The next Government must act quickly on the social determinants of health

Since 1948, the 5th of July has held a special meaning in Britain: it is the day the National Health Service (NHS) began. It was founded, in part, to alleviate the fear many had of the potentially catastrophic cost of ill health. Each year, on the anniversary of its inception, there are often reflections on the health service from politicians, healthcare workers, and members of the public, reviewing its progress and challenges, as well as expressions of gratitude by many. This year, in 2024, the date has an added significance—Britain will likely know the outcome of the election the day before, on the 4th of July, and which party (or coalition of parties) will be forming the next government.

Whoever is in power on 5th July will have to act quickly to reverse the health crisis facing the country. It is surprising to see this missing from the political discourse given what we know. In key summary measures of population health, such as life expectancy and infant mortality (that measures the deaths of babies before their first birthday), the UK is faring extremely poorly. Life expectancy is one of the most used summary measures of the health of a population. It provides a marker of trends over time, and, in general, should steadily increase in a stable, high-income setting^a. Of course, there have been notable times when life expectancy has worsened in the UK such as the two World Wars and influenza pandemics, and more recently, the COVID-19 pandemic. But in the absence of such events, we can and should expect it to keep increasing over time. Not in Britain in 2024. Life expectancy improvements that first stalled in the mid-2010s stopped completely, with falls for certain groups such as older women and women in deprived areas, before falling for the whole population at the latest data release in January 2024 - returning to levels of 2010-2012 for females and just below for males.¹ This is extraordinary.

The terrible state of child health in the UK should be a national disgrace. Shockingly, child and infant deaths have gone up, and the UK has fallen down the ranks globally in both life expectancy and infant mortality rates.^2-4  Children are shorter than 10 years ago, with the height of five-year olds falling since 2013, childhood obesity is rising with poor nutrition, and the number of children living in poverty is the highest since records began at 4.3 million.⁵ Over the past decade, that number has increased by 900,000 of children in poverty with working parents.⁶  

These summary measures only tell part of the story. Inequalities have widened in the UK in these measures, too, with widening gaps between those in the most and least deprived areas. As part of the British Medical Journal (BMJ) Commission on the Future of the NHS,⁷ along with colleagues we published a report outlining these inequalities,⁸ detailing how health is deteriorating “from the cradle to the grave”, that child poverty is a political choice, and that, while a well-funded NHS that is universally available, free at the point of delivery, and centrally funded through collection contributions is essential to reversing the trends,⁹ action is needed beyond health care delivery to improve the country’s health. Action is needed on the social determinants of health.

The social determinants of health are defined by the World Health Organisation as “the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life”.¹⁰ Examples include factors such as housing, education, nutrition, and the conditions of poverty many people in the UK today find themselves in. In 2010, the Marmot review detailed how action on these conditions could improve health and reduce inequalities in Britain.¹¹ No action was taken, and inequalities have widened, further exacerbated by the pandemic.^12-13 Ten years on, Professor Sir Marmot wrote “Britain has lost a decade”.¹⁴

We outlined how such action requires confronting political ideology, and characterising government interventions in health as “nanny state”. Despite such claims, public appetite for intervention on preventable causes of ill health appears to be rising,¹⁵ and the most recent YouGov weekly tracker (accessed 27 June 2024) has shown voters in Britain have identified health as one of the most important issue to them, alongside the economy.¹⁶ Given this, it is surprising to see the lack of discussion on the issue beyond both main parties pledging to reduce NHS waiting lists. While this is, undoubtedly, an important step, it is a short-term solution for a long-term problem. Fourteen years of austerity have left health in the UK in a terrible state. Action is not inadequate due to lack of evidence—we know what to do. Action is inadequate due to political choice.

The founder of the NHS, Labour Minister of Health Aneurin Bevan, wrote in his seminal book In Place of Fear: “The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged”.¹⁷ In Britain in 2024, despite the NHS, those living in poverty are significantly disadvantaged. We conclude in our BMJ report: “We call on all political leaders to acknowledge the problem and the urgent need for action on the social determinants of health. This action can be a story of hope: we can change the direction of health in the UK if we use the robust, broad evidence on how to act.”

a. While it may be that there is a natural limit or plateau to human life expectancy, this has not yet been reached, as shown by countries such as Japan where life expectancy improvements have continued.

1.    Office for National Statistics. National life tables – life expectancy in the UK. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nationallifetablesunitedkingdom/2020to2022  (2024).
2.    National Child Mortality Database. Child death data release 2023. National Child Mortality Database https://www.ncmd.info/publications/child-death-data-2023/ (2023).
3.    Academy of Medical Sciences. Prioritising Early Childhood to Promote the Nation’s Health, Wellbeing and Prosperity. https://acmedsci.ac.uk/file-download/16927511 (2024).
4.    Hiam, L., Dorling, D. & McKee, M. Falling down the global ranks: life expectancy in the UK, 1952–2021. Journal of the Royal Society of Medicine 01410768231155637 (2023).
5.    The Food Foundation. A Neglected Generation: Reversing the decline in children’s health | Food Foundation. https://foodfoundation.org.uk/publication/neglected-generation-reversing-decline-childrens-health (2024).
6.    Number of children in poverty with working parents rose ‘by 1,300 a week over decade’. The Independent https://www.independent.co.uk/news/uk/home-news/child-poverty-benefits-work-parents-b2567667.html (2024).
7.    Abbasi, K. The BMJ’s Commission on the Future of the NHS. BMJ 381, p1000 (2023).
8.    Hiam, L., Klaber, B., Sowemimo, A. & Marmot, M. NHS and the whole of society must act on social determinants of health for a healthier future. BMJ 385, e079389 (2024).
9.    Crisp, N., Bamrah, J. S., Morley, J., Augst, C. & Patel, K. The NHS founding principles are still appropriate today and provide a strong foundation for the future. BMJ 384, e078903 (2024).
10.    World Health Organisation. Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health (2024).
11.    Marmot, M., Goldblatt, P. & Allen, J. Fair Society Healthy Lives (The Marmot Review). https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review.
12.    Marmot, M., Allen, J., Boyce, T., Goldblatt, P. & Morrison, J. Health Equity in England: The Marmot Review 10 Years On. health.org.uk/publications/reports/the-marmot-review-10-years-on (2020).
13.    Build Back Fairer: The COVID-19 Marmot Review - The Health Foundation. https://www.health.org.uk/publications/build-back-fairer-the-covid-19-marmot-review.
14.    Marmot, M. Health equity in England: the Marmot review 10 years on. BMJ 368, m693 (2020).
15.    The Health Foundation. Public perceptions of health and social care: what are the priorities ahead of a general election? - The Health Foundation. https://www.health.org.uk/publications/long-reads/public-perceptions-health-and-social-care-priorities-general-election (2023).
16.    YouGov UK. The most important issues facing the country. https://yougov.co.uk/topics/society/trackers/the-most-important-issues-facing-the-country (2024).
17.    Harrington, D. Aneurin Bevan’s 1952 essay on the NHS – Chapter 5 of ‘In Place of Fear’. https://publicmatters.org.uk/2019/02/05/aneurin-bevans-1952-essay-on-the-nhs-chapter-5-of-in-place-of-fear/ (2019).