As the 2010 Marmot Review (and before that the 2008 WHO report on Closing the Gap) makes clear, significant improvements in population level health, as well as reductions in health inequalities, require actions that tackle the social determinants of health. However, traditional public health policy has tended to focus on modifying individual lifestyles, rather than addressing the more fundamental causes.
The suggestions so far put forward as the SHA’s submission to the Labour Party’s Public Health Policy review also largely focus on these downstream determinants. This review process is an ideal opportunity to put forward more upstream, social determinants based suggestions.
Based on the social determinants of health, and my knowledge of the public health evidence base, I would like the following policy suggestions to be considered by SHA council on 26th April, with a view to including them in our submission to the NEC.
Whilst not all of these policies will be seen by everyone as being “politically possible” in the current climate, however, the SHA is a broad coalition and a range of ideas should be put forward in our submission to the NEC. As Maggie Winters pointed out in her recent post – the NHS and the welfare state were set up in much harder circumstances.
The evidence supporting these interventions can be provided to Council on request.
1. Improving control at work
Studies have shown that employees of all grades with higher levels of control over their work (in terms of content, pacing of tasks, decision-making, etc.) have better health. Low control at work is associated with higher rates of heart disease, musculoskeletal pain, mental ill health and mortality – even when other risk factors (such as smoking) are accounted for.
Interventions to improve control at work (for example rotating tasks, flexible working, employee participation in making company decisions, employee ownership/shares) have been found to improve health – with no detrimental effects on productivity.
The last Labour government introduced flexible working for parents and carers, and Ed Miliband has talked about potentially having employees represented on company boards to influence the remuneration of executives. The health literature suggests that these ideas should be extended to involving employees in other areas of the business so that job control is increased. In other European countries, such as Germany, “worker’s councils” are common place in businesses.
2. Enhancing access to public transport
Access to public transport is an important social determinant of health as it is vital in terms of enabling access to employment opportunities, health care, and other services such as leisure services, food banks etc. However, it has decreased since privatisation due to the costs of travel, and the reduction in bus routes. Local government budget cuts have also led to reductions in the subsidies paid to support less popular routes. This is particularly an issue in rural areas, and for lower income groups.
The last Labour Government introduced free bus passes for the over 60s. These should be extended to the unemployed and workless to enhance employability and job search. Central government should provide funds to local authorities to ensure that public transport is continued to be made available in rural areas to connect communities with services.
3. Introducing 20mph zones
Traffic accidents (non-fatal) are higher in more disadvantaged and urban areas (particularly amongst children and outside schools) – perhaps due to the higher volume of traffic in such areas. There is a strong evidence base that shows that reducing traffic speeds from 30mph to 20mph results in a reduction in accidents. Such interventions are relatively low cost (changing signage) but can lead to a 15% reduction in injuries. Targeting interventions outside schools with high accident rates may be particularly beneficial.
4. Creating healthy places
Geographical research has shown that communities with higher rates of obesity also have a higher prevalence of fast food outlets. Gambling is associated with higher rates of debt, as well as with mental ill health. Betting shops, as well as high-cost credit shops, are more prevalent in poorer areas. There have been big increases in the prevalence of betting shops, fast food joints, and high-cost credit shops in local high streets and town centres since the 2007 financial crisis.
Current planning law does not enable local authorities to properly control the number of such businesses in their local areas because health is not currently a reason to turn down planning requests. A Labour Government should increase the power of Local Authorities to shape local high streets by adding health as factor in planning decisions.
5. Implementing a Minimum Unit Price
The connection between ill health and high levels of alcohol consumption are well known. The Marmot Review advocated a minimum unit price to reduce mortality and morbidity associated with high levels of alcohol consumption. Econometric modelling as well as comparative data from countries such as Canada suggest that a Minimum Unit Price could be a very effective intervention and one that is proportionate – impacting most on the consumption behaviours of those most at risk.
6. Reducing Ill-health related worklessness
Rates of receipt of incapacity-related benefits (e.g. Employment Support Allowance) have increased rapidly over the past three decades and approximately 7% of the UK working-age population is now in receipt of such benefits. Policy has traditionally focussed on reducing the benefits paid to such groups, tightening up eligibility criteria or making employability programmes compulsory. There is almost no evidence that such interventions have been effective. This is because policies have seldom tackled the route cause of such worklessness – ill health.
People in receipt of health-related benefits have multiple and complicated long term illnesses and so tackling underlying health issues could be the first step to successful return to work. NICE guidance recommends a ‘health first’ approach (combining traditional vocational training approaches, financial support, and health management on an ongoing case management basis) to improving the health and employment of people with a chronic illness. The evaluation of a pilot ‘health first’ intervention in County Durham, also suggests that taking a more health focused approach can be beneficial in improving the health of Incapacity -related benefit recipients and thereby putting them in a better place to engage in mainstream job-search activities.
7. Healthy Housing Policy
Housing is one of the major determinants of health – indeed in the Atlee Government, Bevan was Minister for Health and Housing. The quality of housing (e.g. damp) impacts on health, as does tenure (with private occupiers usually exhibiting better health than renters). The cost of housing – both in terms of purchasing and renting – has increased well-above inflation in the UK since the early 1990s. Rents are now considered to be extremely high and in some areas simply unaffordable for large swathes of the population. Much of this increase has been taken on by the tax payer in terms of housing benefit – a subsidy to private landlords.
Evidence suggests that making homes warmer can lead to improvements in health. Improved energy efficiency can reduce fuel bills, freeing up extra money to spend on essential items such as food. High rents also take money away from households. Rent regulation could also improve the wellbeing of vulnerable households by again increasing the amount of money available to spend on other items such as food and clothing.
Restoring rent controls would be an efficient way of reducing the housing benefit bill, whilst protecting tenants. Other policies, such as the welfare cap, merely penalise benefit recipients and have no impact on landlord behaviours.
The quality of private rental properties varies widely, but also follows a social gradient with the poorest renters inhabiting the lowest quality properties. Proper local regulation of housing standards would reduce the ill health burden of substandard housing conditions.
The Labour Party has already made a commitment to abolish the Bedroom Tax – these further housing reforms would make a fuller healthy housing policy.
8. Making work pay
Low income is the most important determinant of poor health. One of the great achievements of the last Labour Government was the introduction of the minimum wage. Despite cries from the opposition, there have been no detrimental economic effects, and for a significant minority of the workforce, it represented a large increase in pay. However, it is well known that the minimum wage is not yet a living wage and that in work poverty is still significant: 46 per cent of adults in working families in poverty are in families where at least one earner is paid below the living wage. There is little scope for these adults to work more hours to escape poverty; they will need higher pay. A Labour Government should pass legislation that sees the minimum wage become a living wage.
9. Minimum Income for Health Living (MIHL)
The Marmot Review proposed a minimum income for healthy living so that everyone – whether they are in work or on welfare – would receive enough money/vouchers/support to ensure a healthy lifestyle. This was the only recommendation of the Marmot Review that the Coalition government did not endorse. Research has shown that the value of out-of-work benefits paid to the unemployed can be important factors in whether unemployment leads to an increased risk of ill health. This means that there is a need to improve the value and accessibility of benefits from a health perspective. This has led to calls for a minimum income for healthy living (MIHL) which will ensure that there is a right to a certain standard of living for those on benefits. A Labour Government should examine how to implement the MIHL.
10. Decreasing debt
Although unable to access mainstream credit, many people on low incomes require credit to ‘get by’ and therefore turn to alternative lenders, generally high-cost credit sources (e.g. doorstep lenders, pawnbrokers, and payday loans). In low income households, credit is used to get by as welfare benefits and/or wages are not sufficient.
Debt has also been linked to suicide, poorer self-rated physical health, long term illness or disability, back pain, obesity and health related quality of life.
Credit unions offer low-rate, small loans, and can have a positive influence on the financial capability and wellbeing of their members. To decrease the health problems associated with debt, the Labour Party should look to supporting Credit Unions as well as capping the loan rates of commercial providers.