Meeting the public health challenge in the age of austerity.

This paper is a powerful wake-up call to the public health community which urgently needs to hone its political advocacy skills in the face of what lies ahead. Sadly, however, its central message is destined to go unheeded by governments throughout Europe, including the UK coalition government. Overnight, in the aftermath of events in Greece, these governments have gone from being enthusiastic Keynesian expansionists, approved of by the paper’s authors, to equally enthusiastic Gradgrind contractionists. Despite a promising start when the global crisis first hit, it seems these governments have learned little from the lessons of previous economic downturns. With the coalition government acting in unseemly haste to cut the public spending deficit, in the firm belief that it is part of the problem rather than the solution, the threat of a double-dip recession looms—now a virtual certainty in the view of several respected economists. The National Health Service (NHS), we are assured, is safe with its budget ring fenced but in practice it is facing cuts in excess of £20billion. Presumably the authors approve of a ring-fenced budget for health care since their thesis is that NHS spending can make a positive difference to health. While there is persuasive evidence for this, there is also substance in the view that ring fencing the NHS budget is likely to have a negative knock on effect on other government departments’ budgets that ultimately risks diminishing health in its wider sense. According to supporters of this view, it makes no sense to protect the NHS’s budget while cutting other services that contribute significantly to improved health and wellbeing and ease pressures on the NHS. We know that the growing demand on the NHS is a product of lifestyle-related disease such as obesity, alcohol misuse, mental ill-health and so on. Although the NHS has an important role to play in tackling these modern epidemics, there are bigger gains to be had from a more effective joined up approach to tackling such complex problems which cut across organizational and service silos and boundaries. If the Total Place initiative, mentioned by the authors, started under New Labour and likely to survive in some guise under the coalition government, has taught us anything it is that tackling ‘wicked issues’ of the type to be found in public health cannot be left to the NHS acting in isolation and that there is a need to pool resources and expertise to address the needs of whole communities and places. The coalition government’s proposal to give local government a lead role in public health is a move in the right direction. In their references to the NHS it is not always clear if the authors mean the broader health system as defined by World Health Organization. Presumably they do but, if not, then special pleading for the NHS in narrower terms is not the answer as public spending cuts are unleashed and if the public’s health is to be advanced. Introduced under the last government to encourage physical activity and promote health, does the ending of free swimming for children by the coalition government do more to worsen health than maintaining funding on health services that may only partly pick up the pieces of failed attempts at prevention? The omens are not good. As its dismissive reaction to NICE guidance on upstream interventions to reduce alcohol misuse and cardiovascular disease demonstrates, combined with an assertion that NICE may have overreached itself, the UK coalition government views public health as largely a matter of individual lifestyle and behaviour and not one for government intervention aimed at tackling the structural determinants of health. The paper rightly argues that public health professionals should familiarize themselves with the economic and political arguments that are raging all round them. In leadership programmes, political astuteness is increasingly one of the competences regarded as critical. Indeed it is, and never more so than right now.