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After giving my 16 year old son his birthday presents (the good news, folks, is that eventually, against all the odds, a fine young person starts to dawn from the dark night of teenage volatility and self obsession), I find myself on the panel for an NHS Confederation event titled ‘inequality, nudge and recession: is it time for a new approach to health politics?’.

There is some agreement among the panel of world renowned public health experts Professor Sir Michael Marmot, Phillip Blond (Demos’s progressive Conservative) and David Stout, Primary Trust Network Director at the Confederation. The themes chime with recent posts on this site. Building community resilience and capacity is central to improving public health, which is itself a more important determinant of health outcome and levels of health inequality than the health care system. But community capacity building is difficult; it is complex in itself, subject to all kinds of uncontrollable external pressures (for example, recession), long term and hard to evaluate.

The worry on the panel and among the audience was that – as has happened before during a fiscal squeeze – the acute sector is much better at shroud waving and thus gets its budgets protected at the expense of public health. (Interestingly, in its commendably forthright list of potential spending cuts the right of centre think tank Reform today proposes abolishing all national expenditure on public health campaigns).

Today is also the day when the public gets over-the-counter access to the weight loss drug, ‘alli’. There has been a predictable chorus of warning that the drug should only be used alongside interventions to tackle the behaviours that give rise to obesity. Which is fine, but while appreciating the limitations of new drugs like this, we should look to technological and pharmaceutical innovation to make major advances in health care productivity.

More and more of us, when unwell, will be able to use the internet to try to find out what our symptoms mean, go to our local pharmacy to have a cheap over-the-counter diagnosis test and then, after some advice from the pharmacist, buy and administer the treatment ourselves. After the initial diagnosis, this can be as true for long term conditions like high blood pressure and diabetes as for bugs, stresses and strains. This is already happening. The task is to re-engineer the processes of health care, maintaining the system improvements of the last five years, but enhancing individual control and responsibility and making genuine productivity gains.

In this new system there will be new risks. Those who are better off and more personally resourceful will find it easiest to thrive. Some people will get it wrong. They will pay for treatment they don’t need. Some may even end up harming themselves. But let’s remember that less than half of existing medical interventions are of proven benefit.

Interventions which tackle poor health through community capacity building tkae time, commitment and investment and involve the long term pooling of public health and local authority funding streams. The social priority for investment to improve the nation's health should be prevention and the promotion of well-being among the least well-off. So instead of public health being the soft target when budgets get tight the primary and acute sectors must take the lead in delivering the productivity savings tomorrow's NHS urgently needs.


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