Healthy Living Text FINAL NEW:Healthy Living · Edited by Christopher Exeter health and healthy living advancing opportunity: 2008 health and healthy living. ... The role of the regional

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health and healthy living

advancing opportunity:

2008health and healthy living

T H E S M I T H I N S T I T U T E



Published by the Smith Institute

ISBN 1 905370 38 5

This report, like all Smith Institute monographs, represents the views of the authors and not those of the Smith Institute.

© The Smith Institute 2008


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Contents

PrefaceWilf Stevenson, Director of the Smith Institute

IntroductionChristopher Exeter, Head of Public Policy Research, NHS CFH

Chapter 1: Health citizenship – leaving behind the policies of sicknessHarry Cayton and Michael Blomfield, Director of Public Engagement and Policy and Research Officer at the Council for Healthcare Regulatory Excellence

Chapter 2: Responsibility for a healthy active lifestyle Andrew Ramwell, Director of the Manchester Institute of Sport & Physical Activityat Manchester Metropolitan University

Chapter 3: Reinventing the politics of healthy livingDavid Walker, Editor of The Guardian’s monthly magazine for public-sector managers, Public, and Trustee of the Nuffield Trust

Chapter 4: The role of the private sector in promoting healthy behaviourShaun Matisonn, Chief Executive of PruHealth

Chapter 5: Towards wholly healthy placesNeil McInroy, Chief Executive of the Centre for Local Economic Strategies

Chapter 6: The role of the regional development agency in health promotion partnerships Thea Stein, Executive Director of Economic Inclusion at Yorkshire Forward, Jane Riley, Associate Director of Public Health for Yorkshire and the Humber, andSue Proctor, Director of Patient Care and Partnerships, Yorkshire and the Humber Strategic Health Authority

Conclusion Christopher Exeter

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PrefaceWilf Stevenson, Director of the Smith Institute

The Smith Institute is an independent think tank set up to undertake research and educationin issues that flow from the changing relationship between social values and economicimperatives. In recent years its work has centred on the policy implications arising fromthe interactions of equality, enterprise and equity.

The health of the nation is closely bound up with the country's economic and social well-being. A lack of access to good physical or mental health can have a significant impact on an individual's ability to participate actively in society - as both a citizen and as an economically-active individual. For the state, therefore, the cost is not only in the health-care being provided, but in the opportunity cost of not having a healthy workforce.Government, at all levels, has a responsibility to invest in and support the nation's health.

With an ageing population and our current lifestyle trends, healthcare will become prohibitively costly unless we are able to make our health services even more responsiveand efficient, and – as addressed in this monograph – unless we can get the public,employers and other partners in the public and private sectors to take greater responsibilityfor the encouragement and support of healthy living.

All the essays in this monograph address themselves to that critical challenge: the needto increase public engagement in personal health issues, influencing lifestyle trends andultimately demand for health services. Encouraging greater health-awareness could bringsignificant economic dividends, but there will be heavy economic costs to Britain if people fail to engage with this health agenda.

Achieving this is no small task, and will involve partnership and engagement across anumber of different sectors and departments. The health service cannot, by itself, achievethe changes necessary to make us a healthier society. Government-backed public healthpromotion is a critical element but, as David Walker’s essay sets out, we need a “new politics of healthy living”.

The challenge for government is to avoid the expansion of a nanny state and instead tostimulate new approaches from a range of other partners and sectors. The essays in thismonograph consider the potential roles of different partners – the insurance industry,planners, developers, regional development agencies and others. The essays highlight the

complexity of the task of improving public health, and set out a range of ideas that mighthelp in developing new ways of working, in which government needs to be more of apartner and orchestrator.

The Smith Institute thanks Dr Christopher Exeter for agreeing to edit this collection ofessays, and gratefully acknowledges the support of the Department of Health, PruHealth,and Yorkshire Forward towards this publication and the associated seminar.


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Introduction Christopher Exeter, Head of Public Policy Research, NHS Connecting for Health

This monograph sets out a series of papers aimed at stimulating a sense of debate for thefuture on one of the issues that affects all people: health and well-being. There can be nodoubt that we are living in changing times. The balance between producer and consumeris slowly edging towards the consumer, though not at a tempo that chimes with people’shabits and wants. In short, we are looking at a changing landscape of needs and delivery.

The key issue is how we shift the emphasis of services away from being producer-orientated to becoming consumer-centred. The implication of this is that radical reformis necessary across the public realm. Yet the means of delivering services must not be confused with the principles at which those services aim. It is clearly in the public interest that services are delivered as efficiently as possible; where public funds are wasted, opportunities – for better health, education, work, social services, housing – arelost both for individuals and for society as a whole.

The state of our nation’s health poses economic as well as social and cultural problems.Inequalities in physical and mental health place a burden on the public purse, and theyare a clear indication of a failure to provide citizens with an opportunity to fulfil theirpotential. The extent to which individuals can realise their full potential is deeply affectedby their health and well-being – and government, at all levels, has a responsibility toinvest in and support the nation’s health.

The challenge facing government is to change the attitudes and behaviours of both individuals and institutions – to reduce the demand for healthcare by stimulating healthybehaviour, and to create a social, educational and work environment in which healthy living is fostered and encouraged.

In the first instance, the aim must be to encourage healthy choices and behaviour, and toaddress the conditions that make unhealthy choices prevalent for many people in society.The objective must be to develop ways of mitigating the harm that has arisen from ourcurrent social trajectory, while at the same time using the tools available to governmentto address the market and marketing failures that are feeding those unhealthy social trends.

Ultimately, the aim is to create a “fully engaged society” – one where pro-health


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consumption choices are the least costly; exercise-based activities are a popular leisurepursuit; the built environment and the transport networks encourage exercise; high levels of education and employment are the norm; and workplaces embody a concern forphysical and mental well-being.

This is a whole-government agenda. It will demand a programme of action to incentivisebehaviour change and to foster cultural change over the longer term. It will entail a programme in which citizens are concerned for the impacts of all their decisions upontheir own health; businesses consider the mental and physical well-being of their employees;and government takes a holistic approach, seeking to promote healthy outcomes acrossall policy areas.

Such a landscape needs to be shaped by socioeconomic trends that demand faster, betteraccess to services – a de facto pre-condition for all providers, whether delivery is by thepublic or private sector.

At a macro level, this is driven by fundamental changes in public behaviour: primarily theempowering nature of the internet, the demand for more personalised services and themuch broader but still increasing lack of deference within society. Taken in combination,both these macro trends will influence the delivery of services and how and where thepublic wish to access them. This is all set against a backdrop of the demographic knowns:an increase in the elderly population, more single-person households and a reducing ratio between workers and retirees.

“Open innovation” is an emerging approach that allows all actors in a process – customers,partners, suppliers, professionals and the front line – to participate in how a service ororganisation develops and manages new ideas. Open innovation must be seen as not somuch a process, but core to the DNA of service organisations. In part, this reflects thegrowth of behavioural economics, recognising that neither public nor professionals act likerational economic actors. This leads potentially to a much more atomised service, basedon the needs of individuals. Yet many problems demand social action. This may require amatrix approach of personalisation, combined with addressing some problems through alens of collective action. Technology and information has an important role to play here:not merely to improve processes, but to deliver a step change in the delivery of care.

A further consideration here is globalisation: borders will increasingly become purely aconstruct of government, and not one that bounds consumers. Even today the internet


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has opened up a world of new experiences, from purchasing different, cheaper goods fromoverseas to planning easily journeys that would once have required lengthy preparations.

At a practical level, globalisation permits an international flow of people and services.People will seek for themselves new treatments for urgent or long-term health problemsvia the web if traditional channels are slow or fail to deliver. This could present a fundamental challenge to the NHS. Flow of information and the use of technology may be a far greater threat to the future of a “national” health service than traditionalconcerns such as the middle-class opt-out.

Once the “Google generation” reaches maturity, their experiences of using horizontal,bureaucratic organisational solutions could be low or non-existent, and they therefore willnot only be unused to being forced through paternalistic channels but may well reject thisapproach altogether, using their own information sources to seek out services.

Customer segmentation will become a high priority for planning care in the future. Allgenerations are becoming adept at using technology in their everyday lives. People’sdemand for more of everything is insatiable, but they see their time as their most valuable resource and want a clear return.

Finally, the pace and scale of technology is unending, and it has to shift to be focused onimproving service delivery. This is met, if not surpassed, by public expectations. However,the public’s attitude fibrillates. The future of information and technology in delivering services is as much, if not more, to do with philosophy and sociology as it is to do withthe technology. Triangulating technology, expectations and attitudes is essential to boththe strategy and marketing of the future of technology in delivering essential servicessuch as healthcare.

This monograph lays out a series of visions on how services must reflect the changingneeds of society. Whatever the service, the same issues apply: in this instance, we are focused on healthy lives and how communities can help achieve this objective – in concert with, not in challenge to, the demands of the consumer. What we do know is thatwe are only at the start of this debate: futures thinking must always carry the warningthat these are possibles, not necessarily fact. Without such discussion, though, we will notachieve progression or, most importantly, meet the demands of those whom we serve.


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Chapter 1

Health citizenship – leavingbehind the policies of sickness

Harry Cayton and Michael Blomfield, Director of PublicEngagement and Policy and Research Officer at the Council forHealthcare Regulatory Excellence


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Health citizenship – leaving behind the policies of sickness

Modern life is making us sick. That may be counterintuitive, so it must be put in context.It is true that we are living longer than we have ever done. Infant mortality is falling; inmany (but not all) countries in the world diseases are being eliminated (though othersappear); medicine is prolonging the lives of people with cancer and heart disease,although the overuse of antibiotics which have saved the lives of millions are also blamedfor new, resistant infections such as MRSA. We have more treatments, more drugs, moreresearch, so how is it that we are so sick?

How is it that in a recent survey1 in England of people with no long-term health problemsor caring responsibilities, only half described themselves as “very well”? How is it thatexpenditure on health services round the world continues to rise and patient satisfactioncontinues to fall? How is it that health, or rather ill health, is always news; and that personal and political anxiety about health is the constant theme of news bulletins andfront pages?

We may be less sick than we have ever been, but we certainly don’t feel well.

A focus on sicknessModern life is making us sick because we have created a healthcare industry that isrewarded by how it deals with ill health. Without illness, doctors, nurses, clinical scientists,pharmaceutical companies, hospital mangers, research charities and health policy makerswould be redundant. The global pharmaceutical industry is the most obvious investor inill health, creating new illnesses for new products or persuading us that their productswork when, as the recent report on antidepressants showed,2 they don’t.

But it isn’t only the pharmaceutical industry that makes money from expanding the concept of ill health and the need for its correction. Global investment in the healthindustry continues to grow. In India more private hospital beds are being built for foreigners seeking elective surgery than to provide care for Indians. The Island ofMauritius, in association with the Commonwealth Secretariat, has recently organised aninternational conference on the export potential of healthcare and life sciences.Meanwhile in sub-Saharan Africa a mere 3% of the world’s health workers face 24% of

1 Macmillan Cancer Support Survivorship in the UK: Preliminary Data (2008)2 Kirsch I, Deacon, BJ, Huedo-Medina, TB, Scoboria A, Moore, TJ and Johnson, BT “Initial Severity and AntidepressantBenefits: A Meta-analysis of Data Submitted to the Food and Drug Administration” in PLoS Medicine vol 5, no 2 (2008), e45

the world’s burden of disease.3

Medical research charities in the UK raise hundreds of millions of pounds each year;money that is almost entirely spent to support university departments and research centres exploring basic science rather than improved care, with just 2% going to supportresearch into the care of individuals with medical conditions.4 They too have an interest in promoting anxiety about illness, as the constant warnings of new risks for cancerremind us.

Just as the economics of healthcare mean that the countries with least illness have mosthealth services, so also the research industry spends most of its dollars in researching the diseases of affluence; 92% of the global burden of disease is borne by developing countries, yet less than 10% of research funding is devoted to 90% of the world’s healthproblems.5 It may be ungenerous to suggest that the people who work in the health industryhave an interest in keeping us ill, but the way our policies of sickness are constructed theyhave greater financial interests in illness than in health.

The single major cause of sickness and ultimately death is smoking. Yet the tobacco industry continues to produce and promote its products and to seek out new markets.Now that the mostly ineffective health education campaigns of the last 30 years in theWest have been replaced by more effective legislation, companies are targeting youngpeople in developing countries.

In South Africa almost a fifth of secondary school students have been offered free cigarettes by representatives of tobacco companies.6 The annual number of deaths indeveloping countries attributable to tobacco is projected to double from 3.4 million to 6.8 million between 2002 and 2030.7 Then there are the sugar and salt manufacturers, thealcohol industry, the fast-food industry, all actively promoting and selling products theyknow are bad for people’s health.


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3 World Health Organisation The Global Shortage of Health Workers & Its Impact (2006). At: http://www.who.int/mediacentre/factsheets/fs302/en/index.html (accessed 8 May 2008)4 UK Clinical Research Collaboration UK Health Research Analysis (2006)5 Global Forum for Health Research The 10/90 Report on Health Research 2003-2004 (2004)6 World Health Organisation WHO/CDC Global Youth Tobacco Survey. At: http://www.who.int/tobacco/surveillance/gyts/en/index.html (accessed 14 April 2008)7 Mathers, CD and Loncar, D “Projections of Global Mortality and Burden of Disease from 2002 to 2030” in PLoS Medicinevol 3, no 11 (2006), e442


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Part of the problem is that we have come to believe that it is medicine that has improvedour health and that it will continue to do so. We look to medical research, to doctors andnurses, to complementary therapies and vitamin supplements to put us right. In truth, itis clean water, proper sewers, warm and dry housing, environmental improvements,decent food and employment that together have done far more. It is those things – alongwith honest and effective government and the development of civil society – that wouldalso transform the health of people in sub-Saharan African countries.

That is why reclaiming our health from the food and sickness industries, including thegovernments seduced by them, is vital for our well-being.

Health education is not enoughMost of the public health campaigns of recent years have been based on the assumptionthat knowledge changes behaviour. Concepts such as “health education” and “health literacy” reinforce an imbalance of power between the health “expert” and the ill-informedpublic, between those who know and those who don’t. But preaching and teaching do not have a great record of success in changing personal behaviour.8

An example is the wearing of seatbelts by drivers. From 1975 the government ran annualeducation campaigns encouraging drivers and passengers to wear seatbelts, with littlesuccess. In 1982, after seven years of public education, only 37% of drivers and 39% offront-seat passengers wore seatbelts. The public knew it was sensible but they didn’t do it.However, when seatbelts were made compulsory for drivers and front-seat passengers in1983, use at once increased to 93% for both drivers and front-seat passengers.9

Similarly, years of exhortation on the dangers of smoking have had far less impact thanlegislation. The two most effective tools seem to be increasing the cost through taxationand restricting the places where people can smoke.

Numerous studies have found that significant decreases in tobacco consumption corre-late with increases in rates of taxation: some smokers are induced to stop, while otherssmoke less. In one UK study, price changes had most effect on the lowest socioeconomicgroups, reducing both the number of smokers and the number of cigarettes smoked.10

8 Coulter, A and Ellis, J Patient-focused Interventions: A Review of the Evidence (Health Foundation, 2006)9 Department for Transport Road Safety Statistics: Great Britain Car & Van Seat-belt Wearing – Percentage Rates (2004)10 Townsend, J, Roderick, P and Cooper, J “Cigarette Smoking by Socioeconomic Group, Sex and Age: Effects of Price,Income and Health Publicity” in British Medical Journal no 309 (1994), pp923-927


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11 Eisner, MD, Smith, AK and Blanc, PD “Bartenders’ Respiratory Health after Establishment of Smoke Free Bars andTaverns” in Journal of the American Medical Association vol 280, no 22 (1998), pp1,909-1,91412 Reid, DJ, Killoran, AJ, McNeill, AD and Chambers, JS “Choosing the Most Effective Health Promotion Options forReducing a Nation’s Smoking Prevalence” in Tobacco Control vol 1, no 3 (1992), pp185-19613 King’s Fund and Opinion Leader Research Public Attitudes to Public Health Policy (King’s Fund, 2004)

Similarly, the banning of smoking in public places, now widespread in the developedworld, has real impact. Following a ban on indoor smoking being implemented in SanFrancisco, a study of bartenders in the city found that within two months they displayedimprovements in respiratory health.11

Given how much effort has been put into health education, it is minimally effective compared with other approaches. A review of international evidence concluded that anti-smoking programmes in schools at best delay the onset of smoking among teenagers,but do not prevent it.12

This does not, of course, mean that communication about health is not valuable and is notpart of the implementation of change. It may indeed be the years of health promotionabout seatbelts or smoking that prepared public opinion for laws to control personalbehaviour and made them politically acceptable. The Labour government in 2004/06 agonised about the political risks of introducing the smoking ban, with John Reed, thenSecretary of State for Health, famously suggesting that having a smoke and a pint wereessential pleasures for working people and Tony Blair admitting that he had doubts aboutthe change right up to the last minute. It seems public opinion was ahead of them.

In fact the public seem less concerned about the “nanny state” than the media claim orpoliticians fear. A King’s Fund study found strong support for government intervention inhealth. Large majorities said government should intervene to: provide information andadvice (86%); put health warnings on products presenting a proven health risk (84%);encourage employers to promote health at work (82%); prevent actions putting thehealth of others at risk (77%); and actively discourage people from putting their ownhealth at risk (75%).13

The King’s Fund study also found particularly strong support for government action toensure the availability of healthy food. Eighty-nine per cent support action to ensure thatonly healthy meals are served in schools, 82% support laws limiting the levels of salt, fat and sugar in foods, and 80% want government action to ensure cheaper and more easily available fruit and vegetables for everyone.


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The public, it seems, have good sense. Eighty-eight per cent agree that individuals areresponsible for their own health, and 93% agree that parents have more responsibilitythan anyone else in ensuring the health of their own children. More than 60% think thattackling poverty would be the most effective way to prevent disease and improve thenation’s health. But over 40% agree that there are too many factors outside an individual’scontrol to hold people solely responsible for their own health.

Health citizenship is what is neededOur proposition in this paper is that public health policy fails when its does not includethe public. To include the public means to start where they are and to build on everyone’sreasonable desire to live well. Living well cannot be measured in the narrow sense of avoiding physical illness; many people with long-term conditions would describe themselves as well. Wellness comes from all the aspects of our lives: home and work, relationships, money, good food, exercise. Wellness does not come about by abstinencefrom life but by participation in it. That is what health citizenship means.

Health citizenship is created when individuals are motivated and competent to take control of their own health and well-being and to participate in personal and communitychoices that promote well-being. Health citizenship requires a combination of personaland social responsibility from individuals, but even more so it requires the institutions of society to promote choice, empowerment, self-management, responsiveness and participation in health and well-being.

In practice it is very hard for an individual to be a health citizen, because the institutionsof society – be they tobacco companies, food and drink manufacturers, health services,employers or environmental planners – either actively oppose or fail to promote choice,empowerment or participation in health and well-being.

Health citizenship is a direct challenge to the notion that some people lack health literacyand can be taught to be healthy. Health literacy is about replacing a perceived deficit;health citizenship is about realising an unrecognised asset. Health education is predicatedon the transfer of knowledge and skills from those who have to those who don’t. Healthcitizenship holds that people have the capacity and the motivation to live well but are unable always to do so. It is from them that we need to learn in order to bring about change.

Since we are describing something rather than inventing something, it is possible to find


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examples of health citizenship in action – although the organisers would not necessarilyrecognise the term. Most, but not all, of these exist on the fringes of health systems; all involve health professionals who are working with individuals and communities to co-create health. All arose because individuals and communities wanted them and tookpart in creating them.

Three examples of health citizenship initiativesWe give three examples to demonstrate the approach: one about individual change, oneabout group change and one about societal change. These examples are the Expert PatientProgramme, Communities of Health in the London Borough of Newham, and the NorthKarelia Project in Finland.

The North Karelia Project The North Karelia Project was a comprehensive community programme for health promotion in North Karelia, in Eastern Finland. There were 180,000 inhabitants, most ofwhom lived in small villages. The project was started in 1972 following a petition fromlocal people requesting the government to do something to reduce high rates of heartdisease in the area. There are two things to note here: the programme started with community motivation, and it recognised the value and role of professionals and the government in bringing about change.

The North Karelia Project has become a famous study in health promotion. It succeededwhere many similar programmes have failed. When compared with a reference area, therewere significant decreases across a range of cardiovascular disease risk factors, including:blood pressure, cholesterol concentrations and smoking rates.14 Measured from the yearsbefore the project’s implementation, decreases in the rates of coronary heart disease andlung cancer in North Karelia have exceeded those in Finland as a whole.15

The approach adopted in North Karelia involved the entire community of North Kareliabecause the risk factors for cardiovascular disease were closely linked with generallifestyles and social behaviour. The specific objectives of the programme were: improvedpreventive services, information, persuasion involving community organisations, and

14 Puska, P, Salonen, JT, Nissinen, A, Tuomilehto, J, Vartiainen, E, Korhinen, H, Tanskanen, A, Ronnqvist, P, Kosela, K andHuttunen, J “Change in Risk Factors for Coronary Heart Disease during 10 years of a Community InterventionProgramme (North Karelia Project)” in British Medical Journal no 287 (1983), pp1,840-1,84415 Puska, P “Successful Prevention of Non-communicable Diseases: 25-year Experiences with North Karelia Project inFinland” in Public Health Medicine vol 4, no 1 (2002), pp5-7


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environmental change. The approach was genuinely comprehensive with a broad range ofcommunity activities, involving primary healthcare services, voluntary organisations, thefood industry and supermarkets, workplaces, schools and the local media.

A study of the North Karelia Project16 drew some key lessons: that a successful communityintervention programme must include a good understanding of the community, close collaboration with various community organisations, and full participation of peoplethemselves, and that the strength of a community intervention programme is derivedfrom its emphasis on changing the social and physical environments in the communitythrough adoption of lifestyles that are healthy or are more conducive to health.Supportive policy decisions are of great importance for achieving this.

The study concluded that communities best know what is meaningful for them and bestknow their own social practices. Thus the most effective way to bring about change is toengage with communities – they best know what will be persuasive to their members,they best know what practical lifestyle changes members will need to be helped to make,and they best know how they can modify their everyday social practices to reinforce morehealthy patterns of behaviour.

Communities of Health Communities of Health in the London Borough of Newham grew out of a recognition ofthe need to tackle unidentified diabetes in an area of great ethnic and social diversity,poor health outcomes and low utilisation of preventative health services. Diabetes ofcourse has its cause in many of the same behaviours and social pressures that cause heart disease and obesity.

Communities of Health engages all kinds of groups where people meet up regularly. Theymay be lunch clubs, mosques or churches or temples, cultural societies or social clubs. Thesecommunities commit to promoting health and well-being for their members, building on thegroups’ own values and internal authority. It is central to its work that Communities ofHealth works in partnership with these groups, which retain control, to achieve positive results;rather than it claiming any sort of intellectual authority or other kind of power over them.

Groups do not need to be formal. For example, white, working-class men in their 50s aretraditionally a hard group to reach with health messages. Communities of Health ran a

16 Nissinen, A, Ximena, B and Puska, P “Community-based Noncommunicable Disease Interventions: Lessons fromDeveloped Countries to Developing Ones” in Bulletin of the World Health Organisation vol 79, no 10 (2001), pp963-970


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small focus group with these people to find out whom they might listen to. They discovered that the men wouldn’t listen to doctors, nurses, health promotion professionalsor community development workers. However, the men were big West Ham United fans who would meet up with friends to go to the games and watch other football matchestogether down the pub.

Having found that West Ham United had authority for these people – that it was the centre around which they organised much of their lives – Communities of Health went tothe football club and booked one of the spaces they rent out. Here Communities of Healthheld a discussion in a circle to get these people involved, rather than using a doctor ordietician to run a didactic seminar. After Communities of Health had booked one of theirrooms, West Ham United itself became involved and offered use of its pitch to the men as a reward for making the changes to their lifestyles.

Communities of Health estimates that an initial investment of £190,000 has led to some40 groups spending on average £5,000 a year more of their own resources on health-related activities.17 Not only does this show that if policy makers empower these groupsthey can leverage extra financial expenditure on health. More importantly, it demonstratesthat where people feel engaged and empowered there can be a shift from a passive culture of sickness to an active culture of wellness. These groups spent significantamounts of their own resources – money and time – demonstrating that people will takeactive responsibility for making their own health; and taking this responsibility as citizens,living it out in civil society.

The Expert Patient ProgrammeThe Expert Patient Programme is an interesting example of the value of collaborationbetween motivated patients, enlightened professionals and progressive government. Itgrew out of the voluntary sector and from the desire of people with long-term conditions,initially arthritis, to manage their own lives better.

Based on the Chronic Disease Self-management Programme developed at StanfordUniversity in the US, it was adopted by various voluntary organisations in the UK duringthe 1990s and following a report in 2001 became government funded.18 Governmentbrought growth and income and established the programme as a viable entity, but it also

17 Personal communication with the authors from Ian McDowell, assistant director for patient and public involvementat Newham Primary Care Trust18 Department of Health The Expert Patient: A New Approach to Chronic Disease Management for the 21st Century (2001)


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19 Cottam, H and Leadbeater, C Health: Co-creating Services (Design Council, 2004)

brought loss of control by people with long-term conditions. In 2007 the Expert PatientProgramme was returned to the ownership of people with long-term conditions when itwas made the first national community interest company, a new kind of not-for-profitlegal entity.

Since then it has both struggled to make its mark locally against the indifference of manyprimary care trusts and health professionals, especially GPs (who get paid under theQuality and Outcomes Framework for giving people drugs but not for referring them to a self-management programme), and made successful ventures into employment and disability issues, having recently started shared projects with employers to help peoplewith long-term conditions to work.

In their valuable paper, Health: Co-creating Services, Cottam and Leadbeater write:

We are arguing not for prevention in the negative sense of avoidance and reduction ofpressure on a service but rather for the promotion of well-being, living well and success-ful ageing … we are suggesting that the core principles of distribution, collaboration andco-creation offer a new way forward.19

The health service by itself cannot achieve the changes that are needed to create healthcitizenship. It lacks the skills, the understanding or the attitudes. As it nears its 60th year,we should leave the NHS to be a sickness service – it is quite good at it. We should recapturehealth from medicine, from research and from nutritionists, and take responsibility for it ourselves.

Principles of health citizenshipWe suggest some preliminary principles of health citizenship that can be learned fromwhat we know so far.

• Start where people and communities are.• Build on their motivation and values.• Have personal and locally, not nationally, owned objectives.• Create health through partnership and not power.• Put resources into the control of individuals or communities, not professionals

or governments.


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• Change the environment to encourage well-being.• Use legislation to promote health, not sickness.

In order to create health citizenship, we need local government, transport, housing, the environment, shops, employers, schools, faith and community groups, and families to engage in policies of wellness. National government should do less but better, concentrating on controlling the purveyors of ill health.

Examples such as the North Karelia Project and Communities of Health demonstrate thatit is simply not enough to know the causes of a particular disease, when these causes arerooted in people’s lifestyles. Rather, what need to be addressed are the social norms andpatterns of behaviour that create ill health in a particular community. This can be doneonly in partnership with people themselves.

Elimination of these root causes of disease requires positive action to be taken by members of communities to change the social norms and patterns of behaviour fromthose promoting sickness to those promoting wellness. Only individuals and communitiesthemselves can change their practices, and so it is at this level that resources need to befocused, and in such a way that there is a genuine partnership that engages with themembers of the communities and can build on their own motivations. Particularly in adiverse society, this will take a radical decentralisation of power, but one that is crucial ifwe are to have a health-promoting civil society containing active health citizens.


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Chapter 2

Responsibility for a healthyactive lifestyle

Andrew Ramwell, Director of the Manchester Institute of Sport &Physical Activity at Manchester Metropolitan University


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Responsibility for a healthy active lifestyle

May you live as long as you are fit to live, but no longer! or, may you rather die beforeyou cease to be fit to live than after!Philip Dormer Stanhope, 1749

These words probably echo most people’s hopes for their own life. But how much controlor influence does an individual really have in determining such outcomes, where the onlycertainty is that as sure as we are born we will die?

The available evidence points to the fact that the time spent between birth and death willdiffer vastly depending on where an individual is born. This stands true at a global, nationalor regional level. Globally life expectancy1 at birth ranges from 82.6 years in Japan to 39.2 years in Swaziland. Similarly, if two babies were born on the same day in the UK,depending on their postcode one could expect to live 8.5 years longer than the other. Thisrepresents the life expectancy gap between the lowest-ranking ward in Manchester andthe highest-ranking ward in Kensington & Chelsea. Living is not just about life expectancy,though; it is also about quality of life enjoyed or suffered depending on an individual’scircumstances.

Certainly, great strides have been made in controlling or eradicating infectious diseasessuch as smallpox and diphtheria. These efforts have had a knock-on effect in helping toincrease global life expectancy. Riley2 produced a paper outlining estimates of global lifeexpectancy from 1800 to 2001, which showed a global weighted average increase from29 years in 1820 to 66.6 years in 2001.

In the industrialised nations the typical killers have shifted from being infectious diseasessuch as tuberculosis and pneumonia, to chronic diseases such as heart disease and strokes.This shift was helped by a focus on public health with an understanding of the medicalconcept of diseases and the conditions through which disease thrived.

Edwin Chadwick’s report The Sanitary Conditions of the Labouring Population of GreatBritain (1842) is generally thought to provide the origin of public health as we now viewit. Linking disease, in this instance cholera, with the prevailing slum conditions, Chadwick,

1 UN World Population Prospects (2006), Table A.17 for 2005-102 Riley, C “Estimates of Regional and Global Life Expectancy, 1800-2001” in Population & Development Review vol 31,no 3 (2005), pp537-543


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a social reformer, “concluded that the most important measures which could be taken toimprove the health of the public were ‘drainage, removal of all refuse from habitations,streets and roads and the improvements of the supplies of water’”.3 The report, along withpublic pressure, helped to ensure that water companies took action to ensure the purityof their product. This was followed in 1848 by the first of the Public Health Acts that gavepower to local authorities to take control of their environment.

In the 20th century, from the 1950s onwards, there have been great advances in health.Improved technology and socioeconomic conditions have helped to create massivechanges in life expectancy and living standards (at least for a certain percentage of thepopulation). Prior to the advent of the NHS, getting sick was a terrifying affair for many,as noted by the title of Aneurin Bevan’s book about the march towards a national healthservice – In Place of Fear.

The emergence of lifestyle diseasesThe increased reliance on a biological model of health, advancements in medical technology,and a “free” health service in the UK have also created a public health dilemma, as issues of health have shifted from controlling infectious diseases (sickness) to managingchronic or so-called lifestyle diseases (well-being).

With a greater understanding of the aetiology of these lifestyle diseases, such as diabetes,strokes and coronary heart disease, we know that many are largely preventable. There is areal danger now of the medicalisation of society actually fostering and nurturing alearned helplessness towards health issues (not including cases of real dependency).Although great advances have been made in enhancing our understanding at a molecularlevel, in general the foundations for good health have been known for centuries. Fromearliest times sages, philosophers and commentators have given us quite detailed information on the necessary conditions to keep healthy and well, based on simple observational research.

Eating alone will not keep a man well; he must also exercise. For food and exercise, whilepossessing opposite qualities, yet work together to produce health. Hippocrates (460-375BC)

With the overwhelming confirmation of existing knowledge consolidated now with an

3 House of Commons Health Select Committee’s second report on health (2001)


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4 Wright, S “Blaming the Victim, Blaming Society, or Blaming the Discipline: Fixing Responsibility for Poverty andHomelessness” in Sociological Quarterly no 34 (1993), pp1-16 5 Wilcox, LS “Onions and Bubbles: Models of the Social Determinants of Health” in Preventing Chronic Disease vol 4, no 4 (2007)6 Quoted in Crister, G Fat Land: How Americans Became the Fattest People in the World (Penguin, 2003), p3 7 Farquhar, J The American Way of Life Need Not Be Hazardous to Your Health (WW Norton & Co, 1987)

ever-growing evidence base, we can confidently say that we should be able to “prescribe”the necessary conditions for optimal health, allowing people to truly realise the idealdescribed in the quote opening this chapter. In doing so, though, we enter into a philosophical and political minefield that has at its heart the notion of the role of the individual and their responsibility towards themselves and to the society they live in. Thisis an issue that Wright4 labelled “the individual/social structure dilemma”.

The individual aspect of the dilemma is consistent with ideologies grounded in beliefs ofindividual rights and responsibilities coupled with an expectation that each person isresponsible for their own particular circumstances. Furthermore, it suggests that the person possesses the solution for dealing with his or her problems. The Framingham studyinitiated in the 1940s was based on this notion and fostered health promotion modelsfocusing on an individual’s behaviour. The model and concept have had wide appeal, especially in America owing “to the deeply held American value of self-determination”.5

Social forces versus individual choice The alternative social view posits that unhealthy behaviours such as sedentary lifestylesare acquired within social groups and influenced by social forces. James Hill,6 an eminentobesity researcher, states that becoming “obese is a normal response to the Americanenvironment”. Certainly the speed of increase in the population levels of obesity cannot be explained by genetics alone, as rates in the US trebled within 20 years.

Social forces are not always as overt as many people believe, but for many the danger is also in the insidious but ubiquitous societal changes, as pointed out by John Farquhar7

in 1987:

The growing urbanization and mechanization of modern life have made it easier for usto become physically lazy and sedentary. We drive rather than walk; we take an elevatorrather than climb stairs; we push a button on an electric dryer rather than bend down andreach up to hang clothes on a clothes line. Whereas exercise was once an inevitable part ofliving, today we must consciously plan to get the exercise needed to maintain good health.


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In the intervening 20 years this has become an even more widespread phenomenon, with increases in labour-saving devices and car ownership. Changing work and social conditions have also contributed to a dramatic decrease in average miles walked and cycled during this period.8 Opportunities for habitual daily activity have been haemorrhaging out of our environments.

However, philosophically and practically the ideal position is not an either/or betweenindividual and societal structures, as ultimately any societal behaviour change will neces-sarily involve individual behaviour change. As Benjamin Franklin pointed out in 1781:

… to get the bad customs of a country changed and new ones, though better, introduced,it is necessary first to remove the prejudices of the people, enlighten their ignorance, and convince them that their interests will be promoted by the proposed changes; and this is not the work of a day.9

A problem identified with individual change is that the notion of lifestyle issues is usuallypresented “as if they reflect the problems of a homogenized society”.10 As already pointedout, health inequalities remain a powerful force within society at all levels. We live in acapitalist society where the classical political economic view arose from the conceptsespoused by Adam Smith in The Wealth of the Nations in 1776. Most striking was his theory of the “invisible hand” of the market, through which the pursuit of individual self-interest unintentionally produces a collective good for society.11 However, as withmany theories, the translation of concepts into the reality of life does not always follow faithfully.

The role of inequalityThe 1980s in both the US and the UK promoted a classical capitalist political ideology ofself and the concept of the individual making and shaping their own destiny. Individualwealth became a focus of attention and a key driver of the economy. The UK prime minister at the time, Margaret Thatcher, famously captured the prevailing political mood in her response to a remark about “people constantly requesting government

8 National Statistics Bulletin (National Travel Survey/Office for National Statistics/Department for Transport, 2005)9 Benjamin Franklin (1781), cited in US Department of Health & Human Services, Public Health Service, Centers forDisease Control & Prevention, National Center for Chronic Disease Prevention & Health Promotion, and Division ofNutrition & Physical Activity Promoting Physical Activity: A Guide for Community Action (Human Kinetics, 1999), p73 10 Crawford, R “Individual Responsibility and Health Politics” in Conrad, P and Kern, R The Sociology of Health & Illness(St Martin’s Press, 1981), pp468-48111 Adam Smith reference from www.wikipedia.org

intervention”. She said:

They are casting their problems at society. And, you know, there’s no such thing as society. There are individual men and women and there are families. And no governmentcan do anything except through people, and people must look after themselves first. It isour duty to look after ourselves and then, also, to look after our neighbours.12

Social divides were further widened, though, as the political landscape changed irrevocably.A discussion paper on international welfare states, looking at developed countries, commented that:

… the UK stands out for the sharpness of the rise in recorded income inequality in thesecond half of the 1980s. This was unparalleled in the countries examined.13

Although many people assume that a large swathe of the population nowadays enjoy ahealthier and wealthier lifestyle, both social and health inequalities have actuallyincreased in certain instances since the 1980s. For example, in the UK in the early 1970sthe mortality rate among men of working age was almost twice as high for those in classV as for those in class I; by the early 1990s, it was almost three times as high.14

Aneurin Bevan counselled against ignoring the individual:

Not even the apparently enlightened principle of the “greatest good for the greatest number” can excuse indifference to individual suffering. There is no test for progress other than its impact on the individual.15

The notion of an “individual” needs careful interpretation, as all individuals are part of asociety and heavily influenced by it. Man is a social creature by habit, as John Donne pronounced in his famous “No man is an island” quote,16 meaning that generally humanbeings do not thrive when isolated from others.


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12 Woman’s Own, 31 October 198713 Atkinson, A Seeking to Explain the Distribution of Income, Welfare State Programme discussion paper 106 (Suntory-Toyota International Centre for Economics & Related Disciplines/London School of Economics, 1994), cited in Benzeval,M, Judge, K and Whitehead, M (eds) Tackling Inequalities in Health: An Agenda for Action (King’s Fund, 1995)14 Acheson, D Independent Inquiry into Inequalities in Health (The Stationery Office, 1998)15 In Place of Fear (William Heinemann, 1952), pp167-16816 John Donne (1572-1631). Quote appears in Devotions upon Emergent Occasions, Meditation XVII

Nancy Krieger,17 in commenting on the logic of social epidemiology, offered the followingdeductions:

I. People live in the world simultaneously as social and biological beings. II. Disease, disability, death and health are embodied expressions of conditions under

which organisms live. III. Explanations of phenomena that address how and why they occur are more

complete than explanations addressing how they occur. IV. Epidemiological explanations of current and changing patterns of disease, disability,

and death must be compatible with temporally relevant and changing distributionsof determinants of and deterrents to the specified outcomes.

Furthermore, she adds:

Taken together these arguments imply that epidemiologically adequate explanations ofcurrent and changing distributions of population health entail simultaneous social andbiological explanations.

Krieger’s views are backed up in the opening statement by the Chief Medical Officer in At Least Five a Week,18 the 2004 Department of Health report on physical activity:

Current levels of physical activity are a reflection of personal attitudes about time use and of cultural and societal values. They also reflect how conducive our homes, neighbourhoods and environments have become for more inactive living.

A holistic concept of “environment”The Chief Medical Officer also noted that a “mass shift in current activity levels is needed”.With echoes of Benjamin Franklin’s earlier quote, it was viewed that such a shift will onlyhappen if “people see and want the benefits” but also by “building an environment thatsupports people in more active lifestyles”. The danger here is to view the “environment” as simply a physical one, but it needs rather to be viewed holistically, incorporating socio-economic, cultural and environmental conditions.


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17 Krieger, N “Commentary: Society, Biology and the Logic of Social Epidemiology” in International Journey ofEpidemiology no 30 (2001), pp44-66 18 Chief Medical Officer At Least Five a Week: Evidence on the Impact of Physical Activity & Its Relationship to Health(Department of Health, 2004)


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This concept and the role of the environment in shaping health were classically displayedin the Dahlgren-Whitehead model of health promotion.19 This showed that while an individual has no control over his or her age, sex and genetics, the wider determinants ofhealth can affect both the quantity and quality of life. Such determinants of healthinclude: individual lifestyle factors, such as diet, physical activity and smoking; social andcommunity factors, such as crime, unemployment and social exclusion; living and workingconditions, such as housing and air or water quality; and general socioeconomic factors,such as poverty and income, economic issues and educational attainment.

Our Healthier Nation 20 talked about a new three-way partnership between individuals,communities and government to help address co-ordinated action on these issues. It supposedly set out “a third way between the old extremes of individual victim blaming on one hand and the nanny state social engineering on the other”. Without individuals, families and communities working together, then any government action taken to addresslarger issues affecting health, such as housing, jobs and education, would be limited.

Intentionally or not we have socially engineered society to a point where, at the end ofthe 20th century,

… probably for the first time in human history, millions of people are able to lead extremelysedentary lifestyles. We no longer have to be active to obtain food, earn a living, or transport ourselves.21

As we know, “for every action there is a reaction”22 and the present sedentary lifestyle hassignificant consequences for an individual, mainly in a reduced quality and quantity oflife. With the estimated annual costs of physical inactivity impacting on the economy in England alone to the tune of £8.2 billion23 and rising, this is a highly significant fiscalissue as well.

Couple a sedentary lifestyle with the availability of high-fat and processed foods and we have the perfect obesogenic environment. This equates to a paradox of dramatic pro-portion, since in striving for a “better life” we have inadvertently created the very opposite

19 Dahlgren, G and Whitehead, M Policies & Strategies to Promote Social Equity in Health (Institute of Futures Studiesin Stockholm, 1991)20 Department of Health Saving Lives: Our Healthier Nation (The Stationary Office, 1999)21 Sallis, J, Owen, N Physical Activity & Behavioural Medicine (Sage, 1999)22 Isaac Newton (1687). See: http://en.wikipedia.org/wiki/Newton’s_laws_of_motion23 Chief Medical Officer, op cit (2004), piii

24 Ibid, piii 25 US Department of Health & Human Services Physical Activity & Health: A Report of the Surgeon General (USDepartment of Health & Human Services/Centers for Disease Control & Prevention/National Center for Chronic DiseasePrevention & Health Promotion, 1996) 26 Cavill, N, Kahlmeier, S and Racioppi, F (eds) Physical Activity & Health in Europe: Evidence for Action (World HealthOrganisation Regional Office for Europe, 2006)27 http://www.euro.who.int/hepa


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of that environment necessary for the optimal functioning of our genetic expression.

The scale of the obesity epidemic has, however, jolted people and created a tipping pointthat demands a response. Physical activity is now firmly on the radar screen of individuals,communities and governments:

The message in this report is clear. The scientific evidence is compelling. Physical activitynot only contributes to well-being, but is also essential for good health.24

I wonder whether, if we could look back at obesity in a couple of hundred years, we wouldview it as the cholera of our time?

The Chief Medical Officer’s report was designed to provide the evidence to support actionsat individual, community and government levels. Similar documents had already beenproduced in other countries, with the US Surgeon General’s Report on Physical Activity &Health25 being perhaps the best-known recent example. The World Health Organisation’sEuropean region also produced a short overview report in 2006, entitled Evidence intoAction,26 to support European policy makers and stakeholders and to provide a stimulusfor dialogue.

Across Europe two-thirds of the adult population do not meet the current recommendedlevels of activity. The WHO estimates that around 600,000 deaths per annum occur acrossthe region through physical inactivity.

Surprisingly, there is no official recommended level for physical activity across the WHOEuropean region, but most experts advocate meeting the UK Chief Medical Officer’s recommendation of “at least 30 minutes of moderate activity on at least five days of the week” (see table 1 for full list of recommendations). The WHO report stresses “the importance of physical activity as part of everyday life, not an optional extra to be addedat the end of a busy day”. The authors term this concept “health-enhancing physical activity” or HEPA, and there is a growing HEPA network across Europe.27


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Table 1: Recommendations for active living covering children, adults and older people, from

the UK Chief Medical Officer

• Children and young people should achieve a total of at least 60 minutes of at leastmoderate intensity physical activity each day. At least twice a week this should includeactivities to improve bone health (activities that produce high physical stresses on thebones), muscle strength and flexibility.

• For general health benefit, adults should achieve a total of at least 30 minutes a dayof at least moderate intensity physical activity on five or more days of the week.

• The recommended levels of activity can be achieved either by doing all the dailyactivity in one session, or through several shorter bouts of activity of 10 minutes ormore. The activity can be lifestyle activity or structured exercise or sport, or acombination of these.

• More specific activity recommendations for adults are made for beneficial effects forindividual diseases and conditions. All movement contributes to energy expenditureand is important for weight management. It is likely that for many people, 45-60minutes of moderate intensity physical activity a day is necessary to prevent obesity. Forbone health, activities that produce high physical stresses on the bones are necessary.

• The recommendations for adults are also appropriate for older adults. Older peopleshould take particular care to keep moving and retain their mobility through dailyactivity. Additionally, specific activities that promote improved strength, co-ordinationand balance are particularly beneficial for older people.

Source: Chief Medical Officer At Least Five a Week: Evidence on the Impact of Physical Activity & its Relationship to Health (Department of Health, 2004)

The big question is, of course: how can we encourage more people to become more activemore of the time? Table 2 highlights some of the key messages emerging from the WHOEvidence into Action report:

Table 2: Key messages from the 2006 WHO report on physical activity and health in Europe

• Three types of determinants of physical inactivity need to be tackled: individualfactors (such as attitudes to physical activity, or belief in one’s ability to be active),the micro environment (the conduciveness to physical activity of the places wherepeople live, learn and work) and the macro environment (general socioeconomic,cultural and environmental conditions).

• Health systems can foster multilevel co-ordinated action to improve participation inhealth-enhancing physical activity by, for example:

– providing evidence on what works;– supporting the exchange of experience and knowledge;– advocating physical activity to other sectors and providing them with the

tools to facilitate its integration in a range of policies; and– ensuring that physical activity becomes part of the mainstream of

health policies.• Physical activity is not just a public health issue; it also addresses the well-being of

communities, protection of the environment and investment in future generations.Countries need to reverse the trend towards inactivity and create conditions acrossthe WHO European region in which people can strengthen their health by makingphysical activity part of everyday life. Action should be large-scale, coherent andconsistent across different levels of government and different sectors.

Source: Cavill, N, Kahlmeier, S and Racioppi, F (eds) Physical Activity & Health in Europe: Evidence for Action(World Health Organisation Regional Office for Europe, 2006)

Translating messages into actionThe difficulty is translating the messages into action. The reality of this being achieved hasto be set against quite powerful forces, both social and commercial. For instance, the literacy skills of 12 million adults in the UK are level 1 or below, which is equivalent to thereading age of an 11-year-old or younger, and 16 million adults have poor numeracy skills.Edward Leigh, the chairman of the national Public Accounts Committee, was quoted assaying: “The low level of literacy and numeracy in the adult population is bad for nationalproductivity and bad for those individuals who may struggle to cope with work and dailyliving.”28 One would assume therefore that this severely limits the ability of these individualsto understand and fully engage with making informed choices about their health.

Simply putting out the messages isn’t enough, as a recent article in The Times 29 shows.Rather tongue-in-cheek, it suggested “Britons are embracing the government’s ‘five-a-day’ message as never before — that’s one cheeseburger, fries, a Coke, ice-cream, and, goon then, a portion of chicken nuggets”. The article was highlighting the fact that despitethe recent health messages McDonalds recorded its best year’s sales in 34 years in the UK,with over 88 million visits to the “golden arches” in Britain in just one month. Despite


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28 http://education.guardian.co.uk/further/story/0,,1693572,00.html29 http://business.timesonline.co.uk/tol/business/industry_sectors/retailing/article3142490.ece

McDonalds overhauling its menu in recent times to include healthy options, about 90%of sales in Britain were still for traditional fast-food fare like burgers, chips and ice cream.

Physical activity levels have remained relatively stagnant for decades despite the promotionof its health benefits. Table 3 highlights the key facts for physical activity and health.Stopping to think about exactly what the benefits are really brings home the fact thatbeing active is as fundamental for us as breathing or eating. The Chief Medical Officer hasstated: “Being active is no longer simply an option – it is essential if we are to live healthyand fulfilling lives into old age.”30 His aforementioned report provides evidence for physical activity offering protection against a broad range of up to 20 different chronicconditions. The National Institute for Health & Clinical Excellence (NICE) is producing aseries of guidelines to support physical activity across a range of settings and targetgroups (see www.nice.org.uk for more information).

Table 3: Activity benefits adapted from the Chief Medical Officer’s 2004 report

What we know about 30 minutes’ daily physical activity:

• It can halve the risk of developing/dying from coronary heart disease and stroke.• It helps relieve moderate and more severe depression.• It can protect against developing Type II diabetes.• It reduces the risk of premature death by 20-30%.• It can reduce the risk of dying from bowel cancer by a quarter.• It provides therapeutic effects for low back pain and osteoarthritis, and protective

effects for osteoporosis.

A recent newspaper article in a regional evening paper31 highlighted the impact at a morepersonal level, in reporting on a local woman who had lost more than 13 stone. She hadalso reduced the need for 24 different tablets she was taking to control various medicalconditions caused by her poor diet and inactivity. While this represents a massive cost saving to the NHS, perhaps the best outcome was what a difference it made to her quality of life: “I just can’t explain how fantastic I feel.” Alongside advice from her GP, she used a local commercial slimming club and a private fitness club to support her new regime.


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30 Chief Medical Officer, op cit, piii31 “Karen’s Half the Woman She Used to Be” in Manchester Evening News, 9 January 2008


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32 A scenario where levels of public engagement in relation to their health are high: life expectancy increases gobeyond current forecasts, health status improves dramatically and people are confident in the health system anddemand high-quality care. The health service is responsible with high rates of technology uptake, particularly in relationto disease prevention. Use of resources is more efficient. 33 Wanless, D Securing Good Health for the Whole Population: Final Report (HM Treasury, 2004)34 Pilzer, PZ The New Wellness Revolution, second edition (Wiley, 2007), p5

This example supports the “fully engaged”32 scenario outlined in the 2004 Wanless review.33

The review states that:

Individuals are ultimately responsible for their own […] health and it is the aggregateactions of individuals, which will ultimately be responsible for whether or not such an optimistic scenario as “fully engaged” unfolds. People need to be supported more actively to make better decisions about their own health and welfare, because there arewidespread, systematic failures that influence the decisions individuals currently make.

These failures include a lack of full information, the difficulty individuals have in considering fully the wider social costs of particular behaviours, engrained social attitudes not conducive to individuals pursuing healthy lifestyles and addictions. Thereare also significant inequalities related to individuals’ poor lifestyles and they tend to be related to socio-economic and sometimes ethnic differences.

These failures need first to be acknowledged and then tackled. Individuals can only do so much by themselves. They may also require wide-ranging support from government, communities and businesses. Since coming to power the government has ploughed significant extra resource into a range of different social programmes to try to reduce the inequalities gap within society. Decades of previous underinvestment by both main parties are not solved overnight, though, and inequalities still remain a pervasive andunwelcome force.

The role of the emerging wellness industryThe landscape is changing, though. Paul Zane Pilzer, an American economist, believes that the wellness industry will be the next trillion-dollar sector. He talks of a “wellness revolution” and points out that it is already a global $500 billion industry. He defines thewellness industry as “products and services provided proactively to healthy people (thosewithout existing diseases) to make them feel even healthier and look better, to slow theeffects of ageing, and/or to prevent diseases from developing in the first place”.34


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He also argues that economics are largely to blame for the current US situation, with largecompanies investing heavily in studies concerned with consumer psychology and demographics and then using this information to influence consumer choice. The scale ofthis was highlighted in a report by City University35 showing that in 2004 the combinedadvertising budget for Coca Cola and PepsiCo ($2.2 billion and $1.7 billion respectively)exceeded the WHO biennial budget.

The leverage power exerted by large companies needs to be noted, and dialogue isrequired to ensure that the private sector is engaged and aware of its responsibilities andopportunities. Companies will follow the line of profitability and shareholder return, asevidenced by the fact that many tobacco companies have diversified into other industriesas well. For example, Philip Morris is now the second-largest food company in the world after Nestlé, owning a raft of processed food brands such as Oreo cookies and Ritz crackers.36

Any public-sector investment must be amply sufficient to make an impact, or it will bedestined to fail from the outset. The funds required for delivery of Choosing Activity: APhysical Activity Action Plan 37 were either unavailable or not ring-fenced at the outset.The 2002 Wanless review38 estimated health promotion expenditure to be in the region of£250 million; this might sound a lot but it is less than the NHS spends in a day and a half.The recent King’s Fund update on Wanless39 reported that “it is impossible to track trendsin public health or health promotion spending since 2002 as no official figures are kept”.The original report had advised a doubling of health promotion spend to £500 million by2007/08.

More worryingly, physical activity seems to have been harnessed to support the drive totackle obesity. The danger in this is that under the obesity banner the focus is on sicknessand not wellness. The government has just announced a comprehensive cross-governmentstrategy called Healthy Weight, Healthy Lives that aims to support individuals, communities,and employers to effect positive behaviour change. The strategy acknowledges that, inparticular, obesity has been some 30 years in the making and will not be halted overnight.

35 Lang, T, Rayner, G and Kaelin, E The Food Industry, Diet, Physical Activity & Health: A Review of ReportedCommitments & Practice of 25 of the World’s Largest Food Companies (City University, 2006)36 Cited in Pilzer, op cit, p22 37 Department of Health Choosing Activity: A Physical Activity Action Plan (2005) 38 Wanless, D Securing Our Future Health: Taking a Long-term View: Final Report (HM Treasury, 2002)39 Wanless, D, Appleby, J, Harrison, A, Patel, D Our Future Health Secured? A Review of NHS Funding & Performance(King’s Fund, 2007)


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The strategy will have five areas of focus:

• the healthy growth and development of children;• promoting healthier food choices;• building physical activity into our lives;• creating incentives for better health; and• personalised advice and support.

The strategy is acknowledged as the first step and will be followed by “an annual reportthat assesses progress, looks at the latest evidence and trends and makes recommenda-tions for further action”. This sounds laudable but when one realises that this strategycomes off the back of a whole series of other strategies and plans, such as the Game Planreview (2002), Choosing Activity (2005) and Everyday Sport (2005), which have not beenrigorously evaluated, and that we still lack evidence of what actually works in practice,especially at a population level, then one does have to question what will make this strategy different. All the available evidence suggests that despite the rhetoric it won’t,unfortunately, be the 2012 Olympics either.

Whatever the source of the promotional message, most documents, strategies or reportsadvocate a similar strategy to the following excerpt:

Promotional strategies need to simultaneously target individuals, government policies,and community organisations if the goal is to create lasting behaviour change in ourcommunities.40

What is missing, though, in most is an explicit reference to any role for the commercialsector to help address the issues. This is not just about condemning or changing existingpractice, but also about opening up new markets and consumers within the wellnessindustry, as advocated by Paul Zane Pilzer.

The 2007 FIA State of the UK Fitness Industry Report 41 stated that this industry was worthsome £3.6 billion in 2006. Other headlines showed that around 12% of the UK populationare now registered members of a health and fitness club or publicly owned fitness facilityand almost 90% of the UK population live within two miles of such a club or facility.

40 US Department of Health & Human Services, Public Health Service, Centers for Disease Control & Prevention,National Center for Chronic Disease Prevention & Health Promotion, Division of Nutrition & Physical Activity, op cit, pxvii41 2007 FIA State of the UK Fitness Industry Report available from www.fia.org.uk.

The market has been growing steadily and has started to consolidate, yet it remains a competitive market. It is part of the solution to a more active nation, but not the sole answer.

There is, however, a difference between being a registered member of a gym and being auser. Gym memberships peak in January but less than six months later the majority ofthose registered will not be regular users. Adherence to structured exercise is difficult,although consumers can be encouraged and different types of reward schemes have beentrialled. The commercial success of large data-capture schemes like the Tesco’s Clubcardwill still probably be attractive to commerical companies wanting to help track and rewardhealthy choices.

The health insurance sector has now started to take a serious look at the prevention angle,as evidenced by the launch of PruHealth’s new Vitality reward system.42 It offers a rangeof discounts, support and other incentives for members who can prove that they are following a healthy lifestyle. For instance, they have a link with several gym chains wherethe more times a member is recorded as using the gym the less they pay for their membership. Since being launched in late 2004, PruHealth now covers over 140,000 lives.The company reported that, in a sample of customers, a third indicated that they hadchanged their behaviour for the better because of the Vitality reward scheme.

However, while both these examples are useful, they need to be placed in context.Individuals who use private gyms and can afford private health insurance are not usuallyin the hard-to-reach groups or among those most in need. The examples show, though,that the power and leverage of commercial companies need to be explored to support agreater reach. As one health commentator reported, the tobacco and alcohol companiesdon’t find it so hard to reach the groups we can’t!

The importance of physical activity in its own rightWith a plethora of reports over the last two decades about the benefits of physical activity, and many more stretching back centuries, the challenge is not to write more butto position the argument better and action it. “Walking is man’s best medicine”43 still holdstrue, but we are doing less and less of it.


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42 http://www.pruhealth.co.uk/medical_insurance/vitality/reduce_premiums.jhtml43 Hippocrates, Greek physician (460-377BC)

Physical activity is often quoted as a best buy for public health, but is it really ready toreceive this accolade? Not in its current state, I fear. There is no central driver for physicalactivity as an issue in its own right. It comes under the banner of obesity far too much.We should be focusing on how to get individuals moving more in their normal everydayenvironments. Physical inactivity is the real issue and this needs to be taken as the central message across all government departments. This is not only a health issue – justto be clear, let me say that again: this is not just a health issue; this is about how we liveour lives and allow our lives to be influenced and governed.

Ill health will be an inevitable consequence of being inactive, and we cannot escape thisabsolute fact. The health service may pick up the bill for the outcome, but it doesn’t run the transport system or build roads, it doesn’t run the education system, it doesn’t plan and build communities, it isn’t responsible for controlling crime and disorder. All government departments have a role to play in creating a more active environment, andthey must recognise that and be made accountable for their actions.

Already the balance is tipping towards the need to take on board a more sustainableapproach to any future policy development. I think that what we are now witnessing inpublic health is the outcome of an unsustainable approach to engaging with and deliveryof our sickness (née health) service and a systematic and prolonged failure to halt inequalities in society.

I believe that moving forward will be about creating markets of choice for individuals,supported by adequate legislation and stewardship from government that protects themost vulnerable, and does not allow rampant commercial monopolisation or exploitationwithin a particular sector. If we are honest, most people want to live well and long, butfor all sections of society to live a long and healthy life requires a four-way partnership.The individual is at the heart of the partnership, supported by and engaged with their localcommunity, the government of the day, and the commercial sector.

We can look at other examples that have worked previously, such as the smoking ban andseatbelt legislation. Both of these bills came into force despite being defeated many timesand regarded by some as “a step too far” and an intrusion into our personal lives. Thesewere long-term campaigns, where the weight of evidence, a shifting tide of public opinion and a commonsense acceptance of the arguments meant that the measures were finally introduced.


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44 Department of Transport Highways Economics Note No. 1: 2002 (2003), cited in Jochelson, K Nanny or Steward? TheRole of Government in Public Health (King’s Fund, 2005), p22

The first mandatory seatbelt bill was introduced in 1973 but did not get passed for another10 years and then only for those in the front of the vehicle. It was not until 1991 that rearseatbelts became mandatory as well. The costs incurred by the avoidable deaths andinjuries resulting from the delay are estimated at £163 billion (this figure includes thecosts of medical care, loss of economic output, loss of life and long-term injury).44

Aside from the lives and money saved, the legislation also prompted changes in designand manufacturing of cars. For example, most manufacturers have now introducedbehaviour prompts so that if seatbelts are not engaged an audible beeping sounds or thedriver may not be able to start the engine. These examples of design changes were initiallysold as safety features to customers, but consumers have begun to expect increasinglysafer cars to drive and actively buy cars based on, among other factors, the NCAP safetyrating.

The effect of the smoking ban cannot really be analysed yet, as it was only introduced in2007, but many restaurants had already banned smoking prior to legislation, in responseto customer demands. They realised that they could increase sales by targeting and so attracting more non-smoking customers or those wanting to eat in a smoke-free environment. The long view must be adopted for societal-level changes, but this is difficult for any government to achieve as the “politics by media” approach that seems toexist in today’s society requires quick action and innovation when things go wrong.

Obesity has been rightly identified as a cross-government issue, but given the currentstarting point it will also be a multi-generational issue – especially in trying to rebalancethe “energy in/energy out” equation. Habitually consuming food is both cheap and easy,while expending energy is much more difficult unless it is programmed in. Food productionalso attracts massive subsidies, with EU and government support, and is backed by bigadvertising budgets and targeted marketing. From this point of view, physical activity isvery much the poor relation in the equation.

If government, society, communities and individuals really want to make a stand andreverse this situation, do we really know – and are we prepared to make – the level ofcommitment necessary in terms of time, money and action? Deconstructing the currentsocial environment and rebuilding one that is better suited to both our genetic make-up


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and aspirations requires that the physical activity lobby learn from the lessons of the anti-smoking and seatbelt lobbies by adopting a longer-range view, celebrating each positivestep and keeping on moving forward until a more active and sustainable environment is created.

It seems that Benjamin Franklin was right all those years ago about this not being thework of a day. As with most things that we already know about health, it is not a lack of understanding that causes the problems but a lack of action. In an era of instant gratification, we may not like what we have been sold, but the price of being born was toaccept an evolutionary heritage that until recently had served the species very efficiently. It is time to get back to basics and start to construct a more sustainable environment thatallows for an optimal expression of the true dynamic of human potential.

Confucius said that “a journey of a thousand miles begins with a single step”; what stepscan you take today to support a more active and healthy society?


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Chapter 3

Reinventing the politics ofhealthy living

David Walker, Editor of The Guardian’s monthly magazine for public-sector managers, Public, and Trustee of the Nuffield Trust


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Reinventing the politics of healthy living

Information about healthy living abounds, both in amount and quality. The topic is culturally salient; it is in the news, in the soaps and has become a standby for documentarymakers. Anna Coote, formerly head of patient and public involvement at the HealthcareCommission, observes that there is “more interest in improving population health than atany time since they worked on the drains [in the mid Victorian period]”.

We know how consumption and lifestyle need to change, if well-established trends inmorbidity are not to accelerate. The fiscal consequences of unhealthy living were spelledout in the Wanless reviews, and no one has disputed the projections. Unhealthy lifestyleswill inflate demands on the NHS in years to come, reigniting the argument that Labourhas so successfully quelled, about whether free-at-point-of-use publicly provided health-care can be met within the bounds of politically acceptable tax-to-GDP ratios.

Miranda Lewis of the Institute for Public Policy Research has said that the state needs tobe “cleverer” in its healthy living interventions.1 But the hard question is not really aboutpolicy design. The preconditions for greater health literacy are well known,2 and the former Health Development Agency is only one of several government bodies in Englandand elsewhere in the UK – public health doctors to the fore – that have worked out howto combine information, fiscal disincentives, primary care practice and propaganda, andto join up tiers of the state itself in a common endeavour.

What is missing is a politics of healthy living. Before policy can grip, will has to be shown,girded by the conviction not only that collective and individual interests can be rebal-anced but that it is the state’s duty (and fate) – amid globalisation – to set boundaries tomarkets and to limit individualism and truncate choice. With banking, so with calories: itis at the moment of capitalism’s triumph when the state is most needed to confine andsometimes abandon markets.

Healthy living demands a dose of revisionism. We need to shift gear intellectually: consumption and lifestyles defy the economists’ models. From obesity to climate change,what we do calls for more textured explanation and, eventually, subtler policies to go withit. A new rhetoric will deny that well-being is freedom to eat chips, and may go on to

1 Lewis, M States of Reason: Freedom, Responsibility & the Governing of Behaviour Change (Institute for Public PolicyResearch, 2007)2 Sihota, S and Lennard, L Health Literacy: Being Able to Make the Most of Health (National Consumer Council, 2004)


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subvert the assumptions behind macroeconomic policy.

If increments in GDP per head contribute virtually nothing to subjective well being whileincreases of inequality are strongly and positively harmful then the rise in GDP andinequality has left society clearly worse off.3

Labour ministers would have to stand up and do something they have found especiallydifficult: declare faith in the state. They would paraphrase Hegel in saying that, in mattersof healthy choices, the state does possess higher rationality – or at least the doctors it employs do. In this arena, post-war Labour minister Douglas Jay’s “man in Whitehall” usually will know better and, in the person of the Chief Medical Officer if not ministersthemselves, should no longer be afraid to say so.

Geoff Mulgan of the Young Foundation (and founder of Demos) prefers to label theapproach “soft paternalism” … although parents still need, occasionally, to reprimand, andthat implies feeling comfortable in exercising authority. Ministers have to come to termswith such (unfashionable) tenets as that professional expertise should trump gut feelingand that it is the state’s job to anticipate the unintended collective consequences ofaction by individuals.

In practice, of course, government does this all the time. Perri 6, the professor of socialpolicy at Nottingham Trent University, has been putting together a “bossiness” index,based on how far departments seek to regulate and change behaviour. Poor people andestate dwellers, let alone perpetrators of antisocial behaviour, are regularly subject to thestate-knows-best doctrine. Westminster speeches about choice and autonomy usuallystop short of low-income households.

The government does, apparently, believe in intervention and the possibilities of behaviouralchange. Alan Johnson, the Health Secretary, recently backed the fluoridation of water – astate instruction to private companies to do something about which individual consumersare not to be consulted – confidently saying that the common good demanded it.

Yet ministers regularly hesitate and zip their lips about the whys and wherefores of action.A preference for stealth has characterised the Blair-Brown era. Just as in the Wilson

3 Offer, A The Challenge of Affluence: Self Control & Well-being in the United States & Britain since 1950 (OxfordUniversity Press, 2006)

government in the 1960s omertà was declared over devaluation, so Blair-Brown has forbidden speech pointing out the malign effects of market freedoms and the benignityof most state action. In health such reflexes have been coupled with a dogmatic insistenceon choice and individualisation which, if followed to the letter, would rule out interven-tions to change unhealthy behaviour.

Towards a new rhetoric of healthy livingTo move forward, ministers have to abandon the neo-liberal fixation of recent years, especially the contention that only prices (“incentives”) change behaviour. A juvenile version of economics has held sway (rejected by the professionally mature) that definessocial life as a set of monetised transactions. Citizens, parents, children, become reducedto consumers and the metaphor of life as consumption rules, as if we are permanentlytrapped in the aisles of Tesco and our only response is to buy the cheapest can. Whitehallneeds to recruit some psychologists.

Individualism has had so much purchase in politics and policy in recent years, and itdeclares that people know what is best for them. They self-evidently don’t, or why wouldobesity have become chronic? (Many cannot of course afford to make healthy choices inconsumption, let alone housing, employment and lifestyle.) Because of ministers’ low ratings on indices of trust, they quail at actions that they fear (often without evidence)might further lose them standing.

Politicians cannot, for instance, say what is manifestly true: that, making due allowancesfor schooling and household income, a large number of people are stupid, perverse, selfish and self-harming in how they behave in the kitchen, in the supermarket, on theroads and towards their children. What cannot be said, in conventional political discourse,is that many people, much of the time, are lazy and unwilling to go an extra inch, let alonean extra mile, towards the “engagement” specified by Wanless – although even that, aswe will see, is far from unproblematic.

Changing behaviour is 21st-century politicsRhetoric and political culture are out of kilter with much of what government does inpractice, and that is puzzling. The Prime Minister’s Strategy Unit in 2004 said that akeynote of public policy during the first two decades of the century, and beyond, had tobe “ability to induce change in the behaviours of the public”.4 Examples are legion.


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4 Strategy Unit Strategic Audit: Progress & Challenges for the UK (Cabinet Office, 2004)

Individuals under-save for retirement, they “over-consume” housing, they fail to conserveenergy at home. Fewer teenage women and men should have children. More homesshould sort their refuse and recycle. We all drink too much and ingest too much energy.And so on.

That “social problems” will be solved or ameliorated only by altered individual and house-hold behaviour is now a commonplace. Yet few seem to have thought its logic through.“Policy is neither neutral or blind to outcomes; it defines certain social goods,” MirandaLewis wrote in her IPPR report.5 But that must mean that government possesses more orbetter knowledge and/or more wisdom than the governed. Ministers are extraordinarilyreluctant to say as much. Perhaps their self-confidence would be infectious.

The means by which governments change behaviour, or not, is a long story. Legislationand regulation are associated with profound alterations in social habits: drink-driving andsmoking cessation are examples. Political will is unlikely to “cause” behaviour to move ina linear fashion. But behavioural change is not random; leadership and political reorien-tation deserve due weight. Take abortion. What people did (see Vera Blake) anticipatedchanges in what they believed about abortion. Then in the 1960s the law changed: MPswere probably ahead of opinion but broadly in line with practice. Then opinion stabilisedat a new level and has since proved resistant to further change. Perhaps external shocksare needed to produce substantive shifts in behaviour – which is what some climatechange activists say.

Price elasticities for various harmful goods vary widely. Despite taxing the consumptionof drink and transmitting a profusion of messages, government has had little discernibleeffect on trends in alcohol consumption. But drink policy is not one-dimensional, asdebate over licensing hours has shown. Under Blair-Brown, heroic attempts have beenmade to change behaviour, though mostly that of the poor and socially problematic.

Sure Start is a grand example of seeking simultaneously to amend behavioural deficits inchildren and push their parents to do things differently. In schools – leaving aside theobvious point that all education is intended to be behaviour changing – take the recentinnovation of home-school agreements. These are a form of contract, binding parents todiscipline their children, prevent them from truanting and supervise their homework. A few parents who were found persistently to have failed to ensure children’s school


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5 Lewis, op cit


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attendance were imprisoned. Health improvement measures are puny by comparison.

The point is not whether interventions work. It is hard to establish links between inter-ventions and results,6 but the complexity of motive and the sinewy resistance of habitualbehaviour do not prescribe passivity for either policy makers or politicians. There is nogeneral formula; interventions need to be tailored and, preferably, go with the grain ofprofessional practice and core public attitude. Ministers (and councillors, along with otherpolitical actors) can influence the “weather” and create a climate of words and values thatcensure the bad and praise the good. Just because they should exercise humility overintervention should not impede ministers in asserting values and political beliefs.

The politics of “encouragement” and “engagement”“It is now generally accepted that engaging the public with policy improves implementation”,the IPPR report said. But what stops engagement becoming another version of the doctrine that individuals know best what is good for individuals, regardless of the collective interest? Engagement is either a truism of everyday democracy – people shouldbe involved – or a radical deconstruction of professionalism, politics and policy making.Take the proposition that behavioural interventions will work only if citizens are “involvedin the larger decisions about which social goods are a priority”. Does that mean taking apoll on the dangers of MMR? Is there evidence for the proposition that civic engagementsuch as voting or attending discussions translates into changed behaviour, either for participants or for those who continue not to be involved?

Wanless and proponents of engagement sometimes sound like they believe cognitionequals rationality. Maximise the flow of information and people will adjust their behaviour. The evidence is indeed that education correlates with capacity to understandhealth matters, as it also correlates with physical health, longevity and well-being. Literacyand health literacy are pretty much the same thing. Years of schooling and college areassociated with (= cause) closer adherence to medical advice. One conclusion is stark. If abetter-educated population is healthier, some of the money spent on health would bebetter spent on education.

During the Blair-Brown era, it could be argued, expenditure was disproportionately directedtowards consumption – healthcare – rather than towards investment – education – thatwould have returned all kinds of benign effects, including more healthfulness (and

6 Person or Place Based Policies to Tackle Disadvantage? Not Knowing What Works (Joseph Rowntree Foundation, 2008)

reduced demand for healthcare) in the long run. It is a curious mirror of the squanderingof resources under Thatcher, with huge sums of money being used to maintain employmentand long-term incapacity instead of interventions in labour markets, projects and infra-structure investment that would probably have had longer-run benefits for productivity.

ChoiceMinisters simultaneously extol choice and deplore the perverse consequences of choice.On climate change as well as health, government seems to say that freedom of choice isthe 21st century’s existential precondition. All government can do is seek to persuadechoosers. In fact what government does is more ambiguous. People are deemed fit tochoose a hospital, consultant and GP, not to mention schools and social care providers,but they are not fit to choose therapies, curriculum or service level. Where do consumptionchoices fit on the spectrum of volition? The rationalist model points to labelling: the stateaccepts choice, and its role is to ensure “adequate” information is provided – usuallymeaning information that will convey to a rational reader the potential harm, as discernedby experts.

This is a curious halfway house. It is as if the harm is explicitly recognised, but not to beacted upon. What if ministers started saying that choice is not a good thing but rather isindulgence and selfishness and, worst of all, self-defeating?

Is “trust” a precondition of intervention?That is naive, it will be argued. In the degraded condition of modern politics, ministerswould not dare. To reject individualism openly would be to invite electoral retribution. It would upset the marginal voter and/or discomfit the southerners on whom a House of Commons majority depends. The IPPR argument was that state interference riskedundermining trust. “If the state is perceived as authoritarian or even simply as nagging,fragile trust in politics can be further eroded.”

There are two responses to this, which are not mutually exclusive. One is to use proxies forpoliticians to convey to the population a collective message (see below). The other is todo more rather than less politics. It is too simple to invoke “leadership” and assert thatpeople would respond to authoritative (not authoritarian) messages about what is goodto eat and drink. But political leaders could talk values much more eloquently than theydo and preach. The Al Gore example shows that preachers do not all have to sound likeElmer Gantry. Preaching runs the risk of hypocrisy: the House of Commons does not needall those bars, and state banquets could be defatted. The state would find it hard to be


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saintly, though in other spheres (diversity, procurement, employment) it often succeeds in setting an example.

Reinventing professionalismRaymond Tallis7 probably spoke for many clinicians in bemoaning the “lopsided idealism”that implied the patient knows best. The patient comes on as empowered consumer and “while the doctor must altruistically treat the patient as an end in himself, most importantly she will not pass judgement on the patient, whatever the demands for treatment, time or attention”. Choice and the encouragement of patient activism raise thestatus of “convinced laypersons” who pit their knowledge against that of the trained professional, which is founded on contestation and peer scrutiny. Post-modernism hasfew outposts in politics, however, and ministers usually know enough to value expertise.

But that is not the same as saying GPs could not be much more effective doctors, if onlythey listened more, if only they were more “engaged”. Studies of patients with chronicconditions suggest there is a wish to be talked to and to be talked through treatments,but not at all to control them. Face-to-face discussion with healthcare professionals ishighly prized by patients. Co-production is a misnomer if it implies subjectivity has thesame chemical charge as pharmaceuticals, but it directs attention to the importance ofdialogue and exchange, which have their place even in classrooms, where the distributionof knowledge between teacher and taught is not symmetrical. Modernity makes “respect”a treasured process. There is no reason that such respect (itself bilateral) could not coexist with cognitive asymmetry.

Doctors, in other words, and their healthcare colleagues have a large and perhaps as yetunrealised role in consumption choices. Their systemic importance does not mean thathealth secretaries should buy them off or interrogate their use of NHS time. But how farhas the realisation of the goals of the healthy living prospectus been helped or hinderedby recent healthcare restructuring, and the poor quality of the dialogue between thesepivotal figures and policy makers?

Conclusion The politics of healthy living need to be reinvented, as a ground for values and ideas.Ministers must not confuse legislation with political action. Labour ministers have beenprone to think that passing laws makes people behave differently: witness the great raft


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7 Tallis, R Hippocratic Oaths: Medicine & Its Discontents (Atlantic Books, 2004)

of criminal justice legislation in recent years. The Brown government’s anticipation of abill of rights suggests that they may have learned that talk – what politicians should do– can be as effective as law in altering perceptions and creating moods. Healthy livingcries out for ideological readjustments, for a statement of the limits to individualism, forjustification of state action constraining choice. Before the long-run health of the publicimproves, politics must move.


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Chapter 4

The role of the private sector inpromoting healthy behaviour

Shaun Matisonn, Chief Executive of PruHealth


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The role of the private sector in promoting healthy behaviour

Historically, members of the public came into contact with healthcare providers (whetherNHS services or private bodies) only when they were ill. However, the recent rise in chronic diseases has, necessarily, led to a greater focus on prevention, which in turn hashighlighted the role that the private sector can play in encouraging healthy behaviour inpeople before they become ill.

While the responsibility of government in promoting public health and preventing diseasehas long been established, the role of the private sector in this area is somewhat under-developed. Important questions include:

• How can the interests of consumers and the private sector be aligned to promotehealthy behaviour?

• What is the relationship between the private sector’s role in promoting healthybehaviour to its customers and promoting it to the public at large?

• Does the private sector have any mechanisms at its disposal that are not available tothe state sector?

• How does the link between health and its financial implications play out in practice?

The rise of “lifestyle diseases” Over the last 100 years, the Western world has seen a revolution in the medical sciences.Not only are people now living longer, but also they are healthy for longer than at anyother time in history.

This progress, however welcome, is not without its problems. People’s expectations abouthealthcare have also risen. There is now a legitimate demand for the latest treatments –both curative and palliative – to be available to all. Moreover, while medical advances havesaved lives, other developments in the modern, affluent world have meant that peoplenow lead much less active lives than ever before. This, coupled with increasingly unhealthydiets, has led to an obesity explosion throughout the developed world, which raises concerns about whether the trend towards increased longevity is sustainable.

The recent Foresight report1 laid great stress on the fact that we live in an “obesogenic”environment, with various aspects of the UK lifestyle making it relatively easy for individuals

1 Tackling Obesities: Future Choices, the Foresight report (Government Office for Science, 2007)

to gain weight. Today, almost two-thirds of English adults are thought to be obese oroverweight – a proportion that is expected to rise rapidly to 90% over the next 40 years.This rise in obesity is forecast to result in a corresponding cost of around £50 billion peryear by 2050 as a result of the increased vulnerability to cancer, cardiovascular disease and diabetes.2

The Foresight report called for a combination of actions and policies to reverse this trendtowards obesity. It warned that if the problem is not addressed, there is the distinct possibility that the generation growing up today may live shorter lives than did their parents.3 Moreover, obesity-related diseases threaten to put significant strain on theresources of the NHS, which is spending more and more on the treatment of essentiallypreventable diseases.

While the statistics and projections are alarming and do give due cause for concern, theproblem is not insurmountable. Obesity and its related risk factors are preventable throughdiet and physical activity: according to the World Health Organisation, up to 80% of type II diabetes could be prevented.4 However, for this to happen, people need to be motivated appropriately and given easy access to healthy lifestyle choices.

Motivating people to make these healthy choices is no easy task. There is no single campaign that can be effective in encouraging everyone who is overweight to changetheir lifestyle, particularly if the healthy choice is not readily available, affordable or,indeed, attractive. There is therefore a risk that the gap between the most and the leastadvantaged members of our society will widen. However, if we can offer a wide enoughrange of tailored interventions so that the needs of each individual are met, we can make the changes needed to halt, and hopefully reverse, the seemingly inexorable trendtowards obesity.

The private sector must sit alongside government as part of the solutionThe causes of obesity and the means by which to tackle it are already becoming wellembedded in the private sector. However, the private sector cannot alone provide thesolution, and a society-wide solution must involve employers, the fitness industry, food


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2 Healthy Weight, Healthy Lives: A Cross Government Strategy for England (Department of Health, 2008)3 Olshanksy, S et al “A Potential Decline in Life Expectancy in the United States in the 21st Century” in New EnglandJournal of Medicine no 352 (March 2005), pp1,138-1,1454 Diabetes Action Now: An Initiative of the World Health Organisation & the International Diabetes Federation(World Health Organisation, 2004)


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producers and supermarkets. This is in marked contrast to, for example, the fight againstcommunicable diseases such as MRSA in hospitals, which is another widespread healthconcern, but one that is very much contained within the health sector itself and wherethe solutions also rest in the public heath sphere.

Given the complex factors behind the rise in obesity, involving market forces (where possible) to bring about lifestyle changes is likely to result in positive outcomes. Individualchoice must be the focus of any attempt to make lifestyle improvements, both in terms of the desire to make a particular change, and in the way that the change itself is accomplished.

Many private-sector organisations are involved in health and wellness initiatives as partof their approach to staff recruitment and retention, or even as part of their marketingstrategies (for instance, in the case of the fitness industry). However, one sector where theincentives for tackling the implications of lifestyle diseases are particularly keenly felt isthat of health and protection insurance providers. For these organisations, the health ofconsumers is more closely linked to the bottom line of company profits than in any othersector.

What is the relationship between the private sector’s role in promoting healthybehaviour to its own customers, and promoting it to the public at large?One consequence of the freeing up of labour markets over recent decades has been areduction in the incentives for employers to take account of the long-term health of theirstaff. Forty years ago, when a job in many organisations meant a job for life (or at least for the next 10 years), it made perfect economic sense for an employer to investheavily in a wellness programme that might show returns over a 10-year period. In the21st century, however, as the average length of employment with the same company isless than five years, this investment is less evidently attractive.

In spite of these developments, some companies in the UK have begun to look at thereturn on investment of their health programmes over as little as three or five years, inrecognition of their value in terms of reduced absenteeism, recruitment and retention.

For health insurers who cover a portion of the healthcare costs of many of these employees,the benefits of investing in wellness are even stronger. Since customers are expected to becovered for many years, insurers can take a long-term view on the impact that lifestylechanges can have on healthcare costs.

This means that there are strong financial reasons to make short-term investments to encourage scheme members to make healthy choices. To some extent, there is also value to be obtained from encouraging non-members as well. An insurer that invests substantially in wellness activity is likely to benefit from a greater credibility in the marketplace among both individuals and advisers. Individuals will benefit from this to theextent that the advice is good. Typically there is a high degree of alignment in practicebetween the health messages put out by the private sector and by governments.

Does the private sector have any mechanisms at its disposal that are not availableto the public sector?As a publicly funded body and as the most significant provider of healthcare to the population, the degree of control available to government in directing the public heathagenda is considerable. Furthermore, the integration between the provision of healthcareservices and public health initiatives should give rise to a greater probability of success. Inaddition, the NHS has the advantage of economies of scale. As a body covering the entirepopulation of the UK (although, admittedly, healthcare is now undertaken by the individualNHS organisations in each of the UK’s devolved regions), it should be able to obtainresources efficiently (whether media or other) for its public health campaigns.

However, the public sector is often restricted in the extent to which it can take risks withnew approaches or deliver innovative solutions. In contrast, the private sector is generallyless risk-averse and is frequently more willing to consider innovative approaches to delivering better public health outcomes. This is particularly evident in the area of incentivising healthy behaviour, where businesses have a much greater freedom to formlinks with other private-sector organisations, by, for example, providing ways to rewardpeople for looking after their health.

Once innovative ideas have been developed by the private sector, then of course the public sector can benefit from them as well. There is therefore significant scope for businessand government to find common ground and benefit from each other’s experiences.Lessons can be learned from the private sector with regard to incentivising behaviourchange, and these models can be transferred successfully to the NHS for the benefit ofthe wider population.

The role of incentives in encouraging healthy lifestylesThere are well-established links between the level of a person’s personal wealth and their health and life expectancy. International evidence broadly shows that the wealthier


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someone is, the more likely they are to live a long and relatively healthy life.

But the links in the other direction are equally strong. A change in health status is one ofthe strongest determinants of a change in financial position. Health has a major influenceon more than simply the ability to work and to be productive. A recent report noted thatwhen an individual’s health status deteriorated from good to poor, his savings decreasedby a factor of five, and that changes in health had a larger impact than any other factoron levels of savings.5

The net effect of this is that there has been an opportunity to develop new insurancemodels that recognise these links between health and wealth. If protection products cango beyond simply paying out when people are ill, to helping them to become healthier,then the financial savings can be shared to give better protection, to more people, atlower cost. The way that insurance schemes have sought to achieve this has been to makeuse of financial incentives to encourage a move to healthy behaviour.

There is a small but growing body of literature on the impact that financial incentives canhave on behaviour. A recent survey from the King’s Fund6 found that these incentives canbe effective in persuading people to make lifestyle changes that will be beneficial to their health. They seem to have greatest impact when the actions being rewarded are simple, and when the rewards are immediate. Furthermore, there seems to be additional, sustainable motivation in the rewards being part of a consistent incentive programmerather than as one-off payouts.

Incentives can be thought of as falling into two main categories. Firstly, they can be usedto reduce the financial barriers to engagement with certain behaviour. For example,reductions in the cost of gym memberships can be used to incentivise exercise. Secondly,they can be used to reward such behaviour change, where the benefits of better healthare perceived as being uncertain or long-term.

One example of an incentive scheme being used to manage health is the Vitality programme being operated in the UK by PruHealth. This scheme acts as a kind of tokeneconomy, with members earning points for positive health-related activities, in a way thatis balanced between the effort put in (for instance, gym visits) and the gains made (such


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5 Gupta, V Wealth Shock & Impact of Health on Risk Aversion & Savings, Watson Wyatt technical paper no 07/07(Watson Wyatt Worldwide, 2007)6 Jochelson, K Paying the Patient: Improving Health Using Financial Incentives (King’s Fund, 2007)


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as a reduction in body mass index). The programme is primarily focused on the lifestylefactors that have an impact on future chronic healthcare conditions.

A recent study of 900,000 people, conducted in conjunction with the University ofWitwatersrand, the University of Cape Town and Harvard Medical School, found thathighly engaged members of the Vitality programme experienced significantly lower costsper patient, shorter stays in hospital and fewer admissions, compared with all othergroups. The difference in cost of treatment per beneficiary of the highly engaged groupwas over 7% lower for cardiovascular disease, over 15% lower for cancer and over 21%lower for endocrine and metabolic disease.7

ConclusionThe rising burden of chronic disease is going to be perhaps the single most importanthealth issue over the first half of this century, and the private sector will be an essentialpartner for government in the task of improving public health. Many companies will findthat their own financial interest is directly aligned with improvements in their members’health, and some of the ideas used by these companies to encourage consumers to makemore healthy choices are likely to have value in the public sector. With both the public andprivate sectors playing to their respective strengths, there is evidence emerging that significant progress can be made in reducing obesity over relatively short timescales. Thisis not to imply that the problem is solved, but it does give significant cause for optimism.

7 Lambert et al “Participation in an Incentive-based Wellness Program and Health Care Costs: Results of the DiscoveryVitality Insured Persons Study (VIP Study)”, under preparation for publication in the Journal of the American MedicalAssociation (forthcoming)


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Chapter 5

Towards wholly healthy places

Neil McInroy, Chief Executive of the Centre for Local EconomicStrategies


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Towards wholly healthy places

Britain’s places are generally improving. Cities and towns have enjoyed a renaissance ofsome public note over the last decade or two. Fresh urban spaces, revitalised commercialcores, improved transport and new city-centre lifestyles have created a vibrancy and energy in many towns and cities. However, in spite of parallel social and communityregeneration initiatives, this renaissance is incomplete and patchy, with the range of beneficiaries sometimes limited by age, ethnicity, gender, wealth and so on.

This variation, of course, correlates in terms of health. For example, work by the NorthWest Public Health Observatory1 reveals that the least deprived in the North West regionmay be expected to live 12 years longer than the most deprived.

Furthermore, in many locations we see significant spatial variations in health. Figure 1highlights a geographic variation in health, with every stop on the Tube travelling on theJubilee line in London from west to east representing one year less of life expectancy.Starting in wealthy Westminster, you could expect as a man to live to nearly 78, and as awoman to 84, but by the time you get to Canning Town you could expect as a man to liveto 71, or 80 if you are a woman.

Figure 1: Differences in life expectancy in a small area of London – the Jubilee line route

to health inequalities

Travelling east from Westminster, each Tube stop represents nearly one year of life expectancy lost

Source: London Health Observatory

Male life expectancy77.7 years (C175.6-79.7)

Female life expectancy84.2 years (C181.7-86.6)

Male life expectancy71.6 years (C169.9-73.3)

Female life expectancy 80.6 years (C178.7-82.5)

Westminster

Waterloo

Southwark

London Bridge

BermondseyCanada

Water

CanaryWharf

Canning Town

North Greenwich

1 Wood, J, Hennell, T, Jones, A, Hooper, J, Tocque, K, Bellis, M Where Wealth Means Health: Illustrating Inequality in theNorth West (North West Public Health Observatory, 2006). Available at: www.nwpho.org.uk/documents


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However, while poverty is an important contributory factor, the situation is complex. Notall forms of ill health correlate to deprivation; some ill health relates to general well-being,which, while potentially exacerbated by income levels, is rooted in more general issuessurrounding modern British life. These wider contributory factors of ill health have traditionally been reflected in the social determinants of health model, in which ill healthis considered a product of individual, social and community living and working conditionsas well as of wider socioeconomic and environmental considerations.

In thinking about health and place, the role of society and the interactions that occurwithin places is well recognised. It may be useful to bear in mind those organic metaphorsthat describe the city or town as a body, with the streets and roads as the arteries, the parks as the green lungs and the city or town centre as the heart or head. Ideally, what we wish to see are places that are in effect living, breathing things – with the environment, culture, society and economy as their key organs.

Therefore, to accommodate the wider determinants of ill health, it is in our view useful tothink about how we create effective places: wholly healthy communities.

A problem of approachThere are a range of policies and strategies that recognise the spatial variation in health.These include specific place-based policies at the local scale, such as the New Deal forCommunities, and national policy targeting resources to particular places, such as theSpearhead group of local authorities and primary care trusts.2 Despite this, there remaingrowing levels of ill health with increasing spatial disparities.

Thus, it is argued in this chapter that the continued problems of ill health and their spatial dimension are not a matter of resources or a focus on place. Instead the reasonswhy some places are not healthy, and why they seem impervious to change, is bound upwith the existing policy approach to creating healthy places, which fails to deal whollywith causes of ill health.

To understand this problem of approach, three key points must be considered. Firstly, thedominance of the economic growth and development agenda over social and healthregeneration: economic wealth is perceived as the key factor, from which it is assumedthat social health and well-being will flow. This entails the view that either place-based

2 Tackling Health Inequalities: The Spearhead Group of Local Authorities & Primary Care Trusts (Department of Health, 2004).Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4101455


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policy such as improving the image of a place or attracting investment, or people-basedstrategies such as improving local skill levels, will create the conditions for healthier places.

Secondly, there is a separation between these two agendas, in terms of strategy, policy anddelivery. It is evident that, whether we are operating at the national, regional, sub-regionalor local scale, in policy terms the issues of economics and social health and regenerationare frequently separated. For example, the New Deal for Communities, as mentioned earlier, is a key local policy with interests in wider well-being and health. In this, it is thenational responsibility of the Department for Communities & Local Government, whileresponsibility for economic development lies with the Department for Business, Enterprise& Regulatory Reform, and health responsibility rests elsewhere.

A recent report by the Joseph Rowntree Foundation3 looking at the economic developmentand social inclusion agendas highlighted this separation, concluding that there was a“split between different policy agendas and government departments”. For instance, theissue of worklessness, which is a key facet of continued ill health, is divided between beingdealt with as a social welfare issue by social service departments, and as an employmentand skills issue by the regeneration/economic development departments.

Thirdly, while much preventative work is going on to deal with the causes of ill health,there is still a heavy emphasis on dealing with the symptoms and effects. This is fuelledby inevitable pressure in healthcare, where high demand means that the health systemtends to deal with the “here and now” rather than tackling the causes of ill health. Thishas to be recognised, but the focus on the individual, in particular on appealing to individuals to change behaviour patterns, is only part of the solution.

What is needed is the development of a much more voracious place-based, embeddedapproach to creating healthy places. The solution requires a significant shift in thinking interms of community place making and the relationship to ill health. I am talking aboutcreating “wholly healthy places”.

Towards wholly healthy placesIn the Local Government Bill, the Lyons inquiry report4 and the Review of Sub-national

3 North, D, Syrett, S and Etherington, D Political Devolution, Regional Governance & Tackling Deprivation (JosephRowntree Foundation, 2007). Available at: http://www.jrf.org.uk/knowledge/findings/government/pdf/2155.pdf 4 Lyons, M Placeshaping: A Shared Ambition for the Future of Local Government (Department for Communities & LocalGovernment/HM Treasury, 2007)


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5 Review of Sub-national Economic Development & Regeneration (HM Treasury/Department for Business & RegulatoryReform/Department for Communities & Local Government, 2007). At: http://www.hm-treasury.gov.uk/spending_review/spend_csr07/reviews/subnational_econ_review.cfm6 Ibid

Economic Development & Regeneration,5 place shaping and the importance of local placeare coupled to a sense that local government needs more powers over its activity. Thechallenge of the place-shaping agenda is about “the creative use of powers and influenceto promote the general well-being of a community and its citizens”.6

This offers an opportunity to begin linking up the economic and health issues within ourcities and towns. For this to occur, local economic actors must actively shape places byfocusing on new economic and health strategies that focus on the social and health prob-lems within particular localities. Local place shapers – such as local authority councillors,officers and partners, including NHS trusts and primary care trusts – need to respond tothe place-shaping agenda in a way that seeks to embrace problems and must be brave increating policy and projects that relate to the health needs of the local population.

The challenge is to use the place-shaping agenda to create local wholly healthy strategiesand develop places that focus on producing wealth and health. In this, a new, place-basedset of wholly healthy policies is called for. These policies should seek to deal with ill healthby connecting it to other policy areas and assist in the process of spreading out wealth,health and opportunity.

We need to start thinking about place-based policy that focuses not only on the traditionalfacets of healthy places – the material aspects of jobs and local services – but also thepsychological and wider health aspects, such as community, neighbourhood, family andthe broader relationships between people. Healthy places require an approach thatencourages people to feel good about themselves. This wholly healthy approach considerscommunities as users, customers, clients and patients but also sees communities as neigh-bours, friends, relations and colleagues. In this we need to think about the public, privateand third-sector actors and how they interact and, hopefully, operate together.

In thinking through this idea of a wealth- and health-producing society, it is useful toexplore the role played by the social economy, or, as the eminent environmental economistNeva Goodwin has called it, the core economy. This provides us with the means to rethinkwhat we mean by “place” and start moving towards wholly healthy places.


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7 Stevens, L The Core Economy, Informal Economy & the Market Economy: Understanding Their Value, unpublishedaction learning paper (New Economics Foundation, 2007)

The core economy: the importance of social placesYou do not need money and prices in order to have an economy. An economy is just aplace where there are transactions of goods and services, in which these are produced,exchanged and distributed. The core economy is the non-monetary, non-price-basedeconomy that we take part in every day – the economy of home, family, neighbourhoodand community. This is the economy where we tend not to be customers, clients or consumers, but rather neighbours, friends and relations.

Professor Edgar Cahn – an American academic and founder of Timebanks, a non-monetarytransactional system – has written extensively on the core economy, using the analogy ofthe computer. Computers, as we all know, run specialised programmes – for instanceword-processing, presentation or graphics. Behind those systems is an operating system.No matter how powerful the programme, if the operating system crashes then none ofthe specialised programmes will work.

Like computers, society has an operating system, which is the core economy: family,neighbourhood, community, civil society. Like computers, society has specialised programmes: schools, hospitals and all the specialised private-sector activity. Cahn concludes that the operating system – the core economy – is currently in trouble.7 As aresult, our specialised programmes are similarly in trouble, as their smooth functioningdepends on effective places with well-developed and neatly functioning core economies.

While these two systems of the core economy and the monetary economy (which comprisespublic- and private-sector activity) work on different principles, they rely on each otherand are interdependent. For example, a core economy of healthy children, functioningfamilies, safe neighbourhoods, viable communities and strong civil society produces theworkforce that the private and public sector need to generate goods and services. The private and public sector, in turn, produce other goods and services that we rely on forsurvival – food, shelter, clothing and other basic elements of good health.

While the two systems work synergistically to promote good health in places, we cannotsolely rely on the wealth-producing and -distributing public and private sectors to support places and deal with ill health. These sectors are only one aspect required to create a wholly healthy place. We also need significant emphasis on the core economy, aneconomy that in some places has been denuded and weakened.

Many of the caring professions that are so valuable to the operating system are under-valued. The price mechanism affects how, in the core economy, we value this activity, andhow in the private and, to a lesser extent, the public sector, we take price for granted. Weknow that when goods are scarce, prices go up, and when they are plentiful, prices godown. The ability to care for others and provide some basic preventative health work issomething that all of us have, and this means that in terms of money, it is worth very little. In short, the supply of looking after people is a human trait. The public and privatesectors do not value (in price terms) the kind of work it takes to create healthy homes,healthy families and communities. Good examples of this are the low wages the markethas set for the services of babysitters and people who care for the elderly and the frail.

While the concept of the core economy is not about money, it does contribute signifi-cantly to the public finances. In estimations by Edgar Cahn and others, if you were to puta figure on this economy it is estimated that in the UK over £87 billion8 of unpaid carework could be allocated to the core economy. Internationally, 40% of economic activitytakes place in the core economy and is not reflected in GDP. In this we can see that, asthe core economy weakens, more of this volume of activity and burden will fall on thepublic and private sectors, creating even greater pressure on our public services.

However, this concept of the core economy is not about narrow efficiencies and trans-ferring activity from the public to the core economy. Clearly, there are activities that thepublic and private sectors perform that can only be carried out within these sectors. Inthis, the solution is to look towards a place-based, community-based set of activities,which value the core economy and thus keep the community and the place functioningand concomitantly provide an operating basis from which the health infrastructure can flourish.

It is evident that we need to nurture and develop this core economy in local places. In thiswe can look to policies relating to community development, and community approachesto health that supplement so-called mainstream health provision. However, these policiescannot be delivered in isolation. We also require a concomitant change in how local monetary economies, including public- and private-sector activity, operate in shaping andsupporting the core economy.


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8 Buckner, L and Yandle, S Valuing Carers – Calculating the Value of Unpaid Care (Carers UK, 2007). Available at: http://www.carersuk.org

Towards a set of policies that promote healthy placesIn terms of joining up the policy agendas, we require a deeper attitudinal change withinpolicy and among policy providers that embraces all facets of local place. For this to occur,we need to start to conceptualise anew what we mean by place and focus much more onthe conditions and nature of that place. We must move away from a simplistic notion thatif we get the economics right then social health will follow. Social health must be seen asan equally important facet of economic health, and the policy agenda must convergeunder the place-shaping agenda.

This so-called well-being agenda has already begun, but a greater voracity of policy needsto exist in four main areas: the local identity of place; public space; employment thatassists the core economy; and encouraging new forms of behaviours and activities.

The local identity of placeSolutions must be context based and reflect the nature of the core economy. We need tolook at creating interventions designed for specific localities. The big departments withcentral targets, such as the Department for Work & Pensions and the Department ofHealth, need to become much more porous to local decision making and control and beplace, people and culturally specific. An emphasis on services that focus on the commu-nity and the nature of the place, rather than on the individual, is key. Recent governmentproposals and the development of local area agreements and neighbourhood governancearrangements have improved the ability to shape mainstream services to fit the localdynamic. This needs to be broadened and deepened.

Public spaceThe work in developing a place in terms of how it looks and how people interact withinthat place is very important. We need high-quality local public places and spaces, in whichpeople want to spend time and interact. Local high-quality public space has two key roles:firstly as sites for healthy physical activity, for sport and leisure activities; and secondly as the locations in which the core economy meets and interacts. To create these kinds of spaces requires not only heavy investment in making them secure and safe, but also land use flexibility through the planning process, and ownership and management ofcommunity assets.

Employment that assists the core economyEmployment policy needs to continue to increase the extent to which it recognises thesignificant role that the core economy plays in the health and well-being of employees.


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This of course includes measures that seek to maximise the ways in which employers andemployment work with and relate to the core economy. Examples are: linking health toemployee contracts, supporting enhanced maternity and paternity pay, volunteering days,childcare, community days and improved occupational health.

Encouraging new forms of behaviours and activitiesDevelopment of core economic activities is vital in providing a supportive weave of activitythat can help in creating healthy places. In this, support for volunteering, user groups andthe development of active citizenship is of great importance.

ConclusionsAt present, changes in approach to local places as part of the place-shaping agenda arelargely being forged by the formation of new partnerships and vehicles through local area agreements and other functional entities, such as multi-area agreements at the sub-regional level, and also new forms of neighbourhood and area governance at the local scale. There is a sound basis to this, as these entities can operate at a scale that isappropriate to the nature of the place and the issues it faces.

The necessary next wave of urban renaissance, which embraces wholly healthy communities,requires bravery, creativity and risk. Some of the mechanisms are already in place.However, for genuine change to be realised, a new wave of enthusiasm for equality andfairness needs to emerge. In this, we have to concentrate on the notion of wholly healthycommunities and create an approach to policy that sees wealth and health as critical andequally important facets of the same aim. This will involve a deeper policy appreciation ofour material and social lives and the interaction between them.


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Chapter 6

The role of the regional development agency in healthpromotion partnerships

Thea Stein, Executive Director of Economic Inclusion at Yorkshire Forward, Jane Riley, Associate Director of Public Healthfor Yorkshire and the Humber, and Sue Proctor, Director of Patient Care and Partnerships, Yorkshire and the Humber StrategicHealth Authority


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The role of the regional development agency in health promotion partnerships

Regional development agencies’ key areas of interest obviously include jobs, competitiveness,productivity and social and economic inclusion. While “health” is a major business in itsown right, this essay argues that health and well-being issues should be high on the priorities of a regional development agency – and of anyone else interested in driving upproductivity, maintaining business value and attracting and keeping the best staff.

Yorkshire & Humber’s GDP exceeds £81 billion and the region ranks among the top thirdof the world’s national economies (outpacing the European average for the last five years).Billions of pounds have been poured into commercial development in key cities over thepast decade – and this is just the start. Today the entire region is a business hot spot anda magnet for ambitious and enterprising organisations, with five of the world’s top 10companies having a presence here. Yorkshire is one of the best-served regions outsideLondon for electronic infrastructure. As one of the UK’s fastest-growing cities, Leeds continues to attract massive investment, with £3 billion worth of property developmentin the pipeline.

Yorkshire Forward is the regional development agency behind the economic regenerationof Yorkshire & Humber. Its vision is for the region “to be a great place to live, work and do business, that fully benefits from a prosperous and sustainable economy”, and its programme to achieve this is investing in jobs, improving towns and cities, and support-ing businesses throughout the region. Progress has been dramatic. Over the past year, theprogramme has created and safeguarded more than 22,000 jobs, assisted 60,000 peoplein acquiring skills, created over 1,000 businesses and attracted nearly £500 million ininvestment.

Promoting health in Yorkshire & HumberIn November 2007 Yorkshire Forward and its regional health partners launched Health andthe Economy, an initiative that identified the major contribution of the healthcare servicein the region, including the value of helping people re-enter the workforce.1 Now it is working in partnership with health and businesses to develop further initiatives in promoting health and well-being more generally.

1 Health & the Economy in Yorkshire & the Humber (Yorkshire & Humber Public Health Observatory, 2007)


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Returning to its former position as the heartland of industrial development and innovation,the region is now seeing the results of billions of pounds of investment and change, usingthe urban and rural renaissance process to make our key towns and cities more attractiveplaces to live, work, visit and invest. A good example is the 40ha Advanced ManufacturingPark at Waverley, on the site of the former Orgreave colliery near Rotherham. Developedby landowner UK Coal and Yorkshire Forward, it has become the hub of the region’s world-class advanced engineering and metals cluster. The opening of Robin Hood AirportDoncaster Sheffield in 2005 will also bring with it a new location for international businesses. Wakefield Europort is Yorkshire’s largest fully serviced industrial developmentsite, located at the heart of the national distribution network.

Yorkshire Forward recognises that such progress is dependent on enhancing and realisingthe potential of Yorkshire & Humber’s people. The region’s 2.5 million-strong workforceleads the country in sectors as varied as advanced engineering, food production, bio-science and digital technologies. Unemployment is at a 30-year low and the same as thenational average. Outside London, Leeds is the largest financial and professional servicescentre in the UK. A recent survey showed that financial and business services companieswere the most optimistic in the region when it comes to future employment. The region’suniversities attract more students than anywhere else in the country and go on to generate 13% of the UK’s graduates.

For the regional development agency, a key way of supporting and maximising the potential of our citizens is to connect people to economic opportunity, encouraginginvestment in and improving levels of education, skills and learning. Despite the hugeimprovements being made and the high-level skills of much of the workforce, there arestill groups for whom the economic success of the region is not yet a reality, and theirexclusion will delay or even hold back the region from reaching its full potential.

Poor physical and mental health restricts the educational and economic opportunities forsome people, depriving companies of people with the skills they need, reducing the scopefor entrepreneurship and innovation, and affecting the image of the region as a dynamicplace to live, work and invest. For those in employment, including many of our most successful professionals, paying too little attention to their health and well-being will alsohave a personal and economic toll.

These are very real issues for a regional development agency. The economy needs people:a workforce – entrepreneurs with skills, ideas and the drive to translate them into


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sustained action, people with the skills to take advantage of technologies, and people in all sectors who are fit, physically and mentally, to work. And it is not just people of working age that are our concern, as we may store up trouble for the future. People maylive longer, but they are not necessarily healthier. Robert Browning’s Rabbi Ben Ezra in hispoem of that name may have looked forward to ageing:

Grow old along with me! The best is yet to be, The last of life, for which the first was made

But this is not a reality for many people. Although overall life expectancy continues to grow over time, marked inequalities still exist between the most deprived and more affluent areas. Yorkshire’s disability-free life expectancy or DFLE – the years of life forwhich an individual can expect to be free from limiting long-standing illness or disability– is the third-lowest among English regions for both males (60 years) and females (62.8 years) and points to a considerable time interval between the point at which an individual is likely to begin suffering from limiting illness or disability and their death.Healthy life expectancy is rising more slowly than total life expectancy, so the gapbetween the two is increasing.

Overweight – a big issue in the regionStress, health and safety, the impact on well-being of having a job, and many other areasare all linked. Recent reports make this an opportune time to consider in particular whatimpact obesity is having on the economic life of the region. We have focused on this areaas a good illustration of why Yorkshire Forward is working with the health sector to challenge and support employers to act now.

In January 2008 the government launched its strategy Healthy Weight, Healthy Lives, setting out an overarching approach to tackling obesity.2 The strategy rightly makes clearthe role that industry and employers can play. The Foresight report on tackling obesity,published in October 2007,3 set out a detailed exposition of the reasons that body mass isincreasing and demands that we consider what 30 years of the wrong sort of populationgrowth really means – particularly for the future.

There is little doubt that unhealthy weight gain is a major issue in Yorkshire & Humber.The region has some of the highest rates of overweight and obesity anywhere in England.

2 Healthy Weight, Healthy Lives: A Cross Government Strategy for England (Department of Health, 2008)3 Tackling Obesities: Future Choices, the Foresight report (Government Office for Science, 2007)


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Foresight identified that male weight levels are rising faster here than anywhere else in England. We have the lowest physical activity participation rates of all English regions. By 2010, almost half of all girls aged 11 to 15 will be overweight or obese, the worst levelsin England. The problems it causes are well recognised – for instance, the Yorkshire &Humber assembly has identified obesity as one of the “landmark” issues that are persistenttrends in the wrong direction and that have major implications for the region.

In the past, people left the land to take up new jobs in mills and factories. Food was notalways readily available or affordable. Today’s industrial revolution is increasingly towardsmore sedentary jobs, coupled with pressures to perform well, work longer hours and livean idealised life with material wealth and competitive hobbies. Rising levels of interest inthe provenance and content of food are not always matched by what we do in practice.

Food is increasingly processed, high in sugar, fat and salt, and eaten “al desko” or on themove. Snatched meals tend to be high-energy but often of less nutritional value – theymay offer instant gratification, but can leave workers with significant dips in energy andspirits. We use food as a reward to ourselves and others, as a way of saying thank you witha box of chocolates, and the sweet that you can eat between meals without ruining your appetite is now the meal itself, suitably treble-sized but somehow still leaving youwanting more.

We can afford gym membership and the latest trainers, but not the time to put them to use. In the past, public health was concerned predominantly with contagion and infection. Today, lifestyles are the major issue – will tomorrow’s good Samaritan be savingpeople from the evils of the double cheeseburger with extra fries? No wonder obesity issometimes called a disease of (comparative) affluence. But are we having it all? Or havinga heart attack?

The cumulative impact is clearly visible in the form of increasing levels of overweight andobesity, growing costs for the NHS, and the physical and financial burden as hospitalsstrengthen their floors and prepare to carry out increasing amounts of stomach-reducingsurgery.

Obesity alone is associated with some 20 major sets of diseases and conditions and isdirectly related to increased mortality and shortened life expectancy. It leads to higherrisks of diabetes, hypertension, breathlessness, coronary heart disease, osteoarthritis in theknees, complications in pregnancy and impaired fertility, as well as a range of cancers.

It is also linked to a range of psychological health problems such as low self-esteem,depression, disordered eating and psychosocial distress. Not surprisingly, it also has animpact on well-being and on educational and economic attainment – as well as costingthe NHS increasing amounts, causing the health service to debate whether “weight” or“waiting” is its major headache.

The economic costs of ill healthClearly, there are human costs as well as rising financial costs for the health service, socialservices and the benefits system. But there are also very significant costs in the workplaceand for the economy, holding it back and restricting growth – for instance, if there are notenough skilled staff to take on new work. A 2006 study by Harvard Medical School andthe Institute for Health & Productivity Management suggests that the healthiest 25% ofthe workforce is some 18% more productive than the least healthy quarter.

Weight is often considered a women’s issue, but more men are overweight than womenand their predisposition to lay down fat around the abdomen rather than the hips putsthem at additional risk of life-restricting and endangering heart disease, diabetes andreduced mobility – all which can have a significant impact on life expectancy, quality oflife and productivity in the workplace. Levels of physical activity are also highly significant.Although men tend to be more physically active than women, even in the youngest adultage group (19 to 24) less than 50% of men take enough exercise to derive a positivehealth benefit and 20% of men are in effect inactive. The World Health Organisation estimates that physical inactivity costs the economy £8.2 billion per year.

These costs include effects on productivity, levels of turnover, ease of recruitment, sicknessand other absences, individuals’ earning potential and levels of disability, legal and moralliabilities, and impacts on business continuity and effectiveness, particularly around keyindividuals whose sudden and prolonged absence can have a significant impact on companies of all size. The evidence base shows that the impact on individual businessesand the economy as a whole is also huge:

• The CBI estimated that in 2004 the average absence from work was 6.8 days peremployee, or 3% of working time, and that the cost to the economy was £12.2 billion.

• A 2006 study by Luengo-Fernandez et al4 estimated that in 2004 cardiovascular


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4 Luengo-Fernandez, R, Leal, J, Gray, A, Petersen, S and Rayner, M “The Cost of Cardiovascular Disease in the UK” inHeart (BMJ/British Cardiovascular Society, 2006)

disease alone cost the UK economy £29 billion (in healthcare and non-healthcarecosts); 23% of these costs were productivity losses due to mortality and morbidity.

• The House of Commons health select committee estimated that the total annual costof obesity and overweight for England in 2002 was nearly £7 billion. This totalincludes direct costs of treatment, the cost of dependence on state benefits, andindirect costs such as loss of earnings and reduced productivity. They estimated thatlost earnings attributable to obesity were between £2.3 billion and £3.6 billion per year,accounting for an annual total of 45,000 lost working years. Subsequent work suggeststhat the total impact of obesity on employment may be as much as £10 billion.

Our own health and well-being can affect every aspect of our lives and have a majorimpact on many other people: our partners, children, parents, friends, neighbours andwork colleagues. Sudden catastrophic illness or death can mean disaster for a companythat depended on a person’s knowledge, expertise and contacts. But it applies to everyone:if people are ill and/or unhappy, it has an impact on everyone around them – including inthe workplace, where their own productivity will be affected and they will certainly beinfluencing their colleagues, who will be picking up their work as well as their moods.

Businesses lose people to retirement reasonably predictably, and they can avoid staff leavingor being poached through high-quality staff support and incentives, but the cost of staffwho leave or who are less productive because their levels of health and well-being dropis also great. The cost of a death or a sudden illness, or of someone chucking it all in tofound a commune or a dot-com company, are all huge – a company can suddenly losemomentum, knowledge, expertise, contacts, reputation and respect that have been builtup over many years.

We invest in our machinery and IT systems, and we fear that they will break down orbecome inefficient, but to what extent do we invest in the smooth working of our humancapital? Business is interested in the education system and training because it relies onthe skills being imparted so that it can recruit people to do its work, produce its new ideas– and earn enough to buy its products and services.

As people live longer, and with pensions likely to be an increasingly key issue, many willbe working longer through either choice or economic necessity. They are likely to be contributing to the economy by many routes, whether it be through specialists providinginput to social enterprises, or as non-executive directors, interim managers and experienced staff providing a warmer welcome at DIY stores, or as grandparents and


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great-grandparents providing safe and high-quality childcare to enable younger people to go back to work or continue their careers.

Rising costs of welfare and pensions are forcing changes in attitudes to personal respon-sibility and self-reliance, and debate about whether those who choose to smoke, becomeand remain obese, or abuse alcohol and drugs should expect the public to pay when theybecome ill. Many doctors are openly calling for a debate around rationing on the groundsof “merit” and likely outcomes. As younger people’s taxes have to support increasing numbers of older, more dependent people, it is increasingly likely that those who have nottaken steps to look after themselves, or whose own actions have contributed to or causedtheir conditions, will find that they have exempted themselves from state support. JohnStuart Mill may have been less willing to allow people to drink themselves to death if hehad had to pick up the bill through higher taxation.

A partnership approachAll these points demonstrate the interrelationship between health and well-being andeconomic success. Just as a regional development agency needs to be concerned with levels of skills, regeneration of down-at-heel areas and the creation of a strong and attractive image for investors and those looking to relocate, successful economic development needs to include a concern to have a large and productive workforce, stability and an environment where people are able and willing to give of their best. Thisis why Yorkshire Forward has already developed a partnership with the health sector, andis planning to build even stronger links with businesses across the region.

Clearly, there are potential benefits for all concerned:

• For Yorkshire Forward, there is the opportunity both to demonstrate leadership in akey area that is likely to be increasingly economically important – in terms of numbersof staff, their skill levels and productivity, as well as image nationally and internationally– and to support the NHS, which is the largest employer within the region, employingover 180,000 people or 8% of regional employees.

• For employers, it means opportunities to reduce the risks, disruptions and costs of illhealth and lack of well-being – including those of losing people at a peak point intheir careers to career changes, early retirement, disability and death – and to secureand retain the best staff.

• For trade unions, the benefits are a healthier and happier workforce, and possibly theopportunity to refocus the idea of “occupational health” as support for the workforce


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rather than as a tool for managers.• For the health service, it means improved health and well-being status, reaching

employers and employees and enlisting their support in changing people’s behaviours,as well as avoiding the huge potential costs of obesity – the 2007 Foresight reportprojects that these will have risen half as much again by 2015.

Organisations are made up of individuals (who influence and are influenced by their families, colleagues and others), their culture and values, and their business methods,ideas, experience and enthusiasm. If those individuals fail to function, there will be significant costs of all kinds. Tackling obesity is a major issue in Yorkshire & Humber – itcannot be solved by any one sector or organisation but rather requires a concerted andsustained effort. Business has much to contribute to solving the problem, by taking thematter seriously: working with partners to help employees change their lifestyles; and creating a supportive environment through food choices available, opportunities for physical activity, and making a healthier work/life balance more of a reality.

Regional development agencies can take a leadership role here, and help business to participate in new initiatives and to access good practice and evidence. The social and moral incentive may long have been obvious, but the financial and competitiveadvantages are also plain to see. Without such leadership action, obesity will be thespreading rot that will undermine the golden layer of achievement by the region. The healthier choice is clearly better for us all as individuals – but equally so for anyone concerned with increasing productivity, business growth, a positive image and full economic attainment and inclusion right across the region.


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Conclusion

Christopher Exeter, Head of Public Policy Research, NHS CFH


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Conclusion

Taken as a set, the papers in this monograph outline a series of potential futures forhealthy communities in England. They are a set of ideas, not a statement of policy, orpoints of law – and this is important to understand, for a number of reasons. Ecclesiastessaid that “men persist in disordering their settled ways and beliefs by seeking out manyinventions”, the point being that change has always been a constant in society – it is partof our DNA as humans. Understanding the range of possible futures and how we get tothis position can help in mitigating surprises and planning coherently.

Considered together, a number of issues begin to become clear.

Firstly, society is changing. We are more mobile, more technologically literate, and expectations have risen and will continue to rise. This is becoming a here-and-now society, less deferential and far less willing to accept second-best services – especially asalternatives are easy to locate through the internet and are more easily accessible. We arewitnessing the birth of a world without borders: driven by the demands of consumers. In short, all services, whether public or private, at the very least must start keeping pacewith if not surpassing the needs of consumers.

Secondly, we are beginning to see the shift in how technology is treated: that is, it is notthe end objective but is an enabler to allow things to happen. Citizens have grasped thisfar more quickly than organisations: networks are created among consumers; buyingadvantages are opened up whether through speed, choice or competitive pricing.Technology is collapsing the relationship between producer and consumer, and this haspresented a challenge to traditional patterns of demand and supply.

The New York Times columnist Thomas L Friedman crystallised this phenomenon in hislandmark book The World is Flat, describing how knowledge and resources are connectingall over the world – underpinned by the information technology revolution. Friedman saysthis “flattening” of the world is a force for good – for business, government and, mostimportantly, for people.

Similarly, Manuel Castells, sociology professor at the University of California at Berkley,has commented:

Information technology is the present-day equivalent of electricity in the industrial era …


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[and] the internet is the technological basis for the organization of the information age.

The public have changed their attitudes and behaviours – but have organisations, whetherpublic or private, adapted accordingly? The answer is largely that they have not, and thereremains a definite lag.

While banks and stores have evolved new approaches – their bottom line depends on it –not all organisations have been willing to relinquish their stranglehold and their comfortableexistence. That requires investment: whether in new approaches, new ways of working ornew ideas. The UK does tend to be quite weak when it comes to looking ahead.

People’s desire for new, faster access to technology has been frequently challenged by a reti-cence to invest and adapt, whether by the public or private sectors. Moreover, we do not makethings easy in this country: from allowing consumers to take advantage of the latest technol-ogy, to the neo-Byzantine process for wiring up our homes, the problems rest on a culturallock-in within major corporations even in the face of public wants and market threats.

We are witnessing a paradigm shift in the way people want to run their lives: if those thatprovide consumers with services do not change their approaches, people will simply findother ways of doing things. This is already happening, and will merely intensify over time.

The third and last issue concerns innovation. Ecclesiastes has been quoted here as providingan early definition of innovation. People adopt new ways of undertaking tasks if the standard approaches frustrate: it is in our genes. This is the core of innovation. In thismonograph, we have seen different approaches: some may call this innovation.

The trick is not to try to process innovation. A culture that allows adaption and adoption,recognising in some instances that there is a risk attached, will frequently allow for newpatterns of service and delivery. Putting innovation under the microscope and trying tounderstand it, in order to try to repeat it, is not innovation; it is process. Process does notencourage change or new ideas. What this monograph has tried to do is not to innovatebut to encourage ideas that may stimulate new ways of working.

This monograph has attempted to bring together a range of views and thinkers to helpstimulate a debate on the future and the issues that need to be considered to aid futurestrategy. They range from personal beliefs to organisational positions; but in each wayprovide ideas for the future.

The Smith InstituteThe Smith Institute is an independent think tank that has been set up to look

at issues which flow from the changing relationship between social values and

economic imperatives.

If you would like to know more about the Smith Institute please write to:

The Director

The Smith Institute

3rd Floor

52 Grosvenor Gardens

London

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Telephone +44 (0)20 7823 4240

Fax +44 (0)20 7823 4823

Email [email protected]

Website www.smith-institute.org.uk

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