Nada Khan is an Exeter-based GP and an NIHR Academic Clinical Lecturer in General Practice at the University of Exeter. She is also an Associate Editor at the BJGP.
The balance between public health measures and free will is not an easy one to navigate, and segments of the UK media have not held back in cries of ‘Nanny state!’ when describing planned public health policies by the new Labour government. Proposed public health initiatives include plans to ban junk food advertising before 9pm, extending the smoking ban to outdoor spaces including pub gardens, and banning children from buying high-caffeine energy drinks. Some media outlets have described them as a ‘Nanny-state‘ crackdown.
The ‘Nanny state’ is a criticism against public health regulation, and acts as a metaphor to describe an overbearing government intruding into the lives and free-will of an infantilised population that cannot be trusted to make their own decisions.1 It is meant as a criticism against government action on public health. However, many of the common drivers of morbidity and mortality have modifiable risk factors relating to lifestyle and environment. The tension between government policy and powerful commercial forces in tobacco, alcohol and food industries needs to be balanced. The concept of ‘choice’ and how people are exposed to risk factors is not as simple as those crying, ‘Nanny state!’ would suggest.’ What issues are at stake here and what does it mean for public health policy and society?
The impact of preventable disease
Morbidity, mortality and health inequalities in the UK are driven by the high prevalence of preventable diseases and their risk factors, including smoking, obesity and harmful alcohol use. This isn’t just a health issue, it’s a public ‘Treasury’ issue, with escalating costs of looking after a population with higher rates of cancer, diabetes, COPD and musculoskeletal disease.
The recent Darzi report calls for a refocus of NHS resources and policy on health promotion and prevention. The report cites the successes of public health policy in reducing smoking rates, taking the perspective that ‘…where bold action has been taken, health has improved’.2 The report contrasts the improvements in smoking-related cancer and cardiovascular deaths with the lack of regulation of the food industry and rising childhood obesity rates as a failure of inaction; while government policy has followed national targets to tackle smoking, it’s unclear how a national target to halve childhood obesity by 2030 and to reduce inequalities in obesity amongst deprived children will be met through current policy. Commitments to improve health and reduce health inequalities mean that the government needs to develop a multi-faceted strategy to act to minimise the impact of modifiable risk factors and future ill health. But as the Darzi report notes, while public health interventions have the potential to improve outcomes, it requires not only political will but also successful public engagement.
Choice, or intervention?
There is not going to be one view on the correct balance between a state’s authority and an individual. At its extremes are libertarian and neo-conservative views on one end, and utilitarian views on the other. The balance that any government must strive to find is some kind of middle ground that accepts a level of choice that is balanced against the welfare of its citizens.
Corporate (ir)responsibility shapes the environment in which individuals make choices and behave, and the media is part of that environment.
A team taking a deep dive into the ethical considerations around the ‘Nanny state’ devised a theoretical intervention ladder describing the different options a state might deploy when acting on public health interests. The bottom rung involves doing nothing, representing a libertarian utopia of minimal involvement from the state where market forces are left to sort things out. The next few rungs up the ladder involve providing information on healthy options, followed by more actively enabling choice through initiatives like offering a smoking cessation programme or healthier choices in the school dinners menu, or guiding choices through policy or incentives such as tax breaks for ‘Cycling to work’ schemes. Higher up the ladder, interventions involve actively guiding choice through taxation of high sugar or high salt foods or levying a charge on cars that don’t meet exhaust emission standards driving into city centres. But top of the ladder are the most restrictive options that underlie ‘Nanny state’ criticisms: restricting choice, like taking unhealthy items out of food or menus, or eliminating those items altogether. The higher up the ladder one goes to restrict choice, the argument goes that the stronger the justification and public engagement has to be for those setting the policy.3
But governments don’t operate in an environment where individuals are free of influence from other sources, and the concept of choice needs to factor in the role of third parties and industry in population health. Private companies and corporations have responsibilities that extend beyond just sticking to the law, with a social responsibility to contribute towards public health. And when they don’t, and they often don’t, then that is a ‘market failure’ that means it’s fair play for the state to intervene to protect the health of the wider population.3 Corporate (ir)responsibility shapes the environment in which individuals make choices and behave, and the media is part of that environment. It’s worth remembering that public health intervention is not a Labour movement alone, with the last government introducing the Tobacco and Vapes Bill to create the ‘first ever smokefree generation’, legislation that has broad public and cross-party support but is criticised as ‘Nanny statism’ by libertarians and those with tobacco-industry support. Instead of focussing on cries of ‘Nanny state’ when describing smoking bans in pub gardens, the media would do well to remain critical of industry pressure and arguments against interventionist policies fuelled by corporate hype.4
An individual or population-level intervention?
The UK government has tended to act within the middle rungs of that intervention ladder of public health policies, focussing on providing options or guiding choices. With this approach, and if we take a view of a stewardship-guided state, public health programmes should aim to promote health and provide the conditions, choices and opportunities to allow people to be healthy.3
The Food Foundation, a charitable organisation looking to change policy around healthy and sustainable diets, situates childhood obesity as one of the biggest public health challenges facing this generation, and encourages us to think more widely about setting out these conditions to allow healthy choices. They describe not just the social, but the commercial determinants of health as a driver of childhood obesity, with the ‘…aggressive promotion of cheap junk food by the food industry’ cultivating an environment where it’s increasingly difficult to make choices to eat healthily.5 Their approach suggests that interventions to make healthy food more available and affordable to enable healthier choices is better than ‘nannying’ people through restrictive policies – those top rungs of the intervention ladder. This would involve better education about healthy eating and restrictions on food advertising and packaging. Children are particularly susceptible to food marketing and may not be able to make a fully informed choice.3 Here, at least, there is an ethical justification for the state to support not only better education around healthy eating, but to regulate advertising targeted to children around unhealthy food.
The majority of interventions on food and diet in England have focussed on changing individual behaviour rather than taking a unified approach through policy to tackle the drivers of obesity. The problem with this approach is that relying solely on interventions that require high levels of individual agency runs the risk of widening inequalities. Population level interventions that impact on everyone may be more effective on a wider scale, as well as being more equitable.6 The Health Foundation supports a multi-pronged approach with population-level policies such as taxation and regulation (yes, those increasingly restrictive policies framed as being part of a nanny-state) alongside individual-level interventions to support healthier choices.7
The vast majority of the public, however, don’
t have strong libertarian leanings, and support greater intervention in public health.Individual-level behaviour change might be easier to implement into policy. They are seemingly more politically friendly, and less likely to incite the wrath of the right-leaning press or lobbying groups within the tobacco, food, or alcohol industries. The vast majority of the public, however, don’t have strong libertarian leanings, and support greater intervention in public health. A Health Foundation poll found that the majority of people across all political leanings support more restrictive government interventions on tobacco, alcohol and heathy eating. This kind of public support, despite the media narrative, suggests that the government has the backing to take bolder action on public health interventions.7
What does it mean for the future?
The Darzi report sets out a challenge to build stronger public health policy to lessen the burden of non-communicable disease on community-level morbidity and mortality. These interventions are not going to have an immediate impact on population-level outcomes, general practice or workload, which explains why public health policies are difficult in terms of political buy in, with today’s government unable to show the impact of interventions that may only be apparent over decades. These kinds of interventions require thinking across generations, and while we might not see the impact on our patients or our consultation rates today, this is one way to try to future-proof the NHS.
Stronger and more interventionist public health policy can support an environment of change – we’ve seen the results from decisive policy and leadership against the tobacco industry, all lessons learned that can be adapted and applied towards combating obesity and harmful alcohol use and continuing to move towards a smoke-free generation. Working in our local communities means that we can better understand the environment in which people are making choices today and support individual patients to change. The media and industry arguments against the ‘nanny state’ are not widely supported by the public, and we have scope to support and encourage change in areas like obesity and alcohol where policy has not always been unified. While it’s not easy to balance choice against intervention in public policy, it’s time to think critically against those decrying public health policies as ‘nanny statism’ and confront the grim alternative of not taking firm action on preventable disease.
References
- Magnusson RS. Case studies in nanny state name-calling: what can we learn? Public Health. 2015;129(8):1074-82.
- Independent Investigation of the National Health Service in England. Crown Copyright; 2024.
- Calman K. Beyond the ‘nanny state’: stewardship and public health. Public Health. 2009;123(1):e6-e10.
- Hartwell G, Gilmore AB, van Schalkwyk MCI, McKee M. Sunak’s smoke-free generation: spare a thought for the tobacco industry. BMJ. 2023;383:2922.
- A neglected generation: Reversing the decline in children’s health in England. London: The Food Foundation; 2024.
- Everest GM, L.; Fraser, C.; Briggs, A. Adressing the leading risk factors for ill health. The Health Foundation; 2022.
- Briggs A. What action does the public think the government should take on tobacco, alcohol and unhealthy food? : The Health Foundation; 2024 [Available from: https://www.health.org.uk/news-and-comment/charts-and-infographics/what-action-does-the-public-think-the-government-should-take-on-tobacco-alcohol-and-unhealthy-food.
Featured image: Three children automatically putting out their tongues for inspection upon meeting the family doctor in Kensington Gardens. Wood engraving after J. Leech, 1861.. Credit: Wellcome Collection. Public Domain Mark
