The recently empowered coalition government in Britain has adopted a new and controversial approach to public health. In 2010, the secretary of state for health, Andrew Lansley, released a white paper declaring that “Responsibility Deals” would be used to promote health lifestyles and reduce the public health and financial impacts of chronic diseases. Lansley specifically states that the deals are “a Conservative response to challenges which we know can’t be solved by regulation and legislation alone. It’s a partnership between Government and business that balances proportionate regulation with corporate responsibility.” The policy approach raises the ongoing issue of deciding what role government should play when it comes to protecting public health.
It just takes a little Nudge, or does it?
The approach is founded on an idea that Geof Rayner and Tim Lang of the Centre for Food Policy at City University in London argue is an extension of neoclassical economics, where rational consumers make smart choices, and in so doing support free and responsive markets. Nudge, as this approach is called, comes out of an eponymous book by Thaler and Sunstein. Positioned as an alternative to regulation and the “Nanny State,” Nudge argues that policy interventions like legislation, taxing, regulations, and bans are ineffective and costly for governments to implement and enforce. Instead, government should work with private industry on matters of health promotion and rely more on social marketing and industry-sponsored programs such as a bank sponsored “public” bike-rental scheme in London.
The responsibility deal focused on diet and physical activity has three objects, or what it calls pillars. These are:
One: To enable, encourage and incentivize consumers to adopt a better diet and to increase their levels of physical activity as part of a positive decision to lead a healthier lifestyle.
Two: To enable and encourage people to drink sensibly and responsibly.
Three: To extend the scope and effectiveness of occupational health services through businesses, especially for small and medium-sized businesses, with an emphasis on maintaining a healthier lifestyle amongst the whole workforce and thereby reducing sickness and absence.
To date, roughly 400 corporations have signed on to, or pledged, promote these goals. In keeping with the theme of voluntary action and self-monitoring, each of these corporations has drafted and submitted its own pledge to the British Department of Health. In April of this year, each will also submit a self-assessment of their success meeting their goals. As an example of the type of commitments made, 40 of the “partners” as the corporations are referred to by the Department of Health, have agreed to start calorie labeling schemes of foods eaten out of the home. McDonalds is the largest retail outlet to sign on. Others among the 40 corporations include Starbucks, Burger King, Pizza Hut, KFC, and several of the large supermarket chains. The Department of Health estimates that by 2012, 8000 food outlets in Britain will have calorie labels on their menus. While this is a move, perhaps nudge, in the right direction, it is a far cry from the scale of change likely needed to create real gains in public health. No aspect of this responsibility deal standardizes or mandates the size and/or placement of the calorie labels. No one other than the corporations themselves will be checking the accuracy of the calorie counts posted.
New York City’s experience provides a useful comparison. In New York, the calorie labeling regulation passed in 2007 applies to roughly 10 percent of the city’s 23,000 restaurants. The city’s legal battle with the food industry over the law shows that in a regulatory context with enforcement, details about the placement, accuracy, and size of calorie labels generate significant debate. For New York, the devil in these details of implementation was believed to be critical to the policy’s impact. Britain’s approach is to be hands-off on these issues.
Medical and Public Health Professionals Respond
Not surprisingly, responsibility deals raised more than eyebrows in the British medical and public health communities. Several of what would have been key partners in this collaborative approach to promoting health have refused to participate. This pushback from health advocates and professionals includes academics (like Lang and Tahyer), the British Medical Association, the British Association for the Study of the Liver, the British Liver Trust, Alcohol Concern, the Institute of Alcohol Studies, and the Royal College of Physicians. A consortium of NHS members, public health professionals, and concerned member of the public called Big Society NHS has critiqued the deals, stating that:
“The model of intervention promoted places government regulation as the last step. Once again shirking responsibility and leaving patients susceptible to corporate promotion of profits over health. In short these reforms neglect and dilute patient care, through the systematic fragmentation of the NHS, decrease in government responsibility and increase in privatisation.”
Other concerns of these constituent groups include:
- The potential for government and private industry collusion behind closed doors on public health policy
- History shows that private industry’s profit motive will prevent it from acting in ways that protect and promote health
- That several of the resource allocating mechanisms of the reform will exacerbate, rather than reduce, health inequalities
- The government white paper outlining the reform fails to include plans for monitoring the impacts of the policy
- The government white paper outlining the reform fails to include plans for recourse or regulation if it turns out that Responsibility Deals don’t improve public health
What about US?
At the heart of the responsibility deal controversy is the very old public health issue of jurisdictions at all levels of government needing independent decision makers to make the sometime tough and almost always unpopular choices that elected and appointed officials can’t. Time will tell if the responsibility deals create the positive impacts the conservatives claim they will. Or, if this collaborative approach including corporations in writing public health policy will backfire in the ways its critics claim.
For this writer the more salient questions are: do we have time to wait? Is saving money in the short-term on enforcing regulation really worth the potential damage to health and its consequences on public spending in the long-term?
As a final cautionary note, it is worth noting that elements of this approach have already worked their way across the pond. The US’s voluntary salt reduction program is modeled on one that originated in Britain. Given the unique powers and protections afforded to corporations in the US, one should wonder how irresponsible it might be to adopt these kids of deals in this context. It may seem like an impossible move today, but with the Tea Party brewing and a contentious election season on the horizon, it is worth keeping an eye on the latest in conservative, neoliberal, health policy.
1. Vissago via flickr.
2. Toban Black via flickr.
3. KR Colvin via flickr.