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Public health: Nanny or nudge?

Mark Easton | 17:42 UK time, Tuesday, 30 November 2010

As Conservative health secretary and architect of England's public health strategy, Andrew Lansley treads warily along the tight-rope suspended between individual liberty and social responsibility.

Andrew Lansley

It is a divide that mirrors the ideological fault-line of British politics and has existed ever since Edwin Chadwick's 1842 Report on the Sanitary Conditions of the Labouring Population prompted Parliament to set up a General Board of Health.

Mr Lansley explains the "dilemma for government" in the foreword to today's Public Health White Paper: "it is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live". (You don't have long to wait for the "but".) "But we cannot sit back while, in spite of all this, so many people are suffering such severe lifestyle-driven ill health and such acute health inequalities."

So there's plenty of "localism" and "big society" in the rhetoric of devolved power and personal responsibility. But...Mr Lansley knows that, historically, significant improvements to public health have required the catalyst of national state action and today's White Paper hedges its bets with taxes on alcohol, ring-fenced budgets, a new organisation to drive national strategies from the centre and the threat of regulation if change doesn't occur.

The health secretary draws a distinction between the "nanny state" and the "nudging state". Last summer he told doctors he is opposed to "lecturing people and telling them what to do" preferring to "harness behavioural science...nudging individuals in the right direction".

It is a contrast that's already drawn ridicule on some Conservative websites. Giving children shopping vouchers if they walk to school, one of the ideas in today's White Paper, is characterised as "more Socialist than the USSR ever was" by one right-wing blog.

Meanwhile, a left of centre site employs irony to suggest the "oppressive tyranny of colour-coded food packaging will be overthrown" by the champion of individual responsibility.

The "people power" ideology of his government might encourage Mr Lansley towards a light-touch public health strategy. But his report on England's Health and Well-Being [955.56KB PDF] today includes some big numbers which suggest an assertive preventative approach could save the tax-payer pots of money.

Here are a few of the estimated annual health costs which, it is argued, a public health strategy might help reduce:

• smoking-related illness - £2.7 billion
• alcohol-related illness - £2.7 billion
• drug-fuelled crime - £13.9 billion
• noise - £5-8 billion
• poor air quality - £9-19 billion
• working days lost to sickness absence - £13 billion (2007)
• hip fractures - £1.4 billion
• poor mental health - £77.4 billion (2003).

Nudge or nanny? Faced with the bills for all of this, one can imagine why Mr Lansley is reluctant to let go of the apron strings completely.


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  • 1. At 7:13pm on 30 Nov 2010, Whistling Neil wrote:

    What a contrast with a government which has just announced the withdrawl of the EMA designed to nudge poorer students to stay in education and Lansleys document which proposes to nudge children to walk to school with a bribe?

    Talk about getting your priorities all the wrong way round.

    Nudge = Nanny they are the same (bribing people to do what you want is still telling them what to do, just trying to make them think it was their idea in the first place) - so given the amount of abuse the Conservatives heaped upon the nanny state they have earned the title of hypocrite as well.

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  • 2. At 7:23pm on 30 Nov 2010, Briantist wrote:

    The day that a person with Asthma can pop into a chemist and buy an inhaler like you can do everywhere else in the world - and for the same price (€2) - I will be impressed.

    Tony Blair promised easy repeat prescription back in 1997.

    If Andrew Lansley can make Asthmatics life so much easier than having to put a bit of paper in a slot every month and wait three days for a doctor to sign a bit of paper and then go back to the doctors and take the slip to the chemist and wait some more.

    How come I can just buy the damn things in France, Spain, Portugal, Morocco, Greece, Belgium, Netherlands, Germany, India and so forth?

    Come, on, easy win...

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  • 3. At 7:56pm on 30 Nov 2010, jon112dk wrote:

    Strangely, as he takes control of education AWAY from (often labour controlled) city councils he is pushing responsibility for nannying ONTO councils.

    Once again there must be a suspicion that this is a government that wants to avoid responsibility for anything unpalatable.

    No hospital bed: blame your GP consortium. No social care for granny: blame local volunteers. No police: sorry its under local control.

    Sick of being preached to about eating a bag of chips? Blame your council - nothing to do with us.

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  • 4. At 9:22pm on 30 Nov 2010, watriler wrote:

    Surely no one thinks that banning smoking in public places is the nanny state, or advertising on the TV about the dangers of drink whether driving or not. How about the provision of decent social housing, adequate supply of jobs or education for citizenship in society. There are millions who need the 'nanny state' because they do not enjoy the basics of a modern advanced economy and society and the dilemma they care about is whether to heat or eat. Such hypocrisy when the government is forcing cuts on the NHS - see for yourself.

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  • 5. At 10:18pm on 30 Nov 2010, Arrrgh wrote:

    50p tax on all take-aways to go towards mental health care in the community. 50p tax on all chill-cabinet/ready made foods to go towards sports facilities. Fat tax on flights, on trains and buses - sliding scale on weight to height, money to go towards old people care. 5p tax on all text messages to go towards after school clubs for children. 2p tax on all videos up loaded on to youtube to fund parks and playground refurbishment. etc etc etc etc.

    Nudge people in the pocket, its the only way it will work.

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  • 6. At 10:37pm on 30 Nov 2010, Arrrgh wrote:

    Surely this can not go on and on any longer. The elephant is still in the room. We eat too much, like the odd drop of the hard stuff, have a liking for the illegal now and again plus like to take our exercise from the comfort of our living rooms. The majority are getting fatter and fatter. Get a fat tax, it could go towards clearing the UK's debts or funding of the NHS plus nudge all us fatties away from the cookie jar.

    We are weak and getting fatter by the day. We need help!

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  • 7. At 09:02am on 01 Dec 2010, Daisy Chained wrote:

    Just how much does it cost to build a megastore complex with huge car parks? Compare this to the cost of ready made units in the high street with buses and even trains already accessing same?

    So why should I, walking to a local megastore because I have no alternative choice, pay within the mark-up prices, the cost of borrowing for the needless monstrsity that a ruling class has forced upon me? If it is justifiable for a child to receive shopping vouchers for walking to school, then it is equally justifiable to give me money for walking to the shops, and, Mr Lansley, staying fit.

    Of course none of this is about being healthy though is it? It is just a further attack on lifestyle choices by people who have enough cash in their grubby pockets to make all the choices they need when they need them. Such as smoking in Westminster Palace alcohol rich bars. "Don't do as I do, do as I say!"

    And while you are acting the mandarin Mr Lansley, dust off that WHO report that says income determines the health of the recipient - always.

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  • 8. At 6:19pm on 01 Dec 2010, clamdip lobster claws wrote:

    I've said it before. A useful nudge would be to provide high quality food to schoolchildren. Schoolchildren could eat organic, whole, local foods cheaper than processed, non food. Giving children two healthy meals/day would ensure a healthy nation of worker bees and soldiers. The government should have a vested interest in the health of children as they will be the future innovators that drive an economy. The government elite can continue to invest in poor education, alcohol and drugs to dullen the minds of a generation of children or they can get busy and spend their money wisely to ensure a future tax revenue stream. Only an idiot government would continue 'business as usual'. Human investment and potential is the future. Not realizing this fact will be the final nail in a nation's coffin.

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  • 9. At 1:42pm on 02 Dec 2010, adamcollyer wrote:

    I've put a longer rebuttal of all this on my blog.

    In short:

    - decisions about what is good for us will be on average more effective if they are dispersed, i.e. made by us all as individuals, rather than made for us by central "experts" with their own agendas

    - "nudging" and "lecturing" are the same, except that nudging is not done openly

    - the figures quoted in your post are ridiculous!

    But thanks for the link anyway!

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  • 10. At 11:53pm on 07 Dec 2010, notinthemanifesto wrote:

    It bemuses me how the politicians who are in the group most likely to have had first-hand experience of nannies have such an aversion to them!
    My sense is that nannies are a good deal more effective than nudges. It makes me wonder how serious Mr Lansley really is about wanting his agenda on bringing about lifestyle changes realised!
    This point has been made by others but worth reiterating here - if we want to get rid of 'telling people what to do' why don't we legalise drugs? Then that astronomical figure you quote for drug-fuelled crime could disappear overnight, and be converted into taxes to help the people who failed to respond to the nudges.

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  • 11. At 4:19pm on 10 Dec 2010, U14717142 wrote:

    This comment was removed because the moderators found it broke the House Rules.

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