Journal of Public Health Advance Access originally published online on June 28, 2005
Journal of Public Health 2005 27(3):239-240; doi:10.1093/pubmed/fdi039
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Editorial |
Health promotion—quo vadis now?
Norman Vetter
Editor
I guess we all remember the first time we bumped into the concept of ‘determinants of health’. For me, hazily thinking back, it seemed to coincide with the publication of Tom Mckeown’s book on the small contribution that health services make to health1 and the more scatological book by Illich,2 both of which, curiously and, as far as I know, by coincidence, contained the word ‘nemesis’ in the title. Both made a point that more medical services are not associated with better health, a point that Archie Cochrane trumped by suggesting that there was a direct relationship between the number of doctors and infant mortality in a number of developed countries.
About that time, the Marxist who taught me about determinants of health, tried to convince me that the definitions of social class had been set according to the mortality of the occupational group, rather than the other way around.
The importance of health in relation to social class had always been in the minds of people in public health then called social medicine (well it would be, wouldn’t it?). Edwin Chadwick probably started it all when he published his ‘General report on the sanitary conditions of the labouring population of Great Britain’ in 1842. This showed that the average age at death in Liverpool at that time was 35 for gentry and professionals but only 15 for labourers, mechanics and servants; but I digress.
These ideas were again developed in the Black Report in 1980. (I have a rare original dark mauve copy, suppressed by the then Prime Minister, Mrs Thatcher, with some vigour by publishing very few copies over a bank holiday weekend. Despite opposition it was published a couple of years later as a Pelican paperback.)3
My next memory in relation to social issues and health is of the rise of the Health Education and Health Promotion groups in England and Wales, respectively, in the mid to late 1980s. Wales, being a more radical country, went for the more radical term—health promotion. These groups owed a lot to the development of ideas by educationists and sales promotion experts on how individuals could be persuaded to take part in healthier lifestyles. I guess this fitted into the Thatcherite principle that people were responsible for themselves and that there was ‘no such thing as society’. Some readers will have been at a Society for Social Medicine meeting where the Bishop of Durham remarked that the host organization mentioned society twice in its title and here was Mrs Thatcher saying there was no such thing.
These two groups rose to giddy heights with a plethora of ideas, and then fell to earth, hardly to be mentioned again in polite society. The ultimate cause of their downfall appeared related to the intensely political nature of their messages. Intervening with ‘lifestyle’ issues appears at first sight to be fairly innocuous, but when one comes to think of it, intervening with lifestyle means trying to change habits: smoking, drinking, eating, exercise, sex. It involves trying to change things at the heart of a family unit and an area where a number of big and influential businesses are making a profit. Even worse, it involves pointing the finger at government policies that are counter to healthy living. The Left accused them of promoting middle-class values, the right of state interference, where it had no business: and businesses paid both sides to maintain the status quo and stop meddling when they were making a nice earner out of people’s bad habits.
There were other problems. Promoting health and educating people about health seemed to go straight to the well-off, who took on the messages. Health promotion and education aimed at individuals, therefore, appeared to increase inequalities. There was the odd belief in some quarters that good prevention would make the NHS cheaper, an idea still peddled on occasion by people who should know better. When this did not happen over a 5-year period, new government fashions began to come into favour.
Both national organizations were absorbed into government departments where they could do little harm. From being groups that went and did things, they developed into collectors of useful information and resources for the local practitioners; in England it became the Health Development Agency. In the Faculty of Public Health the local practitioners of health promotion and health education became part of the health improvement programmes; even the phrase health promotion disappeared.
Now, as a logical next step, the new National Institute for Health and Clinical Excellence (NICE) has taken on the functions of the Health Development Agency to create a single organization for providing national guidance on the promotion of good health and the prevention and treatment of ill health. Within NICE there will be a Public Health Interventions Advisory Committee. The Advisory Committee will look at evidence on the effectiveness and the cost effectiveness of public health interventions and will make recommendations to the Institute on the use of the interventions in England in the NHS, local government and in the broader public health arena.
They will have an interesting task looking at the evidence base for health promotion. The Health Development Agency has been working in this area for some time. Presumably the move to NICE, if analogous with its other functions, will be to look at interventions and decide which are cost-effective for the NHS. The size of their task is considerable. A quick overview, using only PubMed with the search terms ‘evaluation’, ‘health’ and ‘promotion’ since 1984 gives over 4500 hits. Of these there are 53 systematic reviews on a wide range of subjects, shown in Table 1.
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So there will be plenty of subjects to keep the new committee busy. Cost-effectiveness studies in the database were less common, with 17 overall (Table 2). The search most notably showed how often the phrase ‘cost-effectiveness’ pops up compared with the number of times such an analysis is performed.
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It will be interesting to see how many of these interventions pass the acid test when measured by costs per QALY. One of the major problems faced by any organization attempting to follow evidence is the lack of good research, most notably the absence of good costing data. It would be well worth our while for all in public health to start insisting that our health improvement sections look hard at effectiveness and costing data.
The biggest problem, it seems to me, will be the political aspect again. NICE is part of the NHS, and therefore funded by government. In its own words:
"The audiences for the guidance developed by the Centre for Public Health Excellence will include the NHS, local government and education, the public utilities, and the private and voluntary sectors as well as a range of central government departments and their delivery arms that are responsible for taxation, benefits, roads, transport, housing, criminal justice and other aspects of services that determine the health of the public. Therefore the Centre for Public Health Excellence will produce guidance for the public health workforce very broadly defined."4
It will be interesting to see how this relationship develops. Will the Healthcare Commission be sent around to government departments to chastise these that are found by NICE to be promoting unhealthy lifestyles?
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References |
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 TOP References |
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- McKeown T. The role of medicine: dream, mirage or nemesis? London: Nuffield Provincial Hospitals Trust, 1976.
- Illich I. Limits to medicine: medical nemesis: the expropriation of heath. London: Penguin Books, 1977.
- Inequalities in health: Black report. London: Penguin Books, 1982.
- Operating model for the Centre for Public Health Excellence: Consultation document. http://www.nice.org.uk/pageaspx?o=248420 (last accessed 3 June 2005).
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