From one health crisis to another?
A new report on health equity has stark implications for UK policy – particularly taking into account COVID-19, says Chris Seekings
The COVID-19 pandemic has brought health inequality into sharp focus, with the wealthiest among us seemingly able to access testing and treatment more easily than those from poorer backgrounds.
The UK went into lockdown less than a month after the UCL Institute of Health Equity published an analysis of how inequality has evolved during the past decade entitled, Health Equity in England: The Marmot Review 10 Years On (Marmot+10). This concluded that life expectancy has fallen among the poorest in society while increasing in affluent areas. This comes 10 years after the publication of Fair Society, Healthy Lives (The Marmot Review), which found that, the lower a person’s social position, the worse his or her health was.
The latest analysis shows that these inequalities have widened and points to austerity measures as a contributing factor. It links declines in public spending to rising child poverty, falling education funding, an increase in homelessness, and various other health-related impacts, hitting minority ethnic groups and people with disabilities particularly hard. This is the legacy of the 2008 financial crash, and the Institute for Fiscal Studies has said that hundreds of thousands of people may develop chronic health conditions or mental health problems in the coming years as a result of a COVID-19 recession.
As well as threatening global climate goals and sustainable development, the economic and social response to coronavirus has the potential to exacerbate health inequalities and instigate a breakdown in social cohesion. Although the immediate effects of the coronavirus lockdown will eventually pass, questions around the equity and sustainability of healthcare provision are only likely to intensify, and the solutions on offer could deliver vastly different outcomes.
I asked three experts to give their take on Marmot+10, and to suggest how we can avoid simply moving from one health crisis into another.
Inequalities in health: What we know, what we need to do
Dr Jessica Allen
Deputy director, UCL Institute of Health Equity
“COVID-19 will cause inequalities to worsen”
Marmot+10 found deteriorations in health and health equity in England, particularly in poorer communities and areas outside London and the South.
Since 2010, life expectancy improvements in England have stalled – something that has not happened since 1900. Health inequalities have increased, and for poorer women, life expectancy actually fell in 2010-12 and 2016-18. There are marked regional differences; the largest decreases were seen in the North East’s most deprived neighbourhoods, and the largest increases in London’s least deprived neighbourhoods. It is likely that social and economic conditions have undermined health, and these will almost certainly widen as a result of COVID-19.
The report assessed how policies, particularly austerity, have likely driven these deteriorations. It makes recommendations in several health equity domains – early years, education, working conditions and employment, income, welfare systems, and housing and communities – reversing cuts and making proportionately greater investments down the social gradient, as well as in the North and Midlands and ignored communities across England. It proposes government develop a health inequality strategy involving a cross-department cabinet-level group. This will become more critical as COVID-19 causes inequalities to worsen.
Head of lifestyle economics, Institute of Economic Affairs
“Life expectancy is closely linked to GDP”
Life expectancy rose between 2010 and 2018, from 78.4 to 79.3 years for men and from 82.4 to 82.9 years for women. Just a week after Marmot+10 was published, the Office for National Statistics released provisional figures showing a further rise of four months between 2018 and 2019.
The picture is, therefore, less bleak than has been portrayed. Three claims seem to be true: there was a slowdown in life expectancy growth during the 2010s, it was more marked in the UK than in many other countries, and it was greater among low-income groups. Marmot suggested spending cuts were partially responsible, although he made this case more forcefully to the press than in his report, which offered little evidence.
It is difficult to imagine what kind of evidence could prove the hypothesis. It is plausible that inadequate funding of health and social care could cost lives, but it is equally plausible that sluggish economic growth following the recession was responsible: it is well established that life expectancy is closely linked to GDP.
We should be most concerned about unequal healthcare access. GPs in the poorest areas are responsible for 370 more patients than those in the richest areas, according to the Health Foundation, and GP numbers have fallen 50% faster in poorer areas in recent years. This cannot be blamed solely on NHS spending, which has risen.
Senior fellow covering public health and health inequalities, The King’s Fund
“We need a pan-government approach”
Marmot+10 marshals evidence across five of the original review’s themes: the best start in life; maximising capability and control over our lives; fair employment and good work; a healthy standard of living; and healthy and sustainable places and communities. There is more judgment than in the first review (particularly on spending cuts in deprived areas). It is stronger on the role of local and regional policies and ‘place’, and on poverty and ethnicity. It calls for a cross-government health inequalities strategy, and specific actions.
Marmot+10 was preceded by the All-Party Parliamentary Group on Longevity’s report The Health of the Nation. The emphasis of this is more
on what the government must do to meet its Ageing Society Grand Challenge: increasing healthy life expectancy by five years by 2035 while narrowing inequalities. It recommends a pan-government approach, action on health behaviours, tripled NHS spend on prevention, a stronger role for business, support for ‘left behind places’, and a social movement for health.
These reports will be even more important as we recover and learn from COVID-19. Which groups suffered more than others? Why? How we can ensure inequalities don’t widen further? This relates as much to the economic impacts as to direct consequences of the virus.