ANALYSIS
from 27% to 30%, and 1000 Sure Start Children ’ s Centres closed; spending on education per pupil was reduced by 8%; the gig economy increased; poverty increased, as summarised above; little was done to solve the housing crisis; and spending to improve the thermal property of housing was reduced. Looking at one key marker of future ill health, inequalities in childhood obesity increased. Each of these domains was made worse by the pandemic and the cost-of-living crisis. For example, the Joseph Rowntree Foundation defined destitution as doing without two or more of six essential items: housing, heat, light, food, clothing, and toiletries. 44 Inthe UK in 2022, 3.8 million people, including one million children, were destitute. The figure for children increased by 2.9-fold since 2017. Food poverty and food insecurity rose, linked to austerity, 4546 including for children, with the number of children in food poverty doubling between 2022 and 2023 to four million. 47 Between April 2022 and March 2023, the Trussell Trust ’ s network of food banks delivered almost three million emergency food parcels (a 37% rise compared with the same period the year before); one million food parcels went to children. 48 The lack of these essential items will damage health and increase health inequalities. Living in these conditions has a huge social, emotional, and psychological effect, which will in turn affect mental and physical health. Much has been reported on the commercial determinants of health. 49 A review of how industry can affect health and health inequalities summarised the evidence into three areas: employment and working conditions, unhealthy goods and services, and the wider effect on society and communities, including procurement, employment, and the environmental and social impact. 50 The 2010 Marmot review developed the concept of proportionate universalism: universal policies with effort proportional to need. Spending by local government in the decade after 2010 was regressive, showing effort inversely proportionate to need. The greater the deprivation of the area, the greater was the reduction in spending per person. Spending was reduced by 17% in the least deprived 20% of areas (quintile) and by 32% in the most deprived areas (quintile). Spending on adult social care was also regressive, with a reduction of 3% in the least deprived areas and 16% in the most deprived areas. Evidence indicated that the greater the reduction in local authority spending, the worse the mortality trends after 2010. 12 Action on social determinants of health improves health Recognising that the action needed to improve the health of the population is outside the provision of health services is not new, but some political factions reject such action, favouring an individualistic approach more consistent with a libertarian ideology. The great health gains made during the 19th and early 20th century were not because of the therapeutic revolutions of modern medicine but more a result of the sanitary and social reforms that provided people with better living conditions, such as uncontaminated food, clean water, waste disposal, improved housing, and education of children. The marked improvements in life expectancy in the 1940s and 1950s were thought to be a result of a combination of improved housing and nutrition after rationing during the second world war, which improved understanding of the importance of childhood nutrition, free secondary education for all (Butler Education Act of 1944), advancement of public health measures, including in sanitation and access to clean water, introduction of antibiotics and immunisations and, eventually, the introduction of the NHS in 1948. Although the NHS was established after the initial acceleration in improving life expectancy, substantial health gains have been made since, thanks to greater access to effective care that it enabled.
Fig 3 | Estimated child death rate per 100 000 population, by region. Population is children aged 0-17 years 31
Rising poverty, worsening health A wide body of evidence has indicated a link between deterioration in health in the UK and cuts in public spending through austerity policies introduced in 2010, policies that are continuing into 2024. 12 -14 23 25 34 -36 The effect of austerity on poverty in the UK has been so great that two successive United Nations special rapporteurs on extreme poverty have called on the government to take action on the problem. 37 The first, Philip Alston, visiting in 2018, called the policies of austerity “ punitive, mean spirited, and callous ” and the levels of child poverty both a disgrace and an economic disaster. 38 The second, Olivier de Schutter, visiting in 2023, commented that the warning signs his predecessor had given had not been acted upon, that universal credit was too low to protect people from poverty, and that “ There ’ s a huge gap, which is increasingly troubling, between the kinds of indicators the government chooses to assess its progress on one hand, and the lived experience of people living in poverty. ” 39 Currently, government policy does not provide enough money for people to live healthily. 4041 Evidence to support action on social determinants of health Without a change in policy, there is no reason to think that the worsening trajectory of health in the UK will improve. Here, we summarise the key evidence on how action on the social determinants of health can improve the health of the population. How do social determinants of health cause ill health? The WHO Commission on Social Determinants of Health synthesised the evidence on social determinants of health. 42 Building on this global body of work, in 2010, Fair Society Healthy Lives: the Marmot Review , re-examined the evidence as it applied to England. 43 The review categorised the determinants of health inequality into six domains: early childhood, education, employment and working conditions, having enough money for a healthy life, environmental and living conditions, including housing, and health behaviours. Health Equity in England: the Marmot Review 10 Years On , published in 2020, indicated the health picture summarised above and showed worsening in most of these six domains, the likely cause of which was austerity. 14 Relative child poverty, after housing costs, increased
the bmj | BMJ 2024;385:e079389 | doi: 10.1136/bmj-2024-079389
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