The political determinants of health

Mavin Kashyap is an ACF GP trainee at University of Bristol interested in health inequities and public health. He is on X:@MavinNathan

“Medicine is a social science, and politics nothing but medicine at a larger scale.”¹

The stage for a general election in the UK has been set for the 4th July, yet the (political) fireworks will have been let off well beforehand. Amongst the heart of the upcoming debates to ensue will be healthcare, encompassing such topics as the waiting-list backlog and industrial action. This will now be against the backdrop of the threat of mass resignation by GPs following the UK LMC conference² which already lies in direct contrast with the pledge made by the Liberal Democrats to recruit 8,000 more GPs if elected, as a central part of their election campaign.³ These headlines act a stark reminder that health is a political choice and that politics determine the health status of a nation; a position made abundantly clear in the BMJ Commission on the future of the NHS published earlier this year.⁴

The concept of the “Political determinants of health” is not a new one but gives explicit recognition to the power dynamics and ideologies that shape political systems and influence health.⁵ The recent history of austerity, Brexit and the impacts of the COVID-19 pandemic have shone a brighter spotlight on the social determinants of health and health inequalities, which are greatly influenced by political action. So I began to question whether GPs, as advocates for patients and communities, should be encouraging all eligible patients to exercise their right to vote as part of normal discussions on health promotion? A qualitative interview study in the Scottish Deep End illustrated that the ability of GPs to discuss health inequalities as stemming from public policy decisions varied depending on their conceptualisation of health inequalities. Those that understood their patients as targets of social injustice showed more empathy whereas GPs who ascribed health inequalities to lifestyle and cultural issues, were more likely to view patients negatively and emphasise behavioural interventions.⁶

Only recently, the President of the Association of Directors of Public Health in the UK, highlighted that policies that change our environment are more effective than targeting individual behaviour change and whilst the Tobacco and Vapes Bill is a welcome public health policy intervention, it has not yet been passed prior to the dissolution of Parliament, but will undoubtedly feature in the politicking to come.⁷

Health for all policies

Feeling able to talk politics with patients is not for everyone. However, a greater appreciation of the political determinants of health can inform our understanding of the wider forces that impact our patients’ health and wellbeing. ‘Health for All Policies’ describes the bi-directional relationship between health and other sectors and how policies can (and should) align to benefit one another.⁸ For example, a health policy like the Tobacco and Vapes Bill could see improvements in the economic productivity of a healthier workforce and policies that invest in green energy can improve air quality and reduce fuel-costs, consequently reducing the health burden of related illnesses and fuel poverty respectively.

Whilst I would not have necessarily thought myself as being a “Political Doctor” pre-pandemic, I believe critiquing the upcoming policy debates and manifestos through a “Health for All Policies” lens and focusing on the co-benefits across sectors that can arise would be a helpful stance to hold when broaching political determinants of health with patients and understanding what is most important to them.
It can sometimes be hard to sift the wheat from the chaff when it comes to political soundbites, but the Nuffield Trust have helpfully laid out what to expect in the coming weeks with primers to help us go beneath the surface-level statements.⁹ Similarly, the other health think tanks; the King’s Fund¹⁰ and The Health Foundation¹¹ will be trying to make sense of the debate to ensue and remain the critical ally to the political candidates.

We are still viewed as trusted sources of information by the public and may even face questions from our patients about the upcoming election. Therefore, understanding our patients, their context and the political determinants of their health can only add richness to those conversations as practitioners of social medicine.

References

1. Mackenbach JP. Politics is nothing but medicine at a larger scale: reflections on public health’s biggest idea. Journal of Epidemiology and Community Health. 2009;63(3):181-4.
2. Lind S. GPs should be “prepared to walk away from the NHS”, says LMC leaders: Pulse; 2024 https://www.pulsetoday.co.uk/news/2024-25-gp-contract/gps-should-be-prepared-to-walk-away-from-the-nhs-say-lmc-leaders/ [Accessed 7/6/2024]
3. Francis S. Lib Dems pledge to hire 8,000 extra GPs if elected 2024 https://www.bbc.co.uk/news/articles/cy66901gz3po [Accessed 7/6/2024]
4. 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. 2024;385:e079389
5. Kickbusch I. The political determinants of health—10 years on. BMJ : British Medical Journal. 2015;350:h81.
6. Babbel B, Mackenzie M, Hastings A, Watt G. How do general practitioners understand health inequalities and do their professional roles offer scope for mitigation? Constructions derived from the deep end of primary care. Critical Public Health. 2019;29(2):168-80.
7. Fell G. Importance of sustainable local government funding in tackling health inequalities in the UK. Perspectives in Public Health. 2024;144(3):146-7.
8. Greer SL, Falkenbach M, Siciliani L, McKee M, Wismar M, Figueras J. From Health in All Policies to Health for All Policies. The Lancet Public Health. 2022;7(8):e718-e20.
9. Stein T. What to look out for in a campaign speech about health and care: Nuffied Trust blog; 2024  https://www.nuffieldtrust.org.uk/news-item/what-to-look-out-for-in-a-campaign-speech-about-health-and-care [Accessed 7/6/2024]
10. General election 2024: The King’s Fund; 2024 https://www.kingsfund.org.uk/insight-and-analysis/projects/priorities-for-health-care-general-election#our-general-election-priorities  [Accessed 7/6/2024]
11. General election: The Health Foundation; 2024 https://www.health.org.uk/general-election [Accessed 7/6/2024]

Featured image by Ugur Akdemir on Unsplash