A healthy economy

Progressive economic development has the local population’s health and wellbeing at its heart, says Marvin Rees

It goes without saying that we urgently need to refresh the framework through which we understand the purpose and assess the performance of our economy. Laissez-faire capitalism hasn’t worked for too many real people. I believe a better understanding of the economy as a determinant of health and health as a determinant of economic success could provide the perfect vehicle for this reframing.

Population health is an issue of critical importance to sustainable economic development. Mental and physical sickness are core drivers of workforce absenteeism and lost productivity for employers; they increase the likely future demand for public services while simultaneously reducing the supply of the working age adults needed to fund those services. Moreover, the evidence tells us there is a direct link between the health and wellbeing of children and young people and their academic achievement. This puts health and wellbeing at the centre of the challenge of building a workforce with the skills to attract inward investment and they must sit at the heart of any coherent economic development strategy.

But delivering this healthy workforce is not down to professionals in public health and the NHS alone. In fact, it’s the way we choose to do economic development that is perhaps the single most important determinant of population health because of the impact it has on every aspect of life, from where we live to the quality of employment and services we can access to our place in the socio-economic hierarchy to the likelihood of political debate taking our interests into account.

Michael Marmot’s Fair Society Healthy Lives shows there is a social gradient in health – the lower a person’s social position, the worse their health. Action to improve health and reduce health inequalities, he says, should focus on reducing the gradient in health.

Richard Wilkinson and Kate Pickett argue the evidence tells us the decision, or non-decision, to pursue a form of economic develop that increases or reduces inequality is the key social policy question. They say we have reached the end of what economic growth alone can do for us as a policy tool. In relation to population health they contend ‘at any given level of personal income or education, someone’s quality of life will be higher if he or she has the same level of income or education but lives in a more equal society’.

If true, this creates both an opportunity and a threat. The opportunity is to build a virtuous circle into the economic cycle whereby we pursue an intentionally inclusive model of economic development. It reduces inequalities and in the process improves wellbeing, increases health and social resilience, drives down the public and private sector costs associated with illness and improves the capacity to develop a skilled workforce. The threat is to pursue a trickle down model that’s shown to increase inequality. It undermines health, reduces resilience, increases the costs and uncertainties associated with physical and mental illness and weakens the foundations of future economic development.

The challenge is to ensure the leaders accountable for delivering better health and those responsible for delivering stronger economic performance understand their interdependence and the need for a culture and infrastructure that will enable them to exert mutual influence. The NHS must take up a proactive form of leadership that goes beyond the boundaries of health services to ensure no decision – from housing to transport to benefits – is made without considering the ultimate impact on health. We must develop a framework that explicitly and consistently translates population health into economic performance and vice versa.

They must also recognise that their delivery is not solely about the collection of health services they provide but through their full economic, political and social footprint. For example, via their very significant role in the local economy as employers and the kind of working conditions they provide. As place shapers, they have an impact on the infrastructure, culture and resilience of the communities of which they are a part – whether as contractors and the requirements they make of the firms they commission or in nurturing social capital by supporting the voluntary and community sector.

‘We need to move beyond the language that segments institutions into wealth creators and non-wealth creators by recognising the public and voluntary sectors’ contribution to health and resilience are investments in the raw material of the economy’

Simultaneously, economic leads across the private sector must open up to the influence of the public sector. We need to move beyond the language that segments institutions into wealth creators and non-wealth creators by recognising the public and voluntary sectors’ contribution to health and resilience are investments in the raw material of the economy. Society is the place from which the quality of the workforce is drawn and the context within which business is done. When the public sector is better able to get good outcomes, the private sector has a healthier social, political and physical environment in which to operate.

Such an approach has been visible but has not been consistent in Bristol. The early strategies coming out of the West of England Local Enterprise Partnership talked of a skilled workforce but did not talk of a well workforce. The timing of their approaches to the BME and Bristol women’s voice and influence groups showed they were late in the day in considering economic inclusion. On one occasion a LEP representative turned up to a community meeting organised by Voscur and opened by declaring ‘we don’t do social policy’.

And it took a while for the health and life sciences group to get on top of the argument that perhaps the best health technology we could develop was a socio-economic policy that enabled economic development to happen in a way that improved health and reduced the future sickness burden on taxpayer-funded services. Business doesn’t only need grants but also a well workforce.

Simultaneously, Bristol City Council downgraded the role of the director of public health – the health professional best positioned to develop the required approach to health – while CCGs concentrated on getting their legal positions together and health providers focused shrinking resources on the basics of service delivery in order to win the next contract.

Re-establishing population as the primary purpose of economic development is not only a reasonable moral argument. It provides the foundations for stronger and more sustainable local economies and promotes progressive policy directed toward specific social outcomes such as reducing inequality, rather than leaving outcomes up to the market.

It’s a policy door that has now been opened at the highest levels. The World Economic Forum is among the international bodies now drawing attention to the threat inequality itself poses to the socio-political order and the sustainability of economic development:

The inherent dangers of neglecting inequality are obvious. People, especially young people, excluded from the mainstream end up feeling disenfranchised and become easy fodder of conflict. This, in turn, reduces the sustainability of economic growth, weakens social cohesion and security, encourages inequitable access to and use of global commons, undermines our democracies, and cripples our hopes for sustainable development and peaceful societies.

I would like to see Bristol lead the way on reorganising city priorities and the structure of governance so that health is given pre-eminence. To do so we must make the director of public health one of the most influential posts in the city, not just in the local authority. They must be resourced to serve and influence organisations and policy across the public, private and voluntary sectors and assess the health impact of central government policy.

We must also ensure the chair and chief officer of the clinical commissioning group have direct and regular access to the mayor. The mayor must support them to influence any city decisions that will impact on the levels of population physical and mental illness they will ultimately be required to pay to treat.

By working with our universities we can develop a city model that enables us to fully understand and communicate the economic case for health. We need to launch something in Bristol that does for population health what the Stern Report did for climate change.