5 october 2020
At his speech to the Conservative Party Conference, UK chancellor Rishi Sunak spoke of the nation’s ‘sacred responsibility’ to ‘balance the books’, adding that ‘hard choices’ would have to be made. (See our new ebook, ‘Public debt: embracing the new reality’.) Next April, Sunak plans to cut Universal Credit benefit payments back down to the level they were at before being increased because of Covid-19. This move will cost 6 million households £1040 a year. Ten years ago, the Marmot review warned that cutbacks to the welfare state would lead to a chasm in life expectancy between rich and poor. And that’s exactly what happened. (Also read ‘The road beyond Wigan Pier’.)
Even before the arrival of a pandemic to threaten Britain’s health and economy, the UK had lost a decade and the results were showing. Health, as measured by life expectancy, had improved annually for more than a century, but the rate of increase had slowed dramatically, and health inequalities were growing. Bad as the situation was in England, the damage to health in Scotland, Wales and Northern Ireland was even worse.
If health has stopped improving, so has society. Global evidence shows that health is a good measure of social and economic progress. When a society flourishes, so does health; when a society has large social and economic inequalities, it has serious health inequalities.
People’s health is not just about how well the health service is funded and functions, important as that is, but about the conditions in which they are born, grow, live, work and age, and inequities in power, money and resources. Together, these are the social determinants of health.
UK life expectancy had improved since the end of the 19th century, but the rate of increase started slowing dramatically in 2011. In 1981-2010 it increased by about one year every five and a half years among women, and every four years among men. In 2011-18 it slowed to one year every 28 years among women, and every 15 years among men.
I contend that the real causes of the failure of health to improve are social; this is supported by growing inequalities in health according to deprivation and region
This slowing down is real, but the explanations have been disputed. We have considered more prosaic explanations: perhaps we have reached peak life expectancy and it has to slow? Other European countries with longer life expectancies than the UK have continued to increase; we have some way to go before we hit peak expectancy. Perhaps we had bad winters and bad flu outbreaks? Our analyses showed that improvements in mortality slowed in winter and non-winter months. At most, winter could account for between one sixth and one eighth of the slowdown.
Lower life expectancy
I contend the real causes of the failure of health to improve are social; this is supported by the growing inequalities in health according to deprivation and region. The more deprived the area, the lower the life expectancy. In 2016-18 men in the least deprived 10% of England had a life expectancy 9.5 years longer than men in the most deprived; for women the gap was 7.7 years. In 2010-12 the gap was 9.1 years for men and 6.8 years for women. In the most deprived 20% of areas there was no improvement at all for women, in sharp contrast to continued improvement for the most fortunate 20%.
There are well known regional differences in mortality and life expectancy: people in the north of England are sicker. Deprivation and geography come together in important ways. For people in the least deprived 10% of districts, there is little regional difference in life expectancy; it doesn’t much matter where you live, your subgroup will have improved its life expectancy. The more deprived your district, the greater the disadvantage of living in the north compared with London and the southeast.
The social gradient in healthy life expectancy is even steeper: years in poor health increased between 2009-11 and 2015-17, from 15.8 years to 16.2 in men and from 18.7 years to 19.4 years in women. There are no routine figures produced for life expectancy based on race or ethnicity, but those we have suggest half of minority ethnic groups — mostly black, Asian and mixed — have significantly lower disability-free life expectancy than white British men and women.
This damage to the nation’s health need not have happened. After 2008 both the Labour government under Gordon Brown and the Conservative-led coalition were concerned that health inequalities in England were too wide and I was commissioned to review what could be done to reduce them. With colleagues at what became the UCL Institute of Health Equity, I convened nine task groups of more than 80 experts to review the evidence and assembled a commission to deliberate on it.
The result was the Marmot review, Fair Society, Healthy Lives, published in 2010 (1). Though commissioned by the Labour party, it was welcomed by the Conservative-Liberal Democrat coalition government in a public health white paper.
The poor get poorer
A report by the Royal Society for Public Health, based on a survey that asked experts and its members their views, classed it as a major 21st-century UK public health achievement, along with the ban on public smoking and the soft drinks industry levy. However, its central recommendation that ambitious public policies, targeting all age groups, could act on the social determinants of health to reduce inequalities was largely ignored.
The governments elected in Britain in 2010 and 2015 made austerity central to policy. Public expenditure was cut from 42% of GNP in 2009-10 to 35% in 2018-19, to restore the economy to growth by restricting public expenditure. By one measure, at least, it didn’t work: wage growth. International comparisons of this between 2007 and 2018 show that Britain, with minus 2%, was the third worst, above only Greece and Mexico, of 35 rich (OECD) countries.
This damage to the nation's health need not have happened. After 2008, both the Labour government under Gordon Brown and the Conservative-led coalition were concerned that health inequalities in England were too wide and I was commissioned to review what could be done to reduce them
The governments would probably have denied that the real purpose was to make the poor poorer and allow the top 1% to resume the trajectory, briefly interrupted by the global financial crisis, of garnering wealth. But that was the effect. Spending on family welfare was cut by 40%; local government expenditure by 31% for the most deprived 20%, compared with 16% for the least deprived 20%; and funding for sixth-form and further education by 12% per pupil (2).
If the architects of these policies imagined all that money had been wasted hitherto, the evidence indicates they were wrong. Our new report, Health Equity in England: the Marmot Review 10 Years On (3), examines impacts in five of the six areas of recommendations we made in 2010: give every child the best start in life; ensure access to education and lifelong learning; improve employment and working conditions; ensure people have enough money to lead a healthy life; promote sustainable places and communities. We show that austerity has taken a toll on almost all social determinants of health, worsening inequalities.
Yet we know early childhood is a crucial life stage, not just for health but for development — cognitive, linguistic, social, emotional, and behavioural. Good early child development predicts good school performance, which predicts better educational and occupational opportunities and living conditions in adulthood.
The signs are not good
The signs are not good. As a result of cuts to local government spending, 1,000 children’s centres involved in Sure Start (a government programme to support pre-school children and parents) are estimated to have had to close. The welcome support for childcare for older pre-school children does not make up for this.
A much-used measure of child poverty is how many children live in households with less than 60% of the median income. In 2009-12 the figure was 18%, rising to 20% in 2015-18. The cost of housing can drive people into poverty, and after housing costs are taken into account, the figure rose from 28% in 2009-12 to 31% in 2015-18.
The housing crisis has led to a rise in homelessness and increased costs: the proportion of people spending more than a third of their income on housing follows the social gradient, but has risen in all income groups. In the lowest 10% of income in 2016-7, 38% of families were spending more than a third of income on housing: the figure had been 28% a decade earlier.
More people do not have enough money and now resort to food banks. There are more left-behind communities living in poor conditions with little reason for hope of improvement.
All these factors are interrelated, so it is hard to say which affect health inequalities most. In 2010 we wrote, ‘Health inequalities are not inevitable and can be significantly reduced. They stem from avoidable inequalities in society.’ That hasn’t changed.
Michael Marmot
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