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Living with cuts to public services: how can we get more for less?

social welfare spending was correlated closely with mortality from diseases associated with social circumstances (such as diet-, alcohol- and tobacco-related diseases) but that this effect was largely due to spending on areas other than health care. Indeed, we know from a multitude of other studies and reports, that there are a great many so-called ‘wider determinants’ of health and health inequalities, among the most influential of which is fiscal policy and its impact on fairness in society. 5 Unfortunately, in determining fiscal policy, public health is rarely uppermost in the minds of politicians and legislators—their main driver tends to be economic growth. And yet, as Marmot 6 and others have pointed out, a fair and healthy society is a productive society. Public health is all about the ‘bigger picture’, and as public health professionals we spend much time and effort analysing the complexities and interdependencies of the many factors that influence health and wellbeing. But we have been slow to get to grips with analysing the crosssector effects—the way factors such as education, housing, environment, transport, employment, social services and health care interact with each other to influence outcomes, not just health and wellbeing, but also such crucial outcomes as educational achievement, jobs, social cohesion, citienship, personal security, crime, regeneration, and political power. This whole-system or multisector evaluation has been recently dubbed ‘macro-evaluation’. 7 There have been calls for this broader approach to evaluation, particularly multisector cost –benefit analyses and predictive modelling, to be used by legislators in deciding on new laws with multisector impacts, such as whether or not to ban smoking in certain settings, introduce mandatory minimum pricing for alcohol or put extra taxes on foods