Key Concepts in Public Health Modern Public Health
Contributors: Fiona Adshead & Allison Thorpe Edited by: Frances Wilson & Mzwandile Mabhala Book Title: Key Concepts in Public Health Chapter Title: “Modern Public Health” Pub. Date: 2009 Access Date: February 16, 2020 Publishing Company: SAGE Publications Ltd City: London Print ISBN: 9781412948807 Online ISBN: 9781446216736 DOI: http://dx.doi.org/10.4135/9781446216736.n3 Print pages: 11-15
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Modern Public Health FionaAdshead, and AllisonThorpe
Definition
Public policy has been defined as ‘the broad framework of ideas and values within which decisions are taken and action, or inaction, is pursued by governments in relation to some issue or problem’ (O’Neill and Peder- son, 1992). As such, policy generically can be described as a guiding principle of, not a guarantee for, action. Public health policy more specifically reflects an increasingly diverse agenda, developed against a context of global forces and changing social and political environments. An active social justice agenda and growing evidence of the impact of the social determinants of health on health inequalities and outcomes make more complex an already crowded picture. In this chapter we will look at the implications of current policy drivers in England for public health, with a particular focus on how at a national level policy directions are often influ- enced by, and influence, legislative frameworks and policies which are enacted at a European or global level.
Key Points
• Public health policy is not designed or delivered in isolation from the social and political context – it is linked to a wide range of social resources and infrastructures, social capital, social interaction and social support.
• Policy boundaries are often blurred – European directives can both limit autonomy of action at a na- tional level and ensure local activity has a resonance over a larger population level by setting clear parameters for action across nation states.
• Modern public health policy and practice has to be able to respond to economic, demographic and epidemiological transitions, while still enabling everyday action on the ground.
• With lifestyle-related diseases rising, people’s expectation of active engagement in promoting and protecting their own health means that the practice of public health is becoming increasingly person- alised. This is reflected in the policy arena.
Discussion
Policy-makers working in the field of public health today face a very different environment to that which faced our forebears in the nineteenth century. Then, the primary focus of public health activity centred on sanita- tion, slum clearance and the prevention of infectious diseases (Gorsky, 2007). In our more modern complex society, we face new challenges. Rising rates of diabetes linked to obesity, escalating chronic diseases, and global tobacco control – to name but a small selection of our concerns – are juxtaposed with an increasingly articulate, educated consumer society and an increasingly engaged media and business presence. Unsur- prisingly, against such a backdrop, it has long been remarked that for public health ‘boundaries are fiction’ (Terry, 1964).
Determining how best to assure the health of our populations remains an enormous agenda – and one in which the whole of society has a shared interest, with roles for government, the healthcare system, the wider population, the community, and business itself. There has been a tangible policy move in recent years towards health improvement initiatives which take a wider partnership approach to delivering on health (DH, 2007d). Reports, such as the eponymous Wanless reports, have been successful in driving home the message that a sustainable healthcare system requires ‘full engagement’ of the people in its delivery (HM Treasury, 2002, 2004). With recent economic analysis suggesting that the total cost of preventable illness is 19 per cent of total GDP for England (NSMC, 2006), prevention is increasingly seen as the key factor in addressing growing
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concerns about the affordability of healthcare systems into the future (HM Treasury, 2002, 2004). Successive policy documents, such as Choosing Health (DH, 2004a) and Our Health, Our Care, Our Say (DH, 2006e) have reinforced this message, reflecting a recognition that no amount of legislation, regulation or structural adjustment can compete with the ability of people to choose how they live their lives. But such a person-cen- tred approach for public health policy is a challenge in itself.
Case Study
The recent smoke-free legislation, which came into effect on 1 July 2007 in England, provides a tangible demonstration of the relationship between politics, policy development, the individual and the evidence. De- spite evidence that second-hand smoke was a determinant of ill health, there was considerable resistance to the idea of taking a comprehensive legislative approach to the issue, largely centred around the human rights of smokers. The eventual policy decision to allow an open vote on how to progress the legislation was the culmination of a long campaign, which drew upon:
• policy-driven public consultations; • high levels of popular and professional support; • an extensive evidence base; • examples of local-level action which was considerably ahead of the proposed national policy direc-
tion; • international and, in the case of Scotland and Ireland, more local examples of the success of enacting
national legislation in other countries, with Scotland, for example, demonstrating a drop in symptoms in bar workers from 79 per cent to 53 per cent within one month of implementation (Menzies et al., 2006).
The combination of these factors raised the level of debate, and ultimately influenced politicians to vote for the more radical and visionary legislation which was eventually enacted. This reinforces the need to recog- nise that public health policy cannot be designed or delivered in isolation from the social and political context: political decisions have to reflect a balance between the evidence and public opinion regarding what is right – and both affordable and sustainable – for society at the given point in time. The journey there, and the full engagement which characterised it, critically determines the success of the outcome.
However, the success of the policy direction does not lie solely in the enactment of the legislation, but will be measured by its cumulative effect on the health of the population. In this case, enactment of the legisla- tion is only one manifestation of the policy direction. Alongside this policy-makers are working to build on this historic milestone, through effective enforcement, policing and publicity, to encourage people to take advan- tage of health improvement initiatives, such as smoking cessation services, which will spare thousands more lives, and through consultations to raise the age of sale, to ensure that more people are spared the misery of watching their families and friends suffer with preventable smoke-related illnesses (DH, 2007a).
This recognition of the need to take a more personalised approach to health underpinned the Choosing Health White Paper, reflecting a policy commitment to a broader social contract between the state and individuals, with choice and civic action being key elements of this contract. In effect, it recognised that public health pol- icy needs both to provide a direction for and support action in relation to our key health priorities. In practice this means that policies must facilitate partnership across society, with joined up action at governmental, na- tional, regional and local levels, and enable those who have an ability to contribute to do so. In practice, this means that policy direction must be supported by the appropriate levers to drive delivery:
• realistic shared, cross-government targets which commit governments to improving health outcomes in their population;
• co-ordination across government, and where necessary across national boundaries;
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• a commitment to wider action to improve the health of the most disadvantaged and tackle health in- equalities, e.g. through action on housing, fuel poverty and employment;
• use of social marketing and other techniques to change social norms.
Conclusion
Policy direction in England reflects our understanding that health cannot be imposed on people, nor can we expect them to be co-producers of sustainable good health without support from government. The relation- ship between public health, the state and the population is complex. Today, more than ever, we need to face up to a complex conundrum:
• Applying policy consistently across nation states sets clear parameters for action and enables local action to have a stronger resonance across a wider population. Legislation provides one route to en- sure this, but legislation alone will not deliver behavioural change.
• Working with the population, targeting our efforts appropriately, ensures that the effects of our policy will be instrumental in informing a culture that is motivated, progressive, ambitious and constantly striving to improve services: not for the sake of it or to satisfy ‘managers’, but for the benefit of ser- vice users.
But, as the case study demonstrated, it is not an ‘either/or’ scenario. Policy-makers today working in the field of public health face a complex agenda – but they also have a unique range of opportunities. It is up to the population as a whole to ensure that we maximise their potential.
Further Reading FrenchJ. and BlairS. C., (2006) ‘From snake oil salesmen to trusted policy advisors. The development of a strategic approach to the application of social marketing in England’, Social Marketing Quarterly, 12(3): 29–40. http://dx.doi.org/10.1080/15245000600848892 HM Treasury (2002) Securing our Future: Taking a Long Term View. London: HM Treasury. O’Neill, M. and Pederson, A., (1992) ‘Building a methods bridge between policy analysis and healthy public policy’, Canadian Journal of Public Health, 83(32): 25–30. World Health Organisation. (2006) WHO Framework Convention on Tobacco Control. Retrieved January 21, 2007, from http://www.who.int/fctc/whofctc_cover_english.pdf World Health Organisation (2007) Interim Statement of the Commission on Social Determinants of Health 2007. Retrieved January 21, 2007, from http://www.who.int/social_determinants/resources/interim_statement/en/index.html
• health and public policy • public health • health policy • health inequalities • public policy • health • legislation
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http://dx.doi.org/10.1080/15245000600848892
http://www.who.int/fctc/whofctc_cover_english.pdf
http://www.who.int/social_determinants/resources/interim_statement/en/index.html
http://dx.doi.org/10.4135/9781446216736.n3
Key Concepts in Public Health
Modern Public Health