Introduction

“The covid-19 pandemic has exposed the longstanding structural drivers of health inequities, such as precarious and adverse working conditions, growing economic disparities, and anti-democratic political processes and institutions. These important determinants of health have interlinked with class, ethnicity, gender, education level, and other factors during covid-19 to exacerbate existing social vulnerabilities in society”.

Covid-19 pandemic and the social determinants of health, the BMJ

The pandemic, nationally and globally, has not only thrown socio-economic inequalities into sharp relief, but exacerbated them.

Nowhere is this more evident than in relation to health inequalities. Even before Covid-19 health inequalities were widening in the UK. In February 2020 The Health Foundation published Health Equity in England: The Marmot Review Ten Years On which concluded that ten years after Professor Marmot’s landmark report Fair Society Health Lives health in five priority areas was worse (since Marmot) for people lower down the socioeconomic hierarchy in areas as wide as children’s life chances, realising everyone’s potential, ensuring everyone has a healthy standard of living, creating fair employment for all, and developing healthy and sustainable places.

Just three weeks later the UK was in lockdown. And what was clear even in the early stages of the pandemic was that Covid-19 starkly exposed the existing inequality in health and wellbeing, but also that it will have in many cases made them worse. Our briefing considered the possible impact of Covid-19, again drawing on the work of the Health Foundation. Those already facing the greatest disadvantages in society have had a higher risk of exposure to Covid-19 and existing poor health puts them at risk of more severe outcomes if they contract the virus.

The most glaring example of this is the impact of Covid-19 on Black, Asian and minority ethnic communities groups in the UK (and globally) where the pandemic highlighted the structural disadvantage and systemic discrimination faced by some of these groups and individuals.

Health inequalities has been a key issue and challenge for UK local government for years, especially since the publication of Fair Society Healthy Lives. There has been much innovative work (reflected here in a series of case studies) but progress nationally was slow and years of austerity had an adverse impact.

What can local authorities do to help to reverse this? We set out in this paper a series of recommendations for central and local government and focus on the critical role of councillors in tackling health inequalities.

Health inequalities and the crucial role of local government

Covid-19 has exacerbated factors that lead to health inequality; in the UK these are attested to by growing waiting lists and an increase in mental health problems, and an uneven impact of Covid-19 on certain groups, places and communities seems to be universal. As well as damaging outcomes, it has highlighted both  the critical role of local government in managing health crises, and the tensions between centralised, regional and local action. The initial failings of the UK track and trace system provide an example; this system required local action following a major central intervention, and exposed fragilities in the relationship between local and central government. The relationship between the centre and the local will be just as critical in tackling the health inequalities as we go into recovery, and we must do better.

Solutions to the massively complex challenges posed by systemic health inequalities need a decentralised element as the problems have a strongly local character. Many factors produce health inequalities and mitigating reducing them requires wide ranging action beyond health; a “whole systems” approach is critical; reducing health inequalities requires action across many sectors, and much will not be direct action by the health sector. This requires partnership between central and devolved government to be effective, with central government backing local action with sustainable funding and devolved powers. This “whole system” approach needs to be bought into at every level of government involved.

Local factors

Where mainstream approaches to development have often been rigid and focused on narrowly-defined economic goals, post Covid-19 development must be much more inclusive and egalitarian if it is to tackle health inequality. The wider determinants of health include housing, planning, sustainable transport, and the state of local economies, all of which are governed at a local level. The WHO Healthy Cities project puts health high on the agenda of decision-makers in cities. It  emphasises the importance of political commitment, strong leadership and institutional change, intersectoral partnerships, innovative action addressing all aspects of health and living conditions (including issues relating to vulnerable groups, lifestyles and urban planning) and extensive networking between cities across the European Region and beyond.

These aims are laudable, but there are a myriad of challenges and barriers to them, many exacerbated by Covid and by the effect of 10 years of budgetary contraction; the themes highlighted in the 2010 Marmot Review (read our backgrounder on the Marmot review) are as relevant now as they were then. In many crucial public services there has been a shift from prevention to late intervention. Examples include cuts to the local government public health grant and the shift from early years support for children. Analysis by the Health Foundation has shown that the per-capita public health grant had been cut by 24% in real terms since 2015-16, and that the greatest cuts have been in deprived areas which tend to have the highest levels of health inequalities. A review of research funded by the Health Foundation from the University of Cambridge identified 134 public health interventions that were cost-effective, based on National Institute for Health and Care Excellence (NICE) criteria. It concluded that investment in evidence-based prevention represents “excellent value for money” and there is good evidence that it can reduce the gap in health inequalities. The shift away from prevention must be reversed, and partnership working and engaging communities in promoting health and wellbeing remain critical for improving outcomes.

One critical lesson from the Marmot Report [citation] is the need for proportionate universalism, which aims to improve the health of the whole population, while simultaneously improving the health of the most disadvantaged fastest. As explained in this paper from Health Scotland, this is necessary to counteract the tendency for interventions to be disproportionately beneficial to those with better access to resources, who are better placed to take advantage of them. Planning for proportionate universalism requires assessment of individual needs as well as understanding of the impact of social inequalities on health outcomes; as such, it must be carried out at the local level.

Moving forward

As the UK recovers from the pandemic, many commentators have seen this as a real opportunity to transform how we respond to worsening health inequalities.

The Health Foundation’s ‘Unequal Pandemic, Fairer Recovery’ suggests that increased awareness of pre-existing inequalities and the disproportionate effect on some groups “can open new debates about how to address inequalities and clear the way for employers, service providers, local communities and governments to take more action to support these groups”.

“There are many social and political patterns emerging throughout this current crisis that we should hold on to. Local action and decentralised coordination in response to a world-wide crisis has been crucial. We should not forget it.”

The experience of Covid-19 has highlighted how local action and local thinking can help address challenges around health inequalities. In the essay Post-pandemic transformations: How and why COVID-19 requires us to rethink development, the authors describe how  “embedded, inclusive, often informal and unruly, economies, rooted in mutualism and solidarity, have flourished”. They cite food security as an example where there has been a huge increase in solidarity and grassroots activism from widespread donation of food to the destitute in India and Pakistan, to the provision of mobile meals to disadvantaged populations in the US and Canada. They ask (and attempt to answer) “are such solidarities confined to the particular context of an emergency, or do they offer glimpses of alternative economies for the future”? (Leach, MacGregor, Scoones, Wilkinson Science Direct, February 21). The Health Foundation also highlighted how strengthened local communities that emerged during Covid can help increase local social and economic resilience. These new networks have the potential to “create novel ways to adapt and deliver services to meet local needs”.

The UK government’s focus on “levelling up” may be a major opportunity to place reducing health inequalities at the centre of the social policy agenda. There is a lack of clarity about what levelling up will mean in practice (see LGIU’s recent paper). While frustrating, this also provides a space for arguing that one clear objective must surely be to reduce the systematic (and growing) differences in health outcomes between groups within the same population, and between different regions.

The King’s Fund have stressed that levelling up has to extend beyond physical infrastructure, pointing out that although infrastructure is important in addressing inequalities, it will not on its own address disparities in health and life expectancy between the most and least deprived communities. The Health Foundation [citation] also focuses on health inequalities and highlights that action to ‘level up the nation’s health’ has been described as a core part of levelling up; recent public polling suggests that 8 in 10 people in the UK feel that government must address these unequal health outcomes between those living in richer and poorer areas . Nonetheless, measures of health are not yet influencing the initial allocation criteria for levelling up funds, and initiatives are firmly tilted towards boosting financial and physical infrastructure capita

The Heath Foundation report points to the need for action within two areas to put the goal of improving health and reducing inequalities at the heart of the economic recovery. Firstly, they recommend immediate action to address the harm caused by the pandemic and prevent longer term scarring effects, including tackling the health care backlog, increasing mental health support to help people back into work, protecting family finances, creating jobs, and ‘catching up’ education and training. Secondly, they advocate building resilience for the longer term, including putting in place an adequate safety net to cope with future income and health shocks, providing greater protections for low-paid workers, designing better quality jobs, creating stronger communities and investing in higher quality public services, to tackle inequality by putting prevention first.

There is some grounds for optimism perhaps over the government’s approach to health inequalities. The Office for Health Improvement and Disparities, (OHID) was established in October 2021; the government claims that OHID will “mark a distinct shift in focus at the heart of government in addressing the unacceptable health disparities that exist across the country to help people live longer, healthier lives”. it will coordinate a programme across central and local government, the NHS and wider society, “drawing on expert advice, analysis and evidence, to drive improvements in the public’s health”. The pandemic has also seen greater political acceptance for government action and spend to support recovery, through job creation schemes and capital investment projects. In the recent Spending Review that the UK government recognised that  needed to be a change of course, with increases to the local government grant and spending going into areas such as early years support. The austerity of the past decade will, however, be hard to undo quickly, as local government spending remains hugely pressurised, and there are other policy areas where some of the poorest members of society will have been adversely affected, such as the withdrawal of the £20 increase to Universal Credit.

We emphasise again that a key approach to reducing health inequalities over the longer term is the prioritisation of prevention. As the original Marmot report stated, “early intervention and prevention in the early years can have lifelong impact, as well as yielding significant return on investment”. The government needs to pay heed to its advice.

See our recommendations for central and local government below.

Despite a growing understanding of the prevalence and causes of health inequalities and commitments by successive UK governments to close the gap, inequalities persist and widen. The pandemic has exacerbated differences in health outcomes within and between groups. In this next section we explore how.

In October 2020, the Health Foundation launched a UK-wide inquiry to consider how people’s experience of the pandemic was influenced by their health and existing inequalities and the likely impact of actions taken in response to the pandemic on people’s health and health inequalities.

The findings were published in July 2021 in the report, Unequal pandemic, fairer recovery

(Suleman M, Sonthalia S, Webb C, Tinson A, Kane M, Bunbury S, Finch D, Bibby J. Unequal pandemic, fairer recovery: The COVID-19 impact inquiry report. The Health Foundation; 2021)

The report highlighted that “the pandemic has revealed stark differences in the health of the working age population – those younger than 65 in the poorest 10 per cent of areas in England were almost four times more likely to die from Covid-19 than those in the wealthiest”.

The inquiry amassed extensive evidence that existing poor health, reflecting wider inequalities in people’s circumstances, put people at higher risk of death once exposed to the virus. Factors including type and quality of work, housing conditions, and access to financial support to self-isolate all contributed to increased exposure to the virus among working age adults. Key findings include:

• Among workers, men in roles such as security guards, care workers and taxi drivers were more likely to die from Covid-19 – with those working in sectors which remained open not only at highest risk of exposure, but also at higher risk of death due to existing poor health.
• Low rates and coverage of statutory sick pay and difficulty in accessing isolation payments reduced people’s ability to self-isolate, increasing exposure and spread.

The inquiry also explored the disproportionate impact of the pandemic across certain groups in society. People from ethnic minority communities, young people, those suffering from mental health conditions and disabled people in particular experienced worsening and compounding inequalities, increasing their exposure to Covid-19 and threatening their future health. People from ethnic minority communities had significantly higher risk of mortality – 3.7 times greater for black African men than their white counterparts during the first wave and Bangladeshi men more than five times more likely to die during the second wave.

Discussing the impact of Covid-19 internationally the authors stress that while there appears to be little relationship between pre-existing levels of life expectancy or healthy life expectancy and excess deaths from Covid-19 across different countries, greater improvement in healthy life expectancy over the past decade is associated with lower Covid-19 mortality.

Countries with the greatest improvements in healthy life expectancy in the previous two decades, such as Latvia and Slovenia, experienced lower excess mortality during the pandemic. A similar pattern holds for life expectancy improvements.

Lauren Paremoer in an article in thebmj describes how Covid-19 has devastated many health systems and the global economy with serious consequences for individual and household welfare:

While the pandemic has adversely affected virtually everybody, such deleterious effects have not been uniform, with the possibility that certain sections of society are more likely to be affected than others. It can be hypothesized that already vulnerable individuals such as those who have lost their jobs, individuals in precarious employment, those living in poor housing and neighbourhoods and the poor in general are more likely to bear the brunt of the pandemic than the relatively well-off.

Precarious work and exploitative adverse working conditions intersect with multiple factors, including ethnicity, migrant status, class, and gender, to influence which population groups are most exposed to Covid-19 infection. People in precarious forms of work have limited access to sick leave and healthcare services and their often low wages mean they cannot afford sufficient quality food, water and sanitation, and housing. They may also be hesitant to quarantine when they have covid-19 because they cannot afford to lose income and are unable to work from home. For example, major covid-19 outbreaks have occurred among meat workers globally.

What is described here in relation to working conditions is equally true of the UK.

We know that certain occupations are more vulnerable to Covid-19. ONS data shows that men working in what are classified as ‘elementary’ occupations had the highest rate of death involving Covid-19, such as packing goods and security. The links between income and health are complex as different factors interact with each other, but the relationship is clear enough.

The impact of the Covid-19 lockdown on specific groups is also reasonably clear, such as people on low wages being seven times as likely as high earners to work in a sector that has closed down leading to economic insecurity, and that low income jobs were more likely to mean having to go to work rather than working at home and being more exposed to the virus. Poorer people were less likely to have access to gardens or were living in more crowded situations: green space helps to promote both physical and mental wellbeing. Children in low income families had fewer opportunities to have home schooling during lockdown. There are many more examples of the differential effects of the response to Covid-19.

See also LGIU paper Community solidarity, economic division: the story of a year.

People with existing health conditions are more likely to die from Covid-19 and existing health inequalities mean that it is the already disadvantaged who are more likely to be in this group. The WHO explains that “people with disability experience poorer health outcomes, have less access to education and work opportunities, and are more likely to live in poverty than those without a disability”. For example, across the EU, less than one person out of two with basic activity difficulties is employed, according to Eurostat.

Public Health England published in September 2021 Health Profile for England, 2021 which showed that life expectancy in England had fallen to its lowest level since 2011, falling by 1.3 years for men, to 78.7, and 0.9 years for women to 82.7. The data shows that the level of inequality in life expectancy between the most and least deprived areas for both men and women was higher than all previous years for which PHE has data, covering the past two decades: “This demonstrates that the pandemic has exacerbated existing inequalities in life expectancy by deprivation”.

Life expectancy in Wales has also fallen – for men, life expectancy at birth was 78.3 years in 2018 to 2020, a week less than the years 2015 to 2017. For women, the drop was 9.9 weeks, taking life expectancy at birth from 82.3 years in 2015 to 2017 to 82.1 years in 2018 to 2020 (ONS statistics).

The ONS data shows that at national level, male life expectancy between 2018 and 2020 was highest in England (79.4 years) and lowest in Scotland (76.8 years). Within England, sizable regional differences are present, including a three-year gap between the North East (77.6 years) and the South East (80.6 years). For females, country and regional differences were smaller; the pattern mirrored that for males. Between countries it was highest in England (83.1 years) and lowest in Scotland (81.0 years); between regions it was higher in the south and lower in the north and the East and West Midlands.

The King’s Fund has analysed recent ONS data which it says shows ‘institutionalised’ inequalities in healthcare and wider society. They look at Westminster and Blackpool which have the biggest divide. Westminster saw male life expectancy rise from 77.3 to 84.7 years between 2001-03 and 2018-20 whilst in Blackpool it only increased by 2.1 years from 72 to 74.1. Eight of the ten most deprived neighbourhoods in England were in Blackpool.

The analysis shows that the geographical divide in longevity shown up by the ONS figures reflects a deprivation divide. In 2018-20, 47 of the 50 local authorities with the lowest male life expectancy were in the three most-deprived deciles, and the figure was 49 for female life expectancy. Covid-19 has exacerbated the deprivation divide, “increasing inequality in life expectancy between most- and least-deprived deciles from 9.3 to 10.2 years in males and 7.9 to 8.4 in females between 2019–20”.

Evidence from the West Midlands shows that underlying health conditions have increased the risk of serious consequences from infection with 8.2 per cent of the region’s population (compared to 6.8 per cent nationally), for example, having diabetes – a condition reported on more than 20 per cent of death certificates for Covid-19. ONS figures from mid-May analysed by the Health Service Journal (HSJ) indicate that Northern towns in the North West, North East and West Yorkshire are becoming the worst hit from Covid-19 in terms of persistently higher rates, cumulative infection rates and excess deaths. Local lockdowns had been more prevalent in parts of the North West and the Midlands.

There needs to be a reinvigorated debate about policy responses to the growing health inequalities gap – it was a high profile issue after the 2010 Marmot report but it seemed to lose impetus since – there has been more focus on personal responsibility for changing lifestyles and on specific initiatives such as the ‘sugar tax’ on soft drinks.

What is needed – as it was in 2010 – is the recognition of the underlying causes of health inequalities and the ways in which individual lifestyles are influenced by the wider physical, social and economic environment — “the interdependence of places and people”, as described by Professor Danny Dorling. Local government is in a unique place to bring together the two strands.

The recommendations focus on the UK – some will have wider relevance, such as those relating to engagement and placing wellbeing and health inequity at the centre of public policy.

 

Ambition and action

Covid-19 has exposed and worsened health inequalities and especially so in some places and for some groups. It has also stretched already tight resources for tackling health inequalities and the wider determinants of health.

Local authorities need to use the rethinking that is going into Covid recovery to challenge existing resource allocation and to if necessary rethink existing medium and long term plans across all the council’s work.

A council – alone or with others, should consider becoming a Marmot Community.