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Tuesday, May 16, 2017
From The Lancet
Manifesto for a healthy and health-creating society
Brexit and the troubled state of the NHS call for re-thinking the UK's approach to health. The EU referendum vote reveals deep social divisions as well as presenting the country with important decisions and negotiations about the future. At the same time, health problems are growing; the NHS faces severe financial constraints and appears to lurch from crisis to crisis, with leaving the European Union likely to exacerbate many problems including staffing issues across the whole sector. However, new scientific developments and digital technology offer societies everywhere massive and unprecedented opportunities for improving health. It is vital for the country that the NHS is able to adopt these discoveries and see them translated into improved patient care and population health, but also that the UK benefits from its capabilities and strengths in these areas.
A positive vision for health and the economy
This manifesto is a response to these issues and addresses both the UK's external role in the world and the internal provision of services and creation of a healthy and health-creating society (panel). It offers a positive vision for how the UK can benefit from the brilliance of its clinicians, scientists, and entrepreneurs in the fields of health and biomedical and life sciences—but only if all sectors contribute and work together to do so.
Manifesto for a healthy and health-creating society
The UK should strengthen its role as a global centre for health and the biomedical and life sciences
Health and biomedical and life sciences need to be at the centre of the UK's industrial strategy and vision for the future as an outward facing country, networked globally, building on the country's great traditions and values—and helping shape the future health, prosperity, and security of the UK and the world.
The transformation of the health and care system from a hospital-centred and illness-based system to a person-centred and health-based system needs to be accelerated and funded
This requires a massive increase in services in homes and communities, greater use of technology, the involvement of many different partners and providers, and the development of new infrastructure.
The UK needs to develop and implement a plan for building a health-creating society supported by all sectors of the economy and the wider population
Current plans for health promotion and disease prevention are too small scale and fragmented and need to be replaced by a large scale and society-wide approach.
Health, care, and scientific institutions should help develop and restore a healthy society in the UK
The UK's health, care, and science communities have a crucial part to play in developing and restoring a healthy society in the UK.
The manifesto builds on the policy, insights, and actions of many organisations and people throughout the UK and beyond. We, as a small group of clinicians, scientists, social entrepreneurs, and crossbench peers believe that the time is right to bring all these ideas together and to drive forward improvement in health and the economy—the one reinforcing the other—to the benefit of everyone in the country.
The new government, with the Prime Minister's philosophy of leaving no one behind, is ideally positioned to take this vision forward. But this is not just for government and health professionals. This approach will fail without leadership and support from all sectors. Everyone has a role to play.
We propose action in four closely linked areas:
Aim 1: the UK should strengthen its role as a global centre for health and the biomedical and life sciences
Health and biomedical and life sciences need to be at the centre of the UK's industrial strategy and vision for the future as an outward facing country, networked globally, building on the country's great traditions and values, and helping to shape the future health, prosperity, and security of the UK and the world.
This will require all sectors—the commercial life and biomedical sciences as well as the NHS, academia, government, and voluntary organisations—to build closer and more productive links to achieve synergy and impact.
The 2015 report on the UK's Contribution to Health Globally demonstrates that the UK is a world leader in health and associated sciences in academia, commerce, government, and not-for-profit activity.1 From mapping the genome and developing drugs to supporting 4800 health and life sciences companies generating turnover of £55 billion a year and to training 25 000 health workers in Africa, the UK has enormous impact globally.
Investing in the health and life sciences industries is smart economics. The Wellcome Trust estimated that each £1 investment in cardiovascular disease research produced a stream of benefits equivalent to earning £0·39 per year in perpetuity, easily surpassing the UK government's minimum threshold of 3·5 pence per pound for investments.2 During the UK's economic downturns from 2008 to 2013, the health sector and technology sector were two bright spots, helping power economic recovery and growth.3
There is great potential for further growth and for extending the UK's influence globally. A strong health and life sciences industry would boost many aspects of life in the UK and create a “virtuous cycle”. This includes enhancing skills in the workforce, boosting employment among suppliers, and developing products that enable people to enjoy everything that comes with longer, healthier lives.
The UK's ability to reap these substantial economic gains and other benefits, however, depends crucially on it having an effective and sustainable health system available to all its citizens. The NHS, with its integrated systems, good regulation and governance, and well trained staff, provides a unique platform for the development of science, expertise, and products.
Aim 2: the transformation of the health and care system from a hospital-centred and illness-based system to a person-centred and health-based system needs to be accelerated and funded
This will require a massive increase in services in homes and communities and new ways to empower front-line staff, enabled by technology, to manage the complex needs of patients across different services and organisations. It will also require the involvement of many different partners and providers and the development of new infrastructure. Above all, however, there needs to be the far greater engagement of patients and carers in decision making and care, and enabling them to live as independently as possible.
The different countries of the UK have each developed strategic plans to achieve these transformations. NHS England, for example, set out its vision in the Five Year Forward View.4 However, implementation is slow everywhere and the system is struggling with maintaining the old services whilst creating the new—and as a result is facing double running costs and failing to invest in the future.
This transformation will require funding. The UK currently spends about 30–50% per capita less on health than, for example, Germany, Sweden, Ireland, Holland, and Australia.5 Additional funding is needed both to achieve the transformation of the system and to meet the growing needs of an ageing population. At the same time there is a need to bring together health, social care and, potentially, other local service budgets where this is not already happening for maximum efficiency and impact.
Public funding is the most effective and economical way of delivering this requirement. The 2016 UN High-Level Commission on Health Employment and Economic Growth concluded that good health contributes to economic growth and that investments in the health system have spill-over effects that enhance inclusive economic growth, including job creation.6 It also noted that there was evidence that expenditures on health are not dead-weight drags on the economy, but rather can be associated with productivity gains in other sectors. Their analysis is corroborated by a large body of econometric and statistical evidence.7,8,9 As one example, a cross-national analysis of the economic impact of spending in differing government sectors found that spending on health had one of the highest and most positive returns on investment, yielding up to £3 for each £1 invested.10
The long term sustainability of the health system will only come from reducing morbidity and creating a healthier population and strong resilient communities.
Aim 3: the UK needs to develop and implement a plan for building a health-creating society, supported by all sectors of the economy and the wider population, that addresses health inequalities
Current plans for health promotion and disease prevention are too small scale and fragmented and need to be replaced by a much larger scale and society wide effort. The NHS spends very little on prevention,11 and while there are calls to increase it, it is clear that developing and supporting a healthy population cannot be done by the NHS, health professionals, and politicians alone. Achieving real impact on the health of people throughout society requires leadership and action from all sectors.
The founding of the NHS in 1948 was a great national coming together around the shared purpose of providing health services for everyone. An equally bold initiative is needed today to bring together the expertise and resources of all the parts of society which impact on health—employers, teachers, designers, manufacturers as well as citizens, community groups and government—to improve health for all and build a health-creating society.
National and local government have the powers and responsibility to shape the environment and provide incentives for building a health-creating society in every area from employment and housing to welfare support, food, and education—as well as enacting laws and regulations that control the use of tobacco, alcohol, junk foods, and other damaging products and practices. Progress is being made with Public Health England and the equivalent bodies in the other UK countries developing effective policies based on understanding of the social determinants of health.12 Although, as some think tanks note, there is much further to go on cross-government working.13
This approach, however, needs to go far beyond government. Business and other organisations have important contributions to make to health as employers, designers, educators, service providers, and manufacturers. This could build on the successful models developed by existing bodies such as the City Mental Health Alliance (formed by London firms to support the mental health of their employees), Architects for Health (which focuses on how design can create better health facilities and healthier environments), and the Royal Horticultural Society (which developed a programme on health and gardening), and others that are already addressing these issues.
Healthy communities are vital. Yet they can only flourish with adequate support, significant parts of which have been withdrawn in pursuit of austerity, leaving individuals, families, and communities facing a precarious future in which the immediate pressures for survival displace long term investment in health. This reduction in community support also affects the work that informal carers can do. The informal care provided by carers throughout the UK had an estimated value of £132 billion in 2015, almost the same as the total health spend.14 If this informal care fails the burden falls on the NHS and local authorities and vice versa.
There are many good examples of active local groups and social entrepreneurs that are taking up this challenge—and taking action to develop healthy people in healthy and resilient communities. C2 Connecting Communities (a network of local groups with an academic branch at Exeter University), the New NHS Alliance (a movement of people and organisations who are committed to building a sustainable, community-based health service), and other organisations are providing support for local groups and communities engaged in improving health.
Some of these innovative approaches are now beginning to operate on a large scale across entire populations—regenerating communities from within through enterprise, entrepreneurship, and the involvement of multiple partners. Dependency creates ill-health and thriving communities need a different form of support to take control of their own lives. New relationships and greater collaboration are needed to respond to the challenge we now face. Most notably, the St Paul's Way Transformation Project15 in East London has together with local housing companies invested many millions in an integrated approach to housing, health, education, and business development with its philosophy of “bringing together partnerships between public, business and community organisations with a view to addressing the problems faced by local communities.” The lessons learnt there are being transferred through ,16 a partnership undertaken on behalf of Public Health England with ten towns and cities in northern England which aims at “creating a movement to unleash healthy communities across the north of England.”
These developments need to be underpinned by interdisciplinary research that embraces the social sciences, architecture, urban design, planning, and much more, as argued so cogently by the UK Academy of Medical Sciences in its recent publication.17
Aim 4: health, care, and scientific institutions should help develop and restore a healthy society in the UK
A health-creating society can only be built in a society that itself is healthy.
The UK's health, care, science, and broader academic communities embody values of social solidarity and have a crucial part to play in developing and restoring a healthy society in the UK. They are smaller versions of UK society with the same diversity of population, culture, and skills. Tackling racism, promoting equality in all its forms, and celebrating innovation and creativity are vital to the sector—and to the country as a whole.
Promising work is underway. NHS England has developed the Workforce Race Equality Standard to promote and improve the way the NHS handles diversity and the Care Quality Commission reflects on relationships in its reports. The lead inspector of the East London Foundation Trust, for example, which was rated as outstanding, commented on how “The trust recognised and celebrated the diversity of the patients and staff and worked to meet the needs of people using the services.”18 More can be done in health, care and scientific institutions to develop their roles as corporate citizens. This is particularly important in view of the close correlation between management style and culture on the one hand and patient experience of quality on the other.19
We argue that, just as other sectors need to embrace health creation as part of their role, the science and health sectors need to embrace the shared goal of creating healthy societies as part of theirs.
As initial steps in implementing this manifesto we recommend that:
The UK's global role
The UK government develop and implement a strategic plan for strengthening the UK's role as a global centre for health and biomedical and life sciences.
The UK government ensures that both the health and care system and the biomedical and life sciences sectors are able to recruit and employ people from abroad on a long-term and stable basis.
Transformation of the health and care system
Departments of Health and the NHS plan at scale for the transformation of the health and care system from a hospital and illness focused service to a person-centred and health-based one and accelerate the rate of progress.
The UK government supports and funds this transformation—recognising that there are substantial costs in double-running services and managing the necessary changes—and commits to funding health and care services to meet growing needs.
The UK government works with leaders from all sectors to develop and implement a plan to build a health-creating society that covers policies for social and community support, promotes the types of entrepreneurial partnerships described in this manifesto, and incentivises all sectors to participate.
Leaders in all sectors—employers, educators, planners, manufacturers, and others—embrace a responsibility for health and plan how they can have an impact on health and healthy communities.
The UK's health departments and NHS leaders establish and monitor policies for celebrating diversity and tackling prejudice, building on their existing work.
All health bodies recognise their responsibilities as corporate citizens and community leaders and take action to help build healthy and health-creating communities in their areas.
As well as proposing actions for others we will follow this up with further work and analysis and support the development and implementation of this manifesto.
NC and DS conceived the manuscript, with insight from RH. NC wrote the first draft of the manuscript. All authors contributed to the editing of the manuscript.
Declaration of interests
DS is funded by a Wellcome Trust Investigator Award. JB is a Director of Roche AG, Immunocore, Atopix, and Drayson technologies. PHM is funded by Senior Investigator Awards from NIHR and the Wellcome Trust. All other authors declare no competing interests.