162. The Health Gap: Fixing Inequality in the UK

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1:21your own and the cost of money.

1:33Hello and welcome to The Rest is Money. It's just me today, Steph McGovern, but with a brilliant guest, Sir Michael Marmot. Now he is Professor of Epidemiology at UCL and Director of the UCL Institute of Health Equity. But fundamentally, he is someone who has helped shape policy discussions and decisions for at least the last two decades now. He did the famous 2010 Marmot review. Ten years later, went back to see how things have changed. And this is all about highlighting health inequality, what causes it, you know, why are there big differences of life expectancy depending on where you live? and with a decade of austerity, what impact does that have on health disparities in the UK?

2:21He's also done a lot internationally as well. He chaired the World Health Organization's Commission on Social Determinants of Health and has done big work with businesses as well. I'm delighted to introduce now my interview with Professor Sir Michael Marmot. it's an absolute delight Michael to talk to you because I have been fascinated by your work for a long long time you know someone who comes from the northeast of England someone who grew up in Middlesbrough now lives in Newcastle you know I see firsthand the health inequality and the impact that it's had and I know this is something you've been working on throughout your career not just in this country, but in other countries as well.

3:08So can you just bring us up to speed in terms of where we're at at the minute with health inequality in this country? Because I know you've led a big review on this, and then you kind of looked at it. You did that in 2010 and then looked at it again in 2020, 2019. Where are we at now, would you say? The easy answer is we're in a bad place. If we look first at overall life expectancy, and there's a drawback, because we need to look at inequalities in life expectancy. But if we look for a moment at overall life expectancy, between 2009 and 2023, 14 years, life expectancy did not improve at all. And that's absolutely dramatic.

3:56I mean, it's hard to say that nothing happening is dramatic, But it is dramatic because until around 2010, life expectancy for women and for men had been improving about one year every four years for the last hundred years since the end of World War I. And then in 2010, it was a break in the curve. What happened in 2010? We had a conservative-led coalition government elected. I maintain the fiction that I'm not party political. I say it as if I'm not serious, I maintain the fiction. But it's true in the sense that I look at the evidence and analyze it and try and figure out what's going on. And if that sounds party political, it's because we had a party ruling over this period when life expectancy didn't improve.

4:56Yeah. And austerity. austerity. And the government that was elected in 2010 was very clear. They wanted to roll back the state, reduce public spending, austerity. So that's overall. Second, if we look at what happened to inequalities, they increased. One way of measuring inequalities is classify people by where they live, classify where they live by the level of deprivation, the national index of multiple deprivation. And what you see is a social gradient. In other words, the greater the deprivation of a neighborhood, the shorter the life expectancy. It's not just the poor people have poor health.

5:43They do. But it runs all the way from top to bottom. People in the middle have shorter life expectancy than those at the top. If we look at the regional differences, take the Northeast, where you're from, Newcastle, the biggest city in the Northeast. For people in the least deprived 10 % of areas, the difference between London and the Northeast is trivial. If you're rich, it doesn't much matter where you live. The greater the deprivation, the greater the disadvantage of living in the Northeast. The gap between London and the Northeast gets bigger and bigger and bigger and bigger at every decile of deprivation.

6:29The consequence for your health of a given level of deprivation is much worse in the North East than it is in London. So to understand that then, what you're saying is, if someone lives in a deprived area in London, they're better off in terms of life expectancy than someone who lives in a deprived part of the Northeast? Equally deprived part. So this is a national index of multiple deprivation. Exactly what you just said is exactly right. If we look across the gradient, so for each level of deprivation, in London, life expectancy improved. So it improved for the most deprived people and improved for the least deprived.

7:13In the Northeast, it declined for the most deprived. It didn't improve for the second decile, the third, the fourth, the fifth, the sixth, for the bottom 60 % of the population in terms of deprivation. There was no improvement or even decline in life expectancy in the Northeast when it was going up in London. And why is that then? And how can it be that you can live in the same type of deprivation in one part of the country and it be such a big difference in terms of health inequality then? In my 2010 review, I drew on the World Health Organization Commission on Social Determants of Health, which I had shared.

8:02And we summarized the evidence. We had more than 80 experts advising us. And we summarized the expert advice in six domains of recommendations. Give every child the best start in life. Second, education and lifelong learning. Number three, employment and working conditions. Number four, really radical for a rich country. Everybody should have at least the minimum income necessary for a healthy life. Number five, healthy and sustainable places in which to live and work, including housing. And number six, what I call taking a social determinants approach to prevention. In other words, you don't just say, don't smoke, eat healthily, run around the block.

8:51You look at the constraints on people's behaviors. We've since added two more, tackle racism, discrimination, and their outcomes, and pursue environmental sustainability and health equity together. But let's take the six for 2010. What happened post-2010? Number one, child poverty went up. 1 ,000 Sure Start children's centers closed. Government stopped investing in early childhood. They made things worse. The Joseph Rountree Foundation reported on destitution. Destitution they defined as doing without two or more of six fundamentals. housing, heat, light, food, clothing, and toiletries. In 2022, one million children were living in a state of destitution.

9:52That was a 2.5-fold increase in five years. So child poverty went up, destitution went up, children were being admitted to hospital with rickets and scurvy, with Victorian diseases. Second, education. We reported in my 2020 report that the spend per pupil went down by 8 % over the decade from 2010, and the decline in spending was greater in more deprived areas. So the way we deal with inequalities is to spend less on education for poor kids, which is really important and may contain an important answer. We know that over the decade from 2010, central government support to local government went down by 59%.

10:51After 2015, local government could increase their revenue raising, increase council tax. And so the overall reduction was about a third. But we at the Institute of Health Equity plotted life expectancy in 2010-12. So I'm describing a graph for you. We plotted life expectancy in 2010-12 for every local authority in England, and then looked at the subsequent reduction in local government spending power by 2020. And what we found, the shorter the life expectancy in 2010-12, the steeper the subsequent reduction in local government spending power. And I look at this graph, and I think the kindest explanation I can give for this is absent-mindedness.

11:52They didn't know what they were doing. But it looks very systematic. In what moral universe could it be the right thing to do? The poorer the community, the shorter the life expectancy of a community, the more money you take away. Now we come back to Newcastle, and you ask me, why is it for a given level of deprivation, the prospects for healthy life are worse in Newcastle than London? Could it be that the reduction in local government spending power in Newcastle was greater than in London? You think then there's a direct correlation between how much a local authority spends and how long people will live?

12:37Yeah. Conclusions about causality are always hedged around with caveats, but there is a correlation. The bigger the reduction in local government funding, the worse the life expectancy performance. We looked a lot on this podcast. We did a special about children's homes and the amount of money that local authorities are spending on children's services and how a big chunk of that is being basically profiteering from private equity firms and various other different private organisations that are making money out of the fact that the local authorities don't have the capability to provide a lot of the services they did do to kids.

13:22And then it becomes this vicious circle of the demand growing and then them having to pay private companies in order to provide the services that they used to provide in the past in terms of like children's homes and other things like that. And also I see it firsthand living here. My friend's a head teacher in a tough part of Newcastle and she spends the majority of her time dealing with child protection issues, with social services. I don't think there's a week that goes by where she's not dealing with care issues and taken away from actual curriculum driven education. that my worry is if you're saying how much money we spend is you know the kind of key to this in these areas and at the same time you know we've got a government in now who are talking about welfare reform cuts to welfare and we're gonna have to do other cuts by the looks of things given everything that's going on in the world with Trump and you know we've already heard Rachel Reeves saying that there isn't that much headroom anymore in terms of meeting the fiscal rules and trying to balance the books and everything else.

14:27How do you feel now about what's going to happen next? Because it feels like it's going to get worse. It's a good question. And I feel challenged by your question on a daily basis. You know, it's what I worry about. I convey a message of hope, and it's an evidence-based hope. So in 2012, I produced my Marmot review in 2010. In February 2010, the month is important because there was a general election in May 2010, two and a half months after I produced my report, and the Labor government was ejected. I've already said correlation is not causation, so I don't think it was my report. In, I think it was 2012, the English city of Coventry declared themselves a Marmot city.

15:25Wow. They took on my report. I've mentioned my six domains of recommendations, now eight, and they said, we'll do this. And despite the brutal cuts that were coming down the line, we'll do this at the city level. We'll do what we can to reduce child poverty and to support families with early childhood. And right through all six, then Andy Burnham, the mayor of Greater Manchester, and I went to him. He had been Secretary of State when I delivered the Marmot Review, Secretary of State for Health, when I delivered the Marmot Review. And he said, and I don't think he was just saying it to be kind, he said his biggest disappointment of losing office then was that they couldn't implement the recommendations of my review.

16:26But he said, we'll do it at Greater Manchester. We've now got 50 places. We're working, doing a national strategy for Scotland, three Scottish Marmot places. The Welsh Cabinet Secretary for Health, he announced publicly, we are going to make Wales a Marmot nation. And all of these places are are doing the very best they can despite the cuts. Yes, of course, more money would be helpful. No question. But they're saying, with the resources we have, we're going to do the best we can to make a difference. So just on that, just to, because I'm fascinated by this. And as you say, you know, you recently launched this in Newcastle, becoming a Marmot City as well.

17:16So can you experiment what a marmot city is so it's the idea that you embed health equity into all aspects of decision making isn't it but what does that mean like how do you do that if the money isn't there like how are they doing it and what kind of impact you're seeing because obviously you mentioned Coventry the first one there back in 2012 2013 what what have you seen since that they took on this concept of being a marmot city what happens next very good question and it's the right question So what does it mean? It means taking on the Marmot Eight, the eight principles that I elaborated. Secondly, it means an attitude change and a system change of working together.

18:05So Coventry, for example, Greater Manchester too and other places, but Coventry has a Marmot implementation group. It's city government, the health and care sector, voluntary community and faith sector, other public organizations, the police, fire and rescue service, education. We're trying to get business involved as well. We did a report for business. So, for example, on a recent visit to Liverpool, I said, we need the Chancellor of the Exchequer to reduce child poverty. Action locally can break the link between child poverty and poor outcomes. And somebody from the Citizens Advice Bureau said to me, that's not correct.

18:59We can reduce child poverty. We help people get all the benefits to which they're entitled. And we help people get into work. So we're active in reducing poverty. So there's no question that we would like central government action to help to increase the funding to local government. I mean, councils that are going bankrupt, this is not mismanagement. they're not all suddenly there's an outbreak, an epidemic of mismanagement. Reduction of funding to local government of 59 % by central government. So some more money would be helpful. But a great deal of positive action is going on. Now, you asked me, is there any evidence of benefit?

19:49and what I've described are processes. What about evidence of benefit? In Coventry, the percent of children age five with a good level of development went up. Amazing. And the percent of 18 to 24-year-olds not in education, employment or training went down. Yeah. The percent of people in work earning a real living wage went up. And that is evidence? You know, it's not a controlled trial. I don't have the counterfactual. I can't say what would have happened in Coventry without our intervention, but things are moving in a good direction. Michael, I have got loads more I want to ask you in terms of where we can go with all of this, but let's have a quick break.

20:39welcome back to the rest is money i'm interviewing professor sir michael marmot who is um someone who's helped shaped policy decisions around health inequality for the last two decades or more um you know we've talked a lot about what the public sector can do in terms of health and health equity what about businesses can businesses adopt these principles in any way is there something they can be doing. For example, you see businesses now where they have wellbeing services, or they perhaps provide therapists, or they provide platforms in which to get medical appointments or things around menopause.

21:19So do you think business has a role to play in all of this? And if so, what is it? People in public health, in general, have seen business as the enemy. They talk about commercial determinants of health, tobacco, fat, sugar, salt, and food. So people in public health have traditionally seen business as the enemy. And I don't disagree with that analysis about the things that I mentioned. I've long thought, well, hang on a minute. We don't think everybody should be employed by the public sector. A healthy private sector is vital for a good economy. So, just to treat business as the enemy doesn't seem very helpful for all the reasons to which you alluded.

22:08So, when Legal & General, a big insurance company, came to me and said, what could business do? Not just what can we Legal & General do, but what could business do? We produced a report, The Business of Health Equity, the Marmot Review for Industry, and we said three domains where business can be active. First, conditions of work. Do you pay all your employees a real living wage? Do you have opportunities for employees for self-advancement and development and the like? Second, goods and services. To come back to the commercial determinants of health, if you're the tobacco industry, we can't work with you because your product damages health.

23:03End of story. If you're the food industry, which side are you on? We all need the food industry. Everybody who lives in a city doesn't grow much of their own food. We all need the food industry. So which side are you on? Are you going to be promoting obesity and non-communicable diseases or producing healthy, nutritious, affordable food? So the goods and services are important. That might be housing as well. We did a big report aimed at house builders. Talk about my Don Quixote approach, I suggested that house builders should put equity of health and well-being at the heart of what they were doing, not just profit.

23:54And the third is the wider impact of business, local hiring, commissioning, the environmental impact. On the point then of where we're at at the moment and the fact that we've got a government who want to tackle the amount of money we spend on welfare reform you know and there were very various big you know numbers that came out when Rachel Rees delivered her spring statement and delivered the information on how much welfare reform was being cut by one of the things that stood out to me was this sense of how much the number of people claiming disability or incapacity benefit has gone up by so I think the IFS said it was something like, you know, one in 10 now claim disability or incapacity benefits.

24:45And that is up from, you know, like 2.8 million in 2019. And they attribute a half of that, half of that rise coming from an increase in claims relating to mental health or behavioural conditions. Is it the same thing to tackle the change in mental health as it is, given that that's what the biggest increase has come from over that time? Have your thoughts on how we tackle this changed since you started looking into this? Or does it not matter whether it's physical or mental in terms of how we address health inequality? Well, I'd never say it doesn't matter. It matters enormously the type of ill health people have.

25:30But I would say that both are very important. I've said for a very long time that anybody interested in social determinants of health, as I am, has to be concerned with mental health. And anyone concerned with mental health has to be concerned with the social determinants of health. So, you know, I have the Royal College of Psychiatrists are great allies because they like what it is that I emphasize about social determinants of mental health. And I like their focus on coming from the clinical end as psychiatrists of recognizing the impact of the wider society on mental health. When at the beginning of our conversation, I was talking about life expectancy, but we also looked at ill health.

26:26People's reported ill health. And that stopped improving. And for women, it got worse. So in my 2020 report, pre-pandemic, ill health had risen, particularly among women, hadn't improved among men, and it got worse among women pre-pandemic. Then the pandemic made it worse. So that we have to distinguish the part of the increase in people claiming health-related benefits. That's a real increase in ill health. The part that's because of the quirks of how the whole system works, that you get more money if it's health-related. So if you go into work, you lose your benefit. If it doesn't work out, you then get a low rate of benefit.

27:18You know, there are these quirks in the system. And when the chancellor made her announcements about reduction in incapacity benefits, I wasn't thrilled, I have to say. But what I thought was, what I really wanted to hear is how, in a sense, we've had a terrible welfare system. It was very punitive. I tell you, I go around the country, you know, GPs in Edinburgh, they have a group called Deep End practices. They had set up a mental health clinic with the main purpose of advising people whose mental illness was caused by the stress of interacting with the welfare system. Being told, you're a terrible person, you're a fraudster, you're a cheat, you could work, You're just dragging the chain, and the default position is you're a terrible person.

28:23And this was the nature of people's interaction with the benefit system. And a generous benefit system, like in Denmark, in Norway, in Sweden, in other European countries, is a benchmark of a good society. Now, in my mind, the evidence shows that it's much better for people to be in work than not in work. No question. But it's got to be quality work. It's interesting, isn't it? Because it's how do you solve this then? Because what you're saying is we need to spend, I guess, more money in the earlier stages of life. And that kind of correlation there between money spent by local authorities and life expectancy and health and general health.

29:13but then at the same time the welfare spending is constantly going up from what you're saying it needs reform I know you're saying you weren't happy that there was a reduction in incapacity benefits but you're saying it does need reform so how how do you do that because we need to stop spending as much don't we on welfare and it just feels like you've got to do something drastic what is it that you do like what would you do if you were chancellor in terms of the money right now, what would you stop spending it on and instead spend it on? The British people don't know how lucky they are that I'm not the Chancellor.

29:54I don't know, because you're talking sense. And given that example of Coventry, where there is genuine change to a child's health and achievements, is what then sets us the rest of the economy, they'll hopefully then go on to more fulfilling jobs and then contribute more in tax revenues. And it feels to me like this is the key to the whole economics, not just about health. It's about how we prosper as a country, how we get growth, how we get greater productivity. Well, absolutely. I mean, you know, I wouldn't like to be in government right now. So, great sympathies. I mean, you know, I was asked by reporters when the winter fuel payment was reduced, what did I think?

30:41And I said, look, I'm a health person. I would always go for the policy that improves health, but I'm not the chancellor. I'm not the government that's got to balance a whole lot of different things. So I don't think it's just lack of scientific expertise. It's the business of government's really difficult. I'm not letting them off the hook, but it's really difficult. They have to balance lots of things. We want to improve health and reduce health inequalities, not just because it's good for the economy. In fact, my argument is almost the opposite. We want to improve the economy because we want to improve health and health equity.

31:27That, yes, there may be economic benefit if people are in work rather than in illness, then that'll be good for the economy. But that's not the reason. That's not what motivates me. I didn't become a doctor because I thought if I can help people recover from illness, they'll get rich. And I didn't go into public health because I thought if we can make a population healthier, it'll get richer. I'd like us to get richer, but I'll put that in air quotes. yeah oh god it's so fascinating isn't it what a career you've had following all this as well i could listen to you talk all day but i'm very conscious that i should let you have your life back but thank you so much for that i really really appreciate it michael and um keep doing what you're doing because people like me love hearing it and you're clearly making a difference to kids lives and well everyone's life from what you're learning and and yeah a marmot country is what we want isn't it modestly i think so yeah yeah oh well thank you very much my pleasure Thank you.