ANALYSIS
Invest in sustainable housing compatible with good health — The standard of housing in the UK is poor, and homelessness is rising to record levels. Cold, energy inefficient homes cause poor health and cost billions a year, directly and indirectly, through costs to the NHS of associated health problems, energy bills, lost productivity from poor health, and carbon emissions. 19 Prioritise children and young people, giving every child the best start in life — The government must act immediately to reduce child poverty and improve child health, with proportionate universalism, ensuring that those doing worst receive appropriate support. This approach requires acknowledgment of racial, ethnic, and geographical inequalities, as well as their interaction. In addition to the recommendations in box 5, the government should remove the two-child restriction on child benefit and benefit cap, increase child benefit for lower income families, and extend free school provision for all children in households that receive universal credit, as set out in the Build Back Fairer review . 64 For any recommendations to be meaningful, an acknowledgment that the UK has a problem is crucial. Thus we call on the leaders of all political parties to recognise the scale of the problem and the need for action, and to commit to acting on the available evidence (box 6). Support for this initiative must come from an informed, unified general voting population, who are also considering those who cannot vote (eg, those who are too young to vote). Box 6: Call for leaders of all political parties to acknowledge the problem and act on the evidence • Austerity has harmed health, including through worsening of many social determinants of health, including housing, income, and education • Action on the social determinants of health will improve health • Inequalities are rising in the UK, based on factors such as deprivation, race, ethnic group, and sex, which overlap and interact Conclusions Improving the health of the population and reducing avoidable health inequalities must be a national priority. So strong is the evidence on social determinants of health that the health of the population is a good measure of how well society is meeting the needs of its members. If health inequalities are increasing, inequalities in society are increasing, and dealing with these inequalities is urgently needed. Action will include an NHS, free at the point of use, that delivers high quality care proportionate to need. But much more will be needed. A common response is that we cannot afford such action — we argue, we cannot afford inaction. We call on all political leaders to acknowledge the problem and the urgent need for action on the social determinants of health. This action can be a story of hope: we can change the direction of health in the UK if we use the robust, broad evidence on how to act. Recommendations • Form a cross-party task force accountable for public health • Re-establish Public Health England and restore the public health grant to 2015-16 levels • Build and maintain a workforce environment in the NHS that supports action on the social determinants of health and that is conducive to protecting and enhancing the health of staff, as well as patients • Implement policies to tackle poverty so that individuals and families can lead healthy lives
• Invest in sustainable housing compatible with good health • Prioritise children and young people, giving every child the best start in life We thank Gabriel Scally for his significant contribution to the first iteration of the paper, including the section on the weakening of the public health system; Martin McKee for contributing on public health in Northern Ireland and providing further informal review and support in the final version of the paper; and Sophie Cook from TheBMJ for her constant support throughout. Contributors and sources: LH, BK, and MM are members of the BMJ commission. LH is a general practitioner and public health doctor. She is studying for a DPhil in geography and the environment focused on the change in health outcomes in the UK from 2010 onwards. BK is a consultant paediatrician who also leads his organisation ’ s work on its role as an anchor institution, as it tries to play a part in improving the social determinants of health. MM has had a longstanding research programme on health inequalities and led several commissions and reviews on social determinants of health. AS is studying part time for a PhD in the department of global health and social medicine at King ’ s College London. Her research and writing focus on health inequalities. All authors contributed to ideas, writing, and revision of this article. LM is the guarantor.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of The BMJ Commission on the Future of the NHS (https://www.bmj.com/nhs-com- mission). The purpose of the commission is to identify key areas for analysis, lay out a vision for a future NHS, and make recommendations as to how we get there. TheBMJ convened this commission, which was chaired independently by Victor Adebowale, Parveen Kumar, and Liam Smeeth. TheBMJ was responsible for the peer review, editing, and publication of the papers of the commission. The BMA, which owns TheBMJ , grants editorial freedom to the editor in chief of TheBMJ . Theviews expressed are those of the authors and may not necessarily comply with BMA policy. 1 National Centre for Social Research. Public attitudes to the NHS and social care. 2023. https://natcen.ac.uk/publications/public-attitudes-nhs-and-social-care 2 Marmot M, Wilkinson R. Social determinants of health. Oxford University Press, 2006. 3 World Health Organization. Social determinants of health. 2024. https://www.who.int/health- topics/social-determinants-of-health 4 Wormersley K, Hiam L, Issa R, etal. NHS must fix inequity to improve health for all. BMJ 2024;385:e079473. doi: 10.1136/BMJ-2024-079473. 5 Mortimer J. ‘ A poor country with a few rich people in it ’ : renowned inequalities expert speaks out as bereaved families give their accounts of ‘ the unequal pandemic ’ . Byline Times 14 Sep 2023. https://bylinetimes.com/2023/09/14/a-poor-country-with-a-few-rich-people-in-it-renowned-in- equalities-expert-speaks-out-as-bereaved-families-give-their-accounts-of-the-unequal-pandemic/ 6 Royal College of Paediatrics and Child Health. State of Child Health: Infant Mortality. https://sta- teofchildhealth.rcpch.ac.uk/evidence/mortality/infant-mortality/ (2021). 7 Hiam L, Dorling D, McKee M. Falling down the global ranks: life expectancy in the UK, 1952-2021. J RSocMed 2023;116:-92. doi: 10.1177/01410768231155637 pmid: 36921623 8 Hunter DJ, Littlejohns P, Weale A. Public health is in crisis, but it can be fixed. BMJ 2024;384:. doi: 10.1136/bmj.q760 pmid: 38537940 9 Finch D, Gazzillo A, Vriend M. Investing in the public health grant. Health Foundation, 2024. https://www.health.org.uk/news-and-comment/charts-and-infographics/public-health-grant-what- it-is-and-why-greater-investment-is-needed 10 The Public Health Scotland Order. 2019. https://www.legislation.gov.uk/ssi/2019/336/con- tents/made. 11 Green L.Health impact assessment practice in Wales: factors conditioning its success. Eur J Public Health 2022;32:ckac129.101. doi: 10.1093/eurpub/ckac129.101 12 Alexiou A, Fahy K, Mason K, etal. Local government funding and life expectancy in England: a Rashid T, Bennett JE, Paciorek CJ, etal. Life expectancy and risk of death in 6791 communities in England from 2002 to 2019: high-resolution spatiotemporal analysis of civil registration data. Lancet Public Health 2021;6:-16. doi: 10.1016/S2468-2667(21)00205-X pmid: 34653419 14 Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot review 10yearson . 2020. health.org.uk/publications/reports/the-marmot-review-10-years-on 15 Hiam L, Dorling D, McKee M. Things fall apart: the British health crisis 2010-2020. BrMedBull 2020;133:-15. doi: 10.1093/bmb/ldz041 pmid: 32219417 16 Public Health England. A review of recent trends in mortality in England . https://www.gov.uk/government/publications/recent-trends-in-mortality-in-england-review-and- data-packs. 2018. 17 Office for National Statistics. National life tables – life expectancy in the UK. 2024. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectan- cies/bulletins/nationallifetablesunitedkingdom/2020to2022 18 longitudinal ecological study. Lancet Public Health 2021;6:-7. doi: 10.1016/S2468-2667(21)00110-9 pmid: 34265265 13 Resolution Foundation. Britain ’ s housing stock offers worst value for money of any advanced economy. 2024. https://www.resolutionfoundation.org/press-releases/britains-housing-stock- offers-worst-value-for-money-of-any-advanced-economy/
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