The need for a better approach
Introduction
On 16 February, the New Statesman and Pfizer hosted a debate on how public health could be marketed more effectively. The representatives from healthcare, food and sport who took part all felt that this was an exciting time for public health, and especially that the 2012 Olympics offered a unique opportunity to change public behaviour. But there were concerns as to how such chances could be exploited to achieve sustainable long-term changes. The participants advocated better targeted programmes that work across sectors instead of isolated advertising campaigns and government control. The public wants change but people need to feel they are part of that process instead of being lectured to. Only then will healthy living be as normal as brushing your teeth.
Participants
Virginia Berridge - Director, Centre for the History of Public Health, London School of Hygiene & Tropical Medicine
Nick Bitel - Chief executive, London Marathon. Partner, Max Bitel Greene (sports and media law firm)
Edwina Currie - Former health minister, 1986-1988
Mark Duckham - Managing director, Grey Healthcare
Sam Everington (Chair) - GP and deputy chair, British Medical Association. Director, Partnership for Health UK
Michael Farrar - Non-executive director, Sport England. Chief executive, West Yorkshire Strategic Health Authority
Lousie Fish - Communications director, National Institute for Health and Clinical Excellence (Nice)
Jeff French - Director, National Social Marketing Strategy for Health, National Consumer Council
Deirdre Hutton - Chairman, Food Standards Agency
Tamara Ingram - Chief executive, Grey Group UK and Grey London
Tessa Jowell - Secretary of State for Culture, Media and Sport
John Procter - Head, Pfizer Health Solutions in the UK
Mike Rayner - Director, Health Promotion Research Group, British Heart Foundation
Cilla Snowball - Chairman, Abbot Mead Vickers BBDO
Sam Everington (Chair) As a doctor, and especially in light of yesterdays vote to ban smoking, I see this as a fantastically exciting time in public health. Ten thousand lives a year are lost through passive smoking. Seven hundred thousand people might give up smoking as a result of this ban, so it is a great moment in the history of public health. And we also have, for the first time, a Primary Care white paper that really focuses on public health.
As an East End GP, I believe the Olympics are also a marvellous public health opportunity. For example, we are taking on a scheme originally done by one of my GP trainees in Guernsey, where we will test kids both mentally and physically to define their ideal sport. That might be darts, if they're not particularly athletic, running or other sports.
Today, we are going to focus mostly on marketing public health. There are five questions that we are hoping to address in this session. First, what campaigns have been successful and unsuccessful? Second, what are the key ingredients to those successes and/or failures? Third, what skills, ideas and techniques, in marketing terms, have not yet been used but could be to good effect in the future? Fourth, what are the roles and responsibilities of government, doctors and business? And finally, if there were no restrictions, what one issue would you most like to see taken up?
Michael Farrar Having worked in the Health Service for a number of years and been responsible for trying to improve health as well as deliver health services, I feel constantly frustrated by the rhetoric around this agenda. Commitment clearly exists in the health service but there is still a sense of ambiguity about what the responsibility of the state is against the responsibility of individuals and organisations. We spend a lot of time debating that.
We have never really taken advantage of the methodology that other sectors use to change behaviour around purchasing or retailing habits in health terms. Our challenge now is how we exploit this current climate, which is probably the best window we have had due to, as you have said, the white paper, the Olympics and a general consciousness about health. I understand that the fastest selling range of products in Boots stores are health-related products. How do we exploit that positive consumer choice? As Sam said, we are now looking, potentially, at between a 7 and a 9 per cent reduction in smoking. But how long has it taken to shift the public consciousness to accept that degree of legislation?
Virginia Berridge The way we look at things now is very much a result of the recent past, especially the focus on the mass media and mass campaigns. We tend to forget that that development only came in in the 1970s when Saatchi & Saatchi mounted their first health education campaigns - the Naked Smoking Woman campaign and the Pregnant Man campaign - for the new Health Education Council.
Other types of approach under discussion at the time did not get so far. For example, the tradition of local health education, which the Institute of Health Educators were talking about in the 1950s and 1960s, trying to build on local communities. Perhaps we should try to draw on some of those models now.
Another thing we ought to think about in relation to history is structures. In the 1970s, we had a centralist model with the Health Education Authority. Now, campaigns are more diffused. Whether that is a good or bad thing and how that relates to government, are things we ought to be discussing.
Edwina Currie The first question I was asked when I became health minister in September 1986 was, "Are you okay for a campaign on HIV/Aids?" I said, "It's about time". It is lovely to feel that that is still seen as such an important campaign and I am certain it saved many thousands of lives in the UK.
At the time, people felt that government had a lead role to play but that it also had to spread out into a whole host of other areas. For example, one of the questions on the brief was about targeting. The easiest way was to put money into an organisation - the Terence Higgins Trust - and say, "You get on with it". So I had the pleasure of having people shouting at me in the House of Commons about "this disgusting stuff that is being produced" when I knew we had been paying for it.
We used agencies not only for the advertising but to track and check on our progress. We checked what the ignorance levels were before the campaigns and again afterwards and we discovered that the recognition factor was higher than Kellogg's Cornflakes, so we knew we were on the right track. That is the right way to do it. If government opts out then you get confusion and the Daily Mail will opt in. An obvious example of that more recently would be MMR and autism. By and large, government is, or at least used to be, trusted. If government has a clear, consistent and steady line in communicating well, then these messages do get across and they are acted upon.
Nick Bitel When it comes to a healthy lifestyle, we haven't got a great deal of research. And every single study I have seen anywhere in Britain, whether it is in ethnic groups, women or whatever, has always said that it is time poverty that is the principal barrier to participation in sport and recreation. I am doubtful that a marketing campaign is going to change that . Government focus on family-friendly policies and time-friendly policies is the greatest thing that we could do to change people's attitudes.
In terms of facilities, we are probably subsidising the wrong thing. We are subsidising the local authority swimming pool and gymnasium, but most studies show that people who use them can afford private facilities. I would rather direct money to individuals.
Mark Duckham I've been involved in advertising for about 25 years. I actually started advertising cigarettes so I've come full circle. The ban on cigarette advertising achieved very little. We have to recognise advertising's limitations. What is important is where the message is coming from. People will listen to a message from one source but not from another. If it is coming from government, it may not have the same degree of power as if it was coming from, say, a pop star. It is also much easier to sell something that people like.
People are into magic pills, so they are buying lots of vitamins. They are looking for easy ways to make themselves healthier. They don't want to spend two hours a day in a gym because it's hard and it takes time. There has to be a mixture of communication, government action and social pressure. Clearly, you do not let your friends drive a car when they have been drinking, but that is as far as social pressure has gone. If we could use it to exert a greater influence on general health, that would be a positive thing.
Jeff French I have been working in this field for about 28 years, in insurance, teaching, health promotion and for the last ten years as a communications and marketing person.
What I would criticise about policy in general is that it doesn't start with the consumer, but with professional opinion about what messages need to be driven down through the system, and that doesn't work well. We need a better marketing approach where we start with people and what they know and want. People do want to change. The self-esteem industry in this country is worth £30bn. So, we can move away from a paternalistic approach where we tell and sell health to people to a marketing approach based on what people want.
Tamara Ingram Marketing has changed a bit. The Pregnant Man was great but that was at a time when one could be direct and assertive about communication. Television and posters were fantastic in achieving that. Now, we have to think more about people and where they are receptive to messages. We have to get the targeting right. The most successful campaigns, in my experience, are about engagement and involvement and not about telling and selling. There are many more channels where people can respond now. The wonderful thing about mobile phones and the internet is that people have a chance to play with ideas and create their own communities.
One of the ways that government can help is through its own behaviour. Jamie Oliver's programme about school dinners, for example, was telling. It is hard for government to talk about healthy eating if it is not providing healthy food. We cannot expect other people to behave differently if goverment is not setting a good example.
Cilla Snowball Our agency has been working on tobacco control for about 20 years to try to get people to give up smoking, so yesterday was a happy day for us. Everything we have learnt about behavioural changes says that they are hard to bring about: 75 per cent of smokers want to give up but find it hard. Most people want to lose weight but that too is hard. So if you start from the consumer, what you start with is programmes that look at making it easier to adopt healthy behaviours. The motivation and facilitation elements are really important. We can all play a part in that, not just government. Though there have been some successful government behaviour-change campaigns on tobacco, HIV and road safety, so government does have a strong leadership role here.
Equally, there are some easy and successful behaviour-change campaigns from the private sector. For example, Sainsbury's Active Kids campaign, which facilitated healthy eating and active lifestyles, and Boots' Change One Thing programme, which made it easy for people to adopt healthy behaviour. We will only get there when we all work together rather than rely solely on government finding the solutions.
Jeff French The days of the government being like the Lone Ranger have to end. We have to start building delivery coalitions across all the sectors, including the private sector and the NGO sector as well. People are up for that.
Deirdre Hutton One of the things I have done recently is to join the Foresight programme, which is taking a 20 year view over obesity. Clearly, there's no simple answer. It is not even as simple as energy in/energy out. It is much more difficult and incorporates many of the things that people have said so far.
I am always worried when one starts with social pressure. That is an issue, but if I go to Tower Hamlets, there is no shortage of people who know exactly what they should be eating. Access is the main problem; there is only one fresh fruit and veg van that comes round the area that I was in.
One of the great advances at the moment is the extent to which the market is seeing health as a competitive issue. I am delighted that Sainsbury's and Tesco will knock chunks out of each other in order to compete on health.
I am also conscious, for example, of the Salt campaign which we have been running. Over a year, we increased the public awareness of "six grams of salt a day" from 3 per cent to 33 per cent. One of the things we did was to give money to a Muslim association so it could go and talk to the imams in mosques who would then talk to their congregations. Those sorts of marketing techniques, about speaking to people in their own communities, are critical.
Nick Bitel You say that people know what is good for them. That may be right in food but in terms of active lifestyles there is a distinct lack of education. The majority of people think they are active enough, yet the research says that they are not. So a gap exists where an education campaign, whether through government or commercial marketing, does have a role to play.
Sam Everington There is still an enormous lack of knowledge in the community I serve in Tower Hamlets; there are still people who don't know that smoking causes lung cancer.
Mike Rayner You asked at the beginning what works in terms of health promotion. There is a huge amount of literature on what works. We don't need to speculate; we can look to the evidence. What is clear is that education by itself doesn't work and that it needs to be hand-in-hand with environmental change. Just telling people what to do is not going to work; it has to be coupled with giving them the ability and the environment in which to make behaviour change.
Having said that, there is too much emphasis around this table on marketing. I am not keen on the term "marketing" at all. There is too much emphasis on advertising campaigns. Advertising is only one, minor, part of health promotion.
John Procter One campaign had an enormous effect on me as a young person. There is a festival on the BBC of public information films and Dave Prowse, the Green Cross Code man, came on. I realised, thinking through that with my little ones, that I can recite the Green Cross Code. I can also recite the Tufty Club code when I'm teaching my five-year-old to cross the road. That campaign made me learn a behaviour. It became part of what I did. Forming a new behaviour that might take a generation to see its way through into some long-term health benefits is something we have to invest in. We need to start with children and prevent the learning of some of the behaviours that can cause the difficulties that develop over time.
Louise Fish Nice was only asked to take on a public health remit last April. Until recently, our roles were looking at clinical evidence and giving the NHS advice on what works best and what they should and should not be spending money on. Now we've been asked to take on that role in public health as well. Our first public health guidance will be out in March.
The first round is short activities that could help with encouraging people to do more physical activity. Indications so far suggest that pedometers and referring people to the gym for a couple of weeks have not been particularly successful, but that the time spent with a GP, talking through what differences exercise can have on one's life, does have a real impact.
There are some areas which we have not really touched on yet, such as the inequality issues in Tower Hamlets. We are doing guidance in other areas such as TB and drug misuse, and areas where national public health campaigns may not make a huge difference to everybody but campaigns at a local level could make a big difference to particular communities. Hopefully, that will be a changing part of the bigger picture as well.
Edwina Currie We haven't mentioned the cancer screening for women campaign which was, and continues to be, a great success. We needed to get women in this country feeling that it was theirs. A lot of campaigning and work was done in close conjunction with the Health Education Authority - as it was then - and our advertising agents at every health authority. Everyone had to be up and running at the same time so that the partnership was there. By God, it worked. We had 77 per cent acceptance right away and it has stuck at that level ever since. We changed the culture from one where people did not talk about women's cancer - the debate in the House of Commons had the fellows squirming when we used words like "cervix" - and we used women's magazines, not health magazines, to get the message across.
Michael Farrar We get success where we understand what we are doing in the chain of events. So, where we need to raise knowledge we actually use the best techniques to provide information in the most acceptable way, and we get our incentives right, and position government right.
The great boost in road safety was the seatbelt campaign, which in itself probably only changed seatbelt wearing by about 5 or 6 per cent in the late 1980s, but it allowed the context in which legislation then had a massive impact. People understood why government was going to act. Similarly, with immunisations, there were lots of campaigns but it was really only when we incentivised GPs in the 1990 contract that uptake increased from 25-30 per cent to 80-90 per cent.
We need to be smart enough to know whether or not we are raising information to try to change awareness or create a receptive context. And the bit that I think is still a major challenge for us, even though we have had some really successful campaigns, is looking at how they are sustained.
Lots of people sustain good behaviour at the affluent, middle-class end but health inequalities are widening. The people who would be the greatest beneficiaries of health promotion are still disaffected. We are not getting our targeting right. Sometimes in health we draw on expertise, such as marketing expertise, but in an ineffective way. We have asked people to have campaigns about raising information when what we really need is behaviour change and vice versa. Success is when we get those elements right and the coalition lines up properly.
Mike Rayner There is a tendency to think that any one thing in itself will work. My favourite example is restricting junk food advertising to children on television. Nobody is really saying that that in itself would make much of a difference. There have to be lots of different things going on simultaneously. It is also difficult to work out which of these things are going to be most important.
Jeff French Co-ordinated, multi-factor programmes, sustained over a long period of time, get the best results. If you look across government, a number of information campaigns are aimed at 15- to 25-year-olds: smoking, teenage pregnancy and so forth, and separate teams target those issues.
One of the concepts we came across in the States is "bundling". It starts with consumers and a focus on tackling lots of issues together rather than going for individual problems and interventions. Intuitively, it makes a lot of sense. What do young people do? They go out, drink, have a fag, and if they get lucky they have sex with somebody, probably without a condom. We tackle all of those issues separately instead of bundling them together. Some radical thinking about looking at people in the round would be useful.
Tessa Jowell The strategy you take really has to depend on where the countervailing messages are coming from and how strong those messages are.
When I was a public health minister, we had a campaign to help people give up smoking, based not just on advertising but also linked to practical interventions, giving people nicotine replacement therapy, counselling, and so forth. No one would underestimate the complexity of the packages that you have to put together. But one of the problems we have is that we do not evaluate rigorously enough the impact of advertising or a behaviour change campaign.
My second point is do you have the messages working with or against you? The jury is still out on that. Those of us who want to see and understand the importance of people changing their diet welcome the increase in consumer literacy. The simple, five-a-day message is slowly getting through. I once tried to persuade McDonald's to put a piece of fruit in their Happy Meals. They tried it in Glasgow and the outcome was a satsuma mountain. It simply wasn't working.
We are in a different position now. If we can harness the power of the industry to get across the right messages to the right people, that would be progress. If you run a campaign about teenage pregnancy for adults, it is going to fail. You have to be brave and run it for teenagers and accept the reality of those teenagers' lives. Those are some of the inherent tensions in this whole process of changing people's behaviour.
Finally, if you want to get people to change their behaviour, politicians shouldn't be the advocates of that change.
Deirdre Hutton But you also have to face the reality that if you are going to the supermarket, there is at least one whole aisle of crisps, snacks and chocolate. You have to be realistic about the market. Companies are developing healthier food, particularly in convenience lines, but there is also a lot of processed food and all the evidence suggests that consumers don't know what is in it.
Consumers need to be empowered and that is the thrust behind the agency's campaign on signpost labelling, giving people clear, easily accessible information in the supermarket.
Cilla Snowball Successful health behaviour change comes down to four areas that were also expressed in a World Health Organisation report.
The first is new news. Some of the work we did on second-hand smoke was designed to present the case that while people may not be worried about their own health, they are worried about the health of their children. That was new news expressed in a motivating way to smokers. Evidence suggests that a lot of people gave up there and then, or said they would. Second is the need for a continuous presence in behaviour change campaigns. At whatever level you are going to fund campaigns, keep it up and keep going. Third is that a multi-layered approach works best, incorporating advertising, local initiatives, online initiatives, and so on. The fourth area is really important, that there should be more than one voice. If government alone is talking about healthy behaviour, it will not be as effective as if Sainsbury's, the Food Standards Agency, Mars and Pepsi were talking about it too.
The messages have to be simple enough for us to remember, such as "five-a-day" and "belt up in the back".
John Procter Some of the work we were doing to promote self-care was to support behaviour change in individuals with established long-term conditions. The main concern was to make the message meaningful to people.
We spent a lot of time working with colleagues to get them to a starting position where they could talk to patients over the telephone in an entirely different way, empowering the patient to take action for themselves. Often, a key to that is finding a way to get a personalised message across. For example, encouraging someone to walk to the shops every day, instead of talking to them about gyms and running, which are more likely to put them off exercise.
Sam Everington That is the exciting thing about the white paper. Ninety per cent of patients will come and see our practice at a yearly period, and a third of the community use it on a regular basis. It is a fantastic marketing opportunity.
Nick Bitel One of the things that troubles me in this debate is why Britain is so bad at getting women to adopt a healthy lifestyle in terms of exercise - our participation rates are some of the worst in Europe. One thing we have done with a number of events is to try to understand why women do not run, for example. We identified that women don't like running with men because of macho attitudes. Since we started women's only races we have been over-subscribed.
People largely know what they want to do. We need to try to understand what the barrier to entry is and then deal with it.
Tamara Ingram We need to change the framework of the discussions. That could be a social change. Back to your running example, people actually want a sense of community or comradeship. Changes like that can make a huge impact on how people feel about exercise. Again, it is about smart targeting and not always targeting everyone with the same message.
I do take issue with the "keep politicians away from it" attitude though. If we want people to live a healthier lifestyle, then we all, politicians included, have to exhibit the kind of behaviours we want others to emulate.
Mike Rayner Let's have John Prescott take up running!
Michael Farrar When we think about some of the most successful health promoting interventions, they are not empowering, but punitive. For example, seatbelt wearing became a legislative change; people were penalised if they did not do it. And we think the smoking ban will do more than anti-smoking advertising to make people stop.
When governments make changes through legislation, it does have a universal impact. The people who most benefit from change often make more progress in that way than through a more empowering, voluntary method. If we look at what has made a big impression in the health service around improving productivity, it is that you take away choice at certain key stages and you put in evidence of best practice. We should not shy away from that debate about how you get a balance of enforcement and empowerment. We would be mistaken if we thought that the answer was just getting more slick in our empowerment. I would want to see that at the heart of our strategy, but some degree of enforcement around healthy change is justifiable too.
Louise Fish It is also important to empower everybody. You can empower everybody to improve their lives a little bit but you can also work with those people who need to make the most changes in their lifestyles. We are publishing clinical guidelines next month on TB that will recommend harbouring a lot of the resources for those communities that have real problems with TB and need to take a lot of action to try to improve health. Some public health messages are difficult to get across, particularly through daily newspapers, and will be virtually impossible without an advertising campaign, but they are just as important.
Edwina Currie I am a bit concerned. I have heard enemies named - supermarkets with their processed-food-laden shelves - but you should make allies out of enemies.
Deirdre Hutton We are doing.
Edwina Currie If I had had a health campaign on salt that only produced a 33 per cent recognition rate, I would consider it a failure and I would be looking at what happened to the 67 per cent who did not know about it. If a campaign makes enemies of the people who produce most of what we eat, then we are not going to get the message across. Campaigning with the companies and manufacturers, making it something that they have an input into is essential.
I used to get shouted at for talking to tobacco companies, but they own insurance companies, too. There is always something else that they manufacture and they can be encouraged to put forward ideas and then to back them because they own the companies. The same goes for the national press. Go and talk to the Daily Mail. It doesn't always work, but if you don't try and you see them as an enemy, that isn't going to work either.
And can I make a plea for people over 60, please. We are not going running! Is that clear? One of the most useful and valuable things that any GP can say to a family in which there is heart disease is to get a dog. Walk to the pub and the shops. Get a dog. My husband and I got a dog last year as part of our personal campaign and I am astonished at the drop in our blood pressure and the pleasure that it gives us. So there are other answers.
Deirdre Hutton You are right about making friends of the industry. If I were to lay out the Salt campaign to you it would take too long, but it was about persuading the industry to re-formulate, which they have. For example, Sainsbury's has got its salt levels in bread down to recommended levels, which we were aiming at for 2010. We had Heinz with flashes around its tins. It has been a huge success because of that. It was also designed to raise public awareness so that the public themselves would create the demand for the lower-salt products, so it was a virtuous circle , changing the market and the demand. If you can, within the general public, produce a change of awareness in 30 per cent of the population on a £5m budget, you have done pretty well.
Virginia Berridge I am interested in alliances. Many people have mentioned road safety. There has been a huge behaviour change in drink-driving but it has been around an issue that could have been associated with temperance and abstinence, which were not popular at all. So maybe we could think about cultural change by what we can link health issues with.
Mark Duckham Some of the unhealthiest people I know are GPs and healthcare workers. They know what they are doing to themselves but they don't care. Often people are not very good about influencing their own behaviour. The point about women was important. Women have overtaken men massively in terms of smoking. But women are traditionally the people who influence men's and family health. We need to get them, and children, on side. We need ambassadors for what we are trying to achieve and some sort of bandwagon fashion because cultural changes and big marketing changes happen when people start talking about them in the playground or at work. The Olympics may be the perfect opportunity. People do not want to change behaviour if it is hard work. They need attainable goals.
Virginia Berridge The image of women as the guardians of family health is out-dated and can also be counter-productive. It certainly was with that Saatchi campaign of the naked smoking mother which caused outrage among the group of people whom Hillary Graham was researching and actually led to her influential research about smoking and inequalities. Focusing on women is, perhaps, something to be avoided.
Mike Rayner There is a place for top-down and bottom-up approaches. People on the ground tend to think that things are not going to happen to them, whereas people at the top, or the government in particular, know to some degree what is going on within their systems. For example, one of the recent public health disasters is the rise in obesity and the resulting Type 2 diabetes in kids. The public wouldn't know that without government surveys and consequent moves to address the problem. So the government has a clear role to take the lead.
Jeff French I want to go back to what has been said about compulsion versus choice and take Australia as an example in relation to smoking. In 1973, Australia and the UK had the same smoking rates, about 37-38 per cent. Now, we have a rate of about 27 per cent and Australia is down to about 18-19 per cent. How have they overtaken us so dramatically? They do not have any smoking bans, smoking cessation clinics or nicotine replacement therapy. Calculations suggest that even with our new smoking ban, we will be 40 years behind Australia in getting to the point where we have 5 per cent of the population smoking. Australia's success has come about through intensive advertising, community development, local projects and school health education programmes. So there is a different way to go. I am not saying it is one or the other. You need a good mix which can feed off each other.
John Procter We have GPs incentivised around particular clinical targets and markers. No one would suggest that they are not good things to have as a way of improving clinical practice across the board. However, issues around personal choice need to be considered. For example, you may be working with a diabetic who is overweight, smokes a bit, drinks too much alcohol, has a poor diet and whose cardiovascular risk is significantly high. You might get so far getting that person to make behaviour changes. Then they may say, "That is enough. I know I drink more alcohol than I should but I've given up smoking, I do a bit of exercise, and though I'm not quite at your blood pressure target, this is where I want to be". You have to be prepared to accept that there may be times when we will only get people so far. The question for us in healthcare is whether that's far enough? When you have people on your dietary register whom you really need to get to a clinical target are you happy to say, "Okay, I'm going to respect that personal choice". An effective question around legislation is how far can you push people along that line?
Edwina Currie Anything that will improve the risk factors has to be welcome. I was responsible for the original suggestion that the immunisation programme would only work if we got the GPs vaccinating a certain percentage, and that that would only happen if we paid them after they got there. I was accused of being cruel to GPs but it worked. If you can do anything to reduce the risk factors, that is a gain. During the 1980s, we saw life expectancy rise by two years in this country, which is a huge jump. It came partly through smoking, partly through other issues such as immunisation levels rising and so on. If the system is set too high and we are missing it and not getting any benefit from it, then perhaps the system, the little bit of legislative or contract element, needs tweaking. That should be a matter of continual discussion, surely.
Michael Farrar I have been struck with some of the developments recently around using the high street for healthcare provision. An example is the chlamydia screening that Boots is doing and the hypertension screening. The uptake of that looks incredibly promising. I think it is to do with the way in which people interpret their power relationship when they go in to seek services. There is a real difference between going in and having a test in a high street shop as opposed to seeing a health professional in a primary care setting.
Nick Bitel The reason I focused on women was not because of their supposed roles as household leaders but because of the figures that show their lack of education and aptitude, or not. I say it is a lack of opportunity in terms of exercise uptake. I said the same about certain ethnic groups. Bengali women especially, have terribly low uptake.
The most worrying news this week is that men in the Calton district of Glasgow have an average life expectancy of 54 years. That is incredible. If I look for the quickest solutions, it must be to target those groups where the figures are worst; women in terms of exercise and men in terms of alcohol.
Edwina Currie But if you just target the most difficult lot and ignore the population as a whole, you will not see any health benefit whatsoever because you are after improving averages. You are after improving risk averages. You have to look at the population as a whole and then at the black holes. It may well be that public authorities cannot do that very well and that it needs to be done through other organisations. One of the things we proposed for Bengali women, for example, was Bangla dancing. You had to have women-only groups and sports halls had to be set up. Fine. Do it.
Tessa Jowell If you focus on the population as a whole you can get some easy wins. Overwhelmingly, it is people in social classes A and B who give up smoking, while inequalities for the poorest people continue to increase. You do need different messages for different people. And gender differences are important. We have done a lot of work on why girls are so resistant to exercise, even at 11. You have to take account of their selfconsciousness as their bodies change and the kinds of different kit that make them less selfconscious and more likely to take part and the fact that they are more likely to exercise if they can dance or do aerobics. It is an absolute priority to try to increase the scale of equality, and that does mean neighbourhood, locally based approaches to health improvement.
Cilla Snowball Although this is a serious issue, we cannot be too wordy when it comes to the communications. There are some great examples in the health and activity area, such as Everyday Sport, a collection of simple messages about what you can do when you are ironing or walking the kids to school. They are messages which relate to people's everyday lives. I am a non-executive for MacMillan Cancer Relief. It had an excellent example of getting people to walk the road when a new stretch of motorway was opened in a certain region. That was a local initiative which may have got more people walking and seeing that they enjoyed it.
Edwina Currie There are one or two areas where government has a direct influence. Hospital food is an example. It's dire. They are still serving up cooked sponge puddings as they have for the past 50 years. If you ask for something easy to eat such as fruit salad, it's not available. It cannot be a cost issue because it costs money to cook sponge pudding. There are areas like that where we could make more progress.
Deirdre Hutton One of the things we are short of in this country is integrating mechanisms. I'd like to see the Olympics used as a model for a different approach, which is an absolutely integrating one. We have six years to practise this. It is an unrepeatable opportunity. If I think about what the role of government is and also more particularly my agency, it is about helping to provide the evidence. It is about helping to build consensus around that evidence, interpreting and translating it and, as it were, giving pushes or steers in the right direction. We need to start thinking about how we provide that integrated push leading up to the Olympics.
Tessa Jowell I agree. Hosting the Olympics in 2012 is a unique motivator for much of what we are talking about. Kids all over the country, many of whom will not get near medal standard, are ambitious about doing well. We have all sorts of plans for big sporting activities to increase participation, particularly in a way that creates a lifelong habit. That is what we really want to do. We have this sort of cliff-face of young people at 16 or 17, (60-70 per cent), who give up sport and the Olympics are our great opportunity to reverse that.
Deirdre Hutton But how do we build into that information about food, healthy eating, smoking, drinking, and safe sex?
Tamara Ingram I am not an expert in the healthcare area but I am obsessed by the Olympics. The leaders of the household are not women but children. Children are a fantastic opportunity for the whole household as well as for themselves. They are open and they love bossing their parents about. They are the ones who want their parents or their family to be healthy. Their's are also the behaviours that we need to change. At the moment, we don't use them. How can we use them in a way that is engaging, involving, fun, rewarding and that is in the right language? Not just worthy, but with some playground value. We can tie it up with the Olympics, with music, and with eventing. But we tend to ignore it. We tend to be on the worthy side of that.
Sam Everington So what is the one thing we would want to do, with no bars and restrictions on how we would do it?
John Procter I would start to address the issue of the ageing population and the potential impact of the growing burden of long-term conditions. If I could do anything now, I would be working hard on all NHS staff to change some of their behaviours where they interact on a daily basis with the people they come into contact with, particularly around a GP practice. I would also focus a bit on developing the art of medicine. The science of medicine has developed massively over the last century but there is an art to medicine that needs to change; it is much more about empowerment, the change in the message and the less didactic method.
Edwina Currie I would like some consistency. We heard about "bundling" which is good. We have done a lot of that on heart disease. But it can also lead to having too many targets all at once and it can be confusing. What is even more confusing is when you get inconsistency and contradiction. I would love the government, any government, to say the same thing on each issue so that we do not get smoking bans and 24-hour drinking, which is barmy. Go into any big city on a Friday or a Saturday night and see if you feel safe walking down the main street. That is a big issue and it is caused mainly by drink. Is the government in favour of better health or not?
Tessa Jowell Let me reply on consistency, which is to say that the licensing laws have changed. They have changed because the old system promoted and provoked, as the reductions since the new Act came in have shown.
Edwina Currie Nobody believes you.
Tessa Jowell The figures speak for themselves.
Edwina Currie They do not.
Tessa Jowell Go to the centre of Birmingham. Alcohol-related crime there has been reduced by 25 per cent over the last two years. Now, there is a violent crime problem and a disorder problem which the new Licensing Act is tackling, but you cannot misrepresent the Licensing Act as a licence for 24-hour drinking. It is not that. It is a licence for local flexibility.
Edwina Currie Smoking is coming down, which is good news, but drink is causing major problems. That has to be talked about as well; they are not alternatives. I would like to see an end to contradictions, and that is the job of government and nobody else.
Tessa Jowell We do have a problem of young girls who binge drink, and it is cultural and behavioural. It's what they do on a Friday night, knock back four vodkas while they are putting their lipstick on. And we do have to change that.
But picking up Deirdre's point, I would like to see us using the once-in-a-lifetime challenge of the Olympics to create a generation who, at each age, take exercise as simply part of what they do, like brushing their teeth in the morning.
Michael Farrar My one wish would be to double our expenditure on primary care over the next ten years. The importance of healthcare interventions at early stages with credible people in communities is the one bit of evidence I have seen where we can reduce health inequalities for things such as heart disease, and where good quality primary care is available. We still put too much of our energy in secondary care.
Jeff French Understanding the consumer cannot be underestimated. If there is investment in that, solutions will flow. The private sector, the media, the NGO sector and the government need to co-deliver a solution. Government should not do it on its own.
Mike Rayner What I want is a ban on the advertising of unhealthy foods to children, not because it is the only thing that would matter, but because the rise in obesity will lead to a decline in life expectancy in the UK. It is a serious problem and we have to do something about it.
Louise Fish It is easy for us to measure public health campaigns, and to measure what we are saying and whether people remember it. But it is how we set long-term measures of difference in behaviour that is important. Twenty years on from the Olympics, how will we measure how much we have made a real change to the lives of people who are children now?
Deirdre Hutton As chairwoman of an evidence-based agency, I want absolutely compelling evidence, which at the moment is only anecdotal, that eating a different and better diet changes children's capacity to learn and teenagers' tendencies towards violence. If we had that we would start to double the budgets of GPs to get there.
Nick Bitel I have to do something about getting 16- and 17-year olds to continue exercising, whether it is by delivering access to exercise, or giving out vouchers rather than subsidies. My number one thing though, is getting Tony Blair, David Cameron, David Beckham, and Madonna to run the London Marathon. That would change people's perception of exercise.
Mark Duckham The people that we really need to change are going to be the hardest people to change. We all know that if you have a new drug you do not target the most difficult people, you target the easiest ones. We have to look at new ways to get to those really difficult people.
Cilla Snowball My one thing would be to create a single, collaborative campaign to encourage healthy lifestyles. The emphasis would be simple and adoptive. It has been done before. We have done something with "Think road safety" where a number of messages can come together to a number of audiences, and whether you are a local road-safety office or an advertising agency you can contribute to that initiative. We should be able to do the same with healthy living.
Virginia Berridge We need to learn from history. Also, I have an alcohol related point. Maybe now we have the Licensing Act we could move on from the crime and disorder discussion to talk about alcohol as a health issue linking it to the Olympics; we could firm up the messages, or even have a range of messages about what moderate really is, as none of us seem to know. Is there a message there, "It's okay not to drink"?
Tamara Ingram I would use the Olympics hugely. The only thing I would say is about engaging all sectors. We must not forget the power of entertainment, leisure and music. If we can engage a mix of people then we can make it. Making something fashionable, enjoyable and beneficial, makes it easier for people to get engaged rather than making them feel they are dealing with a negative.
Sam Everington When I worked in Bangladesh for a short period of time and looked at the research there, the connection between nutrition, physical, mental, and educational development was absolutely clear. As a result, I would like to see only healthy food as an option in schools, and the banning of all vending machines.
I would also make the hepatitis B vaccination universal for kids. That could prevent one of the commonest cancers in the world; over a million people die from liver cancer a year. We are one of the few European countries that does not have universal vaccination and it is absolutely essential.
Thank you very much to everybody for coming today. It has been a fascinating and productive discussion. Thank you.
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