Investment in public health — we need better arguments, not better evidence
Here in the UK, we’ll soon have a chance to make the case for investment in public health and prevention (again). The NHS 10 year plan and a spending review are on the way, and both the Prime Minister and Secretary of State have said that prevention is one of their main priorities. Should be an easy win.
But it won’t be, will it? In public health we think arguments for investment are watertight, both economically (public health measures tend to give back more than they cost) and socially (keeping your citizens as healthy and content as possible should just be what Governments do, shouldn’t it?). Loads of eminent bodies have said we need to invest more in public health and prevention (e.g. BMA; Nuffield Trust, King’s Fund and Health Foundation; LGA; WHO; PHE; House of Commons Health Committee; House of Lords Select Committee on Sustainability of the NHS). All these reports are crammed full of expert evidence showing that investing in prevention is cost-effective, increases productivity and reduces demand for other services. It’s a no-brainer! And the result? Continual cuts to public health budgets.
Why aren’t we winning the argument?
I think we’re often guilty of thinking if we just keep throwing evidence at people then policy will change. It should work like that, shouldn’t it? But we’ve already got loads of evidence, and it’s made no real difference — I doubt more will.
Why? Well, there’s more to winning arguments than evidence. Most people’s perspectives are based on life experience, their values, opinions of others they’re close to… even those that do look for evidence often ignore it if it doesn’t confirm their existing beliefs. Objective facts are interpreted in subjective ways. Someone might provide me with indisputable evidence that Ed Sheeran has sold more records than Oasis, and interpret that as proof that he’s better than them. But it bloody well isn’t. Here’s my evidence.
We’re already good at evidence, but to be more persuasive I think we can do several other things:
- Call out rubbish arguments
- Understand other points of view
- Clarify what we’re asking for
- Nick some tricks
1. Call out rubbish arguments
The Lords Committee stressed that public health cuts are short-sighted, counterproductive, and a false economy. Their recommendation that ‘the Government restore the funds which have been cut in recent years and maintain ring-fenced national and local public health budgets, for at least the next ten years’ was rejected by the Government for the reasons below. They’re rubbish.
“Public health is about far more than the services funded through the grant”
The statement is true, but it’s not relevant. A straw man. Nobody thinks that public health is all (or even mainly) about the grant, but that doesn’t mean that cuts to the grant are unimportant, or that they haven’t had a detrimental effect. They really have.
“The transfer to local government provided the opportunity to join up public health with decisions on other local services”
Many were excited about public health moving back to local government for this reason. In reality, it often just doesn’t work. Our Council partners have had their budgets slashed, so more people are going without essential council services such as social care, health visitors, housing. The impact of these cuts cannot be alleviated just because we work in the same offices now.
“Many councils have redesigned services, taking a holistic place-based approach and are demonstrating real innovation […] and achieving better value for money than in the past”
Yes, they have, but with often horrible consequences: cutting services, losing staff, watching our neighbourhoods decline. Councils are now at breaking point.
“Local authorities will still receive more than £16 billion for public health over the 2015 spending review period”
£16 billion sounds a lot, until you realise it isn’t. Over half a trillion is allocated to NHS treatment over this period. The public health grant represents less than 2.5% of England’s health budget.
“This is in addition to what the NHS spends on prevention, including well over £1 billion a year on our world-leading immunisation and screening programmes, and the world’s first national diabetes prevention programme”
Even if the £1 billion figure quoted by the Government is included with the public health grant, that still represents just 3.3% of England’s health budget being spent on prevention, despite public support for spending less on treating illness and more on preventing it in the first place.
“Prevention is a core theme of local cross-system Sustainability and Transformation Plans”
On paper maybe, but in real life most STPs/ICSs haven’t prioritised prevention. Where it is included, it’s generally secondary rather than primary prevention (more on this below) i.e. the NHS rather than wider determinants. Funding meant for transforming services has instead ‘been spent on coping with current pressures’.
“We are performing well on a number of public health indicators”
This one particularly annoyed me. The Government cherry picked a few indicators that have improved recently, including smoking and under-18 conception rates falling. All very welcome. But one could just as easily have pointed out that life expectancy has stagnated and is even falling in some areas. Infant mortality rates have increased. I could go on. What also galled me was the idea that improving outcomes somehow provides an argument for cutting the very funding that contributed to these improvements. Shouldn’t we want to keep improving?
The Government’s responses just don’t address the recommendation for more funding or the consensus that cuts to public health are a false economy. They provide no sound reasons to continue to reduce funding. They could be construed as either irrelevant or even deliberately misleading. In short, leaving aside anything to do with policy, they’re just bad arguments.
I tried to refute them in plain English, with no repetition of points we’ve all made countless times before. Might this be more publicly effective than simply providing more and more evidence for things they’ve already said no to? Dunno… More on this a bit later.
‘Nanny state’ arguments will always come up for anything public health related. Greg Fell has recently done a good job writing about why they’re generally a load of rubbish and how we counter them, so I won’t bang on much here. Safe to say, if you do your homework, nanny state arguments should be easy to discredit. My way to do so in lay terms is with a personal example. If there are six Magnums in the freezer, I’ll eat six Magnums. I know that the best way to stop myself eating six Magnums is to not have any in the house. I still have the choice to go and get one from the shop, but I can’t be arsed. That’s all the nanny state really is to me — a recognition that we all need a bit of help doing the right thing, so let’s make doing unhealthy things more annoying.
Economic arguments against investment are often related to the fact that the bar for public health interventions to prove their worth is seemingly much higher than for NHS care, in terms of short-term cost-saving. Nobody expects end-of-life care to be cost-saving to society; it’s done because it’s the right thing to do. So is public health. Cleverer people than me have written more on this anyway (e.g. here and here).
2. Understand other points of view
I reckon that most of us in public health are left-leaning, read the same papers, agree with each other on Twitter. Preaching to the converted. And yet we have a right-wing Conservative Government with a different perspective to us. Perhaps more importantly, most of England (apart from major cities) is small-C conservative. We should be engaging with people who think differently to ourselves. But it’s become fashionable to be tribal, us-versus-them.
I’m in my own bubble too of course. Recently though I took part in a mock debate around minimum unit pricing (MUP), which I’m all for. But I had to argue against it. I read a load of arguments around why it’s a bad idea: it’s based on a flawed model, it’s regressive, binge drinking is already decreasing, etc. Embarrassingly, I probably wouldn’t have ever read any of this stuff in detail normally. It didn’t change my mind on MUP, but I actually found it really easy to argue against, especially when the other side of the table only came back with more statistics (as we tend to do). A really useful exercise and a practice I’ll repeat. Walk a mile in someone else’s shoes and all that.
I often think of my brother when trying to sell the importance of public health. He’s ten years older than me, a builder, works twice as hard as me for half the pay. He reads The Sun, voted Leave, and has voted for UKIP. He calls me a Guardian-reading lefty snowflake. He’s also an absolutely top bloke and one of my heroes. We actually share many of the same concerns but have different opinions on what the causes and solutions are. Usually though, when we have a chat, we end up finding we have a lot in common. Of course we do. So why aren’t our arguments for public health landing with people like my brother? Maybe because we haven’t bothered asking them.
3. Clarify what we’re asking for
“What do we want?”
“Investment in public health!”
“What do we mean?”
Public health is ridiculously broad, so to win arguments we need to be clearer and more specific in what we’re asking for. It’s confusing because ‘public health’ can mean the profession, i.e. local authority teams funded by the grant to provide public health services, or PHE providing national oversight. ‘Public health’ can also refer to the health of the public in a wider sense, influenced by an infinite number of things outside of the health system. Here I’ll use ‘public health’ to refer to the former and ‘population health’ the latter. So public health is the practice of doing stuff to improve population health.
Imagine if the Government said “here’s a billion quid. It either goes on the public health grant, a load of new children’s centres or we spend it all on social housing”. The former is definitely better for local authority public health services. But which is the best for improving population health? I don’t know the answer, but it shows that investing in public health can mean different things to different people.
At the minute we’re all asking for increased investment, but are we asking for more money for the grant or for the wider determinants? Or both? What about PHE? How much do we actually want? (has anybody worked that out yet…?!)
When asking for more funding, can Directors of Public Health reconcile the need to look after their own department with the fact that population health may be improved more by investing elsewhere? Can those of us in local authority public health teams really say we’re more deserving of new money than other departments who could also improve population health? Again, I don’t know, but it illustrates why we must be clear in what we’re asking for. What I will say though is that it’s such a bloody shame we have to choose between equally deserving services for equally deserving residents. That will likely get much worse when the public health grant is removed and all Council departments end up competing for the same dwindling resource.
I think we will have far more chance of success if we can say “right, we need £x billion for the grant this year because that will mean we can do [all these brilliant things]. We’ll then need an increase of x% a year for 10 years because of [this compelling reason]”. Then we can say “outside of the grant, we also need £x billion for [these other things] because they’ll have [this amazing effect]”. We need to make it much more difficult to say no, and being specific in what we’re asking for will help.
Prevention is another term that means different things to different people. Most of us in public health are, I expect, most enamoured with lovely, fluffy primary prevention — keeping people happy and well for as long as possible. But most of what goes on is secondary prevention — waiting for something to happen then doing something medical to it. To Matt Hancock, the new Secretary of State for Health and Social Care, prevention means:
- keeping people healthy and treating their problems quickly
- empowering people by giving them the tools they need to manage their own physical and mental health needs closer to home
- delivering care in the right place in settings that suit them and their needs
Delivering care? Providing tools to manage their own needs? Treating? It’s not prevention as I see it, which is about stopping people needing care, tools or treatment in the first place. Obviously, all levels of prevention are necessary, but primary prevention should be the priority and it’s being side-lined. Not everyone speaks the same dialect as us so, again, let’s be specific about what we’re asking for.
“What do we want?”
“Investment in public health!”
“What do we mean?”
“An immediate additional investment of £1.5billion prioritising health creation and primary prevention, then a gradual transfer of downstream NHS money until 10% of the total health budget is spent on upstream factors by 2030!”
Not that catchy. So, we also need to…
4. Nick some tricks
We need to tailor our arguments to different audiences. Return on investment evidence is important for the Treasury, but won’t inspire the general public. But we need voters to grumble for politicians to listen. The NHS has just been given extra money because the public are angry with what’s happened to it. Why not the same level of anger about children living in poverty, or avoidable illness? We need to get better at making the public angry, to demand change. For that we need simple, emotive messages as well as good evidence; individual stories that sit underneath population statistics, about how upstream investment has led to positive changes in people’s lives and the impact of taking it away.
I recommend Winning public arguments as ecologists by my former PhD supervisor Mike Begon (just substitute ‘ecology’ for ‘public health’). A snippet:
“Public opinion is being driven not by facts or rational argument (the truth), but by emotion, often manipulated emotion, and by what seems or ought to be true. Apart, perhaps, from throwing up our arms in despair, our response to this has been simply to try that little bit harder, and with that little bit more patience, to explain the facts. We tell ourselves that if we keep faith in our ability to convey the truth, and in the ability of others to understand it, all will be right in the end. In doing this we may be making a fatal error.”
Not all will agree, but Mike argues that an obsession with integrity, that evidence will speak for itself, is a hindrance. We need to become adept at using tools that others regularly do, but that may make us uncomfortable, including repeating “emotionally appealing catchphrases”. Make America Great Again! Take Back Control! Sound bites may grate against many of our principles, but they can and often do influence public opinion. I know we all want evidence to be enough, but it just isn’t.
We shouldn’t be afraid to exploit the same tools others use — emotive language, personal stories, sound bites, populism, marketing — if the ends justify the means. Others (‘big food’, tobacco, oil, etc.) use these tools entirely to further their own interests; should we really feel guilty if we do so for altruistic reasons and all the evidence supports us? As Mike says, “we have seen it being effective for lies and distortions. There is no reason why it should not be effective for the truth”.
Any comments always welcome, in agreement or otherwise, via @andykturner
This piece was originally kindly published on Greg Fell’s excellent Sheffield DPH blog in July 2018. Follow Greg on Twitter here.