'At this festive season of the year, Mr. Scrooge,' said the gentleman, taking up a pen, 'it is more than usually desirable that we should make some slight provision for the poor and destitute, who suffer greatly at the present time. Many thousands are in want of common necessaries; hundreds of thousands are in want of common comforts, sir.'
Charles Dickens, A Christmas Carol

As the festive season approaches, it is sobering to reflect on our emerging work on the wider determinants of health. Our office location in Covent Garden highlights a clear juxtaposition between poverty and wealth. On the one hand, there are hordes of cheery crowds purchasing presents and meeting friends in a bustling and beautiful environment. On the other hand, there is constant presence of rough sleepers in the area, people who are often ignored by the commuters and tourists as they go about their day.

Homelessness was described in the London Mayor’s consultation on the Inequalities Strategy as a ‘growing source of shame to the City’. It is striking that Charles Dickens’ quote above is still as relevant today as it was in Victorian times.

So what does this mean for us at the Health Foundation?

We want to promote national policies that support everyone’s opportunities for a healthy life. But it is impossible for us to do that without thinking seriously about poverty and the policies that contribute to unequal living conditions.

The concept of the social gradient of health is well publicised. We know that the higher a person’s social status, the better his or her health is likely to be. If we consider rough sleepers, we know they are more likely to die young, at an average age of 47. While the health care system has a role to play in improving health outcomes for homeless people, it has limited scope or resources to tackle the wider contextual factors that contribute to extreme poverty, which in turn contribute to poor health outcomes.

As a response to the then Chief Medical Officers’s top tips for better health (such as stop smoking, follow a balanced diet, keep physically active) in 1999, the Townsend Centre for International Poverty Research identified its own top ten tips for better heath. Those tips included the following:

  • Don’t be poor
  • Don’t live in a deprived area
  • Don’t work in a stressful low-paid manual job
  • Don’t be disabled or have a disabled child
  • Don’t live in damp, low quality housing or be homeless.

The challenge for us at the Health Foundation is understanding where best to focus our efforts and resources. We are not experts in housing, the benefits system or the education system. However, we do believe we can make a difference by supporting interesting collaborations across sectors and pushing for health impacts to be taken more seriously by national policy makers.

Long-term success for us would be an environment where good population health is viewed as an asset which contributes to the core infrastructure of a prosperous and sustainable society rather as a sole output of the NHS. We are a long way away from that. But one way of achieving this could be to encourage a greater focus on the Sustainable Development Goals (SDGs).  

Sustainable Development Goals – unlocking their potential

The United Nations SDGs, adopted in 2015, are a collection of 17 goals and 169 targets. The SDGs aim to tackle the root causes of poverty, protect the planet and promote prosperity for all. They are intended to apply to all countries, not just developing ones, and cover a broad range of social development issues such as health, education, poverty and energy. 

The UK Government has been criticised for a lack of action on the SDGs at home. In March this year the Department for International Development set out how the UK is contributing to the delivery of the goals. However, it is not clear that there is a robust plan for achieving some of the goals domestically.

For example, within the section on Goal 3: Good health and wellbeing, there was no reference to how the UK would make progress against the target to reduce premature mortality from non-communicable disease by one third by 2030.

Similarly, there was no mention of the target to reduce (at least by half) the proportion of men, women and children of all ages living in poverty in all its dimensions according to national definitions.

A more recent update suggested that Single Departmental plans would be updated to embed the goals within the work of each government department. On 14 December the Cabinet Office set out how the government would be supporting the delivery of the goals through the departmental planning process. While this was a positive step, there still does not appear to be a coordinated implementation plan to ensure that each of the individual targets are achieved within the UK. 

The targets underpinning the 17 SDGs are complementary and mutually enhancing. Progress in each of the goals would potentially support improvements in health outcomes. At our international seminar Hooked on Healthcare, the SDGs were viewed positively by delegates from across the world as a galvanising force for change. In comparison, there doesn’t seem to be the same enthusiasm in Westminster to develop domestic policies that are strategically aligned with the SDGs.

As an example, the Government’s recent flagship Industrial Strategy failed to mention the SDGs, which was a missed opportunity (as was the omission of an impact or health impact assessment).

However, the picture at a devolved administration level is more positive. For example, the Scottish Government announced in 2015 that Scotland would adopt the SDGs. In Wales, the Well-being of Future Generations (Wales) Act 2015  requires public bodies to work to improve the economic, social, environmental and cultural wellbeing of Wales. While the Act focuses on seven wellbeing goals that are distinct from the SDGs, Wales’ example of legislating for sustainable development is a model that could be adopted more broadly.

Set against the challenges of delivering Brexit, it may be tempting for the government to put the SDGs in the ‘too difficult box’ or to focus its efforts on supporting international development. But, given the challenging nature of some of the targets, politicians and organisations like our own cannot be complacent. While it is true that the vast majority of the population is insulated from the extremes of poverty seen in some low-income countries, poverty and inequality of opportunity is still a problem within the UK, just as it was when Dickens wrote A Christmas Carol.

Emma Spencelayh is Senior Policy Advisor at the Health Foundation. Twitter: @ESpencelayh


Christine Hancock

Hi Emma, good to read your support for action on SDGs; I hope you have support within the Foundation? The UK tends to see issues like this as not relevant here, but applicable to "poor countries" Recent news here shows the reality of life in the UK with child obesity rising, homelessness increasing, and inequalities in almost every indicator. More money for the NHS seems to be the only thing of interest to politicians & the media. The SDGs would force us to address the real issues affecting health.

Emma Spencelayh

Hi Christine,

Many thanks for sharing your thoughts. I agree that the discussion on the SDGs has been limited domestically. We are currently contributing to a piece of work led by the UK Stakeholders for Sustainable Development (UKSSD) to review the UK’s performance against the goals and targets.

Best wishes,



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