How the NHS can shift from treating illness to creating health

NHS Alliance chair Dr Brian Fisher looks at how building strong communities can address drivers of ill health such as inequality - and help the NHS move beyond treating illness and into health creation.

NHS (Photo:
NHS (Photo:

Much of today’s ill health is linked to social causes, inequalities and the wider determinants of health, and most of them can be effectively addressed. Yet our health and care systems continue to focus on what’s wrong with people; their illnesses and conditions.

We treat the symptoms and not the cause - we need a different approach; one that creates health by drawing on the strengths and wisdom held in communities. By working with people and communities we can go beyond treating and preventing illness and into health creation.

Inequality kills

We live in a profoundly unequal country - 44% of the UK’s wealth is owned by 10% of the population, while the richest 1% are estimated to own 14% of the nation’s wealth. By contrast, 15% of adults owe more than they own.

Some 14m people (22% of the population) live on incomes below the poverty line after housing costs, making the UK one of the most unequal of western European countries. This includes 4m children in poverty - nearly one in three - and the number is rising. Poverty has made life desperately hard for very large numbers of people.

Inequality builds a politics and a society of division, and poverty brings poorer health: in the poorest areas of the UK, people live on average 10 years less than those living in the richest areas.

High levels of inequality increase social anxiety and heighten psychological and social costs among the vast majority of the population. People and families in poverty are more likely to experience early trauma, which has significant negative impacts on development, behaviour and well-being. 

Inequality affects social cohesion. Community life is weaker. Austerity weakens those civil institutions that support links between people: libraries, social care, youth work, community development. Countries with bigger income differences tend to have less social mobility, and more segregation. People feel a lack of control, they feel more mistrustful and envious.

Health creation

We know that health is a social process, not just an individual one. Our links with other people have a big impact on our health.

There is a 50% increased likelihood of survival for people with stronger social relationships. This effect size is comparable with stopping smoking, alcohol, BMI and physical activity. It is consistent across age, sex, cause of death.

Health creation is the enhancement in health and wellbeing that occurs when individuals and communities achieve a sense of purpose, hope, mastery and control over their own lives and immediate environment.

Health creation is built on control, contact and confidence. When people feel a sense of control over the circumstances of their own life, when they have meaningful and purposeful social contact and activity and the avoidance of social isolation, they can gain the confidence to take control. They can have a more positive impact on their own life and on the lives of those around them. Indeed, when we have control, contact and confidence, our mental and physical health improves and we gain the freedom to live a life we value.

The NHS hardly harnesses these insights at all. The NHS is not responsible for national economic inequality but it can mitigate its effects in various ways: through its role as employer, for instance. And through supporting health creation.

Five key steps to health creation

These were identified to be common features from people´s testimonials about what made them well. We believe that by embedding the five features into professionals’ practices, our day-to-day work with people will become more health creating.

The five features of health creating practice are straightforward. They help people to gain control, make contact and build confidence. They can be implemented in different ways in different communities and settings and we need to both innovate with them in order to develop new health creating practices and adopt them at scale.

Listening and responding: 

Effective, genuine listening to the reality of people’s and communities’ lives is essential. As is acting differently upon what is heard, and not just reverting to the established systems. Listening can also enable truth-telling if people feel safe to open up about matters they might be hiding, even from themselves. Being listened to can also be therapeutic in itself.


When people and practitioners face the truth, and own up to what holds them  back from creating health, rather than treating illness, they can start to get to the root causes  of problems. 

Strengths focus:

Health creation happens when attention is paid to what people can do for themselves or others. Building on people´s strengths unlocks their potential and builds  confidence for creating health. 


Health creating practice enables people to work out what they need for themselves. When people start to rely on themselves, they become less reliant on health and care services. 


Lasting health creation happens when the health creating features above result in a power shift from practitioners to people and communities. When people and communities are the experts, they can make decisions about things that affect them and their environment. Services can then adapt and respond accordingly.

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