This is the latest in a series of lectures about the issues I believe will dominate the public and political debate in the time to come.
Today I focus on what we call "public health" but which is really about "healthy living". In this lecture I will set out the challenge this issue poses for us: in respect of the increasing strain unhealthy living will put on the NHS; in respect of our quality of life; and in relation to reducing inequality in our society. I will describe how we need a new approach to it; in terms of Government, corporate and personal action. But first I want to develop an argument about the changing nature of the state and Government in the modern world, of which the issue of healthy living is actually a prime illustration.
For a hundred years or more the defining division in politics, in Britain and elsewhere, was about the role of the state. Essentially progressives believed in its ability to improve society; Conservatives feared its interference stifled personal liberty. The division became caricatured as between those who favoured a "Big" state and those who favoured a "minimalist" one. Fierce struggles about nationalisation or privatisation, about the precise level at which public spending started to crowd out private investment, dominated the era of post-war politics. Conservatives were for 'business', often 'Big Business', progressives for trade unions and the public sector.
Underlying the formation of New Labour was really an attempt to consign such a division to the past; to escape not just the caricature but also the genuine confusion of ends and means. We believe in the power of Government and of the state to do good; but we do not believe in a Big State or that the more the State does, then necessarily the more equitable the outcome. We have tried to develop a concept of the State as enabling, its task to empower the individual to be able to make the choices and decisions about their life that they want. We abandon explicitly the paternalistic state of the post-war years, not because that state did not fulfil a worthwhile task, but simply because such a state no longer fits the times. The idea of the enabling State whose job is to empower the individual, rather than command and control in the manner of 1945, has profound implications, some of which we are only beginning to see.
For a start, you get out of the bind of saying: 'how much Government?'; and ask the more sensible question - 'Government for what purpose?' Today Government and the State do not need to be, themselves, the providers of services; or running industry or picking winners. Some roles Government should relinquish and is. But in other areas and public health is one, people will expect more active Government. Climate change is another. So this is about - as last week's Departmental Capability Reviews showed - the changing nature of Government, not about whether it should be 'Big' or 'minimalist'. Today across a range of areas, we are opening up provision to the independent and voluntary sectors and making the public sector the commissioner of services: in welfare, in health, even in areas like the management of offenders.
In doing so, we are forming new partnerships with those sectors, barriers are being broken down. It's absurd to try to educate the workforce of the future without encouraging the participation of employers and universities in schooling. Yes the NHS is a public service but how it spends its vast procurement budget, how it uses IT, how it fashions new processes and pathways for patients, plainly benefit from private sector experience. Look at the most innovative ways of helping dysfunctional families or alienated young people and you will more likely find them in the voluntary and charitable sectors, than in central or local government.
An enabling state should be supporting the public service risk-takers, the social and public entrepreneurs who make the changes that make the difference. And above all a state that sees its role as empowering the individual, not trying to make their choices for them, can only work on the basis of a different relationship between citizen and state. Government can't be the only one with the responsibility if it's not the only one with the power. The responsibility must be shared and the individual helped but with an obligation also to help themselves. Business, if no longer subject to a misguided ideological attack on profit, must recognise a corporate and social responsibility as the price of the new consensus in support of their role in wealth creation. So a more responsive NHS can't work unless patients also respond. More successful schools depend also on more successful parenting. If power is put out of the state's hands and into the hands of people, it is those hands that need also to be active.
I mentioned climate change earlier. Government can give people the information, legislate and regulate to encourage sustainable living, help business to function in a more environmentally responsible way: work with other nations to develop the right international framework. But it can't 'do it' by itself. 'Doing it' will depend on the decisions and choices of millions of individuals and companies. Our task is to empower them to make the right ones.
And so it is with healthy living. In the future, health care cannot be just about treating the sick but must be about helping us to live healthily; this requires more from all of us, individuals, companies and Government and for Government it has to encourage, it has to inform, but, if necessary, in a tougher way than ever before, it has to be prepared to act. The alternative will be a future in which the capacity of the NHS to treat us simply won't keep pace with the state of the country's health. It is the questions thrust upon you that define you as a politician. The questions thrust upon a politician of the early 19th Century were stark and bleak. Britain was industrialising and urbanising. The population almost doubled in the fifty years from 1801. The poor crowded into the big cities, usually into desperate slums that became hothouses for the sharing of disease. In the late 1840s the cities of northern England received thousands of starving Irish, fleeing the potato famine. Suddenly, lives that had been lived in semi-isolation in rural communities came into contact with thousands of fellow-citizens. The era of public questions had begun.
And yet the very basics of a public health infrastructure were lacking. Housing was crowded - in 1847 a typical street in the East End of London had 1095 people living in only 27 houses. Sanitation was poor - an outside water privy might have to serve 20 households. Water, usually drawn from sources infected with untreated sewage, was impure - London's water supply came mostly from the Thames into which no fewer than 237 sewers were emptied. Infectious diseases, once they took hold, were deadly; there were no vaccination programmes, few effective drug treatments. Machiavelli once wrote that statecraft involved fortifying the banks against the rivers of misfortune. The cities of the British Industrial Revolution had no fortifications worth the name. Labour was treated as expendable. Life was cheap and easily spent. In 1840 one child in three died before reaching the age of five. Cholera was notoriously disrespectful of classes. It spread across the social scale. The epidemics of 1832 and 1848 killed 140,000 people. Cleansing action by no one individual could ever be certain to be enough. The role for government was clear. This required collective action. It meant property rights needed to be disregarded and land compulsorily purchased, both big issues for a laissez-faire time. The Victorians took up the challenge by legislation, then accompanied by the great feats of Victorian engineering. In 1858 Parliament responded to the "Great Stink" emanating from the River Thames by sanctioning Bazalgette to build 83 miles of sewers to prevent the deposit of raw sewage. The Manchester waterworks had begun in 1847 and by 1875 most of Liverpool's housing had water closets connected to sewers.
The state gradually began to assume responsibility for problems that had once been considered individual or voluntary affairs. Yet the debates of the time show the sensitivity of government intervention. In 1854 there was a leader in The Times that put this point with brutal clarity: "The British nation abhors absolute power. We prefer to take our chances with cholera and the rest than be bullied into good health". We are now in a new era, the time of conditions of affluence, of degenerative and man-made diseases. Today, our main killers are circulatory and cardiovascular conditions which very few people in the Victorian and Edwardian eras would ever survive long enough to contract. The problems of 19th Century public health were colossal. But they were, in a sense, easy to correct. The collective solutions were easy to identify - to improve slum dwellings; to construct a disposal system; to purify the water; to make the fruits of medical research available to the poor. Of course these were great accomplishments and a testament to the political will of many great reformers. But, once the will was gathered, the levers were there and they worked when they were pulled.
In the first decade of the 20th Century life expectancy for men was a mere 49 years. By the final decade of the century male life expectancy had risen to 73. Average infant mortality was 150 per 1,000 births. Now, even in the poorest sectors of society, it is no more than 10 per 1,000. It was an era of great policy success. Perhaps no era can claim such a clear boost to human well-being. It is very different from today. Our public health problems are not, strictly speaking, public health questions at all. They are questions of individual lifestyle - obesity, smoking, alcohol abuse, diabetes, sexually transmitted disease.
These are not epidemics in the epidemiological sense. They are the result of millions of individual decisions, at millions of points in time. For example, 20 per cent of all children in the UK eat no fruit or vegetables in a week. 65 per cent of adults and half of all children do not take the recommended amount of exercise. Obesity is rising rapidly. 1 in 4 adults and children in the UK is obese, and rising. The social effects of alcohol abuse are widespread and worsening. In the last 30 years of the 20th century the death rate from liver cirrhosis went up 8 fold amongst men and almost 7 fold amongst women aged 35 to 44. Smoking may account for half of the social class health inequality. An estimated 1.7 million people in the UK have type 2 diabetes. 10 per cent of NHS resources are used to treat diabetes. This could double by 2010. And it is avoidable. Three quarters of diabetics are type 2 diabetics and two thirds of them have a disease that could be preventable with exercise diet and more healthy choices.
These individual actions lead to collective costs. It is worth pausing for a moment to consider the consequences that inaction will bring. The economic burden of chronic disease, including lost work, the early drawing down of pension entitlements and the need for palliative care, could be vast. Heart disease alone costs the UK nearly £8 billion per annum. The Health Select Committee estimate that the full costs of obesity and overweight people to the country is in the region of £7 billion per year. The NHS spends £1.7 billion treating conditions related to smoking. Health treatment relating to alcohol cost an estimated £1.7 billion with the treatment of alcohol related harm costing a further £20 billion.
But the question still hangs in the air, carrying echoes of that Times leader of 1854: whose responsibility is it? The individual? The state? The company? Should it be a proper area for Government intervention at all? In my view, the reason we need a new and more robust approach to health is precisely because of the facts I've just listed. The truth is we all pay a collective price for the failure to take shared responsibility. That doesn't mean you stop treating people in the NHS who smoke or force people to do what they don't choose to do but it does mean that Government should play an active role in the way the enabling state should work: empowering people to choose responsibly.
In formulating policy, I have undergone my own personal journey of change in this respect. A few years back, I would have hesitated long and hard over issues like the smoking ban. Now, and particularly where children are concerned, I have come to the conclusion we need to be tougher, more active in setting standards and enforcing them. Indeed this is part of a pattern that has developed hugely in the past few years. Now, we have legislation on a host of matters pertaining to public health: food, air, water quality, drinking and driving, drug classification, seatbelts, childproof medicine bottles, speed restrictions and so on.
In 2002 we banned most tobacco adverts and sponsorship. Recently, the success of the smoking bans around the world show that legislation can both express popular opinion and lead it further. Ten years ago a ban on smoking in public places would have been thought an intervention too far. In time it will come to be seen as the norm. Before the legislation making the wearing of seat-belts mandatory, Barbara Castle, amongst others, argued that the public would not stand for being told what to do. Who, now, would go back? We are banning poor meat, fizzy drinks, crisps and chocolate in school meals from September 2006. Pupils should get regular good meat, poultry and fish along with two options of vegetable and fruit every meal. The Education Bill will also ban the sale of junk food and fizzy drinks in vending machines and schools will have to meet tough new standards for school meals by 2008 in primaries and 2009 in secondaries. We are working on a code with the food industry on limiting the advertising of junk food to children. But if by 2007, the voluntary code hasn't work, we will make it mandatory.
We are working in a similar way now with the drinks industry to ensure the promotion of responsible and sensible drinking, to make the true alcoholic nature of products clear and to avoid marketing to those under the age of 18. The industry is reporting back to Government on progress in September. In addition, of course, we have changed the licensing laws to make it easy to close down irresponsible licensees or those selling to under-age drinkers, an approach working well here in Nottingham.
Legislation can, itself, help to change a culture. To outlaw an activity is, of course a strong signal that such behaviour is unacceptable. But we need, at the same time, a more subtle approach. This is partly about providing good information. The consumption of cigarettes declined 50 per cent over 50 years when the true nature of the risks were exposed. The facts changed and so people changed their minds.
But in many cases government is not the organisation to persuade us to change some of our most personal behaviour. So Government needs to work with others - with industry, with the media, with civil society to have an impact on persuading more people to make more healthy choices.
The Small Change, Big Difference campaign that we launched in April this year is based on this principle. Recent research has shown that health promotions have increased the consumption of fruits and vegetables by more than one serving a day. In turn, it has been shown that even a modest change in behaviour, such as taking a small amount of exercise, can reduce the incidence of stroke and coronary heart disease by about 10 per cent. And the campaign that reaches the most people will not only involve the government but must involve the food retailers and the media too.
We know that busy consumers want a single clear system to help them inform themselves about the food they are buying in the shops. We are encouraging the industry to adopt the Food Standards Agency's clear system for food labelling. Already, Sainsbury's, Asda, the Co-op, Boots and Waitrose have indicated they will join the scheme. It will be much better if the industry comes together voluntarily around this scheme but once again, we are prepared to act if the voluntary system does not work. As part of the new relationship between Government and the drinks industry, we have now reached an agreement to an organisation called the Drink Aware Trust. Again this will provide the Government with a different vehicle to help influence people to make healthy choices. The alcohol industry has pledged £12 million for the Trust over the next three years.
In a sense, the issues to do with obesity and in particular how to start turning back the rising tide amongst young people, brings all the different strands of Government, corporate and personal action together. For example, the campaign to reduce smoking was successful long before the ban on public places. It is, in fact, a test case of the need for partnership. Medical research proved the links between tobacco and lung cancer; the government restricted advertising and taxed tobacco heavily to force up the price; many companies and agencies restricted smoking in public places and on public transport; health campaigns were led from within and without government; health warnings were placed on cigarette packets; support for giving up was offered; commercial products appeared designed to do the same. A guiding coalition was built. Out of this complicated web of associations and actors, the right choice became a lot easier.
In the Health White Paper of 2004 we set out six priorities: tackling health inequalities; reducing the numbers of people who smoke; tackling obesity; improving sexual health; improving mental health and encouraging sensible drinking. We will say more on social exclusion in the autumn. Social exclusion is one of the many policy areas that are public health policy in disguise. As people climb the income scale they tend to eat more healthily, smoke and drink less and take more exercise. While only 15 per cent of pregnant women in the most affluent quarter of the population smoke, this proportion is twice as high amongst the least affluent. The case for early intervention is very strong. Parents need to be supported as habits can persist from childhood into adulthood. Sure Start programmes led by health practitioners have been among the most successful.
But in respect of obesity, the issues are really quite stark. For Type 2 diabetics, around half of whose condition is attributable to obesity, life expectancy is reduced by as much as 10 years. Amongst children obesity is growing at a rapid, indeed alarming, rate. This is the reason why campaigns like those run by Jamie Oliver on School Dinners are not a passing fad, they are central to the nation's future health.
School sports are being increased again, there is big investment in new facilities and last year for the first time in a long time, more playing fields are being created or improved than are being lost. This investment, including in the specialist sports schools and academies, will continue and through the Building Schools for the Future, will rise.
We are forming a new partnership with industry and the voluntary sector to prevent obesity in children under 11. Forty Stakeholders from food manufacturing, food retailing, NGO and physical activity sector have been developing this approach. This will now extend to encompass broadcasters, the video game industry and leading employers with large occupational health programmes. In the Clubs That Count scheme, we work closely with the various professional football associations to help their supporters with obesity, as well as with sexual health and drug problems and promote physical activity and healthy eating.
But weight is a combination of calories in and calories out. We need to ensure that we are doing all we can to enable people to take enough exercise. It is disputed whether the calorific intake of the nation has actually increased at all over the last fifty years. But our lifestyles certainly have. Manual, physically demanding occupations have declined to be replaced by sedentary, office-bound work. Labour-saving devices have made work in the home more convenient and less taxing. The time we devoted to physical activities has been squeezed. The municipal facilities we used were neglected, in many cases sold off entirely. At the same time, car use has grown extensively. We drive short journeys that, once, we would have walked. We are more wary of walking or cycling now. The numbers of children walking to school declined from 61 per cent to 53 per cent between 1994 and 2004.
We have already developed some very effective partnerships. By 2007 the NHS will be employing 1200 health trainers help people to make and sustain good lifestyles. Already, some big organizations, like the Army and the prison service, are involved. The Autumn Communities for Health initiative provides the opportunity for all local government and civil society organisations to work together on locally specific healthy activity such as smoking, increased physical activity or diet.
But I think we can be even more ambitious. Already, nearly 400,000 people take part in a Great Run event each year. This is the biggest sporting participation programme in the world. We have the Olympics in London in 2012. There is surely a partnership to be arranged, between voluntary, private and public sectors to encourage mass sporting participation of this sort, as those like Brendan Foster have been arguing. We can join up all the activities that are going on at the moment, engage the private leisure sector, get schools involved and sports clubs. 400,000 could become 2 million. 400,000 should become 2 million.
In the private sector, Tesco have committed to get 2 million people running, cycling or walking in events that they will sponsor as we approach 2012. Boots, whose HQ in Nottingham I visited yesterday, are pioneering a whole range of new ways to engage their customers with healthy living, including helping around 500,000 to stop smoking and giving advice and help to people on how to be more physically fit. The NHS has also increased the number of qualified dieticians by 50% since 1997, though it is clear many PCTs at a local level must prioritise public health much more vigorously.
All of this is good. All of it indicates a big change of approach. But I still think there is a vast untapped potential out there for still greater partnership between public, private and voluntary sectors. There is an industry out there in health and fitness, in improving lifestyle choices whose ideas and experience we could harness; there are huge amounts of community facilities, not least in schools, that are often under-used; and there is a public that, though it may not always know what to do, knows it should be doing something.
I have signalled our determination to act; our willingness to act with others; and our desire to do so in a way that empowers people to lead the healthy lives they want and the nation needs them to have. In 10 years time, and if possible long before, I want the health debate in Britain not to be confined to the excellent NHS that treats people when they are sick; but to the broader national health service that is about prevention as much as cure, about personal responsibility as much as collective responsibility, about the quality of living as much as life expectancy. It is an ambitious goal. But one totally in tune with the times. It means changes in Government, business and people, but that is the way the modern state should work.