Without Walls – Health and Well-being in the Twenty-first Century

Towards Health and Well-being in the Twenty-first Century

Dr Richard Simpson MSP and Professor Trevor Davies

“Our spending and our medical expertise are increasing.  So why, at the same time, does our nation’s health stay bad, even in some areas get worse, and the poor still die younger than the rich?”

“The most important thing we can do is make our society more equal.  And then bring a new focus to our health service.”

“We all benefit when everyone is more healthy in a more equal society.  So we will all gain if we place the best resources where the health needs are greatest: unhealthy communities, people with chronic and complex needs and mothers and infants.”

“Six areas for policy development and action and a new way of talking about health.”

An extended version of this paper is at http://richardsimpsonmsp.com.

It contains a wealth of evidence about our health and many examples of good – and bad – practice in promoting good health at all stages of our lives. It is not to be seen as future Labour Party policy but as a stimulus to informed debate.

Our spending and our medical expertise are increasing.  So why, at the same time, does our nation’s health stay bad, even in some areas get worse, and the poor still die younger than the rich?

Scotland has a proud history of medical advance, from the invention of  anaesthetics and antiseptics in the early years to the ultrasound pioneers of today. We’ve nearly tripled NHS spending in the 10 years since the Scottish Parliament started in 1999  and today, spending on the NHS in Scotland is now up at the European average. In that time, we’ve re-built most of our old and inadequate hospitals and most communities have or will soon have the best we can provide.

Those new state-of-the-art hospitals are there for when we fall seriously ill.  They provide ‘top drawer’ medicine. That’s as it should be.  If we do fall seriously ill, then we are entitled to the very best treatment in the country. Sometimes, with a rare condition, the best treatment means travelling, even to somewhere else in Europe; but, by and large, the best medicine is what is now available to all of us.

But medicine isn’t the same as health. In the UK and especially in Scotland our health remains one of the worst in Europe. We have ‘top drawer’ medicine and  ‘bottom drawer’ health.  People in Scotland can still expect to live shorter lives than most of their European counterparts. And while we are certainly living longer than we were, our “healthy life expectancy” has hardly risen. In Scotland in 2005 it was only 67 years for men and 68 years for women.  The additional average 7 years of life for men and 9 years for women are not spent in good health.

Scotland’s poor health, and the concentration of even poorer health amongst the poorest in our country, clearly is bad for us today. But it has an impact on future generations too.  There is growing evidence that poor health and poverty have a direct physical impact on our children. Dr Harry Burns, the Chief Medical Officer in Scotland has said there is“Clear evidence that adverse early life circumstances have distinct biological effects. These effects include increased activity of host defence mechanisms which ultimately harm the individual.

The signals are that these biological effects are finding their way right through people’s lives.  For many people in Scotland, despite our top drawer medicine, the chance of a healthy, fulfilled and self-confident life appears to be diminishing.  Increasingly, the illnesses consequent on poor health, as distinct from ‘unavoidable’ illnesses,  fill our hospitals.  We see it clearly in two ways – in the great influx of accidents into A&E departments on Friday and Saturday nights after too much to drink and in the rapid increases in diabetes and cancer caused by today’s epidemic in obesity.

It is no small thing. “In Scotland, deaths among men aged 15-44 increased between 1981 and 2001.  They have increased among women aged 15-29 between 1991 and 2001.  These increases are due to deaths from suicide, violence, chronic liver disease and mental and behavioural disorders due to the misuse of drugs and alcohol.”

So why, when our medicine is good, is our health not as good as it should be?

Generally, the better off you are, the healthier you are.  It’s poorer people who fall sick more often. Scotland has many pockets of real poverty and in those poorer areas there are more people with long-term illness and long-term poor health.

Men in the poorest ten percent can expect to live only until 67 – just two years beyond retirement.  For the richest ten per cent, life goes on until 80; thirteen years extra life because of their income.  Nearly twice as many children in poor families fall ill and die in infancy than children in better off families.  More disabled people live in poor communities than wealthier communities.  Heart disease runs at nearly twice the rate in our poorest areas compared with our richest areas.  And the picture is similar with diabetes, with teenage pregnancy, with mental illness, with cancer and much, much else.   Not only are the numbers falling sick greater – people in poor communities are harder for the NHS to reach and don’t as often take up the treatment they’re offered.

But the poor health record of Scotland, indeed the whole UK, exists not just because poor people in poor communities are less healthy than they should be, though they are.  Our poor health is a result of inequality, the size of the income gap between rich and poor. Scotland is one of the most unequal countries in the developed world

Key research has been done by Richard Wilkinson and Kate Pickett in Nottingham. “However rich a country is, it will still be more dysfunctional, violent, sick and sad if the gap between social classes grows too wide. Poorer countries with fairer wealth distribution are healthier and happier than richer, more unequal nations…So Greece, with half the GDP per head, has longer life expectancy than the US, the richest and most unequal country with the lowest life expectancy in the developed world. The people of Harlem live shorter lives than the people of Bangladesh. (The reason) says Wilkinson…is mainly stress, the stress of living at the bottom of the pecking order, on the lowest rung, the stress of disrespect and lack of esteem…Social status and respect matter beyond anything, and the psychological damage done by being at the bottom is crippling.” What’s more, even the rich at the top of the pile have that stress and even they are unhealthier in an unequal society than those at the top in a more equal society; of course, the poor are more unhealthy in both.

That has huge implications for our health service provision. What the NHS does now, by and large, is treat people when they get ill.  And because our country’s health is especially poor, more people get ill and the less there is to spend on keeping us healthy.  Essentially, the NHS is forced, by and large, because of the very large gap between the rich and poor of our society, to wait until we get ill and then try and fix us.  We don’t do that with our cars: we check them every year and see what maintenance is needed.  That way there are fewer accidents.

So wouldn’t it be better if we were just all healthier? If we didn’t need hospitals so much? Wouldn’t it be good to get a regular health check and some simple maintenance when it’s needed?  Wouldn’t it be sensible to get everyone’s health better in the first place so that fewer people fall ill and need hospital?   That’s obviously better for those who stay healthy.  But it’s also better for those who do get seriously ill; hospitals will have more room and more time to treat them well.  When everyone’s as healthy as they can be, then we’re all better off – as individuals, obviously, but also as a society.

  • Better health for everyone would mean so many more of us would be happier.  But it would also have huge economic implications.  The Marmot Review provides some figures for England. If everyone in England had the same level of health as the richest 10% of its population – and remember Nye Bevan, its founder, wanted everyone rich or poor to have the same benefit from the NHS – then the NHS would save about £5.5 billion every year on the costs of treating acute illness and mental illness and on prescriptions.  That would free up about one-third of the NHS budget in England.  The Review also says, again if everyone had the same health as the richest 10%, England would gain about £31 – £33 billion every year in extra productivity and would then recoup between of £20 – £32 billion a year in taxes and reduced welfare payments.  Carried through the UK, what a transformation that would make in our national life – and our national debt.  It’s the NHS budget, and more, all over again.  Better health for all is no small thing.  Better health for all would reduce our tax obligations and reduce the national deficit.

Health isn’t just the absence of illness and disease, it’s not even about fitness.  It’s about mental and physical well-being, with the energy, hope and self-esteem to achieve what you want to achieve. Those kinds of deep changes to our health mostly don’t happen in hospital – they happen at home, in the workplace, the school and the community. And, most of all, in the pay-packet.

If we’re serious about health, and not just about fixing things when they go wrong, then we’ve got to think beyond the walls of the local hospital, important though they are. We have to think about the way we organise our society as well as what we do with our health service. We have to think about unfashionable and inconvenient issues such as equality, justice, sustainability and trust as well as the role of hospitals and GPs.

Thinking those thoughts are political tasks for politics at its best – and certainly they are not tasks just for politicians.

             The most important thing we can do is make our society more equal.  And then bring a new focus to our health service.

Changing the health of a nation requires substantial effort over a long period of time. It has taken us 60 years since the foundation of the NHS to bring medicine, hospital-focused medicine, to the point where it provides a high level service to everyone to the satisfaction of almost everyone in a reasonable time frame and with increasing safety. It might well take that long to bring the health of the nation to the point that will satisfy us all. It will certainly involve working well outside the budgets and structures of the NHS, as well as inside.  If we are to live longer, healthier, happier lives we will need to see some significant transformations in our society.

These are the top four changes we hope to see:


First and foremost our society will be much more equal.  If our health is to improve, the gap between the rich and the poor must reduce significantly.  If our society remains as divided between rich and poor as it is today, then our health will not get better;  if the gap widens it is likely our health will worsen.  The fundamental requirement for better health is to make our society more equal; the sense of fairness, trust and respect we see in more equal societies does at least as much to promote broad good health as any direct health policy.

Progress has been made at removing poverty in Britain with the introduction of the minimum wage and a concentration of the benefit system on the poorest, especially children and pensioners   It is now a major task, and we would say urgent task, for central government not just to renew its assault on poverty, but to create a more equal society. Writers like Tim Hutton and James Gregory have drawn together a strong body of analysis supporting a resumption of  the effort to end poverty. Polly Toynbee and David Walker show that there is much that could and should be done, particularly around the tax system, which would promote greater equality. The crisis that preceded the recession demonstrated to us and, it seems, to many others that ‘rather than adopting an attitude of gratitude towards the rich, we need to recognise what a damaging effect they have on the social fabric. The financial meltdown of 2008 and the resulting recession show how dangerous huge salaries and bonuses at the top can be’ 

Recession therefore provides an opportunity, to re-balance the taxation system in a far more progressive way.  The gradient of direct taxes in the UK is progressive but insufficiently so, with the top 20% of earners paying 24% in tax and the bottom 20% paying 10%.  However when you add indirect taxes the progression reverses – the top 20% of earners pay 35% of their income in tax, the bottom 20% pay 39%.  Changes that make the wealthy bear a far more proportionate burden of taxation, direct and indirect together, would reduce the gap between rich and poor. From their early actions it appears that the Conservative-Liberal Democrat government are heading in the opposite direction. Their first budget and planned spending cuts have a minor impact on those at the top and a potentially devastating impact on those at the bottom of the income scale. It will increase the gap between rich and poor.

Creating greater equality is a long term cultural process as well as an economic one , but there is, perhaps, one bold and immediate way in which income inequalities could be reduced; it would have a cultural impact and would fit with our current economic times. It is something that in pre-election speeches the Conservative Prime Minister proposed for the public sector. And it could be considered by Ed Miliband’s proposed ‘high pay commission’. It is that the differential in pay in any single company or organization, private as well as public, could be restricted by law.

For instance, it could be possible to require that the top payment (salary plus bonus plus other benefits) in any company should not be more than, say, twenty times the pay of the lowest payment in a company. (Twenty is large but is what Mr Cameron proposed for the public sector. The current average ratio in the UK of the pay of a chief executive compared with that of production workers in manufacturing is 31:1. In the FTSE 100 companies the ratio is over 80 and has doubled in the last ten years.) Thus, if the top person in a company were earning £300,000 per year, it would not be possible to pay the lowest paid person less than £15,000 per year without incurring a punitive rate of company tax.  Very few in this country earn those very top payments, and those who do would surely try all kinds of means to retain the extremes of pay to which they are accustomed and to which they certainly believe they are entitled. But a related reform would deal with that quickly – following the lead of Sweden and making tax returns and thus any tax evasion schemes open to public scrutiny.

The message is: by all means be successful and earn more, but make sure that everyone who contributes to your success earns more too, by lifting up low pay.

We look forward to a time when there is broad political consensus that reducing the gap between the income of the rich and the poor is seen as the most fundamental means of securing a safe, healthy and well-ordered society.  We hope to see many high-earners  accept this and tax evasion by the rich and by corporations shrink to almost nothing.  We hope that the great majority will accept that paying taxes is a social obligation which, though immediately uncomfortable, brings broad social improvements from which they benefit directly and disproportionately;  and that some few even see it as a privilege to be rich enough to pay higher taxes.


The second transformation our society, and in particular our government and public services, will undergo is to put innovation at its core. Britain seems to be a extraordinarily hidebound and static, and therefore expensive, in its ways of doing things – particularly in government.  Our law and our habits of thought and action make us far worse off than many of our European counterparts, in everything from high-speed trains to child care.

Innovation involves risk; there will be some innovations which don’t deliver what was expected of them and there will be successful innovations which come from possibly unwelcome sources, unwelcome at least to those in established centres of power.  The UK National School of Government’s Innovation Hub says that effective innovation is characterised by

  • a convergence or alignment between those with a shared interest in innovating
  • a journey involving many people who share, collaborate and adapt practices according to particular challenges
  • curious, open and flexible attitudes to problems and more regard for customers, staff, partners and stakeholders
  • network forms of organization
  • an acceptance of diversity – new ways of working emerge when people from many backgrounds come together to address a common problem and forge new solutions”

That description sounds not at all characteristic of so much of British society and government.  It will have to change.


Thirdly, we will see a transformation in policy thinking and professional practice towards “wholeness”. At present in health as well as across the board, we categorise problems and solutions in terms of small, ‘solvable’, speciality-based slices, a practice which puts us into professional and organisational silos, strengthens vested interests and feeds inter-agency squabbling. We will see a shift towards treating the needs of the individual, and the needs of society, as whole and inter-linked.  We will start to value the generalist as much as we do the specialist.

In other words – we will begin to think about everything together. This will be a significant transformation in the way we think about the world and government and individuals.  We have guidance in this integral thinking from American philosopher Ken Wilber who provides a useful reminder that ‘everything matters’. If the health of everyone is to improve, policy and professional practice will consistently follow a holistic approach, holding together issues of the individual with that of the community and issues, for instance, of psychology or belief alongside those of genetics or economics. Just thinking about one won’t be enough.


Fourthly, we will see altered public expectations about  the need to improve the long-term health of our families and communities and about how that improvement will be achieved.  In the first place people will understand that today’s poor health is not necessary and will expect it to improve through public and governmental action as well as their own, action that will be mostly beyond the scope of medicine and the local hospital.

We hope people will come to expect not to see the inside of a hospital in their whole lives, provided they are supported by their local health professionals. Hospitals will come to be seen as the top quality, but increasingly smaller backstop, for those rare times when things can’t be dealt with safely and well close to home, the front line for the new NHS. People will expect and demand that the heart of the NHS will be local (and therefore necessarily polycentric). They will understand that it is, or should be, the local services provided by primary care teams that bind together the whole of the NHS around the personal needs of the individual. They will expect to deal with a co-ordinated team of different kinds of professionals, from the local authority as well as the NHS, and including volunteers, to support them, inform them, sometimes care for them and certainly help them care for themselves.

Changing public expectations is essentially a political task, and it is part of our purpose here to say to politicians, national and local, why this has to be done and propose ways in which it might be done.  But this is not only a task for politicians. All public professionals will be encouraged to become good and regular communicators as part of their professional repertoire.

3. We all benefit when everyone is more healthy in a more equal society, so we all gain if we place the best resources where the health needs are greatest: unhealthy communities, people with chronic and complex needs and mothers and infants.

Building a fundamentally more equal, and thus more healthful, society will take a generation, even more.  But there are groups in our society who can’t wait that long and for whom we need to start to re-adjust our NHS priorities now.  Overall, it is the poorest who have most to gain from a renewal of our priorities – because poor people fall sick more often than rich people.

So, as well as acting at a national level to reduce inequality and close the gap between rich and poor, and even though it will sometimes be like pushing against an irresistible tide of inequality and poverty, consistent action is required to boost the health and well-being of our deprived, disadvantaged and unhealthy poor.

The question is how. Some things we know. We know that good health is and always will be a shared responsibility – shared between society and individuals.  And we know we can’t talk about health, especially equality in health, by talking only about health. We have to talk about where people live, about people’s lifestyles, their income, their children’s education, their experience at work, their understanding of how to be more responsible for their own well-being.  Ensuring the same equal right to good health for all is going to take more than just contributions from the NHS to achieve.

Successive governments have made attempts at tackling inequality in health. Even the Conservatives in their UK policy of free-market fund-holding in the 1990s introduced payments for deprivation. In Scotland, Labour attempted through its Joint Futures programme to integrate aspects of health and social care. And now through the Integrated Service Framework and ‘Equally Well’ fresh efforts are being made. In England, no commissioning Primary Care Trust can have its plans agreed unless they contain a strategy to shift the balance of care and address inequality.  However, although all these things seem necessary and right, the actual impact of these programmes on people’s health has been minimal.

We believe that special  and separate NHS programmes for the deprived and disadvantaged is the wrong approach. They don’t work. Two things are necessary. First, we need to ensure the sustained and consistent shift in resources towards community health services that the previous Labour administration in Scotland sought, with the consequent renewal of local organisation. And second, alongside that, at local level to provide the best where it is needed the most.  That’s a different view of equality.  Up until now equality has meant aiming for uniformity of provision, the same everywhere for all of us.  That will have to change, concentrating the best on where the health need is most challenging, providing the most resources, unequally, where the need is greatest.

The Marmot Review puts it like this:  ‘Focussing solely on the disadvantaged will not reduce inequalities sufficiently.  To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage, We call this proportionate universalism.’   We call it providing the best where it’s needed most.

There are three areas where we think disadvantage is greatest and where providing the best would make a real difference, three areas of action essential for achieving better health for those who presently most seriously lack it.  We think the best should be channelled towards unhealthy communities, towards people who are chronically ill or disabled or have complex needs and, above all else, towards mothers and infants.

Unhealthy communities

We know that poverty and ill-health walk hand in glove.  And we know, too, that poverty, though it can be found everywhere, is concentrated in certain neighbourhoods; there are poor parts of town just as there are rich parts.  The incidence of multiple deprivation, including poor health, in Scotland is well-mapped (through the Scottish Index of Multiple Deprivation or SIMD) and changes little. ‘…four in every five data zones that were in the 15% most deprived on SIMD 2004 are still in the 15% most deprived on SIMD 2009. Glasgow continues to have the highest concentrations of multiple deprivation in Scotland by some considerable amount … ‘

To begin to counteract that ingrained poor health, we believe that the NHS must provide GP services in these poor areas to a higher quality and greater intensity, perhaps to a very significant degree.  And it should do so in a cross-professional way alongside all the social, economic and educational services beyond the health service that are necessary to secure good health.  There is sufficient existing commitment and expertise, bolstered as it should be by a constant and consistent spreading of good practice, for the simple local concentration of a universal resource to make a significant and lasting difference. The best where it’s needed most.

Chronic and complex needs

As well as those areas of multiple deprivation we must focus, too, on individuals – those with multiple and complex needs. This is a large and varied group of people with, it will now be no surprise to learn, a strong link with poverty.  Some will be people with chronic long term issues, such as people with severe and lasting mental health problems, people with disabilities of all kinds and people who present ‘challenging behaviours to services, for examples in schools, within residential services/hostels or in their own neighbourhoods’. Some will have conditions which are still severe but may be more temporary – again some mental health patients, those disadvantaged by age or transition, like old or young people, people fleeing abuse and violence, offenders, people suffering from cultural or racial exclusion, and people with drug or alcohol misuse problems.

Alongside all those groups we perhaps ought to add the very large number of volunteer carers for many of them.

All these groups present significant problems to the NHS and most will often find themselves suffering as a result of stresses arising from inequality. They will require intensive attention from special cross-professional groupings within the local network of GP practices, allied health professionals and social care professionals from local authorities. It will be care in which continuity, co-ordination and a strong holistic person-centred approach will be deeply important. Again, nothing new, just the best where it’s needed most.

Mothers and infants

And finally, most of all we will need an intense focus on mothers and infants.  Because that is where the big changes over the generations will begin to happen. If you are healthy as an infant, then it’s much more likely you’ll be healthy as an adult.  The health of infants is in the hands of parents, especially mothers, before conception, through pregnancy, birth and the early years of life.   Mothers who smoke, who abuse drugs and alcohol, who are emotionally at risk, who don’t know enough about bringing up children, who neither know about healthy food nor have the money to buy it, who have poor housing and a poor environment – these mothers will have babies and bring up infants whose prospects for a healthy life will be largely denied to them through the impact on their biology.

Again we need to provide the best where the need is greatest. And here the need for local, person-centred, cross-professional working will be even more challenging.  Involved in the mix alongside the health service and the social care agencies will obviously be schools and voluntary groups. But so too should be the planners and transport engineers – making sure that key facilities are all within pram-pushing distance, that there are parks and playing fields where they are needed and that streets and pavements are safe for all.

Today, about 70% of NHS spending is in the last 3 years of life.  Even in these tough times, we will need to re-order our priorities to spend very much more on the first 3 years of life.  One of the most important actions that we can undertake if we want a healthy and just society is to give every child the best start in life.  The important word here is “every”.

4. Six areas for policy development and action and a new way of talking about health.

We all face significant challenges if our country’s very poor health is to change and improve. In the long version of this article we set out a range of detailed changes based on the best practice we currently see here and overseas, some of which stretch far beyond the NHS. Others too will have much to say about what  detailed actions are necessary and how we might achieve them.

But here we attempt a framework, a summary of six areas for policy development and action.  They are based on the fundamental assumption that to get better we need to get fairer.  Surprisingly getting fairer will help those who are already wealthy and therefore already healthy, to get even healthier; it will of course help those who are poor even more.

The Marmot Review also has six policy recommendations.  They are expressed differently, but they certainly match our list.  They are:

  • Give every child the best start in life
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives
  • Create fair employment and good work for all
  • Ensure a healthy standard of living for all
  • Create and develop healthy and sustainable places and communities
  • Strengthen the role and impact of ill-health prevention.

The  list of political and governmental actions for a healthier society, expressed in more general terms, we want to see considered is this:

  • Act at a European and UK level to reduce inequality and pursue equality. The gap in take-home pay between the top and the bottom must be significantly narrowed ; this can be done through more effective redistribution of income by taxation, both direct and indirect, by laws to make gross pay more equal within companies and organisations, and by incentives towards a ‘living wage’. The minimum income standard below which no one should fall should be re-formulated as the minimum income necessary for a healthy life (a good definition for a  ‘living wage’);  minimum wage and benefits should  be lifted to this level alongside more effective incentives for those who can to move from benefits into productive and meaningful employment.
  • Act at UK and Scottish levels to improve our attitudes towards others.  We should seek ways to hold back our increasing tendency, in the press and elsewhere, brought about by the stresses of inequality, to see others (including even children) as rivals, scroungers, sometimes enemies;  we  must encourage our better natural tendency towards trust, tolerance, reciprocity and esteem. Our economy and society will work better that way; competition and co-operation will be compatible and reinforcing activities.  The actions will range from practical support for mutual and co-operative companies to using our planning laws to make the places we use and inhabit more congenial and safe.
  • Act at UK, Scottish and local levels to reform and improve the governance, behaviour and effectiveness of our public institutions. At the moment many of our institutions are hierarchical, protective, centralised, risk-averse and bound by process and performance management.  It may well require change to our laws and to the relationships between levels of government, as well as management and behavioural change, to develop competent public institutions which in their practice are innovative, enabling, collaborative, client-centred and local.
  • Act locally, in local authorities and health boards, to heal the psychological and social stresses caused by inequality. This is hard to conceive and do; it is about trying to reach into the individual and collective ‘interior’.  Action will range from counselling in school for children and parents under stress to continued support for accessible arts, the encouragement of green-space activity and affordable facilities for adult self-reflection and life-long learning.
  • Act locally, in local authorities and health boards, in GP practices and communities, to break into the circle that links poor health and poverty. This is a well-worn route, but ineffective because it has been followed without larger action to reduce inequality.  Special and separate programmes for deprived areas and people do not have meaningful impact.  If a real difference is to be made, we will need to boost, for deprived and disadvantaged groups and communities, both the scale and intensity of what we provide for everyone; giving the best where the need is greatest.
  • Act at UK, Scottish and local levels to change expectations about what the NHS is for: from medicine to health.  Changed expectations will change all that the NHS, and others, do – from the balance of research funding to the status of hospital consultants compared with GPs. It requires a new story about our health and how we expect to improve it. 

Finding a new narrative

Those changes, large and small, we talk about here (and in the longer version), won’t happen unless politicians and public want them to happen and have the words to express changed beliefs about the NHS and our health.  So much has changed since the NHS was founded sixty years ago  and so we need to tell a new story about the NHS and our country’s health.

Though we live longer now and have beaten some of the killer diseases, our health is not improving and is sometimes actually getting worse, in some areas quite quickly.  We get cancer and diabetes, when we need not, because more and more of us are far too fat.  We get cancer and other diseases, and some of us get killed or injured, because so many of us drink far too much. We are so stressed by keeping our lives and living standards on a rising curve compared with others that we are increasingly beset by anxiety, depression and damage to our immune systems.  We may be richer – but we’re neither healthier nor happier.

We’ve rightly spent more and more on our NHS hospitals to bring our health service back up to European standards.  But it’s clear that more and better hospitals haven’t made us healthier  – and they aren’t designed to do that. They are there to help us when we get ill.  The problem is that our poor health is making us ill far more than we should be.  In fact, the illnesses that arise from our poor health look as though they might even overwhelm our hospitals and reverse the rising trend in life expectancy.  Certainly our poor health means money is diverted from where it should be better spent: some hospitals in England are even having to spend money on bigger examination couches simply to cope with the number of hugely obese people.  “Stomach stapling” and similar operations –  unheard of a few years ago – are on the rise just to cope with our excess fat.  It’s not that people don’t need those new operations – but that our fatness epidemic, one of the big symptoms of poor health, is making us spend money which wouldn’t be necessary in a healthier society.  In fact, if we all managed to be as healthy as the healthiest 10% of us, we’d save about one-third of the NHS budget – freeing it up for all the expensive life-saving medicines and treatments for the rarest and unavoidable diseases. Getting healthier isn’t about sacrificing the things we enjoy in life.  It’s about living longer, being happier, getting more out of life.

What’s happened to our thinking is two things.

  •  First, we’ve all got our thoughts trapped in thinking that health is the same as medicine. We think, wrongly, that simply having more and better hospitals will make us healthier: it won’t .
  • Second, we’ve not faced up to the awkward truth that our poor health (and many other social ills) is rooted in inequality, in the gap between the rich and the poor, and that Britain is one of the most unequal countries in the whole world. The wider the gap, the worse our health.

So there are two fundamental lessons for us if we want to be healthier and happier.

  • The first is that if we want to be better, in health and much else, we have to be fairer; the gap between rich and poor must be narrowed.
  • The second is that we must balance to our understandable affection for the bricks and mortar of hospitals with a new demand that more people, skills and resources are re-located beyond hospital walls, out in the community, integrating health, social and other care to improve the health of each of us.

The extended version of the paper contains a wealth of evidence about our health and many examples of good – and bad – practice in promoting good health at all stages of our lives. It is not to be seen as future Labour Party policy but as a stimulus to informed debate.

Dr Richard Simpson is the Labour member of the Scottish Parliament for Mid-Scotland and Fife. He is Labour’s shadow public health minister.  He is a distinguished medical practitioner and was minister for justice in the first Scottish Parliament 1999 – 2003.

Trevor Davies is an honorary professor in urban studies in the University of Glasgow.  He was a Labour councillor in Edinburgh from 2001-07. Office   0131 552 9871


Dr Harry Burns Research Presentation January 2008“Equally Well” 2008 The Scottish Government

Toynbee, P Guardian 30 July 2005 reviewing Wilkinson R, 2005 “The Impact of Inequality: How to Make Sick Societies Healthier”  Routledge London

The Marmot Review “Fair Society Healthy Lives” Strategic Review of Health Inequalities in England Post-2010

‘The Solidarity Society – Why we can afford to end poverty and how to do it with public support’ Tim Hutton and James Gregory’ 2009 Fabian Society

Toynbee, P and Walker, D “Unjust Rewards” 2008  Granta Publications, London

Wilkinson R. and Pickett K. 2009 ‘The Spirit Level’ Routledge London

Office of National Statistics quoted in The Marmot Review “Fair Society Healthy Lives” Strategic Review of Health Inequalities in England Post-2010

National School of Government “The Whitehall Innovation Hub” 2009

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The Marmot Review “Fair Society Healthy Lives” Strategic Review of Health Inequalities in England Post-2010

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