Executive summary


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.

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