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Last Updated: Saturday, 20 November 2004, 01:57 GMT
A public health turning point?
By Nick Triggle
BBC News health reporter

The government proposals for public health reform dominated the headlines all week. But past attempts to address the health of the nation have tried and failed, experts say. Will this latest drive be different?

Overweight woman eating chips
The government set targets in 1992 but obesity rates still rose
The Public Health White Paper was hailed as the turning point in the nation's declining levels of poor health.

It was, many said, a once in a generation chance to reverse the rising levels of obesity and drinking and finally rid England's pubs, restaurants and workplaces of smoke.

But we have been here before.

While much of Labour's focus to date has been on the clinical side of the NHS, Tony Blair's government has already produced one public health policy document.

The 1998 green paper, Our Healthier Nation, set stringent targets for reducing cancer, heart disease and stroke deaths.


The paper also paved the way for a ban on tobacco advertising.

But to the surprise of many at the time, the paper dropped Conservative targets on obesity - now one of the key planks of the latest White Paper.

The Tory attempt to address public health dated back to 1992 and its own White Paper, Health of the Nation.

Unlike Our Healthier Nation, the paper took a more wide-ranging, and some said scattergun, approach to targets.

40 years of public health reform
1965 - Tobacco advertising banned on television
1967- Alcohol driving limits introduced
1980 - Health inequalities highlight by Black Report
1992 - Tories launch Health of the Nation, which sets 27 targets to boost public health
1998 - Labour takes up the reins with Our Healthier Nation but cuts the targets to four
2002 - Wanless Report highlights the cost of poor health to the NHS
2003 - Tobacco advertising banned across all media
2004 - Choosing Health, the latest and most wide-ranging government attempt to tackle declining public health

A total of 27 were drawn up, covering everything from teenage pregnancy and exercise to mental health.

Professor David Hunter, professor of health policy and management at the University of Durham, said: "The problem with past public health policy is that it has tended to start well but the political commitment is not sustained."

Towards the end of John Major's reign the Department of Health commissioned Professor Hunter to carry out an evaluation of the 1992 paper.

His report, Health of the Nation - A Policy Assessed, which was published after Labour came to power, concluded the public health drive became obsessed with targets and failed to achieve everything it could have.

He believes a similar problem happened with Labour and its 1998 paper.

"Within a year or so the NHS Plan was published and the focus came back to waiting lists and hospital closures. That dominated the agenda."

Professor Hunter said he hoped this week's White Paper, Choosing Health, will be different.

'Bogged down'

"Conceivably it could make a difference. I don't think it will be a sea-change but the government's knows that the cost in economic terms to the NHS will be huge if people do not become healthier."

Anna Coote, health policy director at the King's Fund, a health think tank, agreed that the past attempts got bogged down by targets.

But she said the agenda was different now following the Wanless Report in 2002.

The study claimed unless the nation became healthier spending on the NHS would increase by 30bn over the following 20 years.

Past policies had very little impact because they lacked teeth and this will be the same
Dr Laurence Buckman

"People have public health in their sights more now than they did.

"There are some strong proposals in this White Paper, the smoking ban and junk food advertising ban, but there is a question over when and whether they will be introduced."

Successive governments have also struggled to make an impact on health inequalities.

The issue was first raised prominently in the 1980 Black Report, which found death rates for many disease were higher in the lower social classes.

A recent Health Development Agency report into smoking deaths revealed more than 40% of deaths in inner city areas of Liverpool and London were caused by smoking, compared to about 20% in some areas of the south of England.


But Professor Sarah Stewart-Brown, from Warwick Medical School, said: "Some of these issues are fairly intractable. It is unrealistic to expect all the problems to be solved."

She believes ministers have adopted a different approach to public health with the latest policy paper being targeted at individuals rather than health professionals.

"It is interesting approach and in many respects sensible. The government cannot do it all on its own."

And Dr Jim Kennedy, a GP in Hayes, Middlesex, believes it is the right time to target the individual.

Women out drinking
If the price of alcohol rose, binge drinking would fall, experts say

"I think there is a will there. The public are talking about obesity and smoking like they have never done before.

"There is a real debate going and the politicians can see this. We have a real chance of making a difference."

Others remain less sure. Dr Laurence Buckman, a north London GP and member of the British Medical Association's GPs Committee, said: "Past policies had very little impact because they lacked teeth and this will be the same.

"If you want to stop people doing things you have to back policies up with real penalties.

"The government says GPs have a role but we don't know what it is, policy is too vague."

Research by the King's Fund has suggested some of the most effective drives to address public health have involved legislation.

In 1965 tobacco advertising on television was banned and the restriction was extended to all media in 2003.

Over the last 30 years, the number of smokers has fallen from 45% of the population to 26%.

Restrictions on drink driving have also had an impact.

In 1967 the Road Safety Act made it illegal if a person was caught driving with a breathalyser result of more than 80mb/100ml.

'Firm action'

Within a couple of years, the number of fatal alcohol-related crashes fell by 7%.

Professor Martin Plant, professor of addiction studies at the University of the West of England, said: "In relation to illicit drugs and alcohol, successive governments have put great store in education as the way of curbing bad behaviour.

"Education is good in school but you also need firmer action. Drink driving has really dropped in England and other parts of Europe because of legislation that was introduced.

"With alcohol, government could think about increasing the price of alcohol through taxation, politically it would be hard, but it would be effective."

Professor Plant also suggested England could take a lead from Australia where alcohol has been banned from some beaches.

"We should not be tolerating public drunkenness.

"The problem is that politicians are just interested in window-dressing.

"This White Paper does have some firm proposals - the smoking ban, the warning labels on alcohol - but we need more if we are going to make an impact."

Telegraph Nine out of 10 pubs face smoking ban - 6 hrs ago
Guardian Unlimited Reid offers blueprint for fitness - 7 hrs ago
Irish TimesBritain sets out timetable for ban on smoking - 7 hrs ago
IHT Britain cracks down on public smoking - 8 hrs ago
ABCNEWS.com Britain Plans Sweeping Smoking Ban - 13 hrs ago
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