There can be no more important task than to reduce health inequalities The Marmot Review 10 Years On

It’s a globalised world. In November 2018, I was sitting at a meeting in Hong Kong when the BBC World Service called from London. The news that day was that life expectancy in the US had declined for a third straight year. What was the significance? 

Not given to hyperbole, I said simply that this was a health crisis. Health is supposed to be improving all the time. Something is going badly wrong. As it is in the UK. Since the end of the First World War, life expectancy in England and Wales increased about 1 year every 4 years – about 23 years in 90 years. In 2010 that welcome improvement began to slow dramatically. By 2017 it had ground to a halt in England and life expectancy had actually declined in Scotland, in Wales, and among men in Northern Ireland. Again, a crisis. Other European countries continue to get healthier. We are not. Something is going badly wrong with health and with the social conditions which shape our health. 

Part of the reason for the slowdown is an increase in inequalities in health. Public Health England publishes trends in life expectancy by place of residence, with local areas classified by degree of deprivation. The stalling and then falling off of life expectancy is seen at the bottom – most deprived – not at the top. Inequalities are getting bigger; the gradient in life expectancy is getting steeper.

It was to address inequalities in health such as these that I was invited by the government in England to conduct the Marmot Review, which we published in 2010 as Fair Society Healthy Lives. It was our view that we understood a great deal about the causes of health inequalities, and where to intervene. We identified six domains for action:

• early child development
• education and life-long learning
• employment and working conditions
• minimum income needed for health living
• healthy and sustainable environments in which to live and work
• a social determinants approach to prevention – addressing the causes of the causes.

In 2010, the Coalition government in the UK issued a Public Health White Paper with reduction of health inequalities at its heart. The White Paper stated that this reduction would not be achieved through the health care system alone, and called for action on the wider determinants of health – social determinants in my language. Moving public health back into local government seemed like a threat to some, but it was an opportunity for cross-government working at city and local level. While we want central government policies to address the six domains of recommendations, local government action is also vital.

Since then, however, the context for action on the social determinants of health in England has been difficult. The government’s stated priority has been fiscal rectitude – austerity. It may be predicted that cuts in funding to local government, schools and social care, as well as an unfavourable climate for benefits, will take their toll on health and health inequalities. The failure of NHS funding to rise in accord with historical trends won’t help.

To review what has happened since the 2010 publication of the Marmot Review, my colleagues and I at the UCL Institute of Health Equity are working with the Health Foundation to conduct the Marmot Review Ten Years On, to be published in February 2020. 

Certainly, the sheer scale of health inequalities demands attention. Recent analysis by the Health Foundation asks the interesting question: what if everyone in England could have the same life expectancy as the people living in areas in the top 10% socioeconomically. It suggests, reasonably, that if we aimed for everyone to have the same good health as the people at the top, there would be 2.6 million life years added to the lives of people born in 2015. For the most deprived 10% of people, that’s an extra 8.4 years of life per person (on average). Across the entire population, it would be an overall average of 4.0 extra years per person.
 
Is 4.0 years a lot? It would take us from where we are now with national life expectancy – OK among rich countries but not stellar – past France, Sweden and Iceland, up to the summit above Japan and Hong Kong.
 
The Health Foundation analysis has two more important messages. First, the years of life lost to inequalities is increasing. Second, we need to look at the whole gradient. Of all the potential years of life lost due to inequality, half (49%) come from the most deprived fifth of the population. Yet, a quarter (25%) of the years of life years lost come from people in middle socioeconomic deciles (fourth to sixth). We need interventions that improve inequalities across the whole of society, not only for the worst off.

As stated, the urgency for our Ten Years On review comes from the growing evidence of stalling life expectancy and widening health inequalities in England. To understand why and what needs to happen to reduce inequalities, we will look at some of the domains for action identified in my 2010 review. After consultation with stakeholders and with our advisory group, we will pay special attention to: early years and education; work and income; and housing, places and communities.

There can be no more important task for those concerned with the health of the population than to reduce health inequalities. Review what can be done to reduce health inequalities and then do it. Social justice demands it.