Improving the determinants of health and well being

I was once asked “why local government didn’t take the determinants of health seriously“. After I’d picked my jaw from the floor, I had think of an erudite answer. I won’t revise or review my answer further.

Health policy is mostly focused (in the minds of the public) on the NHS. The Health Foundation published an excellent report from the Health Foundation that focused on three questions:

  • Why do governments focus on health care rather than health? 
  • Where has a shift to health started and what have been the contexts, drivers and benefits? Where that shift is held back, what have been the obstacles – funding mechanisms? 
  • What is the relationship of the state and the individual? What is the nature of evidence in complex systems


And to their credit, the HF have published an excellent strategy for health that is very refreshing. It is worth you reading it.


Sheffield City Council has now agreed a strategy for public health. It is referenced.

Health in all policies is a key focus of this. We are trying (again) to move “health policy” away from health care and more toward the things that determine our health – funnily enough often called “the determinants”.


Here I will focus a little energy on “the determinants”.


As we all know the determinants of health are complex. 

Each of the things known as “determinants of health” are 

  • complex, there are many moving pieces, many intersecting service delivery, capital investment and policy areas. 
  • Some of these are in direct control of local govt or other local actors, many are not.
  • This is true for all things considered “determinants” for example air quality, education, spatial planning, economic development, poverty, or housing policy.

To make progress you need to to be able to understand the drivers of those systems… they operate, the incentives, the power bases…..and what outcomes they are measured by…

So “addressing the determinants of health” is just as (arguably much more) complex than many who are outside this world might think.

Take “Education” for example . Education is an obvious determinant of health and well being (and lost of other socially useful outcomes!)

(I won’t dwell on the evidence for this statement. There’s rather a lot of it. Google will set you right if you look. See the ref from RAND as a starter.)
Two obvious indicators of “the problem” and markers of improvement – school readiness age 5, educational attainment age 16 – and the inequalities in both. Again, there’s plenty of evidence of inequality in school readiness and attainment.
Im told both are fundamental determinants of adult outcomes and life chances, and that improving school readiness changes life trajectory age 26 and is a good predictor of income tax paid (a proxy for income among other things). It’s an area I don’t have great expertise in, but have no reason to disbelieve it.


However, it’s complex. Schools are increasingly outside the control of local government. Early years services are not.

 There are no silver bullets, no single investment or intervention that will solve the problem. 

Many aspects of policy of service delivery overtly not within LA control. There are many crazy and perverse incentives and issues.
It is a complex system, difficult to “control”. Obviously this then takes us into complex system type of discussions and the extent to which they are “controllable”
So – some thoughts on improving health via addressing the determinants – here using school improvement as an  example, and a repute to improving educational attainment 

I should caveat that I’m no expert in “education”, nor should I be. If we’ve signed up to a health in all policies type of framework we need to ensure we have organisational competence and a plan.

There’s pretty much universal agreement that in the absence of a mega innovation, an Incremental change with right model of delivery and an intelligent / intelligence led approach is the way to go

Detailed understanding of the data matters
Some investment may be needed in key priorities, but not much.

There may be scope for social investment type models to try and test innovations, this shouldn’t replace state funding.
We have broadly a locality based approach to school improvement and partnership of schools in context of local community. This seems to matter, and I’d argue it’s the right approach.

Academy status doesn’t really matter (it may do if academy isn’t bought into the local vision – this is the bit that seems to matter.)

Leadership matters. A lot.

Accountability for improvement matters. Capacity to improve is inherent in all. We have a model of competitive collectivism, again this seems to matter.
Lastly, it cuts both ways – good health and healthy behaviours is important fundamental for learning (and thus downstream attainment). No shortage of evidence there either.

  • Making improvements to “the determinants of health” is complex, tricky and there are no easy answers. Just like health care?!
  • The logic of improving school readiness and educational attainment leading to improved life chances and downstream health gain is pretty sound.
  • Like most other policy areas we won’t get population gain till we have addressed inequalities
  • If you want to improve “a determinant” you need to be able to understand the system and provide the right sort of help and support, but not necessarily be an “expert” (remember we all hate experts now etc)
  • The same basic principles apply to anything that is a determinant.



If only local government took the determinants seriously –


Why are We Hooked on Health Care? Designing strategies for better health.


The HF strategy for health


SCC Public Health Strategy


Implementing a  health in all policies approach in the context of a public health strategy
RAND- Investing in the Early Years: The Costs and Benefits of Investing in Early Childhood.



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