Michael Marmot on health and the UK election

Michael Marmot, Professor of Epidemiology at University College London, Director of the UCL Institute of Health Equity, and Past President of the World Medical Association, joins Gavin and Jessamy to discuss the centrality of health issues to UK politics, what the upcoming election should be fought on, and the role of equity and equality in UK health outcomes.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello, welcome to The Lancet Voice. This January 2024, I'm Gavin Cleaver. I'm here with my co host Jessamy Bagnall. We're very pleased to have you back for a fifth year of The Lancet Voice. 2024 is a huge year for elections and democracy around the world. And across the year we'll be taking a look at what this means for health in some of these elections.

We're super excited to be joined for a look at health in the upcoming UK election by someone who should need no introduction, Professor Michael Marmot.

Professor Marmot, welcome to the podcast. We're going to talk today a little bit about the upcoming UK election and how health plays a role in UK politics. So you know, we're almost certainly going to have an election this year. That's what it sounds like in the UK. How central do you think health is to that election?

Michael: I have a one track mind. I see everything through the same lens. Some people think about sex. I think about health inequalities. So I think health inequalities are absolutely crucial, but I can justify my argument. It's just. It's not only my obsession, firstly, everybody cares about health, their own health, and surveys show people care about the health of others, and they are concerned if people have ill health through no fault of their own, and I think there's something good about our society that people do have that feeling.

Secondly, because my analysis on the social determinants of health has led to the conclusion that if health is improving, society is improving. If health's not improving, society's not improving. If health inequalities are getting bigger, inequalities in society are getting bigger. And that means to improve health, we've got to improve society.

And that even if A new prime minister said to me, look, I've got so many priorities don't come to me with health because I've got so many other things to think about. My response is the other things that you have to think about, education, the economy, inequality, the environment, communities, maybe even culture and the arts, all of those things.

Impact on health. If you actually want to create a better society, better prospects for the future for our children, you will invest in the social determinants of health. If you put equity of health and being at the heart of all government policy, you will be taking the actions. to reduce crime, to have a greater level of skills in the economy, probably to improve productivity, in other words, to create a better society.

Gavin: But political discussion in the UK, perhaps more so than anywhere else in the world, when health comes into the matter, is incredibly focused on the health system itself, isn't it? How well it's functioning, how long the waiting lists are but that's quite reductive. 

Michael: It's very important that we have a well functioning healthcare system, no question.

I'm not one who says 80 percent of health is determined by what happens outside the healthcare system, therefore, ignore the healthcare system. We're all gonna get sick. We're all going to need access to high quality healthcare. No question, and the NHS has been unloved, starved of funds. Back in 2009 10, when the Commonwealth Fund ranked health systems in 11 countries, consistently the NHS would come out.

We had the best healthcare system in the world. The greatest equity of access and quite efficient. We didn't spend a lot compared with other countries, it was quite efficient. Since 2010, the spend per person, after you've taken into account the growing size of the population and the aging of the population, the spend per person went down by 0.

7 percent a year. for the first five years and 0. 3 percent a year for the next five years. Compared with under the previous Labour government, it went up by 5. 8 percent a year. We've got an unloved, uncared for health system. The waiting, number of people waiting for treatment between 2009 and 2019 went up By 90%, it was 1.

9 times rarer in 2019 than it was in 2000. All of that needs attention. But as many people have said for many years, the NHS is an expression of our values, is not just a very good and absolutely vital health care system, and eroding. This publicly funded healthcare system, free at the point of use, eroding it, is a way of eroding our values, and that has to be reversed.

We need a mixed economy with a thriving private sector, but a thriving public sector, part of which is the NHS. So having said all of that, we need the NHS. And now, my real obsession is with the social determinants of health. What happens to make people sick in the first place? 

Gavin: There's a lot of doom and gloom in the news about how much money incoming government is going to have to spend to address some of these health problems.

What are your views on on the narrative in the media when it comes to headroom for maneuver? 

Michael: The first part of narrative is appropriate. It's narrow. It's a narrow narrative. I, it was just doing some sums for another purpose. In 2010, the conservative LED coalition government said austerity, when they came into power, public sector expenditure was 42% of GDP.

Over the decade, that public sector expenditure went down from 42% to 35%. 7% of GDP is about. A hundred and seventy five billion pounds a year at today's prices. That's what was taken out of public sector expenditure. Let's have a debate. Let's have a proper debate. What do you want to do with a hundred and seventy five billion?

Do you want tax cuts for richer people? Do you want to pay off the national debt? Or do you want to stop people freezing in the wintertime and their children starving? What do you want to do with it? Let's have a proper debate. Let's not just say, oh, your tax cuts, oh, labor will tax and spend.

Take that as a ballpark figure. Some economist will tell me I've got the wrong number, but let's take 175 billion. at today's prices that was taken out of public sector expenditure. And let's have a proper debate and say, yeah, we'd like people at higher rate of income tax to pay less tax. So we'd like to use some of that money to make rich people richer or paying off the national debt.

Or paying teachers, paying social care workers reversing the closure of Sure Start Children's Centers making sure people can afford the necessaries. Joseph Rowntree just published a report today that I was particularly concerned with child poverty. Child poverty. Went up consistently from after housing costs about 27 percent in 2010 to 30 percent by 2019.

Interestingly, it went down in the first year of the pandemic with The furlough scheme and other expenditure, but it's now rising again. We haven't had a fall in child poverty, a consistent fall in child poverty since the first half of the Blair Brown government. Let's have a proper discussion. Let's not have some very narrow discussion about are you going to have this tax or that tax or you Jeremy Hunt mused in Davos.

Oh, maybe low tax is good for economic growth. Again, There was a leak of a report to the treasury saying, don't bother me lowering taxes is not the way to get economic growth. We're not doing better than, apart from the U. S., we have lower tax rates than the other G7 countries. We're not doing better in terms of economic growth, at least than the other European countries.

Let's have a proper discussion about it. And if people say yeah, we'd rather that rich people paid less tax and have visible public services, fine. Let's go that way. Because it won't surprise you to know, I don't know. I'd rather put the money into better public services and pay social care workers a real living wage.

Gavin: You mentioned the COVID pandemic there. The last time we spoke was was during the pandemic where we discussed inequity and how health outcomes in the pandemic have been affected by inequality. Given the kind of benefit of hindsight now, a couple of years removed from the height of the pandemic have any of your opinions on how inequality and equity functioned in the pandemic changed at all?

Michael: I regret to say that they've been reaffirmed. Not that, that sounds like I've learned nothing closed, but reaffirmed. Had we taken inequality into account we might've done a better job. For example, you say to somebody in Manchester, come forward and be tested for COVID. And if you're positive, you've got to stay home, or whatever it is, 10 days, 12 days, 14 days, you've got to stay home.

We won't give you any money. We won't compensate you for the loss of work. Just stay home. Guess what? People aren't very motivated to come forward and be tested. Because if they're positive, they could lose two weeks of pay. And if they're at or below the poverty line, that's not something they can afford to do.

And then because of our total lack of faith in the public sector, look what happened with Test, Trace and Isolate. Having stripped public health budgets, Instead of funding public health to do test, trace, and isolate, that's their job. What was it? We spent 38 billion pounds on a totally ineffective private sector solution to test, trace, and isolate.

And come out of module two of the COVID inquiry was the government was at least as chaotic as we feared at the time, if not more and paid no attention to inequalities, nah. The evidence that Claire Baba and I gave to the Covid inquiry to module one said we were ill prepared for the pandemic because of the rising social and economic inequalities, because of the disinvestment in public services, because we weren't very healthy coming into the pandemic.

We were real prepared. And then what we did during the pandemic, if anything. exacerbated and we can see that life expectancy, not just COVID mortality, but all cause mortality declined for the bottom 40% in the first year of the pandemic. So not only did we have extreme. inequalities, a social gradient in COVID mortality, but it had a big impact on all cause mortality.

The new thing that I learned, and we all should have learned from the pandemic, is the importance of examining ethnic differences the very high mortality in Black African, Black Caribbean, Pakistani, Bangladeshi, and to a lesser extent, Indian populations. British people the very high mortality during the pandemic alerted us much more to what we should have been alerted to all along, the racial ethnic differences in health.

Jessamy: But I wanted to take us back to some of our earlier discussion about your statement that everyone cares about health. Now obviously that's always been the sort of de facto basis for so much health advocacy in global health and public health. I'm just wondering, is that statement true? And what evidence are we using to suggest that everyone cares about health?

Because there's not a word that you've said that I disagree with. Everything that you say, as always, is completely spot on. But, I don't feel that we're in that political landscape. We're not going to have a real honest discussion about public finances or public services. And it doesn't seem to me that people do particularly care about health.

Michael: The Fairness Foundation has done some polling. on health and health inequalities, and not only does it support my view that people care about health and health inequalities, it does suggest. The people would be prepared to pay more taxes to deal with the issue. Now, what people do when they're in front of the ballot paper and all about paying more taxes when it comes to voting is a different question, and that's one that's taxed political scientists a great deal.

But certainly if you ask them, they say they're willing to pay more taxes for better public services, including. Improving health and health inequalities. So when I say people's care I'm referring to polling like that done by the Fairness Foundation 

Jessamy: And I think that's absolutely right. Of course, it is people do care about health, but I suppose What I'm referring to is right now when there's so much economic instability, it's what Ed Miliband says in his book, Go Big, if you're so worried about putting food on the table for the end of the week, you don't care about what's going to happen to your health in the longterm, you don't care about what's going to happen to the planet.

I'm just wondering, I feel, sometimes I feel frustrated that we as a health community, we take this fact as for granted, everyone cares about health and everybody should be doing everything that they can to make health better, but, and I feel like maybe historically we've had more luck cutting through political discourse.

saying this is going to improve population health or this is, but right now I just feel we're not cutting through with that, either to voters or to politicians. Do you think that's fair or am I off? Am I feeling internally frustrated? And it's not necessarily reflected in what's really going on with the conversations that you're having at a very high level.

The 

Michael: reason I'm talking to you today and the BBC's been after me and I was talking to Radio London LBC yesterday is because I think we need to get the word out. We need to get the word out, and you tapped into something very important. You skipped over it quickly, but what you said is very important.

If you're trying to get food on the table today, never mind planning for Friday, but you're trying to get it on the table today, you're not going to be thinking about that. What you need to do for the long term to prevent cancer and heart disease and add 1. 5 years to life expectancy. That's too abstruse and I recognize that.

Those moment to moment, day to day decisions caused by adversity, caused by hardship, of course having a huge impact on your health and the health of your children. for the future, but you're not in a position to plan. I've just been looking today for another purpose at the OECD Social Mobility Report.

It's a bit old, 2018. This has somehow filled the need. If it's not, I don't know. 2023 it's a bit old, but it's highly relevant the OECD Social Mobility Report, and it's brilliant, and it makes clear just how vital parents circumstances are to the chances of their children. There isn't a politician in the land who would say, equality of opportunity, no, I don't believe in it.

Everybody believes in equality of opportunity. It's a chimera. It's a chimera. It doesn't exist. It's just completely out the window. Everybody says you're equality of opportunity. In Britain, if you're rich, your children have good chances. And if you're poor, your children have poor chances. It's not absolute.

It's certainly a lot worse. in Britain than it is in Denmark, and it's slightly better in Denmark than it is in Finland, Norway, and Sweden. We're slightly worse in Britain than the average for the OECD rich countries in social mobility. In general, rich parents have rich children, poor parents have poor children, and educated parents have educated children.

And we love the examples people who break the bounds who come from poor backgrounds and do well. It's wonderful. We love it. The rags to riches story is inspiring always. And the more, the better. The fact is, in general social mobility is limited by two groups of things. One, the equality of economic and social conditions in this generation.

It has big impact on equality of economic and social conditions on the next generation. And the second is how much we spend on early child development, preschool, education on those early years. And in Britain, we're doing badly on both counts. Big inequalities in this generation and growing, and we're very miserly.

In what we spend, again, there's a couple of years old from UNICEF, the average spend on children aged 0 to 5 in OECD countries is 6, 000 per child per year. In Norway, they spend about 12, 000 in Sweden, a bit less. The average is 6, 000 per child per year. In the UK, we spend 4, 000. significantly below the average.

We've heard politicians saying we're world beating this and we're world beating that. No, we're not. We're limping along below the average. So when you say people maybe don't care about health, but they care about their children. 

Jessamy: I agree. And of course I care about health, but I'm just wondering whether this leads us to some kind of re evaluation of how we're communicating our points.

You've obviously had enormous successes with your, Marmot cities and. Do you feel that we need to change how we're talking or what we're advocating for? Or do you think what we've been doing, over the last 5, 6, 10 years is working in terms of getting our points across, in terms of the importance of population health and the importance of the first thousand days, all of these things.

Michael: I I would say, you mentioned Marmot cities, based on my experience of more than 40 places now around the country that have taken on Marmot principles, it's really exciting. People feel in local government, in health authorities in the voluntary and community sector. Even, to some extent, in business recognizing the social determinants of health.

I do not think we've done a good job in getting the message in general to the general population. We've got to do much better. But I'm excited that, the grim statistics that I talk about, but I'm excited by what's happening in places. I was in Glasgow in December. It was the first meeting of Public Health Scotland in person.

They were formed in 2020. And because of the pandemic, they, so they had 750 public health doctors other professionals gathered in Glasgow for their first in person meeting. The day began with some children in an orchestra playing music. I can't speak for the rest of the audience, but I guess they were in tears as I was.

It was so beautiful, it just absolutely, how wonderful, raised the spirits. And then I got up to give the opening lecture and said, just remember how you're feeling right now, having heard those wonderful children create music, because I'm going to give you some very grim news. But, I want to finish with that soaring feeling that you had listening to those children of how we create a hopeful future.

And to hear these children say, we look forward to coming to school on Saturday because we get to play music. What? Normal kids? Looking forward to school on Saturday because they get to, this is not an independent school. This is not one of your fee paying schools. They play raga on Saturday.

These are normal kids from Glasgow, working class kids whose spirits are lifted by indulging in music. And I wrote a piece, forgive me for the BMG but, I don't always, I do write in the Lancet, but and what I said was what we need is some hopefulness, to have one set of politicians tell lies, one lie after another, everything's going well, we're doing brilliantly, everything's fine.

And, everybody knows nothing is fine. Catch a train, try and get a, try and do anything nothing's working. Try and get a medical appointment, nothing's working. So everybody knows the, we're not doing fine. And the other side is saying it's grim and it's doer and we'll be responsible. How about our politicians starting to talk about a hopeful future?

We've got a vision for the future. We've got we want to create a society where everybody can lead lives of dignity. And I can tell you that if you take the decisions that lead to the capability, the possibility of people leading lives of dignity, you will improve health and reduce health inequality.

Because that means we're investing in people. Preschool in education and education includes pitches to play sport and music and we'd stop closing libraries and we'd have community groups thriving. All of this, we want to create a hopeful future. And at the moment that's not happening, but that's what I'm trying to say as we come up to an election.

For goodness sake. Give people something to look forward to. 

Gavin: I wanted to ask, actually, if I could what are some of the practical principles being enacted in Marmot cities and how might they look on a kind of national basis if we adopted some of those principles? 

Michael: Number one, put equity of health and being at the heart of all policy making.

Whatever you do, be it environment education, the economy, migration, whatever it is you're doing, and Put equity of health and being at the heart. What's the likely impact? I remember going all the way back to 2010 when Michael Gove was Secretary of State for Education and introduced free schools.

And I was asked, what did I think about that? And I said I don't have an a priori view other than what's the impact on equity of health and being if free schools benefit. middle class families at the expense of low income families, then I'm not in favor. But that would be the first question I would ask.

What's the impact on equity of health and well being of all policies? And that's happening at local level. And then we've got what was the Marmot Six. It's now eight, but the six were give every child the best start in life, education and lifelong learning. Employment and working conditions, number four, having enough money to lead a healthy life, number five, healthy and sustainable places in which to live and work, and number six, taking a social determinants approach to prevention.

So you don't just say eat healthily, you try and make sure that people have the possibility to eat healthily. They have enough money, supply of nutritious food, and the like. So those are the six that people have been acting on at the city level. The two we've added tackle discrimination, racism, and their consequences in light of COVID.

And number eight, which in a way has been there all along, tackle the climate crisis and health equity together. So we want social sustainability. 

Gavin: So finally then, in the election, in this election year in the UK, what would your hopeful pitch be? 

Michael: What I just said I would want three things. The first is, I would want a spirit of hopefulness.

That we've got a vision of what a better society that everybody looks like where everybody. As I said, can lead lives of dignity, lives they have reason to value, where their worry is not can I put food on the table tonight, but how well my kid's doing at football or ballet or whatever playing music, rock band or whatever it is they want to do.

Lives of value for people. And to have hopefulness. The second is to put equity of health and being at the heart of all policy making. And the third is to build on. Marmot cities and places with the six, now eight recommendations, which the evidence suggests acted on will improve health and reduce health inequalities.

Gavin: How far away would you say the current government is from these sorts of principles? 

Michael: I think, I try not to get too political, but in my 2020 report with the Marmot review 10 years, so I pointed out that. In relation to my six domains of recommendations in 2010 Malmo review, the government had gone in the opposite direction in almost all of them, and that I suggested was why health had more or less stopped improving.

Health. Inequalities had got bigger and health for the poorest people. It got worse. Since then, Health's got even further. Deter has deteriorated even further. got even worse. And they'd not been acting on those principles. The IFS published their 2023

The spending per pupil in deprived areas has gone down more than the spending per pupil in non deprived areas. So the inequalities in education spending continue to increase. So that is one example. Child poverty is going up. They're, the current government's moving in the wrong direction and their only policy to address it is to say things are going well.

They don't seem to have policies to address it. They just say things are going well and okay, we'll all be pleased. So, I wrote an open letter to all the party leaders. I'm trying not to come off the fence here and say I want. This party to be in government or that party to be in government.

I wrote an open letter to all the party leaders and said this is what you've got to do. the current government isn't doing it. 

Gavin: Professor Marmot, thank you so much for joining us on the podcast. It's always fascinating to chat with you. 2024 is a big year and hopefully some of the things that we discussed can be addressed in the forthcoming campaign.

Pleasure to talk with you and thank you so much for joining me. 

Michael: My pleasure. Thank you.

Gavin: Thanks so much for listening this episode of the Lancet voice. Remember, you can subscribe to the Lancet Voice, wherever you usually get your podcasts, and we'll see you again next time.