Health cannot be improved by health care alone

Having spent the last 15 years with a focus on improving health care, the Health Foundation is embarking on a new strategy to influence the wider determinants of health. This week, as a first step, we and the All-Party Parliamentary Group for Health are publishing a set of essays examining the case for cross government action to improve health. They essays explore the current and emerging threats to health and wellbeing and what we know about what works to address them. 

Universal access to health care is widely recognised as one of the greatest social innovations of the last century. In 1942 when Beveridge published his seminal report which paved the way for the welfare state and set out a vision for post-war Britain, he talked about the need to slay the five giants of want, ignorance, disease, squalor and idleness. At that time, antibiotics were a miracle drug, techniques such as advanced imaging, gene therapy, and robotic surgery would have been on the pages of an HG Wells story and no-one could have envisaged what the NHS would look like as it approached its eighth decade.

The NHS has been hugely successful in treating disease and is quite rightly an institution we hold dear. However, when it comes to slaying the other giants Beveridge identified, it could be argued that public policy has not made the same strides, let alone tackle the new giants, such as global warming and urbanisation.

These other giants must be tackled if we are serious about improving the health of the population. Moreover, they are the key to reducing pressure on public services such as the NHS and ensuring the economic strength and stability of the nation going forward.

Most of the factors that contribute to a person’s health sit outside the health care system. The links between poor health and deprivation, unemployment and lower levels of education are well known. For example, between 2012 and 2014, life expectancy for baby boys was highest in Kensington and Chelsea (83.3 years) and lowest in Blackpool (74.7 years) – a difference of over 8 years strongly linked to socio-economic factors.

Poor health has serious economic consequences for the UK. Sir Michael Marmot (2010) estimated that preventable ill health cost the country £50-65bn a year in lost productivity and tax revenues.[i]  Preventable ill health is responsible for around 40% of the burden on health services, but only around 4% of the health budget is spent on prevention. According to Dame Carol Black, almost a quarter (23%) of Jobseekers Allowance claimants and more than 40% of Incapacity benefits claimants has mental health problems. Improving the health of the population is not something we can only ‘afford’ when the economy is thriving. It represents a real and tangible investment for the future.

In recent years, in the ‘iWorld’ where individual preferences are paramount, the narrative has been that it is our choice whether we choose to smoke - or not. Consume more alcohol than is good for us - or not. Eat healthy foods and exercise - or not. In this context, strategies that are about changing individual behaviour have had prominence. 

There is a case for tackling those giants at a macro-level through policymaking. In the last 50 years, deaths on the roads have plummeted even against a rising growth of car use. This isn’t because we all became better drivers, it is because our road system and the cars we drive make it easier to do the right thing - controlling our speed, giving way at junctions - and harder for bad things to happen with design features such as seatbelts and air bags. Similarly, as we think about other causes of premature death - such as obesity - we need to think beyond the actions and choices of the individual and more fundamentally at the environments and systems in which we live.

Yet the challenge is that these systems and the local context for our life are the consequence of a myriad of independent decisions and actions taken across local and national government - whether local planning decisions, housing policies, or regulation of advertising and marketing. 

As life expectancy continues to increase but healthy life expectancy falls, there needs to be systemic and systematic action to create the opportunities, homes, communities, workplaces and environments that give everyone the life chances they deserve.

In the wake of the EU referendum there has been much discussion and reflection on the disparities across the UK. Mental resilience, the ability to work in a positive environment and to live in a community that gives people hope for the future are now more important than ever. Tackling these issues is the remit of policymakers across Whitehall and local government – not the NHS.

Dr Jo Bibby is Director of Strategy at the Health Foundation, which today publishes a series of essays with the All-Party Parliamentary Health Group on the case for cross-government action to improve public health

[i] Marmot, M. Fair Society, Healthy Lives: The Marmot Review. London, 2010. As cited by Alex Bax in A Healthier Life for All: the case for cross-government action.