Which public health intervention do you think should be introduced to address the health inequalities that currently blight Britain? Theresa Marteau explores ideas on health inequality for the 2019 Bennett Prospect prize.
Prevention is better than cure. For example, about 75 per cent of Type 2 diabetes could be prevented if the causes were effectively addressed. Done equitably, this would go some way towards reducing the eight-year gap in life expectancy between the rich and the poor, and the 19-year gap in years lived in good health. The fiscal case for prevention is also strong given that, to use the same example, Type 2 diabetes accounts for around £1 in £11 of the NHS budget.
Successive Health Secretaries have recognised this reality. Yet the governments they serve have generally failed to prioritise prevention. Is the repeated failure because we don’t know what could work? Or are the political costs of implementation too high? Or maybe it’s both? Clearly, fresh thinking is needed, so this year’s Bennett Prospect Prize is asking the question: Which single public health intervention would be most effective in the UK?
Smoking, unhealthy diets, alcohol and physical inactivity are the leading causes of premature deaths in England. These behaviours are more common amongst those living in areas of high deprivation, thereby contributing to inequalities in health. Changing these behaviours at scale requires many interventions at different levels, targeting the “causes of the causes”—including poverty, education and housing—as well as the more direct causes themselves. Priority needs to be given to interventions with the greatest chance of the largest equitable effects. But which are they and how are they most effectively introduced?
Predictive Prevention is one approach that has captured the attention of, amongst others, the current Secretary of State for Health, Matt Hancock. This enthusiasm is born of an expectation that informing individuals of their risks of disease and how to reduce them—such as increasing physical activity to reduce the risk of Type 2 diabetes—changes their behaviour.
The evidence, however, does not support these expectations. While personalised predictions can increase people’s motivation to change, they have (at best) minimal impact on how people actually behave. As attested by almost a century of evidence from the psychological and behavioural sciences, much of our behaviour is shaped more powerfully by the multiple, overlapping environments in which we live—physical, economic, social, digital and commercial—often without our awareness.
In short, changing environments is more effective in changing our behaviour than any form of persuasion. Interventions in economic environments provide one important example: targeting the affordability of products that harm health, whether that be tobacco, alcohol, foods high in fat, sugar and salt, or fossil-fueled transport.
In spite of this, however, the recent “Health Taxes to Save Lives” report co-chaired by Mike Bloomberg and Larry Summers identified such effective fiscal interventions as underused by governments worldwide. Their report also noted affected industries making false or misleading statements about the effectiveness of such taxes and their impact on the poor. Such misleading statements were also expressed by our own Prime Minister, Boris Johnson, when rallying against “sin taxes” in his successful campaign to lead the Tory Party.
All of this adds up to a clear case of missed potential—but, equally, the chance to propose innovative solutions that can meet urgent public policy needs. Ten years ago, Michael Marmot’s “Fair Society, Healthy Lives” sounded a call for intervention. How might interventions in the domains he outlined—from early child development to lifelong learning, and from minimum incomes to good working conditions—be translated into policy? Which public health intervention do you think should be introduced to address the health inequalities that currently blight Britain?
The closing date for entries to this year’s Bennett Prospect Prize is 31 December 2019 with the winning essay published online in Prospect.
How to enter
To be eligible an applicant should be within five years either of having submitted their PhD or of starting work in a policy-focused career. Applicants should not be in possession of a tenured academic position. Click here for full details of the prize.
The views and opinions expressed in this post are those of the author(s).