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A decade on from Marmot, why are health inequalities widening?

BMJ 2019; 365 doi: (Published 17 June 2019) Cite this as: BMJ 2019;365:l4251
  1. Elisabeth Mahase
  1. The BMJ

Experts give a taste of current findings ahead of next year’s update of the 2010 review. Elisabeth Mahase reports

Experts in public health have warned that inequalities in health have worsened since Michael Marmot’s landmark review was published in 2010,1 and they call for major policy reforms to tackle growing disparities in life expectancy in the UK.

Figures published in March by the Office for National Statistics show that the gap between rich and poor people in life expectancy and healthy life expectancy is increasing in England.2

Against this troubling backdrop, a 10 year update to the Marmot review will report next February to provide an update on the existence and effectiveness of national and local policies to tackle the social determinants of ill health and to examine what societal trends have affected health inequalities.

Speaking at the Westminster Health Forum in London on Tuesday 11 June, the Health Foundation’s Tim Elwell-Sutton, who has been working closely on the Marmot update with the Institute of Health Equity at University College London, gave a preview of some of the trends the group had observed.

“It’s not just that the worst-off groups are not increasing [in life expectancy] as fast as the better-off groups; life expectancy is actually going down in the most deprived groups,” he warned. “That’s a new phenomenon. In fact, in Scotland and Wales as a whole life expectancy has declined. There’s something different going on. This is not the norm.”

“Shocking” disparity

Elwell-Sutton emphasised that it was not just about people living longer but living in good health. He pointed to the latest statistics, which show that healthy life expectancy in the most deprived decile of women and men is now 52 years.

“That’s shocking. It’s shocking for the individuals if you think about the impact that has on them. It’s shocking for the families involved, for the communities involved, but also for us as a society and for our economy. That is a massive lost opportunity,” he said.

He added, “We need to understand that health is one of our most important national assets.”

The Marmot review update is also looking at new trends and evidence in connections between work and health, Elwell-Sutton said.

He said it was no longer obvious that having a job was better than not having one, with some evidence showing that having a poor quality job might not actually be better for a person’s health than being unemployed. This was being driven by changes in technology, in the way people were paid, and types of contracts, he said.

He continued, “The other theme that’s come through as we’ve been speaking to people and reviewing the literature is that the relationship between work and poverty has changed.

“We used to assume that poverty was largely a function of people not having work or enough work, but actually a huge amount of poverty now is in working households, and we are seeing an increasing number of children growing up in families that are below the poverty line. It’s roughly 30% of children that are in poverty, and the projections are for that to increase rather than decrease.”

Budgets slashed

The effect on health equality of the government’s cuts to public health budgets should not be ignored, experts say.

A joint analysis on 12 June by the Health Foundation and the King’s Fund estimated that by 2021 public health budgets will have been slashed by around 25% per head in real terms since 2015-16.3

In a statement, Siva Anandaciva, chief analyst at the King’s Fund, said that the continuing cuts were not only shortsighted but “at odds with the government stated mantra that ‘prevention is better than cure.’

“While local authorities have tried to make do by introducing efficiencies like offering online services, the budget squeeze is now taking its toll, with latest figures showing rising incidence of some sexually transmitted infections such as syphilis. By not taking action, the government is simply delaying decisions and storing up problems for the future.”

Elwell-Sutton told the Westminster forum he thought it was important to start “rebalancing public expenditure and public investment” towards things that keep people healthy and “stop pouring money into the services that are mopping up problems which are preventable.”

As an example, he pointed to New Zealand, where the government has decided to use wellbeing instead of GDP to measure national success.

“That’s one of their main measures of success,” he said, “and that work is being driven by the Treasury, really at the heart of government. They have said, ‘Actually, we’re going to take a different approach to what “good” looks like.’ I think that’s a model we should really consider seriously.”

He also highlighted work being done in Wales, which has made it mandatory for government decision making to have to account for the impact on future generations. “There’s a role for governments in creating the conditions which allow community led initiatives to flourish,” he explained.

He added that the NHS had an important role in such a culture shift, as an “anchor institution” and one of the biggest employers in the country.

“The way the NHS treats its staff has a very direct impact on the wellbeing of a large section of the population. In many areas the NHS is one of the biggest employers in the community, and it has a massive impact on the community around it, not only in terms of who it employs but the built environment, the green spaces, and other climate effects as well,” he said.