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


Key points

  • Giving people the best possible chance to lead a healthy life requires organised efforts across all sectors, including central and local government, the health and social care system, the voluntary sector, communities and the private sector.
  • Central government has a responsibility to set a tone that prioritises the population’s health as a core measure of success and uses its levers of taxation, regulation, spending and information provision to this end.
  • The power of place in influencing people’s health outcomes indicates that a comprehensive and integrated place-based approach, underpinned by national investment needs, is central to improving people’s wellbeing and health.
  • In addition to the services that local government directly delivers or funds, it has an important role as a convener and leader in local areas.
  • An effective whole-government approach to health creation requires a commitment to invest in policies that build and strengthen local communities and enable those communities to fully participate in shaping their local areas and the services they receive.

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.

Case Study 1: Legislating to reduce smoking

For decades, smoking has been the leading cause of death and illness in the UK and the biggest contributor to the gap in life expectancy between the richest and poorest parts of society

Since the 1960s, successive tobacco control measures have been introduced nationally including taxation, advertising bans and consumer protection policies. As a result, over the past four decades, the share of adults who smoke has fallen from 39% to 15%.,

Primary legislation is one of the most powerful levers government has for creating health-promoting conditions. On 1 July 2007, smoking was banned inside public places in England under the 2006 Health Act. The government’s aim was to protect people from secondhand smoke and reduce smoking-related harm, and they had the public’s support for a legislative approach.

The ban’s effects were immediately apparent. Within a year the number of people giving up smoking increased and hospital admissions for heart attacks fell by 2.4%; 1,900 fewer adults were admitted to hospital for asthma each year for three years following the ban.

The legislation made an important impact on smoking in the UK. The evidence of its success has also supported other countries considering smoke-free laws and has furthered understanding of how smoking and other health risks can be tackled globally.

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.

Case Study 2: Partnering for greater impact – the role of anchor institutions in a place

Anchor institutions are large organisations such as local councils, hospitals and universities whose long-term sustainability is tied to the wellbeing of the populations they serve. The role of the NHS as an anchor institution is explored below (see Section 4.3 of this report and the Health Foundation’s publication, Building healthier communities: the role of the NHS as an anchor institution). Anchors get their name because they have ‘sticky capital’ (ie their strong connections to the local population mean that they are unlikely to move) and have a significant influence on the health and wellbeing of a local community through their sizeable assets.

Working as anchors, these organisations have the potential to influence their local economy, improve the health of their local community and develop their local environment. They can do this through their roles as large employers, purchasers and land owners, and by taking a leading role in championing environmental sustainability. While individual organisations can make progress through embedding anchor approaches in their own operations, it is the combined weight of working in partnership with other anchors that offers the scale of opportunity for impact.

For example, in the Leeds City Region, the Joseph Rowntree Foundation (JRF) analysed the scale of impact that anchor organisations have when working together. In the region, 70 large anchors employ more than 200,000 people and have budgets in excess of £11bn. As part of its analysis, JRF found that, if 10 anchor institutions (including the local council, universities and hospitals) shifted 10% of their total spending to the local economy, this could drive an additional £168–196m into the local community.

A key challenge to collaborative working across anchor institutions is bringing together complex and multi-faceted organisations with different cultures, often working with different populations and with different pressures and demands. A key to the success of the anchor collaboration in the Leeds City Region case was the development of a shared framework that allows the different anchor organisations to assess their baseline activity across a range of domains and measure progress using shared metrics. JRF observed that, in the UK, local government has a critical role to play in convening and enabling other anchors across a place.

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.

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