In the 2019 Conservative leadership election, Boris Johnson introduced a term that has since defined his platform: levelling up.
‘If I may be permitted to use a metaphor based on the internal combustion engine. We are somehow achieving Grand Prix speeds, but without firing on an cylinders,’ he said. ‘We all know there is a huge gulf in the prosperity between London in the southeast, the most productive region in all of Europe, and the rest of the UK… we must fight now for those who feel left behind.’
Almost exactly two years later, leading epidemiologist Professor Michael Marmot has released new evidence showing that when it comes to health, the government have done little more than level-down the nation.
Marmot’s damning analysis shows that Covid-19 mortality was 25 percent higher in Greater Manchester than in England as a whole. Life expectancy fell more quickly in the North West (1.2 years for women, 1.6 years for men) than in England (0.9 years for women, 1.3 years for men) – accentuating the health inequalities that already existed in the region. A close relationship between deprivation and Covid mortality means these falls in life expectancy were focused on both the poorest parts of England and the poorest parts of the North West region.
At times, in Westminster, there has been a temptation to blame the poor health of the poorest and most marginalised people on their individual choices. Last year, the idea the state might provide food for hungry children was met with outrage and evocations of parental responsibility from more libertarian MPs. But the brutal reality is this: stark and rising levels of health inequality are not down to individual choices – they are down to the places, and the material conditions in which we live.
In not recognising this reality, government policy during austerity and Covid-19 has combined to sustain and accentuate England’s stark levels of health injustice. And while inequality is not inevitable, Marmot’s call to #buildbackfairer can only be achieved with bold policy and a new willingness by this government to change the nature of power in this country.
How Austerity Destroyed our Health
Austerity was clearly detrimental to the NHS. While its budget never fell, it was not given nearly enough to cope with inflation and a population both growing and ageing. But what happened to the health service is far from the whole story. Though it’s relatively old fact, it still surprises many that the NHS only explains 10 to 20 percent of health inequality.
The rest of our health is mostly down to our location and conditions – and this is where austerity hit hardest. Between 2014 and 2019 almost £1 billion was cut from local public health grants. Wider local authority budgets were subjected to stringent cuts, which were much higher in the North of England. And health-critical departments like the Department of Work and Pensions and the Department for Education were among the hardest hit in Whitehall.
Unsurprisingly, the result has been avoidable poor health. During the austerity decade, our progress of preventing avoidable death stalled alarmingly. Should we have just maintained our previous trajectory—from 1990-2012—there could have been 130,000 deaths averted between 2012 and 2017.
Other evidence shows that austerity harmed the resilience of the poorest places, people, and communities to a health shock like Covid. In 2019, Institute for Public Policy Research (IPPR) research showed that the ten most deprived local authorities had experienced £1 in every £7 cut from public health budgets – compared to just £1 in every £46 in the least deprived. In 2020, our research further showed that places with the highest Covid-19 mortality has experienced public health cuts three and a half times as high as places with the lowest.
Covid-19 Policy Has Failed to Compensate
Austerity ripped the resilience out of our public health system. However, when Covid-19 hit, there were still opportunities to react decisively and mitigate the disproportionate risks faced by the poorest places in England.
While collaboration with the TUC on the furlough scheme constitutes good policy—a policy now being phased out far too early—the government has failed to acknowledge the link between material conditions, the places we live, and Covid rates. As such, they have failed the places, people and communities who austerity left at risk.
Manchester, the focus of Marmot’s new study, became the focal point of the government’s reluctance to tailor their Covid policies to the needs and realities of different places. Last Autumn, top-down imposition of tier three restrictions on the city-region—combined with woefully lacking financial support—led to a sustained clash between Westminster and Manchester Mayor Andy Burnham.
In fact, this was not an isolated event, but a trend – and one that underpinned not only class and regional inequality, but racial injustice, too. Research has shown that had the white population experienced the same risk of death from Covid-19 as the Black population, there would have been 58,000 additional deaths. Importantly, for all the troubling discourse around genetics at the time, our analysis showed that the key reason Black people were experiencing more risk was structural and institutional racism – resulting in differences in social conditions (such as occupation, housing, and access to healthcare).
If the government had accepted this evidence, it would have led them to a range of policies to alleviate health inequality and curb Covid. Easy policy would have included an end to NHS charges, offers of accommodation for people who could not isolate due to crowded housing, an extension of isolation pay to all, including those with no recourse to public funds, and targeted health information campaigns.
Instead of taking these sensible steps, the government were wilfully blind to the data – and chose not to act decisively. It is indicative of an approach where there was insufficient tailored support for those whose health was disproportionately put at risk by the last decade of government policy.
A Vicious Cycle
In his first levelling-up speech, Boris Johnson focused on the productivity gap between different regions. In allowing health inequalities to expand during Covid, and in doing too little to tackle them now, the government are allowing that gap to grow.
Poor health is one of the biggest barriers to a just and thriving economy. In 2018, analysis by Professor Clare Bambra for the Northern Health and Science Alliance (NHSA) calculated that health explained as much of a third of the productivity gap between the North of England and the rest of England. At the time, closing that gap would have been worth £13.2 billion per year. Following Covid, that figure is likely to be much, much higher.
The risk is that places now get caught in a vicious cycle. The combination of austerity and the pandemic will undermine their economy, and a weaker and less just local economy will harm public health; poorer health will, in turn, undermine the local economy. This is a mechanism of levelling-down.
Better is Possible
Professor Marmot’s plan to build back fairer shows an optimism that health equality can still be achieved with bold government policy. The difficult reality for this government is that levelling-up rhetoric will not be enough. They will need to address how power works when it comes to our health.
Three power shifts are needed. First, a shift from the personal to the collective. Austerity has shown that state divestment from health—and a focus on personal responsibility—doesn’t work. It’s time to put money back into public and community health.
Second, it is time for the government to protect our health from the worst interests of capital. Preventable ill health and the underlying health conditions that put people at risk from Covid rarely ‘just happen’. They are often a result of bad practice by chronically under regulated industries like tobacco, food and drink, alcohol, and gambling. The cost of these behaviours is now clear, and it is time to regulate on behalf of the many.
Third, it means redistributing power over health policy from national to local teams. If, as Marmot’s evidence suggests, health is determined by the places we live, then we need to empower local teams to create healthy places. There are good examples – the Preston model, the Wigan deal, Salford’s ‘sensible socialism’. It is time to give local leaders the resource, powers, and impetus to scale place-based and community health schemes.
The pandemic means Boris Johnson will be judged in forthcoming elections, and by history, on his record on health. And that record will be determined on his ability to act on Michael Marmot’s evidence, and enact a radical public health policy.