How health is created, why does that matter – and so what?

How health is created, why does that matter (and so what?)

Earlier this month I did the annual lecture for the Sheffield Institute of Policy Studies with the above title. Knowing some of the names who had previously delivered this (way out of my league) I was a bit nervous.

Anyway the lecture will be online as will the slides. I will put the link here when I get it.

The main bit of the lecture covered the title above – how is health created and why does that matter. Key points here

How health is created

Health isn’t “the NHS”. Necessary but not sufficient 

Duncan Selbie – ‘health isn’t what’s the matter with people it’s what matters to them’ 

Sum total of all that happens in society contributes to our health. See the stuff from PH Scotland on power – who has it, why it matters, how it affects our health. Also this on power – the fundamental cause of health, or lack of it, and inequity in health. See also the stuff from Prof Sir Harry Burns on what CAUSES well being. This model of health creation is FUNDAMENTALLY different to “prevention”, it requires a fundamentally different way of thinking and acting. People often put this model of thinking into the VCS box around social well being and social capital (and I have blogged on that recently) but it is WAY beyond “something the VCS does” – fundamentally rewiring how our society operates.

Why it matters

Social justice – some have less health than others – that is largely to do with structural factors not individual choices – you need to decide whether that is fair or not

economy – lack of health is constraint on economic growth (and the dividends that brings)

service demand – when will social care and the NHS break, basically

We can choose to address or not choose to but whatever we choose it matters

So what, why should we care, what is the call to arms

I got thinking afterwards – the “so what” question”. Here are short notes on that.

This was the bit I didn’t adequately address. Here are 10 thoughts

1            the big idea is that there isn’t a big idea

there IS no single thing. We all want simple answers, they don’t exist.

There are no silver bullets

Little things all add up to have big population impact over time (Geoffrey Rose)

A small shift in the whole population mean of some concept of interest can have way more net impact than an enormous shift in “those at high risk” (again Rose)

Don’t neglect the leverage points in any system, the things that shift the rules of the game (see Donella Meadows on making shifts in complex systems and the most impactful interventions)

2            We know A LOT (not all) what to do – it isn’t an evidence problem

Lots want “the answer”. We largely know.

In narrowly defined areas it is straightforward. For example – smoking is the new smoking and we haven’t achieve best in class smoking prevalence by accident – consistent application of right things over a period. Getting to 5% tobacco might in itself achieve the HLE levelling up mission. So we simply accelerate what we know

In more broadly constructed places – for example health inequalities – Marmot GM report (and plenty of other Marmot reports). I also wrote a bit recently on the critical lessons on talking health inequality.

Re economic inequality – Deaton / IFS. LU analysis is v good

3            we all say “Health in all policies”. Its not wrong, but its not easy

Easy to say hard to execute. Technical AND political project. See this excellent blog from Paul Cairney – technical exercise vs political project. I’ve done a fair amount on health in all policies.

Use well being as organising principle. If government doesn’t exist to serve this then what is government FOR.

The gap within that.

Defining well being – economic, social, ecological, personal (not just yoga and head massages etc) that means how do you measure economic growth? 

Who is ACCOUNTABLE for health

there is a valid argument to be made that ministries beyond the “health ministry” have a much greater impact on health than the health ministry, but the health ministry has responsibility. The conundrums are set out in this article summarising interviews with ministers with responsibility for health. Following this – here is a semi serious suggestion for health policy

1 Abolish DHSC as it currently is set up

2 Establish a ministry of NHS (Give primacy to primary care)

3 Establish *health* as a core responsibility of the cabinet office. Till then actual health policy will be second order issue to the burning platforms within the health ministry, which – lets face it – aren’t health creation.

social determinants of health AND commercial determinants of health

obviously cigarettes and alcohol but also commercial determination in the way that at many other factors operate in the privatisation of profit and socialisation of risk. I have written a lot on CDOH recently.

4            redefining “economic” strategy. What is the extent to which the following are reflected in economic policy

1. social outcomes and the well-being of the population as a core goal is as central to the decision-making as GDP growth. Is healthy life expectancy part of core economic metrics?

2. and the distributional nature is more important or at least as important as the net gain.

3. ALL costs and ALL consequences – including all the externalities – are on the balance sheet with a 20 to 50 year time horizon. Timing matters – think decades, not days. Think long term – trends and challenges “mission not a battle”

4. Revalue the Future – Focus Business on the Long Term. People AND tec, Perverse subsidies hydrocarbons / agriculture. Discounting matters: future generations should not. be discounted against simply because they are born tomorrow and not today

5. invest in Younger Generations:  Attack Poverty at its Source. Social protection measures such as conditional cash transfer programmes.

Does your economic story talks to big macro trends – demography, geopolitics, mobility, ecosystem, health, tech, governance shifts. See this on the long term trends we might need to orient on. 

All the above are technical exercises AND political. See this blog based on a note from a NZ treasury civil servant on a Well Being Economy – need to completely redesign the “how to run the economy” manual and here for a bit more.  The NZ Treasury stuff on valuation of well being in long term economic model is hugely important here. Ditto Scotland and Wales – the well being economy model.

5            different operating principles

Cross sector collaboration

No one sector has all answers

operational, tactical, strategic linkages for say housing / NHS / social care.

Nobody is asking the NHS to build houses, but a lot of untapped sweet spots.


Complex problems cant be solved by single constituencies. Develop creative coalitions on the big things – climate change, common threats, health (or lack of it)

Think through what innovative, open and reinvigorated Institutions looks like

In this openly surface big policy conundrums – get them out on the table and openly discussed. Some of these conundrums will be technical, some political, some ideological. Openly talk about the trade offs. For example housing growth vs stock quality, redistribute wealth vs trickle down, extent to which we can / want to regulate private sector created issues. See this article on the policy conundrums and policy trade offs around climate and net zero.

Establish a Common Platform of Understanding – Annual accountability conversation. Who is accountable for delivery on the LONG TERM stuff. What does it look like, how is it executed

independent, accountable institutions and coalitions with long term horizons.

Neither paternalism nor free market is the answer – see the Cottam / Radical help narrative

Strengths based approach. A lot of good at frontline service delivery. Imagine if we used the thinking to fundamentally rewire way in which big institutions operated

Tweaking current vs fundamental shift. Difficult. Easy (ish) to tweak

the welfare state was designed in the 40s and is no longer fit for purpose.

something to be made of appreciative enquiry type methods

This bottom up approach needs to be the new way.

Getting from here to there is will be tricky (Would probably be easier to land on Mars and just set up a new-system from scratch)

6            We know we have basic services significantly underfunded.

Public service funding itself is a determinant of outcomes (see the references in the lecture, see Marmot 10 years on)

And too much emphasis on equal / equality not equity. If we WANT to solve the gap are we prepared to do unequal resource for unequal need.

Equality of opportunity may not be enough to level the playing field

That is a policy choice.

7            don’t neglect intelligence from the frontline

We grossly under capitalise on the skills knowledge and intelligence of those at all forms of frontline in both policy and service delivery innovations.

Not as a route to controlling their blood pressure, or indeed getting them to stop smoking, or “tackle crime)

but to hear what is important to them and allow them to find solutions that are relevant to them. E.g. covid support – VCF both defined the job and then delivered the job WAY better than other services could  have

8            Whitehall vs town hall

Health across ALL govt depts. DHSC is obvious (the dept of hospitals?). HMT, DfT, DfE, DEFRA, DHLUC, and all

Locally. Some enabling infrastructure.

Sometimes we can do not much more than ameliorate the consequences of govt policy decisions

Hugely over centralised society. Whitehall is hugely impactful policy wise, but not in a position to know what will or wont fly on The Manor. See Will Hutton article on Levelling up on the consequences of over centralisation. Plenty of others have written on this.

Many often ask “what powers do I want”. This will vary from policy area to policy area, it is relatively easy to come up with a long list of powers. In my experience we need power AND resources to implement the powers we may have. What would really be interesting to explore is power to intervene in any area that government chooses not to.

9            Beyond the town hall

empower, enable and BELIEVE the voice of communities.

Hyperlocal it’s easy to say we don’t do it terribly well

the above should not be seen as a touchy feely, low-cost, add-on approach that belongs in the voluntary sector, but we (statutory sector and beyond) should be viewing this as the ‘main/stream’ future and start ceding control in a very real way

Investing in the very fabric of our VCS in an unrestricted way– social value and social capital

10          Focus on the Sheffield £ as opposed to individual institution £.

Again easy to say, difficult to do as each institution has different demands, drivers and accountability frameworks.

Economic power of big anchor institutions. City and locality.


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