The UK is experiencing a profound decline in the health of its citizens, long predating Covid-19¹. The last decade saw progress in public health brought to an abrupt end, with life expectancy stalling broadly across the country and even declining for particular groups, such as women living in deprived areas. This largely reflects a worsening of the main determinant of our health, our living and working conditions which account for the majority of variation in health across a society². 

Tax and spending are not typical health policy tools (unless the discussion is on financing healthcare). However, fiscal policy is a highly effective public health tool because it typically affects the whole population at once and influences disease prevention through changing socio-economic factors, the main health determinant. For example, tobacco duty has been instrumental in reducing UK smoking rates from 45% in the 1970s to 15% now, and this has led to marked drops in heart and lung disease deaths³. Meanwhile, universal child benefit, has consistently been shown across the world to lead to improvements in key child health outcomes, such as birthweight, growth and maternal smoking⁴.

These examples also demonstrate another useful feature of using fiscal policy to improve public health: the tendency of this approach to reduce health inequalities (avoidable and unfair differences in health across society) resulting from income and educational differences. This is because the main mechanism of these policies is typically financial, which those on lower budgets are more sensitive to and who also happen to have greater disease burden⁵.

Accordingly, public health spending policies tend to be progressive (a flat child benefit is most effective for low-income families for example). Conversely, public health taxes tend to be regressive. This latter point is often the first argument reactionaries offer for opposing public health tax measures, such as Mr. Johnson’s recent refusal to implement an evidence-based expansion of the sugar tax due to it impacting “hard-working people”⁶. The second point being classical opposition to “nanny state” interference in individual lives.

However, these arguments ignore the fact that these are ultimately social problems that require social solutions. Few people, if any, rationally choose to realise the harmful consequences of smoking or obesity for example (rather these are caused by highly addictive products that are aggressively marketed at susceptible people), and we all pay for those consequences via the cost burden on the NHS. If tax policies exist that effectively reduce public harms, save healthcare costs, generate tax revenue, and restrict liberty only minimally then we should seriously consider them.

For groups disproportionately affected by a public health tax, we should recognise they will likely disproportionately benefit from the health effects of that tax. We can also help to mitigate negative effects by spending the tax proceeds on the public health of the affected groups, such as using sugar tax proceeds to subsidise fruit and vegetables or tobacco duty on stop smoking campaigns. Finally, we should recognise that an upfront, consumption related duty is a fair way to ask the relevant persons to contribute to solving a social problem as opposed to punishing them after the fact (for example by denying elective surgery to smokers as recently proposed) or asking the wider public to contribute through general taxation.

With all of this in mind, here are a range of stop-continue-start proposals for tax and spending that could improve public health in a fair manner:

1. End the two-child limit for universal credit thus reducing poverty for larger working families and improving their health. Whilst politically controversial, this helps a key Labour constituency, and a recent Fabian report explores such proposals in depth⁷.
2. Continue the highly effective Sure Start and Healthy Start schemes but properly fund them and expand eligibility, emphasising them as successful Labour government legacies.
3. Create a headline, social-democratic policy by publicly funding universal pre-schooling in each UK country, thereby cutting current attainment gaps, and improving health for poorer children⁸.
4. End the decade-long freeze on alcohol duty and use the proceeds to fund alcohol outreach. Whilst politically difficult, this would demonstrate a firm willingness to tackle binge drinking and anti-social behaviour, increasingly salient public issues.
5. Continue the current tobacco duty escalator, highlighting its success.
6. Expand the sugar tax to any food/drink containing very high levels of sugar, fat or salt as proposed in the National Food Strategy⁹. This would show a willingness to tackle obesity and allow one to set oneself apart from UK Conservatives given their rejection of the policy.

The above list is by no means exhaustive. In fact, this entire area is fertile ground for the Labour party. The point should be made that obesity, smoking, poor diet, and air pollution are major ongoing social problems for which effective, universal, and equitable solutions exist. Meanwhile, the individualistic, free-market approaches that the current Conservative UK government tout have evidently failed to make any progress on these issues. There is a clear choice here with a clear, social-democratic answer.

1. Marmot M, Allen J, Boyce T, et al. Health equity in England: The Marmot Review 10 years on. London, 2020.
2. CSDH. Closing the gap in a generation: Health Equity through Action on the Social Determinants of Health. Geneva, 2008.
3. Jha P, Peto R. Global effects of smoking, of quitting, and of taxing tobacco. N Engl J Med 2014;370(1):60-8. doi: 10.1056/NEJMra1308383 [published Online First: 2014/01/03]
4. Cooper K, Stewart K. Does Money Affect Children’s Outcomes? An update. London: Centre for Analysis of Social Exclusion, 2017.
5. Backholer K, Sarink D, Beauchamp A, et al. The impact of a tax on sugar-sweetened beverages according to socio-economic position: a systematic review of the evidence. Public Health Nutr 2016;19(17):3070-84. doi: 10.1017/S136898001600104X [published Online First: 2016/05/18]
6. Walker P, Butler P. Boris Johnson appears to rule out sugar and salt tax to tackle junk food reliance. Guardian 2021.
7. Abey J, Harrop A. How to increase social security with public support. London, 2021.
8. UNICEF. The child care transition: A league table of early childhood education and care in economically advanced countries. Florence, 2008.
9. NFSG. National Food Strategy: Independent Review, 2021.

Daniel Jones is a Welsh academic fellow and epidemiologist based at Cardiff University as well as a public health doctor. His research interests include social determinants of health and the Wellbeing of Future Generations Act and he also acts as a representative for junior doctors in the British Medical Association.