Since his seminal review into health inequality more than a decade ago, the UK has only got worse. Sir Michael Marmot tells Richard Purcell how insurers can help to reverse the backsliding, and why a universal state pension age isn’t a great idea.
You may not be familiar with the name Sir Michael Marmot – but you probably should. Known mostly for the Marmot Review of 2010, he has made a significant contribution to our understanding of the impact of social determinants on health inequalities and life expectancy. It’s a topic that has much bearing on actuaries’ work, and yet Marmot admits that he’s surprised he hasn’t had more interaction with them.
Now professor of epidemiology and public health at University College London and director of its Institute of Health Equity, Marmot started his career as a full-time researcher and teacher. He graduated with a medical degree from the University of Sydney and then a PhD from the University of California, Berkeley, for which he studied acculturation and coronary heart disease in Japanese-Americans. He went on to manage several Whitehall research studies and led the English Longitudinal Study of Ageing.
He describes his early work as having “helped to put the idea of a ‘social health gradient’ on the map”. This is the concept that people in less advantaged socio-economic positions experience worse health and shorter lives than those who are more advantaged. “It’s not just about focusing on the worst off but also the inequality between groups on the hierarchy,” he explains. While the way in which poverty affects health has changed – for example, infant mortality rates fell from 65 per thousand live births in 1990 to 29 per thousand live births in 2018, according to the World Health Organization (WHO) – the social health gradient remains an issue for society.
The Marmot Review
One highlight of Marmot’s career was his time chairing the WHO’s Commission on Social Determinants of Health. This developed the concept that we shouldn’t just be thinking about universal healthcare but also about inequalities in how people live, work and age, and the impact of these on health. It brought the idea of social determinants of health to prominence around the world.
Marmot’s work on the commission led to his involvement in several initiatives around the world. In the UK, in 2008, the health secretary asked him to chair an independent review on reducing health inequalities in England. The Marmot Review was published two years later, in 2010, and concluded that reducing health inequalities would require action in six areas:
- Giving every child the best start in life
- Enabling all children, young people and adults to maximise their capabilities and have control over their lives
- Creating fair employment and good work for all
- Ensuring a healthy standard of living for all
- Creating and developing healthy and sustainable places and communities
- Strengthening the role and impact of ill-health prevention.
The review did not prioritise any one point, with Marmot calling all of them “interrelated”. For example, he says, if you cannot ensure a healthy standard of living from your income, it’s hard to give your children a good start.
A decade of failure
How have things have changed since the review was published? They’ve got worse, is Marmot’s simple answer. His report Health Equity in England: The Marmot Review 10 Years On, published shortly before the Covid pandemic hit the UK in February 2020, noted that most government policies had gone in the opposite direction from the report’s original recommendations. Life expectancy reduced. The gradient of inequality steepened. It has been, he says, “a pretty sad tale”.
Marmot points to reduced public expenditure in particular, stating that health spending fell from around 42% to 35% during the 2010s. He notes that this reduction was carried out in a regressive way: “There has been a 16% reduction in health spending for the most affluent, but a 32% reduction for the most deprived groups.” In addition, he says, while unemployment fell over the course of the decade, the income of employed people also went down – so the proportion of people living in poverty rose, as did child poverty.
Of course, we have since experienced the Covid pandemic and the cost-of-living crisis. Increased food and energy costs make up a bigger proportion of spending for low-income households, driving a further increase in inequality, Marmot explains.
Given where we are, what does he think the government should be doing now? “I naively assumed the NHS would continue to be adequately funded when the review was conducted,” he begins. For him, it’s not a choice between spending more on the NHS and less on other areas of government – he says “we need to ask what a good society looks like and start with that. We need to get rid of poverty for those in work.”
While Marmot hopes that work will pay better than benefits, he notes that people who can’t work should have a social safety net that allows them to lead a healthy life: a recent report from the Joseph Rowntree Foundation, he says, shows that Universal Credit pays for just 70% of what people need for a basket of necessary goods. He also points to childcare being too expensive in the UK.
‘When I did the Marmot Review, I naively assumed the NHS would continue to be adequately funded’
Some might say that the level of public spending Marmot envisages will require a big increase in taxation. His response is that the UK is a low-tax country, despite what you read in some outlets, and that tax rises are probably needed to address health inequalities. He points to International Monetary Fund figures showing “government receipts at 52% of GDP in Finland, and similar in other neighbouring countries like France, but the UK is just 32%. The US is similar at 31% – but they are in real trouble, too.”
Businesses should act
Marmot was approached by Legal & General to co-author the report The Business of Health Equity: The Marmot Review for Industry, released in 2022, which includes practical ways for businesses to contribute to health equity and explains why it’s in their interests to do so. It looks at three main areas: the importance of good employment practice; goods and services offered; and impact on the wider economy.
Marmot frames the report as injecting health into the ESG (environmental, social and governance) debate. “Businesses say lots of terrific things but the words are often better than the actions,” he says. From his recent conversations with several big businesses, he says, “things are progressing but stuttering a little.” However, he remains hopeful.
He adds that it’s clear that regulation can play a role in some areas in terms of driving businesses to act, pointing to the example of P&O Ferries’ replacement of permanent workers with contract workers, who have fewer skills and lower pay. He believes regulation can help to remove the incentive to undercut competition using nefarious practices. “No one wants to live in a society without regulations. People want to know that food is safe to eat and water is safe to drink, for example.”
Insurers’ role in inequality
And now, the specific role insurers can play in reducing health inequality. We talk first about the role of insurers as investors, and how they can support the development of sustainable places and communities. Here, the Marmot Review points to the importance of access to good-quality open spaces and energy-efficient housing across the social gradient, as well as the integration of transport, housing, environmental and health systems to help address the social determinants of health. Some insurers are already making conscious efforts to invest in social housing projects or renewable energy projects but there is no doubt that they could play an even bigger role, Marmot says.
We also discuss customers’ and protection insurers’ common interest in improving life expectancy, while noting that this does not extend to pensions. Marmot recalls that women in the most deprived 10% of the population will spend a third of their lives in poor health. “Is it possible for insurers to look not just at length of life but also quality of life?” he asks.
He also points to the issue of ageing populations in countries such as the UK and Singapore, where the big issue is how to ensure that older people can face old age with resilience. He believes that there is a role for insurers to help people live longer in a healthy state, whether that be through ill-health prevention programmes or other products and services.
In terms of pensions, Marmot believes one of the biggest issues is that a uniform retirement age can reinforce health inequalities. Increasing the state pension age to 68 for everyone might be more equal, he says, but he points out that the most deprived parts of society cannot expect to spend their retirement disability-free. A higher state pension age across the board therefore fails to recognise that less affluent people will not be able to enjoy their retirement, and will not experience the same retirement as more affluent people. This, he believes, is another area in which actuaries can play a role.
There is no doubt that Marmot has made a significant contribution to understanding the social determinants of health inequalities, and the role that businesses and insurers can play in creating a better society – much of which has an important bearing on the work of actuaries. We should sit up and pay attention.