Published: 10/01/2001, Volume 112, No. 5787 Page 20

'The final Wanless report may be the last hope of reinstating public health as a central plank of government health policy'

Wouldn't it be ironic if a hard-headed banker put public health back on the policy agenda?

The Wanless inquiry's interim report - surprisingly, given its focus on financing - says sensible things about the public's health.

The review is adopting a 'whole systems' perspective and is as concerned with upstream issues as downstream ones.

The interim report reviews the potential impact of disease prevention and health promotion and that of reducing health inequalities. It acknowledges that 'good public health can also contribute to economic prosperity'.

Wanless pulls no punches. It says improvements in life expectancy have not been shared across the population. The health disparity between rich and poor has widened.Yet a significant proportion of avoidable ill health and death is related to socioeconomic deprivation.

Indeed, the major killers - cancer, coronary heart disease and stroke - are all linked to socio-economic deprivation.

On the evidence base, the report notes this is improving, though large gaps remain.However, even where the evidence is strong, such as with smoking cessation, it is the middle class which absorbs the message. It is also the middle class which secures better access to healthcare services. The Wanless review team concludes that the 'inverse care law', whereby those who need care most tend to get it least, is alive and thriving.

It is a clear manifestation of the tension which runs like a faultline through the NHS, between its role as a sickness service and a health improvement service.

There is nothing new in what Wanless says - the fact that he is saying it is important. The public health lobby must view him as an ally who can perhaps say things that carry significant weight. This is not a government renowned for listening, but it has a weak spot for businessmen (and it is invariably men).

Is the public health community prepared to sup with the devil? Or will it retreat into its traditional haven, offering advice but not lobbying vigorously to effect real change? The final report from the Wanless team, due in the spring, may be the last hope of reinstating public health as a central plank of the government's health policy before the next election.

The key to achieving such an outcome has to be the sentence in the interim report on the concept of health as good economics.

The idea is gaining currency both in the UK and elsewhere.

1But a move from catchy slogan to guiding policy calls for real commitment from policymakers - and requires that the thinking should move out of the groves of academe.

The concept is quite simple.

Healthy communities tend to attract investment and unhealthy ones do not. Only recently have ministers shown any awareness of the connection between the two. In striking contrast, great Victorian industrialists like Sir Titus Salt (Salts Mill, West Yorkshire) and Robert Owen (New Lanark, Scotland), were sufficiently far-sighted to understand the connection and, more impressively, to act on it.

Over a century later, we must learn the lesson all over again.

It is worth remembering that the domination of medical science and healthcare is of recent origin:

until the Second World War, public health flourished. Public health interventions are often criticised for being ineffective and 'fashionable'.Were the same degree of assiduity applied to healthcare interventions, we might restore some perspective about the limits to medicine.

There is evidence to show that the non-communicable disease burden can be significantly reduced in cancer, heart disease and diabetes through lifestyleoriented programmes.Yet it is an uphill struggle to maintain investment in such interventions.

Usually, any resources forthcoming are insufficient and/or short-term.Meanwhile, big money pours into downstream interventions.Why should anyone alter their lifestyles when the myth persists that medical science will rescue them?

Moreover, as Wanless observes, even when public health interventions on lifestyle are picked up by the public, it is the advantaged who benefit - thereby widening the health gap.

The interim report rightly asks how to communicate health messages to those who, for some reason, refuse to hear them.

Widespread political indifference to the public health agenda is more significant than gaps in the evidence base.

IfWanless reasserts the case for investment in public health, and offers guidance on how to direct messages to those least likely to welcome them, it will have earned its place as one of the few of this government's outpourings to make a difference. l REFERENCE 1Rubin, ER (ed).What Determines Health and Quality of Life? Health as Good Economics. 2001. Fourth Trilateral Conference. Association of Academic Health Centers, Washington.