Summary of the impact

The impact is on public health policy. Thomas Baldwin's research helped to develop a new way of characterising the responsibility of Government in the field of public health (`the stewardship model'), leading to the introduction of a way of assessing policy programmes in this area which has been widely adopted (`the intervention ladder'). The beneficiaries of this research have included independent public health policy formers, government departments and parliamentary committees.

Underpinning research

Thomas Baldwin has worked for many years in the fields of moral and political philosophy. An important strand of this work has been the proper understanding of freedom and the relationship between personal freedom and the state's authority. In particular, since 2000 Baldwin has developed this research in the context of problems of public health policy and bioethics (see also `Understanding the opposition' Prenatal Diagnosis 26 (2006), 637-645).

Much of Baldwin's research into this problem was published in the report of the Nuffield Council on Bioethics Public health: the ethical issues (2007). The report starts by developing an ethical framework for the state's role in relation to public health which was largely developed and written by Baldwin. Central to this framework is the `stewardship model' for the government's responsibilities. This model implies that, without intruding into the private lives of adult citizens to coerce them to lead healthy lives, government has a responsibility (as `steward') to develop and maintain a `healthy' public environment, — physical, social and cultural — which helps its citizens lead healthier lives, not only because this is a way of advancing the personal welfare of citizens, but also because the maintenance of a `healthy' environment is one of the best ways of reducing the health inequalities which are due to social and economic circumstances. The model also supports a special emphasis on the situation of children because they are not able to take responsibility for themselves, though the model recognises that interests of parents require respect. In developing policies which realise the stewardship model there is often a tension between creating an environment with significant health benefits and respecting personal freedoms that may be exercised in unhealthy ways; and to help resolve these conflicts the Nuffield working party developed an intuitive guide for assessing policies. Policies are to be thought of as arranged on the rungs of a ladder, the `intervention ladder' as it is called, with the most intrusive and restrictive at the top and the least intrusive at the bottom. The stewardship model then implies that Government policies should remain as low on the intervention ladder as is compatible with the effective reduction of risk of serious harm to the public. In some circumstances, e.g. where there is a threat of a pandemic such as SARS, it is appropriate to `climb to the top of ladder' by taking measures which radically restrict the liberty of those citizens whose illness threatens the health of others. In other cases, e.g. food policy, a lower-rung policy which creates an environment that encourages healthy alternatives without imposing them is appropriate. Where such policies are not effective, and especially where behaviour poses a health risk to others, as in the case of smoking, stepping up a rung or two of the ladder and restricting behaviour, especially in public places, is deemed appropriate.

References to the research

Evidence of quality

Indications of quality are that the report has been extensively referenced in research publications/ the most prestigious online philosophy encyclopaedia.

• Stanford Encyclopedia of Philosophy: Public Health Ethics esp. 2.6-7
(http://plato.stanford.edu/entries/publichealth-ethics/)

• M. Walton `An Ethical Evaluation of Evidence: A Stewardship Approach to Public Health Policy' Public Health Ethics (2012)

• (http://phe.oxfordjournals.org/content/early/2012/01/24/phe.phr037.full)

• Dawson A, Verweij M. The Steward of the Millian State. Public Health Ethics 1 (2008),193-195 doi: 10.1093/phe/phn034

• Calman, K. `Beyond the `nanny state': stewardship and public health' Public health 123 (2009) e6-e10. doi: 10.1016/j.puhe.2008.10.025

• BMA: Behaviour change, public health and the role of the state — BMA position statement, December 2012. http://bma.org.uk/working-for-change/improving-and-protecting-health/behaviour-change

Details of the impact

The report Public health: ethical issues was widely seen as providing a robust and sophisticated framework within which to debate the many ethical challenges in public health policy. The stewardship model and the intervention ladder, in particular, have been referenced extensively by policy makers, the legislature and governmental bodies, and continue to be an important influence to this day. The report thus succeeded in making a substantial contribution to a complex debate on the relationship between the state and the individual, as well as to a topical, relevant, field of practical policy making, reaching many potential beneficiaries of such a research contribution.

The significance of the report was recognized when it was published in 2007 and its impact can be seen in references to it in the House of Lords 2008 debate on disease surveillance. It was also discussed extensively in the 2012 report on Behaviour change by the House of Lords Science and Technology select committee. Even more significant was the fact that in 2010 NICE endorsed the main themes of the report and adopted the stewardship model as a reference point for guiding decisions about what types of intervention may be justified. NICE has subsequently referred to the Nuffield Report in its 2010 guidance concerning Alcohol Use Disorders and reaffirmed the general relevance of the Nuffield approach in its current advice for the development of public health guidance.

Baldwin's role in producing the report led to an invitation to join the Department of Health's Expert Advisory Committee on Obesity which was established in 2007 to advise the Government in the development of a policy to address the problem of obesity (which had been discussed in the Nuffield Report). The policy was eventually published in 2008 as Healthy Weight, Healthy Lives. Although there is no explicit reference in this paper to the Nuffield Report, Baldwin had considerable contact with the team who drew it up and the policy follows the approach to public health recommended in the Nuffield Report. Thus the report starts with the following statement by Gordon Brown, who was then Prime Minister:

"There should be no doubt that maintaining a healthy weight must be the responsibility of individuals first — it is not the role of Government to tell people how to live their lives and nor would this work. ...

The responsibility of Government, and wider society, is to make sure that individuals and families have access to the opportunities they want and the information they need in order to make healthy choices and exercise greater control over their health and their lives. This is what Government can do, and it is what will make a real and sustainable difference to all of us in trying to make healthy choices and lead healthy lives" (Healthy Weight, Healthy Lives, p. iii).

The new coalition's public health policy document Healthy Lives, Healthy People also draws on themes from the Nuffield report (especially the `Nuffield intervention ladder' (see ¶¶2.25-35, 29-30). Baldwin has presented these ideas to senior staff at the Department of Health, and the previous Secretary of State (Andrew Lansley) was been explicit in using them, as is clear from the following report in the BMJ:

"During a BMA organised debate on health inequalities on 28 October 2010, England's health secretary, Andrew Lansley, was questioned over a comment about "collaborative working" with the drink and food industry. ....

Mr Lansley said, "A couple of years ago the Nuffield Council on Bioethics produced what I found was a very helpful illustration of what they described as a ladder or hierarchy of interventions. At the bottom of it was to do nothing, but it went up with starting to impact on behaviour change, influencing choices, default choices, intervention, and possibly introducing a full ban on something'. "We know that tobacco control is quite high up that ladder due to the necessity of doing so because the less intrusive measures have not delivered the objectives we are looking for. In other areas, such as the consumption of food, we are capable of making faster and more meaningful progress through a voluntary partnership with the food industry than in an adversarial relationship."

In many other areas of public health, the Nuffield Report continues to be cited in policy debates — e.g. concerning vaccination and fluoridisation and, most recently, regarding the hiring of smokers; it is also cited in regional public health reports, such as the 2012 report from the Leeds Director of Public Health (see sources below for details).

Sources to corroborate the impact

House of Lords Science and Technology select committee, 2nd Report 2010-12 Behaviour change, esp. ¶2.3 and Table 1, (pp. 9-10), and Appendix 6.

NICE references —

(i) A. Killoran & P. White `NICE update: NICE public health guidance' Journal of Public Health, 32.1 (2010) 136-7. doi: 10.1093/pubmed/fdn117

(ii) NICE, Public health guidance 24 `Alcohol-use disorders: preventing harmful drinking', 2010 (esp. ¶3.1). http://publications.nice.org.uk/alcohol-use-disorders-preventing-harmful-drinking-ph24

(iii) NICE, Methods for the development of NICE public health guidance (third edition) 2012 (esp. ¶7.2.9) http://publications.nice.org.uk/methods-for-the-development-of-nice-public-health-guidance-third-edition-pmg4

Previous government

Department of Health Healthy Weight, Healthy Lives, 2008
http://webarchive.nationalarchives.gov.uk/20100407220245/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_084024.pdf

Current government —

(i) Department of Health Healthy Lives, Healthy People, 2010 (esp. ¶¶2.25-35, 29-30).
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216096/dh_127424. pdf

(ii) British Medical Journal `Doctors question government collaboration with alcohol and food industry' 341:c6128 (Published 29 October 2010). http://www.bmj.com/content/341/bmj.c6128

Leeds public health

(i) Annual Report (2012) of the Director of Public health in Leeds —
http://www.leeds.gov.uk/docs/Director%20of%20Public%20Health%20Annual%20Report%202012.pdf (esp. chapter 5).

Current debates and reports

(i) Should childhood vaccination be mandatory? — Responses:
http://www.bmj.com/content/344/bmj.e2435?tab=responses

(ii) Ethics of water fluoridation — http://www.bfsweb.org/onemillion/onemillion2012.html(esp. pp. 19-22)

(iii) hiring smokers — Asch DA, Muller RW and Volpp KG (2013) Conflicts and compromises in not hiring smokers New England Journal of Medicine 368:1371-1373 DOI: 10.1056/NEJMp1303632