Policy context
The Wider Determinants of Health are the social, economic and environmental conditions in which people are born, live, age and work. These factors interact with an individual’s genetics and behaviours to strongly influence health outcomes.
The Marmot Review (2010) and subsequent work of the Institute of Health Equity has highlighted the social gradient in health, whereby the most disadvantaged in society experience poorer health outcomes, leading to health inequalities.
Health inequalities have widened over the last decade and have been exacerbated by Covid-19. Disparities in access to healthcare services have also widened as a result of the pandemic. The Levelling Up the United Kingdom White Paper links health and productivity and includes specific health related targets to decrease the gap in healthy life expectancy between the least and most affluent areas (currently around 18 years) by 2030 and increase healthy life expectancy overall by 5 years by 2035.
Meeting these targets will require a whole-system, place-based approach, bringing together the NHS, local authorities, the VCSE sector and other stakeholders. The establishment of Integrated Care Systems provides a legislative framework for the NHS to work more closely with local partners on wider population health approaches. The NHS can also act as an anchor organisation, positively influencing the health and wellbeing of communities.
How can Creative Health approaches help?
In areas experiencing high levels of deprivation, initiatives which increase community engagement, social cohesion and social capital can help to mitigate some of the detrimental impacts of the social determinants of health.
Creative health implemented at community or place-level can achieve this. Creative initiatives can provide people with a sense of agency, power and control over their circumstances, which can improve individual and community health and wellbeing. Mobilising existing creative, cultural and community assets through the provision of a supportive infrastructure will lead to stronger, more resilient communities with less reliance on public services in the long-term.
Social Prescribing recognises the influence of the wider determinants of health – it is estimated that 1 in 5 GP appointments are for non-medical reasons. Through social prescribing, patients are linked to non-clinical community-based activities to help meet their needs, thereby reducing healthcare appointments and the burden on the NHS.
Key Areas of Focus
Employment
Evidence shows that being in work is linked to good health, where the work is safe, secure and with good working conditions (Public Health England).
Conversely, health conditions can also keep people out of work. Unemployment is strongly linked to mental health conditions including depression, anxiety and self-esteem, and can lead to unhealthy behaviours. Job insecurity is linked to stress, leading to long-term conditions such as hypertension (Health Foundation).
Poor conditions can impact on workers physical or mental health. One of the policy drivers recommended by the Marmot Review (2010) was to create fair employment and good work for all. A healthy workforce is key to productivity and a strong economy and therefore employment is central in the levelling up agenda. Creative health approaches can be used to help people build skills and confidence to enter the workforce and to improve health in the workplace.
The Gloucestershire GEM Project (Going the Extra Mile) is an employability and social inclusion programme, delivered by a partnership of over 50 community based organisations managed by Gloucestershire Gateway Trust on behalf of the lead organisation Gloucestershire County Council. GEM Project helps people in Gloucestershire to overcome challenges to employment and move them closer towards or into work. The organisation Art Shape is a partner.
Art Shape’s employability programme consists of various creative development courses, that focus on creative and practical techniques which could be used in a professional environment.
The ‘State of Flux 2.0’ case study from Ludus Dance describes using the arts to support soft and hard skills development, to reduce social isolation and develop self-worth and aspirations in young people from The Cove (Child and Adolescent Mental Health Service CAMHS), Heysham. Outcomes include young people being inspired to use the skills learnt to explore career options.
Beating Time runs three prison programmes aimed at helping people put prison behind them and build lives they want to live. ‘Choirs Beating Time’ serve their communities whilst preserving mental health, as people who feel excluded and have poor mental health cannot find, or make, work. ‘Inside Job’ is an in-prison recruitment consultancy, and ‘Upstart’, helps entrepreneurial prisoners play to their strengths.
Financial wellbeing
Financial insecurity and lack of sufficient resources is strongly linked to poor health outcomes. The Marmot Review (2010) highlighted the social gradient in health whereby those with lower socio-economic status experience poorer health and die sooner. The situation had not improved in an update to the review in 2020.
Poverty in childhood is associated with infant mortality, low birthweight, obesity, asthma, tooth decay and accidental death. In adulthood it is linked to diabetes, cardiovascular disease and premature death (Health Foundation).
The effect on health outcomes can be a result of not having resources to meet basic needs, and through the persistent stress of financial insecurity. The numbers of people falling into poverty are likely to increase as a result of the cost-of-living crisis.
Housing
The availability, affordability and condition of housing can have a large impact on people’s health. Poor quality housing can lead to physical health issues, as exemplified by the spread of Covid-19 in overcrowded housing conditions. The health impacts of homelessness have been discussed in the ‘Health Inequalities’ section of this toolkit.
Insecure housing also impacts on mental health. Research by the Health Foundation shows that people living in non-decent housing, particularly rented accommodation were more likely to self-report poor health, and that housing problems and frequent house moves also impact health. Levelling Up the UK includes targets to improve housing quality and to increase the number of people who are able to own their own homes.
Granby Four Streets was the result of a 20-year battle by local residents to save a series of terrace housing from demolition. Forming the Granby Four Streets Community Land Trust, the residents hired multi-disciplinary collective Assemble to devise a vision for the area, which could bring the empty homes back into use as affordable housing.
There are several examples nationwide where housing associations partner with arts organisations on targeted interventions in the places where people live. For example, Barnsley Homes worked in partnership with Creative Recovery on ‘Lets Blow Out the Blues Together!’ to help tackle social isolation and mental health. Cherwell Theatre Company is running a pilot project, supported by Sanctuary Housing to equip young people in Banbury to deal with negative and harmful attitudes and behaviours towards women.