ANALYSIS
step too far. We should see the key social determinants of health as the responsibility of government and other social actors, not simply individual responsibility. Asking individuals to make choices that their circumstances do not allow almost guarantees persisting health inequalities. Weakening of the public health system across UK Because of the political climate, at least in part, the public health system across the UK is now arguably weaker than at any point in history, going back as far as the 1870s, with substantial reductions to public health budgets and staffing levels. Northern Ireland and England have seen significant changes, with the functions of public health severely weakened at local, regional, and national levels. In England, the abolition of the regional tier of government has seen the end of regional development agencies, regional assemblies, strategic health authorities, and government offices for the regions, among other subnational infrastructure. The abolition of regional emergency planning and response functions, which had worked effectively during crises, such as foot and mouth disease and the fuel tanker drivers ’ action, was a weakness in the poor response to covid-19 in the UK. The role of public health has been curtailed, with major reductions in resources and expertise, and changes in the role of directors of public health. The abolition of Public Health England and creation of the UK Health Security Agency as an executive component of the Westminster government ’ s Department of Health and Social Care not only saw the disappearance of the term public health but cast the new and undefined function of health security as part of the country ’ s security system. This change has been accompanied by attempts to replace the term health inequalities with the ill defined and obscure health disparities. In Northern Ireland, local director of public health posts have disappeared entirely, and the public health function has been severely weakened. The absence of a functioning government for several years has created something that resembles a failed state. 71 The re-establishment of the Northern Ireland Executive offers a mechanism to begin to deal with these problems, and the current health minister is familiar with his brief. The legislative agenda is enormous, however, and health might not be a priority. Northern Ireland ’ s unique position with regard to the European single market is a further advantage as it limits the ability of the government at Westminster to enact health damaging policies, such as relaxation of restrictions on harmful chemicals. 72 The Good Friday Agreement also offers opportunities to learn from and expand joint programmes with Ireland, where in marked contrast with the UK, life expectancy is improving. Recommendations Just as the health of people served by the NHS is determined by their economic and societal conditions, the future of the NHS is inextricable from the future of society and policies that provide for good health. Our recommendations focus on what the NHS can do in each of the four nations of the UK and what the whole of society can do, to act on the social determinants of health. Restore, revitalise, and prioritise the public health system in the UK We recommend urgent restoration of the public health system across all four nations of the UK. The evidence base for what needs to be done to improve population health continues to strengthen, as we have highlighted, even while the capacity in the UK to carry out the necessary actions to improve health is depleted. The deterioration in health and the social determinants of health, such as housing, have been accompanied by the dismantling and the imposed
disorganisation of the public health system, particularly in England and Northern Ireland. Thus, we recommend that the government should restore the public health grant to at least 2015-16 levels 73 and re-establish Public Health England. Dealing with the population health crisis in the UK requires urgent, in-depth consideration and substantial commitment to creating a system that can deliver all WHO defined essential public health functions. One way to engage in this task would be the formation of a cross party task force accountable for public health, enabling non-partisan consideration of the necessary actions. The task force should cover the whole of the UK and seek to learn from the positive experiences of public health structures in Wales and Scotland. Because of the long term nature of public health change, there would also be value in creating this cross party task force as a standing body so that it could review the implementation of its recommendations and measure the results. Role of the NHS The NHS is predominantly focused on providing clinical care and support to those needing treatment for health conditions. It is because of its role in the delivery of care that the NHS can do much more as both a health service provider and the country ’ s largest employer 74 to ensure that fewer people are burdened with poor health and that many more enjoy healthy lives. What individuals working in the NHS can do — Recognising that improving the social determinants of health will improve health, and thus reduce the burden on healthcare, those working in the NHS might consider the effect they can have as individuals. Box 3 shows some examples. Box 3: Examples of actions on social determinants of health by individuals working in the NHS As an individual healthcare worker • Focus on co-production for service design, development, and evaluation. 75 • Use clinical encounters with patients and their families to ask about, and listen to, some of the wider problems that might be affecting the patient ’ shealth. • Consider if adaptations to how care is delivered could be helpful (eg, adapting the follow-up conversation to a time and method that saves travel and thus has less impact on time, carbon, and money), and fit around the patient ’ s work (which might be paid by the hour or on a zero hours contract) and their children ’ s schooling (education being a critical social determinant)? As a community member • Consider and mitigate for the effect of all activities on the environment, such as changing methods of travel, reducing waste, and switching off unused desktops/lights. • Support initiatives on anti-oppression and raise awareness on how intersecting factors can worsen health outcomes. As an organisation member • Advocate for a more thoughtful, intentional, and effective organisation in its role as a partner in civil society (eg, explore the organisation ’ s role in working with multi-agency partners such as housing departments of the local council, voluntary sector, public health teams, schools, and police). As a member of the electorate • Build knowledge on policies that can affect the social determinants of health, while supporting organisations and voting for policies that proactively deal with these concerns.
the bmj | BMJ 2024;385:e079389 | doi: 10.1136/bmj-2024-079389
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