This long read was produced during the 2019 General Election.
- A healthy population is one of the nation’s most important assets. It is valuable in its own right and also creates value for society. It allows people to participate in family life, the community and the workplace.
- Long-term improvements in life expectancy and mortality in the UK have stalled and are falling behind other high-income countries. At the same time the difference between the health of people living in the best- and worst-off communities is widening.
- Action is needed across the whole of government to address these trends. Investment needs to be directed towards areas of public spending that create the right conditions for people to lead healthy lives.
- Stronger measures are needed to ensure that government is held to account for the health of the population. This should include adopting a legislative framework, along the lines of the Welsh Wellbeing of Future Generations Act to encourage long-term action across government to promote good health. It should also include establishing an independent body to track and analyse trends in mortality and morbidity.
- Similarly, the way success is measured nationally needs to change, moving beyond GDP to evaluating policy on the basis of health and wellbeing as a primary measure of successful government.
In this election campaign, a lot of attention has focused on the NHS. This is unsurprising since people generally value their health above most other things including income, careers and education. Good health is valuable in its own right but it also creates thriving economies and communities. Everyone needs to be able to rely on the NHS when they are unwell, so a properly resourced health care system is vital, and the NHS has a clear role to play in preventing ill health.
But evidence shows that staying healthy depends on much more than health care. In fact, the strongest influences on health are the circumstances in which we are born, grow, live, work and age: the wider determinants of health. These are the underlying drivers of health and can either enable individuals and societies to flourish or not. These conditions affect people’s health directly – for example, poor quality housing can lead to respiratory problems and stressful work can affect mental health. They also have indirect effects through their influence on people’s behaviour and the choices available to them – for example, living in neighbourhoods with limited green space increases exposure to pollution and reduces opportunities to be active.
Worrying trends in the UK’s health have emerged in recent years that cannot be overlooked by the incoming government. Improvements in life expectancy, which have been steady over the past 50 years, appear to be stalling. At the same time the difference between the health of people living in the best- and worst-off communities has been widening, with healthy life expectancy (the number of years people can expect to live in good health) sitting at just 52 years in the most deprived areas compared to 70 years in the most affluent.
The current picture
People in the UK today are living longer than at any time in the past, but stark differences remain between how long people in different communities live and their quality of life. For example, people born in the most deprived 10% of local areas in England are expected to live 18 fewer years in good health than those born in the least deprived.
People living in deprived areas are also at greater risk of having multiple health conditions and developing these at much younger ages. This is because of increased exposure to a variety of risk factors, as Box 1 explains.
What causes heart disease? The obvious answer is probably blocked arteries. But what causes those arteries to become blocked? Perhaps it’s the consumption of unhealthy food and drink, a lack of exercise or higher stress levels. And what, in turn, makes us feel stressed, shapes our opportunities to be active and determines our choices about what we eat and drink? The answers lie in the circumstances in which we are born, grow, live, work and age: the wider determinants of health. These are the ‘causes of the causes’ of poor health.
People’s socioeconomic conditions affect exposure to risk factors in multiple different ways. A low income can be detrimental to people’s health because of the following:
- constant stress related to financial hardship and the lack of a sense of control which can result in poor mental health
- a greater likelihood of living in poor-quality housing and in areas that lack green space and community facilities
- exposure to stress increases the likelihood that people will adopt behaviours that are not good for their health
- a lack of money limits the ability to adopt a healthy diet and participate in activities that are good for wellbeing.
Trends in life expectancy and mortality
The UK performs poorly on life expectancy compared to other similar countries, particularly for women. Female life expectancy at birth was 83.1 years in 2017 compared to Japan at 87.3 years and Spain at 84.1 years. The UK is towards the bottom of the rankings in the OECD and has fallen further behind since 2000.
There has been a steady decline in mortality in the UK since the middle of the 20th century. But since 2010 there has been a marked slowdown in improvements. This slowdown has been seen across western Europe and the USA, but it has happened most rapidly in the UK. Worryingly, trends in younger age groups in the UK are particularly bad compared to other countries. There has been no improvement since 2011 for the under 50 population as a whole and mortality rates actually increased for 45–49-year olds. Moreover, recent changes in mortality have not affected everyone in the UK equally, meaning that the gap between best- and worst-off has widened.
Trends in risk factors for poor health
There have been improvements in some of the strongest risks for poor health but these tend not to be shared evenly by all sections of the population. Smoking is still the largest avoidable cause of mortality and illness in the UK. As a result of multiple, coordinated and sustained government policies the proportion of adults smoking tobacco in England has fallen from 19.8% in 2011 to 14.4% in 2018, although it continues to be much more common in more deprived communities.
Meanwhile, levels of obesity remain stubbornly high and are increasing in many parts of the population. A fifth (20.2%) of school children in Year 6 in England are now obese. The chart below shows that not only are children in the most deprived areas more than two-and-a-half times more likely to be obese than those in the most affluent areas, but the gap between those communities is growing.
Young people’s mental health is another area of concern, with the latest data from 2017 showing that 11.2% of 5–15-year olds report having at least one mental health disorder, up from 9.7% in 1999. This rise has been driven by increased rates of emotional disorders, particularly anxiety and depression. Emotional disorders are particularly common in teenagers, with 14.9% of 11–16-year olds affected.
Finally, drug misuse deaths and alcohol-specific deaths are now higher than at the turn of the century, with both rates over 30% higher than in 2001. In parallel, over the last five years there has been an 11% fall in the number of people receiving treatment for drug and alcohol misuse. The success rate of treatment has also been falling: it is now five percentage points lower than it was in 2013/14.
Changes in living and working conditions
To understand what might be driving some of the trends in health already detailed, it’s helpful to consider the important changes in people’s living and working conditions over the past decade and those that are likely in the near future. There have been significant cuts to working age social security spending over the last decade. Although headline poverty rates have seen little movement – partly due to strong employment growth – some individuals have been severely affected by measures such as the benefit cap or poor implementation of universal credit. In the coming years further planned reductions in the generosity of welfare payments are forecast to increase child poverty to record highs by the early 2020s. More broadly, rising pressure from housing costs has squeezed household budgets.
There are also concerns about the impact of insecurity on health, particularly for young people, in areas from work to housing. While employment rates have been high, the quality of work people do also has important implications for health. Low-quality work can be damaging to mental and physical health. Good-quality work gives people job security, autonomy and support where that is needed. Forthcoming Health Foundation analysis shows that there has been little change in the levels of low-quality work over the past decade, highlighting an opportunity for government action.
Changes in housing tenure can also have implications for health. While the number of non-decent homes has been improving in recent years, the growth of the private rented sector – particularly for younger people – has potential implications for health through insecurity and affordability.
Changes to government investment in health
Since 2010 there have been major reductions in overall public spending but there has also been a change in the balance of that spending. The biggest cuts have been in areas that are important for promoting good health more widely, while spending on services which address acute, avoidable problems has often grown. For example, the chart below shows the changing pattern in spending on children’s services in local authorities. Total spend on preventative services (such as Sure Start and Early Help) has fallen by £0.6bn, over a fifth, in the past five years while spending on acute services has increased by a £1bn (16%). Provision for the most acute need now represents 77% of spend on local children’s services.
The same is true for the pattern of spend within the Department of Health and Social Care budget. Between 2015/16 and 2019/20, spending on NHS England is expected to have grown by 8% on a real terms per head basis. That compares to a reduction of 23% in the public health grant on a real terms per head basis (a grant paid by DHSC to local authorities to deliver public health services) over the same period. This is despite recent analysis that found 75% of public health interventions reviewed by NICE were either cost-effective or cost saving over time and research that suggests public health interventions are better value for money at the margin.
The real terms increase in the public health grant announced for 2020/21 falls significantly short of the additional £1bn required to reverse the real term per head cuts since 2015/16. Nor will it keep pace with growth in frontline NHS services, meaning health spending is likely to become further skewed towards treatment rather than prevention.
Priorities for the next government
Any new government should look to address some of the long-term trends in health outlined in this long read, including the stalling of long-term improvements in life expectancy and widening health inequalities. This requires action that goes well beyond the health and social care system. It also requires mechanisms that hold government to account for national progress on health.
Important steps should include:
Putting in place mechanisms to ensure all government policies and spending enable people to stay in good health. This could include:
- Adopting a legislative framework, along the lines of the Wellbeing of Future Generations (Wales) Act 2015, designed to encourage long-term joined-up action across all aspects of government policy and spending that can promote good health.
- Changing the way success is measured, moving beyond GDP and evaluating policy based on health and wellbeing as a primary measure of successful government. Here the UK can learn from the Wellbeing Budget adopted in New Zealand in 2019.
Implementing policy, spending and regulatory measures across all government departments to improve wider determinants of health. This should include investment in areas such as housing, social security, early years services, transportation and education. Box 2 gives a specific example of what this would include for young people.
Ensuring the NHS plays a stronger role in disease prevention and creating the conditions for good health. The NHS is the UK’s largest employer: through its size, scale and reach, it can leverage its assets to improve health. This would be helped by a new government:
- setting expectations about the broader role and responsibility the NHS has as an anchor institution and maximising this through national policy, guidance and frameworks
- supporting NHS organisations to systematically implement cost-effective preventative interventions not currently used consistently across the NHS (for example smoking cessation services) and prioritise health promotion and ill health prevention in all pathways of care.
Reinvesting a minimum of £1bn in the public health grant, which would reverse real term per head cuts between 2015/16 and 2020/21, to enable local authorities to deliver vital preventative services – such as sexual health clinics, stop smoking support and children’s health visitors – that protect and improve health. This also enables public health teams to influence the wider determinants of health at local level. Beyond 2020/21, government should commit to maintain the grant’s value relative to spending on NHS England.
Establishing a new independent body to track and analyse the nation’s health. This would provide expert advice to policymakers and regular reporting to parliament, on current trends in health – including mortality, indicators such as obesity or smoking rates and wider determinants such as work quality and poverty – and how health could be improved for future generations.
Between the ages of 12 and 24, young people go through life-defining experiences and changes that shape their future health. Action to improve the health prospects of people in this age group needs to reach across the whole public sector and beyond including:
- public bodies committing to becoming youth-friendly workplaces
- educational settings promoting and safeguarding wellbeing as well as achievement and being monitored against appropriate measures of wellbeing
- a strong, affordable rental sector where young people can put down roots, through measures such as developing a set of minimum standards for landlords, greater investment in build to rent, and greater education about the rental sector
- strong skills pathways through adequate resourcing of further education and development of a national careers offer
- thriving youth provision with adequately-funded services
- investment in transport connections that allow young people to get to employment, education and development opportunities in their area, including a consistent offer on discounted fares for young people undertaking skills training.
- A health index for England: opportunities and challenges – Responding to the government's prevention green paper (October 2019)
- Creating healthy lives: A whole-government approach to long-term investment in the nation's health (September 2019)
- Harnessing data and technology for public health: five challenges – Responding to the government’s prevention green paper (October 2019)
- Invest in public health now, or store up problems for the future (June 2019)
- Mortality and life expectancy trends in the UK: Stalling progress (November 2019)
- A healthy foundation for the future (October 2019)