Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Wider health determinants aren’t just for pandemics

BMJ 2021; 372 doi: (Published 03 February 2021) Cite this as: BMJ 2021;372:n276

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  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

Health politics are dominated by the power of the immediate. Future health gains through long term policies are easier to ignore than what happens now. The truism that we need to rebalance priorities away from reacting to sickness towards preventing ill health, tackling inequalities, maximising wellbeing, or helping people live better with long term conditions has become an orthodoxy. But the rhetoric is rarely matched by policy levers and investment big enough to do the job. We haven’t put our money where our mouth is.

Rapid access to urgent and emergency care, responsive primary care services for patients with immediate needs, and shorter waits for planned investigations and procedures always seem to dominate headlines. Political efforts to improve these are more likely to deliver measurable improvements within the lifespan of a parliament or politician. Bad publicity and scandals are more likely to follow when they’re not delivered.

The lockdowns and behavioural restrictions deployed by the UK governments in response to the covid-19 pandemic bucked the trend by getting politicians, lobbyists, and the mainstream media to discuss the impact of these policies on people’s mental and physical health and wellbeing. We saw a surge of interest in poverty, domestic violence, child abuse, alcohol dependence, social isolation and loneliness, access to exercise, housing quality and affordable rent, early years services, and their impact on health. Suddenly, in home care services and especially care homes, covid put a spotlight on social care and the key role of unpaid and unsupported family carers. People argued that prioritising covid cases would damage health further by denying care to people with other conditions. The evidence for socioeconomic and health inequalities, long emphasised by the public health community, gained new momentum as data emerged on the profoundly unequal harms and risks from covid-19.123

This attention is, we might think, overdue and welcome. But let’s face it: some of the lobbyists, think tanks, media commentators, and politicians flagging the risks to jobs and the wider determinants of health from lockdown policy had happily colluded in creating a policy landscape which, until 2020, had done little to tackle prevention, wider health determinants, or inequalities and had often worsened them.4

Since 2010 we’ve had austerity, flat funding increases, real terms pay cuts in the NHS, and sustained cuts to local government, adult and children’s social care services, and public health.56 We’ve had underinvestment and real terms funding cuts to schools7 (with a distracting focus on gimmicks such as free schools and termination of the well regarded Sure Start programme for children’s early years),89 as well as cuts to alcohol and drug services10 and to legal aid,11 courts,12 and probation services13—none of which can have helped stem the rise in domestic abuse reported by the Office for National Statistics.14

Socioeconomic equalities have become entrenched, and more workers are in precarious zero hour contracts and the “gig economy.” Not enough investment has been made in affordable or subsidised social housing or rent control.15 And workforce as well as immigration policy has made it harder for health and social care services to recruit and retain staff who might support socially vulnerable or homeless people.16

Successive parliaments have ducked difficult decisions on obesity, sugar, food, and alcohol policy that might signal intent and make a dent in the prevalence of potentially preventable, non-communicable diseases.1718 Despite rhetoric about giving mental health services “parity of esteem” with those for people with physical health problems the two have remained poor relations in terms of access, staffing, and capacity.1920

The sudden interest in prevention, wider health determinants, and wellbeing in social care also seems driven largely by immediate concerns over money, jobs, ruined industries, unhappy voters, and bad press. Once we’re through with this pandemic will we all still be so interested, outside the professional communities and advocates who always have been?

I’m not holding my breath.