A cure for a broken land

‘I got so agitated while I was listening to it that I got a blister on my morning walk.’

Professor Sir Michael Marmot is reflecting on an interview former chancellor George Osborne gave recently, where he described the UK as ‘the envy’ of the rich countries of the world prior to Brexit.

It was a defence of their records in government that Mr Osborne and former prime minister David Cameron also doubled down on in their evidence to the COVID inquiry. In what might seem like an entirely alternative universe to many doctors, they described a country which had been well prepared for the pandemic, thanks to their rigorous programme of austerity.

Sir Michael is eviscerating in response. ‘Austerity killed the UK,’ he says. ‘If you look at the changes the chancellor made to the tax and benefit system after 2010, working families with children in the bottom 10 per cent of household income, their incomes would have gone down by 20 per cent. And for families in the second poorest decile, their income would have gone down by 12 per cent. It was clearly regressive – these were just simply regressive policies making it harder for poor people to make ends meet.’

Sir Michael says that by 2019 government spending went down from 42 per cent of GDP to 35 per cent, and local government spending per person went down by 17 per cent in the least deprived 20 per cent of areas and 32 per cent in the most deprived.

‘Why would you imagine that wouldn’t have a negative effect? Do you think that all public money was going to waste, and you could cut with impunity?’

The result? Public services were in a ‘sorry place’, regressive cuts to local government meant authorities’ ability to support communities was deeply limited and, perhaps most damningly of all, child poverty increased. Sir Michael echoes the confusion of a whole profession when trying to find ‘the envy of the world’ or a well-prepared country among the inequitable ruins of society in the UK.

It is now 13 years since Sir Michael’s landmark strategic review of health inequalities in the UK, Fair Society, Healthy Lives, which called for urgent action to address health inequalities in the UK.

The recommendations were to give every child the best start in life, enable all children, young people and adults to maximise their capabilities and have control over their lives, create fair employment and good work for all, ensure a healthy standard of living for all, create and develop healthy and sustainable places and communities and strengthen the role and effect of ill-health prevention.

The report was followed by a 10-year update in 2020 which revealed that, for the first time in more than 100 years, life expectancy had failed to increase across the country and, later that year, another report examining the relationship between COVID-19 and health inequalities – urging UK politicians to rebuild the country more fairly.

In the 13 years since Fair Society, Healthy Lives, there have been great successes for Sir Michael’s campaigning including cities, regions and local authorities declaring themselves as basing their work around the Marmot principles.

In recent days and weeks Sir Michael has been invited to put together a report looking at health inequalities in Mexico and will look to work with the national institute of public health in italy on a plan to create a network of modern, healthy, cities.

He continues to work with the Welsh and Scottish Governments, too. ‘The fact is the arguments I’ve been making are being taken up all over the place,’ he says. 
‘I don’t feel like I’m being ignored – I’m being listened to.’

There is, however, one glaring exception – the Westminster Government. Sir Michael says he ‘could spend all my time being unhappy because the Government in Westminster isn’t listening’ but is resolved to work with anyone who wants to in his bid to improve lives across the country and the world.

With a general election required by January 2025 a change in government may lie ahead.

So, what is Sir Michael’s prescription for the country’s health should politicians be listening? He says: ‘First we make sure we give every child the best start in life – that includes reducing child poverty, investing in pre-school, restoring closed Sure Start centres and addressing having among the least affordable childcare in Europe. Second, education and lifelong learning. Third, employment and working conditions.

Fourth, everyone should have at least the minimum income necessary for healthy life. Fifth, healthy and sustainable places in which to live and work. And six, taking a social determinants approach to prevention. So yes, we would look at obesity and smoking and drinking but we also look at the social determinants.’

Those principles remain true to the original asks set out 13 years ago, but Sir Michael has also added two more for the ministers of 2023. He says: ‘We need to tackle discrimination, racism and their outcomes. And, finally we must tackle the climate agenda and the inequality agenda together.

‘That’s my prescription for the next government – that’s what I’d like them to do.’