The future of the NHS. We currently hear a lot about this subject, and an awful lot of what we hear is basically handwringing; either because the writer comes from the camp that feels the NHS is underfunded, or is suffering from budget cuts; or because the writer feels that the NHS is too big and needs trimming; or because the writer wants to see more input from the private sector into NHS services. All points of view share a couple of common assumptions: first, that public health is worth spending money on (the question is usually how much); second, that the NHS as presently constituted is in need of some kind of improvement; and third, that there is a solution to the perceived crisis.

But the subject of public health is bigger than the NHS. It involves us all, and it involves all aspects of public life, from government and local politics to the world of private economics; personal choices have public impacts. So against this background, a recent paper in the Lancet, authored by (among eminent others) the Chief Medical Officer, Dame Sally Davies, makes fascinating reading. The picture presented by the Davies paper, and the recommendations it makes for the future of public health in the UK and beyond, impact on every aspect of contemporary life.

The paper starts by setting out a history of public health initiatives and strategies in the UK. It suggests that public health strategy has been implemented in four ‘waves’ since the nineteenth century (this idea is effectively the consensus view among historians of public health, as the references in the paper make clear). It’s worth sketching out those four waves, as it helps to understand the context in which public health has been set in the UK, particularly if we want to develop a future strategy that builds on the work already done, and the successes achieved by previous strategies.

The first wave took place in the nineteenth century, as part of the great programme of public works implemented by Victorian movers and shakers: the recognition that clean water, and a healthy environment, lead to good health in the population at large, led to the creation of publicly funded water and sewage facilities, and also to advances in the concept of population health itself. This work was conducted by thinkers who saw themselves as guardians of not just the public good, but also civil order and stability.

The second wave, which spanned the first half of the twentieth century, was the age of scientific rationalism. During this time, huge advances were made in the identification and characterisation of diseases, in the development and mass production of both medicines and medical equipment, and a whole range of private and household improvements with health implications. It marks the beginning of what we now take for granted as the environment of the modern world.

The third wave, from 1940 – 1980, saw the introduction of the welfare state, and the institutions of public good, including the NHS itself. This era is often characterised as ‘the state as machine’, built and fixed by professionals. Again, it provides much of the infrastructure we now take for granted.

The fourth wave, roughly from 1960 to the present, has three main characteristics: health interventions to prolong life and improve quality of life; lifestyle and risk analysis as base criteria in thinking about public health; and the recognition that economic inequalities are reflected in population health (the birth of the postcode lottery as a concept, you might say).

So the purpose of the fifth wave is primarily to ask: Where do we go from here? And more importantly, to offer suggestions for public policy that build on past achievements, while recognising that our health concerns, and the ways we tackle them, must inevitably change as society changes.

Davies et al offer a number of models for thinking about public health, and doing something about it. They suggest three main strategies for the promotion and maintenance of public health: maximising the value of public health; promoting healthy choices as a default position; and minimising the factors that lead to unhealthy choices.

The first proposal begs the question: How can we offer incentives to good health? There is a body of research into how health incentives work; interestingly, this research suggests that directly paying individuals to take the healthy option is not necesssarily an efficient strategy. On the other hand, offering incentives in a group or social context can have a beneficial effect. The moral here is that society as a whole needs to take a collective responsibility that is then reflected in individual choices. That is to say, we don’t need to pay people to be healthy, we need to make people see that their health is a factor in public health, and act accordingly.

The second proposal is in effect about supporting the first. If government, health institutions, and (very importantly) the private sector tell us how to be healthy, how to make healthy choices, we are more likely to respond positively. There is a particular moral here for marketers, obviously, and obviously enough a problem. It’s not easy to see how a company that makes a living from products or services that carry a health risk might be persuaded to tell people to take the healthy option. On the other hand, it is hard to see how government in the modern context could force the private sector to act in a way that some of us (and although it’s probably a majority, it is only some of us) would consider responsible.

The third proposal is a mirror of the second, and consequently carries much of the same baggage. The big question here is: Is it possible to steer people away from unhealthy choices, without interfering in the market to the extent that some sectors of it go out of business? More fundamentally, we may have to make a choice between a relatively free market, and a health-directed public environment; a conceptual choice that strikes at the heart of our current economic infrastructure.

The role of marketing, and social market initiatives such as behaviour change, are clearly central to the vision set out in Davies’ paper. In a culture saturated with media, and media messaging, there is an obvious arena in which to play out the struggle for public health. But that arena is not the property of the state; a large number of interests are vested in it, and we the public enjoy the freedom of choice it offers, often to the detriment of our personal health, and thus to the health of the population as a whole. Transforming that arena, or at least making space within it for the kind of education implied by a new consensus approach to behaviour change and the public good, may in the end turn out to be the core struggle of the fifth wave; more important, ultimately, than the amount of money we do or don’t put into the NHS.