on why the OHP is indeed a golden opportunity. It is important we work out how to develop it so that it can be optimally effective and get behind it.
As a jobbing DPH for me the overall opportunities the reforms present must end with:
- Strengthened local public health systems, including the role of the DPH
- Improve our ability to deliver scalable health protection response, including preparedness for future pandemics and emergencies
- Reduce health inequalities/level up
- Deliver cross-government policy and action on health and wellbeing
- Invest in prevention and public health
The opportunity and challenge is to make it better than what we are leaving behind.