19 July 2017
There is cause for alarm. Something has happened to slow health improvement in the UK. It is entirely reasonable to think that health just gets better and better. Indeed, over the last century, in the UK, life expectancy showed a steady increase: about 1 year every 3.5 years in men; about 1 year every 5 years in women. As you think about it, such improvement is quite remarkable: every 24 hours male life expectancy increased nearly 7 hours. Since 2010, this rate of increase has halved. Indeed, the increase has more or less ground to a halt.
What’s going on? The first thing to say is that we have not reached peak life expectancy. A levelling off is not inevitable. In the Nordic countries, in Japan, in Hong Kong, life expectancy is greater than ours and continues to increase. There must, inevitably, come a point where levelling off occurs, but we are not there yet
In considering reasons for this stalling, there is another part of the picture that claims attention: inequality. Since we published Fair Society Healthy Lives, the Marmot Review, in 2010 we have been monitoring health inequalities and their social determinants. In our July 2017 publication, we showed the longest life expectancy in the country was in the richest borough, Kensington and Chelsea: 83 for men and 86 for women. By contrast, the lowest life expectancy was in the North: Blackpool, 74 for men; Manchester, 79 for women.
Even more dramatic than these regional inequalities are the inequalities within local areas. In Kensington and Chelsea, life expectancy was 14 years shorter among the most disadvantaged compared to the best off. Alarming, but perhaps not surprising. Kensington and Chelsea may be the richest local area in the country, it is also the most unequal economically. The average salary in Kensington and Chelsea is £123,000. But the median is £32,700; i.e half the earners have £32,700 or less. There are some very high earners in the borough. Parenthetically, no prize for guessing correctly that Grenfell Tower, the tower block that went up in flames, is in the poor part of the borough.
In the Marmot Review, we identified six domains that cause health inequalities and where action is required to reduce them: early child development, education, employment and working conditions, minimum income for healthy living, healthy and sustainable places to live and work, and taking a social determinants approach to prevention.
Each of these raises cause for concern. To illustrate, our fourth recommendation was that in a rich country such as Britain everyone should have at least the minimum income necessary for a healthy life. The Joseph Rowntree Foundation monitors the minimum income standard – akin to our minimum income for healthy living. In 2008/9 about 25% of people lived in households with incomes below the minimum income standard. By 2014/15 this had risen to 30%. Not just the very poor, but the just about managing simply do not have sufficient income to lead a healthy life.
Inequalities in these social determinants provide potential explanations for a slowing of improvement. It is worth, though, thinking about the elderly, specifically.
The majority of deaths occur after age 75. Here, as well as effects from earlier in life, it is possible that spending on social care and health care could have much more immediate effects. Spending on adult social care has been reduced by more than 6%, since 2009/10 at a time when the population aged 65 and over increased by a sixth. Given that we show a big increase in deaths with dementia written on the certificate, and given the growth in the number of people aged 85+, there will be an increase in the need for social care. With cuts in funding, it is likely that there are unmet needs.
Similarly, funding of the NHS, which historically increased at about 3.8% a year since the late ‘70s, has, since 2010 been increasing at about 1.1%. And the spending per person is projected to go down.
It is tempting to link policies of austerity since 2010 to the slowing in increase in life expectancy since 2010. So far, I have resisted that temptation. What I would conclude, though, is that less generous spending on social care and health will have adverse impacts on quality of life of the elderly. It is urgent to determine whether austerity also shortens lives.
Professor Sir Michael Marmot is Director of the UCL Institute of Health Equity www.instituteofhealthequity.org and author of The Health Gap: The Challenge of an Unequal World