Public health: Nanny or nudge?
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.
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.