Johnson’s bigger crime is failing to take the nation’s health seriously enough

The ideal of living longer and healthier has proved to be fool’s gold. Instead, people are living for longer but with chronic disease and a poor quality of life. The unwellness industry in older age is doing a roaring trade. Wellbeing and quality of life are also important considerations for young people with chronic disease, such as diabetes, who may be reluctant to engage with services (doi:10.1136/bmj.o750).1 And the services they need should include psychological and behavioural interventions to support emotional wellbeing and mental health (doi:10.1136/bmj-2022-070530).2

A new study offers some hope in older age. K Dhana and colleagues looked at the effect of lifestyle factors on life expectancy lived with and without Alzheimer’s dementia and found a longer life expectancy and about a 50% decrease in life years lived with Alzheimer’s disease in people older than 65 years (doi:10.1136/bmj-2021-068390).3 People who exercise enough, have cognitive engagement, eat a healthy diet, are non-smokers, and consume low amounts of alcohol live longer and for more years without Alzheimer’s disease (doi:10.1136/bmj.o885).4

The upper limit of life expectancy has changed little in 1000 years, with improvements in maternal and child health the greatest contributions to increases in average life expectancy. Compression of morbidity, a hypothesis proposed by James Fries in 1980 (doi:10.1111/j.1468-0009.2005.00401.x),5 suggests that the proportion of healthy life years can be increased, leaving a shorter period of ill health before death. The hypothesis may be sound enough and is well argued, but making it a reality has proved difficult.

The importance of prevention is also a bitter truth for governments and health systems that continue to ignore systemwide measures, such as “availability interventions” for food and drink (doi:10.1136/bmj-2021-069848),6 but are quick to acclaim and promote treatments for which evidence is mixed (doi:10.1136/bmj.o926).7 Deterioration in baseline population health, notably in countries that persisted with economic austerity measures, is one reason for the excessive demand now placed on hospital services (doi:10.1136/bmj.o950).8 That excessive demand contributes to the perception that health services are more inefficient than they are (doi:10.1136/bmj.o929).9

But providing a health service with enough resources to meet demand is a delicate balance between rationing, taxation, and collaboration. Matt Morgan condemns the British deceit that rations without honesty, taxes without equality, and collaborates without transparency (doi:10.1136/bmj.o928).10 It’s the same mindset that sells a tax rise as ringfenced funding for health and social care when government health funding will remain static and any visible effects of the ringfenced funding will be hard to establish (doi:10.1136/bmj.o948).11 Or the logic that leaves doctors unable to order a diagnostic test for covid (doi:10.1136/bmj.o951, doi:10.1136/bmj.o900).1213

If there is such a thing as “British deceit,” it starts at the top and leads to a breakdown in trust. Prime Minister Boris Johnson showed his disdain for public trust when he refused to sack Dominic Cummings for a trip in 2020 that broke covid restrictions. He further showed his disregard for proper conduct by allowing billions of pounds of public funds to be siphoned to political allies and associates of ministers without sanction or remorse. He has answered calls for accountability for the more than 100 000 excess deaths during the pandemic with fantastical claims about the UK’s world beating covid response. We still await a public inquiry.

Now, Johnson is the first prime minister to be fined by police for breaking the law in office. Why is this relevant to The BMJ? It is relevant because the law related to an important aspect of the pandemic response. It was a time when staff and families were under immense pressure to abide by the law to protect the NHS and save lives. Staff workload and stress grew beyond breaking point to meet covid restrictions. Bereaved families will be haunted forever that, to abide by laws, they had to allow loved ones to suffer and die alone. The point here isn’t that the laws were necessarily wrong; indeed, the population embraced them. Meanwhile, Johnson and his ruling cabal flaunted them at will. They behaved as if they were above the law and took the lives of their citizens for granted. There is a view that, if Johnson goes, whoever follows will only be worse for health and wellbeing. But that isn’t a basis for leading a country. Public trust is a basis for leading a country, and whoever follows must rebuild it.

When the UK’s prime minister, his wife, and his finance minister are fined for breach of covid regulations, it takes only a tiny leap of imagination to conclude that this government doesn’t take the nation’s health seriously enough. In these circumstances, Fries’s commendable hypothesis about compression of morbidity is still some way from being realised and would be served better by leaders who understand the virtue of leading by example.