1. Introduction and context


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.

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