We often think of health as being all about doctors, medicine, and operations. We might occasionally contemplate our lifestyle, but rarely will we factor in our friendships or the kind of home we live in. Governments promise answers to health worries by building more hospitals – big physical things that we can tangibly see – even if it’s unclear whether they are as enthusiastic about spending the money to fill them with nurses.
It’s natural to think this way, but seriously misleading. The foundations of our good or bad health are often much more to do with other factors, often termed the social determinants of health. Our health is impacted by the job we do, the income we have and the lifestyle our place in society leads us towards. It’s about whether we are stressed all the time, whether we enjoy loving friendships and relationships that nurture our wellbeing, whether we live near a polluting major road and breath in toxic air. These are the factors that really cause the underlying problems.
The new report by Sir Michael Marmot, updating his work from ten years ago, makes pretty unhappy reading. To be blunt, things are not getting better. Ominously, he says that “Since 2010 life expectancy in England has stalled” something that “has not happened since at least 1900”. Worse still, inequalities in life and healthy life expectancy have grown, and even more worryingly, “among women in the most deprived 10% of areas, life expectancy fell”. We can speculate why but Marmot certainly points towards the contribution of ‘large funding cuts’ in areas like housing, education and youth services during the years of austerity.
Our work on health
At NPC, we are striving to keep the social sector fully engaged in these debates:
- We are members of the Collaboration for Health and Wellbeing, coordinated by the excellent Health Foundation who are increasingly committed to this agenda.
- We have conducted research to help non-health charities understand their contribution, and we’ve shared our ideas with funders and philanthropists who want to help address these issues.
- We’ve been promoting place-based system change, which is even higher up the agenda given the recent post-election focus on levelling up, and is often relevant to the social determinants of health agenda.
- We seek to be an informed and critical friend in the social prescribing agenda, which aligns with social determinants of health by putting non-medical approaches to improving health at the centre of its thinking. Our upcoming roundtable will discuss the challenges of applying this idea at scale and evaluating its impact.
Out of all this, we’ve learned a few things that we think really matter if our society is to respond to Marmot’s findings.
Responding to Marmot: How charities can help
First, many of the social determinants are deep and structural. They are not just about whether we eat enough fruit or go to yoga. They are about poverty, bad housing, and horrendous experiences (like rough sleeping or domestic abuse). Charities and their funders need to keep up their unwavering commitment to defeating these evils, whether through service delivery or advocacy.
Second, many charities and community groups are improving social determinants of health as a by-product of what they do. Whether it’s a sports charity, an arts charity, or even a so-called hobby charity, they bring people together. Charities give people a sense of connection, purpose and agency, all of which contribute to better lives. This is the value of the social infrastructure we argued for in our recent paper on Where are England’s charities? Charities need nurturing and they need funding, especially as our paper showed that there are fewer charities in more deprived areas, arguably the places which most need them. The new Marmot report shows how many of the areas with poorer life expectancy have been hardest hit by public spending cuts over the last ten years. If levelling up is to mean anything, it must surely mean levelling up the time one can expect to live, irrespective of one’s postcode.
Third, metrics matter. But we need to be careful here. We need theories of change that push us towards action that is likely to work to attack the social determinants of health. We need to check we are doing the right things and helping the right people. But approaches like Randomised Control Trials do not get us far in this area. Likewise, only looking for Treasury savings, instead of wellbeing and other impacts, is a mug’s game. Ideally, we would be persuading NHS England to set up a Health Data Lab to capitalise on the great wealth of administrative data they hold and so help tell us which interventions by charities are working best, something argued for in a recent NPC paper.
Conclusion: Charities need to get behind the attack on the social determinants of health
We hope the new Marmot report raises these issues in the minds of everyone working keep us healthy. For our part, NPC will continue to champion the potential of charities to improve health outcomes so the social sector can make its full contribution.