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Michael Marmot: ‘The Social Contract Has Been Broken’

Michael Marmot

Michael Marmot - one of Britain’s leading healthcare voices - speaks to Tribune about how austerity and the epidemic of social inequality threaten the future of the NHS.

Interview by
Karl Hansen

Over the course of a forty-year career, Michael Marmot has changed how the public, politicians, and academics think about health.

The professor of epidemiology and public health at University College London (UCL) and director of the UCL Institute of Health Equity has led research that challenges the orthodox view that lifestyle choices predominantly determine good or poor health.

Instead, Marmot emphasises ‘the social determinants of health’ — the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.

From this perspective, social and economic factors — such as income and wealth — that are shaped by public policy, are foregrounded; health inequities are ‘not in any sense a “natural” phenomenon but the result of a toxic combination of poor social policies, unfair economic arrangements, and bad politics’.

This argument caught the attention of politicians domestically, resulting in the New Labour government commissioning the landmark 2010 report Fair Society, Healthy Lives: The Marmot Review, which proposed the most effective strategies for reducing health inequalities in England.

However, the election of the Conser- vative-led government and the austerity policies it enacted foreclosed the possibility of implementing the report’s recommen- dations. The following decade would see social and economic deprivations worsen, with health inequities deepening as a consequence.

On the release of his follow-up report, Health Equity in England: The Marmot Review 10 Years On, Marmot decried the 2010s as a ‘lost decade’. Laying bare the damage done by austerity, the report argued that people could expect to spend more of their lives in poor health, face stalling improvements to life expectancy, and suffer staggering geographic inequalities.

Marmot’s pandemic report, Build Back Fairer: The COVID-19 Marmot Review, spelled out how inequalities in social and economic conditions before the pandemic contributed to the high and unequal death toll. Since then, the government has presided over the most severe cost-of-living crisis in living memory, prompting Marmot to warn of an impending ‘humanitarian crisis’ brought about by rising energy bills.

To mark the seventy-fifth anniversary of the NHS, Tribune sat down with Michael Marmot to discuss the relationship bet- ween health and inequality, and why addressing poor health demands wider poli- tical change.


What does public health tell us about the state of Britain?


Health is a good marker of how well the country is meeting the needs of its citizens because if social conditions are improving, health and well-being improve — they are outcomes of our set of social arrangements. If our set of social arrangements is not going well, our health will be damaged.

From 1900 until 2011, life expectancy had been improving by about one year every four years, and then the rate of improvement slowed before grinding to a halt. You can see the break in the curve. Then, if we look at inequalities, they increased. It’s a social gradient: the greater the deprivation, the shorter the life expectancy. That gradient got steeper. Life expectancy for the poorest people outside London actually went down. That’s pretty dramatic.

Our political–social settlement is based on the assumption that health will improve over time; we expect health now to be better than it was a decade ago. For significant parts of the country, that social contract has been broken. This tells us that social and economic inequalities have increased.

So when we look back at why that might be the case, I keep having imaginary conversations with George Osborne. I would tell him that he failed the country. He told us we had to swallow austerity to get the economy moving — and it didn’t move. Even on its own terms, austerity was an extraordinary failure.


Consecutive governments have claimed that they have broadly safeguarded NHS funding, but health outcomes worsened despite this. How true is that?


They didn’t safeguard NHS budgets because spending wasn’t maintained in line with historical trends. I won’t call it a lie because it is strictly accurate, but it was a deception; it was misleading. Health outcomes, at least until the pandemic, were not primarily due to NHS spending. They’re more to do with the social determinants of health.

Poor people use the healthcare system more than richer people because our wonderful NHS has broad equity of access, and poor people are sicker. One way to reduce the burden on the healthcare system is to reduce the avoidable inequalities in health. There’s so much illness in the poor parts of the population and that puts enormous strain on the NHS. So this intersection between need and provision is really crucial.


The NHS endures, while other elements of the post-war settlement that are vital to our health and well-being, such as the provision of public housing, have almost disappeared. Does this demonstrate a problem with how politicians understand the relationship between the state and our health?


There is a problem. The historian Peter Hennessy described my Build Back Fairer report as a ‘Beveridge Report for our times’. Now, nobody queued around the block to get copies of Build Back Fairer — Beveridge sold half a million copies of his report — but a Beveridge for our times is needed.

Some people point to how little we spent on the welfare state at its inception and how much we’re expected to spend today and in the future as an argument against its continuation. But the reason we had improving health, well-being, and equity in the years since the Second World War until the years of austerity is because of spending on the welfare state. We spent more and we got a healthier population as a result.


The New Labour government commissioned your landmark 2010 report. What interaction have you had with UK governments since?


I was happy to work with the current government; they just weren’t very interested in working with me. I met Andrew Lansley when he was secretary of state for health. That relationship terminated rather abruptly when I co-signed a letter urging the House of Lords to reject the Health and Social Care Bill. Unsurprisingly, Andrew Lansley was thoroughly annoyed with me. I did brief Jeremy Hunt when he became secretary of state for health. And that was it; he had no interest after that.


In linking health with wider social and economic inequalities, your work prompts questions about how the economy works and in whose interest. Do you think that is why some politicians are less receptive?


Of course. I try not to be party political, but if your instincts as a politician are to be suspicious of social action, and you are eager to stress that the public sector is inefficient, then you’re going to be less open to my kind of message. I try to get through this prejudice with evidence.

There was a recent study looking at two similar regions in Sweden. One privatised its ambulance services; the other was run in the public sector. If you’re on the Right politically, you’d say, ‘Well, of course, it’ll work better under privatisation.’ And indeed, if you look at the evidence, it was cheaper. They delivered the service at less cost, with a minor problem: the mortality rate was higher in the privatised service. So, if you think the purpose of public services is to keep costs down, privatise everything. If you think it’s got some other purpose, like saving lives, it’s better to keep things in the public sector.

I can’t argue with people who are not in good faith — that’s impossible. But if you’re a person of good faith, we can have a discussion. When I published the WHO Commission on Social Determinants of Health in 2008, one government representative said, ‘This is ideology with evidence.’ I quite liked that, though it was meant as a criticism. My ideology is pretty clear: health inequalities that are avoidable and not appointed by reasonable means are unjust. But the evidence really matters because that determines if your policies will be effective. The government has ideology with no evidence.


In response to the NHS crisis, Sajid Javid, the former secretary of state for health, called for patients to pay for GP appointments and A&E visits. What would this mean for public health?


Well, let’s start with the evidence: 31 percent of families with children now live below the poverty line. They clearly cannot afford the charges, so the result would be that they use the NHS less. But, as I said earlier, there is an increasing burden on the NHS due to greater deprivation, which leads to more illness. It’s not because people are saying, ‘How can I waste a doctor’s time this morning?’ I reject his proposal on evidential grounds, quite apart from moral grounds.

We already have the principle of a taxation-funded NHS, and people with higher incomes should pay more; we should have a more progressive taxation system. We should close tax loopholes, have a progressive council tax, and a property tax, and raise income tax for the richest. There are plenty of proposals to make our taxation system more progressive without creating great burdens for poor people. You don’t do it by undermining the very principle of our universal health service, free at the point of use.


There is a constant push to individualise responsibility for one’s own health for people who smoke or are overweight. How do you respond to that campaign?


When I was president of the BMA, there was one debate where somebody said that people who abuse alcohol or smoke should not get treated or should have to pay. He was slapped down in milliseconds. Nobody was going to entertain it; it was seen as immoral and a non-starter. The view was, ‘That is not the principle on which we behave. We treat people when they come to us. We don’t ask, Are they worthy?’

Illustrating my evidence-based response to that personal responsibility argument, if you asked, ‘How much would it cost for people to follow the Healthy Eating guidance?’ — for the poorest 10 percent of households, they would have to spend 74 percent of their income. They’re not being irresponsible by feeding their kids junk food — that’s what they can afford.

People in the top 10 percent need to spend about 6 percent of their income to eat healthily. So coming back to personal responsibility, if people in the top 10 percent of household incomes feed their children junk food, they’re being irresponsible. Poor people are being poor, not irresponsible.

I wish some of our politicians would get educated. If you eat junk food, if you’re under stress, and if you’ve got few opportunities to exercise because there’s no green space or safe areas for children to play, you’re more likely to get overweight. So yes, food insecurity can contribute to being overweight. When they say, ‘Anybody who’s got a mobile phone should be denied food from the food bank’ — no, people need mobile phones in the twenty-first century. You can’t deny people one basic need in order to meet another basic need.


What do you make of the government’s argument that we have to sacrifice, in terms of social spending for the health of the economy?


That argument of sacrificing for the economy was brought home during the pandemic. There was a correlation between Covid mortality, or excess mortality, and a decline in GDP. The countries that took the view that it was counterproductive to close down their economies to protect the public saw their economies suffer the most. The worse the Covid, the greater the economic hit. The idea of making sacrifices for the economy is based on a misunderstanding of how the economy and society work.

When Liz Truss was campaigning to be prime minister, I wrote a little rant in The Lancet looking at her arguments and the evidence behind them. She [thought] tax cuts and making rich people richer [would] lead to economic growth. I cited an IMF report — the International Monetary Fund, the cradle of neoliberalism — which gathered data from many countries and looked at the correlates of economic growth.

The report concluded that making the top decile of the income scale richer did just that — it made them richer, while there was a negative correlation with economic growth. The best correlate with economic growth was making the poorest 60 percent of the population richer. Well, for a non-economist, that just makes sense, doesn’t it? If you want people to repaint their kitchen or buy new clothes for their children, that helps the economy. Of course, everything’s got to be put in the context of sustainability and the climate, but if people are too poor to consume, the wheels of the economy can’t turn.


We’re in the midst of a historic strike wave, including across the NHS. What is the link between the bargaining power of workers and health?


I support the right to strike. It’s very important. The history of the improvement of working conditions and society has been based on workers’ right to withdraw their labour.

An economist from the Institute of Fiscal Studies argued that public sector pay should be determined by what you need to pay people to attract good staff and keep them, which I agree with — and I would add that they should also be paid according to the value of their work, not by some theoretical notion of inflation. Inflation should be controlled by other means, not by public sector pay.

I continue to emphasise this not on ideological grounds but on evidentiary ones. So people in employment were being asked to take a cut in real incomes. In the case of nurses, they had a 5 percent drop in real incomes from 2010 to 2022. And then, in 2022, they were being asked to take another 5 percent drop in real terms. And guess what? They didn’t like it.

Why should the public sector be condemned while companies make rip-off profits and cause inflation? It wasn’t wage settlements that were causing inflation; it was rip-off profits from corporations, in food and energy in particular. That was being used as an excuse to take even more money away from labour.


All the opinion polls suggest that the next election will return a Labour government. Is Labour pledging to deliver the policies and the type of redistribution needed to address the problems you highlight?


Keir Starmer has to win an election. That’s his job. But the Left’s question — ‘What will he do if he wins that election?’ — is important. There is no doubt that income and wealth inequality has gone too far.

In this regard, the UK is second worst among rich countries, only behind the US. Do we want to be more like Brazil or like mainstream Europe? If you look at the level of social mobility in Denmark, it would take two generations for somebody of low income to become someone of a medium income. In Norway, Finland, and Sweden, it is three generations. In the UK and the US, it would take five generations. And in Brazil, nine generations.

We know that the greater the inequality of income and wealth, and the lower the spending on children up to the age of five, the less [the] social mobility. We’ve already discussed the UK’s wealth and income inequality, but we also have below the OECD average spending on children. We are saying, ‘If you’re poor, your children are going to be poor; and their children are going to be poor. And we’re not going to do anything about it.’

I don’t know what Labour will do — but I’m sure we need a radical rethink.


If the UK is a case study in how not to do things, what country should we look towards for inspiration?


Take spending on children up to the age of five. The OECD average is $6,000 per child. In Norway, it’s $12,000. In the UK, it’s $4,000. In the US, it’s $3,000. We could choose to spend more by moving money from one budget to another or by raising taxes. We know childcare is unaffordable for many people. Politicians have recognised that.

In London, you can pay £18,000 per year, per child. Well, the median income is around £30,000. In Sweden, the maximum cost is $1,500 per year. If you’re poor and in a low-paying job in Sweden, you can go and work. Many can’t in the UK; it’s unaffordable. We privatised the whole childcare system so that those who need it can’t afford it. Instead, there are profits being made by private equity companies and corporations. The same is true of adult social care.

I don’t want to hear that we have to consign old people to the scrap heap and children to a diminished life because we can’t afford it. What do you mean, we can’t afford it? We have a lower rate of taxation than the average for OECD countries. These are political decisions. I try not to get involved in partisan politics, but look at the evidence. I want the government to solve that. And it’s soluble because they’ve solved it in the Nordic countries.


What is your message to those who will be the custodians of the NHS and the welfare state in years to come?


Put equity of health and well-being at the heart of all policy-making. When I was in Australia, there was a debate over the affordability of new nuclear- powered submarines. Now, I have no idea if that is a good or bad expenditure, but what I do know is that it’s not an excuse to take money away from children.

Britain is a low-tax country. If we raise taxes, then we won’t have to take a single penny away from spending. My message is that we can afford it. We can afford a properly funded NHS; we can afford to spend money on children. Our model isn’t working. We know that the economy is not growing in the way that the people who are supposedly committed to economic growth are hoping. The next government needs to grasp that. I want to see that new model being developed.

There is a prevalent mood of despair. We’ve had a government for the last dozen years which, according to the evidence, has damaged the health and well-being of the population. Most people on the Left and the Right have recognised the damage that austerity has done. So even though Jeremy Hunt is imposing austerity again, he’s not trumpeting it as the moral thing to do.

But I’m always hopeful for two reasons. One is theoretical and the other is experiential. The theoretical one is that hope results in more change than despair does. We need to believe that we can change things.

The other reason is experiential. There are many countries that are taking serious action to tackle health inequalities, some of which I have mentioned. But also within Britain, Greater Manchester is now a Marmot region. There are local and devolved governments that are trying to make a difference, looking at the evidence I have been producing and putting it into practice. I’d like the national government to do it too. So I think the message of hope and not giving in to despair is of vital importance.

About the Author

Michael Marmot is professor of epidemiology at University College London, director of the UCL Institute of Health Equity, and past president of the World Medical Association.

About the Interviewer

Karl Hansen is an assistant editor at Tribune.