Hamish McRae: A lesson from America in how to improve our health

Obama is prepared to tell people to change their behaviour. But would Brown be?

President Obama urged children at a Back to School event yesterday to "wash your hands a lot". He has given this eminently sensible advice before and doubtless he will give it again, for there is a mass of evidence that people who wash their hands frequently pick up fewer respiratory and gastrointestinal infections. So it is good to see him deploying some of his charisma in such a helpful way.

His charisma is however being more sorely tested later today when he makes a huge push before a joint session of Congress to sell health reform to the American legislature and to the nation as a whole. Expect a wall of sound in the coming days from this ill-tempered debate, one that has resonated here with attacks on the NHS, and one that has unnerved even the President's staunch supporters. The view in Washington is that he will get something positive out of all this but it will be far from an optimal solution.

But then there is no optimal solution to health care. Even countries that have widely admired systems have difficulties maintaining quality and containing cost. Take France, which has a generally good record, though it failed during the August heatwave six years ago when most medics were on holiday and there were an estimated 15,000 excess deaths. The French have to cut costs: the country's budget minister confirmed on Monday that it might have to increase charges on hospital stays and on common drugs.

What Mr Obama's two speeches do, however, is to highlight two different broad themes that will dominate government social polices over the next generation. Governments everywhere will be under desperate budgetary pressure, more severe than anything they have experienced in most people's lifetimes. It will not just be a question of correcting the present deficits. The squeeze will go on and on. The task faced by governments everywhere will be to maintain adequate services with little increase in tax revenue, maybe none.

Japan was the first developed country to experience the combination of very slow growth and an ageing population and its government revenues are now lower than they were a generation ago. Here in Britain we may not quite find ourselves in that plight but we cannot assume that revenues will recover as the economy starts to expand again. And as they do, much of that additional revenue will be needed to service and pay back public debt.

That is why those two speeches are so important. The president's speech to Congress will be about extending healthcare but just as important, containing its cost. His speech to the schoolchildren was about people taking care of themselves. People need healthcare when they get ill, but much better if they don't get ill in the first place.

The debate will go far beyond health care and into every aspect of the relationship between the individual and the state. Of course the state has to take responsibility for people who for whatever reason are unable to take care of themselves. No one can seriously question that. But the more that people take responsibility for themselves, even if is it just at matter washing their hands, the smaller the burden on the rest of society. It is win, win.

The issue is how might governments nudge people to change their behaviour. For the Victorians it was easy. They had no compunction in being judgmental. For us, perhaps rightly, it is harder. There are some things we can agree on, such as limiting smoking and leaning hard against drink-driving, but there are others where we are divided: single parenthood being an obvious example.

Looking ahead you can see some areas where the anti-smoking approach might be extended. Alcohol consumption is one. I could also see carbonated drinks and fast-food being targeted on the grounds that they contribute to obesity.

In the US there are suggestions of taxing sweetened drinks and perhaps using the revenue to fund dietary education. But there are clear and proper limits of the extent to which we would accept more intrusion by the state, particularly one who is as distrusted as ours is by the citizenry. A much better way of changing behaviour is for the drive to be from the bottom up rather than the top down.

That still needs leadership and it is worth going back to that Obama speech to the students to see how that might be done. The "wash your hands" bit got the headlines but actually the thrust of the speech was about responsibility. Let me give you a taste of some of it:

"Now I've given a lot of speeches about education," the President said, "and I've talked a lot about responsibility. I've talked about your teachers' responsibility for inspiring you, and pushing you to learn. I've talked about your parents' responsibility for making sure you stay on track, and get your homework done, and don't spend every waking hour in front of the TV or with that Xbox. I've talked a lot about your government's responsibility for setting high standards, supporting teachers and principals, and turning around schools that aren't working where students aren't getting the opportunities they deserve.

"But at the end of the day, we can have the most dedicated teachers, the most supportive parents, and the best schools in the world – and none of it will matter unless all of you fulfil your responsibilities. Unless you show up to those schools; pay attention to those teachers; listen to your parents, grandparents and other adults; and put in the hard work it takes to succeed..."

You get the point? Here is a political leader talking in language that is quite different to that any recent British leader would dare use, even one with great rhetorical gifts. You may recall that Tony Blair's core message after being elected was quite different: "I will not let you down" – something that sounds a bit rum now. The very notion that Gordon Brown could talk in that way is unthinkable. Even David Cameron, who has as close to perfect pitch as any active British politician, would find it hard to say those words. Margaret Thatcher would have urged people to take responsibility but would have done so, indeed did so, in a hectoring and unpleasant way.

There are a string of areas where people throughout the developed world will have to take greater responsibility for themselves. Healthcare is one, because the great health issues of an ageing population will be more about people leading generally healthy lifestyles than receiving hi-tech medical interventions. Education is another, because increasingly it will be something that carries on into middle and old age, as we adapt to new technology and work in jobs that don't even exist right now.

Pensions are yet another, partly because of the decline in the size of the working population relative to the retired one, but also because more older people are choosing to do some work after formal retirement age. Indeed the very idea of there being a specific retirement age may seem an anachronism 30 years from now.

President Obama gets all this and articulates it in a way that no European politician would dare do. I find that inspiring and I dare hope a bit of that charisma – and wisdom – wears off on us too.

h.mcrae@independent.co.uk