ANALYSIS
THE BMJ COMMISSION ON THE FUTURE OF THE NHS NHS and the whole of society must act on social determinants of health for a healthier future Health is going in the wrong direction in the UK, and reversing the trend requires political and societal commitment to deal with the underlying causes Lucinda Hiam, 1 Bob Klaber, 2 , 3 Annabel Sowemimo, 4 Michael Marmot 5
1 University of Oxford, Oxford, UK 2 Research, Innovation, Imperial College Healthcare NHS Trust, London, UK 3 School of Public Health, Imperial College London, London, UK 4 Lewisham and Greenwich NHS Trust, London, UK 5 UCL Institute of Health Equity, London, UK Correspondence to: L Hiam lucinda.hiam@kellogg.ox.ac.uk Cite this as: BMJ 2024;385:e079389 http://dx.doi.org/10.1136/bmj-2024-079389
are going in the wrong direction for all four nations of the UK. The UK consistently ranks poorly for infant mortality, 6 and its global ranking for life expectancy has fallen, with only the US faring worse of the G7 countries. 7 The public health system in the UK has been decimated over the past decade, 8 particularly in England and Northern Ireland, with the unexpected abolition of Public Health England in 2020, and a 27% real terms per person cut to the public health grant since 2015-16, 9 with greater cuts in poorer areas of England. In contrast, both Public Health Scotland, reformed in 2019, 10 andPublic Health Wales and are making progress in improving the health of the populations they serve. 811 Shorter lives spent in poorer health People in the UK are dying earlier. Life expectancy can be calculated at any age and provides an estimate of the average age a person would live if the current mortality rates were applied over their lifespan. Since 2010, the long history of improvements in life expectancy have plateaued and, for some groups, declined. 12-16 As of early 2024, the latest figures from the Office for National Statistics show that the combination of slow improvements for the past decade and the covid-19 pandemic have decreased overall life expectancy, returning to 2010-12 levels for women and below the 2010-12 level for men, and falling in all four nations for 2020-22 compared with 2017-19. 17 Furthermore, people are spending less of their lives in good health. Health Equity in England: The Marmot Review 10 Years On reported that healthy life expectancy has reduced for women since 2010, and the proportion of life spent in poor health has increased for both sexes. 14 A 2024 report found 9.6 million households are living on incomes below the minimum income standard and in some of the least well insulated, cold, damp homes in industrialised countries, 18 with negative consequences for the health of children and adults. 19 The decline in health shows marked inequalities across factors such as ethnic group, race, sex, and deprivation, many of which intersect with each other. Life expectancy and healthy life expectancy are closely linked to deprivation: the greater the deprivation, the shorter the life expectancy. Those living in deprived areas spend more of their shorter lives in poor health. 14 This relation represents a social gradient: each increase in socioeconomic level results in an increase in health and lower mortality rates. Health Inequalities: Lives Cut Short found that that
The UK is facing a prolonged and serious health crisis. At a time when the future of the NHS is in jeopardy after over a decade of austerity, and with public satisfaction at an all time low, 1 it must pick up the pieces of failures across government. Attaining good health requires more than healthcare, and improvements in the provision of healthcare by the NHS alone is inadequate to address the health crisis — action is needed on the social determinants of health 2 (box1). Box 1: Definition of social determinants of health 3 The social determinants of health are defined by the World Health Organization as: “ the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems. ” In this paper, we propose evidence based solutions to the worsening health and widening inequalities in the UK through action on the social determinants of health. (A separate article within the commission is focused on health equity. 4 ) We first outline the problem of deteriorating health across the UK. We then provide an overview of the evidence, showing how action on the social determinants can improve health. We confront the challenging political nature of this area, including rebuttal of criticisms of interventions as actions of a “ nanny state ” and the neoliberal focus on individualism. Finally, we offer action focused solutions and recommendations on what NHS workers, leaders of NHS organisations and integrated care systems, and the government can do to urgently deal with the deteriorating health of the population. Although much of the evidence we draw on is focused on England, or England and Wales, we suggest that the overall findings and recommendations are relevant to all of the UK nations, and we emphasise where these might differ. Furthermore, throughout we highlight that health is inherently political, but it is not party political. Politicians from any party can choose to act on the ample evidence available to them. The problem: why is action needed? Among European countries, the UK is a relatively poor, sick country with some rich, healthy people. 5 Summary measures of the health of the population
the bmj |BMJ 2024;385:e079389 | doi: 10.1136/bmj-2024-079389
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