A Manifesto for Health

Debate in the run-up will be dominated by the Northern Ireland protocol, the future of political unionism and the prospect of a government being formed at all given the near certainty of a Sinn Fein First Minister. It will be a landmark election.

Demographics are shifting. Academic analysis suggests that cultural Catholics already outnumber people from a Protestant background. This will likely be confirmed by the 2021 Census when it is published in around a year’s time. The constitutional issue will dominate politics. Matters are inexorably coming to a head.

Meanwhile something else is coming to a head: the crisis in our health and social care system. The pandemic has served to underscore just how fragile our health care is – fixing it is beyond urgent, and the consequences of collapse unthinkable.

Politicians of all parties know this. And as we near the elections we can expect health and social care to figure in speeches and media appearances. However given the existential nature of the constitutional issues any expectations of a prolonged and informed debate around health and social care is for the birds.

Yet if and when a new government is formed this will be by far the biggest item on the political agenda. It affects everyone, orange or green and all shades in between. It is also existential - it concerns life, death and wellbeing.

So what should politicians do?

First it is not necessarily an entirely bad thing if discussions about health are drowned out during the campaign – if and only if – political parties can find common purposes around the challenges that lies ahead around health reform and can commit to collectively help people better understand them.

This involves being honest about the tough choices that lie ahead.

For example how can you have a debate about how to fund adult social care when so many people assume it is free until they or a loved one needs it?

And do people fully understand that social care is the bedrock on which health depends – and is, according to the expert review, Power to People collapsing in slow motion? And that without suitable care packages people otherwise able to leave hospitals have to stay there “bed blocking”?

And how do you balance competing demands on services when you have a finite budget which is dependent upon the Barnett formula and no independent means of raising revenue through taxation?

Furthermore whilst it is quite right to do everything we can to reduce waiting lists, we can’t pretend that achieving this through an extra one-off investment will in itself solve what caused them in the first place:  a system in crisis that can’t cope with demand. Remember in this context that excessive waiting lists have been exacerbated by the pandemic, but were growing before it broke out.

And as staff shortages both in social care and health continue to rise, driving the crisis, how do you find the money to remunerate people in these critical posts fairly? Where does that extra money come from?

These are just a few of the dilemmas an incoming government will face. They are inter-connected and complex. There are no easy answers – and that’s just when you are looking at the health and social care system in isolation, which is only part of the problem that needs to be resolved.

This because improving our collective  health and wellbeing cannot be achieved through the health system alone given that 80% of health determinants are outwith healthcare itself.

It is well established that 40% of health outcomes are determined by socio- economic factors, 10% by our physical environment and 30% by our (health) behaviours, leaving just 20% to healthcare itself.

The biggest determinant of poor health and mental health is poverty, with the interrelated issues of poor diet/obesity/ educational disadvantage/ poor housing/fuel poverty/unemployment/drug and alcohol abuse/poor mental health. And then there are specific vulnerable groups to factor in: the homeless/Travellers/ethnic minorities/the prison population/LGBTQ+ etc.

Tackling these lie largely outside health and social care and if health spending is ringfenced at the expense of them, pressures on the health service will mount, not reduce.

This is not a theory, it is already happening.

Last year the  Health Equity in England report was published as a follow-up to the Marmot Review of 2010 which examined health inequalities. 

It found that in the interim life expectancy in England had stalled for the first time in more than a century. The report directly attributed this to government policies of austerity.

This was a study of impacts in England, but there can be no doubt that it applies to Northern Ireland as well – perhaps even more so given the levels of deprivation in many communities here.

Austerity costs lives, but it also has unintended consequences, and it is these that our politicians also need to consider.  The Marmot Review estimated that around 40% of health care costs involve treating preventable illness. Cutting housing, welfare and education budgets transfers many of the costs to the health service. This increased demand leads to more health spending and less investment elsewhere: a vicious spiral which leads to further ill-health.

And even beyond that the costs of poor health are not just to be measured in health spending. They also include welfare payments to those with ill-health, early retirements, people giving up work to care for others, overall falls in productivity.

So therefore poor health impacts economic performance as well. A flourishing nation needs to be in flourishing health.  We’re not and the situation is getting worse.  

It follows from this that we need to treat health as the precious national asset that it is, and that improving health and wellbeing and reducing inequality is as important as improving GDP.

If our local political parties were able to agree on that the big prize would be to put improving health and wellbeing at the core of a new Programme for Government and recognise it as the main challenge across all of government.

This would re-define the health challenge as a collective all-of-government task, not one just for the Department of Health. And it means a greater effort across all departments to tackle the causes of physical and mental ill-health, acting as a single team, pushing back against the silo mentality which blights the civil service and is such a formidable obstacle to effective change.

So whilst the public debate will be dominated by constitutional issues and the election campaign will be fractious and difficult let’s hope that amongst all the sound and fury there are quiet discussions going on as well, building a consensus around tackling health.