Back in 2010, Sir Michael Marmot’s landmark report exposed the strikingly large and widening inequalities in health outcomes across the UK. Complex interactions between health, economic and social outcomes are at the centre of these disparities and so a multi-pronged approach is needed to tackle them by embracing economic, social, and clinical interventions.
Even before the Covid-19 crisis, little action had been taken on health inequalities across the UK. Slowing rises in Healthy Life Expectancy (HLE) mirrored the stagnation of real median wages in the 10 years after the first Marmot report. Among more disadvantaged communities, health and economic outcomes had worsened and inequalities widened further.
The Covid-19 crisis once again laid bare the symbiotic relationship between health and socio-economic outcomes, individually and nationally. The pandemic has been anything but an equal-opportunity threat. Its effects have been felt disproportionately by poorer and less advantaged communities and cohorts, amplifying pre-existing inequalities in health outcomes as outlined in the Health Foundation’s Covid-19 impact inquiry.
The pressures facing households today, both in health and economic outcomes, are probably as or more intense than at any time since 2010. Today’s dramatic squeeze on household balance sheets from the ongoing cost of living crisis will, if history is any guide, lead to an equally dramatic worsening of health outcomes among the least well-off households, compounding the pressures arising from the Covid-19 crisis.
Flat-lining economies and communities = poor physical and mental health outcomes
The link between socio-economic and health outcomes can be seen from the strikingly high correlation between outcomes for health (physical and mental) on the one hand, and pay or productivity on the other, across the UK.
Indeed, it is not just current economic outcomes but future outcomes that can affect health. The “deaths of despair” discussed by Angus Deaton and Anne Case in the United States – from alcoholism, drug addiction and suicide - can often be traced to people perceiving themselves to have limited future career and life opportunities. There is evidence the UK could be following a similar path.
When it comes to the links from health to the economy, the costs are equally large and long-lived. They show up in wide inequalities in levels of economic inactivity across different communities and cohorts across the UK. They appear as wide polarities in levels of absenteeism for health reasons, both physical and mental. And they manifest as a shortening of healthy life expectancies – and hence career spans - for individuals.
To give some idea of the scale of these effects, imagine the healthy life expectancy of the UK working population were to increase by just a single year. Given reasonable assumptions about retirement ages and the age distribution of the population, this might eventually be expected to deliver a boost to aggregate lifetime earnings of around £60 billion per year – or £1,000 extra per person per year on a permanent basis.
Recognising these costs, later this year the UK Government will publish a white paper on health disparities. It has already set itself a target of shrinking health ‘disparities’ by 2030 and raising healthy life expectancy by five years by 2035. Achieving these objectives would mean turning a tide that, if anything, has been gathering pace over recent decades. A reversal of these trends has eluded governments, of all colours and across many countries, since at least the late 1990s.
Economies for Heathier Lives
So, what programme of change is needed to contribute to preventing a repetition of this pattern of serial failure, especially among the most disadvantaged people and places in society? Now is the time for local experimentation with different approaches that can then be rigorously evaluated, and the lessons learned – and, if successful, scaled.
That, in a nutshell, is the approach being taken in the Health Foundation’s Economies for Healthier Lives programme, being conducted in collaboration with the RSA. This programme focuses on a set of diverse interventions in four places - Glasgow, Havant, Leeds and Liverpool - each facing distinct health-cum-economic challenges. These interventions embody several features likely to be important when breaking the adverse health/economic cycle of the past several decades. Let’s take a look at just four of these features.
Health and economic outcomes are often hyper-local. That means they require hyper-local solutions, which in turn need to be designed and delivered by local anchor institutions - local government, local healthcare providers, and local community groups. Only these institutions have the knowledge, as well as agency, to tackle these problems at source. The push towards not just devolution but ‘double devolution’ across the UK in the government’s recent Levelling Up white paper will, I hope, help put more power in the hands of local communities.
These interventions are most likely to be effective when they are part of a coordinated local plan, embracing not just health but transport, business, social care, employment, education and skills policies. These are all key parts of the local ecosystem, and any misfiring element jeopardises the chances of system-wide success. Another benefit of local control is that it enables collaboration in a way that is likely to be more successful than if it were done at the central government level.
Testing and takeaways
Experimentation and evaluation are likely to be key to success. In this fledgling field, case studies on “what works” are still being built. So, some degree of ex-ante local innovation and experimentation is likely to be crucial, along with rigorous ex-post evaluation to enable robust conclusions about these interventions' scalability and wider applicability. The more diverse these sets of local interventions, the richer the evidence base and the stronger the likely policy conclusions.
Mental and physical health, and access to opportunities
Issues of health, inclusive growth and wellbeing need to be centre stage when it comes to evaluating the success of policy interventions. This too would be a decisive break from the past where the focus had been exclusively on economic outcomes. That is why, in the recent Levelling Up white paper, health and wellbeing were given equal status in the 12 missions defining success, alongside living standards and job creation.
At this critical moment for the fortunes of the nation’s health – to say nothing of its wealth and happiness – we need radical but rigorous policy experimentation; we need the joining together of policies and actors – including disadvantaged communities - too often siloed in the past; and we need delegation and decentralisation of design and delivery of these interventions to the local level. The Economies for Healthier Lives programme will tell us a great deal more about whether this kind of action is sufficient to reverse the increasing breadth and depth of health inequalities.
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