Our health crisis - which party has the best prescription for our nation’s health?

Health is far more than the NHS and Social Care - which party is more likely to improve the wider determinants of health?

I’m back from two weeks of holiday and before Thursday’s general election, I wanted to write something about our nation’s health, what matters for improving it and what the Conservative and Labour parties have said about it in their manifestos.

The short version is that we are in trouble, almost all the wider determinants of health (e.g. housing, employment, poverty, environment) have worsened over the last decade and neither party fully acknowledges the scale of the problem in their manifestos. Labour come closest in explicitly building health impacts across their portfolio of policies while the Conservatives largely stick to an unhelpful model of individual responsibility.

In this post, I take a deeper dive into the wider determinants of health, with a summary of each, before looking at each party’s policies.

Our health is getting worse

The UK population has a health problem. After steady gains in life expectancy for decades, The King’s Fund reports that life expectancy flatlined during the austerity years (2010 -2019) and fell for the first time this century with the Covid pandemic. The number of people out of work for long term sickness is approaching record levels. Millions of people of working age are now living with multiple health conditions and there are huge inequalities between rich and poor. For instance, according to ONS statistics, boys born in 2018-2020 in the most deprived areas of the country can expect to die almost 10 years earlier than their peers in the least deprived areas. Even worse, they can expect to spend 18 fewer years of their (shorter) life in good health (52 years) compared to boys born in the richest areas (70 years).

These are official figures and are neither disputed nor controversial. My personal opinion is that they should be controversial – such numbers should be shameful and unacceptable for a rich country like the UK. They also make it much harder to be a happy country and to have a productive economy.

The NHS is a necessary part of the solution but only a small part

A strong health service is necessary for a healthy population but not sufficient. Health is not guaranteed by check-ups and treatments. Nor is it just a factor of your genes and your individual lifestyle decisions. While those all matter, the wider context in which we live is crucial – from housing to employment to education to the environment.

The wider determinants of health have been known for decades (The Health Foundation has particularly good, accessible, explanations). Austerity, compounded by the pandemic, has made almost all the determinants worse. Additionally, short-termist, Conservative policies such as reducing the ability of people to be signed off sick or making it harder to access benefits for the long term sick will just increase poverty rather than improve health.

I’ve made a diagram showing how social factors feed into health, how poor health and social care services can exacerbate health issues, and how poor health in turn can influence social factors (such as losing employment, losing housing or reducing exercise) in a vicious circle. Below I go through each aspect of the diagram, with the heading numbers corresponding to the numbered box in the figure.

1: Health

Too often people use the word “health” to mean “physical health” only. Being in good health requires being in both good physical health and good mental health. Loss of either one makes you sick. Unfortunately losing either one can impact the other: loss of physical health can easily lead to depression or anxiety for instance. Poor mental health is strongly associated with worse physical health, as it becomes much harder to adopt a healthy lifestyle. Either one can drive you out of work, triggering poverty, which in turn can worse both your physical and mental health.

Wider determinants of Health

2: Housing

Homelessness is terrible for your health. In 2021, ONS reported that 44% of homeless people identified as disabled compared to 17% for the rest of the population. Temporary accommodation (housing 309,000 people including 140,000 children), while preferable to street homelessness, means that adequate nutrition is difficult, with little ability to cook or to store fresh food. Shelter report that over half of homeless families are in work, but jobs become harder to keep once homeless (especially if temporary housing is far from work).

Temporary housing or poor quality housing also often means minimal space or privacy and insecurity of tenancy. The constant high stress of living with insecure or poor housing takes a toll on mental health. Housing with mould, damp, or lack of heat can lead to physical diseases, in particular respiratory diseases. In extreme cases they can kill, such as the death of toddler Awaab Ishak in 2020.

Homelessness is increasing (in England, the number of people in temporary accommodation increased by 10% in just the last year and more than doubled since 2010), fuelled by a lack of affordable housing and the cost of living crisis. Paying for temporary accommodation is also impoverishing local councils (who fund it), reducing their ability to support their population in other ways.

3. Nutrition and exercise

Food deserts – areas where there is limited access to healthy, affordable, fresh foods - are linked to obesity and poor health. Many of the most deprived populations are trapped in such deserts. The Trussell Trust reports that 1 in 7 people in the UK face hunger because they don’t have enough money. Hunger creates physical and mental stress and makes it hard to function. Obesity, poor nutrition and hunger go hand in hand. Over time, poor nutrition contributes to elevated risks for heart conditions, high blood pressure, cancer and dementia. The worse your diet at an earlier age, the worse the prospect for good long term health. According to a parliamentary report, by 2019, overall obesity levels have almost doubled since 2019. Inequalities are clear by the age of 4 and have worsened over time.

There is often a simplistic call for people to simply “move more”. “Get up off the couch” or “It costs nothing to go for a run”, people say. These are not helpful responses. Maintaining healthy exercise habits relies on people having all of the following: time, energy, space and not hating it. Working in jobs where you are on your feet all day, struggling with a busy family life, especially as a single parent, struggling with mental health, or struggling with insecure housing or income saps time and energy. Being able to afford an expensive gym makes the experience much more pleasant. Good shoes and exercise gear can cost a significant amount of your monthly income. There may be nowhere that feels safe or easy to exercise anywhere near your home. Meanwhile, physical ill health obviously severely limits the exercise people can take.

Exercise is brilliant for health, but we must not pretend that everyone has equal access to its benefits.

4: Education

In theory, education should act to reduce socio-economic inequalities, but in practice, the UK education system perpetuates existing inequalities, with children from deprived areas doing worse at all levels of the education system. High quality education sets the foundation for a healthier and longer life, by supporting people to enter into employment and empowering them by teaching the levers for a healthier lifestyle. However, knowing the levers is of no use if other circumstances prevent you from pulling them.

5: Employment

Long term unemployment is associated with worse mental and physical health. Poor health also makes it harder to find and sustain employment, particularly full time work.

But employment is not a panacea. The World Health Organization highlights that “Poor working environments – including discrimination and inequality, excessive workloads, low job control and job insecurity – pose a risk to mental health.” If your employer provides no sick pay or job security, then you might be pushed into worse health by working while ill or forced out of employment altogether.

If there is no flexibility to cope with changing circumstances (for instance new caring responsibilities) you may also be forced out of employment. In 2019, Carers UK estimated that 2.6 million people had left employment because of caring responsibilities, a 12% increase since 2013.

6: Environment

There are obvious factors that directly impact health: indoor and outdoor air pollution being the most important examples, or as increasingly the case in the UK, poor water quality. The government itself estimates that around 28,000-36,000 deaths in the UK each year are attributable to human made air pollution.

But indirect things matter too. Noise pollution can be very detrimental to health: firstly constant noise is stressful and secondly it reduces quantity and quality of sleep, which is in turn linked to many mental and physical health problems. Green spaces are not just good as a way of reducing air pollution and providing opportunities for exercise, but they are simply good for wellbeing. The mental health benefits of being in a natural environment are increasingly being recognised - even in dense urban settings.

Air pollution, noise and access to green space are all significantly worse in more deprived areas, acting to widen existing inequalities.

7: Crime

Crime can obviously directly impact on health if you are the victim of a crime. But crime also had an indirect effect: areas with a high level of crime add to stress and worsen mental health while also reducing opportunities for exercise or other beneficial community endeavours.  

8: Poverty and chronic stress

Cutting across all these wider determinants of health are poverty and stress. Chronic stress has a directly adverse impact on health, including higher risk of depression, anxiety, cardiovascular disease, sleep disorders, muscle pain and obesity. Poverty makes it more likely that you are in low quality or no employment, poor housing, higher crime areas, and with poor nutrition. All of those factors make it harder to then escape poverty. Any policy which exacerbates poverty will be detrimental to the population’s health, and the largest impact will be on children growing up in poverty. The most recent House of Lords estimate from May 2024, is that 30% of the UK’s children (4.3 million children) are living in poverty right now.  

9: Service provision - NHS and social care

The NHS is in crisis and has been for several years. The Covid Pandemic substantially worsened the situation and every winter emergency care is strained to breaking point while elective treatments are delayed. Waiting lists for treatment are at near record levels, while access to adult and child mental health services is increasingly difficult, with long wait times.

An NHS in crisis is exacerbated by a social care system in even worse crisis – lack of social care means too many people in hospital when physically health because there is no safe place for them to go, and it means more people become sick or injured through lack of preventative care in the community.

Strains across the provision of NHS services and social care act to worsen the population’s health, which only add more strain to these same systems in another vicious circle.

Labour and Conservative manifestos

The Labour party’s manifesto explicitly advocates for a holistic approach to health, recognising the wider determinants of health, particularly poverty, education and employment. It has a firm commitment to tackling inequalities and instituting initiatives such as expanding free school meals, creating more affordable housing (both to own and to rent) and enhancing job security and working conditions. Disappointingly, Labour does not commit to abolishing the two child benefit cap, recognised as a key driver of child poverty in the UK. It also aims to tackle the NHS and Social care crises, but the consensus seems to be that their plans will require more funding than Labour plan to spend to have the desired impact.

The Conservative party starts with a black mark for being in power for the last 14 years. The wider determinants of health, health and social care provision and the nation’s health have all worsened on their watch. Their manifesto does not take a systems approach to population health, instead focussing on economic growth and isolated interventions to improve health outcomes in a specific domain (e.g. by focussing on specific diseases or technological solutions). Additionally, Conservative plans to cut benefits further will only worsen health.  The Conservative ethos seems to be to create conditions that promote individual responsibility and action to manage one’s own health.

Individualistic solutions are not the answer

Of course we bear some responsibility for our own health – particularly those of us lucky enough to be in a position where our health is not adversely affected by any of the wider determinants of health. If you and your peer group are in that situation and have been from birth (which includes many politicians and public sector decision makers), incentivising personal responsibility might seem the obvious place to start. But marginally improving the health of those where personal responsibility is the biggest factor in determining their health outcomes is not going to address the deep rooted issues of this country or meaningfully improve our health.

Instead, we need a government that recognises the fundamental importance of these wider determinants and commits to improving all of them (not least because they interact with and compound each other). It’s an extremely difficult task and will require significant upfront investment now for a healthier future that will not be realised for years, sometimes decades. It still needs to be done. Out of the two main parties, I believe Labour has the best plans for taking on this challenge. Whether Labour’s commitments survive the reality of politics and extreme funding pressures remains to be seen.