Sunday 25 September 2016

What is Public Health?

Recently, I’ve been thinking a lot about what people mean by ‘Public Health’.  This is mostly in light of going to the Public Health England annual conference a couple of weeks ago.

(As I write about this, I’m aware that I haven’t read or written as much about public health as many people, and I’m probably making some pretty basic arguments and missing some crucial points.  Even so, I think it’s helpful to have this discussion and spark some debate.  And the points I’m making are as much about the politics and practicalities of doing public health work, which I’d suggest I’m perfectly capable of commenting on, having worked in a local authority for 5 years.  Let me know your thoughts in the comments section.)

There are many potential public health issues on the horizon, from dementia and cardiovascular disease, type 2 diabetes and so on, to childhood obesity and alcohol misuse.  But the epidemiological data is astonishingly clear (echoing the alcohol harm paradox that I’ve mentioned before): these diseases and ailments are, above all, correlated with socioeconomic status.

Slide taken from Susan Jebb's presentation at the PHE Conference, available here.

Now the response of some people I’ve mentioned this to (notably not part of the public health community, and not on the left politically) has been, on childhood obesity, to lament that parenting skills just aren’t distributed equally across society.

But the response of the public health community would be to argue that it’s environmental factors and ‘choice architecture’ that structure the choices of parents and children in an unhealthy direction.

And the soft sociologists amongst you might add that class is not just about wealth and income, but culture, and so particular patterns of behaviour are transmitted that may or may not have been positive adaptations in the past, but are now potentially ‘maladaptive’ (to use a word that makes me hugely uncomfortable).

But however we look at it, there’s no doubt that housing, local amenities, education, employment opportunities, diet, and so on are all affected by who our parents are and where they live.  They are associated with locality and socio-economic background – or class, to put it bluntly.  And all those factors influence our health in the long term.

So therefore, one ‘public health’ argument runs, public health needs to be about changing the way housing, local amenities, education, employment and so on are provided.  If the job of public health professionals is to influence health inequalities – as the Coalition Government stated quite plainly – then it has to be about wider socio-economic inequalities.

This where those on the right politically, or those who are more libertarian, start to suggest that public health these days is more about political campaigning than direct health interventions.

And there’s some truth to that.  Gerard Hastings isn’t just opposed to marketing for alcohol; he’s opposed to marketing for all consumables.  The ‘Future Public Health’ (framed as a successor to ‘the new public health’) is all about saving the planet for future generations.

And indeed saving the planet was the topic of the keynote address at the PHE conference.  Of course there are health issues associated with climate change – it will affect where malaria and other diseases are prevalent, and it will cause migration that will affect disease transmission.  But if the issue is preventing (or reducing) climate change, is this a ‘public health issue’?  What is it that PHE or local public health teams can or should be doing on this?

There is a case to be made that climate change is an extreme example, which was really included at the conference as a bit of background and scene setting as an interesting talk before dinner.  And not all public health professionals or academics are (thankfully) like Gerard Hastings.  Indeed, Duncan Selbie is a great example of a political pragmatistalthough this does frustrate many of his professional colleagues.

But the issue doesn’t have to be so huge as climate change for the point to still apply.  If housing is a public health issue, what is the public health intervention?  We know what ‘good’ housing looks like – and if there’s any debate about this, it’s likely to be amongst architects, town planners and engineers rather than people with a master’s degree in public health.

Are public health professionals well placed to argue about what ‘works’ in relation to employment strategies, local economic growth, or education policy?  I’m not sure they are – and local and central government, not to mention the private and third sectors, have plenty of able individuals already well qualified to lead on these issues.

So what is the public health contribution?  Well let’s think about the classic example of the Broad Street pump.  The reason cholera spread in Soho was primarily the poor quality of housing and drainage.  This was particularly bad in this area of London because the people were much poorer.  Richer areas had much better and more hygienic facilities.  So the health of the public was improved by better housing and could possibly have been improved earlier by a more equal distribution of wealth and resources.

But that required a political solution in terms of housing and social policy, as well as the simple macro-economic trend of increasing wealth and income.  But I’d argue the public health intervention is about the water supply and sewerage.

This is, in a way, tinkering at the edges: it’s a safe bet there will continue to be more diseases, even now, and that they will hit the poorest hardest.  That might not always be true, but as I say, it’s a pretty safe bet when we look at Ebola and other outbreaks.

So there is a public health point to be made that if you want to avoid these, certain improvements in housing and so forth would be beneficial, but the public health contribution is the evidence and advice to the politicians and officials who actually determine and implement housing policy.

In fact, that’s even the case in relation to improving the water supply.  It’s not the public health department who would necessarily enact something new, it would be the water board or its modern equivalent.

But the public health contribution, in all these cases, is to focus attention on the health of the public and how this might be affected by wider factors.  It has a role in contributing to the debate.

Take the example of alcohol guidelines.  There was much debate about these, but the key point is that they offer guidance to people who can then make their own decisions about how much alcohol to drink, if any.  The guidelines – perfectly justifiably – only refer to health risks.  You’d have to factor in your own thoughts about taste, intoxication, sociability and so on.

And this, rather than being a failing of the guidelines, is actually a strength.  As soon as public health somehow becomes about wider flourishing – with that worrying word ‘wellbeing’ – it is in the domain of ethics and politics.  And as Katharina Kieslich reminded the PHE conference, fair-minded people will not all agree on the priorities of any department or organisation, even in public health.  Despite the attempts of philosophers through the ages, we haven’t agreed what universal human aspirations and aims should be.  Wellbeing does not look the same for everyone, and is not as easily defined as disability-adjusted life years, which can only be a partial measure of happiness, fulfilment or wellbeing.

Yet there is this tendency for the domain of ‘health’ to expand and include various wider value judgements.  This is to some extent unavoidable, given the blurred boundaries between structure and agency, and the spectrum from choice to coercion.  And we should be more open about these grey areas.

Part of the reason that wellbeing seems like an apolitical area is that politics has been emptied of these fundamental philosophical, ethical debates.  In taking forward agendas clearly underpinned by certain ideological and ethical assumptions, successive governments from Thatcher to Cameron have sought to suggest that they are only introducing ‘efficiency’, and managing the machinery of the state more ‘effectively’ than their opponents.  If politics is simply the domain of securing economic prosperity and opportunity, while managing the neutral state apparatus effectively, then other areas – such as health and wellbeing – can reasonably be understood as being outside of politics.

So once the discussion of ethics is removed from politics, it becomes harder to see where ‘health’ ends and ‘politics’ starts.  Of course this isn’t a clear dividing line, and drawing it anywhere it arbitrary, but my fear at the moment is that it is not drawn at all, and that makes it difficult to identify what domain and responsibilities belong to ‘public health’ professionals at all.  Is it everything or nothing?  I’m certainly not an expert in everything, and no-one wants to be told they have a remit for nothing.  I think public health would flourish best with a smaller scope, but more clearly and carefully defined knowledge and responsibilities.  So before we celebrate what PHE does, it might be worth coming back to that question: ‘what is public health?

Saturday 3 September 2016

When clear thinking can be muddy

One of my most common requests at work is for people to think clearly and consistently, and follow this up with a definite decision.  But when I write on this blog, I’m often calling for people to think not in terms of ‘bright lines’, but messy nuance.

I’ve been wondering about this possible inconsistency recently, and then a story has come out that has put things into focus for me.  The simple, and slightly trite answer, is that we can think perfectly clearly and openly, with consistent principles, but sometimes these come into conflict with each other, or meet complex problems were a perfect – or even neat – solution is impossible.

I was originally going to write something making the point that there are straightforward, but painful, choices for the public sector to do in the next few years, as predicted ‘demand’ increases for a range of reasons (mostly demographic) while funding from central government decreases – to zero, in the case of local authorities.  When systems are having to generate savings of 50% or more, talk of efficiencies is not just irrelevant, but potentially misleading and unhelpful.  Although the NHS hasn't been cut in the way that local authorities have, the reason there is increasing interest in tying health and social care together is that they are inextricably linked – not just for the patient or service user, but in terms of costs.  ‘Savings’ in social care, if not planned and delivered in partnership with the NHS, will simply lead to the balloon bulging elsewhere, in hospital admissions and length of stays, for example.

How are the choices ‘straightforward’ then, if funding is falling, demand is rising and the costs are shared between a whole range of organisations?  Well, the decision boils down to the fact that if the current spectrum of services are to be delivered, even if in a more ‘efficient’ way, there won’t be the budget to offer them to everyone – so they will be more ‘rationed’ in the terms of the article about NHS treatments.

That is, organisations will do less for some people, but maintain a stronger (or cheaper) service for others.  This does indeed undermine the principles of the NHS, but it’s the way local authorities and other elements of government have always operated, using means testing and targeted support, even where it’s not immediately apparent.

The only real alternative is to do less for everyone.  My gut feeling is that this would require a change in our attitude to the NHS, which can sometimes be seen as a universal service as delivering support not only to everyone, but for everything.  (Of course there is one alternative, which is to change the funding envelope.)

But what about my calls for ‘irrational policy’ and ‘compromise’?  The reality is that while you can accept a clear principle, there are no simple answers about what that means in practice.  What do you stop doing?  Why?  Who do you target?  Why?  How?  What are the consequences?

And that’s where the thinking is sometimes muddled, or there’s a reluctance to take the decision between those two very clear options.  There’s reluctance to draw a line because it’s seen as too definite.  Some people might say that it’s too difficult, or inappropriate, to draw lines like this.  We’re on a slippery slope by making a dent in universalism.

But universalism is drawing a line too.  It’s just that the line is either at one extreme or another, and is therefore can appear very simple.  It’s this simplicity that brings together self-styled defenders of the NHS – like Laurie Penny – and those who would prefer a market-based solution – like Chris Snowdon – in attacking the decision of the Vale of York CCG.  They’re at one extreme or another, but highlighting the inconsistency.

The thing is (and I should acknowledge this is where the opposition of people like Chris to the NHS is perfectly coherent*): with a fixed budget there is always a trade-off between those same ideas of doing less for everyone, or targeting particular groups.

The NHS is a classic example of this.  We need NICE and CCGs to make decisions about what treatments are available, because they can’t offer everything.  And with a fixed budget that principle has to apply even if those decisions apply equally to all users of the system.  (And the budget is inevitably fixed to some extent; it is not infinite.)

There are good reasons to maintain that absolute principle of universalism in the NHS, but we mustn’t be under any illusion: this equally requires the ‘rationing’ of services through CCGs and NICE.  And those ‘rationing’ decisions can’t be straightforward.

This all sounds a bit academic, and perhaps even a case of semantics.  But let’s see how it can work in practice, and how point about complexity is exactly how we go through our lives – not just for better or worse, but for better.

David Seedhouse, Professor of ‘values-based practice’ at the University of Worcester, wrote in the Guardian that just as hospital sites have gone ‘smoke free’, they should go ‘meat free’ too, as both meat and tobacco are carcinogens.

By taking this consistent position, it’s suggested, we can avoid ‘stunning inconsistencies’ such as this form of Orwellian ‘doublethink’:

“Either it’s OK to allow free choice or it’s OK to prevent ‘unhealthy behaviours’, but you can’t have it both ways … If you don’t ban meat, then you can’t ban smoking.”

Perhaps unsurprisingly, Chris Snowdon swiftly congratulated this reasoning.  (Although it wasn’t planned, it’s no coincidence we both chose to write about these two articles together, from quite different perspectives.)

In fact, the decision isn’t simply a choice between ‘free choice’ and preventing ‘unhealthy behaviours’.

First, on a technical point, health isn’t a binary.  Substances and behaviours – and particularly patterns of behaviour – can’t solely be described as ‘healthy’ or ‘unhealthy’.  The category of carcinogen depends on a causal link between the substance and cancer, not the probability or level of risk.  That is, someone whose published academic work focuses on health promotion makes exactly the mistake that has frustrated many who are interested in the new alcohol guidelines.

Meat might have some similar attributes to tobacco or smoking, but it’s not the same.  And that’s before we even get started on the fact that most people, if they had to choose one category, would probably classify meat as a food (a group of things essential for life), rather than as a carcinogen, while tobacco would be an intoxicant (something of a luxury, if perhaps essential for a functioning society).

What’s more, freedom isn’t a neat binary of ‘free’ and ‘unfree’, as politics, philosophy, theology, psychology, sociology, neuroscience and any other area of human study will tell you.  False consciousness, structure and agency, predestination – all these concepts and more are attempts to cut this Gordian knot.

But we know all this intuitively already.  That’s why the reaction I saw this article receive on Facebook and Twitter was ridicule, without even having to enter into an extended period of intellectual reflection.  We see the world not in black and white, but in infinite shades of colour.

Of course Seedhouse would respond that it’s revealing that those Twitter and Facebook comments didn’t involve much reflection:

“So long as we see the world in disconnected chunks, we can avoid serious thought, and preserve the status quo. We need more opportunity to think deeply for ourselves.”

In fact, he’s the one who is thinking in a superficial, simplistic way.  He writes that “Illogical beliefs appear compatible if their true connections are disguised.”  But the point is that things that are connected are not identical.  It’s easy to make a connection; more difficult to specify precisely what the nature of that connection is.  I’ll say again, meat and smoking are not the same.

The point is that all issues are on a slope, which means that libertarians fear the ‘slippery slope’ and others like David Seedhouse want everything to slide down to the bottom as quickly as possible.  But the fact is that not all slopes are or should be slippery.  It’s more likely the best solution is somewhere along the slope rather than at the top or the bottom.  If you find yourself at either end you’ll soon discover there’s another slope available.  Personally I think individuals and society are better served having a bit of stability rather than constantly sliding up or down the endless slopes that exist in the world.

But let’s bring the discussion back to me, this blog and my personal frustrations.

What all this means is that even if the principles are clear, and a decision is taken, we still have to face a messy reality.  So let’s not be afraid of making decisions and drawing lines, but equally let’s not imagine that act of drawing a line will simplify and make everything follow.  It won’t make things simple; it will only make things transparent.  But I’d say messy clarity is better than messy confusion.

*I have much more to say about this, and how insurance and purchasing schemes don’t really avoid this trade-off, but I’ll save that for another day.