Health equality - can it ever be reached?

22 May 2020

Landmark reports have shockingly revealed growing gaps between the health and life expectancy of the rich and poor in the UK. Journalist Jo Waters asks why these inequalities exist, plus if and how it’s possible to help bridge the divide.

Improvements in life expectancy and overall health are things we’ve taken for granted in the UK over the past century, with each generation seemingly healthier than the last, and certainly living longer (Institute of Health Equity, 2020).

But new evidence says that not only has this progress stalled, but that the inequalities that existed 10 years ago have now widened. New reports published in February and March (just weeks before the Covid-19 lockdown), revealed deeply worrying trends in life expectancy and health inequalities…

The data speaks

The startling main finding of Health equity in England: the Marmot review 10 years on was that for the first time since 1900, after decades of consecutive improvements, life expectancy has not improved in England (Marmot et al, 2020). In fact, for some groups of women in poorer areas of the North East of England, it has actually got worse. Not only that, but inequalities in life expectancy and health have increased.

The difference in life expectancy at birth between the least and most deprived deciles was 9.5 years for males and 7.7 years for females in 2016-18. Back in 2010-12, the corresponding differences were smaller – at 9.1 and 6.8 years, respectively.

The findings echo a UK-wide analysis of life expectancy trends commissioned by the Health Foundation and published in November last year (Marshall et al, 2019). This report also found that inequalities in life expectancy between the richest and poorest have widened since 2011. Not only that, but for the under-50s, while life expectancy improvements continued in European countries such as France and the Netherlands, the UK fell behind. The report found that overall life expectancy in all four countries of the UK has stalled since 2010 to 2011, and now lags two years behind Spain, France and Italy.

Sir Michael Marmot, director of University College London’s Institute of Health Equity and chair of the Marmot review 10 years on, talks about the findings for young people: ‘If we look specifically at children, what we see is that child poverty went up – child poverty after housing costs was around 26 to 27% in 2010 and that rose to 31% in the latest figures. Child poverty for single parents not in work rose from 62% to 70%.’

At the same time, the Marmot review says funding for local authority children’s and young people’s services fell by £3bn, down 29% in 10 years. The steepest fall was in the North East of England, where the budget was cut by 34%, and the smallest decreases in the South East of England, where the budget decreased by 22%, so cuts hit the poorest areas hardest. Around 1000 Sure Start centres were also closed.

What about the kids?

A report by the Royal College of Paediatrics and Child Heath, The state of child health (RCPCH, 2020), also released this year in March, takes a UK-wide snapshot of child health in all four UK nations. The authors state in their summary that some of the findings ‘may make uncomfortable reading’ and ‘inequality continues to blight the lives of children and young people’.

Like the Marmot review, it also reveals a stalling of improvements in important aspects of child health including infant mortality (in England only), increasing child mortality and adolescent mortality (both in Scotland only) and big falls in immunisation rates for both the 5-in-1 vaccinations coverage at 12 months and MMR vaccinations (second dose coverage) in all four countries. The percentage of overweight or obese children aged four to five increased in all four countries too, with the biggest increases in Scotland and Northern Ireland. Across most indicators, health outcomes are worse for children in deprived areas. Child poverty rates also rose throughout the UK, with England at the highest rate of 31% (see Unequal numbers below).

Professor Steve Turner, a consultant paediatrician at Aberdeen Children’s Hospital and Scottish officer for the RCPCH, says that although there have been some improvements, such as more children living in smoke-free homes and much lower teenage pregnancy rates, many challenges remain.

‘Progress in reducing child and adolescent mortality has stalled in recent years. Of greater concern is the lack of progress in infant mortality in England from 2013 to 2018 with a slight rise in 2017 - a measure which acts as an index of the overall health of the nation,’ says Professor Turner.

‘Tackling obesity continues to be a challenge, with 34% of children and young people aged 10 to 11 in England being overweight or obese. Uptake of early vaccination has universally fallen for both the MMR and the 5-in-1 vaccines and across all four nations, with England and Wales recently losing their WHO measles-free status.’

The austerity effect

But just how could all this happen in the fifth richest nation in the world? And what exactly has gone on in the past 10 years to cause this marked step backwards in health?

‘Austerity has taken its toll in all the domains we set out in the 2010 Marmot review,’ says Sir Michael. ‘So, rising child poverty, the closure of children’s centres and declines in education funding; an increase in precarious work and zero hours contracts; a housing affordability crisis and a rise in homelessness; people with insufficient money to lead a healthy life and resorting to foodbanks in large numbers; and ignored communities with poor conditions and little reason for hope. And these outcomes are on the whole even worse for people from minority ethnic population groups and people with disabilities.’

The Marmot review attempts to answer some of the complex and difficult questions about why all this has happened, by analysing progress made under its six objectives to reduce health inequality recommended back in 2010. These include giving every child a fair start in life, enabling all young people and adults to maximise their capabilities and have control over their life, creating fair employment and good work for all, ensuring a healthy standard of living, and creating and developing healthy and sustainable places and communities.

Sir Michael said that although the authors could not say with certainty which of the adverse trends might be responsible for the worsening health picture in England, ‘austerity will cast a long shadow over the lives of children born and growing up under its effects’.

Tim Elwell-Sutton, assistant director for Healthy Lives at the Health Foundation, the independent health charity that commissioned the Marmot review 10 years on says: ‘We have come to expect that each generation will have much better health than the previous one, and that is still likely, but it is no longer a certainty like it used to be. Although those trends [of stalling life expectancy] have been seen across many high-income countries – they have been faster and sharper in the UK and US, so there is something different going on for us.

The A-word is highlighted yet again. ‘Austerity has almost certainly played a part in this. We had this huge economic shock in 2008 and living standards have improved very slowly since then. At the same time, there have been huge cuts to public services for children and young people.

‘Professionals such as health visitors are paid from the Public Health Grant and this has been cut by 22% in real terms per capita since 2015-16, so services have been squeezed.’ Tim says there’s nowhere near enough emphasis placed on creating long-term health in the UK.  

‘[The squeeze on public services] reflects the fact that nationally we tend not to give priority to things that create health in the long term – for example, in health we spend far more on treating ill health than measures that keep people well.’

‘Austerity will cast a long shadow over the lives of children born and growing up under its effects’

Poverty poison

Tim points out: ‘Although we now have low rates of unemployment [before Covid-19], according to one analysis by the Health Foundation (2020) around one-third of workers are now in low-quality work – that’s a job that has two or more negative aspects, such as pay, insecurity, a lack of autonomy, and low wellbeing.  

Imran Hussain, director of policy and campaigns for the charity Action for Children, says: ‘The story on poverty from the government from 2010 onwards was that what mattered was the number of people in work. But a study in 2013, and updated in 2017, looked at the impact of low income on child health: the study found it’s not just whether you are employed or not, but the levels of income that protect child outcomes [Cooper and Stewart, 2017].

‘If you’re working with vulnerable families, very quickly they will tell you that their biggest problem is poverty, mainly as a result of benefit problems – particularly the benefit sanctions regime. These were like a trapdoor where people would fall straight through the net. Sanctions and other problems in the benefit system are the leading causes of people being referred to foodbanks.’

Imran says the triennial analysis of serious case reviews from the Department of Education – a study of serious case reviews (where a child has died or been harmed, and abuse or neglect is suspected) held between 2014 and 2017 – mentioned poverty time after time, in a way it hadn’t before (Brandon et al, 2020). ‘Local authorities have such a high caseload because of cuts that they struggle to provide services, and they wait until there is a crisis before they intervene. The welfare of children is being imperilled by cuts to children’s services,’ says Imran.

‘You wouldn’t have an NHS that only provided A&E services. Child protection services need to be able to make early interventions as well as just putting children into care.’

Rhian Beynon, assistant director of policy and campaigns at the children’s charity Barnardo’s, agrees that the triennial analysis of serious case reviews found there had been an escalation in cases of serious harm arising from physical abuse and neglect. ‘And neglect can be linked to poverty,’ says Rhian.

‘What we are seeing across the Marmot review and the serious case reviews is that the profile of poverty and austerity are frequently highlighted as important factors which contribute to children’s outcomes, both health and safeguarding.

‘Austerity will have played a part in the resourcing of services, particularly for those with pre-existing vulnerabilities such as traumatic events, including abuse and bereavements. Other factors which contribute to children’s outcomes include the gig economy, people’s ability to access training, jobs, and adequate support for families with drug and mental health problems so they can overcome their difficulties and enter employment.’


How can you help?

Government action aside, what can you do to help as CPs? The RCPCH State of child health 2020 report makes specific recommendations for how health practitioners can practically help to tackle inequality. Overall, they are pretty much standard fare for CPs: making every contact count; signposting disadvantaged children, young people and their families to sources of support; advocating for local children, young people and their families; taking an active role in supporting child health research and data collection; and, finally, making child health a joyful place to work in.

On being involved in data collection, Professor Turner of the RCPCH says: ‘HVs and school nurses are uniquely placed to help provide data that’s crucial to us providing the best environment for children and driving improvements in child health: for example, breastfeeding rates, vaccination uptake, height and weight, mental and emotional health and wellbeing. Of course, we appreciate completing paperwork and populating websites to fulfil this will add to workloads.’

In terms of advocating, Ruth du Plessis, speciality registrar in public health and chair of the public health specialists committee for doctors in Unite, says: ‘HVs have important roles to play in supporting parents, talking about poverty and being their advocates. The Marmot review is very clear about the importance of supporting children in the early years to improve their lifelong health and opportunities.’

Professor Turner gives some examples of how he sees HVs playing a crucial role in changing lifestyle in the early years. ‘You could be particularly helpful in tackling childhood obesity for instance, explaining to parents that they can be role models for healthy eating. You could also give wider advice not just about developmental milestones but other issues such as safety.’

Imran reveals his concerns over the shortfall of children’s centres: ‘We feel HVs and other community practitioners have a very important role to play, especially in children’s centres,’ he says. And as many members will recognise: ‘With fewer children’s centres and HVs we feel there are fewer “eyes and ears” to spot problems and issues at an earlier stage than waiting for when a child starts school.’

"Experts agree health inequalities are not inevitable: there are positive steps that can be taken to address the problem"

What will be the impact of Covid-19?

‘People living in more deprived areas have experienced Covid-19 mortality rates more than double those living in less deprived areas,’ reveals head of health analysis, ONS (2020).

Before this shocking figure came out, reports suggested that those in lower paid, public-facing jobs who can’t work from home, live in more densely populated housing and use public transport, have been more exposed to catching the virus – with disproportionate numbers of people from ethnic minority groups in intensive care units with Covid-19 (Croxford, 2020). And record numbers of people have applied for Universal Credit (BBC, 2020). Indeed, there are fears that health inequalities and life expectancy for certain groups will worsen in the next decade because of the huge economic fallout of Covid-19: some economists are predicting it will eclipse the 2008 financial crash (Ahir et al, 2020).

Families are already struggling

Debbie*, a health visitor in southern England, says the profession’s come under increasing pressure over the past decade.

HVs are now spread very thin and we are under a lot of pressure. After the age of two we rarely see pre-school children, so if there is a developmental problem or other issue it might not become apparent until they start school. We’ve also seen a lot of Sure Start centres close and Home Start schemes discontinue, so there’s less support for families under pressure. Local authority children’s services have also been cut. The feedback from schools is that there’s been an increase in the number of children who don’t have ‘school-ready skills’. More children are not potty-trained for instance or have speech problems. We see a lot more families who have been housed out of London away from their families and support networks, which can be difficult. I’ve met lots of families who have had problems with Universal Credit and accessing benefits. Lots of people now have insecure employment too – working in the gig economy – and this causes financial insecurity and stress. Housing costs have also risen. The Covid-19 lockdown has exacerbated all of that – I’ve met families who had been badly affected within weeks.

*Name has been changed

What needs to change?

Experts agree health inequalities are not inevitable and there are positive steps that can be taken to address the problem, as several case studies have illustrated (see Success stories below). But they need to be actioned.

Tim says: ‘It seemed that austerity was at last coming to an end and there was going to be investment in professions that can achieve long-term health benefits rather in the acute end of the sector – but Covid-19 has thrown all that out.’

‘It’s very hard to predict the future at the moment; there are going to be enormous challenges – money is going to be extremely tight and the danger is the same people will lose out again unless we prioritise them. It does feel like we have reached a turning point.’

Already, Covid-19 has further highlighted the inequalites that exist in the UK (see What will be the impact? above).

Ruth, whose background is in nursing and health visiting, says it’s crucial there’s now more investment in public services. ‘It’s not only morally the right thing to do, but economically right too. If you don’t invest in the nation’s health then productivity will fall because you don’t have a healthy workforce.

‘We must invest in more school nurses and HVs because giving children the best start in life is one 
of the most powerful interventions of all.’

On poverty, Imran says: ‘Putting people into poverty weakens their life chances and their health. Children now have double the risk of poverty pensioners do. We need help for the low paid, with employers paying a living wage (although the living wage doesn’t consider family size).’

He continues: ‘The government has to get rid of its policies such as the benefit cap and two child limit for benefits. Post-pandemic, there are going to be a lot more people needing to claim benefits because they have had the rug pulled from under them by the lockdown. The government won’t be able to get away with depicting benefit claimants as “shirkers”. There are going to be lots of people really scared about their financial future.’

The Marmot review calls for action across government, recommending the prime minister chairs a cross-government initiative to tackle health inequalities. Sir Michael concludes in the review’s foreword: ‘The question we should ask is not can we afford better health for the population, but what kind of society do we want?’

Success stories

How the health gap can be closed…  

  • London: Richmond upon Thames has almost doubled the number of low-income children reaching school readiness from 36 to 61% in the last three years, partly as a result of a local authority-led campaign to improve support for disadvantaged children.  
  • Manchester: Greater Manchester has developed a new model for United Public Services, with the ambition of integrating health and social care services. The aim is to provide teams of public servants to serve population footprints of 30,000 to 50,000.  
  • Wigan: Wigan’s Deal for Health and Wellness is a citizen-led initiative with the emphasis on working ‘with’ the local community. Close to one-third of the population live in the most deprived quintile. The approach has seen healthy life expectancy in men and women rise faster than surrounding areas, smoking rates are better than the England average and the proportion of adults who are physically active has increased by 15% in five years.

Marmot et al, 2020



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