Determinants Health In All Policies Public Health

What proportion of health outcomes are attributable to health care

how much does health care contribute to health

Debate rages.


I don’t know the answer.

Lots of different agendas contribute to health outcomes, we know this. Dalghren and Whitehead highlted it nearly 30 years ago, maybe more. The basics haven’t changed.

The relative contribution of different determinants

Debate continues to rage on the extent to which health care contributes to health outcomes.
The Health Foundation have been in thus space recently:

The Kings Fund are also there

Click to access inequalities-in-life-expectancy-kings-fund-aug15.pdf

The best I’ve ever seen is the work done by RWJF, summarised here:

nb – not both the quality and access issues around healthcare (you could make the same argument around any other service)

This study finds that between 1900 – 1999, life expec at birth increased from 47 years to 77 years. 25 of the 30 years gained can be attributed to PH advances. The aggregate effect of medical care on life expectancy is found to be roughly five years during this century, with a further potential of two years.

The Caveat re medical care is re alleviation of the enormous burden of pain, suffering, and dysfunction that afflicts the population for which medical care can provide a large measure of relief. See this blog also, and this interesting and useful blog on the quantification of the importance of healthcare for population health.

I’ve also written other stuff on this – The flat of the curve. Do you want more health, or health care and How can we measure how much the NHS is contributing to lifespan

Does it matter. Maybe, maybe not
My previous view was as follows:

  • Depends on timeframe, local context, what outcome measiure, what coverage of interventions that make a difference to outcomes of interest, a host of other factors
  • Im rarely absolutist about it
  • Health care is one of the determinants of health
  • Heath is one of the determinants of well being
  • Without doing the analysis it is impossible to give  quantified answer
  • I think trying to nail a quantified number is likely impossible and we’d spend more time arguing the question
  • Even WITH the analysis the answer is incredibly nuanced, context specific and full of methodological fine print that few are prepared to engage with.

On this last point, see Krieger – there’s some very tricky to handle messages in here, the methodological stuff in the Global Burden of Disease referenced here (the maths is in the appendix) and here – the methodology paper describing how they incorporate Comparative Risk Assessment (CRA) to figure out attributable deaths, DALYs, exposures etc. This has been built on as the GBD study has grown, but the method is basically unchanged as far as I can see.

You quickly get into a discussion on methodology for competing risk epidemiology. Anyone up for it? No I thought not. And that’s with simple neat, clean defined risk like smoking , blood pressure – not complex messy stuff like housing or poverty.

thanks to @drchrisgibbons for nuggets of wisdom

Why it DOES matter…..

There’s a great pic in circulation on twitter underscoring the notion that BOTH supportive policy environments AND social factors beyond health care are considerably more important than health care interventions delivered one person at a time

There’s a key weakness in this (excellent) picture in that it doesn’t represent the unequal distribution of the those determinants of health, or the determinants of the determinants (current economic model, underling ideology).

That would be a tricky diagram indeed, but may significantly steepen the hill for some and make it shallower for others, and determine how strongly individuals needed to push etc.

This picture and this picture alone underscores the point about the need to focus on communities, populations and toxic environments and give this primacy over services that help individuals

And doesn’t it depend how steep the hill, how big the ball, and how strong the push? That all varies over time/case. ‘Very often’ not always?

I’m firmly of the view that the allocative split of resource within the health care system is not in keeping with our stated goal – healthier folk etc.

The implication is an investment in social care, mental health and primary care, at the expense of other investments.

If we want more health, we may need to shift our profile of investments away from health care towards other social investments that are more closely related to health outcomes.

As Richard Smith points out we may be at (in some cases well over) the flat of the curve (of diminishing marginal return)
Quoting directly……

We know, however, that healthcare has only a small effect on length of life and that its benefit is on quality of life. But attempts at aggregating health benefit show a similar graph to that for life expectancy—at a fairly low point further expenditure produces little benefit. What is sure is that the extra value produced by further expenditure becomes smaller and smaller, meaning that hard-hearted economists (and even rational soft-hearted ones) would spend the money on something else—housing, environment, education, the arts—where extra spending would produce unquestionable and easily measured benefit.

In fact, in many places increased spending on health is “crowding out” expenditure on other areas. Don Berwick, a paediatrician who recently ran for governor in Massachusetts, shared a graph at the World Innovation Summit for Health in Doha that showed that state expenditure on health had increased considerably while expenditure on everything else had gone down.

Worse than flat of the curve healthcare is the point where more spending means worse outcomes. Enthoven thought that he saw this in areas like coronary bypass surgery where people may be given operations that they don’t need with some of them being harmed by the surgery. This is the phenomenon of “supply led demand:” once you have many (indeed, too many) cardiac surgeons they will not be idle, they will operate on people where the benefit of the operation does not outweigh the inherent risk..”

Don Berwick says pretty much the same when he was interviewed by Simon Stevens (pre beard)

If we want to control spiralling health care costs, we must invest for health

The path to healthy life expectancy is a complex one, but health care doesn’t feature that strongly in it, certainly not beyond primary care.

As I have made the case in many previous blogs the problems in health care are accountable to unrealistic expectations, high cost low value technology and disease incidence (and not the ageing population). Turn disease incidence on its head, you have “health”

If we want better healthy life expectancy, we can either choose to invest our resources in health care or things that might lead to health.

Government have stripped local government cupboard bare. We are 7 years into a 4 year austerity programme. Of course it’s the result of a policy choice. The requirement of governments to make those choices must be respected, but there are consequences of those choices we may come to see – note faltering life expectancy worries.
the solution‪ to the conundrum depends whether you want more health or more healthcare. ‬

Of course this is difficult, of course we always need more CT scanners, and diagnostic capacity. These priorities will always be present. If we only ever address the (unending) demands of the present we won’t make the right long term investments.

‪If we want health, we should invest in things that might best lead to health. In the era of boundaryless accountable care, that means using “health” money to invest in non “health” investments.‬
My own solutions

  • I’d invest in primary care and social care (best chance of addressing here and now challenges) & primary schools (short hand for best start in life and best life chances). Particularly, I’d focus my investment according to the principle of proportionate universalism.
  • I’d end austerity – it is doing harm, directly and indirectly through stripping out services that help folk.
  • And ensure decent & affordable housing standards
  • One last thought – community building. There are two things that really worry me, one is an outbreak that goes wrong – can go wrong quickly and in a big way; the second is our perilous state of community based approaches, often focused on strong community anchor organisations. This is a trickier problem to solve than the outbreak issue. I suspect Roz Davies knows how.

That’d do for week 1, most of the Ottawa Charter picked up. Maybe in week two I’d look at the economic determinants of health and the determinants of the determinants.

Just saying…….


Don Berwick

Richard Smith: “Flat of the curve” healthcare

Richard Smith: How to stop the medical arms race?

11 replies on “What proportion of health outcomes are attributable to health care”

Thanks, interesting and clear argument. Great infographics. To even start to do this I think we would need to change the value that is placed on hospitals and CT scanners by our society… how do we change mindsets about health vs healthcare?


It’s you. I’m in Sheffield. I’m a GP trainee and leadership Fellow working in HEE working on tackling health inequalities in general practice largely through an educational lense. Realising that in care delivery we can only do so much, it needs a societal and cultural change to drive reDistribution of resources (chicken and egg though I suppose). We met briefly a few months ago. Thanks for the blog.


Part of the problem is the phenomena of the identified individual. Assume the system has £100,000 to spend. You have an identified individual with a name whose life will be saved with that money. Or you could spend it on a population and be confident you will save 4 lives – but you don’t know who those individuals will be. The system tends to spend it on the identified individual. Unless your this government, in which case you say you haven’t for the money, you need to save £20,000 of the £100,000 and then announce £3,000 as ‘extra investment’.


Thanks so much for this Greg – Simply put! Shifting the emphasis, the paradigm to what creates health and how to do it. I’m sure engaging with local people in places, neighbourhoods etc. is the way, challenging the conflation of being healthy with NHS (places such as hospitals etc) is part of the task, #it’snotthehospitalstupid.
On a similar and related issue – gang violence and its culture as PH issue?


Gang violence….why not
I always struggle to define boundaries about “public health”
Gang violence has consequences for both individuals and for pops, thus a ph issue…..? Its not something I’ve through too deeply re the specifics tho…


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