The scandal of Britain’s health inequalities

Take a train from London King’s Cross to Newcastle and your journey will span 245 miles and several years of a child’s life. According to the most recent estimates from the Office for National Statistics (ONS), a baby boy born in the north-east of England in 2020 is likely to enjoy just 59.1 years of good health before starting to slide into infirmity, then death, at 77. A boy born in the south-east at the same time has a healthy life expectancy of 65.5 years and a total life expectancy of almost 81.

It’s a grim fact of national life that people in poorer places live shorter, sicker lives than those in richer ones. This should be a scandal, the sort of thing that grips political attention and demands remedy.

Yet health inequality is one of those problems that is just too large, too complicated and too long-lasting for politicians to really grapple with. People who don’t know if their ministerial careers will be over next year struggle to prioritise problems that can take decades to turn around. The civil service is just as susceptible to short time-horizons. Most civil servants remain in post for a couple of years before moving on: a new job is often the only way to get a pay rise.

So quick fixes that show results during the mayfly lives of Westminster and Whitehall officials are hard to bring about, to say the least. In the dry words of the ONS earlier this year: ‘Healthy life expectancy at birth in the UK showed no significant change between 2015 to 2017 and 2018 to 2020.’ That’s half a decade and no change in one of our country’s starkest inequalities.

This is the context for the biggest, boldest and hardest challenge set in the Levelling Up White Paper, which promises to narrow the gap in lifespan between the richest and poorest places. ‘By 2030, the gap in Healthy Life Expectancy (HLE) between local areas where it is highest and lowest will have narrowed,’ the paper says, adding: ‘By 2035 HLE will rise by five years.’

That second target, an overall increase in healthy life expectancy, will be extremely hard to deliver, though not unprecedented. HLE improved by around four years in the ten years to 2009–11, so a five-year rise over the next 13 is achievable.

However, it will very likely depend on things that any government finds very hard to deliver. That decade of improvement mostly saw rises in wages, employment, health spending and housing quality. All those are generally necessary for longer, healthier lives, but will be tricky to conjure up in an era of low growth and high inflation.

The real levelling-up challenge on health and lifespans is to narrow that gap between rich and poor – and here the figures are horrifying. Life expectancy at birth for girls in the most deprived 10 per cent of local council areas in England is lower than the life expectancy in all OECD countries apart from Mexico – while healthy life expectancy is just 51.4 years. For women in the richest parts of England HLE is 71.2: a difference of 19.8 years. For men, the difference is 18.4.

There are a great many reasons for these gaps, which make the problem so tricky to address. Those reasons include – among many other things – NHS provision of primary care, employment, housing quality, smoking habits and air quality.

Most of these factors are the responsibility of a different part of central or local government – and fragmented management means inadequate focus. Funding cuts that have fallen hardest on councils in the poorest parts of the country have only made it harder for the state to respond.

I worry that healthy life gaps will not narrow and may even worsen, because of one thing I didn’t put on the above list. It deserves particular attention: obesity. Being obese significantly increases your risk of experiencing early ill health and death.

Obesity levels have increased from 15 to 28 per cent since 1993. But the rise has been very uneven: people in the most deprived areas are much more likely to be obese.

Again, that train journey from South to North is a good illustration of regional differences. Some 66 per cent of people in Northumberland (where I was born) are obese. The rate in London is less than 55 per cent.

Perhaps the grimmest aspect of all this is the way that today’s problems will echo down the decades to worsen lives many years from now. Childhood obesity is a case in point. An obese child has a good chance of becoming an obese adult and then living a shorter, sicker life.

Again, there is a horrible geographic and economic gap: 15.5 per cent of children leaving primary school in the least deprived areas are obese, compared with 32.1 per cent in the most deprived. These figures from the National Child Measurement Programme are for the year 2020/21. We have yet to see the full impact on obesity – and therefore, on eventual lifespans – of two years of reduced physical activity due to Covid restrictions.

What’s to be done about this? The promise in the White Paper is a good start. It says this is something on which we should judge ministers, even if that judgment will not be passed for many years.

But words are the easy bit. What about action? Unsurprisingly, I can’t offer a single, simple answer to a challenge so big and so complex. A multifactorial, decades-long problem requires remedies to match: a complete overhaul of public and acute health systems; a rebalancing of public spending by region; an urgent improvement in the financial position of local authorities in the poorest areas; dramatic increases in housing quality; a better economy with more high-wage jobs in more places; a shake-up of a Whitehall machine that still works in silos.

It will also require significant changes in habits. Smoking is dying out, but bad diets are replacing it as a drag on lifespans and health. So the first thing for politicians to do is to put much more focus on obesity and take effective action.

This means moving beyond willpower narratives which suggest that all people need to do is try a bit harder and they’ll be able to eat better and lose weight. All the evidence shows that policy based on willpower is doomed to fail.

Instead, obesity should be approached as a systems-based or even an environmental issue. We should look at what every bit of policy – healthcare, education, transport, housing, welfare, taxation – can do to support people in eating better and weighing less.

And don’t think this is something the state alone can solve. The private sector has a major role to play, starting with the food companies. Investors in food companies have started to realise that unless something changes, such firms could be the Big Tobacco of the coming decades. A good obesity policy should seek to work hand in hand with those investors pushing for change in the industry – and reward firms that respond to the challenge.

Tackling health inequalities will be slow and difficult. The first step is to accept that levelling up must mean slimming down.