- During the period of lockdown unprecedented steps have been taken across the UK – not just to protect people from coronavirus (COVID-19) but from the consequences of the economic impact. These interventions have touched on all aspects of our lives and illuminated many long-standing inequalities. It raises the question: If such support is important now, then why not in the future?
- Here we consider the areas where the actions taken during lockdown should be retained beyond the pandemic to build a recovery that supports everyone’s health and wellbeing. We describe the lessons that can be drawn in the areas of: mutual aid and voluntary action; prevention-led strategies; housing security; employment and rebuilding for inclusion.
- Stark differences in COVID-19 outcomes have placed the role of racial discrimination in influencing health outcomes at the centre of debate and will require action to be taken by all sectors of society.
- The rapid shift to online services and information – while essential to maintaining business as usual for many sectors during lockdown – has highlighted the need to ensure greater digital inclusion.
- During the pandemic, protecting people’s health has been the single focus for governments across the UK. As restarting the economy becomes a priority, policies will need to support an inclusive recovery if everyone is to have the same opportunity of a healthy future and ensure long-term prosperity and wellbeing. The ‘levelling up’ of health outcomes needs to be the ultimate measure of success for the government’s levelling up agenda.
The coronavirus (COVID-19) pandemic and the response have touched every part of our lives and every part of society. We outlined how existing inequalities have affected people’s experience of the pandemic recently in Will COVID-19 be a watershed moment for health inequalities? We concluded that unless these events are viewed through the lens of inequalities, we risk ending up in a place of even greater injustice than where we started. So, as attention turns to the recovery phase, we revisit these themes and consider the opportunities to create a fairer and healthier society.
There is already much discussion on the theme of ‘building back better’ to create a more resilient and sustainable economy. This phrase will only ring true if it has the goal of improving health and reducing health inequalities at its heart. A healthy nation is essential to a flourishing society. Good health and wellbeing is an important enabler of participation in family, community and working life. Our report Creating healthy lives outlined the role all sectors have to play in creating a healthy society and similarly all sectors will have a role in recovery. But plans for recovery do not need to start from a blank canvas. Alongside the hardship and suffering experienced by so many over the past several months, there have also been glimmers of hope for a better society.
The response to the pandemic has been breath-taking in its scale, breadth and pace. Take, for example, the Coronavirus Job Retention Scheme, launched by the government on 20 March 2020. As of June 2020, the scheme had supported 8.7 million people across the UK but it comes at an expected cost of £60bn. Analysis from the Joseph Rowntree Foundation shows that the sectors with the highest furlough rates also had the highest rates of in-work poverty (after housing costs) even before the crisis began, such as wholesale and retail, accommodation and food. Putting this measure in place may have come at a high cost, but it was critical to protect those on low incomes from the impact of an economic shock which, in itself, will be a significant determinant of long-term health.
As the UK edges out of lockdown, we should all be asking the question: what do we want to keep hold of from our response to the pandemic?
Looking to the future: what can we learn from the pandemic response?
Many of the actions taken to mitigate the impact of the pandemic have been ‘emergency’ measures and are unlikely to continue without wider societal consensus. However, the pandemic has forced some very different ways of working and precipitated changes in people’s appreciation of the disadvantages many in our society face. As the emergency measures recede there is a chance to reflect on which of the many changes should be sustained to build a better future and address some of the inequalities exposed.
Local communities, employers and national and local governments have galvanised efforts in far more ways than could be described here. However, there are some common themes that have particular relevance to creating the conditions for healthy lives and are illustrative of the changes needed to protect the nation’s long-term health and wellbeing. We consider what can be learned from the pandemic in the following areas:
- Increased mutual aid and voluntary action
- Collaborating on prevention-led strategies
- Greater housing security
- Supporting full employment
- Rebuilding for inclusion
- Addressing the inequalities exposed by the pandemic.
A sense of belonging is a basic human need and has been shown to have a beneficial impact on people’s health. Whether through providing support networks that help people develop new skills and face uncertainty or providing a shared sense of purpose and identity. Mutual aid stems from strong communities. It fills gaps in provision and has a long and important history in the UK. This includes the early 19th century’s friendly cooperatives through to community-led welfare, such as disabled mutual aid groups, black supplementary schools and gay counselling services in the late 1960s.
Over the last few months, people have come together within their communities to set up 4,000 mutual aid groups across the UK. People have supported each other within their communities with help picking up groceries or prescriptions, as well as offering an ear to listen or a shoulder to cry on during this exceptionally difficult time. From people with long-term health conditions or disabilities and in need of care, to those experiencing financial hardship and struggling to afford food, local communities have provided essential support to those who needed it. This is reflected in emerging data from lockdown, with the ONS reporting in early June that 79.9% of people were doing more to support others in their community. This contrasts with a Community Life survey before the pandemic suggesting only 35% of people felt they could borrow or exchange favours with their neighbours.
While the resurgence of mutual aid is something to hold onto, over 95% of respondents in the New Local Government Network’s survey of local government leaders said that the contribution of community groups to their COVID-19 response has been significant. Yet it is not a replacement for the voluntary sector, left in a precarious state over the last decade and facing ever greater demands as support previously provided by the state has declined.
The government has set out plans to deliver £750,000 in funding for the local voluntary and community sector. The Health Foundation, along with other foundations, have stepped in to provide emergency funding. However, this is not enough to meet the scale of the challenge facing the sector. Pro Bono Economics have found that the sector now faces a £10.1bn funding gap in the next 6 months due to COVID-19. Nine in ten charities surveyed anticipate a reduction in their income, with over half believing this will mean significantly reducing their activity.
The pandemic response has shown the critical role of mutual aid and voluntary action. Continuing to value and provide the necessary support to maintain this will benefit health and wellbeing. The role of small, community-based organisations is too easily overlooked and resources will be needed during recovery to support their critical work. One option is a stabilisation fund to secure the long-term financial health of the charity sector, as recommended by the Digital, Culture, Media and Sport Select Committee.
Supporting someone to live well is as much about enabling them to solve their finance or housing difficulties, as it is about managing their illness. However, siloed working by service providers reduces the opportunities to take a proactive and holistic approach to meeting people’s needs. The pandemic has seen local statutory services put collaboration at the heart of the solution to tackling COVID-19 in their local area. Better sharing of information across all local services can provide the foundation for more joined up and prevention-led approaches.
One example is Barnsley Council’s experience of developing a vulnerability index during the pandemic. Before the outbreak began, the local health and social care systems lacked the information to understand service users’ financial or social status, or what was available to them in their neighbourhood. While sharing data between local systems had always been seen as desirable, it was not until the first week of the outbreak that they were able to get this work started.
They organised a workforce of analysts from each of the organisations in the system, such as different local authority teams and NHS services, to develop the vulnerability index. Starting as a list of vulnerable people shielding due to underlying illnesses, it is now a much more sophisticated database which also identifies households experiencing financial difficulties or with safeguarding concerns. Having identified around 65,000 households with some form of vulnerability during COVID-19, this has improved the ability to anticipate and respond to people’s needs. Dr Andy Snell, Public Health Consultant at Barnsley Hospital, explains:
‘We are able to risk stratify [people], knowing their risk of health problems, social problems and financial or other problems. We can identify what kinds of needs they have and prioritise support for them based on a much more holistic understanding of health. We’ve opened the doors to people who we didn’t even know needed help. People who are depressed or experiencing hidden harm – they’ve always been there but we haven’t always known about them.’
This crisis has at times pushed local systems to work better together in order to provide more effective support. It has also demonstrated how extensively people’s health is shaped by social inequalities. Continuing to build on the collaborations formed through the crisis will increase the capacity and capability for local areas to adopt prevention-led strategies.
The founding of the modern welfare state is viewed by many as one of the great achievements of the 20th century. While the form and structure of the welfare system has faced long-standing critique from across all sides of the political landscape, the pandemic has been an important reminder of just how important a safety net it is for everyone when they face a crisis.
One of the most prominent examples was the action taken to house rough sleepers within days of the lockdown starting. A range of other measures were also taken to increase people’s housing security with mortgage holidays and a freeze on evictions. One emergency measure that should be high on the list to maintain is the increase in the Local Housing Allowance. This makes more of the housing stock affordable to those in receipt of benefits and can provide greater housing security.
On 20 March the government announced that the Local Housing Allowance would be restored to previous levels so that housing benefit would cover rents for the bottom 30% of the rental housing stock in each local area – it had been frozen from 2015. The Local Housing Allowance is designed to ensure that people receive enough housing benefit to cover the cost of renting a cheaper home in their area. Research from Crisis and the Chartered Institute of Housing found that last year over 90% of areas in the UK are unaffordable to people supported by the Local Housing Allowance. And that by increasing the allowance to the 30th percentile it would prevent more than 6,000 households from becoming homeless over 3 years, and lift 32,000 households out of poverty, including 35,000 children.
This measure will play an important role in providing housing security for private renters, a third of whom have experienced a hit to their earnings due to COVID-19. And while the current increase will only last for 12 months, the financial insecurity renters are likely to face will continue well beyond this. Maintaining this support will both provide a safety net for those facing financial uncertainty and mitigate the immediate and long-term impact housing insecurity has on people’s health.
A secure and rewarding job has been shown to be a contributor to good health, while unemployment has a negative impact on people’s health and wellbeing. During the 2008 financial crisis, researchers found that in the UK a 1% increase in unemployment led to a 2% increase in the prevalence of chronic illness. So, when an economic crisis hits, it is a critical time to help keep people in employment, whether through supporting them to retain their job or to find new opportunities.
The Job Retention Scheme was a bold and necessary step by government at the start of lockdown. The question of when and how this is finally phased out needs to be balanced against the impact of unemployment on people’s livelihoods and wellbeing. So far, younger people have been disproportionately disadvantaged by the crisis. Research from the Resolution Foundation found that one third of 18–24-year-old employees have lost jobs or been furloughed as a result of the crisis, compared to less than 15% of 35–44-year-olds. There are additional concerns that young people leaving education this year will be entering a challenging job market with few opportunities, which could have a scarring effect on future job and pay prospects.
Some groups of young people are likely to face an even greater disadvantage. Previous work by the Institute of Employment Studies found that black and minority ethnic young people, disabled young people, young parents and those with the lowest qualifications are less likely to be in employment compared to the average for the 18–24 age group.
Regions and local areas can play an important role in supporting employment. One such approach has been the newly created Reskilling the Recovery Fund, launched by the London Progression Collaboration and the Greater London Authority. The fund calls for large organisations to pledge their unspent apprenticeship levy, which is then given to small businesses to create apprenticeship opportunities for young people living in London. This model not only offers support for small businesses that may be struggling from the crisis, but also creates new opportunities and career pathways for young people.
Insights from Health Foundation-supported analysis of young people’s working experiences will contribute to providing better employment opportunities and improving young people’s life chances.
The roadmap out of lockdown and into recovery starts and ends with local places. Various places across the UK have been affected differently by COVID-19: whether it is new pressures on health care systems, local industries being impacted in unique ways, or even the ability of public transport to adapt to new social distancing measures. As the four UK governments decide how to build back better, local government must have a seat at the table and autonomy over decisions in their area.
Cities across the UK are already planning for a post-COVID world. Kirklees Council have redesigned their cabinet to focus on COVID-19 recovery. New roles for cabinet members include voluntary sector engagement, recovery strategy, and planning the post-pandemic inclusive economy.
Derby City Council are exploring how they can work with partners across the city in their new Coronavirus Economic Recovery Task Force. The public and private sectors are working together to identify areas that have been worst hit by the crisis and partnering together to build an economic recovery plan. For example, the task force is taking an immediate focus on supporting workers recently made redundant by Rolls-Royce, helping them to find alternative employment or launch their own business. Longer term, there are plans to decarbonise the city and deliver major regeneration schemes.
Creating inclusive places where everyone has the opportunity to thrive depends on citizens having a say in decision making. Sunderland Council are relaunching their ambitious community involvement programme, Let’s Talk Sunderland, as they look to build more resilient communities after COVID-19. Residents, and vulnerable people in particular, are being contacted by the council to find out what their needs are and what changes they would like to see to improve their neighbourhoods.
Just as each area has had to respond in different ways to COVID-19, their recovery plans will look different too. Rebuilding from local areas upwards will harness and build on existing local commitments, ensure that areas are supported to be more resilient and give citizens a voice in these plans too. The Health Foundation is supporting local governments to take system-wide action on the wider determinants of health in a new funding programme with the Local Government Association. We have also announced future funding opportunities aimed at using local economic development to improve health outcomes.
Addressing the inequalities exposed by the pandemic
The pandemic has exposed the differences in opportunity and barriers that some people face in building the foundations for a healthy life. This long read has highlighted some of the ways in which national and local responses can seek to reduce inequalities. But many remain and cannot continue to be ignored. Two aspects of inequality that have risen to particular prominence during the pandemic are the digital divide and the consequences of racial and ethnic discrimination.
Closing the digital divide
Lockdown saw large sections of society shift online. This experience has shown what is possible and that this will continue to form a greater part of our lives. The shift online has been visible in the health care sector. In March alone online consultations doubled from around 900,00 to over 1.8 million. Several digital projects the Health Foundation has supported over the years have come into their own. For some who may have faced physical barriers to services it has improved access. But for many more it has highlighted the need for greater digital inclusion.
The Good Things Foundation recently estimated that 11.3 million people in the UK do not have the basic digital skills they need to thrive in today’s world, which has implications for employment, financial security and long-term health. The digital divide has been stark in the education sector. As schools and colleges had to deliver lessons online it exposed the number of children and young people that do not have access to an appropriate device at home and/or a reliable internet connection.
Overcoming digital exclusion has become a priority for many councils. Manchester City Council’s Community Response Hub has been offering one-to-one telephone advice to residents who have access to the internet at home but are not able to use it confidently. Support can cover everything from turning on a device, through to applying for benefits, booking GP appointments, shopping or connecting with family and friends via video calls. The service has taken more than 12,000 calls since opening on 30 March. The council is also distributing free tablets with internet access to vulnerable residents who could not previously access the internet.
The pandemic has precipitated a shift in the way we use services and interact with our communities. The patient charity, National Voices, is one of many organisations to consider what this means and how further inequalities can be prevented.
Addressing the systemic barriers faced by people from black and ethnic minority communities
The stark differences in COVID-19 outcomes have placed the role of discrimination at the centre of the debate. Data from the ONS published on 7 May show that, after adjusting for age, black men and women were at the highest risk and they were more than four times as likely to die from COVID-19 as people of white British ethnicity.
The reasons for this are complex. As our separate analysis explores, a wide variety of explanations have been examined about these long-standing ethnic inequalities in health. These range from upstream social and economic inequalities to downstream individual characteristics. Teasing out the contributions made by different factors is difficult, particularly because they do not all act independently; for example, living in more deprived areas that have higher air pollution increases the risk of having an underlying respiratory illness.
Experts in the field point to racism as a ‘fundamental cause’, affecting health in multiple ways. A strong evidence base has demonstrated that racial discrimination affects people’s life chances through restricting access to education and employment opportunities, for example. Black and minority ethnic groups tend to have poorer socioeconomic circumstances that lead to poorer health outcomes. In addition, the stress associated with being discriminated against directly affects mental and physical health through physiological pathways.
The heightened awareness of the discrimination experienced by sections of our society cannot be lost as the acute phase of the pandemic recedes. It will be incumbent on all parts of society to examine the role they have to play in using their power, resources and privilege to tackle racism, and racial inequalities in health and health care.
The COVID-19 pandemic has exposed the sharp differences in people’s circumstances and the implications this has for their health and wellbeing now and in the future. It has also shown how quickly positive changes can be delivered and that every section of society has a role to play. As life begins to slowly return to normal, we find ourselves at a turning point. Should we choose, we can learn lessons from the response to the pandemic to create a fairer and healthier society.
The Health Foundation’s Mortality and life expectancy trends in the UK showed that since 2011 improvements in life expectancy in the UK have stalled, and for certain groups of the population gone into reverse. While people in wealthier areas of the UK continue to live longer, life expectancy improvements are stalling for those living in the most deprived areas. For women in these areas, life expectancy has fallen.
During the pandemic, protecting people’s health has been the single focus for governments across the UK. As restarting the economy becomes a priority, economic policies will need to support an inclusive recovery if everyone is to have the same opportunity of a healthy future and ensure long-term prosperity and wellbeing. The ‘levelling up’ agenda, heralded in the government’s manifesto commitments, will need to focus not just on enterprise and productivity-increasing infrastructure but also on social protection. Government will need to adopt policies to tackle the ‘wider determinants’ of health, from improving the availability of children’s centres to reducing child and in-work poverty.
This will require an explicit strategy to join the dots on existing efforts, coordinate, scale and boost action. It will also require setting manageable targets to reduce health gaps, and publicly report performance against them. Such a strategy would show cross-government commitment, coordination and a consistency of focus over the life of several parliaments. Key ingredients include: investment in prevention; funding and empowering local government to make progress; and encouraging businesses to contribute more through their employment practices and wider corporate social responsibility agenda.
The response to the pandemic has shown the type of cross-sector action required to protect people’s health and wellbeing. This same approach is needed to build a society where everyone can enjoy the same opportunity for good health. Now more than ever.