UK Government would need to make 'complete reversal' of policies to tackle health inequalities - Sir Michael Marmot

When Sir Michael Marmot first began to study medicine and then public health in the late 1960s and early 70s, health inequality was very much not on the agenda. It remained a “niche interest,” he says, even as he published his first papers in the late 70s, around the same time as Sir Douglas Black – a Shetlander who played a key role in setting up the NHS – was commissioned by the then Labour government to chair an expert panel on the topic.

“By the time Black reported, Margaret Thatcher was prime minister and she said famously, ‘there’s no such thing as society’, so how can there be social inequalities in health? And it was just brushed under the carpet,” Marmot says.

He goes on to describe his career at the time as being on the “margin of the margin”. While he did manage to secure funding for his research, he explains he had to place the emphasis on “biological mechanisms” rather than how it “fed into a fundamental public health issue”.

“That started to change when the Labour government was elected in ‘97,” he explains. “One of the first things they did was to appoint Sir Donald Acheson to lead a committee on inequalities in health [the Independent Inquiry into Inequalities in Health], and I served on that committee. The Labour Government said we need to take this seriously. Nothing’s been done about it for 18 years – we need to recognise it, we need to act on it, we need to do something.

The only senior group of politicians who don’t want to talk to me is the present government in Westminster

“I would say now, in my experience, the interest is unprecedented. There’s been nothing like it and I’ve been doing this, as I’ve just laid out, for 50 years.”

Marmot now heads up the Institute of Health Equity at UCL. He’s also been the president of the British Medical Association, president of the World Medical Association, chaired the World Health Organization’s Commission on Social Determinants of Health, and taken part in various other commissions on the topic around the globe. He was knighted for his services to public health in 2000, and in the most recent New Years Honours was appointed a Member of the Order of the Companions of Honour.

One of his most notable pieces of work, at least in the UK, was the Marmot Review. That was commissioned by Labour in 2008, to investigate health inequalities in England and to help inform decision-making for 2010 onwards. Fair society, healthy lives was published on 1 January 2010. It’s key message was: “Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health.”

But, in a strange parallel with the late 70s, the Conservatives took power five months later. The programme of austerity ushered in by the Cameron government made inequality worse.

I ask whether the body of evidence that inequality does have an impact on health is being taken seriously enough by decision-makers today. Marmot goes on to detail his relationships with politicians of various hues, that he’s given evidence to Holyrood and the Senedd, that he’s on the Welsh government’s constitution commission, that he has presented reports to local government and that places all over the UK have expressed interest in becoming so-called Marmot Cities or Marmot Regions.

“The only senior group of politicians who don’t want to talk to me is the present government in Westminster. So you could say, it is being taken seriously – it’s just not being taken seriously by the Westminster government,” he says.

Fuel poverty and food insecurity, that’s going to potentially damage the next generation’s health because it’ll damage children today

At the start of 2020, he and his colleagues at the Institute of Health Equity published the Marmot Review: 10 Years On. It was sharply critical of UK Government policy since 2010, highlighting a drop in life expectancy, an increase in ‘deaths of despair’ (those caused by suicide, drugs and alcohol abuse), rising child poverty and a housing crisis.

I wonder if this is the reason the UK Government isn’t listening. “I think so,” he replies. He points to the planned white paper on health disparities being shelved at the start of this year, saying that while he was “disappointed” he was “not surprised” by that decision.

“The actions that the government have taken since 2010 were all in the direction of increasing health inequalities and if they were going to produce a white paper that was serious about addressing health inequalities they would have to push back against their own policies… They would have to do a complete reversal of the policies they’ve been pursuing for the last dozen years, and that was always unlikely.

“So I’m not surprised that they didn’t produce a disparities white paper because either it wouldn’t have addressed the fundamental causes of health inequalities or they would have to say the policies we’ve been pursuing were increasing them.”

While the Marmot reviews have focused on England, he says that the worsening health inequalities he found in his 10-year update also apply to Scotland. “Everything we’ve said about England applies to Scotland, only more so… This slowdown in improvement in life expectancy we saw at the end of and during the decade of austerity, we saw in Scotland even worse.”

Since that report, life expectancy has dropped further – in large part driven by the coronavirus pandemic. Marmot says: “I was just looking at the data, before we spoke, for Scotland. You can see that particularly men’s life expectancy fell during the pandemic... It fell more sharply in the most deprived areas. You can see the pandemic had the effect of making overall health worse and increasing inequalities.”

It’s not as simple as just putting money into people’s pockets. You need public goods as well

And now we are in the midst of a cost-of-living crisis, which he warns will be a “big challenge”. “The evidence is so strong that fuel poverty will damage the health of children, will increase the excess winter deaths, it will damage not just the lungs of children, but the mental health of children. Children who grow up in cold homes have more mental illness problems. It’s less good early child development and more difficulty in school. And without government intervention, we said something like 60 per cent of households will be facing fuel poverty this winter.”

The government did intervene via the energy bills support scheme, which will have stopped some families slipping into fuel poverty. But even then, average bills increased by 68 per cent in the year to January and the Office for National Statistics said six in ten adults used less fuel over winter due to the cost increases.

At the same time, food insecurity has also risen. Marmot says: “The latest figures from the Food Foundation is that in September last year, one in six households without children and one in four households with children had food insecurity, which means going without food for a whole day, not eating enough to satisfy your hunger or missing meals because of lack of money.

“So take those two, fuel poverty and food insecurity, that’s going to potentially damage the next generation’s health because it’ll damage children today, which will affect their health through the life course.”

The solution to these problems, though, isn’t just about giving people more money. And when asked whether he’d support a universal basic income, he’s hesitant to give an answer. “People do need to have money, no question, and guaranteeing that everybody has at least the minimum necessary for a healthy life is important. But it’s not as simple as just putting money into people’s pockets. You need public goods as well.”

Health tells us a great deal about how well the society is doing and if the society is doing well, then health is doing well

Those public goods include the health service and universal education, naturally, but Marmot would also extend this to things like transport and food. “If public transport were appropriately subsidised or even free at the point of use, it would get people out of their cars, encourage them to use public transport. And if nutritious food were available without the cost premium currently associated – it’s cheaper to feed your children junk food than it is nutritious food – then individual income would matter less.”

That brings our conversation onto policies like minimum unit pricing for alcohol or the sugar tax. What are his views on these types of action, given they seek to address behaviour without modifying circumstance?

“It’s not either/or. Taking action on specific hazards, like smoking, is of vital importance and if the sugar levy means that people reduce their consumption of sugar and sweetened beverages, which we know has an impact on obesity, good. But that’s not instead of acting on the social determinants of health.

“If public health only acted on anti-smoking or sugar-sweetened beverages, I’d say it was deficient. It wasn’t addressing the real issues. But if somebody says to me, should we forget anti-smoking and just focus on doing something about child poverty? No, do both. They’re both important.”

And likewise on the prevention agenda, Marmot is keen to emphasise that its ability to change individual behaviours alone is limited. He gives an example from a trip he once made to Alice Springs in Australia. As part of that visit, he travelled to an Aboriginal community around two hours outside of the town, where a health clinic had been set up. On the walls of that clinic were posters encouraging people to eat more fruit and vegetables in order to prevent diabetes and obesity. “I thought, heavens, do you know much an apple costs in Alice Springs, which is two hours’ drive away? Where are they going to get fruit and vegetables in the middle of the desert? It’s not bad advice, but it’s not very helpful.”

And so I ask what changes he would make, if he were prime minister for a day, to improve health equity. “Firstly, if I were prime minister, I’d feel very sorry for the British population. I’m not suited for such a job and I would make a mess of it and people would say thank goodness it only lasted a day and we’ve seen the back of that fellow!”

Then more seriously, he says: “My advice to the prime minister is for every policy you have, your goal should be to improve equity of health and wellbeing. After all, what are you there to do?

“My general approach is that health tells us a great deal about how well the society is doing and if the society is doing well, then health is doing well. If society is unequal, we will have unequal health and so it’s a kind of social accountant.

“If you want to create a better society for people, put the likely impact on equity of health and wellbeing at the heart of all government policy.”