Guest editorial Health promotion in England: Sleeping beauty or corpse?

Transcription

1 Health promotion in England: Sleeping beauty or corpse? Like Sleeping Beauty, health promotion (HP) in England may either be dead or just becalmed and waiting to be brought back to life. HP is variously used to describe activities leading to the outcome of health ; a discipline or way of organizing knowledge; a set of principles which underpin a way of working; and a specific occupational group or title. All are under threat. Whilst there is much de facto HP activity such as the development of health trainers, smoking cessation work and the promotion of healthy school meals for children, the failure to acknowledge and to badge it as HP has contributed to an effective invisibility of the discipline. Even its clothing has been stolen as in the appropriation of the 1980s HP rhetoric of making healthy choices easier for the subtitle of the Choosing Health White Paper on public health 1. The same can be said of the current focus on multidisciplinary public health, given that intersectoral collaboration and action formed one of the WHO health for all (HFA) principles in Many of the other central HFA concerns, such as active community engagement and action on the determinants of health, have now become part of mainstream English public health policy. Successive NHS reorganizations have dispersed the specialist HP workforce. Shaping the Future of Public Health: Promoting Health in the NHS 3 stated that in 53 Primary Care Trusts (PCTs) there were under five specialized health promotion staff (two apparently had none, eight had one member of staff and 12 had two); 69 PCTs had between five and nine staff; 54 had between 10 and 19; and 26 had over 20 staff. Although there is widespread acknowledgement of a wider health promoting workforce in local authorities and the voluntary sector, they are not badged as such. Indeed, the term health promotion has lost considerable currency. Shaping the Future of Public Health uses the phrase specialized health promotion staff to mean public health staff with particular expertise in health promotion (our emphasis). The Faculty of Public Health in describing the field of public health refers to a domain called health improvement. The national agency for health promotion changed its name to the Health Development Agency in 1999 and ceased to exist altogether in The institutions that used to practise and teach HP now tend to describe their courses as public health. Health Education Journal copyright SAGE [DOI: / ] Health Education Journal 66(2)

2 A Scott-Samuel, J Wills Many may have been misled by the welcome release of Shaping the Future of Public Health which defines the roles and development needs of specialist health promotion staff in Primary Care Trusts into presuming a recognition of the importance of the discipline. Rather, it reflects a preoccupation with occupational positioning, prompted by the opening up of public health practice to those not medically qualified. A professional registration system such as that offered by the UK voluntary register and the definition of competences and standards such as that being carried out by the Faculty of Public Health and Skills for Health 4 offer the undoubted benefit of quality assurance and the carving out of an occupational territory that can be called health promotion. But in the 1980s, mandatory registration was strongly resisted by the 1500 or so health education/promotion officers as inconsistent with the philosophy of health promotion, and as excluding entrants from both a broader disciplinary base, and from a variety of different levels. Because the process is inherently reductionist, it is likely to narrow down the wide field of HP activity and to reduce the discipline to a body of knowledge and skills devoid of underlying principles and values. Globally, the discipline of HP is on a firmer footing with the term widely used, many countries having national associations, continuing WHO-sponsored global conferences on HP (the 6th conference was in 2005 in Bangkok and the 7th will be in 2009 in Africa), and the Ottawa Charter which came from the first global conference in 1986 still providing the platform for strategic developments and national policy. So what accounts for the struggle for survival of HP in England? It has to be acknowledged that there has never been a platform from which to carve out a distinctive and discrete role for health promotion. Neither the Labour government which was in post when the 1974 Lalonde report 5 invented HP, nor of course, the Thatcher government which followed it, showed any sign of progression beyond preventive medicine and behaviour modification. This was despite the pioneering work of the Unit for the Study of Health Policy in the 1970s 6 8 and of the Health Education Council (HEC), the Local Authorities Health Network and others in the 1980s Indeed, the HEC was abolished in favour of the Health Education Authority (HEA) in 1987 precisely because of what would now be seen as the efforts of its chief executive to espouse health-promoting public policy 13. Progressive voices within the successor organization fared no better as evidenced both in a notable resignation editorial in this journal 14 and in subsequent reports 15,16. The publication of the Ottawa Charter in 1986 coincided with the early middle age of a UK government diametrically opposed to its social justice agenda; it was to be another 11 years before the election of a government prepared to even acknowledge the existence of inequalities in health. But much else had changed by then. New Labour s pragmatic scientism ( what counts is what works ) emphasized disciplinary frameworks that would describe the problems to be faced and data, or facts, that would provide both the explanations and the strategic directions to tackle ill-health and health inequalities 17, Health Education Journal 66(2)

3 It is not only England where the hegemony of the new public health is marginalizing HP. In Canada, population health has become the prevailing discourse on health; Robertson 19 and Labonte 20 have argued that this is because it provides depoliticized rhetoric for the retreat of the welfare state. In England, the increased prominence of public health in health policy since 1997 has been accompanied by an almost total absence of the phrase health promotion in official rhetoric. But we need to look further to be able to answer whether, like Sleeping Beauty, HP is not dead but merely sleeping, waiting to be awoken with a kiss. The answer may emerge from the ad hoc ideological jumble that characterizes current public policy discourse in England. This is a context steeped, on the one hand, in a reductionist attribution of ill-health to the behaviour and lifestyles of individuals, with consequent victim-blaming policies and activities designed to heighten risk awareness and risk management. More than a quarter of a century after Thatcher first expressed her distaste for the nanny state, England s successor government continues to draw back from health-promoting intervention, as in its dithering over the imposition of tobacco controls and food labelling. Yet at the same time, New Labour s Third Way philosophy emphasized communitarianism and the necessity of rebuilding communities, social networks and social cohesion. Since 1997 there has been huge investment in neighbourhood renewal and in area-based initiatives such as Sure Start. These social projects are not, however, part of a coherent health-focused strategy. Indeed, since 2000, health strategy has increasingly endorsed the explicit and implicit values of neo-liberalism, emphasizing the competitive market and private over public financing for health and social care. Treasury driven performance management and public policy, exemplified in the Wanless Reports 21,22, has focused attention on data, targets, outcomes and evidence, posing major challenges for any reintroduction of HP into public health policy. Health promotion may be part of an overall public health commitment but activity and resources are being pulled in other directions such as payment by results and practice-based commissioning. Some of the recent concerns of government environmental sustainability and green issues, happiness and well-being, devolved and local decision-making would, if implemented through national policy, amount to a de facto prioritization of HP. Health promotion rests on a broad conceptualization of health that understands the context in which people make decisions on risks, dangers and health, in which health may not indeed be an explicit goal at all but happiness might be. Health promotion is the human aspiration that has always aimed to give voice to those whose needs are ignored or forgotten when health is discussed, be they people in poverty, migrants or indigenous peoples. A significant strand of health promotion is healthy public policy 23, which includes such broad policy measures as local economic development, the amendment of current macroeconomic thinking 24 and the reallocation of resources towards sectors which enhance health, such as housing, transport and employment. Health Education Journal 66(2)

4 A Scott-Samuel, J Wills In the light of this, is it too much to hope that New Labour s new leadership will kiss health promotion in England back into life? Alex Scott-Samuel Senior Clinical Lecturer in Public Health, University of Liverpool, UK. Jane Wills Reader in Public Health and Health Promotion, South Bank University, UK. References 1 Department of Health. Choosing Health: Making Healthy Choices Easier. Cm London: The Stationery Office, World Health Organization. Targets for Health for All. Copenhagen: WHO Regional Office for Europe, Department of Health. Shaping the Future of Public Health: Promoting Health in the NHS. London: DH Health Improvement Directorate, Skills for Health. Completed Frameworks: Public Health Practice. Online. Available: (accessed 29 December 2006). 5 Department of National Health and Welfare. A New Perspective on the Health of Canadians (Lalonde report). Ottawa: Ministry of Supply and Services, Online. Available: (accessed 29 December 2006) 6 Draper P, Dennis J, Best G, Popay J, Partridge J, Griffiths J. The NHS in the Next 30 Years: A New Perspective on the Health of the British. London: Unit for the Study of Health Policy, Department of Community Medicine, Guy s Hospital Medical School, Dennis J, Draper P, Griffiths J, Partridge J, Popay J et al. Rethinking Community Medicine: Towards a Renaissance in Public Health? London: Unit for the Study of Health Policy, Department of Community Medicine, Guy s Hospital Medical School, Draper P, Griffiths J, Dennis J, Popay J. Three types of health education. British Medical Journal, 1980: 281: Health Education Council. Healthy Living: Towards a National Strategy for Health Education and Health Promotion. London: Health Education Council, 1983 (unpublished). 10 National Advisory Committee on Nutrition Education. Proposals for Nutritional Guidelines for Health Education in Britain (NACNE report). London: Health Education Council, Unemployment and Health Study Group. Unemployment, health and social policy. In: Unemployment: A Challenge to Public Health (pp ). Occasional Papers 118 Health Education Journal 66(2)

5 no. 10. Manchester: Centre for Professional Development, Department of Community Medicine, University of Manchester, Nuffield Centre for Health Services Studies. Health for All by the Year 2000 Implementation of Strategies at Local Level. Leeds: Nuffield Centre for Health Services Studies, University of Leeds, Anonymous. The health divide: Swan-song of the Health Education Council. Lancet, 1987: 1: Maryon Davis A. Proud bantam or headless chicken? Health Education Journal, 1988: 47: Anonymous. Making the headless chicken squawk. Lancet, 1988: 2: Anonymous. England: Health promotion downgraded. Lancet, 1990: 336: Macintyre S. Reducing health inequalities: An action report. Critical Public Health, 1999: 9: Deapartment of Health. Saving Lives: Our Healthier Nation. Cm London: The Stationery Office, Robertson A. Shifting discourses on health in Canada: From health promotion to population health. Health Promotion International, 1998: 13: Labonte R. Population health and health promotion: What do they have to say to each other? Canadian Journal of Public Health, 1995: 86: Wanless D. Securing Our Future Health: Taking a Long-Term View. Final report. London: HM Treasury, Wanless D. Securing Good Health for the Whole Population. Final report. London: HM Treasury, Milio N. Promoting Health Through Public Policy. Philadelphia: FA Davis, Rotering F. Human economics: Putting humanity and the environment before profit. Feasta Review, 2004: 2: Online. Available: documents/review2/rotering.pdf (accessed 29 December 2006). Health Education Journal 66(2)