Glaring Omissions

After months of anticipation, many health and social care
professionals have excitedly unwrapped the government’s Choosing
Health white paper and been unable to hide their disappointment
with what’s inside.

Told to expect a far-reaching reorganisation of policy that
would place public health at the top of the political agenda, they
have been presented with a document that is long on good intentions
but short on concrete proposals. The document pledges £1bn to
be spent over the next three years and a new partnership between
the statutory, voluntary and private sectors. Yet, aside from the
headline-grabbing plan to ban smoking in the workplace by 2008,
much of the document seems to be stymied by a fear of being accused
of creating a “nanny state”.

Despite one of the largest public consultations ever undertaken,
and more than 1,000 submissions from individuals alone, the white
paper has left many care professionals wondering what all the fuss
was about.

Most crestfallen have been those working in the sexual and
mental health fields who feel that the needs of their service users
have been either misunderstood or ignored. Many mental health
professionals feel that the white paper’s emphasis on lifestyle
issues and the importance of taking personal responsibility for
one’s own health have little relevance to those suffering mental
health problems.

“The public could be forgiven for thinking that Britain’s health
problems are confined to smoking and unhealthy eating,” says
Richard Brook, chief executive of mental health charity Mind.

“Healthy lifestyles are important – that cannot be denied. But
we would like to see the government recognise that improving the
nation’s mental health is an integral part of a much bigger

Angela Greatley, chief executive of the Sainsbury Centre for
Mental Health, points out that, although an individual’s risk of
heart disease or cancer may be influenced by his or her lifestyle
and dietary choices, the same cannot be said for illness such as
depression or schizophrenia.

“Nobody chooses to have a mental health problem,” she says.
“Mental illness cannot be prevented by promoting healthy
lifestyles. Promoting mental well-being is about tackling the
things that put people at risk of mental ill health and taking
action to offer fair chances in life to those with mental health

This will require more public health measures to be focused on
the needs of people suffering mental health problems and more
resources allocated to mental health promotion, says Greatley. “It
is vital for our nation’s health that efforts to promote good
mental health become a real priority for public health
professionals, and that more resources are put into mental health
promotion. To date, mental health promotion has been starved of
resources and existed on a shoestring.”

The Royal College of Psychiatrists says the white paper’s
emphasis on self-help could lead to the impression that mental
health is a matter of choice. This could “increase the guilt, shame
and stigma felt by patients, carers and their families”, it

The RCP has called for a complementary – but separate – public
health strategy for mental health. This would include measures to
promote mental health in the workplace, improve access to mental
health care, increase public education on mental health issues and
address the problems caused by the “prevailing social and economic

Mental health is not totally ignored in the white paper. There
are proposals to improve access to mental health services for
ethnic minorities. It also pledges guidelines on the management of
mild to moderate mental ill health in the workplace, to be in place
by 2005, and to use the Sure Start programme to protect children
and young people against mental health problems later in life.

However, mental health user groups are annoyed at the lack of
any proposals to address the specific physical health needs of
people who use mental health services.

“It is a scandal that mental health is not at the heart of the
government’s public health plans,” says Rethink chief executive
Cliff Prior. “All the available research shows that people with
mental illness face an earlier grave because their physical health
is often neglected. People with mental illness need extra support
and information to ensure all their health needs are met.”

Prior points out that problems such as obesity and smoking are
particularly prevalent among mental health care users, yet the
white paper offers no specific measures to address these

There are also concerns that the proposed smoking ban in the
workplace could work against the needs of people being treated in
psychiatric institutions. While it is hard to argue against a
smoking ban on the grounds of physical health, its implications for
mental health may not be so clear cut. It is estimated that up to
70 per cent of people treated in psychiatric wards smoke. Many use
cigarettes as a coping mechanism and there is even evidence that
nicotine may help alleviate the symptoms of some brain illnesses.
To ban smoking within psychiatric hospitals may therefore be
counter-productive. Likewise, a smoking ban in the prison service
may also be impractical.

While mental health campaigners have been the most vocal in
their criticisms of the white paper, others have voiced disquiet
about the plans to improve sexual health, saying they fail to
promote sex education in schools and do not go far enough.

The white paper proposals include a new national campaign
targeted at those at greatest risk of catching a sexually
transmitted infection or having an unplanned pregnancy, a national
chlamydia screening programme in place by 2007 and a pledge that by
2008 everyone referred to a genitourinary medicine (GUM) clinic
will be offered an appointment within 48 hours.

What the proposals do not include, says Deborah Jack, chief
executive of the National Aids Trust, is anything likely to meet
the specific needs of people affected by HIV/Aids. Particular
challenges with HIV, including stigma and discrimination are also
not addressed, she says.

Rod Griffiths, president of the Faculty of Public Health, says
the white paper’s sexual health proposals should be welcomed.
However, he questions why the public has to wait so long to see
their benefit. He says: “The year 2008 will be too little, too
late. The government recognises that delay in access to treatment
has a major impact on future health and fertility. How, then, can
they justify a four-year wait to implement its goal of 48 hours for
a GUM appointment – a recommendation made by the health select
committee in June 2003.”

Serious infectious diseases, such as chlamydia and HIV, should
be treated as emergencies and access to GUM services should be made
available within four hours – in line with other accident and
emergency cases, says Griffiths.

Jan Barlow, chief executive of the Brook sexual health advisory
service for young people, sees the white paper as a missed
opportunity. She says: “Research shows that young people who have
received good sex and relationships education, combined with access
to confidential services, start having sex at a later age and are
more likely to use contraception when they do become sexually

“If the government is serious about bringing down rising rates
of sexually transmitted infections and achieving a consistent drop
in rates of teenage pregnancy, sex and relationships education must
be made a compulsory part of the national curriculum.”


The public health white paper emerged from a consultation
process that ran between 3 March and 28 June 2004.

More than 2,500 responses were received, with individuals
contributing more than 1,000 responses.

The government will publish a delivery plan early next year
outlining how each of the commitments in the white paper will be

 It will also establish a public health research initiative
which will receive £10m by 2007-8 to help develop front-line

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