Comment

Prevention is better than cure

Sir Michael Marmot and Dr Jessica Allen, director and deputy director of the Institute of Health Equity, assesses the government’s commitment to prevention and what this means for health inequality, eight years on from the Marmot Review.

The government recently set out its vision for a new approach to health, ‘Prevention is better than cure.’ The vision, to be followed by a green paper, focuses on health improvement and an ambition to improve healthy life expectancy by five years by 2035. The level of this ambition and the focus on prevention are welcomed. In particular, the emphasis on the environment and early years as drivers of poor health is important. However, we think that a different approach to improving health to the one set out is needed if health inequalities and healthy life expectancy are to improve significantly.

The public health community has been drawing attention to the fact that since 2010, life expectancy has stopped improving in England, and is now actually falling in Scotland, Wales and Northern Ireland.

This stalling, and in some areas declining, life expectancy is hugely worrying. While some other European countries have also seen slowing improvements in life expectancy, the stalling in the UK has been more pronounced; and many other countries, in Europe (for example, Iceland, Italy and Spain) and further afield (Japan and Hong Kong) have a higher life expectancy than England.

Further work is needed to ascertain exactly what is driving increasing mortality rates to help us understand which policies may have played a role. Based on previous evidence, we know it is almost certainly related to social and economic factors. The government’s vision doesn’t answer these questions, and the emphasis on behaviours and technology as remedies will not adequately address these significant policy questions.

Looking only at the average life expectancy for a country can disguise the clear inequalities in health and wellbeing faced by the population. Life expectancy and healthy life expectancy relate closely to level of deprivation – there is a remarkably clear social class gradient in health and length of life.

The 2010 Fair Society Healthy Lives (Marmot Review) analysed the drivers of health inequalities, calling for action in social, economic, political, and cultural spheres. The review described actions in six key policy areas which would result in reductions in health inequalities:

• 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 healthy standard of living for all;
• Create and develop healthy and sustainable places and communities;
• Strengthen the role and impact of ill health prevention.

Since 2010, however, inequalities have persisted and appear to be worsening. Data from 2014-16 shows that there is a 9.3-year gap between the life expectancy of men living in the least and most deprived 10% of local authorities in England, while for women the equivalent figure is 7.3 years. There was a difference of 19.1 years in healthy life expectancy between both men and women living in the most and least deprived areas.

Even more concerning is that health inequalities are widening. Life expectancy for women in the lowest two deciles is actually declining, while those in the top deciles are living even longer. These worrying trends demonstrate the urgent need for a renewed focus on health inequalities and their causes, and one which we don’t believe will be met by the governmentʼs vision.

Our work on reducing health inequalities suggests this will not be solved within the healthcare system alone, or simply putting emphasis on health behaviours. There’s more the NHS can do on prevention and addressing the causes of ill health. However, the scale of the challenge requires a society- wide effort and cannot rely on the already- stretched health and social care system, even in collaboration with local government – although this is a step in the right direction.

To reduce health inequalities, and improve healthy life expectancy and life expectancy, action needs to be taken on the social determinants of health – such as high-quality early years education; affordable, decent housing; access to quality primary and secondary education for all children; fair and decent work; and dignity as we age.

The Health Foundation has commissioned the Institute of Health Equity to mark in 2020, 10 years from the Marmot Review, by exploring how policies have influenced health inequalities since 2010 and to make clear, practical recommendations for future action.

Enjoying NHE? Subscribe here to receive our weekly news updates or click here to receive a copy of the magazine!