Personal responsibility in the NHS Constitution and the social determinants of health approach: competitive or complementary?

Abstract

The final report of the World Health Organization’s (WHO) Commission on Social Determinants of Health (CSDH), Closing the gap in a generation: Health equity through action on the social determinants of health, was published in August 2008 (CSDH, 2008; Marmot et al., 2008). Welcoming the document on behalf of WHO, Director-General Margaret Chan noted: ‘‘the Commission’s main finding is straightforward: the conditions in which people are born, live, and work are the single most important determinant of good health, or ill health; of a long and productive life, or a short and miserable one’’ (Chan, 2008). The report presents an excellent overview and analysis of the range of structural factors that influence individual and population health, and makes a number of practical recommendations that seek to ensure that avoidable health inequalities are levelled out, so that everyone has an equal opportunity of leading a healthy life. Roughly around the time of publication of the CSDH report, and in the 60th anniversary year of the NHS, the UK Department of Health (DH) held a consultation on a draft NHS Constitution. The document aimed to set out the NHS’ fundamental values and principles and included a range of individual rights of NHS users, detailing also their responsibilities. A final version of the constitution was published in January 2009 (DH, 2009). Given the CSDH’s emphasis on the primary role of the social determinants of health (CSDH, 2007, 2008), what should we make of the DH’s initiative to introduce, for the first time in NHS history, explicit health-related responsibilities for individuals? Why talk about individual responsibility if yet further evidence has been produced that demonstrates the importance of environmental factors? For those sympathetic to the social determinants of health (SDH) approach, there seem to be three principal types of response: (i) to reject the DH’s move; (ii) to agree that it makes some sense, but to argue that it should