Leading Article: All hole, no doughnut

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The Independent Online
IF YOU want to get on and get ahead in the 1990s, you must talk of targets. Companies set sales targets; schools set targets for reducing truancy or increasing exam passes; advertisers and publishers have target audiences; political parties look for target voters and seats. Governments have all manner of targets: for cutting inflation, for reducing nuclear arms, for restraining wage rises, for increasing the number of trains that run on time. Last week Virginia Bottomley, the Secretary of State for Health - an upwardly mobile minister, politically - produced a White Paper setting yet more targets. There is to be a 40 per cent reduction in deaths from heart disease, a 33 per cent cut in smoking among 11- to 15-year-olds. Suicide, teenage pregnancy, gonorrhoea, obesity, all are to be ruthlessly slashed.

This, as Scottish newspaper columnists like to say, is fine and dandy. But how are these targets set? 'A combination of science and informed judgement', the White Paper informs us, which sounds suspiciously like the sort of thing you hear in the high-street betting shops. How are the targets to be achieved? For each one, the White Paper proposes, in various forms, research (of course), expert advice, leadership, promotion, guidance, all designed to change our behaviour. We are to improve our own health. The targets, it turns out, are not targets for Mrs Bottomley or for any other ministers, but targets for us.

Yet the great improvements in the nation's health over the past century were not achieved by people setting targets and exhorting the populace to pull its socks up. The dramatic falls in infant mortality, the increases in life expectancy, were the result, as the White Paper acknowledges, of social and public health measures: clean water, safer sewerage, better housing, for example. It is said that the modern killers - coronary heart disease, strokes and cancer - are not preventable through public health measures in the same sense as, say, tuberculosis and typhoid. This is only half-true, at best.

The White Paper proposes, for example, to 'disseminate information about healthy eating'. It observes: 'A whole-diet approach is crucial if the balance of the diet is to be sensible.' In one publicly funded service, the schools, the Government has an opportunity to ensure not only that millions of children have something approaching adequate nutrition, but also that good dietary habits are established from an early age. Yet, largely for budgetary reasons, it has abandoned nutritional standards for school meals. The Government could, by regulation, ensure that adults have adequate information on which to base choices about what they eat. Yet nutritional information on food-and-drink tins and packets remains inconsistent and, frequently, misleading. (Working out your calorie intake from a tin of Diet Coke, for example, involves at least two sums and very good eyesight.) Again, the White Paper proposes, in its strange language, to strive for 'smoking cessation'. Yet the Government continues to insist that it can restrict tobacco advertising and promotion only through voluntary agreements. And, while failing to tax cigarettes to an extent that would make the cost prohibitive to young people, it insists that addicts should pay the full cost of tobacco substitutes, even when they are available on prescription.

There is more. The White Paper's biggest shortcoming is that it fails to tell us, except in passing, that ill-health and premature death are not evenly distributed across the social classes or even across the regions. Disease is still associated, as it always was, with poverty. Suicide and mental illness are strongly associated with unemployment. But there are no targets here. Ministers are happy to lecture the poor about leading responsible lives, and to tell them that they should stew beans and mash lentils, give up cigarettes and play squash. But people accept responsibility for themselves and their children when they have secure jobs, adequate incomes, good education and decent houses. Setting targets in these areas will do more for the nation's health than any amount of exhortation from Mrs Bottomley.

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