Reading the Public Heath England report ‘Evidence into Action” I sometimes get the feeling that Duncan Selbie is being held in a room by the Governments Public Health Minister and a bunch of doctors from the Health Protection Agency.
Every so often he manages to get out a passing reference to inequality or the social determinants of health – but for most of the time all that escapes the room is talk of diseases, clinical interventions and changing the behaviour of the irresponsible public.
The values are right.
“Evidence into Action” starts by recognising the importance of a new approach:
- that encourages everyone to gain more control of their health
- where prevention and early intervention are the norm
- where action on health inequalities is across all the wider determinants of health
- where assets of individuals families and communities are built on to support improved health
Unfortunately aside from a passing reference to “Due North” which is in effect the unofficial Public Health England Strategy (it has a very strong focus on the social determinants of health) the report rapidly defaults to a clinical view of priorities with the majority of the document focussing on 7 very traditional public health areas with predominantly technocratic solutions that fail to recognise the socio-economic circumstances that people live in.
These traditional areas are:
- Best Start in Life
- Anti-Microbial Resistance
The rot sets in on page 6 with a graph which; while making the case that health care makes only a small contribution to preventing premature death also implies that the biggest contribution to premature death is behaviour. This contrasts with information that PHE was sharing in 2012 (Spotlight on wellness) when Duncan Selbie was clear that the biggest factors that affects the health outcomes were socio-economic.
This is important because while the rhetoric is about tackling inequality and partnership with citizens the priorities and actions are predominantly all about medical conditions and interventions that fall into one of three categories – treatment, legislation and behaviour change. This approach ignores peoples socio-economic circumstances and reduces citizens to consumers of services or even worse those whose behaviour needs to be changed.
This very traditional approach to breaking people into chunks of conditions or behaviours and then trying to treat these has two effects. It takes away the focus on the whole person and it does not see the socioeconomic context within which people live their lives.
Failing to take a holistic approach allows the focus on mental health to slip through the net (again). Mental Health is mentioned 7 times but always within the context of something else – obesity, smoking, work etc. This lack of attention means that the impact that chronic mental health problems have on people’s ability to take control of their own lives is not acknowledged and as importantly the effect of socio-economic conditions on mental health – debt, impact of welfare reforms, stress of exploitative employment (zero hours etc) is not heard.
Tuberculosis is a disease of poverty
A further example of the effect of failing to recognise the impact of socio-economic context comes in the section on tuberculosis. In fairness the report notes that TB disproportionately affects the most deprived communities. However it then sets out a set of actions that focus on structural change and clinical interventions. Nothing about poverty, decline in access to and quantity of housing, the growth of low wages and impermanent employment economies!
What is to be done?
I have now seen two public health ministers in their addresses at conferences say directly to Duncan Selbie – ‘we want Public Health England to challenge government policy – be a thorn in our side’. I think it is clear from this document that this is the last thing the government wants. The Department of Health clearly treats Public Health England as one of its dominions and has no intention of granting it even the limited freedom that NHS England ‘enjoys’.
Luckily there are those in Public Health England who are willing to support arms length initiatives – such as Due North which better reflect local priorities and reality on the ground.
What do you think?