Structural changes in society with health as their focus would save many billions of pounds and be good for everyone - especially the most disadvantaged, says Alex Bax 

Alex Bax

Alex Bax

Alex Bax

In 2010, Sir Michael Marmot estimated that the annual cost to the UK of illness-related health inequalities was £31bn–£33bn in lost productivity, £20bn–£32bn in lost tax revenues and increased welfare costs, and over £5.5bn in direct health care costs in his report Healthy Lives: The Marmot Review.

His extensive reviews highlight that we know how to prevent these inequities in health, and yet they persist.

Marmot showed that it is the wider determinants of health – our environment, governance, wealth – that drive health injustices. The healthcare community deals with the consequences of health inequalities every day, but health care-led actions rarely tackle the underlying causes.

However, we can shine a light on ‘the causes of the causes’. For instance, the All-Party Parliamentary Health Group and The Health Foundation recently collaborated on the release of a collection of essays which highlight how social inequality usually results in health inequality.

What we must realise is that structural responses with health at their core would be better for us all, but they would bring most health gains to those at the very bottom.

They are urging the government to invest in prevention and say that a more proactive approach to tackling the determinant of poor health across all policy areas is urgently needed.

This is further backed up by examples such as the statistics collected by Public Health England includes 100,000 children, which show that in the south-east of England, 80 per cent of five-year-olds have a clean bill of oral health, but in the north-west the proportion is just 67 per cent.

I’d like to use a case study here to highlight what I mean when I say ‘good or poor health in society is neither equally nor randomly distributed – it is socially patterned’. The reality is that this case study is just one example of how wider determinants cause ill health, suffering and death through a preventable means: inequality.

Case study

Imagine: Joe was a 52-year-old alcoholic who died in a London hospital this year. Liver disease was given as the cause of death. Why did Joe die 31 years earlier than a man born in Kensington (the district of the UK with the highest average life expectancy)?

Let’s look at his background. Joe was born in 1963. His parents lived in poor quality housing. By the age of seven he was in a children’s home.

He attended school but was bullied for being in care. Having not had anyone to read to him regularly he struggled with literacy. Having not witnessed many positive relationships he struggled to make friends.

By his early teens he was identified as a ‘troublemaker’ and regularly ran away from the children’s home. He found alcohol as a cheap relief from reality, ducked and dived on the streets with no opportunity for housing. In the 1980s, as a single man, he was judged under the regulations not ‘to be in priority need’ for housing. By the age of 35 he was labelled an ‘entrenched rough sleeper with a personality disorder’.

Underneath these patterns are structural social and economic inequalities: in housing, pay, wealth and control over life’s outcomes. The harms are greater the further down the social scale you travel

For Joe, post-war housing policy didn’t move fast enough to help his parents. Their pinched backgrounds and lack of governmental support undermined their ability to care for him, while the poverty that surrounded his early years, the lack of a stable home and opportunity for education, and perhaps the awareness that other children judged him, pushed him to the margins.

If Joe’s parents had had a secure home and some income, he might not have been ‘different’ at school. A better-resourced secondary school might have managed his challenging behaviour.

Each step reinforced the last. Unfortunately for Joe he reached adulthood in the middle of the 1980s, when prospects for poorly educated, working-class men were at a particularly low point with a government reproaching the unemployed for such problems – in 1984 British unemployment peaked at 3.3 million.

Joe suffered with little education or employment prospects, and as the economy began to improve in the late 80s, the poverty gap grew.

The health care community deals with the consequences of health inequalities every day, but health care-led actions rarely tackle the underlying causes

All of these factors have long term health effects. These wider determinants of health in action forced him into unhealthy living conditions, poor hygiene, and drinking for escapism.

Joe’s story is an extreme example, but the wider determinants of health affect everyone. The obesity epidemic is socially patterned; smoking is socially patterned; environmental quality is often worse in poorer areas.

Underneath these patterns are structural social and economic inequalities: in housing, pay, wealth and control over life’s outcomes. The harms are greater the further down the social scale you travel.

What we must realise is that structural responses with health at their core – policies for cleaner air, safer roads, good housing, secure employment and a more even spread of wealth – would be better for us all, but they would bring most health gains to those at the very bottom.

And, according to Sir Michael Marmot, action on these wider determinants of health might also save us £50bn–£70bn each year.

Alex Bax is the chief executive of Pathway