Institute of Health Equity - Michael Marmot

Foreward from Marmot Review 10 Years On

England is faltering. From the beginning of the 20th century, England experienced continuous improvements in life expectancy but from 2011 these improvements slowed dramatically, almost grinding to a halt. For part of the decade 2010-2020 life expectancy actually fell in the most deprived communities outside London for women and in some regions for men. For men and women everywhere the time spent in poor health is increasing.

This is shocking. In the United Kingdom, as in other countries, we are used to life expectancy and health improving year on year. It is what we have come to expect. The UK has been seen as a world leader in identifying and addressing health inequalities but something dramatic is happening. This report is concerned with England, but in Scotland, Wales and Northern Ireland the damage to health and wellbeing is similarly nearly unprecedented.

Put simply, if health has stopped improving it is a sign that society has stopped improving. Evidence from around the world shows that health is a good measure of social and economic progress. When a society is flourishing health tends to flourish. When a society has large social and economic inequalities there are large inequalities in health. The health of the population is not just a matter of how well the health service is funded and functions, important as that is: health is closely linked to the conditions in which people are born, grow, live, work and age and inequities in power, money and resources – the social determinants of health.

The damage to the nation’s health need not have happened.

When, in 2015–16, statistics from the Office for National Statistics and Public Health England first showed that the increase in life expectancy had nearly ground to a halt, we at the UCL Institute of Health Equity were cautious, in the usual academic fashion. We were reluctant to attribute the slowdown in health improvement to years of austerity because of difficulty in establishing cause and effect – we cannot repeat years without austerity just to test a hypothesis. The fact that austerity was followed by failure of health to improve and widening health inequalities does not prove that the one caused the other. That said, the link is entirely plausible, given what has happened to the determinants of health.

The evidence we compile in this ‘ten years on’ report, commissioned by the Health Foundation, explores what has happened since the Marmot Review of 2010. Austerity has taken its toll in all the domains set out in the Marmot Review. From rising child poverty and the closure of children’s centres, to declines in education funding, an increase in precarious work and zero hours contracts, to a housing affordability crisis and a rise in homelessness, to people with insufficient money to lead a healthy life and resorting to foodbanks in large numbers, to ignored communities with poor conditions and little reason for hope. And these outcomes, on the whole, are even worse for minority ethnic population groups and people with disabilities (1). We cannot say with certainty which of these adverse trends might be responsible for the worsening health picture in England. Some, such as the increase in child poverty, will mostly show their effects in the long term. We can say, though, that austerity has adversely affected the social determinants that impact on health in the short, medium and long term. Austerity will cast a long shadow over the lives of the children born and growing up under its effects.

Given the strength of evidence on social determinants and health inequalities, it is not an act of hubris to speculate that had the Government acted on all the recommendations in the Marmot Review, health would have continued to improve and health inequalities not have grown larger (2). Certainly, a report we subsequently prepared in 2012 warned of the risks to health from austerity policies.

We endorse today what we wrote in the Marmot Review 10 years ago:

Health inequalities are not inevitable and can be significantly reduced… avoidable health inequalities are unfair and putting them right is a matter of social justice. There will be those who say that our recommendations cannot be afforded, particularly in the current economic climate. We say that it is inaction that cannot be afforded, for the human and economic costs are too high (3).

In this ‘10 years on’ report, we rely on updated evidence but we use the same framework of analysis as the 2010 Marmot Review. In support of that judgement, we cite the Royal Society for Public Health, which surveyed its members and a panel of experts on their views on the major UK public health achievements of the 21st century to date (4). The top three were the smoking ban, the sugar levy and the 2010 Marmot Review. We cite this as an indicator that the public health community judges that we got the evidence, approach and proposals broadly right. This review, therefore, looks at what has happened, or is new, in five of the six domains that we judged to be crucial for improvement of health and reduction of health inequalities, and makes recommendations for what needs to be done now (4).

Globally, actions to address inequalities have moved on since 2010. We are reporting in the era of the UN Sustainable Development Goals, or SDGs. At least 11 of the 17 SDGs can be seen as key social determinants of health. The twin problems of social inequalities and climate change have to be tackled at the same time. Addressing each is vital to creating a society that is just, and sustainable for the current and future generations. New Zealand has shown the way a government can reorder national policies. The government there has put wellbeing, not growth, at the heart of its economic policy: enabling people to have the capabilities they need to lead lives of purpose, balance and meaning.

The question we should ask is not, can we afford better health for the population of England, but what kind of society do we want? The recommendations we made 10 years ago, and those that we make here, will create conditions for all members of society to lead flourishing lives, to achieve their full potential, and to enjoy levels of good health currently experienced by people who live in the most advantaged circumstances. Every society will have some level of economic and social inequalities. What we can envisage, and work towards, is a society that creates the conditions for everyone to be able to lead lives they have reason to value (5). That we do not have such a society at the moment is shown by the slowdown in life expectancy improvement, deteriorations in physical and mental health and widening health inequalities.

Michael Marmot (Chair)