Social determinants of health
Professor Sir Michael Marmot published his seminal report ‘Fair Society Healthy Lives’ in 2010. It was a comprehensive review of the causes of health outcomes and contained a damning indictment of the health inequalities prevalent in many of our most deprived communities in the UK. One of the key contentions of the Marmot Review, and one that has been continually affirmed ever since, is that positive health outcomes are significantly more influenced by social and economic determinants than by clinical determinants. Indeed, the conclusion of the report and the subsequent work of Professor Marmot’s team at the Institute of Health Equity at UCL, broadly suggests that our health and wellbeing is up to 90% driven by social and economic determinants and by as little as 10% by clinical factors.
Yet despite this evidence little mainstream health policy seems to take the findings of the Marmot Review and turn them into a new and radical approach to how we both define health and wellbeing and how we create and deliver provision in communities that more effectively promotes them. As Professor Marmot himself asks, ‘why treat patients and send them back to the conditions that made them sick?’
It feels like our attention has been deliberately drawn into an important, but nonetheless constrained, conversation about the integrating of health and social care. It seems to be that this narrowly defined ‘health and social care debate’ has had two consequences:
- First, it has enabled the principal focus to remain on how the public and statutory systems talk to each other. Not exclusively, but largely. There is a constant flow of earnest initiatives that propose the pooling of health and social care budgets and structures and forcing a new way of working. This seems to keep the thinking away from a more radical debate.
- Second, the ‘health and social care debate’ has kept us away from the conclusions of the Marmot Review, including the fundamental questions which inextricably link health and wellbeing outcomes with their economic and social determinants. It resists the awkward question about how we unshackle the central control of health and health creation and unleash it out into communities.
The story of a real person
The Bromley by Bow journey and the model we have developed has been heavily influenced by the life and sad death of a young East End mother who died of cancer over 20 years ago. She died in tragic circumstances. Her name was Jean. She was a single mum with two kids and she had two brothers that she looked after and elderly parents who needed a lot of support. There were two sides to Jean’s story.
The first was that she fell through all the nets of statutory provision that she, and we, reasonably expect to be there for us. The health system didn’t work for Jean. The social care system didn’t work for Jean or for her family. In short, everything that could go wrong went wrong. Jean was badly let down by the state.
But the other side of Jean’s story was much more life-affirming. Just as the state was busy letting Jean down something very interesting, and very normal and human, happened. Suddenly there was a rota for going to the launderette and doing her washing; people were going off to Tesco to get her shopping; Jean was inundated with offers of help…‘I’ll come in and look after the kids for you this afternoon’…‘let me sort out dinner for your mum and dad’… ‘let me know when you’re going to the doctors and I’ll come with you’…‘let me speak to the housing office about that repair that needs doing’. Jean was being cared for. But she wasn’t being cared for by professionals, but by young mums like her. Women who were as vulnerable as she was. She was being cared for by the community, in the community. She was having the social determinants of her health addressed.
Some months later there was an enquiry at the Royal London Hospital into the circumstances of Jean’s death. That, in turn, led to the building of the first healthy living centre in Britain at Bromley by Bow. This was the first health centre in Britain to be owned by the patients and rented to the doctors. Something had shifted in who owned health in that community.
A more radical approach is needed
The experience at Bromley by Bow suggests the need for a more radical approach in our health planning and less control from the centre of government and public agencies. We need radical community-based solutions that don’t just focus on the symptoms of disease, but focus on the wider economic and social determinants of health. Public Health England is at the vanguard in the battle to build healthy communities. And its leadership is very clear that the key to healthier communities is empowering communities to achieve change.
Broadening our definitions of health
The key to this different approach lies in creating centres of health and wellbeing in our communities that address the full range of health determinants. These will differ from place to place. It will be different in leafy Richmond to inner city Moss Side. That’s why we need to resource health at local levels and in doing so, fully embrace every model of delivery that is likely to promote wellbeing, as well as narrowly defined clinical health.
If we have a broad definition of health then we will also need to have a broad definition of what communitybased approaches look like, in terms of buildings, open spaces and partnerships. They might not look like health centres. They might be owned by patients. Clinical health may just a small percentage of what goes on inside them. They might be drive by communities and not by the NHS, or local authorities.
We need to have a big purpose in our pursuit of a healthy community. We all know it’s possible to be diseasefree, but have a poor sense of happiness or wellbeing. It’s also possible to be clinically very ill, yet have a positive sense of wellbeing. We start to really address the big health questions when we broaden our understanding of what we mean by ‘health’. That’s when we really start to be radical.
Stop building health centres
Today the Bromley by Bow Centre offers a vast array of services to its local community. They stretch from conventional healthcare for local residents to opportunities to set up your own business; from support with tackling your credit card debts to becoming a stained glass artist; from learning to read and write to getting a job for the first time or a helping hand up the career ladder.
The centre’s School of Integrated Solutions hosts thousands of visitors every year who come to learn from its experience and who want to see the model in action first-hand. Many of these people are leaders of health systems from the across the UK and globally. Recently, in one of our seminars a Darzi fellow asked: ‘What do you think we learn from the Bromley by Bow Centre’s experience about how we should build health centres in the future?’ The answer was very simple: ‘Don’t build health centres!’
This is not an argument that denigrates clinical health. On the contrary it positions it within a broad range of services that drive wellbeing in communities, by creating a locally blended offer, where doctors sit alongside others – including a wide range of non-clinical professionals, patients and local residents – in order to provide what people need. It encourages the design of high quality clinical spaces, but enables them to be owned by communities in buildings that are accessible and fully integrated. Not in a ‘them and us’ culture (which sadly still prevails across much of the health and social care system) but in a fully holistic and integrated culture.
Unleashing healthy communities
And, of course, creating buildings which act as ‘centres of the community’ not just ‘health centres’ makes sense for so many other reasons, not least financial reasons. The people who operate successful department stores, like John Lewis, will tell you that the idea of a well-run shop where you can offer a whole range of products, makes complete sense for the customer and complete financial sense for the business. You can ‘capture the customer’ and have the opportunity, in the convenience of one place, to offer myriad products and services.
This is the same principle in integrated holistic centres where health is about life and living, not just disease and illness. It’s about sweating our community assets and ensuring that one investment in a new set of buildings creates benefits and savings across a whole range of Whitehall departments, not just the Department of Health.
Popular myths would have us believe that there are very few avowed disciples of the silo approach left. Yet in many parts of Whitehall and the health system it seems to remain the prevailing culture despite a nod toward the integration of health and social care. But that is such a small part of the story that the Marmot Review pointed us to.
We need much more of the full service department store. It has to focus on an approach where we stop building health centres and start building centres in communities; places that really address all of the factors that determine wellbeing. And in so doing, we will start to create a way of working which liberates the health system to dance with a whole range of services that can combine to empower individuals. And ultimately create new and healthier communities.