Intended for healthcare professionals


A return to austerity will further damage the public’s health

BMJ 2022; 379 doi: (Published 18 October 2022) Cite this as: BMJ 2022;379:o2507
  1. Michael Marmot, professor and director
  1. Institute of Health Equity, UCL

Brutal public spending cuts will lead to increases in health inequalities, writes Michael Marmot

UK government policy has changed at such dizzying speed that any comment or prediction is likely to be out of date by the time it was written, let alone published. What follows was initially written ahead of the new chancellor, Jeremy Hunt, making an announcement on the budget on 17 October. By the weekend, the conclusions of the market that unfunded tax cuts, and large increases in government debt, were no recipe for economic growth—actually, were dangerous mismanagement of the economy—were so dramatic that the Truss government’s fiscal policy was largely jettisoned. What we were promised instead from Jeremy Hunt was not a new recognition of equity of health and wellbeing, but a return to austerity. If that means a return to the brutal cuts in public spending and increases in inequality of the Cameron/Osborne government we can expect further damage to the public’s health, increases in health inequalities, and an NHS left in an even more parlous state.

Along with the chaos, there was more than a whiff of nostalgia about the approach to government of the UK’s prime minister, Liz Truss. We were back in the 1980s. Reagan-style “supply side” reforms were thoroughly debunked then, as was the odd idea, the Laffer curve, that lowering the tax rate increased government’s tax receipts through economic growth. Thatcherite commitment to neoliberalism—free markets and a small state—may have revolutionised the City of London, deindustrialised the rest of the country, and sold off public services to goodness knows who, but inequalities increased. A more enlightened idea, that economic policy should be oriented to wellbeing, and saving the planet, rather than to growth of GDP, was nowhere to be seen. ( Consistent with this commitment to old-fashioned debates is the rumour that a health disparities white paper, promised for Spring 2022, will not appear. It seems that the government would rather trust its libertarian instincts than plan public health policy on the basis of evidence, such as a sugar tax to combat obesity, or other interventions to encourage health behaviours.1

Such libertarian antipathy to “nannying” is entirely predictable, albeit silly, but reduction of health inequalities requires more than changes in health behaviours. It needs a commitment by the whole of government to address social conditions that lead to the unfair distribution of health—health inequalities. Such commitment is so far not in evidence from Liz Truss and has been sorely lacking in the UK national government for the last 12 years. When David Cameron was UK prime minister, a public health white paper recognised the importance of health inequalities and the wider determinants of health but, with austerity the priority, the government pursued policies that, predictably, made things worse.2 Theresa May, as prime minister, declared that health inequality was a burning injustice and expressed sympathy for the “just about managing” but her premiership was eaten up by Brexit. Under prime minister Boris Johnson, the main initiative was to change the language from inequalities to disparities—a doubtful contribution to the nation’s health. The Levelling Up White Paper certainly had the possibility to address the socioeconomic causes of health inequity, but the scale of investment has been tiny, compared to the need.3

An important debate about causation notwithstanding, it is likely that the effect of this neglect, since 2010, was a marked slowing of improvement in life expectancy, an increase in social and regional health inequalities and, chillingly, a fall in life expectancy for the most deprived 10% of the population.2 The sheer brutality of a decade of austerity was “justified” by the government to get the public finances in order—as if that somehow justified poor people dying before their time.4 What we are potentially facing now—hard to predict because of the frequency of government U turns—is more brutality of cuts in public spending, but with the public finances in complete disarray.

Whether or not the government produces a “disparities” white paper, at the very least we would want two kinds of things from government: that their plans be likely to work; and that they be devoted to the common good. From my point of view the common good includes greater equity of health and wellbeing and living in a sustainable way. Neither looks likely.

Firstly, as we have seen, Truss’ policy objectives are unlikely to succeed in their own terms. Tax cuts do not lead to growth in GDP. It is what Paul Krugman calls zombie economics.5 The markets don’t believe it either. The PM’s idea of enlarging the pie to help everybody by making rich people richer has also been discredited. The IMF, previously a bastion of neoliberalism, in a 2015 research report surveying rich countries and emerging markets, concluded that the way to economic growth is to expand the incomes of the poorest 60% of the population. There is a negative relation between expanding incomes of the richest 20% and economic growth.6 Making the rich richer does just that—it does not trickle down.

Second, it is not fanciful to assert that the political complexion of the government really can change health equity. We know that health inequalities narrowed during the New Labour period, compared to what came before or after.7 In the US, counties that tend to vote for the Democrats in elections have better health, fewer deaths of despair, than counties that who vote for the Republicans. Such comparisons may be telling us more about the characteristics of voters than the quality of governance. Looking at trends in mortality is more informative. Counties that voted for the Democrats in Presidential elections from 2000 to 2016, had greater declines in mortality than those that voted for the Republicans.8 What Americans call “liberal” policies are good for health.9

In the end, it is not the presence or absence of a disparities white paper that should concern us. More worrying is a government, fixated on growth in GDP, with apparent complete lack of concern either for the health of the planet or for a fair distribution of health and wellbeing in the population.


  • Competing interests: none declared

  • Provenance and peer review: commissioned, not peer reviewed.