Low life expectancy in the north east, and what to do about it – with Alice Wiseman and Professor Clare Bambra Episode 28 of the Health Foundation podcast

Dr Jennifer Dixon: Today we're looking at life expectancy and why in England it's lowest in the north east. We know, of course, that life expectancy across England is improving overall, but less good is that improvement slowed in the last decade. And in some communities it's even gone into reverse. The region in England with the lowest life expectancy is the north east. But more than that, the last decade and a half has seen a worrying increase in mortality amongst younger people, those aged 25 to 44, and in particular men who are dying a long way before their time. This is a very unusual finding compared to many other countries. And in the north east, the big chunk of this excess mortality seems to be down to so-called deaths of despair. That's deaths by suicide, violent injury and substance misuse, particularly of course in the poorest areas. So what's going on and what can we do about it?

Well, with me today to discuss all this, I'm very pleased to welcome Dr Alice Wiseman, who is Director of Public Health at Gateshead Council, where she's been working since 2016, and Clare Bambra, who is Professor of Public Health at Newcastle University and leads the health inequalities research team for the NIHR School for Public Health Research. A big welcome to both. I think the first big question then is can you, Alice, just outline for us what the main key trends are in the north east and how they compare with the rest of the country?

Alice Wiseman: There is significant differences in overall health and wellbeing of people in the north when compared to the rest of England. If we look at differences in life expectancy, there can be as much as 12 year differences for men and around 10 for women. And during 2021, premature mortality was around three and a half times higher in the most deprived parts of the north east than the least deprived parts. So there are definitely not only differences with the rest of the country, but also differences within the north east as well. And the leading causes that we are seeing locally around premature death include external causes such as poisoning and suicide, those real issues around death of despair and that's particularly relevant for men but also big issues around cancer and cardiovascular disease and digestive issues and respiratory conditions. And I think there are some really significant challenges that sit behind that.

Despite really good progress around smoking, for example, we've had a 47% reduction in smoking prevalence since 2005 was still higher than the England average smoking. If I look at the hospital admissions and deaths as a result of alcohol misuse, we're still much higher than the rest of the countries. It lends itself to think about the conditions that people are living in and some of the behaviours that people are adopting to manage those situations in terms of the impact of poverty and the impact of poverty linking to depression, then linking to maybe a higher level of health harming behaviours. So there are some really significant challenges that we're seeing play out in the north east and despite much great progress over recent decades, we're actually seeing that stall and in our most deprived communities, sadly we're seeing some of the progress that we've made in the past reverse and go in the opposite direction.

Dr Jennifer Dixon: I was looking at some of the data and there are big differences in the most deprived communities in the north east aren't there compared to the south east.

Alice Wiseman: If I look in Gateshead, if I compare the most deprived part of Gateshead to the most affluent part of a local authority south in the country, it's around a 15 year difference in life expectancy. But it's not only the bit about life expectancy. People and on most disadvantaged communities are living more of their shorter life in ill health. If somebody's unwell and certainly the vast majority of our population have a life-limiting illness before retirement age, then it means that they're less able to play into the economy and therefore they're more likely to be affected by those issues such as poverty. And certainly that is something that we're seeing play out at the moment with the context that we've got as a post pandemic, the COVID impact, but also the cost of living crisis. There's lots of things that are playing in and actually is affecting on most disadvantaged communities most.

Dr Jennifer Dixon: And can you just give us a flavour of the geography? Where are the more deprived communities in your patch?

Alice Wiseman: So the north east runs from the Scottish borders down to Middlebrough, Teesside way, there are pockets of deprivation across the whole of that patch. So every local authority has challenges within that area and actually sometimes some of the local authorities have really significant challenges in small pockets that are masked by more affluence in other parts of the region. When it comes to Gateshead, we know that there are at least a third of our children who are growing up in poverty at the moment. We know that there's a really significant number of our population who are not in secure employment. And again, this has been a really big challenge post pandemic. There are fewer jobs available in the region than there are in other parts of the country as well. And when I look at the proportion of workless households for Gateshead, but also across the region, it's reached the highest level in seven years.

So it's about 18.5% and about 19% of households in the north east, well in Gateshead in the north east that are workless compared to a British average of 14%. And even if people are in work, median pay amongst Gateshead residents as well below the regional and national average. Again, the unemployment count in Gateshead persistently exceeds the average as well. So there is a real concern that our communities are not having the opportunities, I guess to be in good quality jobs where there's really good terms and conditions, good pay. And actually this has been impacted on over recent years with the Covid pandemic where we had the lowest paid workers and part-time workers were twice as likely to lose their jobs compared to the highest paid. And of course many of our industries were affected. The service industry if you like, we're affected by many of the lockdowns and the jobs' insecurity I guess, as a result of all of those things. So it's almost a combination, a layering if you like, of disadvantage that's really impacting on the people that are living and working in the north east.

Dr Jennifer Dixon: Just on the early deaths in particular, what size of chunk of that is deaths of despair do you think, or looks like that compared to particularly in this younger age group?

Alice Wiseman: Yeah, when I look at the inequality data, that's probably the most important, but it's a particular concern for men where actually external causes which include those deaths of despair are the leading cause of inequality in life expectancy. And certainly today in Gateshead we're reviewing on 19 drug related deaths for last year, 2022. And what we're seeing in that is polydrug use is really prevalent in those deaths, but it is really hard to know whether some of the deaths have an element of intent. And alongside that, we're also seeing deaths, drug related deaths if you like, but from with people who have underlying physical health conditions, mental health conditions linked to childhood trauma and bereavement as well.

So there is a real picture of that. And if I look at the deaths from drug misuse in the north east, we are almost double the national average. So it's about 9.9 per 100,000 compared to five per 100,00 for England. So it's a real challenge and we're also seeing a significantly higher level of deaths related to alcohol. When I look at the leading causes of inequality for women, it is those digestive issues, particularly cirrhosis and liver disease that are really adding to the inequality for women in the North East as well. So it's all very worrying.

Dr Jennifer Dixon: So Clare, I wondered if you might chart out what's been happening up there economically, socially, what's it like to live there at the moment?

Professor Clare Bambra: We can see particularly over the last decade or so, the life expectancy in the most deprived areas of the north east has fallen behind that in, for example that the south east, so it's about the deprivation effects on health being amplified in the north east. And we've also seen that for example, with Covid deaths being higher in deprived areas in the north east than in equally deprived areas in the south east. So there's something particularly perhaps structural about the long-term nature of a deprivation in the north east. And I think what we can think about is that the general long-term trend is that within the 2000s there was improvements in terms of closing the gap between deprived areas and more affluent areas, both in terms of infant mortality rates and also in terms of life expectancy and other indicators such as smoking for example, as Alice mentioned. And then since around 2010, we've begin to see the north east falling further behind on various indicators.

I think there's going to be a lot of factors in play, but my personal view is that we have to look at the impacts of austerity over the last decade in the north east. The economy of the north east is more dependent on transfers from government in terms of public services, but also in terms of for example, child tax credits as were and things like that. So we've seen a big reduction in finances for the north east, both for particular families in deprived areas, but also for the public services which they have to access more perhaps than more affluent people. And this has disproportionately impacted on the north east. So I think we're in this situation where for a decade we've borne the brunt of austerity, we had a worse experience of Covid and I believe we're having a worse experience of the cost of living crisis as well.

Dr Jennifer Dixon: Can you say something about what's happened before then, particularly the longer run changes in the north east.

Professor Clare Bambra: The north south health divide in the north east, doing less well than the west of the country is something that we can actually track back almost to when statistics began in the 1830s, but looking at more recent data then obviously from the 1970s onwards, because the north east is very reliant on heavy industries. So mining, steel, ship building, these are all industries that are almost extinct within Britain now. And that de-industrialisation was particularly rapid and painful for the north east with the very drastic closures that happened throughout the 1980s with mass unemployment and whole communities. So for example, you have ex coal mining villages now in County Durham in the North East. The whole purpose of that village, it was built because there was a mine. In effect, the whole community was dependent on that mine, either through direct employment or indirect.

So you see this huge decimation both from an economic perspective but also from a social perspective in terms of the impacts that unemployment have, not just from a financial perspective, but in terms of families being able to stay together and the pressures that that puts on them. So the north east economy is very dependent on public sector employment. So the biggest employers are all the NHS, the education system, the local authorities. And there's much smaller in terms of private sector employment, particularly if we compared to the south east and London.

So there's not been an alternative side of the economy. Looking more recently, so since the 2008 financial crisis, and not only has there been this austerity draining out of the support mechanisms that were helping the north east, but the north east itself as an economy, it's not grown at all in that period. So there's a lot of discussion nationally at the moment about cost of living crisis, potential long-term economic recession for the UK. The north east has almost been in recession for the last decade. There's been very little in terms of economic growth for our region. It's all been fuelled by the south east.

Dr Jennifer Dixon: And you will have read Angus Deaton and Anne Case's book Deaths of Despair, focusing on the US and in fact we had Angus doing a podcast for us a couple of years ago on this very subject. And one of the aspects that he and Anne Case talk about is obviously long run structural changes of the type you mentioned, but also some social changes to do with reduction in social glue coming from religious, collective church going to divorce rates and fewer marriages and et cetera, et cetera. And I just wondered if you were able to say anything about those particular changes.

Professor Clare Bambra: I think those are obviously longer term trends that affect the whole of the country. I think what we could think about in terms of what happened in the north east and why it might be particularly impacting on the health of men and the higher rates of deaths of despair amongst men in the north east is that loss of identity both for individuals and for the community. So your coal mining village in County Durham is now an ex-coal mining village. That identity was gone. Your job, and this literature suggests particularly impacts on men, is that your job is part of your identity. That's taken away and there's no replacement. So I agree that there are social factors like that playing in as well to what we're seeing.

Dr Jennifer Dixon: This may seem like a wild comment, but I was looking at some of the figures on health between East and West Germany in the period immediately before reunification and then around that and then afterwards. And the life expectancy was worse in East Germany, better in West Germany as we would expect. And then there was a period of extreme economic insecurity just after 1990 where there was a real downturn in life expectancy in the east before it then began to improve. And that downturn, there were a lot of deaths of despair amongst men of this age group going on in that area. And I don't know whether you've seen a uptick in these particular conditions in previous recessions or if anyone you know has looked at that.

Alice Wiseman: There's national research that showed that babies that were born in the seventies and were teenagers in the eighties are more likely to have a higher level of deaths of despair. So we saw more deaths of people in their twenties during the nineties of people in their thirties during the early 2000s. And there is something about that generational spread if you like, and if we accepted people's view that the world solidifies around the early teenage years, then we have a generation whose eldest members are maybe around 25, 27 who've only really known the 2008 economic crash, the subsequent authority measures, the turmoil around Brexit, the impact of the COVID-19 and now the cost of living. So it's a generation who've been raised in almost crisis mode.

Dr Jennifer Dixon: And going back to the specific issue of austerity since 2010, which is obviously when some of the trends changed, many have pointed out that other countries also experienced austerity around that time and some didn't. But they all had stalling life expectancy over this period. And I'm wondering from what you were both saying that whether just health up in the north east was just generally more fragile and in that environment austerity would just have a much bigger effect when the public service security blanket was just taken away or removed or frayed. Is that your conclusion?

Professor Clare Bambra: For England, pre-Covid we had the first registration of a fall in life expectancy since the post-war period and that's then unprecedented. And of course what we see is when you dig into that data, that that fall is basically in the most deprived areas. There's not a fall if you live in an affluent area and we see those falls in deprived areas are bigger in deprived areas of the north east. So there is, I think, it would inevitably be overall in high income countries a stalling growth in life expectancy because we are pushing the boundaries of what's possible. The fall comes because you've got more drastic falls of up to 12 months, for example, in Darlington since 2015 in life expectancy at the bottom end, then is in a sense dragging down the national average.

Alice Wiseman: And I think link to that, you've got the issue, and this is highlighted in some Michael Marmot's report in 2020, was that areas outside London and the south east have experienced the largest cuts to local authority budgets, really limiting the availability of action on the social determinants of health. And I think what we're seeing locally is an increase now in demand for crisis support. We've got the most number of children in care that we've ever seen in Gateshead at the moment. We've got more people in our NHS emergency care system, we've got a reduction in preventative services.

And if I use Gateshead as the example for that, actually we've got £900 less to spend per resident than we had in 2010. And when you think that that is also mapped against the fact that there's been a increase in cost of living, it's a really significant reduction. And it does mean that local authorities need to start looking at their statutory offer, which often ends up meaning that the preventative work is something that is reduced as a result of that. And like I say, I don't think that's necessarily been done equally across the country. Sadly I think the way local government is funded is unsustainable.

Dr Jennifer Dixon: If you look back over time, there's been a lot of research, hasn't there. A lot of inquiries into health in the north east and the gap and also a lot of work that's been done on how to try and improve economic conditions in the north as well. Can you just chart out what the responses have been in the north east to this clearly changing health picture, what's been done here and with what effect?

Alice Wiseman: Each local authority obviously has action on all of those areas in terms of thinking about how we improve the economy, how do we encourage businesses to come to the local area. There's also been quite a bit of work that has been done at a larger scale across, for example, the North East Combined Authority area in which are the seven local authorities north and south of the River Tyne. There's been conversations ongoing at the moment around devolution and the opportunities that devolution may play into that.

And then like I say, at a local level, so for Gateshead we've refreshed our health and wellbeing strategy, making sure that it is focused around those Marmot policy objectives. And despite all of the challenges that we've spoken about, there are some really exciting projects that are coming to fruition such as we've got a really big development in Gateshead on the quayside and there's a focus on that about actually how do we bring in good quality jobs for local people, apprenticeships for our young people as they're leaving school.

But we've got all of this work happening almost alongside the context, which is just so incredibly challenging. We've got some great work, like I say, the quays development. Actually we've also got on the other side of it, we're talking about having to close our leisure centres because we can't afford to continue to run them in the same way. So there are some real challenging decisions that local authorities are having to make.

Dr Jennifer Dixon: Clare, I don't know what your perspective is on the overall policies in the north east to try to address some of these issues, particularly on poverty?

Professor Clare Bambra: Yeah, I totally accept that local authorities, particularly outstanding ones on health inequalities action like Gateshead, are doing everything they can, but they're doing it in a context where it's not just one hand that's tied behind their backs by austerity, but now the second hand is tied because of the cost of living crisis. I think the real issue is not what we can do in the North East on our own, which is actually very limited because even with lots of money, local authorities have very little actual control over the real key drivers.

So if we see how poverty impacts, for example, on infant mortality rates, local authorities, even if they had lots of money, there's minimal action they can take on that. That action really has to come from national government. And when we had a national health and equality strategy in the two thousands, which really tried to tackle some of the underpinning causes, we did see an improvement in life expectancy and a reduction in infant mortality rates in the most deprived parts of the country, including the north east. So it really is a case of needing national government to consider the health inequalities that we face as a region, but also the economic inequalities that we face and that are driving the problems.

Dr Jennifer Dixon: So a national health inequalities focus strategy is something that we want. Of course, we're not getting yet, are we, because that there isn't anything like that at the moment, although devo hopefully that was what it was formed wasn't it, to try to produce. So that's one area. And then the other area is the background economic development in the region and Alice, you quite rightly point to the devo deal there. So those who don't know, there was a proposed devo deal put on the table on the 28th of December last year for the north east bringing together all the councils and to have a directly elected mayor from 2024 covering Tyne and Wear, Northumberland and Durham. And the focus there is giving more powers locally for education, schools, housing, regeneration, transport. I don't know what you feel about that development. Do you think it's just going to scratch the surface or do you think it really is a promising first stop?

Alice Wiseman: When you look at the amount of money that has been taken out of local government over the last decade, I don't necessarily think we can get back to a position using this devolution deal that we were in 2010 and earlier. But what I do see is that this is the only show in town in terms of opportunities to work at a sub-regional level because it's just north of the north east that we're talking about in relation to this one. The ability for an elected mayor to influence national decision-making for the benefit the area, I think that's crucial in this.

And we've talked a lot about austerity but we haven't necessarily talked yet about welfare reform and the impact that welfare reform and particularly universal credit had on the health and wellbeing of our residents. There is something about having that opportunity to try and influence national policy around some of the issues that we know can create health, but actually have the opposite impact when we look at it locally. I think that the local authorities that are involved in the devolution deal discussions at the moment tend to work well together. There are some real opportunities I guess in that space to be able to transform some of the work, but I don't think it replaces where we were back in 2010 when we had the national strategy or pre-2010 even to national strategy on health inequalities, which was just much more comprehensive in its approach.

Dr Jennifer Dixon: Just going back to OHID for a minute, that might help to be the epicentre of this health inequality strategy, but what's your intelligence at the moment about the extent to which it is able to craft such a strategy and hasn't it done something specifically on the north east I was reading recently?

Alice Wiseman: My concern is that to tackle health inequalities, we need a cross-government strategy because we need action on all aspects. And if we focus purely on the services and interventions that are within the gift of Department of Health, then we will only continue to stick plasters over the problems that we've got rather than really get into the root causes. So even if we do end up with a national health inequality strategy, unless it is cross departmental, then I think again we will just, like I say, stick plasters over problems as opposed to really deal with the conditions that enable health and wellbeing to develop as opposed to inhibiting it. So I'm cautious around what I'm asking for and as much as we would like to have some action on it, I don't want it just to be focused on the treatment end of the pathway if you like. And I think that if we do that, that's a mistake certainly for the north east.

Dr Jennifer Dixon: Yes, and a lot of public health people sort of say follow the evidence, but the evidence does run out, doesn't it? Although I think Clare, weren't you an author of a very interesting report looking at the evidence on some of the wider determinants of health and concluded that there was definitely scope for action because the evidence was strong enough.

Professor Clare Bambra: Getting shifts in population health are quite hard. Getting reductions in inequalities are even harder. But we do have case studies of when this has happened and it's never been through doing just one thing. It's been through multiple concurrent policies and interventions. So the national strategy in the 2000s in England is one example that impacted on, for example, reducing child poverty. There was a child poverty reduction target. Child poverty is massively associated with adverse health education and employment outcomes.

It also reduced a pension of poverty. And we can see how that impacted on reducing inequalities in mortality in older age groups. So that's one example. Another example returns to what you were talking about with East and West Germany. So after reunification, the four-year life expectancy gap between east and West Germany within a 20-year period disappeared. And whilst there's debate as to why that might have been, the huge investment from West Germany into East Germany during that period has to be part of the story. And there are other historical examples what happened with health inequalities between black and white Americans, for example. These were massively reduced in the 1960s after the Civil Rights Act and the war on poverty. So there is evidence, it's just not necessarily the evidence that you get from a randomised control trial.

Dr Jennifer Dixon: Yes. And whether that evidence can cut through in such a challenging environment as now. And also the need for longer term policy, which we return to again and again in this podcast because these things aren't going to be solved from a two or three year strategy, are they? It's more like 10 to 20 years if you really want to build health capital. Where is the hope? Where would you like to see policy go next?

Alice Wiseman: There are some opportunities and we have to remain positive because otherwise the world that we're work in would be too depressing. So we have opportunities with the potential for the devolution deal and the resources that will bring into the region, the collaboration between the seven local authorities who are involved with that. What we haven't spoken about today is about community engagement in the solutions. And we've got some amazing community and voluntary sector projects positioned in our most disadvantaged communities that are delivering health improvement at a local level. But because they are enabling, there's almost an infrastructure to bring communities back together again and to identify what the challenges in their area are for them and what the solutions are.

So I think we can't underplay the importance of that type of really small scale approach in our most disadvantaged places. We continue to have the challenges of austerity. So again, in Gateshead looking at trying to find another £55m saving over the next few years. I really don't know the long term future of local government across the country when I think about the funding pressures that we're all under. Really we need action at a national level. We need a health and equality strategy that is cross-departmental in the way that we've done with the drug strategy.

We've got a drug combating drugs unit, but actually we need to recognize that the reason that there are many people who are experiencing issues with addiction is because of the psychosocial impact of the issues that they're facing in their day-to-day lives around poverty and unemployment and educational experiences, educational attainment. So unless we really do get back and think about some of those root causes, then we're always going to be continuing to using the public health analogy, pull people out the river rather than preventing them from falling in the first place.

Dr Jennifer Dixon: And Clare, you all, what do you think is in reach what you'd like to see?

Professor Clare Bambra: Well, what's within reach and what I'd like to see are probably quite different. So I'm going to talk about what I would like to see and what I ultimately think we need, which is to have a focus as a country, policymakers and people on health, to give health the same status as we currently give economic growth. So all policy, regardless of which party is in power, tends to focus on how can we improve economic growth. I think if we had health and wellbeing as outcomes, which we rated ourselves on and which we tried to aspire to as a country, then the policies and decisions we would make would really radically change.

And so I think it's about how we think about what is valuable to us as a community. Is it more money but worse health or is it maybe less money, but better health? And the Covid pandemic, whilst it was obviously a horrific experience for many people, and particularly in our deprived communities, what it did show is that government can take action and will take action over health. All of the lockdowns, everything was to prevent death. So actually the principles within that emergency situation that health is valuable should be taken across into our everyday policy decisions as well.

Dr Jennifer Dixon: So thanks again very much to Alice and Clare for their terrific insights into North East. Hope that gave you a flavour and whetted your appetite for more because we are bound to cover these issues again. And many of you who are podcast aficionados will remember our episode looking at health deterioration in Glasgow, which had some very similar themes and also the deaths of despair podcast we had a couple of years ago with Angus Deaton and Sarah O'Connor, where those issues were discussed again with also different angles. So have a look at those.

As ever, lots more information in our show notes that we refer to, so have a look at that. And next month we're going to return to healthcare and with a release before Christmas of Open AI's Chat GPT, we're going to be looking at what are the new models of AI and what they really mean for the shape of care. Should we be techno ecstatic or techno pessimistic? That is going to be extremely interesting. So listen in next month. Until then, big thanks to Grace Everest and Kate Edison at the Foundation and Patty Melt Productions for this production. Thanks for listening. And goodbye from me, Jennifer Dixon.

Local healthy life expectancy at birth by region and sex (2022) The Health Foundation 

Map of healthy life expectancy (2022) The Health Foundation 

Major study outlines wide health inequalities in England (2022) The Health Foundation 

Health inequalities are worsening in the North East of England (2020) NIHR 

Making health services work for deprived populations in the North East (2022) NHS England 

Deaths of Despair: Conceptual and Clinical Implications (2021) Cognitive Behavioural Practice 

Health Equity in England: The Marmot Review 10 Years On (2022) The Health Foundation 

What is happening to life expectancy in England? (2022) The King’s Fund 

Life expectancy declining in many English communities even before pandemic (2021) Imperial College London 

Our approach to reducing healthcare inequalities by NHS England 

Historic £1.4 billion devolution deal for North East (2022) Department for Levelling Up, Housing and Communities