“Why treat people and send them back to the conditions that made them sick?”

Michael Marmot

The Health Gap: The Challenge of an Unequal World

Adopting a social determinants of health approach

People’s health is influenced by political, social, economic, environmental and cultural factors. These factors shape the conditions in which we are born, grow, live, work and age. They are affected by the distribution of power, money and resources across society.

Although at lower income levels the health of a population is related to GDP, above a certain threshold this relationship becomes a lot more complex. This tells us that health is not just about wealth. For example, the US has a lower life expectancy at birth than less wealthy countries including France, Sweden, Spain, the UK and Japan., Furthermore, the US spends more on health care than the UK, yet has higher prevalence of conditions such as heart disease, diabetes and cancer.

The social determinants model is important because it seeks to identify the ‘causes of the causes’ – for example, the inequality in social and economic conditions that may explain a child developing asthma due to poor housing conditions and lack of access to green space, or the psychosocial effects of a low-paid, temporary job on a worker’s risk of experiencing chronic stress and developing cardiovascular disease. These conditions are largely, or completely, outside of an individual’s control.

“Most of the determinants of health have nothing to do with health services and have everything to do with broader public services, the environments in which we live, and people’s opportunities to lead healthy lives.”

Naomi Eisenstadt

Healthier lives: a listening exercise

Unequal distribution of social determinants contributes to disparities in health – for example, in Scotland life expectancy at birth is usually higher in the least deprived council areas compared to the most deprived council areas (as measured by the Scottish Index of Multiple Deprivation).

Work on the social determinants of health has been underway for decades; however, recent publications such as the 2008 WHO Closing the gap in a generation report and the 2010 Marmot Review have contributed to their increasing recognition. In England, over 70% of local authorities are now working towards implementing the Marmot review’s six policy recommendations.

Taking a systems approach

Complexity theory and systems thinking are important frames for considering action for improving health. They consider the numerous interactions between multiple parts of a given situation and the adaptations that arise from these interactions. The idea of finding a modern-day ‘pump handle’ to solve the problem of, for example, obesity is alluring in its simplicity. However, the reality of the current environment and the vectors of modern diseases means that, as one system property changes, the system self-modifies. This is sometimes positive – reinforcing and amplifying health-enhancing habits – but can be negative, making goals harder to reach. Fundamentally, when working in systems ‘the single most important intervention is to understand that there is no single most important intervention’.

“Systems change aims to bring about lasting change by altering underlying structures and supporting mechanisms which make the system operate in a particular way.”

Pennie Foster-Fishman

How to create systems change


Taking a systems approach emphasises the importance of looking beyond the tangible intervention and understanding issues including: the wider conditions within which the intervention was developed (eg how problems and the need for change were identified); how ideas and solutions were generated; how motivation was harnessed; and the underlying attitudes and beliefs of those involved in the intervention. Particular focus is needed on:

• the less tangible aspects of an intervention that may influence how it plays out – for example, behaviours and attributes of those leading the initiative, the relationships between the formal agencies and the community or environment
• potentially unexpected consequences of the intervention’s interaction with elements of the wider system – for example, moves to reduce the amount of fat in biscuits and cakes to create products marketed as ‘lower fat’ or ‘better for you’ have in some cases led to increases in the sugar content and no reduction in calories.

Seeing health as an asset

Although the health of the UK population has seen improvements in the last 50 years, we nevertheless face a formidable burden of preventable disease. The shortcomings of a system that has focused disproportionately on treating disease when it arises, rather than investing in actions that maintain health over the life course, is becoming more visible. The loss of economic value of a workforce no longer able to participate in employment up until their retirement age is calculable. The loss in social value as a consequence of a population limited in its capacity to contribute to family life and community is inestimable.

A social determinants approach which frames good health in terms of the conditions and attributes that maximise health over the life course offers a fresh perspective on this challenge. This view would define a ‘healthy person’ not as someone free from disease but as someone with the opportunity for meaningful work, secure housing, stable relationships, high self-esteem and healthy habits. Understanding health in these terms would highlight lack of employment opportunity and access to affordable housing as a health problem. Rather than simply improving society’s ability to respond to disease, more emphasis would be placed on actions that promote the conditions for good health.

“The ultimate source of any society’s wealth is its people. Investing in their health is a wise choice in the best of times, and an urgent necessity in the worst of times.”

David Stuckler

The Body Economic: Why Austerity Kills

Good health is both of value to the individual and a societal asset necessary to generate social and economic value. When seen as such, health takes a position as an important aspect of social infrastructure – an enabler of the prosperous society governments strive to create. The case for investing for the longer term then becomes apparent – just as the case for long-term investment is accepted when it comes to transport, energy, or telecommunications infrastructure.

Working across sectors

Maintaining and improving health cannot be the responsibility of a single sector. While government has a central role in shaping much of the environment that influences people’s choices and opportunities for a healthy life, everyone has a role to play in supporting and promoting health. For example:

• communities depend on individuals being able to play an active role
• employers and businesses need a productive workforce now and in the future
• national government and local authorities want to promote economic and social prosperity.

It is hard to find a sector that doesn’t have a bearing on our health. For example: schools and colleges build our future potential; the arts, culture and sport support our mental and physical wellbeing; unions and others promote work environments that protect our health; the media explain and inform (or misinform).

“Few health threats are local anymore. And few health threats can be managed by the health sector acting alone.”

Dr Margaret Chan

Address to the Sixty-Ninth World Health Assembly

More can be done to align the decisions and actions of these stakeholders with the goal of maintaining and improving health. Greater knowledge and understanding of the evidence on the social determinants of health is a necessary first step. However, even where this is understood, there can be disincentives to taking action as the benefits often don’t visibly accrue to the sector making the investment, or within a timeframe to overcome short-term interests.

Building shared goals around improving health across agencies at local level can catalyse effective action. The Robert Wood Johnson Foundation, whose aim is to build a ‘culture of health’ in the US, has championed a systematic approach to engaging local communities in the factors shaping their health through its County Health Rankings and Roadmaps. The rankings highlight clearly the contributions to health made by factors beyond health care. Making these apparent has been effective in engaging local communities and has mobilised joint action across civil society, statutory agencies and local businesses.

Using the principles of co-creation

While government policies influence the macro environment, an individual’s health is also shaped by their day-to-day experiences within their local community. There are many examples of community led action to create healthy neighbourhoods but little understanding as to how such initiatives can be replicated elsewhere.

In complex systems, solutions are context specific and cannot necessarily be ‘lifted and shifted’ from one place to another. It is the processes that enable solutions to be co-created that need to be replicated.

Successful community interventions share a number of similar characteristics:

• Engagement is with a community – rather than through a focus on single issues – enabling a holistic understanding of the underlying causes of poor health.
• Priorities for action are set by the community, thereby increasing ownership of proposed changes.
• Solutions are co-created, drawing on assets within the community, meaning they are attuned to local needs and values through open dialogue.
• Positive outcomes build a sense of agency and support further community action.

“Fundamentally [asset-based approaches] ask the question ‘What makes us healthy?’ rather than the deficit-based question ‘What makes us ill?’”

Simon Rippon and Trevor Hopkins

Head, hands and heart: asset-based approaches in health care

Supporting successful community action demands different skills and behaviours to those needed for the planning and delivery of services. It requires a rebalance of power from the state to communities and from professions to the public – those in statutory roles at local level must re-think their roles in terms of community empowerment rather than service provision.

Shifting habits and norms

Although people seemingly make their own choices about the factors that influence their health – whether or not they smoke, how much physical activity they do, the nature of their diet – these decisions are heavily influenced by social norms and the range of choices available. Promoting healthy behaviours needs to reflect this.

“…changing behaviours is challenging, as the contexts in which they occur are complex, involving the interaction of people’s individual characteristics, social influences and physical environment – among other things.”

Dr Ildiko Tombor and Professor Susan Michie

A healthier life for all

Social norms are not static and the factors that shape them are complex. Tighter legislation on tobacco, for example, has led to significant reductions in smoking and changed attitudes towards tobacco consumption. However, the introduction of this legislation would not have been possible without many years spent building public acceptance of the case for greater control. In contrast, the liberalisation of licensing laws in the post-war era has led to normalisation of greater alcohol consumption, making it hard for policy makers to act on public health evidence.

Even when there is a wider shift in societal views, attitudes and expectations may differ within specific communities. For example, expectations of ageing healthily are very low among some socioeconomic groups in the UK and these expectations may be linked with unhealthy behaviours such as very sedentary lifestyles.

The influence of social networks illustrates the limitations of individually focused interventions and highlights the need for systems approaches that influence habits and norms of populations not simply individuals. Behavioural insights studies have shown that most decisions people make are fast, instinctive and automatic, rather than slower, considered and logical. Environments and initiatives that are conducive to healthier, automatic choices are the most sustainable and should be targeted as part of public health efforts.,

Building the evidence base

Public health research largely sits within or alongside the world of medical research, looking to the same funding streams, employing similar methodologies and publishing in many of the same journals. These approaches to building evidence tend to focus on individual-level action in comparatively straightforward cause-and-effect relationships.

However, securing good health over the life course requires population-level as well as individual-level action. And the steps that need to be taken will be mediated by other factors in the context in which they are implemented. This demands a new approach to measuring and evaluating that reflects the complex and adaptive nature of the challenge and solutions.

“…reshaping public health research, policy and practice to take full account of the central importance of complex systems will be essential to improve health and reduce inequalities globally.”

Harry Rutter

Towards a complex systems model of evidence for public health

In the absence of an agreed alternative to generating public health evidence, there is a bias towards funding interventions to improve health that operate at an individual level over the short term. Common to other fields of research, there is tendency to focus on evaluating the impact of an intervention without fully understanding the context within which it plays out and how that context may amplify or mitigate the desired change.

Taken together, these biases impede the generation of evidence needed to understand the impact of population-level action, how context contributes to outcomes, and how interventions that are shown to make a positive contribution can be translated effectively into other contexts.

Recognition of the importance of a wider set of approaches to generating evidence is gaining traction. Moving towards greater design and evaluation of population-level interventions focused on prevention will be helped by:

• decision makers understanding the limits of evidence generated by randomised controlled trials (RCTs) and the value of alternative approaches to generating evidence
• training public health researchers and supporting them to embrace a wider set of methodologies
• the creation of funding mechanisms to support evidence building in this field.

Mobilising wider resources

The £116.4bn allocated to the Department of Health in 2015/16 and, through them, to the NHS and other agencies is generally described as the ‘health’ budget. However, given that health is determined by wider social factors, all public spending has the potential to influence health. In addition, looking beyond government spending, business and the third sector can also make significant contributions to people’s health.

The value to employers of a healthy population needs to be made explicit both in terms of the importance of good health among existing employees and the health of the future workforce. Michael Grossman’s concept of health capital – described as a ‘stock’ that degrades over time without investment – could be a helpful way of doing this. His model illustrates the greater return on investment for interventions that preserve or replenish health capital in early life compared to those made in later life.

If considered at population level, health capital has the potential to shift attention beyond static measures of health and wellbeing. The rate of depletion of the stock of health capital in a community could provide a predictor of future social and economic prosperity. Such a concept could be a catalyst in engaging local leaders across statutory authorities, local businesses and whole communities to take collective responsibility in planning and acting to protect and grow health capital over the long term.

“…a longer-term perspective on the future benefits of investing in health and its drivers is especially critical. New and creative thinking is needed about sources and flows of funding; the balance over time of preventing conditions versus preventing their progress and complications; and the motivators for cross-sectoral investment in health.”

Dr Louise Marshall and Anita Charlesworth

A healthier life for all

There are many thousands of voluntary organisations that are health creating – for example, supporting children and families, building communities, or helping people manage crises such as debt or homelessness. There needs to be more explicit recognition of the value they generate and support for their continued contribution.19 Not only because of the benefits of the contribution itself, but because volunteering and giving are also health enhancing.

“The shift of the Health Foundation to move from a pure focus on health care to address the broader issues of health is extremely welcomed.”

Derek Yach

Healthier lives: a listening exercise

---