Why the Long Term Plan is a missed opportunity in health promotion

A Queen’s Nurse says medical models alone will not address social determinants of health 

A Queen’s Nurse says medical models alone will not address social determinants of health 

Addressing social isolation is an essential component of person and community-centred
care. Picture: Chris Balcombe

Life expectancy has stopped improving in England, and is falling in Wales, Scotland and Northern Ireland, according to the Office for National Statistics. In addition, health inequalities are widening.

Last autumn, health and social care secretary Matt Hancock published a green paper that stresses the importance of prevention, while chapter 2 of the NHS Long Term Plan is devoted to how to address health inequalities.

But what is the role of 21st century nursing in preventing ill health, promoting health and tackling health inequalities?

I believe we should balance improvements in conventional healthcare – a biomedical model of health – with a bio-psychosocial model.

Relying on outdated models 

The history of nursing shows that we practise holistically. The relatively recent move towards person and community-centred care means we must have due regard not only for patients’ wishes but the social determinants of their lives.

The NHS remains wedded to a needs-based, siloed, service-driven and paternalistic culture. When the predominant issue is medical (a heart attack, for example) our healthcare is world class. But when faced by multifactorial issues, that same culture creates a dependency that drives up demand and widens inequality.

I looked in vain at both the green paper and NHS Long Term Plan for any sign that healthcare might be moving to embrace the strengths and capabilities of our patients, carers, families and communities. Instead, I found traditional health promotion, protection and prevention – what I call ‘the 3 Ps’.

These can be effective, but I fear they will have little impact on inequality and in fact may even widen it. We need to understand the ‘causes of the causes’ of smoking in working class men, for example. In my experience, it’s as American psychologist Abraham Maslow said: when you’re worried about keeping a roof over your head, the last thing you’re thinking of doing is giving up those roll-ups.

The origins of health, rather than illness

My world view of what makes us healthy (rather than what makes us ill) developed after I was made redundant from an NHS post eight years ago. I retrained at the University of Exeter in a form of community development that focused on working in equal partnership with citizens and communities, using a strengths or asset-based approach.

I saw that people and communities can radically transform, and I learned why that happens and how to enable it to happen.

‘When we introduce people with long-term conditions to others in the same position, something happens’

I became chair of a national membership organisation called New NHS Alliance, refocusing it to be a vehicle for tackling health inequalities. A group of us, focusing on the social determinants of health, then sought to write a manifesto for well-being called ‘health creation’.

Health creation comes from something called ‘salutogenic’ theory – salus meaning health, and genesis meaning origins, which is complementary to patho (illness) and genesis. Having read the evidence for salutogenesis, I boiled it down to ‘3 Cs’: control over the circumstances of your life, meaningful social contact, and the confidence of people to change their own lives.

Lack of control over working life

In the groundbreaking Whitehall Study: Longitudinal Research of Chronic Stress in Civil Servants, Michael Marmot found that the lower echelons of staff experienced more cardiovascular events than their more senior colleagues. Basically, the lack of control over their working lives made them increasingly stressed. There’s a moral in that for the nursing workforce.

Social isolation and loneliness are now recognised as a major cause of morbidity and mortality. In response, we have embraced initiatives such as social prescribing. But this is just the tip of a large ‘asset-based’ iceberg that I want to explore.

The evidence tells us that what makes us healthy is not only social connectedness but also having meaning and purpose in our lives – using our strengths, not just addressing our weaknesses. This gives us a clue to simple actions that nurses can take to help tackle health inequalities. People can support each other and their communities if nurses help build their confidence to develop these capabilities.

Leg clubs show how clinical interventions in a social environment can foster peer
support and education. Picture: Chris Balcombe

Connecting people to their peers

When we introduce someone with a long-term condition or complex need to others in the same position, something happens. They take notice of how others are coping, they learn, they become more active themselves and then, quite often, they start to give back. If nurses created the conditions where people could connect, we could improve their well-being.

The Lindsay Leg Clubs are a well-known example of this – people with leg ulcers socialise while district nurses carry out their clinical interventions. Group consultations or shared medical appointments are another example of how people with the same condition can be encouraged and supported by each other.

‘The NHS is becoming less of a silo... Now is the moment to exert our holistic credentials’

Healthcare has much further to go down a salutogenic route, but the signposts are there. NHS England’s clinical director, Alf Collins, alongside the Royal College of General Practitioners, has recently started a debate in the medical profession about ‘rethinking medicine’. This considers whether the medical profession has over-reached and asks whether doctors should take a social approach more seriously.

Devolution in the UK, integrated care systems, place-based care and personal budgets mean the NHS is becoming less of a silo. There are, for example, nurses working in local authorities, education and housing.

But we can go further. Now is the moment to exert our holistic credentials throughout the social determinants of health. In the future, will we engage the strengths of our communities and nurture our patients’ desires and capabilities? Or will we continue just to dress their physical and emotional wounds?

Heather Henry is a Queen’s Nurse and owner of Brightness Management. She holds the Sue Pembrey Award for Person Centred Care 2018 

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