comment But his criticisms may give public health the focus it so badly needs

Published: 04/03/2004 Volume II4, No. 5895 Page 17

Public health likes nothing better than feeling it is 'on the map'. That was the expectation created by the first Wanless report in 2002 and many hoped the sequel would consolidate its position.

It did not. But his critics could not accuse Derek Wanless of failing to provide a clear message. In fact, behind the rather dry language, he delivers a damning verdict.

Public health may be on the map, but public health policy and implementation are neither going in the right direction nor at anything like the right speed.

To reverse the motivational quote that opens the report, the impression created by Wanless II is that public health policy is created and delivered by 'tinkerers who merely patch and mend'. The targets are either absent or wrong-headed; primary care trusts have neither the necessary incentives or muscle; the evidence base is nothing more than small, isolated heaps of information. Many commentators said the report lacked a clear message, but how much clearer could it be?

But there is something odd about the report - it is a dog that did not bark. It seems to build up to making recommendations, but then instead invokes the forthcoming white paper as a reason not to suggest specific policies. It is open to debate whether the ex-banker has been muzzled by the regime change at the Department of Health or whether the consultation that opened this week was a reaction to his lack of bite (news, pages 6-7).

What the report does do is highlight the central debate in health improvement on which the white paper consultation will have to deliver - the negotiation of a new balance between the reliance on changes in individual behaviour and state intervention. Some critics disagree, but Wanless II seems to push towards the latter and expresses doubt about how effective behavioural change can be in improving public health.

The problem with hoping that a great mass of people will adopt new lifestyles is that there is little, or no, precedent for it. The great strides forward in public health in the last 150 years have not been brought about by a great number of individuals deciding to do things differently, but by the provision of improvements like clean water and immunisation.

Government advertising would have little impact on drink-driving if it were not accompanied by the increasingly likely prospect of prosecution and prison. Telling the poor to read more did not work - providing cheap books and libraries did.

Fifty years from now, the behaviour-vs-regulation debate will surely look like the muddled and indecisive dialogue it still is. At the moment 'behaviour change' enjoys the ascendancy in policy circles, the flip side of giving people more 'choice' and 'freedom' in managing their health. Regulation, on the other hand, is perceived as unwelcome and unnecessary interference by the state, the same criticism levelled at the campaigners for clean water and public drains 150 years ago.

The white paper consultation is an opportunity to challenge those easy assumptions:

to ascertain the right balance between the necessary advances in personal choice and responsibility and the state interventions needed to underpin them.

To take the most obvious example, the increase in obesity has not only been caused by behavioural change. People are not more greedy - it is simply far easier to get fat these days.

Relying on education and encouraging exercise or greater availability of fruit and vegetables is likely to turn out to be an inadequate response. Some way needs to be found to damn the tide of fat-soaked low-cost foods targeted at the section of the community with the greatest obesity problem.

Tax + education + assistance has, after all, proved a powerful equation in reducing smoking. And even here Wanless hints at the need for greater state intervention.

The question is whether a report that has disappointed many will in time turn out to have laid the foundations for a sustainable, balanced and effective public health programme.