When health is a personal responsibility

Health will be a central part of the election campaign – it always is. But will the debate be the right one? Will politicians actually discuss health or will they only talk about the NHS? Will the conversation be about the institution or the outcomes?

As the cliché goes, Scotland doesn’t actually have a health service, it has an illness service. It treats the consequences of ill health rather than preventing it in the first place. There is a reason for this: providing hospitals, A&Es and GPs is the easy thing to do.

Sure, there are funding constraints and the cost pressures of new drugs and treatments. But all you are really doing is meeting or managing demand. 

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The problem with prevention is the human factor – you and me. Some of the fastest growing pressures on the health service are caused by our own behaviour. Sometimes this is stark. It is estimated that half of the difference in average life expectancy between the working classes and the middle classes is caused by smoking.

Not only do smokers know that smoking kills them, they mostly want to stop and, actually, we know how to help them do that. But still smokers smoke – still around a quarter to a third of Scots – and lose five years of life.

It gets more complex with diabetes and obesity. Lifestyle and diet are direct causes of these. By and large, most people know that consuming more calories than you burn makes you fatter and that fresh food made from fresh ingredients is healthier than processed foods. The message of five-a-day is widely understood. But knowledge is very different from action.

Just as many more people have gym memberships than actually use them, so many more people know they should eat more fruit and vegetables than actually do. It’s a question – in the jargon – of motivation, incentives and reinforcement.

Why don’t we do what we know we should? Because we’re only human. Food, for example, has multiple social and psychological meanings. Here’s the challenge and the opportunity. The challenge is that politicians have to embrace that hated concept – the nanny state.

Douglas Jay’s infamous statement, “in the case of nutrition and health... the gentleman in Whitehall really does know better what is good for people than the people know themselves” has much truth. It’s just a very uncomfortable position for politicians to be in, telling people how to act and what to eat. 

The opportunity is for some real leadership. Not just telling people the truth – that their health is, by and large, in their own hands – but by supporting them as well. We know that the makers and sellers of fast food and processed foodstuffs have ingenuity, marketing skills and understanding of psychology.

The very skills that make us fatter can also be used to help make us fitter. In the end it needs political will. But surely far better than an arid dispute about waiting time statistics would be a strategic conversation that starts to shift health from providing welfare to supporting wellbeing.