Michael White on public health policy

Despite fatty headlines, it wasn't all about obesity, of course. It was about the wider context of public health and the government's record since 1997 in talking more than it has managed to deliver, even though such policies are crucial to Labour's very proper drive to cut health inequalities.

As that tireless (sometimes tiresome) Liberal Democrat health guerrilla Evan Harris was quick to point out, the Tory record on public health - smoking, sex education, tobacco advertising etc - isn't brilliant since 1997 either (or before).

But, as with the economy and chancellor Alistair Darling's candid admission of serious problems, we have finally reached a stage in the political cycle when the Tories' own record in office is now too remote for most voters to blame them. So chutzpah is back.

Copy cats

Alan Johnson's line of attack is that all Mr Lansley's ideas for doing better are already in the government's policy portfolio, in the Healthier Weight, Healthier Lives paper, for instance. It's thin stuff, lacking novelty or substance, the health secretary countered.

Fair enough, but even a degree of consensus on an important issue should be welcome, though it's hard for politicians to do that, especially when real differences are modest and results difficult to achieve on the ground.

Lansley is not exactly a tearaway populist and he knows his subject. So where I thought he was on strong ground was in asserting that healthcare - let alone funding - is not the sole determinant of health. If that were so, "Glasgow would be the healthiest place in Britain and Wokingham the least healthy".

There's an old Tory grudge there against Labour's shift of resources to poor areas. Deep down both sides understand each other's position: cash matters, Wokingham has more degrees, jobs and money than East Glasgow, but they are not enough.

Victim culture

That's where Mr Lansley, echoing David Cameron, is also saying "no excuses" for avoidable fatness. Blaming environment or genes is not the way forward, it's victim culture.

It's always good to hear Tory politicians talking class. The C-word has become unfashionable as race and gender grabbed headlines.

Mr Lansley produced two strings of ideas, one aimed at the food industries and exercise. The other would seek to create a ringfenced public health budget, a departmental leadership in Whitehall focused on these big public issues - not micromanaging NHS managers - plus the restoration of what sounds like local medical officers of health, abolished by Tory modernisers years ago.

Laudable stuff, but tricky. Lansley talks of not nannying adults or (especially) teenagers. But the Blairites can confirm that it's not easy changing voters' behaviour. Hence, perhaps, Lansley's stress on a "positive" message and "fun".

Striking a balance

By chance I recently stumbled on a useful Blairite speech by ex-Number 10 adviser Julian Le Grand, who seeks to strike a balance between individual autonomy and the state's duty to protect people from themselves as well as each other.

Politicians like Ronald Reagan explicitly reject that as going too far. That may be why many Americans over-eat, but why Andrew Lansley (Barack Obama too?) wants the food firms to make smaller portions and other improvements to diet.

Le Grand used his 2007 Beveridge Memorial Lecture to highlight "libertarian paternalism" as a way through the problem. This concept developed by US "nudge" theorists says a mixture of incentives - financial bribes if necessary - and inducements can improve behaviour and long-term lifestyle and health.

Walking the line

Negative incentives like higher cigarette, petrol or drink taxes are one approach. Extra methadone for drug addicts who produce clean samples is another. Changing the organ transplant law to require citizens to opt out - not in - makes doing the right thing easier.

But Professor Le Grand got into trouble for suggesting smokers should be required to buy an annual permit to smoke. It's a fine line.