The nation’s new year’s resolution

A blog based on the presentation by ADPH President Dr Jeanelle de Gruchy on: factors influencing public health in England and priorities for policy for improving healthy life expectancy at Westminster Policy Health Forum – Thursday 16^th January.

Laughter is just the best medicine. One of my more successful New Year’s resolutions was simply ‘to laugh more’. This simple statement of intent led to quite profound personal changes for me that year. My laughter and wellbeing went hand in hand, tripping along nicely among the daisies.

I’m suspecting many had a bit of a nod to a new year’s resolution or two – and I’m guessing most of them were broadly about improving health and wellbeing. However, no matter how many of us had new year’s resolutions, I suspect the large, unchannelled rush of resolve on this across the land won’t actually deliver an improvement in the population’s wellbeing and health.

So what are the key forces driving the public’s health in England today – and what should the nation’s collective new year’s resolutions to improve healthy life expectancy for all be? 

I believe there are four overarching factors influencing the public’s health and wellbeing:

1. Firstly, social trends and the rise of social movements. Social movements, social media, digital technology – all enabling us, the citizen, to shape our society; and of course all shaping us as citizens. At speed. It’s messy and complex, for the public’s good – and not good. The ‘New Year, New Me’ mantras of individuals are now more supported by inspiring social public health movements, such as Dry January and Parkrun. The level of public engagement demonstrates the huge appetite that exists for wellbeing. However social media has also helped those who would, to drive a rise in the dismissal of inconvenient facts (or the dismissal of evidence and facts altogether) – from the UK’s relationship to the EU to vaccination to climate change.
    
2. So on to the climate emergency. Extinction Rebellion and Greta Thunberg inspired social movements to more successfully challenge the dominant denial of climate change by vested interests over the last decade. Yet our actions so far fall woefully short of what is needed to achieve net zero by 2050. The British Heart Foundation yesterday warned this month that heart and circulatory disease deaths attributed to particulate matter air pollution could exceed 160,000 over the next decade in the UK (read the recently released report here).
   
   
3. Politics - austerity and uncertainty, rising inequality, and Brexit. Currently 4.1m children in the UK are living in poverty. Poverty is the most significant determinant of the health of our children and young people. These are the consequence of political choices. After a decade of austerity and a bruising process leading to Brexit, our institutions are under strain as never before with, some would argue, a challenge to democracy itself. After a long period when we believed that inequality was reducing in this country, the deeply entrenched structural inequality in our society has been exposed. It remains to see what ‘levelling up’ means, and how it is delivered. Brexit and all its repercussions and consequences will have a profound impact on the nation’s health and wellbeing over the next decade.    
   
   Publically funded services have become more efficient over the last decade, however a huge amount has just disappeared; and we will continue to see considerable change in public services – their purpose, funding and delivery - over the next decade. For now, England continues to have an incredible universal health – and public health – service offer free at the point of need, treating ill-health – and protecting the financial impact of poor health.
   
   Political decision-making has its own short-term timing rhythm and preference for a simple response with shiny things that grab headlines; this continues to drive the award of small, disconnected pots of funding and contradictory policy positions from different Westminster departments. It’s generally left to local places to integrate and make sense of how all of this can impact positively on residents’ lives. Advocates for the public’s health and wellbeing, with the necessary focus on complex causation and evidence-based, whole system responses to deliver in the future, struggle to make our case nationally and locally. Indeed we need to be constantly alert to being side-lined with less and less influence and resource. I’m hoping that the next decade will see a new narrative and a new approach to making the case for health and wellbeing in our society – and a deeper appreciation by public and policy-makers.
   
   
4. Finally, the social and commercial determinants of health and wellbeing - Health expectancy is stalling and the healthy life expectancy gap widening. Poverty – of money, of good housing, good relationships, of good air, good jobs, good food – is the root cause. Take transport – the dominance by the car and fossil fuel industries has profoundly shaped our society where cities and streets are designed by middle-aged men primarily for middle-aged men, where passenger roads deaths have decreased whereas those of cyclists and pedestrians have not; it's contributed to climate change, a rise in poor air quality and a reduction in people being physically active.   
   
   Yet too little are these social and commercial determinants understood or addressed. Instead, the myth of the ‘lifestyle choice’ is used to perpetuate a disproportionate focus on the individual over the range of behavioural, environmental and social determinants of health - and on individualistic solutions aimed at the individual just making different choices and changing their ‘unhealthy lifestyle’. It remains to be seen whether we can make ‘the lazy language of lifestyles’ an anachronism by the end of the decade (see ‘The lazy language of lifestyles’)

Social movements and politics, the climate emergency, poverty and inequalities, and the kind of country we live in – the local places we live in – these are the key factors influencing the public’s health as we enter the 2020s.

So what now of the policy priorities we need to influence this context to improve healthy life expectancy over the next decade.

Firstly, we need to shift the public and policy-makers’ understanding of the factors driving the population’s health. We need to reframe the conversation, from one that simplistically uses the words NHS and health interchangeably and sees the NHS as providing the best and only route to the nation’s health. Rather we know that only about 10-20% of healthy life expectancy is determined by access to the NHS. The remainder is shaped by the economic, social and environmental conditions of our lives. We need a new narrative for health and wellbeing.

The Association of Directions of Public Health published a Manifesto for Public Health in the lead up to the General Election. Our aim was defining a realistic programme that would make ‘prevention is better than cure’ – and indeed health creation – a reality. Our asks are:

1. Make wellbeing a cross-government ambition. Drawing inspiration from the Wellbeing legislation in Wales and New Zealand, wellbeing should be built into the fabric of Government decision-making when it comes to both policy-making and funding allocation. This means challenging the dominance of GDP as a measure of national successes with a ‘health index’ and the introduction of a Wellbeing Act. This should drive public investment across the social determinants of health.
   
   
2. Set binding targets to reduce child poverty. Poverty is the most significant determinant of children and young people’s health in the UK. Currently, 4.1 million children in the UK are living in poverty. At the turn of the millennium the Government committed to abolish child poverty by 2020 and this was enshrined into law in 2010. We must renew this commitment.
   
   
3. Take a whole-system and place-based approach to health inequality. We need to take wide-ranging action on the social determinants of health (including housing, the environment and skills), as well as acting on health inequalities caused by the commercial determinants of health such smoking, alcohol use and obesity, expanding the use of the ‘Polluter Pays’ principle. A combination of bold national action and trusting, empowering and funding councils is essential.
   
   
4. A new era of partnership and collaboration. The relationship between the NHS – the home of treatment – and local government – the home of prevention – is key. We need to be in the same room and on the same page about both creating seamless care pathways in services like smoking cessation and sexual health, as well as health creation – working together to make the places we live and work help rather than hinder our health and wellbeing.
   
   
5. Deliver a multi-year funding settlement for public health. With the Spending Review coming up, we need to make the case for not just more investment in public health but also more long-term certainty. The ADPH supports the call from the Health Foundation and The King’s Fund for at least £1 billion more a year for the Public Health Grant in England.

On public health specifically – since the transfer of public health services from the NHS to local government, there has been intense scrutiny on how well the move has worked. Seven years on – despite austerity – the evidence for making local government the primary promoter of public health is strong. An independent review of the reforms published earlier this week by the King’s Fund finds that “significant innovation and integration” has been achieved and “public health teams have integrated well into local government, influencing policy at both local and regional level.” The Local Government’s most recent evaluation of performance – as measured against the Public Health Outcomes Framework - shows 80 per cent of indicators improved or were unchanged in the financial year to 2018.

So, there is a really good story to tell.

Last century, Antonovsky spoke of ‘the creation of appropriate social conditions which underlie or facilitate health-promotive behaviour’. This is a timeless articulation of what public health should be about. At the start of a new decade, the challenge for the public health community is clear: we need to work to create the conditions for public health and wellbeing. This should be the nation’s new year’s resolution.