Health Policy Paper
The term 'policy' as used in the context of health, refers to the plans, actions, and decisions undertaken to realise definite health care objectives/goals within a given society (WHO 2016). Health policies come in various forms, including pharmaceutical policy, personal healthcare policy, public health policy (for example, tobacco control policy, vaccination policy, or breastfeeding promotion policy). Health policy, based on the definition provided, is characterised by several distinctive features: it is an area that attracts high-profile political interests; governments assumes responsibility over a national health service (WHO 2016); it is an arena that attracts significant media attention; it consumes considerable amount of public resources; it is an area that presents significant commercial opportunities (Baggott 2015). Two vital concepts crucial to our understanding of health are health promotion and social determinants of health. Whereas health promotion involves allowing people to enjoy improved health and have control over it (Clavier & de Leeuw 2013), on the other hand, social determinants of health refers to aspects of social wellbeing like employment security, incomes, and housing security, and how these working and living conditions structure determine our access (or lack of) health. In this case, their unequal distribution leads to health inequalities. Health policies are therefore development with a view to reducing health inequalities brought about by social determinants of health and health promotion. One such policy is the “Healthy lives, Healthy people” policy. This is a white paper produced by the UK Government with the overarching goal of ensuring enhanced localisation of such public health services as emergency preparedness and immunisation programmes. Previously, these health services have been best handled at national levels (Royal College of General Practitioners 2016). The purpose of the essay is to discuss this document as it relates to obesity, the influence of political ideology in moulding this policy, and its likely impact on the obesity client group.
Political ideology underpins public health policies and in this respect, it has an influence on people's lives (Bambra, Fox & Scott-Samuel 2005). The political nature of health can be explored in various ways: first, health can be viewed from a political context since like any other commodity or resources under neo-liberalism certain social groups have more of it in comparison with others. Health is also regarded as being political given that its social determinants are responsive to political interventions, and are hence reliant on political action. Also, the political inclination of health is underpinned by the United Nations (UN) recognition of 'a standard of living adequate for health and well-being' as a component of a human right and citizenship. Finally, health is political considering that the power exercise over is constitutes a more diverse social, economic, and political system (Bambra et al. 2005). Accordingly, changing such a system calls for political struggle, political willingness, and political awareness. The political context of a country depicts power relations between different stakeholders, sectors, and actors. These power relations in turn influence policy formulation, execution, assessment, and the manner in which resources are to be allocated.
The fundamental orientation of neoliberal government is such that it endeavours “to extend the rationality of the market; the schemes of analysis it proposes, and the decision-making criteria it suggests to areas that are not exclusively or not primarily economic” (Foucault 1997, p. 79). With regard to public health, the operation of a neoliberal government is evident in the construction of rational, individual participants in the health care system whose decisions on behavioural changes are best assessed via a cost-benefit analysis
(Department of Health 2004); the adoption of subjective, theoretical models whose main focus is on behavioural determinants of health outcomes (Glasgow 2012), and the promotion of health strategies aimed at individuals, aimed at developing self-governing participants capable of assuming an entrepreneurial approach in managing their well-being and health.
‘Healthy Lives, Healthy People’ White Paper of 2010 is both a healthy policy and a political document. This is because the development of a policy, including healthy policies, hinges on a deeply entrenched ideological position. It is important to note that the Healthy Lives, Healthy People policy document was developed by the current coalition government consisting of Liberal Democrats and Conservatives and as such, it reflects a strong neoliberal political stance. Harvey (2007) describes Neoliberalism as a an ideology that views market exchange as an ethic in its own right, and hence regards it as having the capacity to guide all other human actions. Elsewhere, Gallaher (2009) describes neoliberalism as “a set of economic policy initiatives that came to prominence in the early 1980s” (p. 152). These policies draw their neoliberalism is based on the underlying principles of laissez-faire economics, which gained prominence across Europe in nineteenth and twentieth centuries. According to Gallaher (2009), “neoliberalism is based on the assumption that the economy works best when left alone.” (p. 152). Accordingly, quotas, subsidies, tariffs, and other types of economic intervention instituted by the government, are seen as impediments to economic growth. Neoliberalism acknowledges the rights of the individual, a free market, and limited government controls. In Great Britain, some political commentators have also used the term Thatcherism in reference to neoliberalism. The late Margaret Thatcher who was UK’s Prime Minister on two occasions between 1979 and 1990, is credited with having developed firm neoliberal polices in the country, and hence her association with the Thatcherism concept that draws heavily from neoliberalism (Evans 2013). Thatcherism describes the political, social, and economic policies as advanced by Margaret Thatcher (Vinen 2009). Thatcherism thus symbolises a systematic but decisive turnaround, and denunciation of the of post-war consensus in which key political parties generally agreed on essential themes of the welfare state, Keynesianism (Vinen 2009), close government regulation of the economy, and nationalised industry (Gallas 2015). Accordingly, the ideology has been equated to Neoliberalism given that is assumes the form of a political platform that stressed on free markets, tax cuts, and limited government spending, privatisation and deregulation (Giddens 2006).
Neoliberals hold a strong opinion that governments should be actively involved in reducing health inequalities and minimising health risks linked to epidemics through immunisation programmes. However, neoliberals are of the view that that the government should desist from regulating an individual's health choices as this is tantamount to intruding on their civil liberties.
Successive UK government have demonstrated a commitment to reduce health inequalities in the country. This is evidenced by their commissioning of various reports to assess the level of health inequality in the UK. Notable publications include the 1980 Black Report, (Black 1980) the 1987 Health Divide (Whitehead 1992). The two reviews were published at a time when government showed limited commitment to limit health inequalities. In contrast, the 1998 Acheson Review (Acheson 1998) was commissioned by the Labour party under Tony Blair before he assumed his role as Prime Minister. Findings of the review enabled the Labour government to develop the first health inequality strategy in the country and encompass targets for infant mortality, and life expectancy, to be realised by 2010. the 2010 Fair Society, Healthy Lives report (The Marmot Review Team 2010) proposed several recommendations to help reduce health inequalities in England: Ensuring that every child in the country gets the best start in life; Enable everyone (including adults the youth, and children), to take control of heir lives and enhance their capabilities; create good work and fair employment for all; guarantee everyone a healthy standard of living; create healthy and sustainable communities; and improve the impact and role of ill health prevention. The report further stressed that the realisation of these policy objectives calls for action from local and central governments (Bambra et al 2011), the private sector, the NHS (National Health Service), and community groups. Immediately after the Fair Society, Healthy Lives report had been published, the coalition government came into power and the new government was thus charged with the responsibility of addressing these recommendations.
The ‘Healthy Lives, Healthy People’ White Paper therefore constitutes the coalition government’s responses to the recommendations made by the Fair Society, Healthy Lives report (Secretary of State for Health 2010). Neoliberalism bears a lot of resemblance with the nudge theory as espoused by Thaler and Sustein (2009). This theory has influenced political debates globally, especially in the United States and the UK. In the UK, nude's basic concept became the source of inspiration for the BIT (Behavioural Insight Team), a unit established within the Cabinet Office. The BIT describe their aims as: 'encouraging and supporting people to make better choices for themselves; considering the applications of behavioural science to policy design and delivery; advancing behavioural science in public policy; championing scientific methodology to bring greater rigour to policy evaluation' (Organization for Economic Co-operation and Development 2015, p. 7). BIT was a development of the Labour government and considering that the same government had commissioned the ‘Healthy Lives, Healthy People’ White Paper, this is a clear testament to its inclination towards neoliberalism and Thatcherism concepts in designing its policies.
The Liberal Democrats Ideology is based on the premise of establishing and safeguarding a free, open, and fair society, with a focus on balancing individual fundamental values of equality, liberty, and community. Liberal Democrats also believe in the idea of a free-market, even as liberal democrats are opposed to the idea that private choice should be removed in health and education (Clavier & deLeeuw 2013). In contrast, localism refers to several political ideologies which emphasise the local. Localism thus supports control of government at local levels and in the case of health, promotion of health and well-being at local levels.
Cameronism can be viewed as an extension of the neoliberalism propagated by Margaret Thatcher and the labour government before it. Cameronism favours low taxes and reduced government spending on social welfare systems (Cameron & Jones 2014). Like Thatcherism, Cameronism also favours free market radicalism as evidenced by its quest to advance the Conservative discourse.
The Labour party is committed to provisions of social justice and this stance is evident when the party commission a report that would address health inequality which is an aspect of social justice in the country (Bambra et al. 2005). As seen earlier, the values of Liberal Democrats and Conservatives are not so much entrenched in advancing social justice but the Labour party acknowledged that the adoption of policies that would reduce health inequalities, as opposed to coercion was the way to go in addressing social inequalities. However, a central focus of the ‘Healthy Lives, Healthy People’ White Paper is that it is upon the individuals to make healthy choices that will ensure that they enjoy improved health and well-being. This is indicative of a laissez-faire approach that is fundamental to neoliberalism. Accordingly, this is an indication that the New Labour party embraced some neoliberal values as a means of dealing with the issue of social inequalities in Britain, of which health inequalities is part of.
In its call to action on tackling obesity in England, the ‘Healthy Lives, Healthy People’ White Paper delineates plans for involving the entire society in reducing obesity. The report indicates that since obesity is everybody’s business, individuals have to take personal charge in changing behaviour in order to lose weight. The report further indicates that various partners, including business and government, have a crucial role to play in reducing obesity in society.
Moreover, the report recognises the need to empower individuals and communities through funding of local authorities in their quest to prevent and treat obesity at the individual and community level. This calls for the establishment of local capabilities through cooperation between local and national governments as a means of supporting individuals and communities deal with obesity (Glasgow 2012). More importantly, the central government has to demonstrate its clear leadership capability is spearheading action to tackle obesity at societal levels, and the ability to forge partnerships with the business
The Healthy Lives, Healthy People White Paper presents a shift from treatment of obesity towards its prevention through behavioural change, and recognition of the recommendations by the Marmot’s report on the need to address wider social determinants of health as the first step to dealing with inequalities. However, this demands that the national government allocates sufficient funds to local authorities that are now charged with the responsibility of managing obesity, in line with the proposals outlined by the public health Outcome Framework. Nonetheless, local authorities are only receiving limited funding towards tackling obesity, raising fear of a possible significant increase in obese people in future. In the absence of full support form the national government, local authorities cannot tackle social inequalities at the local levels, and they cannot also identify and meet the needs of obese people at local levels.
Various studies have pointed towards a correlation between obesity and socio-economic status (for example, Gortmaker et al. 2011; Dietz et al. 2015; Lobstein et al. 2015), although this correlation is less pronounced among children. For this reason, many have interpreted obesity as an indicator of health inequality. While some of the proposed strategies to tackle obesity, such as joining a gym are beyond the reach of poor people owing to gym membership, the poor still record high levels of obesity and this has been blamed on dietary choices. This has seen critics de bate whether eating badly is cheaper compared to eating well. This is supported by the fact that junk food costs much cheaper in comparison with a healthy meal. Imposing a 'food tax' would likely reduce the demand for junk food by levying a charge on high salt, high fat or high sugar foods. However, political willingness to institute such a policy is lacking, as well as lack of public support. Some members of the public have even faulted the supposition that obesity is a health risk.
Obesity is correlated to a rise in a host of other chronic illnesses, such as Type 2 diabetes, cardiovascular diseases, and various forms of caner. The World Cancer Research Fund (2007), in its reviewed of 7,000 studies, established that one in every three cancers is associated with diet. In addition, the review identified obesity as a major risk factor for at least six forms of cancer. Nonetheless, some commentators have indicated that these could be as a result of the lifestyle enjoyed by obese individuals, as opposed to excess fat per se (Swinburn et al. 2011). For this reason, some people have argued that one can be obese and still healthy. This has however not deterred efforts by the Coalition government to reduce obesity levels in children and adults alike.
According to the Public Health England (2014), obese children have a higher chance of becoming obese adults. Despite this, the Healthy Lives, Healthy People White Paper, has not delineated plans to improve people's standards of living. However, the report has placed emphasis on lifestyle change during childhood in regards to behaviour change through exercise and change of diet.
The Royal College of Nursing has registered its concern over 'nudges' as a mean s of promoting behaviour change in regards to obesity, stating that such a strategy could have limited success in the absence of regulation (RCN 2013). This is likely to elicit controversy considering that the Coalition government and the New Labour party before it have both sought to recognise individual freedom and choice, including making health choices. By regulating healthy choices, the government would be seen as renegading on its promises. The RCN further points out that even as the focus of the ‘Healthy Lives, Healthy People’ White Paper is on service design and evidence based practice, the evidence base with regard to the 'nudge' concept remains weak.
While the White Report has recognised obesity as constituting a considerable burden on the NHS and overall economy, the Coalition government has allocated significantly less fund towards the obesity initiative, in comparison with other public health initiatives. The Royal College of Physicians, in their 2015 report, also indicated that strategies to manage weight among the obese members of the population were, at best, “patchy”.
In 2013, Primary Care Trusts under the management of Local Authorities were entrusted with the management of obesity, in keeping with the recommendations of the Healthy Lives, Healthy People White Paper. This move was based on a realization that local authorities were best placed to identify local priorities and provide public health services to address the demands identified. Such a move was crucial especially in regards to obesity as this disease burden costs the wider UK economy 7 times the cost incurred by the NHS (Marmot Review Team 2010). However, funding to manage obesity so far is not commensurate with the significance of obesity as a health problem.
While the RCN welcomes the government’s stance of embracing ‘localism’ in its approach to public health, including prevention and management of obesity, based on the arguments that most public health issues have a strong basis at local levels (RCN 2013). However, the RCN has voiced its concerns over a likely fragmentation of commissioning certain services resulting in poorer access, gaps, confusion in service delivery, fragmented teams, differential conditions and pay. Still, nurses working within local levels such as within school settings have a vital role in realising the main constituents of the ‘Children’s National Service Framework’ (Department of Health 2004), including empowering young people with information on exercise and good nutrition as a first step towards reducing obesity.
Political ideologies have a great impact on various policies, including health policies. Nowhere is this more evident that in the ‘Healthy Lives, Healthy People’ White Paper which was commissioned by the New Labour party. The Labour Party draws its approach to policies on Thatcherism, which is in turn heavily influenced by Neoliberalism. Accordingly, ‘Healthy Lives, Healthy People’ White Paper recommends supporting local authorities in delivery of care and management programmes for obese people, in line with the localism ideology that neoliberalism espouses. However, since the Coalition government under former Prime Minister David Cameron was charged with the implementation of this policy, it is worth noting that there have been expressions of dissident in the manner in which it has been implemented, especially in regards to limited funding. This is characteristic of the Cameronism concept which seeks to limit funding to government authorities as a cost-cutting measure, even as it endeavours to empower local people and accord them more freedom. There is fear from various health professionals such as nurses that localisation of health services to manage obesity might lead to increased workload on the staff, experience limited funding to support programmes and train nurse. This could end up jeopardising the noble plans by the government to promote health and well-being of its people, especially for the obese population.
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