Addressing the political determinants of health

‘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 4 July, yet the (political) fireworks will have been let off well beforehand. Among the heart of the upcoming debates will be health care, 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 local medical committee conference,² which already lies in direct contrast with the pledge made by the Liberal Democrats to recruit 8000 more GPs if elected, as a central part of their election campaign.³ These headlines act as 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 while 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 such as 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.

While 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 Fund and the Health Foundation,^10,11 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.