A public health prescription for the UK Government
Authors: None The Lancet Public Health
Journal: The Lancet Public Health (2019)

On Dec 12, the people of the UK voted and elected a Conservative party government for the next 5 years. The Conservative party's biggest electoral victory since the 1980s, predominantly based on the promise to “get Brexit done”, raises a number of questions about the UK's future. In their election campaign manifesto, the Conservative party made several funding pledges for clinical health services (eg, extra funding for the National Health Service [NHS], 50 000 more nurses, and 50 million more general practitioner surgery appointments a year) but their plan for public health is less easy to discern. There was a welcome commitment in the manifesto for an extra £1 billion per year for social care and a pledge to bring into legislation the NHS Long-Term Plan that includes a focus on prevention through primary care services and greater use of digital technologies. However, the government's commitment to a wider and ambitious public health approach remains unclear. The reports published in The Lancet Public Health urge the new government to commit and invest in public health to safeguard the most vulnerable in our society and address deepening inequalities in health and life outcomes. Homelessness—a barometer of the increasing social injustices in UK society, as notes Rob Aldridge in his Comment—should be a source of concern for the government. A family becomes homeless every 13 min and a child becomes homeless every 8 min in Great Britain, according to the charity Shelter. In England, the number of homeless people has increased from around 1700 in 2010, to about 4700 in 2018. Aldridge advocates ending unsafe discharge of homeless people from hospital care, reinvesting in specialist integrated homeless health schemes, and providing more intermediate care facilities for those with chronic conditions. A systematic review and meta-analysis by Jacob Stubbs and colleagues highlights the increased health risk for homeless and marginally housed people, who have a much higher incidence of traumatic brain injury (TBI). In a linked Comment, Jesse Young and Nathan Hughes note that people's first experience of homelessness and TBI tended to occur in adolescence, which stresses the importance of providing stable housing to young people in particular. The rise in homelessness is one example of increasing inequalities in the UK. A study by Dan Lewer and colleagues reports the highly pattered and preventable social disadvantage that characterises England today. The authors examined the gap in premature mortality (before the age of 75 years) between English regions according to various measures of socioeconomic disadvantage. They estimated that 35·6% (877 082) of premature deaths between 2003–18 might be attributable to socioeconomic inequalities and would equate to an average of 1·2 years of life lost due to socioeconomic inequality. Inequality was greater among men, but worryingly the proportion of deaths attributable to inequality increased for women. That an estimated one in three premature deaths could be attributable to socioeconomic inequality make this “our most important public health challenge”, Lewer and colleagues concluded. For John Newton, such findings highlight the need for place-based policies and investment that tackle the underlying determinants of these social and geographical health inequalities. Adding to this evidence, the study by Aline Dugravot and colleagues, also published in this issue, explored how socioeconomic inequalities might playout over the life course. Their 24-year follow-up study of the Whitehall II cohort of British civil servants found that socioeconomic disadvantage was associated with higher odds of transitioning into frailty, disability, or multimorbidity in older age, after which the odds of mortality were much higher—suggesting that primary prevention would be key here to reducing inequalities in mortality. After a decade of austerity and the erosion of public services, short-term cash injections into clinical care are not going to address the country's growing health inequalities. Evidence from public health research documenting the links between poverty and health outcomes is unequivocal. Just 1 year ago, the UN Special Rapporteur on Extreme Poverty and Human Rights, Philip Alston, concluded his visit in the UK with the damning statement “poverty is a political choice. Austerity could easily have spared the poor, if the political will had existed to do so”. The newly elected government needs to grasp the opportunity to rethink austerity and social justice in the UK—tackling upstream determinants of health should be the priority. Traumatic brain injury in homeless and marginally housed individuals: a systematic review and meta-analysisThe lifetime prevalence of TBI is high among homeless and marginally housed individuals, and a history of TBI is associated with poorer health and general functioning. Health-care providers and public health officials should have an increased awareness of the burden of TBI in this population. Prospective and longitudinal studies are needed to better understand how the health of this population is affected by TBI. Full-Text PDF Open AccessPremature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational studyOne in three premature deaths are attributable to socioeconomic inequality, making this our most important public health challenge. Interventions that address upstream determinants of health should be prioritised. Full-Text PDF Open AccessSocial inequalities in multimorbidity, frailty, disability, and transitions to mortality: a 24-year follow-up of the Whitehall II cohort studySocioeconomic status affects the risk of multimorbidity, frailty, and disability, but does not affect the risk of mortality after the onset of these adverse health conditions. Therefore, primary prevention is key to reducing social inequalities in mortality. Of the three adverse health conditions, multimorbidity had the strongest association with mortality, making it a central target for improving population health. Full-Text PDF Open AccessHomelessness: a barometer of social justiceThe number of people experiencing homelessness in the UK has dramatically increased since 2010. In the autumn of 2018, 4677 people in England were estimated to be sleeping rough, a worrying increase from 1768 in 2010.1 Although these numbers almost certainly underestimate the total number of people affected, the trends in these data are important and unsurprising, given that one in five bed spaces for single homeless people have been lost during the same period, a reduction from 43 655 in 2010 to 34 900 in 2018. Full-Text PDF Open AccessTraumatic brain injury and homelessness: from prevalence to preventionTraumatic brain injury (TBI) is a major public health issue. Each year, 50–60 million people will experience their first TBI and it is estimated that half of the global population will experience at least one TBI during their lifetime.1 TBI disproportionately affects young people and is a leading cause of death among children and adolescents in high-income countries.1 Despite increased education and prevention efforts, the global burden of TBI is increasing.2 Emerging evidence suggests that the risk factors for TBI closely align with the social determinants of health and causes of social exclusion, including poverty and marginalisation. Full-Text PDF Open AccessCounting early deaths due to socioeconomic inequalityDescriptive studies of inequality in England include classic works such as Charles Booth's poverty maps of London,1 and the Black report.2 The Black report powerfully linked measures of deprivation to health outcomes. Similar analyses are now widely available for many other countries.3 Statistical summary measures, such as the slope index of inequality, are routinely used to inform public health practice and policy in England.4 Therefore, more descriptive studies of inequality might not seem needed and the focus now might seem to be on what to do about this inequality. Full-Text PDF Open AccessAddressing social inequalities for longevity and living in good healthDeaths resulting from population ageing have steadily declined, as people live longer with conditions which were historically fatal.1 However, even in countries with good social circumstances, social inequalities exist that can shorten life expectancy.2 Whether social inequality will reflect the extent to which longevity can be extended with a lower burden of age-related health problems is uncertain. Full-Text PDF Open Access