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The newly published alcohol harm reduction strategy sets out measures to protect citizens from some of the worst effects of drinking. It begs the question: how far should government intervene to protect us from risks to our health?

Like "political correctness", the phrase "nanny state" seems to be a strong deterrent to some government action. The Blair administration is probably more prone to control freakery than any government since the second world war, but is highly averse to being accused of "nanny statism". To protect itself from the charge, it has taken to evangelising about the need to promote individual choice. Meanwhile the public has signalled that it doesn't really want choice in public services, it just wants good services.

A recent BBC opinion poll shows heavy support for government intervention in what many would see as matters of personal choice. Seventy-three per cent say they want a ban on smoking in public places; 72 per cent want junk food and fizzy drinks banned from school premises and 65 per cent want government health warnings on bottles of alcohol. The government is lagging behind the public on these issues - not least because it fears attracting the nanny tag.

It is time to think carefully about the boundaries and overlaps between the responsibilities of the individual and the state.

Individuals are not just passive consumers of health services but active producers of their own health and well being. What we know, how we use our knowledge and how we behave and make decisions all profoundly influence our health. In addition, our sense of autonomy and control over our lives are factors that make a significant contribution to our mental and physical well being. So freedom is to be cherished not just as a political value, but as an important determinant of health.

Yet our choices are thoroughly constrained - by how much we earn, where we live, how well educated we are and much else. You can't choose to eat healthy food, for instance, unless you know what is healthy, can find where to buy it and can afford to pay. You can't choose to take exercise if your work and family responsibilities leave you no extra time, if you can't afford to buy a bicycle or join a gym, or if your local streets are unsafe for pedestrians.

And sometimes the choices of one individual can put their health at risk, for example, by driving dangerously or smoking indoors near children, or having unprotected sex. If I drink heavily, eat fatty foods and fail to take exercise, I am more likely to get ill and need your taxes to pay for my health care. If I fail to save for a decent pension, I am more likely to be poor in retirement and more vulnerable to illness and dependency, needing a range of publicly funded services.


So individual choice only works positively for health in the context of a close relationship with responsible government acting on behalf of the whole population.

This involves at least five functions. The first is to facilitate the gathering, analysing and dissemination of information about the causes of health and illness. The second is to set a good example through its own behaviour. The third is to create the conditions for equal choice, though education, employment, housing and neighbourhood policies, so that everyone can choose healthy lifestyles, regardless of their background. The fourth is to try and make sure that, in the interests of society as a whole, every individual takes reasonable steps to safeguard their health and well being in the long term. The fifth is to discourage or prohibit individual or corporate behaviour that endangers the health of other people.

Whether any of this is achieved through information, education, exhortation or legislation should depend on the severity of the risk and on evidence - if it exists - of the willingness or otherwise of the parties involved to act voluntarily. Jumping straight in with a legal ban may not be the best way to encourage responsible behaviour by citizens or corporations. But if all else fails, then compulsion may be necessary.

According to the BBC poll, people are quite grown-up enough to understand that some freedoms must be curtailed for the sake of more precious ones.

Anna Coote is director of public health at The King's Fund.