Published: 04/03/2004, Volume II4, No. 5895 Page 10 11 12

Wanless on public health has arrived, but was it worth the wait? Stripped of specific policy options, the report leaves the government to fill in the gaps with its crucial public health white paper this summer.

Helen Mooney opens a four-page special with an overview of the report's findings, while overleaf we focus on two of the areas which come in for particular criticism, smoking and obesity

It is light on proposals, lacks its predecessor's impact and has had its limelight stolen in large part by the announcement of a forthcoming white paper on public health. And yet Derek Wanless second report on the nation's health, published last week, delivers a clear message.Namely, that as far as achieving the 'fully engaged scenario' of health improvement advocated by his first report, we are going nowhere fast.

Securing Good Health for the Whole Populationmakes it clear Mr Wanless believes not just that the train is not going fast enough, but that it is taking the wrong line. He is critical of policy, frameworks and targets in both the key areas he studies - smoking and obesity - and says lack of evidence on cost effectiveness makes decisions about funding interventions difficult. The report also suggests strongly that primary care trusts have been saddled with the wrong targets and too little support.

The main area of disappointment will be the lack of firm proposals for positive action. Some commentators feel that this shows Mr Wanless's original intentions were curtailed by ministers.

Others believe, rather, that he failed to deliver specifics and the white paper announcement was, in part, a reaction to this.

Given the size of this task, why just 21 recommendations? The report is stripped of specific policy options, leaving it to the government to fill the gaps with a white paper this summer, following another planned consultation.

One source consulted widely by Mr Wanless told HSJ: 'We know that he was in talks with the Department of Health before his report was published. The general line he was giving was that if it wasn't willing to adopt the fully engaged scenario, then there was no point in writing it.

'I think the trade-off he has given is that the government will be expected to deliver on the policies and for that it can take the glory this summer. Obviously the danger is that the government gets cold feet and we end up with another damp squib.'

Many hope the resulting white paper will be a panacea curing the long-endured ills of the public health community: something which would encourage people to commit to shedding excess weight, stopping smoking, cutting back on binge drinking, and so on.

Those in public health have been more realistic, but they are acutely aware of the lessons of history. For, despite promises, governments overawed by the scale of the political challenges have shrunk back and not delivered.

As UK Public Health Association chair-designate Professor David Hunter says: 'On the big political issues, he [Wanless] pulls his punches. It is all left to the government and public to debate. [But] as Wanless argues, successive governments have failed to deliver over the past 30 years. Is the present one really so different?'

However, Faculty of Public Health president Professor Sián Griffiths says: 'The analysis in the report is pretty good and provides a very useful discussion of the key areas to be tackled.' She suggests that it is up to health secretary John Reid to lead a 'paradigm shift'.

According to Mr Wanless, 'a step change' is needed if we are to get anywhere near his fully engaged scenario. But, importantly, he seems to suggest that simply offering more information leaflets to help 'consumers'make choices for themselves will not be enough.

He is critical of a government that would attempt to shy away from addressing the problem because it fears being accused of encouraging a nanny state. The report says that 'shifting social norms is a legitimate activity for government where it has set for the nation objectives for behaviour change'.

And he issues a stark warning that unless the increasing public concern about issues such as diet and smoking in public places are addressed, 'yet another opportunity to act will have been missed'.

It is the strongest statement yet that action is needed now at all levels, and Mr Wanless decrees that his 21 recommendations must form the basis for the white paper on public health.

On smoking and obesity, the report is as damning as possible in the sober officialese used by Mr Wanless.

Targets are again attacked, particularly those on smoking, which he describes as devoid of ambition, and on obesity, which he says lack a grasp of the endemic currently facing the country (see page 12).

Mr Wanless does not take issue with targets per se, but argues that they need a degree of realism and they should be based at local and regional level. This is the sort of thinking ministers are already coming to grips with in their newfound enthusiasm for localism.

He says that the government should set targets to reduce smoking, obesity and other risk factors for three and seven-year intervals. And he calls for much more research and information on what works.

NHS Alliance public health lead Chris Drinkwater says the report shows a positive direction of travel: 'I am happy that it recognises the need for a national health service rather than a national sickness service. There could have been more work on the detail, but I am hopeful that the forthcoming white paper will flesh this out.'

But the UKPHA's Professor Hunter describes the report as equivocal: 'In an understated way the report is very critical about what has happened in the past, but it does not address the vacuum at the centre. It is not enough to leave the lead on public health to the health secretary.'

The report makes reference to the need for more joined-up local policy and it says much of the work will have to be carried out by PCTs and bodies such as the Health Development Agency.

HDA chair Dame Yve Buckland says she was pleased to see that Mr Wanless identifies the need to implement research to gain the evidence that has so far been lacking.

While Professor Hunter says he feels that the report has been sanitised since the announcement of the forthcoming white paper, he is positive about its ability to make a difference where other public health reports have failed. He says this is because it has been commissioned by the Treasury and carried out by someone regarded as independent of both government and the public health profession.

The second Wanless report may seem an all-round disappointment. But history will judge it on the basis of the challenges it sets the white paper consultation later this year.

Governments have long proved adept at ducking real action on health improvement. Mr Wanless's legacy may be to make that just a little more difficult this time. l advertisements, and a retail-led labelling scheme for food products represent the way forward.

Consumers'Association campaigns director Nick Stace says: 'Clearly, while the government drags its feet, there is no incentive for industry to take action.

'How much higher does the death toll need to be before the government stops allowing industry to dictate policy over public health in this way?'

International Obesity Taskforce director of policy and public affairs Neville Rigby suggests that schools and health professionals can start to take action now by banning junk food on school premises and getting hospital staff engaged in promoting healthier lifestyles.

'How many more reports do we need before we start acting? Why do we need to wait for the white paper? This is a very serious issue and we should have a Cabinet minister with authority to bring all government departments together to address it.We also need an independent agency to monitor progress.'

Speaking last week at the Tackling Obesity in Young People conference, culture, media and sports secretary Tessa Jowell said the government was trying to achieve a balance between using regulation and letting people decide for themselves.

'Industry has an allergic reaction to government influencing private behaviour, but I have never received a complaint from one of my constituents about the so-called nanny state.'

And public health minister Melanie Johnson commented:

'Obesity is a time bomb and is top priority for the government.'

She added that the government was looking at ways of supporting parents in tackling child obesity.

'We do not want the state or the individual to have all the responsibility.We need to bring in changes and work together to give consumers a choice of a healthier lifestyle.'

The Wanless report is coy about recommendations, saying only: 'In view of the current and future impact of obesity on population health and demand for healthcare services, and in light of the evidence base demonstrating effective interventions, it is imperative that interventions to reduce obesity are sufficiently resourced, fully researched and implemented in a coherent manner.'

Perhaps the coyness is for a good reason.

The question nagging at everyone studying the alarming demographics trends - including, no doubt, ministers themselves - is probably, 'is it actually going to be enough?'. l