The need for a new social model of health ensuring all parts of the system work together

20 June 2019

By Sally-Marie Bamford and Ben Franklin

As a country we are still overly preoccupied with cure rather than prevention and it is leading to an inefficient allocation of public spending and stagnating health – a point we argue in our latest report, Beyond the NHS: Addressing the root causes of poor health, write Sally-Marie Bamford and Ben Franklin.

It is widely accepted that a population’s health is largely shaped by factors beyond health care and that to radically improve health outcomes, we need to address the key drivers of poor health. The prevention agenda to a large extent focusses on behavioural change, such as smoking cessation or tackling obesity, but conspicuously overlooks the social gradient of health within our communities.

Our report marks the end of the Centre for Progressive Policy’s (CPP) inquiry into the future of health and social care and heralds a renewed focus on the social determinants of health. At the heart of this inquiry is a concern to re-establish the virtuous circle between health and prosperity. There are serious signs that this circle is broken.

The case for change has never been more compelling – our new analysis reveals:

  • Lost lives: Lives are being significantly shortened by socioeconomic inequality. Based on the assumption that everyone could live as long as those in the least economically deprived areas, CPP estimates that for England’s population today, almost 80m life years will be lost, 1.5 years per person.
  • The social determinants: Breaking this down, 30m of these years can be explained by differences in education, 18m by differences in disposable income, 15m by employment, and 8m each by crime and housing.
  • Impact on healthy lives: Social deprivation not only affects how long people live, but also how healthy their life is. Equivalent analysis of healthy life expectancy estimates 170m years of healthy life are being lost, or 3.2 years per person.

This is set against a backdrop of rising demand and a tiny proportion of the overall health budget dedicated to prevention (circa 5%) and even less to addressing the social determinants of poor health. Local authorities, who are well placed to tackle social determinants, have seen their overall budgets cut substantially. And despite taking on responsibility for public health, they have experienced significant funding cuts.

Dr Tom Coffey OBE, Mayor of London Health Advisor, said:

“Shockingly, the health of Londoners is still profoundly shaped by who you are and where you live. Giving children the best start in life is the most effective way to address these health inequalities in the long term, and the Mayor is taking bold steps to make London a healthier, fairer city."

But the enormous pressures facing the NHS and cuts to local government funding are putting people’s health at risk and allowing inequalities to widen. Without the Government committing the funding that our communities need, tackling London’s health inequalities is going to be much harder.”

The importance of tackling the root causes of poor health is not new and yet action is not forthcoming. Many an NHS leader has been called to account for their failure to meet A & E targets and yet no one has ever been sacked for failing to tackle the social determinants of health.

Furthermore, the general populace has little awareness of the importance of the social determinants of health and so with low levels of public pressure, there has been no ‘bottom up’ push for government action. Initiatives and interventions can also take years to demonstrate positive outcomes, while the day to day pressures of curing and treating illness continue unabated.

And arguably there is no clear ownership of the agenda or consensus on where it should lie.

Our final report calls for a new social model of health ensuring all parts of the system work together. What does this mean in practice?

  • Strengthening the role of the Chief Medical Officer (CMO) as it pertains to social determinants and making the role accountable across government.
  • All government departments at national and local level putting health first when developing public policy and evaluating impact.
  • Strengthening the remit of Directors of Public Health to deliver place-based population health and ensure they are afforded a significant role in the development and delivery of the Integrated Care Systems.
  • Develop and learn from emerging whole-systems approaches to health in large and complex local areas. Examples in Greater Manchester, Coventry and Newham show how to build the necessary mechanisms for leadership, accountability and collaboration.
  • Within the NHS prevention budget, money should be ring fenced for addressing the social determinants of health

Our inquiry supported by a team of expert clinical and non- clinical advisors has set out a compelling case for the need to rethink the relationship between health, wealth and income inequalities and how the solution will only be found if we look beyond health care and towards health in all policy and places.

This article was first published by the Health Service Journal.