"Levelling up health is the most important levelling up of all": so says he at the TOP of Government
Post by Jonathan Wistow
On 25th February Professor Sir Michael Marmot and his team at the Institute of Health Equity produced a detailed follow up to the 2010 Marmot Review. For those that read the original review (and there are many people out there who have done so) it will make for depressingly predictable reading. Of Marmot’s many major contributions focusing academic and policy debates on a social gradient in health, significantly advancing the Social Determinant’s of Health (SDH) perspective, and advocating for ‘proportionate universalism’ in responding to health inequalities standout. He has also argued long and passionately for us to consider health inequalities as a measure or indicator of the nature of the societies in which we live, as a form of litmus test for how we are doing at an aggregate level. Most recently, in the forward to Health equity in England: The Marmot Review 10 years on, Marmot states:
"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."
In the ten years since the Marmot Review the position has worsened with both life expectancy and healthy life expectancy gaps growing between income deciles and places. The 2020 report demonstrates that the life expectancy gap between the top and bottom income deciles is now 9.5 years for men and 7.7 years for women with the most deprived expected to spend about twice the proportion of their shorter lives in ill health. The 2020 reports moves on to argue that "since 2010 national political leadership on reducing inequalities in health and the social determinants has been weak" and that there has been a failure of government policy and a failure to challenge economic inequalities and market failure.
In his response to the report Matt Hancock, the Secretary of State for Health and Social Care said:
“I thank Professor Sir Michael Marmot for his dedicated work to shine a light on this vital issue. His findings show just how important this agenda is, and renew my determination to level up health life expectancy across our country. After all, levelling up health is the most important levelling up of all."
Whilst I would like to agree with him that it is the most important issue in society, using the new rhetoric around levelling up suggests a profound misunderstanding about the nature of society and social inequalities. We can certainly try to improve places and social outcomes but to do so by concentrating on levelling up we tend to assume that the level (whatever that is!) is static.
Health inequalities provide a particularly intractable example of levelling up. After all, under New Labour (which had a targeted programme to tackle health inequalities and made big increases in public expenditure) health inequalities grew in terms of overall life expectancy (the differences between the least and most deprived area quintiles in 2001 were 7.4 years for men and 5.0 years for women, increasing to 7.5 and 5.4 years, respectively, in 2010). The New Labour governments did have major successes in modernising and improving access to health services and also met its target to narrow inequalities in infant mortality rates. However, narrowing gaps in life expectancy proved too challenging to achieve. There are plenty of reasons for this but a key one framing these is the nature of the target itself. It is moving and dynamic. For the gap to narrow, those with the worst outcomes need to improve at a greater rate than those at the top are improving. The context in which this improvement has to take place is one shaped by a market economy geared towards competitive individualism. Life expectancy (as opposed to infant mortality) takes place across the whole life course, cutting across the social determinants of health whilst people are competing for things like higher education places, jobs and status. Our lives are influenced by the social determinants in persistent and complex ways and we are provided with differential and socially structured access to opportunities and services across these.
One of the headline findings about life expectancy relates to the decline in female life expectancy of women in the bottom income decile. It is indeed shocking that this can happen in a country as rich as the UK. However, it is also important to acknowledge that women still live on average about five years longer than men in the most deprived decile. Another way of reporting this finding then might be as a ‘levelling up’ of health for the most deprived men relative to the most deprived women in terms of health inequalities between genders! Whilst this might be deliberately provocative way of presenting the data it does draw attention to the enhanced potential to close inequality gaps if those that are doing better reverse their performance. So, do we need to start thinking about levelling down, or at least curtailing the progress, of those at the top of society? How can those with less resource and less incentive to live sufficiently healthy lives catch up with those with more resource and living in less stressful communities with more opportunities? Taxation and redistribution need to be part of the agenda of levelling up alongside massive investment in deprived (and largely post-industrial) places. However, this does not appear to be sufficiently popular with either politicians or enough of the public.
Finally, whilst the 2020 report cites some significant evidence about the decline in public health expenditure and about strategic priorities to develop prevention not being matched with funding, it is possible to argue that the authors pull their punches around the role of the NHS and DH (especially in terms of headline findings and recommendations). For example, one of the quotes above criticises national political leadership and is followed by the following text:
"At this stage, and with abundant evidence and experience about what to do and how to do it, PHE, NHS England and the Department for Health and Social Care have significant opportunities to further lead and influence action on the social determinants and become world leaders in this area."
But the question that occurs to me is why haven’t they done this sufficiently already? Are the leadership of these organisations as culpable as national political leaders? Are these institutions all equal players in health systems? Does power, status, resourcing of these bodies have a role to play in terms of how we frame, respond to and resource health inequalities? The 2020 Marmot report refers to the limited role the NHS can have in narrowing health inequalities, in line with a focus on social determinants of health. However, given HM Treasury data for the 2020 financial year expects £158.7bn will be spent on health care and only £6.4bn of this on public health we might want to consider the role of the NHS and medicine in hoovering up a large slice of the public spending pie. The 2020 report alludes to this in terms of seeking to engage the public more in health inequalities and moving public understanding away from free health care and individual behaviours to the social determinants of health. However, is this enough in terms of levelling up health inequalities, do we need to develop an evidence-base that explores moving spending away from health/medical/treatment services, in order to increase spending in the areas the two Marmot Reviews identify?
Jonathan Wistow is an Assistant Professor in the Department of Sociology at Durham University