Human flourishing in a health-creating society

The way we think about health and health systems needs to reflect the realities of the society we live in. There is no going back to the world before COVID-19. And, more fundamentally, it is time to finally leave behind the mindsets and practices of 20th-century medicine. COVID-19 is still doing terrible damage. Many countries are in the grip of a second or third wave of infections—in some cases worse than the first. COVID-19 vaccines bring optimism, but access to them is unequal for low-income and middle-income countries. We don't yet know the full extent of this pandemic's impacts on our mental and physical health, economy, and society. Reductions in trade, aid, domestic activity, and employment together with inadequate social and economic safety nets have led to an estimated 150 million more people falling into poverty and a developing crisis in food supply. Many of the development gains of recent years are being lost. The pandemic has made existing inequalities and divisions in all societies more severe. Leaving aside health workers, it is manual and casual workers, migrants, people from ethnic minority groups in high-income countries, and the poorest people in every society who have suffered more illness, deaths, or economic hardships.

The impacts of the pandemic are a reminder that the old normal was not good for many people and that far-reaching social and economic change is needed. We should treat COVID-19 as a syndemic characterised by biological and social interactions that all need to be addressed. The virus is also a reminder that WHO defines health as about physical, mental, and social wellbeing and not only the absence of disease or injury. Yet too little attention is paid to social wellbeing. Government policy in many countries, particularly those that embraced austerity, has damaged social wellbeing. The important research by Michael Marmot, Ilona Kickbusch, and others has shown how the social and political determinants of health shape our wellbeing and life chances. This understanding and linked ideas about health in all policies and wellbeing budgets are beginning to influence policies globally and present a challenge to the status quo. Other developments are also galvanising change. These include the growing importance of non-health actors and communities in health, ideas about health creation and human flourishing, and a renewed focus on the causes of health, not only the causes of disease. COVID-19 has accelerated this trend. Our behaviour as citizens has mattered in controlling virus spread. People throughout the world have set up community help schemes and social media groups, looking after neighbours and developing local activities. There are village COVID-19 groups in Uganda, for example, helping to manage the spread and the impact of the virus. As importantly, many businesses have supported local communities through staff volunteering and donations.

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This sort of activity has always happened but, with rare exceptions, has been treated as unimportant by health services and professionals. An appropriate syndemic response would recognise community activity as an integral part of a wider response. Although there is increasing interest globally in patient empowerment, self-care, engaging citizens and communities, social prescribing, and health co-creation, it is mostly on the health system's or the health professionals' terms. People and organisations are being engaged to serve the health agenda; healthy activity is prescribed, people are assets not autonomous agents, and patient compliance is still expected.

This professional-led approach is a crucial part of the future but is not the whole story. Educators, civil leaders, employers, community organisers, and households are creating health for themselves and their communities and organisations. These health creators are doing so for their own reasons and in their own way because they see something that needs doing. Some of these initiatives involve health professionals while others don't. There is institutional resistance to these ideas. In the UK, for example, organisational changes to the National Health Service (NHS) have been dominated by 20th-century concepts, oversimplistic economic ideas about markets that ignore the reality of how services are delivered and health improved, continuing outdated professional hierarchies and demarcations, and adherence to a biomedical model. The dominance of economic thinking leads to an emphasis on incentives to the exclusion of motivation and on contractual relationships rather than shared vision. By contrast, the health creators speak a different language. They focus on building relationships around shared interests and values, strengths not weaknesses, and the importance of community, personal control, meaning, and purpose. They are purpose-led and can be flexible and experimental in their approach, learning by doing. And social and mental wellbeing are treated as being as important as physical health.

There is an alternative way to think about health that doesn't involve starting with health professionals, health systems, or government policy. It starts with people, communities, and wider society. I visited some health creators in the UK before the COVID-19 pandemic struck. They helped me understand better what Francis Omaswa of Uganda meant when he said “Health is made at home, hospitals are for repairs”. Health systems and professionals can't deal with the underlying social, commercial, and political determinants of health that cause so many major health problems. My visits showed me, however, that other people are collaborating to tackle some of these causes and are creating health—people like the teachers who provide one-to-one support for children excluded from education, the out-of-work men who run community activities for children and bring isolated men together, the leaders of the Black Health Initiative who combine advocacy with community provision for older people, or the women who brought their community together around growing vegetables, swapping recipes, and community feasts and now support a national network of more than 150 groups, among many others. These groups are developing an approach to the creation of health that has links with older concepts of salutogenesis and eudaimonia. These ideas are not in themselves new and can be found in some form in many different cultures and philosophies but are surely now due for a revival.

Health creation is so much more than prevention. Health and wellbeing are about human flourishing and agency, the conditions and communities in which we live, learn, play, and work, our social relationships, and planetary health. Creating health depends on nurturing environments, communities, and, above all, relationships that enable people to grow and develop. The best example is how a good parent, mentor, teacher, or leader acts. It is about creating resilience and confidence as well as physical, mental, and social wellbeing. In other words, human flourishing.

This must surely be the foundation of our society for the future and we should be actively building a health-creating society where every individual can thrive. Government has a vital role to play, but government and policy are never enough by themselves. Change requires people and buy-in, motivation, passion, and action. And we also, of course, need a well resourced and high-quality health and care system to tackle disease, foster prevention and promotion, and support health creation where it can.

I believe that, to adapt a phrase from the historian Eric Hobsbawm, we have reached the end of the long 20th century and can finally discard the values, behaviours, and concepts that it represented. Change is underway, bottom up, and we can see the emergence of a post-industrial health and care system and a health-creating society. A post-industrial society is one where the emphasis has shifted from the production of goods to services, that stresses user engagement and personalised services, and is knowledge based and supported by technology. I suggest that a post-industrial health and care system is one that no longer treats health and health services as commodities but, rather, engages users in co-production, makes full use of technology, and, importantly, views individuals in the context of their community and society, integrating social and mental as well as physical dimensions of wellbeing.

There is a continuum here of three vitally important activities: health care, prevention and protection, and health creation. The first is professional led, the second involves government and all sectors of society, and the third is generally led from outside the health sector with professional support on request. Many health professionals are adapting to the new environment and helping create this new approach. In the UK, people like nurse entrepreneurs Hazel Stuteley and Heather Henry see their role as facilitative and believe that communities know what they need to do to heal themselves and that professionals can work with them to create the right conditions for this to happen. They often need, in Henry's words, an injection of confidence rather than an injection of medicine. They are not alone in pressing for change. General practitioners are supporting health-creating networks locally and some NHS trust chief executives and medical directors are embracing health creation, building links with local communities, enterprises, and institutions and aiming to improve quality of life and not just health. The Health Creation Alliance in the UK identifies five health-creating practices for professionals that start with listening and responding and finish with handing over control. And outside the NHS, New Local describes the community model as a new approach to public services.

COVID-19 has shown us the vital importance of science and technology, but it has also demonstrated the even greater importance of people—both health professionals and health creators—with their passion, commitment, and creativity. Rebuilding requires a 21st-century vision for a post-industrial health system and a health-creating society that embraces health creation and is ultimately about human flourishing.