The challenges of achieving change in population health

Professor Sir Liam Donaldson was Chief Medical Officer for England and the UK’s Chief Medical Adviser from 1998–2010. He is also one of the contributors to A healthier life for all: the case for cross-government action, an essay collection published jointly by The All-Party Parliamentary Health Group and the Health Foundation this month.

We spoke to Sir Liam about the big challenges facing our health service today and how approaches to public health have changed over time.

How have priorities for health changed since the NHS was first set up?

The founders of the NHS had inherited the legacy of a period of great improvement in the country’s health, particularly the conquest of many vaccine-preventable diseases as well as those associated with poor sanitation, like cholera. They assumed that the major disease problems were conquered and therefore the NHS could act as more of a health maintenance service. Nobody had the foresight to realise that the so called ‘diseases of civilisation’ would come into play, problems like cancer, heart disease, diabetes, obesity, mental health problems, and dementia. As we know, the NHS has instead ended up dealing with ever growing demand as the population lives longer and accumulates more of these chronic diseases.

Today the priorities for health essentially fall into three big categories. The first challenge is to control some of the known major risk factors for chronic diseases, to eliminate them or least try to delay their onset. Secondly, we need to try and address the enduring health inequalities in this country. And finally we mustn’t forget that communicable diseases are still capable of surprising us, as we saw with the Ebola epidemic in Africa, which could easily have become a global catastrophe.

How much is it the responsibility of the state to try to influence the causes of bad health?

It comes down to a balance between the action that can be taken by government, including regulatory action, and individuals taking responsibility for their own health. There’s always a strong debate about the role of the ‘nanny state’, but as I mention in my essay, these problems need multiple and complex solutions so we need action from all sides.

The longstanding issue is really about addressing health inequalities – the social and economic determinants of health – and this is deeply enmeshed in wider aspects of government policy including things like social mobility, poverty, education, and early start in life. My career spanned lots of posts in public health and government approaches really varied over that time. During Thatcher’s government we were not allowed to use the term ‘health inequalities’ in policy discussions about health, it was informally banned. When the Major government came in it started to rise up the agenda again. And then during the Blair government, particularly with Gordon Brown in the Treasury, there were major efforts made to address health inequalities and indeed a lot of cross-government action, which was very welcome. With the Coalition government, and now with the Conservative government, although these things are talked about, the action so far has been pretty weak.

In your essay you talk about how devolved government has led to interesting variation in how the UK countries approach public health. Which countries do you think are making the most progress?

By and large, the administrations in Scotland and Wales have given more attention to addressing health inequalities and have had a bigger appetite for strong government action. England has a more chequered record and is more at the mercy of different political ideologies.

Certainly Scotland has been quicker to move on some of the big public health interventions, for example introducing smoke-free public places. We eventually got this through in England, but the Scots moved much faster, firstly because the politicians there weren’t so nervous about being labelled as members of the nanny state, and secondly because Scotland’s smaller and can make faster decisions.

Although they haven’t implemented it yet, Scotland has also committed to minimum alcohol pricing (a proposal in one of my Annual Reports rejected by both Brown’s government and the Coalition government in England). Another example is that Wales has now implemented presumed consent for organ donations, where it is assumed that you do want to donate your organs unless you opt out. Again, I recommended this in England because of the unacceptable number of people dying on transplant waiting lists, but it wasn’t accepted.

Interestingly, all the polling I saw when I was Chief Medical Officer for England suggested that the public quite like strong government action, particularly when it has to do with protecting children’s health.

What one thing could the UK government do that would have the biggest influence on health?

I think we want to be a country where all individuals value the importance of their own health, and I’d like to see us use the education system more to instil this as a fundamental value. A lot of the current emphasis in education is on conveying knowledge about health, and to a certain extent encouraging the good behaviours that promote health. That’s really important, but no one has ever suggested that we should be instilling fundamental values in our children and young people so that they grow up putting the maintenance of good health at the heart of the way they view life. I know that might seem rather idealistic, but if we actually set it as a serious measurable goal lots and lots of good things would flow from that.

What should organisations like the Health Foundation be doing to improve health in the UK?

It’s really important that we have strong commentary and action on the state of the country’s health and question why things are not being done. I used to get in so much trouble in the media for making bold statements about the problems and the action required. Quite honestly I’m astonished now by how meek and mild everyone is on this topic. Even some of the think tanks seem frightened to upset the government of the day. They don’t want to be seen as not constructive, but we need some noise and heat and light out there, we need some rabble rousing. We need people really wanting to campaign in order to get things done. Unless you keep these issues in the public eye and point out the action that’s required, then everyone will just forget that public health is important. And they’ll just spend all their time talking about the NHS and health care services, which is often missing the point.