Social determinants of health Any rays of hope in the election manifestos?

Each of the election manifestos paints a vision of a better society, but viewed through the lens of the social determinants of health (the factors that are the root causes of ill health), they make less sense. If a health service treats a child for asthma, but the same state that provides the NHS then sends that same child back to a damp home in a high crime neighbourhood with limited green space, polluted roads and cheap junk food outlets lining the streets, is that state meeting the needs of its citizens?

The NHS and social care are rightfully fundamental parts of the general election debate, and improving quality and access to health and social care has never been more important. But if we want people to have healthier lives, we need to step beyond the clinical paradigm and broaden our perspective of how we create health and wellbeing. What about the other public policies that will have an influence on health? After all, we only have to look at the US to know that spending more on health care doesn’t necessarily mean better health. In the UK, the Health Foundation has been working with partners to try to change the conversation from health being viewed simply as an output of the NHS, towards health viewed as a social and economic asset – one that can help us all lead flourishing and prosperous lives.

Any rays of hope in the manifestos?

At the Health Foundation, we are thinking about how policy can be used to create health, and a necessary first step is the recognition that all policy has health impacts. Looked at through this lens, examples of health promoting policies from last week’s manifestos might include:

• The costings of Labour’s increasing tax and ‘borrow to invest’ approaches are rightfully being scrutinised heavily by the media and public. However, policies such as scrapping university tuition fees and restoring maintenance grants for university students could go a long way to helping those from more disadvantaged backgrounds afford higher education. The evidence linking education (at all stages of life) and better health is clear, yet spending on further education is at a similar level to what it was 30 years ago.
• The Liberal Democrat focus on young people might be music to some of the ears attuned to the social determinants agenda. Bad housing (including insecurity and temporary accommodation) can lead to health problems such as anxiety, depression and respiratory conditions. Pledges like the restoration of housing benefit for 18-21 year olds are more closely related to health than many might imagine. Investing in young people seems crucial at a time when in the Youth Index 2017, almost a fifth say they do not have the ability to change their circumstances if they want to, with devastating impacts on their wellbeing.
• Recent strikes by cleaners at the London School of Economics over their terms and conditions shines a light on a crucial social determinant of health: work, and working conditions. The Conservative manifesto nods to the importance of good work conditions through a pledge to protect people working in the ‘gig’ economy, a sector characterised by short term contracts. That’s important because these kinds of jobs are often linked to job insecurity and work stress: factors which have been shown to lead to illnesses such as cardiovascular disease and cause-specific mortality.

What would an ideal manifesto look like, if we broadened our perspective of health and wellbeing?

It’s hardly surprising that there’s not enough focus on the potential of social policies to create health and wellbeing in the 2017 General Election. Successive governments have failed to address the social determinants of health, and therefore health inequalities since the 1930’s. (It’s worth noting that the UK is one of the most unequal of the advanced economies: the incomes of the richest 10% of UK households are on average, 11 times higher than those of the poorest 10%.)

Creating health and wellbeing through policy isn’t impossible. It’s already happening at a local level in England, where local authorities are working towards taking action on the social determinants and tackling health inequalities. In Wales, the Well-Being of Future Generations Act 2015 requires public sector bodies to incorporate long term, sustainable wellbeing goals into their work. NHS Health Scotland’s 2012-17 strategy departs from traditional ‘behavioural’ approaches to health improvement and focuses on how to improve health equitably, reflecting Scotland’s social justice agenda going forward. In New Zealand, the government is considering the long term cost of social issues to the state, and is using cost-benefit analysis and other sources of data to identify particular populations at risk in order to design effective services.

That’s not to say that all this is easy. There’s a solid evidence base for the importance of the social determinants of health, but research on the impact of public health interventions often doesn’t take into consideration the complex-systems context they’re operating in. It’s also often difficult to measure the benefits of these interventions. Research funding needs to adapt to generate robust evidence to support system level action.

By the next election, we need to see more political focus on health creating policies such as those outlined above. As Professor Johan Mackenbach once said, ‘Human health and disease are the embodiment of the successes and failures of society as a whole and the only way to improve health and reduce disease is by changing society by, therefore, political action.’

This may take time, and needs to be driven by people’s understanding that health and wellbeing is created by factors much wider than the NHS. But it is certainly a journey worth making. For now though, remember that health isn’t only related to the chapters of these manifestos entitled ‘NHS’.

Natalie Lovell is a Policy Analyst for the Health Foundation

For more information on policies that support everyone’s opportunities for a healthy life, and some of the examples referenced in the above blog, please read our Healthy Lives Strategy Resources Guide.