Richard Smith: “Whole of government and whole of society”: making it real

Richard Smith

Have you heard the phrase “whole of government and whole of society?” If you haven’t you soon will. It’s the summary of the formula for fixing many of the world’s most intractable problems—like climate change (or climate disruption, as Martin McShane suggests we call it). I heard it first at the United Nations meeting on non-communicable disease (NCD) last September. But making it happen is very hard.

If trying to counter the pandemic of NCD is left to the health system we will make little progress. The health system can do its best to patch up those who have had heart attacks and strokes and can work on the biological risk factors of hypertension, hyperlipidaemia, raised blood glucose, and obesity. The biggest gains will come, however, from progress on the social determinants and social risks factors of tobacco use, poor diet, physical activity, and the harmful use of alcohol, which demands action from many more players in many more systems.

Even working within the health system, which in many countries is fragile, thin, and short of health workers, will demand the cooperation of government finance departments to boost funding for the health system, transport departments to improve access, immigration departments to help with skill shortages, businesses like pharmaceutical companies, and NGOs and faith organisations, which deliver many of the services.

Let’s consider the complexity of encouraging a healthy diet. Clearly it’s something to do with departments of agriculture, but also with food subsidies, many of which are negotiated at a global level. Farmers, big and small, agricultural companies, retailers, ranging from street vendors to global chains, and food companies, big and small, all have a part to play. Transport is fundamental for the distribution of food. Departments of education, schools, and employers, both public and private, are important. (The chair of a big hospital told me how she’d tried to stop the hospital serving chips every day, prompting a protest by the junior doctors.) Media, as Jamie Oliver has shown, can have a powerful impact, but media are also dependent on income from unhealthy advertising.

I could go on, but you get the point. At the moment not only do many of these not work together but they work against each other and against health. Subsidies to tobacco, corn, and dairy farming but not to fruit, vegetables, and oats is the classic example.

Most people, perhaps everybody, would thus agree that a “whole of society and whole of government” approach is essential, but making it happen is hard, perhaps even impossibly hard.

“Whole of government” might seem easier than “whole of society” in that governments have one leader—a president or prime minister. But government departments seem almost hermetically sealed. Partly it’s a problem of size. Even within departments communication may be difficult. I always remember the head of research in the Department of Health pointing to the wall of his office and saying, “It’s quite possible that there’s somebody through that wall who is working to undermine everything I’m doing.” It’s also a matter of culture and conflicting missions. The Department of Business aims to maximise a country’s income from business, including tobacco companies, and its staff probably use a completely different jargon from the staff in, say, the health department.

Society, which Margaret Thatcher famously said didn’t exist, is much more complex than government, and perhaps the biggest difficulty revolves around attitudes to business. Everybody agrees that tobacco companies are to be excluded, although even there it’s complicated in that tobacco companies are legal and have large numbers of employees who have as much right as anybody else to health. (I was taken to task when editor of the BMJ for allowing British America Tobacco to advertise for a doctor to head their occupational health services). Alcohol companies present special difficulties, which I’ve discussed before, and people divide over food companies.

George Alleyne, a former director of the Pan American Health Organisation and one of the  architects of the United Nations meeting on NCD, told me that he thought that business, including food companies, had the wherewithal to make a big difference with NCD. In contrast, PloS Medicine has run a series on Big Food, in which they take pride in having excluded the food industry and argue that public health practitioners should regard Big Food like Big Tobacco.

Despite my long connection with PloS and great admiration for PloS Medicine, this seems to me a mistaken view, but its stance—very different from that of a recent BMJ editorial—illustrates the difficulty of making “whole of government and whole of society” a reality.

I was reflecting on all this today as I attended the board meeting of C3 Collaborating for Health, which is very much in the business of collaborating, convening, and networking, bringing everybody together—mostly successfully. The observation was made, however, that if you try to convene a meeting of all players it’s easy to get the academics to attend—because words, reports, and meetings are their core business. NGOs will also come, but business people are hard to get—perhaps because they are more interested in doing (making money) than talking and perhaps because they are offended by the holier than thou attitude of academics. Government people or regulators seem to be even harder to get to come, perhaps because they are worried about being held hostage in some way.

So, as is typical of somebody who deals primarily in words, I’ve elaborated on the problem, but I don’t have a neat solution except to say that we need to keep finding ways for “whole of government and whole of society” to meet and work together. Perhaps too people who move between the worlds of government, academia, and business are to be particularly valued rather than criticised as is often the case.

Competing interest: RS is a trustee of C3 Collaborating for Health and was a board member of PLoS from 2004 to 2011. He was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.