In the decade to 2010 life expectancy in England for the worst off increased by three years. In the last 10 years, according to a landmark study released on Tuesday, life expectancy has stalled for everyone in the country, the first levelling-off of health gains for a century. It is a national scandal that has poor women living shorter lives. In England, men in the poorest housing estates die, on average, nine and a half years earlier than those in the grandest homes. The poor in this country will not only die sooner, they will also spend more of their lives with a disability. In developed countries, death rates are supposed to decline. However, since 2011 there has been no sign of a decrease in mortality for people aged under 50. As the report warns: “If health has stopped improving it is a sign that society has stopped improving.”
It is clear that something has gone very wrong. The question is what? Sir Michael Marmot, the author of the report, says that the slowdown in life expectancy improvements cannot be attributed solely to severe winters or flu. What Sir Michael’s work points to is that inequalities are a matter of life and death, of health and sickness, of wellbeing and misery. It is unfair that in England people in different social circumstances experience avoidable differences in health, wellbeing and length of life. Yet the poor odds of life’s lottery are a result of political choices made since 2010.
What has happened in the last decade has been a significant erosion of power of those in the bottom half of society and a sharp increase in the power of those at the top. This transfer of power has coincided with an economic crisis: productivity growth, the source of a continued rise in the standard of living, has flatlined, and total average wages are still behind their pre-crash peak. Government spending as a percentage of GDP declined by seven percentage points between 2009-10 and 2018-19, from 42% to 35%. Time and time again, Conservative ministers have put the state at the service of the wealthy rather than the poor: more than 4 million children now live in poverty; Britain has higher income inequality and lower social mobility rates than many European peers; by 2016, the richest 1% owned 29 times what the bottom 20% own.
Boris Johnson secured a Tory majority by winning seats in the “red wall” across the north of England. Yet the voters in many of these newly won constituencies are at the sharp end of health inequalities: women in these seats have average life expectancies four years lower than those in true-blue seats Mr Johnson held. The prime minister says he wants to level up the country, but nothing in his government’s policies suggests an acceptance that ill health is directly related to inequality. It is also unlikely, given past utterances, that he sees the need for early intervention. As an MP and cabinet minister he supported the cuts that withered the state so much that every child could not possibly flourish.
The instinct of all British governments has been to help the poorest. This is a good thing. But ministers cannot just level up the chances of those at the very bottom of the pile; they must flatten the steep social gradient of health inequality. If ministers spend money only on improving things for the worst-off, then what happens to those just above the bottom, or at the median, who have worse health than those above them? This is not bureaucratic point-scoring. Around three in four people cannot expect to be disability-free at 68. So one has to address the inequalities for the bottom 75% of the country if you want to have a healthy population working at 68 – as envisaged by statute.
Unless they are well off, improving a person’s health requires a weakening of the connection between their social position and health. People need to be able to take control of their lives in ways that enable them to influence their health. Sir Michael’s work shows that this is a much better strategy than targeting behaviour directly. Economic growth without reducing relative inequality will not lower health inequalities. There is more to inequality than just income. But, as the Nobel prize winner Amartya Sen has long argued, income inequalities affect the lives people are able to have. To lead flourishing lives, people need a fair society.
• This article was amended on 25 February 2020. An earlier version said that a fall from 42% to 35% was a decline of 7%. It should have said a decline of seven percentage points.
