ANALYSIS
What the NHS can do as a health system — Leaders of NHS organisations and systems can act on the social determinants of health: firstly, as an employer, considering their staff as a key population; secondly, on staff recruitment, development, and training, working towards self-sufficiency in the workforce; thirdly, as important social partners within local communities; fourthly, as a procurer of goods in its supply chain; and finally, in reducing its environmental impact (box 4). These actions are linked to recommendations to enhance the NHS ’ s role as an anchor institution (ie, an institution that can positively contribute to the wellbeing of the population it serves and the communities it is based in). 77 Healthcare leaders might draw inspiration from the East London NHS Foundation Trust, which is working with University College London Institute of Health Equity to become the first Marmot Trust, exploring how trusts can work upstream to tackle the drivers of poor health and implement the Marmot principles (box 2). 78
Role of policy makers The health crisis cannot be solved by the NHS alone. Action on the social determinants of health requires changes in policies and political support from local and central governments. We know what to do. The political will to implement the recommended measures has, so far, been missing. The UK lost a decade between the government commissioned 2010 and 2020 Marmot reviews; the findings and recommendations were not acted upon by successive governments. 79 Since then, the covid-19 pandemic has worsened the crisis, 64 and life expectancy has regressed to 2010-12 levels. 17 Time is of the essence. We are not recommending further reviews, research, or commissions; these processes would delay urgently needed action. Instead, from the Marmot reports, 14194364 we highlight three recommendations (box 5): implement policies to tackle poverty so that individuals and families can lead healthy lives; invest in housing that is compatible with good health; and prioritise children and young people. These recommendations are, of course, related. Reducing child poverty and improving child health will, in turn, improve the physical and mental health of families, strengthening the workforce and productivity, as well as reducing costs to the NHS. Although managing poverty does not level the social gradient, proportional universalism does, and a focus on housing and childhood can help deal with the gradient, as will further action on the Marmot principles (box 2). Similarly, by dealing with key policy areas, such as working and housing conditions, people experiencing intersecting factors are most likely to benefit, because the data consistently show that they are over-represented in these areas. Box 5: Recommendations for the government 1964 Implement policies to tackle poverty so that individuals and families can lead healthy lives • Ensure the national minimum wage and national living wage are sufficient to lead a healthy life • Adopt more equitable redistribution of profits in companies to reduce in-work poverty • Support the Joseph Rowntree Foundation and Trussell Trust campaign (Essentials Guarantee) 40 to raise universal credit to ensure that essentials are covered, with at least an annual review Invest in housing compatible with good health • Introduce schemes to increase the supply of affordable, good quality, sustainable housing (eg, by reform of the private housing market and by increased investment in building social housing) • Commit to a 10 year retro-fit programme targeted to people on low incomes in energy inefficient housing, tackling both the negative effects of poor housing on health and the effects on the climate Prioritise children and young people, giving every child the best start in life • Reverse the deterioration in mental and physical health of children and young people, and improve levels of wellbeing from the current low rankings internationally, as a national aspiration • Reduce levels of child poverty to 10% (comparable with the lowest rates in Europe) • Prioritise reducing inequalities in early years development (eg, allocating additional spending to early years in more deprived areas) Implement policies to tackle poverty so that individuals and families can lead healthy lives — Poverty causes poor health. 80 Treating people in a health service that returns them to conditions that are making them sick is futile. Policies to deal with poverty will, evidently, improve health.
Box 4: What the NHS can do as a health system As an organisation or system that employs staff
• Build and maintain a workforce environment that is conducive to improving the health of patients, and protecting and enhancing the health of staff • Ensure staff have the pay, conditions, and opportunities to learn and develop, and have inclusive working environments where they can thrive • Take a proactive approach to workplace health and wellbeing • Encourage an open and supportive culture for the early recognition and proactive management of mental health problems • Ensure a continued commitment to educational programmes that raise awareness on how factors such as race, sex, sexuality, and deprivation can affect health outcomes As an NHS workforce • Work towards a model of workforce self-sufficiency for the UK • Ensure adequate support structures are in place for international staff, because marked inequalities also exist in access to healthcare for staff and their families 76 • Support local communities to explore the roles available in the health service, and support apprenticeship schemes in the NHS • Increase training opportunities and skills development for all staff As an organisational partner in civil society • Learn from others, share and adopt ideas that improve health and care, and model broader civic responsibility • Build relationships and partnerships with organisations (eg, local authorities, voluntary sector organisations, local businesses, sports club foundations, community groups, healthcare providers) • Harness these relationships to work in multi-agency partnerships within a defined place, forming a strong collective power to tackle barriers to good health As a procurer of goods and services • Ensure contracted service providers have fair working conditions for their employees. • Where possible, procure goods and services locally that benefit the community and minimise harm to the environment As a sustainable healthcare system • Continue to work to reduce the environmental impact, working in partnership with others on key concerns • Continue progress towards the NHS becoming the world ’ s first net zero health service
the bmj | BMJ 2024;385:e079389 | doi: 10.1136/bmj-2024-079389
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