"It’s the eye-catching pledges about more money, more nurses, more GPs and more hospitals that are shouted about the loudest. But it’s elsewhere in some of the manifestos where the potential for a real revolution in our health and wellbeing quietly sits."Sally Warren
05 December 2019
Our health and wellbeing is more than the NHS
SALLY WARREN: There are many factors that impact our health and wellbeing, which of the parties recognise this in policies beyond cash for the NHS?
The Policy Institute is producing a series of comment pieces analysing election manifesto pledges from the different parties across a range of policy areas. Read the full series here.
At the start of the election, the King’s Fund's ask of the parties was that they recognise that our health and wellbeing is about more than the NHS alone. Yes, the NHS is a vital service and needs to have the staff, buildings, equipment and resources to do its job well and to meet growing need for healthcare. But it does not work in isolation, and, as evidence shows, nor does it have the biggest impact on our health and wellbeing.
Academics differ on the exact split between different factors, but there is agreement that when it comes to our health and wellbeing, the hierarchy of impact starts with wider determinants (social, economic and environmental factors such as education and housing), next comes behaviours (such as diet, smoking, alcohol and exercise, all informed by our wider environment), only then is it our health and care services, and finally genetics. So, to be serious about health and wellbeing, you need to be serious about more than the NHS.
This focus on health and wellbeing isn’t just about changing the pattern of demand for (pricey) healthcare. Nor it is just about improving our quality of life. There’s cold hard economics in this too. When Greater Manchester considered what were the biggest barriers to economic prosperity of the city region, it was the health of its population (and therefore the health of its available workforce) which was one of the top three barriers. This helped shaped their region’s approach to health and wellbeing.
Looking at the manifestos for the three main English parties, there is clear difference amongst them to the extent to which they embrace the idea of health and wellbeing rather than healthcare. The Labour and Liberal Democrats have a much more comprehensive approach to health.
Those working in public health have long advocated a "health in all policies" approach – one where the impact (positive or negative) on health and wellbeing of any policy developed anywhere in government needs to be explicitly assessed, and all the levers pulled to make it better for our own health and wellbeing. Both Labour and the Liberal Democrats commit to this type of approach in their manifestos, using slightly different vehicles and approaches. Labour with a Future Generations Wellbeing Act, modelled on recent experience in Wales, and the Liberal Democrats build on New Zealand’s approach to wellbeing. Disappointingly, this kind of thinking is largely absent from the Conservative’s manifesto.
If implemented well, this could be transformational for our health and wellbeing, putting it at the core of policy development and delivery. We can see some examples of what this might mean in practice throughout the Labour and Liberal Democrat manifestos – where prospective governments are thinking about using the full range of levers at its disposal to improve health. This includes: using tax and regulation to tackle obesity (advertising restrictions, fast food restrictions near primary schools, extending the "sugar tax" to more drinks), introducing a minimum unit price for alcohol to curb the availability of lower price, high strength alcohol, and a public health approach to gambling and knife crime (the gambling example being the only time the Conservatives step into this type of thinking in their manifesto). The King’s Fund work with the public show that these kind of interventions that support public health have more public support than many – including politicians – might assume.
Each individual measure mentioned here will have its own evidence base, and its own supporters and detractors. I’m not advocating for or against the specifics – it’s the mindset that it represents that is exciting. This type of thinking shows they understand that the wider determinants of health are societal, economic and environmental. That they are deeply rooted. That it is not solely about the lifestyle choices people make, good or bad. And that the response needs to be about more than individual responsibility – it needs to shift all of the dials in favour of supporting the best possible health for us all. It’s encouraging to see some of our political leaders thinking so widely about health and challenging themselves to do better.
As much as a "health in all policies" approach would be a brilliant step forward, it’s not enough. There is every risk that despite the best of intentions, health inequalities could actually widen. It should shock and shame us that in one of the world’s richest countries, men in the least deprived areas live almost a decade longer than those in the most deprived, with the gap for women being seven years. The gap in healthy life expectancy is 18 years for both men and women. This is why health in all policies matters, and why at the core of it there needs to be an explicit strategy to tackle health inequalities, so those with the worst health outcomes benefit the most.
With spend on the NHS in England accounting for £130 billion of public spending, it is hardly surprising that the NHS gets a lot of attention in an election campaign. And it’s the eye-catching pledges about more money, more nurses, more GPs and more hospitals that are shouted about the loudest. But it’s elsewhere in some of the manifestos where the potential for a real revolution in our health and wellbeing quietly sits. People aren’t shouting about it from the rooftops, but could this be the moment when our political leaders have the confidence of thought to improve health, rather than healthcare alone?
Sally Warren is Director of Policy at the King's Fund.