1. Introduction and context

The health of the population is one of any nation’s greatest assets. Good health improves people’s wellbeing, their productive capacity and their ability to participate in society. Yet a healthier population cannot be achieved by focusing solely on the treatment of illness. In fact, the strongest determinants of health are the social, economic, commercial and environmental conditions in which people live. Unless there is sufficient government attention paid to these wider determinants of health, major improvements in health and reductions in health inequalities will not be possible.

The health inequalities that exist in the UK, and the unequal living conditions that drive them, have been comprehensively studied over many decades.,, There have, at times, been effective policy initiatives to tackle them, including the introduction of the welfare state and, more recently, the health inequalities strategy implemented by the UK government between 1997 and 2010. However, the gains from these policy initiatives have not always been sustained.

Life expectancy in the UK has been stalling since 2011, and there is an 18-year gap in healthy life expectancy between the least and most socioeconomically deprived populations. Fluctuations in government priorities, a tendency towards short-term political decision-making, and challenges in addressing complex dynamic issues, all lead to insufficient attention by government on creating the conditions for a healthy life.

This suggests that a more fundamental change is needed; an approach where people’s health is valued as an asset by government and society. While all sectors have a role to play in addressing this agenda, many of the issues are structural and require government to recognise this issue more explicitly and take an active lead.

The Health Foundation, alongside others, is working to bring about this change through our Healthy Lives strategy. Building on our previous work, this report makes the case for a whole-government approach to improve the nation’s health, and identifies some of the steps required to achieve it. An effective approach needs:

• an explicit recognition of the value of good health in contributing to a more prosperous and flourishing society
• long-term thinking from government, with more focus on maintaining people’s health throughout their lives
• more joined-up policy action on the strategies that enable people to stay healthy.

With a growing number of working-age adults experiencing avoidable illness, and rising levels of multiple long-term conditions in the population (not least in mental health), now is the time for a reassessment of how the government invests in the nation’s health and wellbeing. Ambitions such as those set out in the 2017 Industrial Strategy – to ensure that people can enjoy at least five extra healthy years of life by 2035 while narrowing the gap between the richest and poorest – are welcome but require a whole-government strategy to be delivered effectively.

In England, the prevention green paper recently released by the government, Advancing our health: prevention in the 2020s, also sets out proposals designed to contribute towards that target. What is needed, however, is not a short-term policy initiative but a fundamental shift in government strategy that is long term in focus, underpinned by investment that prioritises keeping people healthy, and places the value of the UK’s health on an equal footing with measures of GDP.

2. Achieving good health for all: where are we now?

A flourishing society depends upon the whole of government taking responsibility for maintaining and improving people’s health throughout their lives. The stalling life expectancy and widening health inequalities seen in the UK today mean a major change in the action being taken to improve the nation’s health is imperative.

However, the challenge of building the UK’s health should not be underestimated. Life expectancy in England does not compare well to other similar countries, showing that there is significant room for improvement (see Section 2.1). Moreover, while there have been some advances made in public health outcomes in recent years, other indicators show worrying signs of longer term problems ahead if action is not taken soon (see Section 2.2). Against this backdrop, meeting the government’s Ageing Society Grand Challenge of giving people extra years of healthy life, will be extremely challenging (see Section 2.3). For women, healthy life expectancy actually fell slightly in recent years, while for men, it would take 75 years to complete the Grand Challenge at the current rate of improvement.

3. What is the social and economic impact of poor health?

Poor health has significant social and economic consequences for society and individuals. Evidence shows that health status has one of the largest impacts on a nation’s wellbeing (see Section 3.1). Good health also allows people to maintain social relationships and play an active role in their communities (Section 3.2). Poor health has significant economic consequences both for society and individuals, whose participation in the labour market may be limited by health problems (see Section 3.3). Consequently, poor health carries a high financial cost for the state, including the costs of treating avoidable illness and social security costs associated with poor health (Section 3.4).

4. Government, communities and business: the role of all sectors in creating health

A shift towards health creation cannot be delivered purely or even primarily by the health and care system or through focusing on individual responsibility. It requires organised efforts across all sectors, with government showing the required leadership.

Ensuring that everyone has the best possible opportunities to be healthy requires action across the whole public sector. Departments across central government have necessary and important roles to play in creating the conditions for good health and preventing avoidable ill health – whether through shaping local economies, providing services or, perhaps most importantly, through setting the tone for the national conversation (see Section 4.1). Nevertheless, many of the most important levers for creating healthy living conditions sit at local level, so place-based approaches led by local government need to be at the heart of the government’s approach to improving the nation’s health (see Section 4.2).

The public sector has an important role in investing in community infrastructure such as leisure, social care, crime prevention and housing. However, an effective approach to enhance and prolong health needs to extend well beyond the actions of the state. Strong communities are an important contributor to people’s wellbeing. Moreover, local communities are often best placed to know what is needed to improve their local environment (see Section 4.3). A whole-government approach, therefore, requires a commitment to create the structures and support that will allow local communities to participate as partners in a new approach to enhancing health and wellbeing.

While the strongest determinants of health lie outside of health and care services, the health and social care system has an important part to play (see Section 4.4). The NHS can reduce levels of poor health through its role as a direct provider of health care, as an employer, as a partner in local systems and as an anchor institution in local communities.

The private sector can play either a positive or negative role in creating health. As businesses have significant influence over the conditions in which people live and work, they can have a greatly health-enhancing influence on their employees and the communities which they are part of (see Section 4.5). Local and central government can shape the role of the private sector, both through regulation of health-harming products and by designing economies that share the benefits of economic growth.

5. Storing up problems for the future: the price of short-term approaches to government spending

A wide range of government budgets have an impact on people’s health, across social security, housing, children’s services and investment in the natural environment. A failure to take a long-term view of the value of investments that promote and maintain people’s health means that recent trends in government spending are storing up problems for the future.

At the national level, even accounting for real term increases in day-to-day departmental spending set out at the 2019 Spending Round, austerity has resulted in significant spending reductions across some areas of government that play a crucial role in creating the conditions for good health (see Section 5.1).

Moreover, current spending plans for future years appear set to tip the balance further away from investment in maintaining good health (see Section 5.2). For example, plans for NHS spending to make up an ever-greater share of government expenditure puts pressure on funding available for areas such as housing, social security and local services that are all vital for long-term health.

Analysis of local government spending (see Section 5.2) shows that, on top of large reductions in spending on areas vital for creating healthy places, there has been a dramatic shift away from proactive spending that maintains people’s life chances towards reactive, crisis management services. This is demonstrated most starkly in children’s services at local level (see Section 5.2). At national level, health spending has become increasingly skewed away from prevention, particularly through major cuts to the public health grant between 2015/16 and 2019/20 (see Section 5.3).

6. In it for the long term: What is needed to embed health across the whole of government and beyond?

Securing a future where everyone has the opportunity to enjoy the best possible health requires specific policy actions and investment in the right areas, but it also needs mechanisms that embed health and health equalities as a shared value across government and beyond. This requires government to show the necessary political will and leadership, to harness the full potential of opportunities in existing legislation, and to put in place structures that can counteract tendencies towards short-term decision-making and focus on a narrow range of issues. This will require government to:

• Change the way success is measured. Good health should be considered a primary measure of successful government. There are already examples of such approaches within the UK and internationally – most notably, New Zealand’s efforts to put non-GDP measures of wellbeing at the heart of government decision-making. This case provides an example of how using broader measures of success can create the right incentives for a shift towards long-term investment approaches within government (see Section 6.1).
• Embed long-term health considerations in legislation and policy across the whole of government. Mechanisms could include development of legislation such as the Well-being of Future Generations Act for Wales and the use of independent bodies to scrutinise and advise on health, in the way the Children’s Commissioner does for England (see Section 6.2).
• Prioritise investment in people’s health as one of the nation’s greatest assets. This will involve rebalancing investment towards health-creating areas of spending such as children’s services, housing and social security (see Section 6.3). Investment should begin with reversing cuts to the public health grant and making a commitment to maintain its value as a proportion of total health spending. In the longer term, finding ways to measure and monitor the balance between preventative versus reactive spending across government will be important to aid rational, long-term decision-making.
• Enable the NHS to play a stronger role in prevention (see Section 6.4), particularly as the integration of health and social care is set to progress rapidly in the coming years.
• Ensure that national policy enables coordinated, place-based approaches to improving health that involve communities and local government. Local government can provide leadership with other public-sector bodies but creating healthy social, economic, environmental and commercial conditions will only be possible with full involvement and participation of local communities in decision-making and action (see Section 6.5).

It will take bold political decisions at national government level and commitment over the long term to create the conditions for good health. There’s an opportunity now to set the direction for a healthier, more prosperous future.

This report has been developed as part of the Health Foundation’s long-term strategy to improve people’s health in the UK. It sits within a broader Healthy Lives programme of work aimed at focusing policy attention on the wider determinants of health, building evidence on the social and economic value of health and supporting action to address health inequalities.

Securing a healthier population over the long term requires a different conversation; one that focuses on people’s health as one of the nation’s greatest assets, rather than a preoccupation with the burden that arises from ill health.

The issues explored in this report are not new. Over several decades, independent reviews have been undertaken for the UK government that have drawn attention to widening health inequalities and called for urgent action. This includes the ‘Black Report’ on inequalities in health published in 1980,1 Sir Donald Acheson’s 1998 Independent Inquiry into Inequalities in Health, and Sir Michael Marmot’s strategic review of health inequalities in England, which concluded with the Fair Society, Healthy Lives report published in 2010.

There have also been notable previous attempts to implement health-creating policy change in England. Between 1997 and 2010, for example, there was a strategic government focus on tackling the underlying determinants of health and increasing social investment for the most deprived areas of the country. There is evidence that this approach led to a decline in geographical inequalities in life expectancy. But, such progress has been short-lived. Not enough has yet been done to create the foundations for a more sustainable framework for action – one in which people’s health is at the heart of every part of government as a shared value. The analysis presented in this report shows that recent trends in government spending, rather than investing in people’s future health, are instead storing up more problems.

This report argues for both investment in people’s health over the longer term and new mechanisms to embed a whole-government approach to creating good health. Action needs to be taken across the factors that have the strongest influence on people’s health, such as transport, education, social security, children’s services, housing and work. The seeds of a longer term and more holistic approach to health creation are already being sown across other nations of the UK, with opportunities to learn from the recent steps taken to create an enabling policy context in both Wales and Scotland. There is also much to learn from further afield, with New Zealand leading the way on embedding wellbeing at the heart of government. The consultation around the prevention green paper recently released by the government, Advancing our health: prevention in the 2020s, could provide an opportunity for progress, but only if supported by more fundamental change across wider government.

Social, economic, commercial and environmental conditions are the strongest determinants of people’s health. This includes people’s access to homes that are safe, stable and warm; the quality of their work; the availability of an adequate financial safety net; and a healthy, affordable food environment. There is abundant evidence that when the right conditions are in place, people lead long, healthy and productive lives.

Individual behaviour is part of the causal chain that links the wider determinants of health to avoidable illness, but there is strong evidence that people’s behaviour is highly constrained by their social, economic, commercial and environmental circumstances. For example, while good diet is a key driver of good health, approaches to changing what people eat that focus solely or primarily on influencing individual choices have been found to be extremely limited in their impact. There is good evidence that healthier diets are more expensive and that meeting basic nutritional guidelines is unaffordable for many families in the UK, who may face other barriers such as lack of access to healthy foods.

Moreover, there is abundant evidence that inequalities in health between different social groups are driven primarily by the conditions in which they live.,, Reducing major inequalities in health requires improvements in the wider determinants of health, particularly for people living in the most deprived communities. However, current trends in a number of areas suggest that conditions may be getting worse for many people rather than better, making the need for a whole-government approach to health improvement even more pressing.

Creating healthier lives in the UK therefore requires a significant reframing of how people understand what shapes their health. There needs to be a shift away from the individualistic ways of thinking that too often dominate discussion. As identified by recent Health Foundation analysis with the FrameWorks Institute, despite extensive evidence for the impact of wider determinants on people’s health, public discourse and policy action is currently limited in acknowledging the role that societal factors such as housing, education, welfare and work play in shaping people’s long-term health.

While bold political decisions will need to be driven forward at national government level to create the conditions that lead to good health, sustainable change will not take root without communities also participating in the agenda. The engagement undertaken as part of the Health Foundation’s Young People’s Future Health inquiry provides one example of how policy development can begin by developing an understanding of the concerns of people with lived experience.

This report begins by outlining the scale of the challenge the nation faces to improve health and reduce health inequalities, including an assessment of how England fares compared to other countries (see Section 2). It goes on to demonstrate the social and economic impact that poor health is having, as well as the potential for far-reaching benefits from improving health (see Section 3). Every sector in society has a role to play in improving health – Section 4 outlines the contributions needed from central government, local government, communities, the health and social care system, and the private sector. Section 5 examines recent trends in government investment, showing the tendency for short-term priorities to skew spending away from long-term investments in health towards reactive services. Finally, Section 6 considers the implications for policy, outlining a range of ways in which health can be embedded as a shared value across the whole of government and beyond.

3.1 Impact of health on wellbeing

The health of its population is one of any nation’s greatest assets. Good health improves people’s wellbeing, their productive capacity and their ability to participate in society. As such, it is an important contributor to a successful economy and a thriving society.

However, a study by Newton et al estimated that around 40% of health care provision in the UK is used to manage conditions that are potentially preventable. This is a lost opportunity for individuals and society.

Repeated studies have found that people’s health status affects their subjective wellbeing. Indeed, comparisons across countries show that health status has one of the largest impacts on a nation’s wellbeing. In the UK, people with ‘good’ self-rated health are more likely to be satisfied with life, less likely to be anxious, and more likely to be happy and feel that life is worthwhile.

3.2 Impact of health on communities and society

Good physical and mental health allows people to play an active role in society and their local communities. For example, the Community Life Survey (2017/18) found that disabled people or those with long-term limiting illness were less likely to have someone to socialise with or feel they belong to their neighbourhood. The same survey found that 13% of disabled people or those living with long-term illness often or always felt lonely, compared to 3% of people living in good health. A number of studies have also highlighted the often profound effects of living with multiple health conditions, finding that people living with multiple health conditions have poorer quality of life, difficulty with everyday activities and often experience isolation as a result of reduced mobility.,,

There is some evidence, too, that inequality can damage communities. For example, income inequality, which is closely linked to health inequality, is linked to higher rates of crime and lower social cohesion. It is important to recognise that these inequalities do not simply arise from different levels of education or employment, other barriers (such as discrimination) can limit people’s ability to access good employment and housing.

3.3 Economic impacts of poor health on workforce supply and productivity

Poor health has significant economic consequences for both society and individuals. For individuals, poor health can mean they are unable to participate in the labour market altogether, or it can limit the amount or nature of the work they do.

Figure 8 highlights the scale of the gap in economic activity between those who report a long-term health condition and those who do not, by age. In 2018, 31% of the working age population (aged 16–64) report that they have a long-term health condition. People with a long-term health condition have an economic activity rate of 68% – a fifth lower than for those without such a condition. As might be expected, it is a gap that gets wider with age, increasing from 5% for those aged 16–24 to 20% for those aged 55–64.

Figure 8: Employment rates for people with and without a long-term health condition, by age group, UK, 2019

Source: ONS, Quarterly Labour Force Survey (LFS), 2019 (quarter 1).

Poor health can affect an individual’s productivity through missed days of work or reduced performance. Analysis by the Health and Safety Executive shows that there were 26.8 million working days lost to work-related ill health in 2017/18. Although this was, on average, just under one day lost per worker across the entire population, this was not evenly distributed; those who were absent for health-related reasons were, on average, likely to miss 16.5 working days. Stress, anxiety and depression accounted for 15.4 million lost working days, with those affected missing an average of 25.8 days of work. A large proportion of the illnesses causing a loss of working days are likely to be avoidable.

‘Presenteeism’ – turning up to work when unwell – can also reduce productivity at work or lead to lower quality of work because people spend less time on tasks compared to those who are well. The European Working Conditions Survey 2015 found that 59% of workers in the UK reported working when sick at some point in 2015.

Poor health can also compound economic difficulties for the individual. For example, people who have excellent health have been shown to earn 4–7% more than those with average health after controlling for other characteristics, while people experiencing health shocks (measured by large declines in an index of different health measures) have been found to be more likely to enter retirement at younger ages.

Differences in employment because of people’s health status have consequences for individual incomes. For example, analysis from the Institute for Fiscal Studies has shown that those of working age in poor health are 50% more likely than healthy individuals to experience income poverty. Health status also has important implications at an aggregate level for the national tax base and economic dependency ratios (the number of non-working people for each person in paid employment). A population that is supported to remain fit, healthy and working for longer can both increase tax revenues through a larger, more productive workforce and can reduce the costs of supporting an ageing society.

Figure 9: Mortality rate by age and Townsend deprivation quintile, men

Source: Health Foundation analysis using ONS, mortality rates by deprivation decile.

Health inequalities are not simply an injustice for the individuals affected but are also a lost opportunity for the national economy. Less productive local areas of the economy are related to areas with poorer health. The causal links between low productivity and health in local areas are complex and poorly understood at present. A previous Health Foundation publication – The nation’s health as an asset – outlined a programme of research that is currently underway at six research institutes across the UK to try to improve understanding of these issues. However, a population’s health is an important determinant of potential labour supply. As Figure 9 shows, by 65 years of age, 21% of men from the most deprived fifth of areas in England and Wales will have died: more than twice as many as men from the least deprived fifth (9%).

3.4 The cost of poor health to the public sector

Avoidable poor health carries a high financial cost for the state, manifesting across several different areas of government spending, including the costs of treating illness in the NHS, the costs of supporting people whose poor health means they need assistance from the social care system, and the costs to the social security system through a range of benefits. In analysis for the Chief Medical Officer’s annual report, the Institute for Fiscal Studies estimates the total cost of all of these at around £200bn or 7% of GDP in 2016/17. Moreover, the costs across these different areas of spending have been rising both in absolute terms and as a proportion of GDP. As recently as 2001, the cost was lower at about 5% of GDP, or £80bn in 2016/17 prices.

While not all these costs can be avoided, poor levels of health in a population have major economic and social impacts. Comparisons between areas with better and worse health give some indication of the scale of that impact. For example, there is greater entitlement to Employment Support Allowance (ESA), an ill health income-replacement benefit, in the most deprived 10% of areas – with 7.7% of the working age population in England in 2018 in those areas in receipt, compared to 3.3% of those in the least deprived areas.

4.1 The role of central government

Creating healthy social, economic, commercial and environmental conditions for people’s lives is a responsibility shared across all levels of government. Key determinants of health include housing, education, transportation, work, the environment and the quality of a person’s physical surroundings.

Taken together, it is clear that many parts of central government have a role to play across the spectrum of activity to maintain and improve health. Many factors are also the responsibility of more than one government department. For example, poverty has long been recognised as cutting across several policy domains and is itself a common factor underlying many of the conditions that result in avoidable illness.

Often policy success stems from a combination of policy levers and joint cross-government action to achieve a shared aim (see Case Study 1 on smoking legislation for an example). There are four main channels of government influence, which in the UK tend to be delivered from the centre, and to a lesser, but increasing, degree through forms of local government:

1. Taxation: Taxes are well known to affect the behaviour of companies and individuals through their effect on the prices of the goods and services they are levied on. Some taxes are designed specifically to reduce consumption (such as the high rate of tax imposed on tobacco products or, more recently, the soft drinks industry levy). Evidence suggests that taxing unhealthy foods, tobacco and alcohol can be beneficial to health and health equity.
2. Regulation: The control of particular goods, services or activities have proved to be highly effective for tackling public health issues, especially on a national scale. The 2007 smoking ban exemplifies the large health impact such legislation can have (see Case Study 1) but this also includes road safety measures, work standards, and gambling and alcohol licensing.
3. Spending: This can take two main forms, the first being direct transfers to redistribute income, which from a health perspective can be important in alleviating poverty and reducing inequality. Second, directly funded service provision or investment in infrastructure can play a redistributive role, such as the provision of universal education. The balance of spending between proactive, health-creating services and reactive services is an important lever explored in detail in Section 4.
4. Information: The provision of information can help people, businesses and other institutions to make more informed choices about the types of activities they engage in, or the goods they consume. However, it is important to understand the constrained choices people can be faced with when seeking to influence their behaviours.

An effective strategy to maintain and improve people’s health will need to maximise the use of all four of these levers in a concerted fashion. However, over and above the technical levels of government, it is the tone it sets for the national discourse that is important.

This will require governments to frame their measures of success in terms of investing in the long-term health outcomes of the population and reducing health inequalities, and will also require them to put in place coherent policy frameworks that span central and local government, communities, business and voluntary sectors. Potential approaches are discussed further in Section 5. Other practical attempts to improve health and health equity through cross-sector action are also explored in the Health Foundation’s case study collection, Implementing health in all policies: lessons from around the world.

4.2 The role of place-based approaches led by local government

While place may not be an absolute determinant of outcomes, it profoundly shapes experience, expectation and opportunity, and has implications for long-term health and wellbeing. The extent to which people have access to the spaces, services and social networks they need to lead healthy lives varies considerably across the UK. The power of place in influencing people’s health outcomes indicates that a comprehensive and integrated place-based approach, underpinned by national investment – particularly for those areas experiencing the greatest deprivation – needs to be adopted as a core component of any strategy to improve people’s wellbeing and health.

Alongside the development of an enabling national context that regulates and invests to lay the foundations for good health across the country, local authorities have a pivotal role to play in creating health in their communities. They have responsibility to deliver many of the local services that support good health and the devolution agenda means that there is increasing opportunity for locally determined policy. For example, local authorities can do the following:

• Deliver early years services that bring long-term benefits for children through creating healthy educational and social environments at crucial points in their lives. By supporting a child’s early physical, social and cognitive development, these services in turn influence their school-readiness, educational attainment, economic participation and adult health.
• Design transport systems that are accessible, affordable and support those least able to travel. This also has the potential to transform a place and enable healthier lives, opening up access to jobs, markets and goods, social interaction, education and a range of other services.
• Provide public services such as libraries, which can create a wide range of health-promoting conditions, such as encouraging reading and literacy, supporting local businesses and providing spaces for people to meet and socialise. Research suggests that people who use libraries frequently report better wellbeing and visit the GP less.
• Provide financial support for services such as Citizens Advice that help resolve benefits, debt and housing problems, as well as offering information and advice on health issues. Citizens Advice estimates that, for every £1 invested in the service in 2018, it saved the government and public services £1.88 and generated over £11 in public value.
• Through their economic development role, create inclusive economies, that work for everyone. Places can do this by using data to understand the ways in which local economies influence health and health inequalities in their local population (for example, by developing interventions that address health-related barriers to employment, and by working to ensure that the jobs being created locally are beneficial to health). As Case Study 2 illustrates, large organisations can act as anchor institutions – using their procurement, employment and estates to deliver added benefit to their local community and economy in line with the Social Value Act 2012.

In addition to the services that it directly delivers or funds, local government has an important role to play as a convener and leader in local areas. Local government can promote health through working differently with local businesses and voluntary, community and social enterprise organisations. For example, civic leaders can encourage businesses with a strong record on workforce wellbeing and procure services from local organisations that benefit the community. A key part of the role of local authorities, therefore, is creating the conditions in which other sectors can flourish and make a positive contribution to health.

The current focus on rolling out social prescribing schemes that enable workers to connect with local groups and support services – as advocated within The NHS Long Term Plan and referenced within the Prevention is better than cure vision – should also be viewed within this context. While social prescribing services may have an important preventative role to play, such schemes will not be sufficient on their own to ensure action across the wider determinants of health and must be underpinned by wider place-based approaches led by local government. Indeed, many social prescribing services provided by the voluntary sector are directly supported by local government, with cuts to local authority budgets likely to have a harmful impact on their ability to support and empower local communities.

It is vital that national strategies should not impose top-down priorities on local areas where they may be inappropriate. Similarly, at local level it is vital that strategies to improve health should be co-created with local communities rather than being imposed by officials. Local authorities have a critical role to play, therefore, in working alongside local communities to plan and design effective local responses to improve their health and wellbeing and to tackle inequalities.

4.3 The role of communities

A whole-government approach is needed to create good health, but it would be a mistake to think that government alone can create the conditions needed for healthy lives. The approach needs to extend well beyond the public sector, with communities and families being a fundamental part of the health environment. Not only are strong communities and families a vital contributor to people’s wellbeing, it is also important for the public sector to acknowledge that local communities are often best placed to know what is needed to shape their local environment. An effective whole-government approach to health creation requires a commitment to invest in policies that build and strengthen communities and enable local communities to fully participate in shaping their local areas and the services they receive.

Relationships are a vital part of people’s lives and there is growing evidence of their importance for health. Loneliness is known to be a strong predictor of poor health and living alone is associated with increased health care use. By contrast, people with high levels of social capital (ie strong networks of relationships) are likely to have better health. However, there is evidence that individual social capital seems to be a significant contribution to health only when people live in regions with sufficiently high community social capital. This highlights the importance of building strong communities that have high levels of trust and strong social connectedness.

The role of government in building strong and healthy communities is two-fold. First, investing in community infrastructure has been found to improve social relations and wellbeing in a community. Community infrastructure – places designed for people to meet – includes public places and spaces where people coincidentally meet such as squares, parks, play areas, village halls and community centres. Other places that have a dual role in allowing people to meet include libraries, schools and places of faith and spirituality. Recognising the value of these to individual and community wellbeing and investing in community infrastructure is an important part of a whole-government approach to creating health.

Equally important, however, is the need to give local communities a meaningful role in shaping the places where they live. Local government has an important part to play in facilitating co-production of its services and its place-making by working in partnership with communities, while central government needs to put in place an enabling policy environment to support co-production and community participation in decision-making.

4.4 The role of the health and social care system

Last year in England there were 307 million GP practice appointments, 93.5 million outpatient appointments and 24.8 million A&E attendances. Many of these appointments and interactions with the health service were for conditions that are largely preventable, and which have a significant direct cost to the NHS. In addition, the NHS is the largest employer in the UK (employing 1.6 million people) and has a significant economic influence across most regions of the UK. All of these factors provide an opportunity for health care services and organisations to do more to focus on prevention and contribute to improved health for local communities.

Too often, the NHS is seen solely as a sickness services, and a prevention strategy should recognise and support the wider impact the NHS can have on prevention and population health. Not only does there need to be more coherent and systematic implementation of cost-effective preventative interventions and services, but all care pathways and services need to emphasise prevention. Nor can the NHS operate without greater awareness of how people’s circumstances affect their ability to be full partners in their care. Services need to understand and address this wider context. Examples of such interventions funded by the Health Foundation include: a community-based clinic to reduce social isolation and anxiety for people with severe chronic obstructive pulmonary disease; a physical health intervention for young people with psychosis; and a youth violence intervention programme based in hospitals.

Beyond provision of services, local NHS providers and commissioners need to find opportunities to participate in initiatives that shape the wider community within which they operate and ensure they are advocates for health creation.

Prevention and population health are central to greater integration of health and care at a place-based level and need to involve working in collaboration with partners across local government and the wider public sector. There is more scope for the development and use of linked data in local planning systems. The linking of electronic health records to data from local authorities, mental health providers in schools, and other providers of health and care services (including voluntary sector) can improve understanding of inequalities in access, care quality and outcomes across the full range of services that can impact on health. This will enable better monitoring of people’s health and enhance understanding of the relationship between health outcomes and wider determinants.

As the country’s largest employer, the NHS has a responsibility to act as a role model to provide good physical and psychosocial working conditions, as well as to advocate for improved health and wellbeing of its staff and communities. More locally, the NHS is often the largest economic force in local communities (an anchor institution). The NHS can have far reaching impact by intentionally leveraging its resources and activities to maximise social value and contribute to wider economic and social wellbeing in a place in order to create healthy local areas. The roles it can fulfil are as a:

• Major employer: The NHS can act as an important ‘ladder into employment’, particularly for underserved or disenfranchised populations.
• Large purchaser: Procurement and commissioning practices can be used to build community wealth and derive greater social benefit for local populations by shifting more spending locally, and working with suppliers that help achieve broader social and economic objectives.
• Significant owner of capital estate and property: Using its buildings and lands in a way that maximises population welfare.
• Leader on environmental sustainability: Using its position to influence others and adopting practices to improve environmental sustainability.
• Partner across a place: Working collaboratively with others, the NHS can learn, spread good practice and model civic responsibility to have a greater impact on community development.

4.5 The role of the private sector

While the role of government is crucial, the step-change needed to improve the nation’s health and reduce health inequalities cannot be achieved by the public sector acting alone. The private sector has an important role to play in creating the conditions that allow people to live healthy lives. Embedding health creation as a goal for all sectors will be necessary to see the desired improvements in people’s wellbeing and health.

Businesses have the potential to play either a positive or a negative role in creating a society that keeps people well and avoids preventable illness. Businesses can influence health through their role in producing and marketing potentially health-harming products (including tobacco, alcohol, food and drink) and their role as employers, as well as through the impact they have on their local – and the wider – environment.

The role of government regulation and taxation of commercial products is explored above (see Section 3.3). There is also a wider potential role for government to reward or recognise good practice in the private sector and to encourage or require further measurement of the health impacts that businesses have. This would ideally take into account all of the impacts, from those on consumers to those on employees and supply chains.

Beyond the role and impact of individual businesses, there is a role for government (at both local and national levels) to design and incentivise inclusive economies that share the benefits of economic growth with all sections of society. Over the long term, reducing poverty and creating economic opportunities for all sectors of society may be a significant strategy for addressing health inequalities.

5.1 How trends in central government expenditure are storing up problems for the future

Since 2010, reducing the extent to which annual government revenues are exceeded by spending, and reducing the existing stock of debt, have been a core focus for government. This has largely been achieved by reducing spending, as opposed to increasing tax revenues, with net debt falling as a share of GDP since 2017/18.

With some areas of spending protected, there have necessarily been larger than average reductions in spending across other areas of government (see Figure 11). Current spending plans suggest that this trend is set to continue, with many of these areas playing a crucial role in creating and maintaining the conditions that lead to good health – such as education or local government services. Under-investment in such policy areas that create the conditions for a healthy life risks significant problems being stored up for the future.

Social security

Social security is an example of government spending that helps protect people’s health. Around 28% of government spending is on social security, and the majority of that support (excluding most State Pension provision) is targeted at the most vulnerable in society – people who are out of work, disabled people, people with long-term illnesses and people with low income. This provision of supplementary income helps to protect the living standards of the most vulnerable and, in doing so, their health.

Targeted support through the Tax Credit system and Pension Credit has had some success at reducing poverty among children and pensioners since their introduction in the late-1990s. However, while pensioner benefits have been protected since 2010, working age support has been subject to a series of cuts that are set to continue until the end of the decade, as shown in Figure 10.

Figure 10: The changing generosity of working age welfare and percentage of children in poverty, index (100=2013/14), constant price terms (GDP deflator)

Note: Data from 2018/19 onwards are projections.

Source: Health Foundation analysis using Spring Statement 2019 Benefit Summary Table; Households Below Average Income, DWP.

Social security spending is measured on a per person basis across the non-pensioner population; that is, taking into account all those of working age, not just those receiving benefits. This makes the measurement sensitive to the number of people receiving benefits. On that basis, social security spending increased in 2009/10 due to a rise in unemployment and falls in earned income that led to higher overall spending on unemployment benefit and tax credits. The reduction in spending since 2012/13 – to below pre-financial crisis levels – partly reflects further falls in unemployment but also reflects a series of cuts to working age support. The largest of these were introduced in the Summer Budget 2015 and will mean further reductions in generosity across the rest of this decade. Resolution Foundation analysis anticipates that these cuts are likely to lead to nearly 35% of children living in poverty, a level not seen for two decades, with the accompanying risks to health outcomes. In comparison, pensioner poverty is expected to remain broadly flat over the period after experiencing significant reductions since the turn of the century.

5.2 Likely implications of future government spending plans

The spending plans set out in the 2019 Spending Round are intended to end the era of austerity with real term increases for all day-to-day spend of all departments announced in the 2019 Spending Round and overall departmental spending set to rise on a per capita basis. However, spending plans beyond 2020/21 are yet to be set out and large commitments to increase NHS funding are likely to mean that budgets for other departments will come under pressure, continuing the broad pattern of the last decade where NHS spend has represented a growing share of government spend (see Figure 11).

Figure 11: The differing impact of austerity across government departments, 2009/10 to 2020/21, real change in departmental resource budgets (resource Departmental Expenditure Limit per person, GDP deflator)

Source: Resolution Foundation, Rounding up: putting the 2019 Spending Round into context.

Even with the increased spend for 2020/21 set out at the 2019 Spending Round, compared to 2009/10, there have been substantial reductions to most government department budgets; the exceptions being international development (which accounts for a relatively small share of spending), the home office (following the 2019 Spending Round) and health and social care. By 2020/21 per person spending on health and social care is expected to be 14% higher than in 2009/10, while departments from education to local government will experience reductions of 11–77%.

There are already signs emerging that the drift away from expenditure that maintains wellbeing and health is leading to the emergence of considerable public health challenges – both in the short and long term. Ultimately, this approach creates a false economy. Underfunding preventative services and inadequate action across the wider determinants of health will only further increase pressure on the NHS and other crisis services. Such short-termism cannot continue as the demographic shifts towards an ageing society, which will bring its own pressures on government finances through both increased demand for services and pensions for the older population, and a relatively smaller working age population to provide the revenues to fund that support.

However, governments face a conundrum. The upfront investment required to maintain people’s health over the long term, while providing enough support to the current population with acute need – both older and younger – will require higher levels of spending. The next big debate will need to be about where those revenues come from. Investments in strategies that maintain and improve the nation’s health should not be considered solely as a ‘cost’. An effective strategy that places people’s health as a primary asset could in itself help improve the long-term fiscal picture, with a healthier population reducing future costs of poor health and increasing the productivity and activity rates of the population to fund those necessary services.

In a context of fiscal austerity and rising demand, the capacity for local authorities to focus on the strategies that support better health and wellbeing has been eroded. There have been substantial reductions in central funding to local authorities since 2009/10. The often statutory nature of services that are required to meet immediate needs and the discretionary nature of preventative spending has meant that, to stay within budgets, cuts have disproportionately targeted activities that maintain and protect health.

This is most starkly illustrated through the changing patterns in spending on children’s services and housing. While cases are few relative to the total population, being homeless or in the care system is associated with considerable health challenges. Cases of severe need increased at the same time as spending has shifted from prevention to meeting these needs (Figure 12). This creates the risk of a cycle, whereby prevention spending is cut to meet crisis need, thus fuelling greater future need.

Figure 12: Indexed changes in measures of severe need for housing and children’s services, England, 2010–2018

Source: Ministry of Housing, Communities and Local Government (MHCLG), Live Tables on Homelessness; Department for Education, Looked-after Children.

Children’s services

Children’s services encompass a range of activities from proactive early intervention, such as spending on youth centres, family support and children’s centres, to reactive, late intervention, which includes youth justice, and support for ‘looked-after’ children. ‘Looked-after’ children experience poor outcomes across a range of measures, including educational attainment as well as physical and mental health.

Figure 13 shows that spending by local authorities in England on children’s services between 2013/14 and 2018/19 has fallen by 2.9% in real terms. At the same time, the focus of that spending has changed considerably. By 2018/19, the share of spending on reactive services (children in need or ‘looked-after’) had reached 73%, up from 64% in 2013/14. There has been an increase in both the total amount spent and the share of what is an overall smaller budget for children’s services in the period. The share spent on preventative services has fallen from almost a third (32%) to less than a quarter (24%).

This increase in spending on more acute need appears to be a result of the growth in the number of children in the care system. With a statutory obligation to provide care, spending has increased: there were 75,000 children ‘looked-after’ in the year ending March 2018, up by 2,800 on the previous year and an increase of 7,350 (11%) on five years earlier.

Figure 13: The changing pattern of spend on local children’s services, England, 2013/14 to 2018/19, constant 2019/20 price terms (GDP deflator)

Source: Health Foundation analysis using Department for Education, Children, Schools and families financial data collection, 2013/14 to 2018/19.

The drift of spending away from prevention has important health implications. For example, a recently published evaluation of the Sure Start children’s centres programme found that it significantly reduced hospitalisations among children by the time they finish primary school. Importantly, the benefits of the programme were found to be greatest for children living in the most disadvantaged areas. The two-thirds reduction in funding for the programme (from £1.8bn in 2009/10 to £600m in 2017/18) is likely to have had a detrimental impact on children’s health and health inequalities.

Local housing provision

Rough sleeping is associated with tri-morbidity (physical and mental ill-health combined with substance misuse) and an average age of death 30 years shorter than the general population. The health care costs associated with homelessness are much higher per person, for example.

As well as being harmful to the health of those experiencing severe need, the risk is that cuts to preventative services will lead to further growth in reactive need and, ultimately, higher spending. For example, a study looking at the rise of homelessness in local authority areas found that reductions in local authority housing spending (including prevention spending) led to higher rates of homelessness. It also found a similar effect across a broader range of programmes not specifically designed to prevent homelessness, such as adult social care and other areas of social security.

Figure 14 shows that spending on homelessness activities has increased by a quarter since 2009/10, rising from £1.1bn to £1.4bn by 2017/18 (in 2019/20 real terms). Within that, however, the greatest increase has been in provision of temporary accommodation – a rise of £0.4bn since 2011/12 – rather than prevention to avoid homelessness in the first place.

Figure 14: The changing pattern of local authority spend on housing, 2009/10 to 2017/18, constant 2019/20 price terms (GDP deflator)

Source: Health Foundation analysis using MHCLG, Local authority expenditure data: 2009/10 to 2017/18.

5.3 Health spending increasingly skewed away from prevention

Within the Department of Health and Social Care’s expenditure there has been greater protection of spending on more severe needs via the NHS, while support to local authority public health services that help prevent ill health in the first place has been reduced (see Figure 15). Between 2015/16 and 2019/20, spending on NHS England is expected to have grown by 8% on a real term per head basis, relative to a 23% cut in the public health grant since allocations were first set out for 2015/16. This is despite recent analysis that found 75% of public health interventions reviewed by NICE were either cost-effective or cost-saving over time.

The public health grant supports prevention services and enables directors of public health to influence the determinants of health at a local level by working across other departments in local authorities.

The public health grant, currently £3.1bn a year, was first introduced in 2013/14. At this point, responsibility for preventative services – such as sexual health clinics, stop-smoking support, and drug and alcohol abuse services – moved from the NHS to local government. Responsibility for services for children aged 0–5 years was also moved to local government in the middle of 2015/16, with the annual equivalent of an additional £0.9bn a year of funding. But the total value of the public health grant has declined (in real terms) since 2015/16.

Figure 15: Growth in elements of health spend per person, 2015/16 to 2019/20, index (100=2015/16), constant price terms (GDP deflator), England population (all ages)

Source: Health Foundation analysis using Department of Health and Social Care, departmental spend; and MHCLG, Local government finance and expenditure, various.

The public health grant allocation for 2019/20 was £850m lower (23% lower in real terms per person) than when the grant was implemented in 2015/16. The 2019 Spending Round announced a real term increase in the grant for 2020/21, but this is likely to fall significantly short of the additional £1bn required to reverse real term per capita cuts since 2015/16. Nor is the increase in the public health grant likely to keep pace with growth in frontline NHS services. The result is that, since 2015/16 the public health grant represents a decreasing share of total health spend.

Making the case for public health interventions against health care treatments (in the context of the share of health spending dedicated to acute or preventative measures) can be difficult, given that the former tend to be assessed on an overall return on investment (ROI) basis and the latter in relation to the cost per quality-adjusted life-year (QALY). Research into the ROI from local-level public health measures suggests a typical return of 14:1 – that is, society benefits by an average of 14 times the initial investment into each intervention. There can be a wide range of returns, depending on intervention type and the geographical level (national or more local) at which it takes effect. For example, regulatory measures such as smoking bans (typical ROI of 46.5), health protection such as immunisation schemes (typical ROI of 34.2) and social interventions such as working with young offenders (typical ROI of 5.6). However, this research indicates that there is a clear case for greater ‘upstream’ public health investment.

6.1 Change the way success is measured

Good health is a country’s greatest asset but is not considered a primary measure of successful government. There needs to be new ways of measuring policy success, moving beyond traditional economic indicators such as GDP and encompassing wider metrics of population wellbeing and health equity. This would enable policies to be evaluated in terms of their contribution to health and wellbeing as well as their economic impacts, and would incentivise all areas of government to put health and wellbeing at the heart of policy.

A leading example of this approach comes from New Zealand which, in 2019, became the first country to commit to setting budgets on the basis of wellbeing rather than economic growth (see Case Study 3). The prevention green paper recently released by the government committed to developing and launching a new ‘Composite Health Index’, a policy that was originally recommended by the former Chief Medical Officer for England in her 2018 Annual Report. This could be a useful tool for embedding health as a shared value, but will only have the necessary impact if it is based on meaningful measurement of people’s wellbeing and health. If it is used in policy evaluation right across government, it could help to embed an approach that views health as one of the nation’s primary assets. Further research has also found that public health expenditure is three to four times as productive at the margin than health care expenditure, adding to the case for greater investment in public health.

6.2 Embed long-term health considerations in legislation and policy for the whole of government

A long-term, cross-government approach is critical to improving health and reducing health inequalities nationally. However, short-term political cycles act against this. As outlined in the Health Foundation’s report, Shaping Health Futures, governments in the UK have often found it difficult to plan and prepare for the future – for health and social care as well as on infrastructure, tax and other policy areas. Legislative frameworks are increasingly being used in other parts of the UK to help public bodies break out of short-term decision-making cycles and take a long-term approach to improving health and wellbeing. For example, in 2015 the Welsh government enacted the Well-being of Future Generations (Wales) Act, which placed a duty on public bodies to work towards improving the health and wellbeing of both current and future generations. Case Study 4 illustrates how public bodies in Wales are working differently since the introduction of the Act, and what can be learned from their experiences.

A legislative framework of this kind would need to consider health and wellbeing in the widest sense, including the social, environmental, commercial and economic conditions people live in. It could be designed to ensure that government investments are evaluated in a way that recognises the long-term value of health and wellbeing to society as a whole. While more could be done to ensure that existing legislation – such as the Public Services (Social Value) Act 2012 – is used to its full effect, more wide-ranging legislation could be a powerful tool to drive change.

Legislation on its own, however, is unlikely to be sufficient unless structures are put in place to support its implementation. For example, it would be helpful to establish a high-level cross-government working group or committee, ideally with Cabinet-level accountability, with responsibility for overseeing the implementation of a whole-government approach to keeping people healthy and reducing health inequalities.

Similarly, embedding long-term decision-making at the heart of government could be aided by an independent public body, which is able to scrutinise government policy and provide independent, expert analysis. Examples of such bodies include the Future Generations Commissioner in Wales, the Children’s Commissioner for England and the Office for Budget Responsibility for the UK. Case Study 5 gives further analysis of what can be learned for existing bodies of this kind. Establishing a commissioner to provide independent analysis of trends in the nation’s health and advise on the actions required to address health inequalities could be an important way of embedding health creation across the whole of government.

6.3 Invest in people’s health as one of the nation’s primary assets

Government should explicitly acknowledge good health as one of the country’s greatest assets and prioritise long-term investment in health across the whole of the public sector. Investment across government needs to be rebalanced towards health-creating areas of spending such as children’s services, housing and social security. In order to counteract past and (planned) future trends away from spending that keeps people healthy (outlined in Section 5), mechanisms are needed to review the balance of health-promoting versus reactive spending across and within different areas of government. One specific area of investment that should be addressed is the public health grant (see Section 5.3).

However, changing the circumstances in which people live is not simply a question of government spending. Other levers, such as social protection through regulation and taxation, can be used to promote a general shift towards creating health, with particular attention given to those strategies that most effectively support communities experiencing the greatest deprivation. Specific areas of focus could include:

• action to improve the quality of housing by enforcing health-informed minimum housing standards and addressing the quality of homes built outside of the usual planning system through ‘permitted development’
• extending ‘polluter pays’ regulation and taxation of health-harming commercial products. This could include extending the Soft Drinks Industry Levy to other products with negative impacts on people’s health
• supporting early years development including through measures to address child poverty and re-invest in local early years services, which have seen major funding cuts in recent years
• proposing amendments to the UK Corporate Governance Code to require businesses to report on their impact on the health and wellbeing of employees, customers and communities.

6.4 Enable the NHS to take a stronger role in prevention

A whole-government approach to creating health also needs to include the NHS. The role of the NHS is explored in detail in Section 4.4, but key principles for ensuring that health creation (as opposed to health care) is embedded in the way the NHS works include:

• ensuring that prevention and population health are at the centre of moves towards greater integration of health and social care
• encouraging or requiring NHS organisations to work in collaboration with local government and the wider public sector to support a place-based approach to prevention
• supporting the development and use of linked data that could be integrated into local planning systems, to enable better monitoring of people’s health and enhanced understanding of the relationship between health outcomes and wider determinants
• systematically implementing preventative interventions that are known to be cost-effective but are not currently used consistently across the NHS (for example, smoking cessation services)
• promoting the role of the NHS as an anchor in communities. NHS organisations should act as a role model and advocate for the improved health and wellbeing of their staff and communities, working alongside other anchor institutions including local authorities, universities and housing associations.

6.5 Enable coordinated, place-based approaches to improving health and reducing health inequalities

While there is a great deal that can be done by central government, locally-led approaches are also vital. Central government has a role to play in creating the conditions that can allow genuinely locally-led approaches to improving health and reducing health inequalities. The devolution of power and budgets to the Greater Manchester region is a leading example of this approach (see Case Study 6).

Central government needs to create the conditions for locally-led, place-based approaches to improving wellbeing and health by giving local governments the responsibility, powers and funding needed to create healthy living conditions. As outlined in Section 4.3, it is vital that communities are empowered to be part of the decision-making process and that the value of community infrastructure is recognised and given appropriate investment. This may require significant changes in the relationship between local government and residents.

The Wigan Deal is an example of an approach that has successfully engaged local people in working with the local authority through taking an asset-based approach to community engagement. The Deal is credited with boosting rates of volunteering and recycling in the borough as well as helping to ease the pressure of adult social care services. Although the council faced severe budget cuts, as part of the deal £10m was invested in the community sector to empower hundreds of community groups.

This report shows that the government’s recent short-term spending decisions over the past 8 years are already widening inequalities in health outcomes and storing up problems for the future. This position is not sustainable. It will take bold political decisions at national government level and commitment over the long term to create the conditions for good health. This is the time to set the direction for a healthier, more prosperous future.

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