Published: 15/07/2004, Volume II4, No. 5914 Page 14 15

The public supports a new focus on health improvement, says new research, with strong backing for more government regulation as well as education

Can the government have its health policy cake and eat it?

Can it promote patient choice and 'personalised' services with so much missionary zeal and still pick up the Treasury gauntlet to achieve a 'fully engaged scenario' where everyone is keen to stay healthy and the NHS is transformed from a sickness service to a health service?

The Department of Health's new-found commitment to public health is buried so deep in the avalanche of service reforms in the new NHS improvement plan that one worries whether it can be dragged out alive. Once again, the talk is all about waiting lists and the role of private sector providers. Is this what the voters - as opposed to the headline writers - really want?

New research into public attitudes to public health policy suggests otherwise. A qualitative and quantitative study, commissioned by the King's Fund and the Health Development Agency, asked people across the country what they thought about their own health, their own responsibilities for health, and the role of government and the NHS.

Findings from this multilayered study provide a rich picture, too complex to do justice to here. But three clear messages emerge that should provide some useful pointers for policy makers in the health field.

One message is that there is strong support for changing the priorities of the NHS. Nearly half of those questioned in the quantitative survey said the NHS should take the lead in providing information, advice and support to enable everyone to prevent illness and lead healthier lives.

A further 18 per cent said the NHS should seek to improve the health of people at risk of illness, but not to promote health across the population. Less than a third said the NHS should just focus on providing services to sick people.

Seventy-nine per cent agreed we should be told more about the long-term costs to the taxpayer of failing to prevent illness.

The second message is that people understand that, in order to prevent illness and promote health, individual responsibility and government action need to go hand in hand.While nearly nine in 10 agree that individuals are responsible for their own health, there is also strong support for a range of government interventions - although support is stronger for some than for others.

Three-quarters of people said the government should actively discourage people from doing things that put their own and others' health at risk.More than eight in 10 said the government should encourage employers to do more to promote health at work, put health warnings on products that posed a serious risk to health, and provide information and advice to enable people to make healthy lifestyle choices.

Asked which specific government interventions would be effective, endorsement was strongest for those aimed at improving diet and exercise.More than eight in 10 respondents also favoured action to ensure that schools provide healthy meals, as well as laws to limit levels of salt, fat and sugar in processed foods, action to make fruit and vegetables cheaper and more easily available, and investment to ensure that people have access to safe green spaces and streets.

Seventy-nine per cent endorsed a law requiring local authorities to provide free access to sports facilities for local people on low incomes.More than seven in 10 endorsed a ban on TV advertising of junk food to children.

On anti-smoking measures, more than two in three said a ban on smoking in workplaces, including pubs, bars and restaurants, would be an effective way to curb the health risks of tobacco. Slightly fewer endorsed a voluntary scheme to encourage workplaces and public venues to be smoke free, and more funding for GPs to help smokers give up.

There was less clear endorsement for measures to tackle alcoholrelated health risks. Support was strongest for banning on-street drinking and for government action to cut the price of soft drinks in pubs (over 60 per cent).

On sexual health, more than eight in 10 supported more effort to increase young people's awareness of the risks of sexually transmitted diseases and nearly three in four supported outreach services to take contraception and sexual health advice to young people outside schools and youth facilities.More than two-third supported chlamydia screening for young people.

By contrast, when asked whether government should restrict the availability of condoms in schools and youth facilities, only one in four thought this would work and more than half said it would be ineffective.

But this was the only proposed intervention that got a clear thumbs down. Taken together, these responses suggest overwhelming support for the government taking firm action to help prevent illness. So who is really afraid of the nanny state?

Not the public, apparently.

The third message is arguably most important. People make finely calibrated judgements about what is in their interests, according to their socioeconomic status. Those who are better off (social groups A and B) enjoy better health and have higher expectations of being healthy in future. They are generally more enthusiastic about improving health through lifestyle changes, about information and advice as a way of encouraging health improvement, and about the NHS taking a lead role in promoting better health for all.

Those who are poor and disadvantaged (Ds and Es) are less healthy and have lower expectations for their health. As they anticipate being ill themselves, they are more inclined to want the NHS to focus on services for the sick.

They are more likely to feel that health is out of reach for them.

Fifty-four per cent of DEs agreed there are too many factors beyond individuals' control to hold them solely responsible for their own health, compared with 31 per cent of ABs.

They are also more likely to see a link between poverty and illhealth. Seventy per cent of DEs agreed that tackling poverty would be the most effective way of preventing disease and improving the nation's health, compared with 51 per cent of ABs.

They are less enthusiastic about restrictive measures, which they see as eroding their already diminished capacity to control their own lives.

For example, 33 per cent of DEs said a smoking ban was the most important anti-smoking measure, compared with 52 per cent of ABs. They are more attracted to certain kinds of 'enabling' government action, such as tackling poverty, healthier school meals, more affordable fruit and vegetables and better access to green spaces and sports facilities - because these are measures that extend their choices rather than restricting their freedom.

So the challenge for government is to get the balance right between measures that encourage healthier lifestyles through information and advice, measures that enable people to make healthier choices by tackling social and economic disadvantage, and restrictive measures that ban or regulate. If there is to be any hope of narrowing the 'health gap' between rich and poor, they must be combined in ways that are sensitively tuned to the interests and attitudes of social groups.

Anna Coote is director of the King's Fund public health programme.Public Attitudes to Public Health Policy, by Opinion Leader Research, is available free for download at.

www. kingsfund. org. uk/pdf/public attitudesreport. pdf