Health in a sick society

The UK government has launched Choosing Health: Making Healthier Choices Easier, a glossy, flagship policy document awash with ‘eye-catching’ initiatives, including a forthcoming ban on smoking in most enclosed public places, personal health trainers, food labelling, a national screening programme for chlamydia, and much more besides.

The White Paper is very much a statement of values in the run-up to the forthcoming general election. As others have observed, Choosing Health is about ‘the behaviour of the individual’ (1), en route to the ‘good life’ (2), a set of moral signposts pointing the way to New Labour’s Jerusalem. Many have complained that the government hasn’t gone far enough in this direction or that, and said that health secretary John Reid needs to ‘think again’ (3) about a White Paper that ‘heralds more talk than action’ (4).

But this is to miss the deeper significance of a policy sphere that, these days, is less concerned with caring and curing than it is with the moulding of lifestyle ‘choices’ through the medium of public health.

There are two particularly striking themes in the White Paper. The first is the model of health on which it is premised, in terms of ‘consumer demand and market provision’ (5). The second is the level at which it is pitched, as summed up in the ‘shift in public health approaches’ from ‘advice from on high to support from next door’ (6). Taken together, these two themes confirm just how far New Labour has travelled from expert-led, centralised systems of welfare. Instead, we are invited to think of health as a virtual commodity, as something that is consumed, traded and branded. Nobody is quite sure what this commodity looks like, but everyone assumes that it must be a good thing to have more of it in circulation.

In ‘developing the market opportunities on offer for health’ (7) government arrogates to itself the role of brand manager, wherein the brand is a particular lifestyle. There are a ‘wide range of lifestyle choices…marketed to people’, notes the White Paper, ‘but health itself has not been marketed’ (8). Cue the new marketing strategy from HM Government plc, aiming to ‘create a stronger demand for health’ by means of its conceptual inflation.

Securing good health

While the roots of this inflation predate the current government, the pace of change has undoubtedly increased under its influence. In 2002 Derek Wanless, former head of NatWest bank, presented his report to the Treasury, Securing Our Future Health, in which he identified three possible models for healthcare in the UK: ‘slow uptake’, ‘solid progress’ and ‘fully engaged’. The government asked him to report back on the ‘fully engaged’ scenario. In his report of spring 2004, Securing Good Health for the Whole Population, Wanless outlined steps necessary to engineer a ‘massive shift away from seeing the NHS primarily as a “sickness service”’, toward a service which would aim to ‘keep healthy people fit, and people with morbidities and chronic conditions as active as possible’ (9).

The outlook of the Wanless report accords with the broader thrust of government health policy, for which funding has been generous (10). The Wanless view of health services as a ‘vibrant sector of the economy’ (11) suggests that the NHS is seen as an asset rather than a drain on the public purse. Already almost one in 20 fulltime jobs in the UK are within the NHS – which makes it the third largest employer in the world after the Chinese Army and the Indian Railways – and the proportion is set to increase (12).

One might imagine that an increase in health spending is somehow due to declining standards of health, but this is clearly not so. Over the course of the twentieth century, life expectancy in the UK rose along with general living standards, and as the Office for National Statistics says, in ‘more recent years the increase in life expectancy among older adults has been particularly dramatic’ (13). On almost every score we enjoy higher standards of living and better health than the previous generation. Of course there are certain exceptions to this picture, mostly arising out of extended longevity, but the general trend remains true, aided and abetted by the upward curve of medical science over the course of the postwar period.

One might ask why health has come to occupy a more central place in the minds of policymakers and the general population? Why opt for a ‘massive shift’ toward prevention when existing systems of cure seem to be doing so well? The answer to this lies in the conceptual inflation of health, a category that has expanded to fill gaps left behind by the retreat of older norms of institutional and individual life. Notions of collective and personal advancement that once took health for granted, as an effect of substantive social progress, have been eclipsed by more immediate concerns about the welfare of personal and political bodies.

The most significant expression of this shift is in the area of public health: a discipline once at the margins, but now at the centre, of the medical endeavour, as exemplified by the Wanless reports and the new government White Paper. The rising star of this new public health is intimately related to the declining authority of the conventional clinical paradigm known as the biomedical model, with its implicit assumptions about the self-determining individual as the locus of moral autonomy. The waxing of the new public health, and the waning of the bio-medical model, reflects and reinforces the erosion of the public/private distinction that has been such a key dimension of modern, liberal democratic life.

In blurring the distinction between public and private the new public health allows diagnoses of illness that are simultaneously social and individual, refracting ailments of the body politic through the lens of individual illness.

Fully engaged

The idea that we should be ‘fully engaged’ with health has its origins in the ‘social medicine’ of the interwar period, the apogee of which was the definition by the World Health Organisation (WHO) in 1946 of health as a state of ‘complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (14). This remarkable statement, so all-embracing as to be meaningless, reflected the weakened stature of conventional moral norms – which were the traditional measure of ‘wellbeing’ – in the immediate aftermath of the Second World War, and a corresponding need for an apparently non-aligned institutional agenda of social cohesion.

As two authors in the American Journal of Public Health said in 1946, there was sense of despair at the ‘moral and intellectual bankruptcy of mankind and its leaders’ (15). This informed a medical model that, in the words of Flanders Dunbar in 1947, identified ‘sickness in the body individual’ with ‘sickness in the body politic’ (16), as cause and consequence of war and discord. As JA Ryle said, a more inclusive ‘emphasis on man…in relation to his environment’ displaced the older laissez-faire model of man as free-willing, autonomous individual (17).

However, the rewiring of domestic and international affairs that was the Cold War soon dimmed the light of social medicine. ‘Wellbeing’ was once again illuminated in more explicitly political tones, as functional fit rather than existential harmony, and the WHO definition of health-as-happiness was, for the time being, outshone.

In Britain, the division of labour in the newly established NHS reflected the essentially curative, as opposed to preventive, focus of postwar medicine – much to the chagrin of those, such as Sir Henry Brackenbury, who had laboured so hard to establish the psychosocial as the ideal medical model (18). As Honigsbaum subsequently described it, in his work on The Division in British Medicine, a ‘catastrophic fall in morale’ ensued, among those who ‘saw the GP mainly as an instrument of social reform’ (19). The problem, as one informed commentator saw it in 1947, was that most people considered social medicine ‘an unwarranted and expensive interference with the liberty of the individual, savouring of snooping, restriction and prohibition. The average individual, not being sick, resists all attempts to protect him against the hazards of disease and refuses his cooperation’ (20).

Such hostility would prove hard to dislodge, but, as we now see, not impossible. The route to change would come through the conceptual amplification of sickness, by persuading the ‘average individual’ that ‘not being sick’ was perhaps not such a healthy thing after all.

From good life to sick life

In retrospect, former Labour prime minister Harold Wilson’s celebration of the ‘white heat of revolution’ of scientific and technical progress, in 1963, can be seen as the high point of postwar social optimism. It was a short boom. From then on a less positive mood began to pervade policy thought, fuelling a wider audience for the message of social medicine – that the very structure of society is the source of sickness, and the self-determining individual the ideal host of such sickness.

The second wave of social medicine is conventionally known as the ‘new public health’ movement, the founding tenet of which came from Canada’s minister of public health, Mark Lalonde, in 1974. His was ‘the first national government policy document to identify health promotion as a key strategy. It was subsequently used as the basis for similar policy documents in other countries, including Sweden and the United States’ (21).

For Lalonde, the new public health was a necessary corrective to ‘the dark side of economic progress’ including ‘environmental pollution, city living, habits of indolence, the abuse of alcohol, tobacco and drugs, and eating patterns which put the pleasing of the senses above the needs of the human body…For these environmental and behavioral threats to health, the organized health care system can do little more than serve as a catchment net for the victims’ (22). Two years later, the British Labour government published a discussion paper on similar themes, but in different terms, downplaying ‘man’s outside environment’ in favour of an emphasis upon ‘personal behavior; what might be termed our lifestyle’ (23).

The two wings of public health, one emphasising external environmental factors and the other internal lifestyle factors, shaped a debate that is still ongoing. Whether pitched in terms of victim-blaming or victim-making, though, the assumption remains the same: that health has meaning beyond the individual, either as a measure of social inequality or a mark of moral failure. It is the argument of this essay that health and sickness have meaning only in a most particular and restricted context, and that the current preoccupation with health is itself a sign of sickness.

Health as a public/private partnership

The contraction of conventional liberal-democratic political discourse as motor of public life is reflected in the expansion of health as a moral discourse toward the end of the twentieth century. Paradoxically, the expansion of health is accompanied by the diminution of medicine. This is because medicine is founded in the particularity of the relationship between doctor and patient, itself an expression of the most fundamental of modern distinctions, between public and private.

Wherever health surfaces as a general public good, it clashes with the intimate and particular nature of the private persons of whom it is comprised. The vexed nature of debates over mass vaccination programmes and fluoridisation of water is testament to the sensitivity of the balance between individual and collective interests.

The vigour of such debates is contingent upon the way in which we understand self-interest and the extent to which it reflects a strong and stable moral culture, or, by contrast, a weak and unstable moral vacuum (24). An atomised and disengaged electorate tends to identify its collective interests in relatively shallow terms. But a weak sense of the ‘public’ does not necessarily entail a strong sense of the ‘private’. In such a context health assumes a qualitatively different role and meaning, less a means to an end as defined by an individual, and more a symptom of system failure at the level of the body politic.

Take the ‘epidemic of obesity’, for example, described in a recent influential report as the ‘biggest public health threat of the twenty-first century’ (25) – as if it were an infectious disease. Melanie Johnson, parliamentary under-secretary of state for public health, refers to obesity as a ‘scourge’, (26) a punishment from without. As the writer and academic Paul Campos points out, obesity is a ‘cultural construct, not a scientific fact’ (27). But it is also more than this, imputing sloth and disorder to an entire cultural constellation. Thus, when the Royal College of Physicians’ suggest that by the year 2020 over 50 per cent of children will be obese (28), this merely confirms the extent of a problem for which there is no solution. According to the House of Commons Health Committee, obesity is a ‘lifestyle’ disease, ‘likened…to alcoholism’ and therefore ill-suited to punitive or regulatory solutions (29). The solution, says the Department of Health, ‘needs to take a lifecourse approach’ an ongoing relationship with a cultural problematic as evinced in the bodies of the obese (30).

Like all psychosocial questions, the key to therapeutic resolution is collaborative rather than clinical, a debate rather than an intervention. And the premise of such a debate is the dangers of individualism and self-interest as pathways to anomic and destructive ‘lifestyle’ choices. If Alcoholics Anonymous urges adherents to admit their powerlessness over alcohol as a precondition for acceptance into the group, public health goes one step further and promotes powerlessness as the defining feature of the group or culture.

The predicament of the obese, therefore, is perceived as a standing indictment of contemporary values more broadly. And at this level of the social whole, current health policy justifies its intervention into the individual part, in the effort to ‘co-produce’ an alternative value-set. While this may well work for the government as a rolling programme of therapeutic legitimation, identifying and addressing errant behaviours as a way of justifying its own existence, it undermines people’s capacity to define their own interests and act upon them.

This brings us back to the matter of self-interest and how it is defined. At what point does an individual’s health become the legitimate focus of state policy? The answer to this question used to be framed by a robust morality of the public sphere. The nineteenth-century association of public health with sanitation and infectious diseases, rather than lifestyles and inequality, reflects this division. Inequality was the very stuff of political life from which health was a derivative policy arena, and if lifestyle issues were addressed then they were so in fundamentally moral terms, as deviations from a standard otherwise upheld. This remained the case through to William Beveridge, whose declamation of the five evils of ‘Want, Disease, Ignorance, Squalor and Idleness’ would be almost unthinkable now.

Today, less condemnatory language is deployed and we find a morality less concerned to hold individuals up to a given standard than it is concerned to explicate the general paucity of standards. There is less clarity about the general public interest and therefore greater uncertainty about the parameters of personal interest. In this context the language of health and lifestyle is not so much about the imposition of an authoritarian agenda of behavioural conformity than it is about a groping for connections between state and society at the most elementary level, reaching out to engage with bodies where it cannot win minds.

Healthy living

When the secretary of state for health says that ‘the government can’t force people to be healthy. And it should not tell people how to run their lives’ (31), one is tempted to believe that this is precisely what it wants to do. After all, the sheer range of government-sponsored initiatives devoted to ‘healthy living’ seems to suggest a desire for a nation of non-smoking, teetotallers consuming ‘at least five portions of fruit and veg each day’, practising ‘safer sex’, managing stress levels by ‘talking things through’, queuing up for one of the 10,000 pedometers distributed to local Primary Care Trusts (PCT) in order to hit the target of ‘30 minutes of moderate intensity physical activity…on at least five days a week’, and much more besides (32).

Up and down the UK hundreds of ‘healthy living centres’ are being established in areas of deprivation with the express aim of driving up the standards of health of the local population by offering a range of activities designed to engender what one might call ‘lifestyle correctness’. Every PCT now has its own director of public health, who no longer has to be a medically qualified person, as confirmation of an increasingly frontline role for the public health function. Derek Wanless’ model of a society ‘totally engaged’ in the care of its own health is already underway.

So it does appear that the government wishes to ‘force people to be healthy’. But it is the argument of this essay that this appearance masks a deeper dynamic, and that there is in any case a limit to the extent to which health can be forced on individuals. Take smoking, for example: some 27 per cent of the adult population continue to smoke in the UK, including 20 per cent of mothers who smoke throughout pregnancy (33), despite decades of evidence as to the deleterious consequences of tobacco and many campaigns that have led us, if anything, to overestimate the risks associated with smoking (34). In which case it seems reasonable to conclude that there are complex reasons for the habit that may well serve a deeper psychological purpose, and that exhortations to quit may further complicate the need that it serves – quite apart from questions of individual liberty. Punishing smokers for their habit simply does not work. The health benefits of stopping smoking cannot be forced on to individuals, and attempts to do so run the risk, for the government, of a wider collapse of authority.

But this is true of all policy areas in the current context. A recent discussion paper from prime minister Tony Blair’s in-house think-tank, the Strategy Unit (35), states the problem in clear terms: ‘that government cannot simply “deliver” key policy outcomes to a disengaged and passive public.’ An ‘appropriate division of responsibility between the individual, community and state’ can only arise out of a political relationship, or what the authors term the ‘co-production’ of policy.

Another way of putting this is to say that the government still fails to connect with the electorate. This is the deeper dynamic of the healthy living initiatives, as ‘the design and authorisation of more sophisticated methods of behavioural change, between state and citizen and between citizens themselves’. To this end, it is recognised that in the harnessing of ‘psychological and social pressures to change…It may be wise to rely more heavily on GPs and other trusted health professionals as agents of persuasion’ because ‘they are uniquely well placed to reshape unhealthy behaviour’, though ultimately it is the ‘modest but important role’ played by the state in facilitating ‘mutual support’ that is seen as the key to success.

Whether it is termed ‘mutual support’ or the ‘co-production’ of policy, the Strategy unit goes on to say that a central concern of government now is ‘greater public engagement’ (36). As Professor Angela Coulter, chief executive of the health quango the Picker Institute, argues, this greater public engagement is sought through ‘encouraging patients and citizens to play a more active role in health care and health improvement’ to help ‘shore up social solidarity’ (37). This is not a new view. One publication from the 1970s discussed the need for mediating ‘structures that stand between government and the individual’ that can be regarded as ‘expressions of the real values and the real needs of people in our society’ (38); and one publication from the 1980s had an understanding that ‘participation in health’ serves as one of ‘the bridges that do, or might, exist between the private world of the individual and the public world of the statutory services’ (39).

In the context of Thatcherism, many on the left saw health as the basis for a political relationship free from the materialism and narrow self-interest conventionally understood as the key to the success of the New Right. As one leftwing writer put it, the idea of ‘the transformation of patients from an essentially passive status as consumers, to become active co-producers of health gain’ appeared as one of the more promising ‘perspectives for local participative democracy’ (40). Unfortunately, however, the ‘co-production’ of health does much more than bridge public and private interests. It tends to efface the distinction altogether, and in so doing undermines the capacity for the active engagement with self-interest that is subjectivity.

Diminished subjectivity

The relation between our sense of self and our understanding of health is intimate. One might even argue that they are two sides of the same coin. The fact that mind and body are inseparable means that our sense of personal agency, of self, has to bend and flex with the powerful forces we know as health and illness. We laugh and cry and live and die as whole beings, rather than a collection of parts; we are, as Georges Canguilhem, the radical French philosopher and historian of science, put it, ‘historical as well as histological’ (41). Another way of expressing this relationship is in relation to subjectivity, as agency and existence combined.

Subjectivity can also be considered as one side of a dualistic relationship with an objectively verifiable universe – as Ovid says, our ‘upright countenance’ that enables us ‘to survey the heavens, and to look upward to the stars’ (42). Such a dualism tends now to be regarded sceptically, a cross between Panglossian naivety and quixotic recklessness. As one book about political subjectivity argued, the idea that ‘discourses rooted in the notion of a unitary, rational subject’ are ‘untenable’ (43), and that the ethically correct response to such chronic uncertainty is humility and caution, is a cultural current running deep and fast in the West today. The source and course of this current cannot be addressed here – suffice to note the depth of pessimism toward all that was regarded as uniquely human that followed the period of total war, from 1914-1945, with the crushing defeat of civilised values that this period brought about.

A consequence of the shrunken authority of the ‘liberal rationalist experiment’ was the rise of what the American historian Lewis Mumford termed ‘addled subjectivity’, a quality of ‘the depleted human organism’ whose ‘autonomous functions, orderly processes, and cooperative associations’ were ‘almost relinquished’ (44). In losing grip of his own functions, processes and associations, the depleted human organism entertained a weaker sense of self-determination, at the individual and the collective level. A more inward-looking self crystallised as an ethical ideal, as a ‘culture of narcissism’ in the terms of American social critic Christopher Lasch (45), in explicit opposition to the deferential, rule-bound norms of the preceding generation. In the political theorist Russell Jacoby’s terms, ‘I feel, therefore I am’ stood as an endorsement of the authority of inner-organic intuition over outer-rational knowledge (46).

A by-product of the diminution of subjectivity was the undermining of medical science and the corresponding inflation of health as a moral discourse. As suggested above, the medical endeavour is rooted in particular relationships between doctor and patient. Beyond this relationship other interests arise. If a patient carries an infectious disease, for example, then a doctor might put the interest of the community above that of the individual concerned and have the patient forcibly quarantined. But this is the exception that proves the rule. The ethical obligation of a medical practitioner is to his patient, whom he seeks to understand as a whole person rather than a mere body.

Expertise assumes the mantle of authority in the context of socially sanctioned norms. No matter how expert an individual, his authority remains a function of consent – unless of course one resorts to force. If we discount force, then we must conclude that the authority of a medically qualified practitioner rests upon his place within a moral universe. But when that universe is uncomfortable with the concept and practice of authority in general, then the doctor’s position is undermined. The undermining of the authority of medicine dilutes the doctor-patient relationship and reconstructs it as a partnership of equals, thereby neutralising the expertise required for cure.

To grasp the significance of this point it is necessary to step back to subjectivity, as a vehicle for the advance of self-interest. One might imagine that self-interest is hostile to sickness, and that this justifies a collaborative approach between patient and doctor in order to address such a condition. This is the foundation stone of current health policy and the logic of initiatives such as the Department of Health’s Expert Patient Programme, which aims to engage with the ’60 percent of adults (who) report some form of long-term or chronic health problem’ (47). And there is symmetry to the argument that we all have an interest in looking after ourselves in order not to get sick, and then if we do fall ill we have an interest in getting better.

But at the core of this argument resides the dualist distinction between mind and body, as if one’s head could take issue with the rest of one’s flesh. If my car breaks down I take it to the mechanic and organise other means of transport. He fixes the car while I get on with my life. But because, as Harvard professor of psychiatry Arthur Barsky, argues, our ‘perception of what is going on inside our bodies is often unreliable’ (48) we find it hard to know how to fix our organic selves. Attempts to distinguish mind and body are fruitless, and in the context of medical care, inhuman.

We are, when sick, less than our full selves – a dose of flu is enough to remind the most robust among us of this. Which is why we seek out a medical expert, not just to fix a problem that we suspect in our mind, but to diagnose and treat a problem that addles our mind just as much as it does our body. As the authors of a seminal text on the doctor-patient relationship observed, the challenge for a doctor is to be able to sympathise with and see through ‘the individual’s myth of himself’, in order to ‘avoid the pitfall of treating presenting symptoms only’ (49). For ‘We are not ourselves’ as King Lear said, when ‘nature…commands the mind to suffer with the body’ (Act II, Scene 4).

The peculiarly vulnerable nature of the sick makes them ripe for exploitation, which is why medicine is hedged in with ethical compacts against instrumentalism. All doctors learn that a patient is not a means to an end, but an end in himself. The medical endeavour is to help in the alleviation of suffering, which takes as many forms as there are individuals. Which is why the idea and practice of ‘health promotion’ is such a crude instrument, promulgating the myth of a general standard of wellbeing that is inevitably expressed as a campaign against the ‘wrong’ sort of lifestyle.

Conclusion

The conceptual inflation of health does not serve the interests of those who are ill. As it engages and empowers, it also dilutes and debases the expertise that is the precondition for effective medical care. Of course, many people still receive effective medical care and the NHS does not grind to a halt, despite the incessant policy churn to which it is subjected (50). But it is the site of a subtle yet significant shift in values and behaviours shaping British public and private life, engendering a more therapeutic polity. Chief among these is the propagation of a prosaic morality inviting individuals to identify with little more than their own body.

Bereft of a transcendental vision of the good life, the government instead seeks to connect with a disengaged public by exhorting them to adopt ‘healthy living’. But, of course, health is in the eye of the beholder and meaningless as a norm. For many people health is understood – with no little justification, given the government’s message – as a measure of happiness, much as the WHO once implied. Thus, as Norwich Union Healthcare has reported, ‘Doctors are increasingly playing the role of social worker, financial adviser and counsellor to patients who feel they have nowhere else to turn…. Nearly half (48 per cent) of GPs say at least a third of their time is spent on social, rather than medical issues…. Nearly a third of GPs’ consultations are spent with patients who didn’t need to see a doctor at all, and many doctors are spending a great deal of time dealing with social rather than medical issues’ (51).

The fact that GPs are overwhelmed by the ‘worried well’ and feel that 40 percent of requests for sick-notes are ‘questionable’ (52) is a direct consequence of the conceptual expansion of health. But the key driver for such trends is less a matter of behavioural change, to which there are definite limits, and more a matter of political distance between electorate and elite. In seeking to close this gap, health is merely one of the more opportune vehicles for making contact. The problem with this approach, though, is the price paid at the level of medical authority and the concomitant consequence of this for those who are genuinely sick.

Already, clinicians hesitate to speak authoritatively, preferring instead to present the patient with a range of options from which they must choose. This is no wonder, given the constant pressure, from those such as academic lawyer Professor Ian Kennedy, for ‘both parties in the doctor-patient relationship’ to ‘recognise and respect the other’s area of expertise’, the disastrous consequence of which was glimpsed in relation to the MMR scandal, where expertise became wholly detached from authority (53). Cranks and charlatans abound when we are all experts in our own field, and consequently nobody is a real expert at all. This is fuelled by a policy agenda promoting the idea of ‘active citizens’ as ‘proactive partners’ in the system of health care, as if being a ‘patient’ were a lifestyle choice. To be merely a ‘contingent user’ of health is not enough; we are urged to buy into the brand.

And of course, the policy is not without consequence: with enough effort, sickness may indeed be made an acceptable and almost desirable identity, and society be transformed into one big daycare centre. Meanwhile, the genuinely ill individual is poorly served by a system that confuses clinical with political therapy.

Stephen Bowler is a lay member of the South Sheffield Research Ethics Committee, England. Email sbowler@onetel.com.

(1) Her health, her cash, her life. Is it anyone else’s business?, Observer, 14 November 2004

(2) Why isn’t New Labour proud to be the nation’s nanny?, Polly Toynbee, Guardian, 17 November 2004

(3) Editorial Ibid.

(4) Editorial, The Times (London)

(5) UK Department of Health

(6) Ibid. p.106

(7) Ibid. p.19

(8) Ibid. p.20

(9) Securing Good Health for the Whole Population, H.M. Treasury, London. p.14

(10) ‘From 2002-3 the Government committed to a 40% increase in real terms in the funding of the NHS over a five year period, bringing spending from £65 billion in 2002-03 to £106 billion in 2007-08. This level of spending is significantly higher than the average under any government since the advent of the NHS in 1948’ Evans, D. (2004) Critical Public Health, 14, 63-75. p.70

(11) Securing Good Health for the Whole Population, H.M. Treasury, London. p.11

(12) ‘Approximately 1.3 million were employed in the NHS in September 2003 on a headcount basis. This represents an increase of 60,000 since 2002 and an average increase of over 37,000 per year since 1997’. NHS workforce statistics, 2004.

The 1.3 million figure translates to just over one million ‘whole time equivalents’, in contrast to 20.94 million persons in full-time employment in the UK in May 2004 – Labour Market Trends incorporating Employment Gazette, 112, 133, Office of National Statistics, 2004. Spending on the NHS is ‘projected to rise from an estimated 7.7 per cent of GDP in 2002-3 to between 9.4 and 9.5 per cent in 2007-8’. Securing Good Health for the Whole Population, H.M. Treasury, London. p.11

(13) Office of National Statistics

(14) Definition of health, World Health Organisation

(15) Parran, T. and Boudreau, F. G. (1946) American Journal of Public Health, 36, 1267-72.

(16) Dunbar, F. (1947) Mind and Body: Psychosomatic Medicine, Random House, New York. p.237

(17) Ryle, J. A. (1948) Changing Disciplines: Lectures on the history, method and motives of social pathology, Oxford University Press, London. p.11

(18) Brackenbury, S. H. (1935) Patient and Doctor, Hodder & Stoughton, London.

(19) Honigsbaum, F. (1979) The Division in British Medicine: A history of the separation of general practice from hospital care 1911-1968, Kogan Page, London. p.122

(20) F.A.E. Crew, Professor of Public Health and Social Medicine at the University of Edinburgh, cited in Holland, W. W. and Stewart, S. (1998) Public Health: The Vision and the Challenge, The Nuffield Trust, London.

(21) Rootman, I., Goodstadt, M., Potvin, L. and Springett, J. (2001) In Evaluation in health promotion: Principles and perspectives, Vol. European Series, No.92 (Eds, Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D. V., Potvin, L., Springett, J. and Ziglio, E.) WHO Regional Publications, Europe, pp. 7-38. p.7

(22) Lalonde, M. (1974) A new perspective on the health of Canadians. A working document, Department of National Health and Welfare, Ottowa. p.5

(23) Department of Health & Social Security, London, 1976, pp 96.

(24) Hunter, J. D. (2000) The Death of Character: Moral Education in an Age Without Good or Evil, Basic Books, New York.

(25) House of Commons Health Committee, London, pp. 148. p.104.

(26) Johnson, M. (2004) In Self-Management – the Confidence to Choose, Department of Health, Royal College of Physicians

(27) Campos, P. (2004) The Obesity Myth: Why America’s Obsession with Weight Is Hazardous to Your Health, Gotham Books, New York. p.xxiii

(28) Royal College of Physicians

(29) House of Commons Health Committee (2004) pp. 148. p.148>

(30) Department of Health, London, pp. 32>

(31) Cited in Coote, A. (2004) Prevention rather than cure: Making the case for choosing health, Kings Fund, London. p.2>

(32) Department of Health, London, pp. 4

(33) Infant feeding 2000, Hamlyn, B., Brooker, S., Oleinikova, K. and Wands, S. (2002) The Stationery Office/Department of Health, London, pp. 242. p.65

(34) Sullum, J. (1998) For Your Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health, The Free Press, New York. p.65-8

(35) Halpern, D., Bates, C., Beales, G. and Heathfield, A. (2004) Prime Minister’s Strategy Unit, London, pp. 70

(36) Ibid.

(37) Coulter, A. (2002) The Autonomous Patient: Ending paternalism in medical care, The Stationary Office, London. p.117

(38) Berger, P. L. and Neuhaus, R. J. (1977) To Empower People: The Role of Mediating Structures in Public Policy, The American Enterprise Institute for Public Policy Research, Washington D.C.

(39) Hatch, S. (1984) In Public participation in health: Towards a clearer view(Eds, Maxwell, R. and Weaver, N.) King Edward’s Hospital Fund for London, London, pp. 101-12. p.104

(40) Hart, J. T. (1994) Feasible Socialism: The National Health Service, past, present & future, Socialist Health Association, London. p.43

(41) Canguilhem, G. (1966) On the Normal and the Pathological, D. Reidel Publishing Company, Dordrecht: Holland. p.119

(42) Ovid Metamorphoses Book I:85: ‘Homini sublime dedit coelumque tueri, Jussit; et erectos ad sidera tollere vultus’.

(43) Henriques, J., Hollway, W., Urwin, C., Venn, C. and Walkerdine, V. (1984) Changing the subject: Psychology, social regulation and subjectivity, Routledge, London. p.ix

(44) Mumford, L. (1971) The Myth of the Machine: the Pentagon of Power, Secker & Warburg, London. p.432 & 370

(45) Lasch, C. (1979) The Culture of Narcissism: American Life in An Age of Dimishing Expectations, W.W. Norton, New York.

(46) Jacoby, R. (1975) Social Amnesia: A Critique of Conformist Psychology from Adler to Laing, Beacon Press, Boston. Ch.5

(47) (2001) Department of Health, London, pp. 35.

(48) Barsky, A. J. (1988) Worried Sick: Our Troubled Quest for Wellness, Little, Brown and Company, Boston. p.58

(49) Browne, K. and Freeling, P. (1976) The Doctor-Patient Relationship, Churchill Livingstone, Edinburgh. p.59 & 71

(50) Pollock, A. M. (2004) NHS plc: The Privatisation of Our Health Care, Verso, London.

(51) Health of the Nation index, 2004, Norwich Union Healthcare, London.

(52) Ibid.

(53) Kennedy, I. (2003) British Medical Journal, 326, 1276-7