Michael Marmot is the Professor of Epidemiology and Public Health at University College London and Director of the Institute of Health Equity.
This interview was conducted on 27 February 2023.
Q: Could you please give us a brief overview of your interest in the question of regional inequality and growth over the period from 1979 to 2015?
I’m Michael Marmot; a Professor of Epidemiology and Public Health at University College London (UCL) and Director of the UCL Institute of Health Equity. I’ve been researching health inequalities and social determinants of health since the 1970s. I published my first paper on Inequalities in Health in the UK in 1978. I chaired the World Health Organisation Commission on Social Determinants of Health, which ran from 2005 to 2008. We launched our final report in 2008: ‘Closing the gap in a generation’. I was invited by Gordon Brown, who was then the UK Prime Minister, to answer the question of how the findings and recommendations of the Global Commission could apply to one country, England, and conducted a new Review with a new set of experts and we published that in February 2010, ‘Fair Society, Healthy Lives: The Marmot Review’.
I’ve been involved in several reviews of the evidence. Regional reviews for the World Health Organisation in Europe, in the Americas, and most recently in North Africa and the Middle East. In February 2020, on the 10-year anniversary of the Marmot Review, we published ‘Health Equity in England: The Marmot Review 10 Years on’, and then later in 2020, we published ‘Build Back Fairer: the COVID-19 Marmot Review’, looking at the impact of the pandemic. Then we’ve done several reports across Greater Manchester, Cheshire and Merseyside, Lancashire and Cumbria, Waltham Forest, Luton and around the country. The earlier ones I mentioned are all very much about the North-South disadvantage.
Q: Were you surprised that the growth between UK regions seems to have grown rather than narrowed?
I wasn’t surprised because I’m not like many scientists; I’m not in the business of prediction. We can’t tell what would happen. But the government pursued a set of policies which were the opposite of what my 2010 review recommended. So it was hardly surprising given we reviewed the evidence, then made a series of evidence-based recommendations about how to reduce inequalities both between socio-economic groups and regions which intersect, in a way. So, it was hardly surprising, given what happened, that the social and regional inequalities in health should increase.
Q: What’s your overall assessment of policy over the last 40 years? Where have there been frustrations and successes?
I recently read Gary Gerstle’s book, “The Rise and Fall of the Neoliberal Order”. I think he’s based in Cambridge, England, but he’s an American historian. He’s writing mainly about the United States, but not exclusively. He’s not the first to make this point, of course, but he starts his account with the New Deal, and he said the New Deal 1933 ushered in a new political order. It assumes that free markets, or capitalism left alone, will yield all kinds of problems. Remember that the New Deal was launched when there was a depression and following the Wall Street crash in 1929. Gerstle says from 1933 to the end of the 1970s the New Deal order prevailed. So, Franklin D. Roosevelt’s assumption is that you have to intervene to stop the problems of unrestrained capitalism; they’ve increased inequality, and failure to get services to people who need them if you leave it to market mechanisms.
Gerstle argues that the welfare state in Britain, post-war, was really part of the same kind of New Deal settlement, and it was continued by conservatives and labour alike. Then he says, in 1979-1980 Margaret Thatcher in the UK, and Ronald Reagan in the US ushered in the neo-liberal order. Meaning a hollowing out of the public sector, a mistrust of the state, with a view that markets were a much better way to deliver services to people than central government control. So privatized utilities, water, electricity, gas, the railways and so on. That brought a big increase in inequalities in the early 1980s, both in the US and the UK, with bigger inequality, such as income inequalities.
That’s the model that we’ve been working on, and he argues that Bill Clinton was a neo-liberal Democrat, and he argues Tony Blair is likewise. They called themselves Third Way. That’s what they called themselves, Bill Clinton and Tony Blair, but, we continued with this model. Now you can see a big difference between a Labour neo-liberal regime and a Thatcher neo-liberal regime. Then the 12 years of austerity that was launched in 2010 was continuing that model, financialisation of the economy, hollowing out of the public sector, mistrust of public sector solutions to anything, the rise of consultancies, and outsourcing of services to the private sector. So that’s been the context, a lack of faith in the whole idea of the common good, a lack of faith in the public sector.
Q: What’s your assessment of the successes?
Well, in general, what we saw from around 2000 on, was that the gap in life expectancy between the poorest 20% of local authorities and the rest reduced. It got smaller from around 2000-2012 onwards. So, it reversed a trend of the gap getting bigger between the poorest 20% of local authorities and the rest. It reversed that gap, but it started to increase again from around 2012. So, it’s hard to draw a cause and effect, but it’s consistent with saying the policies of the Labour government led to a reduction in health inequalities and then reversing those policies post-2010 led to a gradual increase in the inequalities. That’s not commenting on the North-South, but it includes the North-South.
Q: What’s your sense of the strongest drivers of the reversal?
I have to be cautious and say we don’t actually know that a change in factor X led to a change in outcome Y. So it’s very hard to demonstrate. What we do know is that the government, elected in 2010, had a stated ambition to roll back the state. They called it Austerity, or “Getting the public finances in order”. When they took over, public expenditure was about 42% of GDP, and by the end of the decade, that 42% had gone down to 35%. If we look at spending per person by local authorities in the least deprived 20% of areas, the spending per person decreased by 16%. The greater the deprivation, the greater the reduction in spending. In the most deprived quintile, it decreased by 32%, the spending per person.
If you work on the assumption that what local authorities do might actually benefit people, then if you reduce spending by local government, more in more deprived areas, it’s hardly surprising that health will stop improving, and that health inequalities will increase and that life expectancy in the poorest areas will worsen, which is what we saw. So if you ask me, Yeah, but which services? Well, there were cuts in adult social care which will be important. There were other cuts that will have longer-term implications that may not have affected the life expectancy in the short term. So child poverty in 2010, after housing costs, was 27% using the relative measure of less than 60% median income, and over the decade, that 27% went up to 30%.
The spending on education, over the decade, went down by 8% per pupil. So that won’t impact life expectancy in the short term, although child poverty might because if child poverty has gone up, that means poverty has gone up in households with children, which can have an adverse impact. There were cuts across the board.
I made six domains of recommendations in 2010. Give every child the best start in life, education and lifelong learning, employment, working conditions, and having enough money to have a healthy life. Today’s report from the Joseph Rowntree Foundation and the Trussell Trust suggested that the shortfall in the Universal Credit is about 30%. In other words, Universal Credit provides 70% of the amount of money you need for essential goods to have a healthy life. The shortfall has had a progressive reduction. It’s not too difficult to see how just making it more difficult for people to heat their homes, to have healthy food, and the stress of trying to make ends meet causes problems. All of those are going to damage health in the short term, as well as the medium to longer term.
The housing crisis, the affordability of housing all adds to the mix. That also became more difficult in the decade after 2010. Now all of that is for the country as a whole. I don’t have figures for all of these changes by region. But what we do know, looking at life expectancy, it follows a gradient. The greater the deprivation, the shorter the life expectancy. If we compare, for example, the Northeast and London, if you’re in the least deprived 10%, the life expectancy in the Northeast in London are more or less the same. The greater the degree of deprivation, the greater the disadvantage of being in the Northeast compared to London. The gradient is steeper in the Northeast than it is in London, and this is a national index of multiple deprivation. So, it means that those measures of deprivation are predicting more strongly in the Northeast and similar in the Northwest.
Q: Has the gradient changed over time?
The gradients got steeper over time, but that’s more marked in the Northeast and the Northwest than it is in London. The gradient in life expectancy has got steeper. The gradient difference between the Northeast and the Northwest and London also grew over that time because, in London, life expectancy for the poorest 10% actually went up over that decade, whereas in virtually every other region outside London, life expectancy went down for the poorest 10%. So the gradient increased in the Northeast and Northwest, and it did in London, and the gap for the more deprived between the Northeast and Northwest and London increased.
Q: What is your assessment of the local government capability in being able to deliver the interventions needed to support health?
Well, talking to local authorities around the country, they’ll tell you that they’re in danger of being stripped back to their statutory duties and nothing more. So libraries become a luxury, green space becomes a luxury, and leisure centres become a luxury. The statutory duties for social care, children and older people, they’re in danger of being stripped back to that. Now, that said, local governments are trying to make a real difference despite the reduction in their capacity. But if your local government and your ability to spend is cut on average by 32%, in the poorest quintile. But for some, it was bigger than that, more than 40% cut. Well, people say, Why aren’t you doing more? You just cut our budget by 40%!
Q: Do you think that Whitehall spoke uniformly?
After around 2011 or thereabouts, a year or so after the coalition, the conservative-led coalition government was elected. They had very little interest in talking to me. So I used to spend a lot of time going to Richmond House or Skipton House. At one point, the doorkeeper of Skipton House said, if you come here a lot, there is a shower you could use. I thought that was quite a nice way of telling me that the hot weather and cycling were somewhat incompatible with certain standards of presentability. But it was a statement that prior to 2010, the government was quite interested to hear from me because I’d been doing research on these topics.
I was not involved in party politics, it’s not that I was campaigning for a particular political party or campaigning against it, but I was doing a lot of research. Their view was that I was a leading expert on health inequalities, and so they wanted to hear from me. Well, after, you know, maybe the first year of the conservative-led coalition government, they didn’t want to hear from me anymore. I remember I used to brief every public health minister, they’d invite me in to see the Secretary of State. I did brief Jeremy Hunt when he became Secretary of State. So maybe that was 2012, and I was still having discussions with civil servants and ministers. We had an hour, and he was very polite and interested, it seemed. Then that was the end of it. I had very little contact with the government after that. At one point, I counted that I’d briefed 11 ministers of public health. If you’re appointed minister of public health, don’t get too comfortable in the office because you’re not going to last long, that was my experience. You start from scratch each time, and then they decided they didn’t want to hear from me anymore.
Q: Could sense there was a difference in accountability for health inequality changes over this macro period?
So the good news came from Public Health England. We worked with them to produce a set of Marmot indicators. I mean Public Health England doesn’t exist anymore, but you come up on the government website, and there are Marmot indicators on health, social determinants and health inequalities. Health inequalities were seen as a core concern, so we have to pay attention to it. We’ve had this national review, The Marmot Review, that’s given us the guidance of what we need to look at. So there are a set of indicators that can be used for monitoring, and that’s very positive.
Q: Do you think that the success of London has helped or hindered the rest of the country?
I don’t know is the answer. I went to see Boris Johnson when he was already Mayor, and I went to see him when I was doing the 2010 Marmot Review. So in 2009, because I wanted to get his sign up to it. I wanted London to take it seriously. London did launch a draft health inequalities strategy, with Boris Johnson’s photo on the cover. They also compiled a set of Marmot indicators. So we worked with them, which I was very pleased about.
I very much wanted what I did not to be the province of one political party; I was commissioned by New Labour. But I didn’t want it to be like the Black report, which was commissioned by the Labour government and then ditched by the succeeding conservative government. I wanted the conservative-led coalition government to take it on. So that was one of the reasons I went to see the Mayor of London, who was the leading Tory elected official, Boris Johnson. I was delighted when they issued a health inequality strategy and produced, with our help, a set of Marmot indicators.
Q: Do you think the policy focus in respect of health inequalities has been right in terms of the level of focus on improving the situation in cities versus in towns and rural areas?
I don’t think the focus has been right at all, not in respect of towns or cities but we haven’t had a focus on it since 2010. London perhaps is the exception. But, we haven’t had a focus on it. Coventry declared itself a Marmot City in 2010, I went to Coventry just before we launched the report, the Marmot Review. I have a little carrier bag which my daughter took to school saying, “Marmot the way forward”. So that was Coventry, and it wasn’t my pushing them to do it. They said, “this is going to be the way we’re going to do things, we’ll take the Marmot Review, the six domains of recommendations, and we’ll make that the basis for our city planning”. Then with the Coventry experience, I went to Greater Manchester and Andy Burnham, the Mayor picked it up, and we worked with officials and others in Greater Manchester. The work changed because we started the work there pre-COVID and then COVID changed everything and so on in other regions of the country.
We were quite pleased that these were regions, so they were big and small local authorities. I mean Greater Manchester, they’re 10 local authorities. The biggest is Manchester, but then nine others of different sizes, which include smaller areas and larger areas, and quite pleased that that was the case and similarly Lancashire and Cumbria. I mean, there’s no Manchester in Lancashire and Cumbria. There’s not a city of the size and importance of Manchester or Liverpool, and they’re much smaller places.
Q: When you moved from advising government ministers to regional-focused work, did you find that your focus internally on the social determinants moved more into drivers and barriers?
Absolutely. It’s a challenge because people’s default position is to think if you’re talking about health, you must be talking about health services. I’m going to a WHO meeting tomorrow evening, a European meeting about the well-being economy. But the default position, WHO is managed by health ministers. So, in a way, their default position is, can we have more money for health services? I’m not against that by any means. But that isn’t my focus. So my focus is, take the steps to create a well-being economy, and you’ll improve health and reduce health inequalities, rather than which health ministers tend to argue, give us more money for health services, and we’ll contribute to the well-being economy by having a healthier population.
Q: What is your conceptualisation of the well-being economy?
The well-being economy, and the problem in the Northeast and the Northwest particularly, has been that with industrial decline, it hasn’t been replaced by anything. That’s been a real problem. Many people have made this argument that the Brexit vote, which came from the particularly deprived areas in the Northeast and the Northwest, was a vote saying, “you’ve forgotten us, and we’ve been left behind”.
How can you have a well-being economy when there is nothing there for you. Trump’s Russian advisor, Fiona Hill wrote, “There’s No Future For You Here/ There’s Nothing For You Here”. She grew up in County Durham with a dad who had been a miner till they closed the mines, and he said, “there’s nothing for you here”. So she went and did a PhD at Harvard and became the senior US Adviser on strategy to deal with Russia. All right, that’s a slightly unusual case history. But forget the last part of the case history. The first part is that there’s nothing for you here. How could you have a well-being economy if you’ve got fathers telling their daughters that there’s nothing for you here?
Q: Do you have a view on whether the government has got the focus right on the mix of investing in skills, infrastructure, and transport?
Let me give you a figure, which I’m sure you know, in the Levelling Up White Paper, they quoted. I like the White Paper by the way, I thought get that right and you will improve health and reduce health inequalities. They pointed out that when Germany levelled up, in other words, it incorporated former communist East Germany into the federal republic. They spent €2 trillion over 25 years, which amounts to about £70 billion a year, and the budget in the Levelling Up White Paper was £4.8 billion over four years. That’s 1.2 billion versus 70 billion, and IPPR North did a calculation and said the 2021 levelling up allocation amounted to, I may have the figure slightly wrong, but amounted to something like £33 per person per year and with the kind of cuts that I described to you in local government funding. So, this is in the North of the country and the cuts to the North had been in excess of £400 per person, per year. So you asked me, did they get the balance right? What? They cut £400 per person per year. Plan to give £33 back, and that’s going to level up. You sure you’ve asked me the right question about did they get the balance right?
Q: Have we spent the money on the right things?
We haven’t spent the money on anything. We’ve been taking money away. Now there is a strong feeling, if you talk to people in the Northeast and the Northwest, there’s a strong feeling that they don’t think the northern powerhouse is going to give them very much. And, I don’t have a strong view, I have to say, whether having a high-speed train from Manchester to Leeds is the right thing to do or the wrong thing to do. I do have a view that if you’ve got really terrible services between Manchester and Leeds and this is a real level of disadvantage, people do need to travel around. If the rail system isn’t serving people in that part of the country, that’s one more problem. But what I don’t have the view is, should they spend more on rail, or more in education, or more on occupational, on work possibilities? There was less spending on everything.
Q: Overall, what are the most important lessons for us to take away from this period?
Well, so you know, I’m often asked, is this just about money? And no, it’s not just about money. It’s a great deal about my six domains, that I laid out before early childhood and through the life course. We need to look at all of those. We need to think about the well-being economy, it’s not just a matter of growing the GDP in the North, but creating the conditions for people to flourish, the well-being economy and which I would operationalise by investing in my six domains. I think there’s been serious neglect. The Brown Commission about devolution is interesting. I don’t think devolution could be done without proper funding. You can’t just do it. But thinking about more regional control, I think, is important, but there has to be money that goes with it.
Q: Is it your view that there is an optimal way to devolve decision-making world decisions in respect of health services?
Well, I would never pretend to be an expert on implementing devolution. What I can say, it’s not just about health services to say again, that’s not the main thing we’ve been dealing with. But what I can say is that engaging people in cities and regions is a vital part of the agenda. If we came in my colleague’s line from the Institute of Health Equity and said: “do this”, that would not be very acceptable. Rightly so, but working with local colleagues who understand their context and their issues, seems to be the right way forward. So that means a great deal of local control.
Q: What’s your view on whether there are any ideas or innovations which have really worked over the course of the last 40 years?
Until 2010, health was improving regularly. Life expectancy was improving about one year, every four years. During the New Labour period, the life expectancy gap narrowed. They did take about half a million children out of poverty, that worked, that was quite good. Establishing Sure Start children’s centres, seemed like a pretty good innovation. Establishing a minimum wage seems like a good thing to do. I don’t want to be a spokesperson for New Labour, but they did some good things that probably did work to improve the quality of people’s lives. And we did see a reduction in health inequalities during that time.
ENDS