After taking office, the Labour government signalled significant changes in policies aimed at creating and maintaining good health more equally in the population as a whole; changes with profound implications for social work. First, tackling health inequalities was moved to centre stage: one of the two declared aims of ‘Our Healthier Nation’ (DoH 1998a: 5) was to ‘improve the health of the worst off in society and to narrow the health gap’. Second, the government argued that the primary means of reducing health inequalities was not through NHS policy and practice: ‘Tackling inequalities generally is the best means of tackling health inequalities in particular. This means tackling inequality which stems from poverty, poor housing, pollution, low educational standards, joblessness and low pay’ (DoH 1998a: 12). This agenda mirrored an international perspective on health creation in which health was seen as a collective good: in which one person’s health should not be achieved either at the expense of others’ ill health (equity) or at the expense of the environment (sustainability) (Dahlgren and Whitehead 1991 ; Labonte 1997). These changes in policy direction have had two major consequences for social work. First, social work, in social services departments and the voluntary sector, is now expected to play a key role alongside others in developing strategies and implementing policies for maximising population health and reducing the ‘health gap’. Second, any reductions achieved in social inequalities in general, in order to underpin this health focused agenda, can be expected to bring benefits for social work service users. However, of all the dimensions to social work’s contribution to health which we discuss in this article, health creation remains the least visible in terms of mainstream practice. In recent years the perception has been that social work mainly becomes involved in health issues after illness has led to difficulties in daily living, rather than playing a primary role in preventing sickness and promoting good health. We argue that this view reflects a lack of awareness and analysis in social work itself of the interaction between lay efforts, inequitable material and social circumstances in the creation of good health, and that it fails to recognise the actual and potential impact of social work and social work organisations on health creation.

Leaving care: A threat to health

One brief example serves to underline the point. For most 16- and 17- year-olds, parents are still the main front-line health workers (Brannen et al. 1994). It is parents, mostly mothers, who are usually responsible for young people’s diet, involved in negotiations about smoking and drinking and in detecting and advising about ill health, and who are active participants in arranging medical consultations. However, social work’s record in ‘parenting’ young people who are leaving the care system does not compare well (Action on Aftercare Consortium 1996; Broad 1998). On two main grounds, practice can be identified as damaging to the health prospects of young people. First, care leavers have often been required to move out of their homes and live independently at an age much lower than ‘loving parents’ (DoH 1991a sec.1: 97) would expect. In 1996–7 records show that 3,400 young people left care at 16, while over 20 per cent of those leaving care over the age of 16 were already living ‘independently’ (McClusky and Abrahams 1998). Second, care leavers have commonly been discharged to exceptionally high levels of poverty, unemployment, homelessness or poor accommodation, early pregnancy or parenthood and social isolation (Action on Aftercare Consortium 1996; Save the Children 1995). For example, Broad (1998) found that around half of a large survey of care leavers were in temporary accommodation. These damaging social circumstances have been exacerbated by changes in public policy over the past twenty years which have reduced the employment opportunities and resources available to young people living independently (Broad 1998; Holtermann 1995). Thus care leavers have been expected to achieve independence despite the fact that damaging life experiences, reduced opportunities to acquire social and life skills and attenuated material and social support systems combine to render them more vulnerable than young people who have not been in the care system (Corlyon and McGuire 1997; DoH 1991b and 1991c). These issues are rarely characterised in terms of the threats to health which they pose, but the well-being of young people who have been in care is clearly at risk.

The stresses associated, not only with the reasons for initial entry to care but with what being in care entails – the multiple moves, lack of continuity in relationships, low educational attainment, reduced privacy, poor physical conditions and poverty levels of allowances for food, leisure, travel and holidays commonly experienced by these young people – are surely examples of cumulative environmental insults (Davey Smith 1996) and of the psychological intermediaries which link relative material deprivation with poor health outcomes (Blane et al. 1996; DoH 1991b and 1991c). Moreover, social services’ leaving care programmes have often barely begun to offer protection from the health-damaging material and social conditions commonly faced (Action on Aftercare Consortium 1996; Broad 1998) and, though care leavers are a focus of attention in the National Priorities (DoH 1998b) and Quality Protects (DoH 1998d) documents, targets set do not cover accommodation. The health consequences are manifold and dire. A consistent picture emerges of a high incidence of malnutrition, hypothermia, mental illness, sexual exploitation, susceptibility to physical attack, complications following drug use, serious consequences from otherwise minor infections and higher risk of HIV/AIDS, compounded by difficulties in accessing health care (Anderson et al. 1993; Boulton 1993; Centrepoint 1997; The Big Issue in the North 1997). These conditions also contribute to high death rates (Reuler 1993). This example demonstrates both the relevance of social work to health creation and that social work can be involved in practice which has damaging rather than protective consequences. In doing so it also implies three key features of the social context in which social work contributes to health creation: • the central role played by lay people (adults and children); • the crucial significance of (unequally distributed) social, economic and environmental conditions in supporting or undermining lay health work; and • the relevance of social, economic and environmental policies and institutions, including social work and social work organisations, for health creation. In the remainder of this article we first highlight lay people’s active engagement in creating and maintaining health against the background of unequal social conditions. Second, we discuss the limitations of health promotion policies which focus on individual behaviour and action. Third, we analyse in more detail the changes in policy signalled by the government. Fourth, through some key examples of positive initiatives being taken by local authorities corporately, by voluntary agencies and by self-help activists, we examine how social work can make a positive contribution to more equal chances of securing and maintaining good health.