Health a Consumer Good? Considering issues arising from the White Paper on Public Health – Choosing Health

Friday 18th February 2005

Choosing health: the market, culture and the government.

Dr Geof Rayner, Visiting Research Fellow, City University, London, lately Chair, UKPHA:

1. Surveys show that people are not very interested in choice of where they are treated and any choices offered must be local choices

2. The person centred approach of the English Public Health White Paper fails to recognize the clear evidence of the importance of environmental and socio-cultural factors ie the ecological approach. This feature of the White Paper stems from a paper from Mulgan et al to the Prime Minister a year ago or so promoting the importance of focusing on personal behaviour

3. Big business, the CAP and public services including the NHS are working against the health interests of the population in the field of food and nutrition and by analogy almost certainly in lots of other fields too.

4. The change, over the last 30 years, from a producer society – manufacturing important and people did their own cooking and made their own jam and bottled fruit – to a service / consumer society with more cooking on TV than in the home kitchen.

Public Health and Personal Choice

Prof Chris Drinkwater Head of the Centre for Primary & Community Care Learning at the University of Northumbria:

1. The Benwell experience

2. Failure of early regeneration programmes such as City Challenge because they focused on physical / environmental regeneration rather than social and community regeneration

3. Operation of the inverse care law in respect of health promotion activities under the 1991 GP contract which introduced health promotion activities into general medical services but failed to reach those most in need, including in Benwell

4. The crucial importance of empowering local communities to enable them to exercise choice – without it they cannot choose

5. Through community development control is handed over to communities. This is uncomfortable for public bodies but is crucial. Also means that the outcomes of projects eg funded by NOF cannot be predicted in advance because they depend on what communities want which is not known until the project is being implemented. Important to realize that ordinary people are used to being economical and realistic in the use of their own funds. Experience shows that they are equally economical and sensible in the use of public or other external funds!

6. The importance of commissioning for health and commissioning for healthcare being separated; otherwise the latter will always outshout and subvert funds from the former. The importance of the public health function being shared by health and local government

7. The importance of facilities for the community actually belonging to the community through for example community based charitable trusts. For it is through having ownership and thus responsibility that communities are empowered and take control .

Inequality, Social Differentiation and Health

Prof Richard Wilkinson Division of Epidemiology & Public Health, University of Nottingham Medical School, author of many publications on Income and Health:

1. Inequalities in wealth are widening in Britain. Countries with the greatest inequalities in wealth have the greatest inequalities in health and lower overall health than more egalitarian countries

2. Inequalities in wealth are associated with – ? cause – inequalities in every other feature of life

3. In unequal societies only the most advantaged approach the performance of their counterparts in other more egalitarian societies; the disadvantaged perform much worse than their equivalents in egalitarian societies. Rem the example of youngsters in US and Sweden in terms of years of education and that of their parents

4. The importance of status and locus of control – high status people have internal locus of control whereas low status people have an external locus of control

5. The mediating impact of chronic stress as a cause of poor health and other disadvantages

6. The importance of respect as well as status. The example of Japan was quoted where low status people are accorded respect by higher status people because it is recognized that someone has to do the difficult and dirty jobs in society and they deserve respect for being willing to do these. Japan is the most egalitarian society in terms of distribution of wealth and health.

7. Contrast cooperative societies such as Sweden with essentially competitive ones such as US and UK. Friendship and positive social relationships and networks are features of cooperative societies rather than cooperative ones

8. The crucial importance for humans of being able to read other peoples thoughts and attitudes – Rem the issue of whites of eyes being only found in homo sapiens not other primates

9. Remember the Revolutionary Slogan – Liberty, Fraternity, Equality – or death!! Born out by recent evidence!

MMR and Consumerism

Janine Arnott, University of Manchester,

Overview of the MMR controversy in the UK, examines the questions raised by the case – what counts as evidence and whose evidence counts – in evidence based policy making.

In 1998 a report published by Dr Wakefield et al suggested a tentative link between the MMR vaccine and autism and Dr Wakefield called single vaccines to replace the existing combined triple vaccine. The claims attracted intense media attention and despite assurances from experts that no link had been proven take up rates of the vaccine fell from 92% in 1995 to 82%, and demands for single vaccines increased.

This case highlights the tensions between individual and collective public health and raises the question of how these tensions can be reconciled. Broadly speaking policy makers can respond in three ways. First: provide single vaccines. However, this raises ethical questions. The combined MMR vaccine has been shown to be both more efficient and more effective. Changing policy may also signal uncertainty in the combined vaccine.

A second option is compulsory vaccination. However, this is only ever achieved through incentives and sanctions, usually financial (conditional benefits) or by conditional entry into state education or employment. This impacts on lower social economic groups and higher economic groups can ‘buy out’ thus reducing collective herd immunity.

A third option is to continue with voluntary vaccination. This is the most effective choice but also raises the question of how public health professionals can increase public confidence in the MMR vaccine. This paper suggests that health professionals need to engage with the wider public debate about the role of vaccines and adopt a more active approach to building public trust in childhood vaccinations. More importantly parental decisions must be based on informed choice. Information, education and parental support must be targeted more effectively but professionals must also be accepted that some parents may make informed choices that they do not agree with.

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