Everyone has a role in building a health creating societyBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6654 (Published 16 December 2015) Cite this as: BMJ 2015;351:h6654
- Nigel Crisp, independent member, House of Lords, London, SW1A 0PW, London
The World Health Organization in Europe has said that modern societies actively market unhealthy lifestyles.1 What if they actively marketed healthy lifestyles instead? How could we begin to build a health creating society, with all sectors working towards a healthy and resilient population?1 2
In November I introduced a debate in the House of Lords on this topic, in an attempt to start to build the political will needed for change. Much of what we talked about was not new, although recent advances in our understanding of social determinants of health, better evidence of what works and of the potential role of technology, and a greater willingness to learn from other countries are all very important. Timing, however, is crucial, and I think the time has come to really make a difference. A profound shift in thinking is under way, globally influenced by people such as Michael Marmot in the United Kingdom and Amartya Sen, Ilona Kickbusch, Julio Frenk, Maureen Bisognano, K Srinath Reddy, and Francis Omaswa around the world.
Health and care systems are under great strain globally, as needs grow—particularly from older people with long term conditions—and costs rise. Not surprisingly, there is widespread concern and confusion about the future of health. This uncertainty and insecurity make it more important than ever to understand the complex nature of health problems—and what can be done about them—and to set out a long term vision and strategy for the future.
Health problems are complex, and they go beyond the reach of the NHS, the government, and patients themselves. They affect all ages. Barely half of all children achieve a “good level of development” by the time they start school, which affects their future physical and mental health and their ability to learn.3 Social isolation and loneliness in adults affects health; people with adequate social relationships have a 50% greater likelihood of survival—equivalent to the effects of quitting smoking.4 Lower subjective wellbeing and higher burdens of ill health are found in black and minority ethnic populations,2 5 and men and women with severe mental health problems die up to 20 and 15 years earlier, respectively, than those without these problems.6 Inequalities and social disadvantage affect health, wellbeing, and life expectancy around the world.7 8
National and local governments are responsible for the legislation and regulation that shape the environment for economic development and for safeguarding access to healthcare and the right to health. They also have an important role in convening leaders and inspiring action across sectors. People are responsible for their own health and that of their families, although some aspects are outside their control. Many UK organisations are providing support to people locally (through health and wellbeing centres, schools, community action, and volunteering) and nationally (through organisations such as the Silver Line (www.thesilverline.org.uk) and Connecting Communities (www.connectingcommunities.org.uk)).9 10
Perhaps the most comprehensive approach has been developed in east London where the St Paul’s Way Transformation Project has been “tasked with bringing together, in a joined-up project, the physical improvements along St Paul’s Way, creating new networks and relationships between parties [businesses, government agencies, and others] and local residents and pursuing a coordinated vision for the future of the area.”11 The local community, private sector, and education, health and care services have come together to develop better schools, housing, and health services and to create greater employment and career opportunities for local residents. Although health is not the primary objective, the project has had a profound effect on the health of the local population.
More could be done
The beginnings of a policy shift are under way in the NHS in England, with renewed emphasis on prevention, social medicine, sustainability, and the psychosocial perspective on health.7 9 10 But I don’t think it’s enough to make a difference yet, for three reasons. Firstly, it’s not happening at the scale that is needed or with enough mainstream priority and commitment. It does not take precedence with policy makers and politicians. Wonderful initiatives can be easily discounted when set alongside more immediate priorities.
Secondly, not everyone is playing their part. Could schools do more? Employers certainly could. Some companies, like those of the City Mental Health Alliance, are tackling particular concerns, but much more could be done. Designers, architects, and planners are able and willing to do much more: creating buildings that encourage people to walk, to use the stairs, and to easily encounter others.
The third, and perhaps most important, reason is that government policies are inconsistent and can undermine each other. In the House of Lords’ debate Jane Campbell explained how policy for independent living had developed over the years but was cut when recession hit. She said, “Independent living pays for itself again and again. It is well evidenced that people who live independently in the community, with the right support, lead healthier and more cost effective lives. It is the basis of health and wellbeing creation. The professionals enable, facilitate, and inform. The service user learns, takes control, and lives—not just survives.”
I have been asked to chair a commission on inpatient mental health services for the Royal College of Psychiatrists and have been struck by the disconnect between housing and mental health policy—where housing can be so vital for patient wellbeing—and by the way many carers feel they are excluded from assessment and other key processes. Nationally, unpaid carers contribute services estimated to be worth at least £119bn a year (€165bn; $179bn).12 When this informal care sector fails, the burden falls on the formal sector. Are national and local policies fully supporting carers and voluntary effort?
“Health is made at home, hospitals are for repairs”
Medicine has caught up with the traditional African saying, “Health is made at home, hospitals are for repairs.”3 13 Research has shown the importance of the first few years of life in determining health throughout life and of the influence of positive and sustained social, psychological, and physical environments.4 14 Encouragingly, the NHS—which often ends up just repairing the damage—is moving upstream into prevention. A health creating society needs an effective and high quality health and care system that tackles both—the repairs need to be lasting ones that help to prevent future problems.
The NHS will only be sustainable in the long term if we can take some of the strain off it. This doesn’t mean that the focus on health improvement will lead to reducing healthcare costs overall but that it will help limit the increase in expenditure that will be needed. UK citizens can expect about six years of ill health before death. Reducing this by even six months or a year would be an enormous benefit to people and the exchequer.
The sustainability of the NHS is too often discussed in purely economic terms, with debates about future financing arrangements and restrictions on services. Experience from countries such as the Netherlands and the United States shows that these solutions produce limited gains, at best, and may increase economic costs to society and to individual people. Long term sustainability will come from changes in practice, continuous quality improvement, and finding health solutions to health problems.
The NHS needs to change too. Today’s hospital centred and illness based health and care system, where things are done to or for a patient, is shifting to a person centred and health based one, where people are partners in health promotion and healthcare and where all sectors of society actively promote health. The new system will offer access to advice and high quality services in homes and communities as well as in clinics and specialist centres.
This vision of the future maintains the founding values of the NHS and builds on the skills of health professionals and the achievements of the past, but it demands new approaches and infrastructure that will be challenging to implement. Achieving this vision will require time and will depend on the ability of NHS and local authority leaders and organisations to plan effectively across the increasingly fragmented health and care system, as well as an explicit commitment from the government to fund transition for the long term. All sectors of society must play their part in creating health.
Building the political will for change
We need to take this discussion out of the House of Lords into wider discourse and to build political will for a radical change in how we think about and act on health and wellbeing. The House of Lords’ debate identified three essential components.
Firstly, the government needs to propose a plan, preferably instigated by the prime minister and with a cabinet minister as its leader. When the NHS was founded in 1948 the whole country came together around the shared purpose of providing health services for everyone. An equally bold initiative—both locally and nationally—is needed today to bring together the expertise and resources of all parts of society to improve health for all and build a health creating society.
Secondly, we need a shared vision across society and political parties about what the future for health should look like. I think there will be considerable consensus around the vision I have suggested here, although I recognise there will be different ideas about how to achieve it. We need a process or commission to help develop a clearer shared vision for the benefit of the public and the people working in the health and care system.
Thirdly, we all need to get involved. Real, sustainable change in health only occurs when it takes place inside the heads of the clinicians and other professionals who lead the system. It needs to be thought about and experienced, reinforced by the education system, and internalised. Moreover, patients and the public need to be co-producers of health with professionals.
The UK was one of the pioneers in introducing a universal healthcare system available to the whole population. It could lead again in the development of a health creating society.
Cite this as: BMJ 2015;351:h6654