At the Conservative Party conference Rishi Sunak surprised delegates by making a bold health policy commitment – his intention to ban cigarettes for anyone currently aged 14 or under. The Prime Minister’s announcement incited outrage from his libertarian peers, including his predecessor Liz Truss, who made it very clear she would vote against such “illiberal” legislation.
Disagreement over what role the government should play in personal choice is not limited to the Conservative Party. People invoke the “nanny state” to deride official protectiveness and over-involvement in our lives. But health is impacted not only by individual choice, but by factors beyond our control.
In fact, it is unfair to place the onus of “good health” on the individual, says Greg Fell, the president of the Association of Directors of Public Health (ADPH), when conglomerates like big tobacco “invest millions into clever marketing and advertising strategies that are specifically aimed at [securing] the next generation of smokers”.
The ADPH represents England’s directors of public health – experts placed in local authorities to deal with major health issues affecting their local populations. Fell is the director of public health in Sheffield.
“It’s a watershed moment, just as the ban on smoking in public places was,” he tells Spotlight regarding Sunak’s conference announcement. “And it’s an opportunity to make a long-lasting, significant difference to our nation’s health. It’s vital that we get it over the line.”
The Conservatives’ plan would gradually ban smoking by lifting the age at which people can legally buy tobacco products by a year each year; no one presently aged 14 or under would ever legally be able to buy a cigarette. Wes Streeting, the shadow health secretary, has said that Labour would do the same if it wins the next general election. While Fell is supportive of such legislation, he says the next government should be mindful of the potential of the emergence of a black market. “We should be very careful about our implementation of it,” he says. “I worry a lot about the unintended consequences, [such as] the illegal sales point.”
“Public health” is not easily defined or wholly understood. It refers to factors that influence rates of “non-communicable disease” – illnesses such as cardiovascular disease and diabetes that are not spread through infection but are typically caused by unhealthy behaviour. These diseases make up three quarters of deaths globally, killing 41 million people every year. The Health Foundation has predicted that by 2040 more than one in six people will be living with a major illness, placing a profound burden on the NHS, social care and the economy.
Fell describes public health as both the “science and art” of preventing disease and promoting health “through the organised efforts of society”. Key to this is trying to close the healthy life expectancy gap – the age at which people stop being in good health – between the most and least fortunate. In South Yorkshire, where Fell is based, the difference in life expectancy between the most and least deprived areas is 8.7 years for men and 7.6 years for women.
The public health services provided by local authorities are broad and not necessarily what we might consider to be “health”. In Sheffield they fall under six main categories, says Fell: health visitor checks and school nursing for children; alcohol and drug misuse; smoking cessation; sexual health; obesity and weight management; and “social prescribing”, which connects people to community activities, groups and services to positively impact their health and well-being, often in the charity sector. This could include helping digitally excluded people to access all the welfare they are entitled to, or connecting older people with a charity such as Age UK that tackles loneliness. In reality, public health covers all facets of daily life, from housing conditions and public transport options, to access to parks, the internet and educational opportunities.
“There isn’t a single big idea,” says Fell, when asked what he thinks the most pertinent public health issue is. “If we want to accelerate the improvement to life expectancy, let’s start with tobacco and air quality. But really, if I had to say one thing, it’s reframing our narrative on health.”
By this, he means redefining what “health” is – not simply intervening with treatment when someone gets ill, but stopping them from getting ill in the first place. He also wants to challenge the perception that public health legislation restricts personal freedoms, when historically, he says, it has done the opposite.
“Let’s be honest, the ‘nanny state’ has actually given us an awful lot of freedom,” says Fell. “As a direct result of these and other measures brought in by the state, disease and accident incident has fallen, life expectancy has risen, and we’ve been given the freedom to live and enjoy our lives for longer.” Banning smoking in enclosed spaces has reduced the risk of cancer. Introducing a Public Health Act in 1848 helped to eradicate cholera and other waterborne diseases. Enforcing the use of seat belts has reduced the likelihood of death from a car crash.
Fell believes that the idea of personal liberty is used to shift responsibility onto individuals, while corporations use their power to exploit behaviour for profit. As a result, the population gets too sick to work, and people need higher levels of support and treatment from the state.
“Individual agency matters,” he says. “But we are products of the environment in which we live, which is saturated with gambling and fast-food adverts. If our environment cues us to behave in a certain way, we’re going to do it. Advertisers spend millions of pounds influencing our choices – who’s the nanny in that context?”
Fell does not deny that everyone needs to take responsibility for their own actions when it comes to health, but to ensure our choices “really are our own” rather than ones “pushed by profit-hungry industry” the playing field needs to be made fair, he says, starting with how we regulate industries such as tobacco, fast food and gambling.
Structural inequalities from poverty to lack of public transport to living in densely populated or polluted areas also stop people from being able to make healthy choices, he says. Healthy food is more expensive for poorer people; the Food Foundation’s Broken Plate 2023 report found that the most deprived fifth of the population would need to spend 50 per cent of their disposable income on food to afford a healthy diet, while the least deprived needs to spend just 11 per cent.
Fell believes that the UK could consider going further on food restrictions – for example banning trans-fats, a fat found in processed foods that is very harmful to heart health. Several European countries and US states have banned them, but the UK government instead encourages food companies and manufacturers to reduce them on a voluntary basis.
Despite the large number of people expected to be living with preventable disease by 2040, public health has been largely neglected compared with seemingly more urgent issues, such as the NHS crisis. Fell likens this to the attitude towards climate change, adding that politicians often neglect things that don’t have “immediate payback”.
Political discourse, strategies and funding from both the Conservatives and Labour have focused on bringing down waiting lists, improving access to GP and emergency care, and recruiting more doctors. The Public Health Grant – which is the money allocated from central government to local authorities – is £3.529bn for 2023-24, an increase of 3.3 per cent on last year, while the NHS England budget is £160.4bn. The Public Health Grant has not risen in line with inflation, and the ADPH says it is “simply not enough” to make up for “years of effective cuts to funding”, which have resulted in services being reduced.
More local government spending power on public health would save money and reduce the burden on the NHS in the long run, says Fell. Research from the University of York shows that local authority public health interventions offer good value for money – it costs £3,800 in public health services to give someone an extra year of good health, compared with £13,500 for NHS interventions. Cuts to the grant will severely impact the voluntary and community sector, he adds, which he believes is the “bedrock for the creation of well-being”.
Alongside more funding, Fell wants the next government to employ a “health-in-all-policies” approach, where it is considered across all government departments and areas, from housing to public transport infrastructure and education. The ADPH is also calling for a new Public Health Act, Child Poverty Act, and a dedicated health inequalities strategy. The government previously committed to a health disparities white paper, but scrapped it in January this year.
“We can’t expect to prevent ill health in adults if our children are growing up without the basic foundations for a healthy life,” says Fell. “And it just isn’t okay that depending on where you live, you can expect to live more than ten years less.”
But ultimately health itself is a means to an end, not an end in itself, he says: “Health isn’t the goal – health enables us to live the kind of life that we want.”