A sickening White Paper

One of the central features of last week’s health White Paper is the plan to provide free medical check-ups at key life stages through the National Health Service (NHS) (1). The proposal for periodic ‘health MOTs’ emerged as the ‘top people’s priority’ in the government’s much-vaunted consultation exercises.

Health ministers are keen to encourage people ‘to look after themselves’ and thus ‘to reduce demand on conventional health and care services’. The latter aspiration is destined to be disappointed. The most likely outcome of the health checkups programme is that it will boost the ranks of the 2.7million people already claiming long-term incapacity benefit (a figure that another government programme is striving to reduce).

There is a paradox at the heart of the White Paper. It proclaims that people should play an independent role in relation to their health – yet it also insists that they need comprehensive professional intervention if they are to achieve the goals of healthy living: ‘People want to keep themselves well, and take control of their own health. This came through clearly in our consultation. People asked for more help to do this, through better information, advice and support.’ (p31)

‘Support’ is the key concept of the White Paper, recurring in every section and defining the relationship between an earnestly health-promoting government and the newly health-conscious citizen at every stage of life. This relationship of support is mediated by a burgeoning army of professionals, including not merely the familiar doctors, nurses and teachers, but extending to counsellors, therapists and the new ‘health trainers’, the barefoot doctors of the Blair healthcare revolution.

The Life Check programme aims ‘to help people – particularly at critical points in their lives – to assess their own risk of ill-health’, by focusing on ‘major risk factors’, such as obesity, smoking, binge drinking, mental illness and stress, and sexually transmitted infections. It ‘will be a personalised service in two parts’. The first part is an initial assessment, which people will complete for themselves. This is merely the prelude to the second part – a discussion with a ‘health trainer’ providing ‘offers of specific advice and support on the action people can take to maintain and improve health, and, if necessary, referral for more specialist diagnoses for those who need it.’ (p35)

Let’s look more closely at the conception of health promoted in the White Paper and its consequences. Take this quotation from a participant at the Citizen’s Summit in Birmingham: ‘[As a young person] I feel that better education is needed for young people…. We don’t think about our health until it’s not there. We need to encourage that way of thinking right from the start.’ (p26)

This quotation – set out at the head of the section of the White Paper detailing proposals for implementing the Life Check programme in childhood – reflects the government’s emphasis on the role of education in promoting awareness of the risks of disease and of the measures deemed necessary to achieve and sustain health from infancy onwards. (Indeed, the section opens with the statement that ‘healthy living starts before we are born’, and proceeds to indicate risks to be avoided in pregnancy.) But if health becomes the goal of life – as in the terms of the World Health Organisation (WHO) definition ‘a state of complete physical, mental and social wellbeing’ – then it becomes an unattainable ideal, a state of perfection that may be striven for but never reached. From this perspective, health becomes exceptional – and illness, understood as the inevitable failure to achieve the ultimate goal, becomes normal. This is the new doctrine that the government wants to preach in schools – and it has already persuaded many young people that this is the way forward.

The new approach to health and illness marks a dramatic break with tradition – but not a progressive one. In the recent past, health was regarded as the normal state of affairs and illness was considered an exceptional departure from normality, a transient state through which the patient passed – with the blessing of medical authority (even if no great benefit accrued from medical intervention ) – before returning to good health and a familiar level of social functioning. Now health has become a state that can only be attained through a high level of personal awareness and commitment to a prescribed lifestyle, through intense vigilance against health risks and through a willingness to submit to regular professional intervention in the cause of preventing disease (or at least of detecting it at an early stage). At the same time, illness has lost much of its stigma and even confers a series of socially approved identities – ‘person with HIV/Aids’, ‘cancer survivor’, ‘sufferer from stress’, ‘victim of bullying’ – confirmed by patient organisations, celebrity sponsorship, soap opera story lines, autobiographical accounts and other forms of media coverage.

If health becomes the goal of life, then when individuals encounter dissatisfaction and disappointment, these are likely to be experienced as forms of illness, which may well find expression in physical or psychological symptoms. ‘Doc, I just don’t feel well’ is a familiar cry of existential distress in my surgery, uttered by ever-younger patients, and followed by the request, now endorsed by the government, for ‘a complete check-up’.

According to the section of the White Paper on ‘mental health and emotional wellbeing’, ‘there is much that can be done to reduce the frequency of the more common illnesses such as anxiety and depression, and the widespread misery that does not reach the threshold for clinical diagnosis but nevertheless reduces the quality of life of thousands of people’ (p36). In fact, the ‘much that can be done’ amounts to little more than offering banalities about ‘eating well’ and ‘valuing yourself and others’ and ‘getting involved and making a contribution’. Yet, once the sphere of therapeutic intervention is expanded to include everyday misery, then illness has become the universal condition of humanity and health a utopian – if not a celestial – vision.

As health awareness has grown over the past two decades so have a number of indicators of illness. Surveys reveal that more and more people report feeling unwell, the numbers of people consulting their GPs and other health professionals (and alternative practitioners) have multiplied and levels of sickness absence from work have increased steadily. The intensive promotion of disease awareness fosters a climate of fear around issues of health, as people worry about their risks (and the risks of their loved ones) of succumbing to cancer or heart disease as a result of their deviant or merely deficient lifestyles. The particular virulence of the campaign against obesity creates enormous misery among those designated overweight, who are the targets of unrestrained popular and medical prejudice.

Perhaps the most dramatic indicator of the rising tide of ill health is the number of people claiming incapacity benefit (for which they become eligible after six months sickness absence). The total is now 2.7million, more than three times the level when Margaret Thatcher became prime minister in 1979, and more than the number officially registered as unemployed (3). It is clear that the major explanation for this increase lies in the growth of conditions which are subjectively defined by the individual concerned and often cannot be objectively verified by any doctor – or welfare bureaucrat. More than one million people, some 40 per cent of the total, are claiming incapacity benefit with diagnoses of anxiety and depression and stress, a four-fold increase in 20 years.

The second leading cause of sickness absence is back pain; again numbers have increased steadily over recent decades – among non-manual workers as much as among manual workers. As it is often impossible to correlate complaints of pain and stiffness with the results of X-rays or other imaging techniques, the key judgement is the patient’s – if they do not feel well enough to work, then they are eligible for benefits. Other claimants suffer from a range of ‘unexplained physical symptoms’, such as joint pains, fatigue, abdominal discomfort and distension. These may be described as ‘fibromyalgia’, ‘chronic fatigue syndrome/ME’ or ‘irritable bowel syndrome’ but these labels merely provide medical legitimacy for the experience of illness: they offer neither rational diagnosis nor effective treatment.

The government may take steps to tighten up the provision of incapacity benefit, but these measures will do nothing to stop the growth of illness that results from wider cultural forces that its wider health promotion policies have done much to encourage. Given the focus of official health promotion propaganda on young people, it is worth noting that half of all people on incapacity benefits are under the age of 50. Long-term incapacity is often a life sentence: though two thirds of claimants get a job within two years, those who do not are more likely to retire (or die) on benefit than return to work.

In a chapter entitled ‘Enabling health, independence and well-being’, the White Paper makes clear that self-monitoring of lifestyle in the cause of better health is not enough. ‘Independence’ here means subordination to health professionals, from antenatal clinic to residential care home; ’empowerment ‘ means surrender to the authority of the health trainer. At every stage of life the responsible citizen must seek professional assistance to discover the appropriate form of support for their needs.

The White Paper details the support required by prospective parents and by parents of young children, the support needed by children at primary school and in the transition from primary to secondary school and beyond – here ‘joined up’ or ‘new integrated forms of support’ will be provided by health, education and social care agencies. ‘People of working age’ also need support, whether they are in work or unemployed (when they need additional support). There is no respite for the elderly: ‘older people’ are the targets of programmes to increase exercise and of measures ‘to increase uptake of evidence-based disease prevention programmes’.

In fact, there is little evidence for the efficacy of any of the disease prevention programmes included in the White Paper. Though it is true that smoking is bad for health and stopping smoking is beneficial, the evidence that either moral exhortation or therapeutic intervention is successful in reducing levels of smoking or smoking-related illness remains contentious. Despite four decades of anti-smoking propaganda and therapies, nearly a quarter of the population is still smoking. In relation to other lifestyle factors – such as diet and exercise – the evidence that these cause disease and or that campaigns to change behaviour in these areas have any preventive value is either weak or non-existent. By contrast, there is very good evidence that the approach to tackling obesity that has been pursued for the past 50 years by health professionals and is implicitly followed by the White Paper – telling people to eat less and exercise more – simply does not work: hence more people are overweight.

However, we should not worry too much about this, because it also apparent that we are living longer. The White Paper’s claim, emphasised in bold print, that ‘our children will not live as long as their parents unless there is a shift towards healthier living’, is quite absurd. (The authority for this claim is the discredited 2004 House of Commons Health Committee report on obesity – see Choking on the facts, by Brendan O’Neill). In the USA, while obesity has steadily increased over the past 50 years, life expectancy has increased by more than seven years (2). The only modern case of a population in an advanced industrial society in which life expectancy has declined is the former Soviet Union, where a profound social, economic and moral crisis was accompanied by the collapse of the public health system.

It is not surprising to find that those deemed to be in most need of support are those on incapacity benefit. Having been supported into chronic invalidity, they must now be given extra support in the quest to return to the world of work. Pilot schemes have been established with an army of support workers – including personal advisors, job coaches, occupational health specialists, finance and debt counsellors – aiming to provide the systematic support deemed necessary to encourage the chronically ill down ‘pathways to work’ (4). While punitive measures to curtail benefits may succeed in intimidating some claimants, it seems likely that all this support will only further undermine the capacity of the long-term sick to pursue an independent life.

Behind the ’empowerment’ rhetoric of health promotion lies the presumption of individual incapacity. The consequences of this approach are already evident in the trends of the past two decades: elevating health to become the goal of all human endeavour is making more and more people ill. It is causing an epidemic of subjectively defined ill-health, an increased demand for healthcare services in all forms and a growing burden of state expenditure on welfare benefits.

Dr Michael Fitzpatrick is author of The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA), and MMR and Autism: What Parents Need to Know (buy this book from Amazon (UK) or Amazon (USA)).

(1) Our Health, Our Care, Our Say: A New Direction for Community Services (.pdf 3.01 MB), Department of Health

(2) Medicine Matters After All: Measuring the Benefits of Medical Care, a Healthy Lifestyle, and a Just Social Environment, John Bunker, Nuffield Trust, 2001

(3) ‘Long-term sickness absence’, Kevin Holland Elliott, Nicholas Glozier and Max Henderson, British Medical Journal 330:802-803, 2005

(4) ‘Long-term sicknees absence’, Guardian, 25 January 2006