Professor Michael Marmot’s latest report on health inequality did at least stop short of endorsing claims that ‘austerity kills’. But the hard evidence of causal relationships between trends in life expectancy, economic conditions and government policies is still desperately thin.
The Marmot Review is based on two simple propositions. First, the report highlights what appears to be a major change in health trends. In the foreword it states that “from the beginning of the 20th century, England experienced continuous improvements in life expectancy but from 2011 these improvements slowed dramatically, almost grinding to a halt. For part of the decade 2010-2020 life expectancy actually fell in the most deprived communities outside London for women and in some regions for men”.
Second, the report pins the blame squarely on the impact of austerity, ‘from rising child poverty and the closure of children’s centres, to declines in education funding, an increase in precarious work and zero hours contracts, to a housing affordability crisis and a rise in homelessness, to people with insufficient money to lead a healthy life and resorting to foodbanks in large numbers, to ignored communities with poor conditions and little reason for hope.’
So far, so bad. I’m perfectly willing to believe that the severe recession which followed the global financial crisis had an adverse impact on health outcomes, and that austerity played some part in delaying the economic recovery. However, the Marmot Review doesn’t advance our understanding of any of these points.
Let’s deal with those two propositions in turn. First, it’s not so certain that there has been a marked deterioration in health outcomes. The raw data on life expectancy cited in the Marmot Review are ONS statistics and do indeed suggest that the pace of improvement has slowed since 2011. However, they also show that average life expectancy is still increasing.
There was a pause between 2015 and 2017, due in part to a spike in mortality during the winter of 2014 to 2015, but average life expectancy has since risen to new highs. Professor Marmot therefore has to limit himself to the statement that life expectancy has fallen for some groups and ‘for part of the decade’ – not all.
What’s more, even many years of data may not be enough to be confident of a material change in trends, which could take decades to confirm. This is particularly important when talking about what are actually relatively small changes in life expectancy at birth, and when comparing population cohorts that may have very different risk profiles (such as vulnerability to dementia and Alzheimer’s).
Of course, this isn’t my field and I’d happily give way to others here. But some far more qualified than me have already cast doubt on similar studies, such as claims that cuts in health care spending have led to 120,000 more deaths than might otherwise have been expected.
It is my place, though, to comment on the economics arguments in the Marmot Review. These are very shaky. For example, a central theme is that rising economic inequality has contributed to rising health inequality. However, most measures of economic inequality (certainly those that might explain different health outcomes) have barely changed since 2010, whether you look at income or wealth. The report has therefore had to cherry-pick data to support its narrative.
The analysis of changes in the labour market is also weak. I was particularly struck by the assertion that the growing use of zero-hours contracts may have had some impact on life expectancy. Whoever wrote this bit seems unaware of evidence that zero-hours contracts are most common among 16-24 year olds, who are typically in full-time education and who might actually value the increased flexibility. It’s certainly a huge leap to suggest that their lives are being shortened as a result.
Blame is also laid at what the report calls ‘an abrupt change in the state pension age for women, which has risen from 60 to 66’. As it happens, ‘abrupt’ is a stretch for increases in the state pension age which were first announced in 1995, even allowing for the acceleration in the 2011 Pensions Act. But most independent commentators have supported these changes, not least given the increase in life expectancies.
Finally, like many of these studies, the report chops and changes between relative and absolute measures to make its points, especially in the discussion of child poverty.
To be fair, there are undoubtedly some valid points in the report. There are clearly problems with housing affordability, the rollout of Universal Credit, and the provision of social care. There is also plenty of evidence that the rich enjoy better health than the poor. But the Marmot Review simply repeats the standard ‘big state’ solutions to all of these challenges – more government intervention, more public spending, and higher taxes. It therefore adds little, if anything, to the debates on these crucial issues.
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