The Health of the Nation: Who’s Keeping Score?

First published in the NASGP Newsletter in April 2021

European Stone Stacking Championship © Sally Anderson Photography

How many new year’s resolutions have you kept? If I don’t get around to clearing out the box room, no-one is going to hold me to account and it isn’t the end of the world.

How many countries fulfil their undertakings to cut carbon emissions? If they don’t get around to it, the world may indeed end. If it ends, who would hold them to account?

Government policy shapes our chances of a healthy life. The pandemic has highlighted starkly that deprivation kills. A large proportion of our health is dependent on our luck in the tombola of social determinants of health: education, housing, transport, employment opportunities, our exposure to all sorts of pollution. Slapping a pre-election Elastoplast on our National Illness Service won’t improve these. If the government fails in its duty to the society it governs, everyone’s health suffers suffer. But how can we ensure that governments accept responsibility for their actions – or inactions?

We can vote the scoundrels out of office, but elections are a blunt instrument, and very rarely issue-based. In any case, governments have time to lie their way out of a predicament and to announce generous-sounding bungs to the NHS.

Judicial review is a powerful way of challenging the way decisions have been taken by public bodies. The government didn’t like judicial review rapping its knuckles over Covid-related contracts, and is working out how to make it a less effective weapon.

What if we had a single measurement for the nation’s health?

The NHS does not equal health. But it takes years to demonstrate that improved air quality has improved the health of the population, and governments want to see results they can boast of in the next election campaign.

Health is seen as a cost – an overhead – rather than an investment. Yet the pandemic has demonstrated that economic performance depends on health, not vice versa. Investing in health is a national insurance policy. With all the Departments clamouring for funds, it is flashier to commission an aircraft carrier or launch Eat Out to Help Out than to tackle intractable long-term problems like housing or social care. Or to invest in horizon-scanning committees, spare capacity and stockpiles. Over the past year the country has had to count the cost of inadequate insurance.

You can’t improve conditions without measuring them. So we need a mechanism for assessing our long-term progress in health improvement, something which keeps the government’s eye focused on its responsibilities. We have a few bodies which look beyond the next parliament.

There is the National Risk Register, which evaluates possible catastrophes, including pandemics, and discusses mitigation strategies. (It has now withdrawn its 2020 pre-pandemic report.)

The Climate Change Committee advises the government on tackling climate change, and an all-party Committee for Future Generations – middle-aged MPs mulling over plans for generations unborn.

David Cameron abolished the Sustainable Development Commission, a watchdog that monitored government targets, and the government has just announced that it is putting the axe to the Industrial Strategy Council. But, though these organisations have a value, none directly holds the government to account for the nation’s health. Nor does a yellowing White Paper, however laudable its proposals for future legislation.

Do other nations do better at getting their governments to think beyond the next election? Countries all over the world have Future Committees but few have enough power to make a government uncomfortable. Scotland’s Future Forum is strong on worthy aims and its website is extensive, but I could find no practical suggestions and no list of achievements. In Wales, however, the obligation to protect future generations is enshrined in law, and a dynamic Future Generations Commissioner has secured changes in plans for transport, housing and land use to take into account the lives of future generations. Is there any other way of putting pressure on Westminster to move away from short-term thinking based on cost to, and substitute social benefit as the yardstick?

“Whose health is it, anyway?” ask former CMO Dame Sally Davies and her colleague, public health doctor Jonathan Pearson-Stuttard. It’s our health, but so much that influences it is beyond our control. So in 2018 they proposed a composite health index, a highly visible measure incorporating not just healthcare data but, crucially, also data on all the social factors.

The index would track progress in improving what is arguably the country’s most valuable asset – the health of its people. Year on year, we, and those in power, could see how we were faring and how they were doing. It would shine a light on successes and illuminate the dark corners of failure.

Governments rely on an index, the Gross Domestic Product, to measure how the economy is performing Every three months the government, economists and business scrutinise the GDP data: two falls in succession and they declare we are in recession.

But what national assets are included? As Bobby Kennedy said in 1968, “the production of napalm and nuclear warheads counted towards GDP but the health of American children and the joy of their play did not.”

A Health Index would not oblige a government to take specific decisions, any more than GDP does, but if it had the same visibility it could be a powerful stimulus to action. If it showed that respiratory illness and air pollution had been increasing for several years, it would provide strong pressure to tackle air pollution, albeit at the cost of measures unpopular with organisations that fear decreased profits.

Similarly, governments would be less reluctant to tackle alcohol and keener to promote public transport and protect green spaces if they were being judged on the adverse health consequences.

The Office for National Statistics (ONS) has taken on the challenge. It is developing the toolkit for a ‘health index’, working out how to incorporate information about all the topics that influence health, and how to keep the Index updated. It has to ensure that it is useful not just for keeping Westminster’s attention on what is affecting the whole nation’s future health, but also providing information local authorities and others can use in their planning. The ONS then has to incorporate all this into a practical guide. It’s a huge undertaking, but one that future generations should thank us for.

Whose Health Is It, Anyway? Sally C Davies & Jonathan Pearson-Stuttard, OUP 2021