Recent statistics reported in The Guardian – that people in the UK are spending fewer years in good health than a decade ago – should be a wake-up call. As we experience growing political uncertainty and public dissatisfaction, there is an expanding case for progressive social and economic change.
As we argue in our book Getting Better: The Policy & Politics of Reducing Health Inequalities, the health gaps between wealthier and poorer communities are not inevitable. They are socially produced, systematically patterned and, crucially, politically determined. When healthy life expectancy declines, especially among poorer communities, it signals that something has gone wrong not just in health care, but in the wider social and economic fabric of society. What makes matters worse is that we have good evidence about the types of policies that could halt this decline but we are not yet seeing the kind of concerted political action required to implement this policy mix.
A crisis years in the making
Across high-income countries, health has followed a troubling trajectory over the past 15–20 years. While life expectancy rose steadily throughout much of the 20th century, since around 2010 progress has stalled, and in some cases reversed. The UK is a stark example. Not only have improvements in key health indicators slowed, but inequalities between richer and poorer areas have widened, with the most disadvantaged communities experiencing the sharpest declines.
This pattern reflects what we describe as a ‘U-shaped curve’ of health inequalities in the last century. Inequalities narrowed during the mid-20th century, particularly in the post-war decades, before widening again from the 1980s onwards. Today’s decline in healthy life expectancy is part of that broader trend.
Our research emphasises the importance of understanding the political and economic structures and forces that mould the conditions that impact life expectancy. Policies governing wages, welfare, housing, education and health care determine the distribution of resources and opportunities across society. In turn, these shape the social determinants of health.
These political choices are also conditioned by powerful economic actors. The ways in which corporations produce, market and price unhealthy commodities, from ultra-processed food and alcohol to fossil fuels and gambling, are now widely recognised as ‘commercial determinants of health’. These industries influence health both directly, through exposure to harmful products, and indirectly, through lobbying, political donations and framing public narratives about responsibility and regulation. As a result, the environments people live in are not neutral: they are actively structured in ways that can undermine health, particularly in more deprived communities.
Put simply, policy mixes that work to ensure that people are supported to live well help extend life expectancy and reduce health inequalities, while policy mixes that reduce these support structures can reduce life expectancy, especially for those most in need of support.
The impact of austerity and fiscal crises
In the UK, a decade of austerity since 2010 has reduced public spending on welfare, local government and many health-related services. At the same time, wages have stagnated, insecure employment has expanded and living costs have risen.
As our book shows, when social safety nets are weakened, poverty increases and health outcomes worsen. The consequence is that more people need support to live well but the services supposed to provide this support are in a frayed and fragile state.
At the same time, commercial pressures have intensified. In an era of squeezed incomes, cheaper but less healthy products, often aggressively marketed, have become more dominant, while regulatory approaches to industries linked to poor health have remained relatively weak.
These changes have disproportionately affected those on lower incomes, exacerbating existing inequalities. The result is exactly what we are now seeing: widening health gaps and declining healthy life expectancy. The COVID-19 pandemic and the subsequent cost-of-living crisis have only intensified these pressures, exposing and amplifying underlying inequalities.
Change is possible
This situation is far from inevitable. In Getting Better, we examine periods and places where health inequalities have declined as a result of better policies. These include the ‘Great Society’ reforms in the USA, German reunification and democratisation in Brazil in the late 20th century, and the English Health Inequalities Strategy of the 2000s.
Across these diverse contexts, we identify four ‘great levellers’:
- an expanded welfare state
- improved access to health care
- policies that reduce income inequality
- greater democratic participation
While not evident in every case study, our analysis also points to the importance of addressing the commercial drivers of ill-health – through regulation, taxation and restrictions on harmful products and practices.
These policies did not just improve overall health; when implemented in combination, they reduced the gap between the most and least advantaged. This demonstrates that it is absolutely possible to reduce health inequalities, where there is political will.
Lessons for today
Reversing the decline in healthy life expectancy in the UK will require action that goes far beyond the NHS.
First, tackling income inequalities and preventing poverty, especially deep poverty, must be central. This means strengthening social security, raising incomes and ensuring secure, well-paid work.
Second, investment in public services is essential. In the UK, cuts to local government, social care and public health have eroded the infrastructure that supports healthy lives.
Third, reducing inequalities in broader socioeconomic determinants of health such as education, housing and employment must be a priority.
Fourth, there must be a renewed commitment to long-term, coordinated policy action. Short-term fixes will not reverse decades of widening inequality. As our research shows, meaningful reductions in health inequalities require sustained, large-scale interventions across multiple sectors.
Finally, across all of this, we need stronger efforts to democratise policy making so that people, especially those from more marginalised and disadvantaged communities, can shape the policies that impact them. The work of community organisations and trade unions is key here, but policy makers also need to make stronger efforts to engage and listen to communities. If policies are to be sustained long enough to make a difference, they must be supported by a credible, shared vision of hope. Efforts to create such a vision will only succeed if we also work to protect policy from the undue influence of large corporations, especially those producing health-harming products.
A political choice
The Guardian’s report highlights a troubling reality: people in the UK are living fewer years in good health. But it also points to an opportunity.
Health inequalities are not fixed. They are shaped by the choices governments make about how to organise society. The policies of the mid-20th century reduced inequalities and improved health for millions. The policies of recent decades have had the opposite effect.
The question now is not whether we know what works. As we show in Getting Better, we already know a lot about what works. The question is whether there is the political will to act.
At a moment when UK politics feels unusually volatile, with growing dissatisfaction towards established parties and continuing uncertainty around political leadership, there is clearly a public appetite for change. If we are serious about improving healthy life expectancy and ensuring that those extra years are shared more equally, then any political change needs to focus on achieving sustained action on the social and economic conditions that shape people’s health and wellbeing.
Clare Bambra is Professor of Public Health at the Population Health Sciences Institute, Newcastle University.
Julia Lynch is Professor of Political Science at the University of Pennsylvania.
Katherine Smith is Professor of Public Health Policy at the University of Strathclyde.
Getting Better by Clare Bambra, Julia Lynch and Katherine Smith is available to read open access on Bristol University Press Digital here.
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