By Lucy Gavens

The message that “we’re all in it together” has spread far and wide in recent months. But, evidence tells us that we are not all affected in the same way or to the same extent by Covid-19.

In the short-term, our national response to Covid-19 is likely to affect health and exacerbate inequalities for particular groups of people including (but not limited to) older people, people with mental health problems, people with a disability, people on low income and workers on precarious contracts. People living in the most deprived areas of England are more than twice as likely to die with Covid-19. There have also been countless stories in the media about the impact of Covid-19 on the number of people living in poverty and on food insecurity and increased demand for food banks.

Models, when deployed alongside other evidence, can provide valuable information to support decision-making. Modelling complex systems accurately is really hard, and even more so when people are working very quickly to respond to an emerging and rapidly changing situation such as a pandemic. Over the past few months attention has turned to modellers to help predict a range of things related to Covid-19 including how the disease would spread, who would be greatest affected, how to prevent transmission and how we release lockdown. Not all the models developed have hit the mark, and there are certainly challenges around model transparency to support replication and evaluation. In addition, the politics of modelling, and evidence-use more generally, have been thrown into sharp relief by this pandemic.

In SIPHER, we are working to understand the implications of Covid-19 for inequalities, and to hardwire consideration of inequalities and their impact on health and wellbeing into wider decision-making processes. Ultimately, we hope this will lead to better health and a more resilient system as a whole. We are focusing on three areas.

Firstly, we are developing a detailed understanding of the unequal impact of Covid-19 on different places and people, and over time, to understand who is most affected. In a few short days we have identified almost 150 factors we think play into how the pandemic, and responses to it, will impact unequally on health and wellbeing. Factors including the availability of official information, transport availability, isolation, neighbourhood deprivation, anxiety, household composition, lack of control, and many more. We are now starting to map out how all these interlinked moving parts relate to one another in a complex web of dynamic and non-linear relationships, and are in the process of using this information to guide our modelling.

Secondly, we are engaging across sectors and communities of practice to understand the most pressing challenges and to help build solutions. This includes working with Sheffield City Council, Greater Manchester Combined Authority and the Scottish Government to understand how Covid-19 has shocked our economic system and what this means for modelling whole-systems effects of economic policies. Evidence does not simply speak for itself and that is why in SIPHER we co-produce our research directly with policy-makers at different levels of government. Together, we are exploring how to build a fairer society that considers health, wellbeing and sustainability in all decision-making and increases resilience to future shocks. Ensuring that we develop an inclusive economy through a focus on evidence-based approaches that balance social, economic and environmental sustainability with prosperity will be key to this.

Thirdly, we are starting conversations and encouraging decision-makers to keep inequalities in mind as attention turns to how we re-build the economy over the longer-term. Although the context in which this thinking is applied will be challenging, by sharing evidence and promoting discussion of trade-offs and the differential impact of policies (particularly on the most disadvantaged in society) we hope to avoid the ‘growth at all costs’ and assumed trickle down associated with the response to the last recession. As local businesses, the organisations and networks that support them, and governments start to focus their attention on economic recovery, we see guidance emerging on how best to focus those efforts (e.g. Rescue, recover, reform: A framework for new local economic practice in the era of Covid-19 and Build Back Better in Greater Manchester). This economic recovery phase is an opportunity for us to reflect on what is most important to us all as we seek to restart and revitalise the economy. The WHO has already highlighted how countries affected early in the pandemic – for example Germany and South Korea – are looking at ways to boost sustainability in their recovery plans. In SIPHER, we believe that as well as embedding sustainability, our local and national recovery plans should make a priority of how best to reduce inequality, which will ultimately benefit health and wellbeing.

In short, the evidence tells us that we are not all in this together and in SIPHER we are committed to ensuring those who are worst affected are visible and represented in our economic recovery plans. Such a focus on reducing inequality can only benefit health and wellbeing, which in turn will help to strengthen and rebuild our economy.

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By Greg Fell

Health and wealth is a two way relationship. Here is why…

The economy is everything, everything is connected.

The economy is not just about the activities of private sector business. Investments in the public sector, voluntary sector and the actions of individuals all contribute to outcomes we individually and collectively value and thus what we consider “the economy”. Sometimes measurement and valuation is difficult, but that doesn’t make it less important. Everything is connected.

Healthy Life Expectancy is an economic issue.

Healthy life expectancy is the age to which a person can expect to live in good health. In the UK healthy life expectancy is 63.1 years  for men and 63.6 years for women. With the retirement age rising to 67 by 2028 this means on average we will be working for 3-4 years in less than good health. So how healthy we are (or not) has critical implications on how actuaries advise the government about the retirement age.

Inequality

There is deep inequality in the distribution of illness. This is an economic productivity issue, as well as intrinsically bad. There is a 25 year gap in healthy life expectancy so a baby born in the most deprived areas can expect to live to just 45 years old in good health whilst a baby born in the most affluent will reach 70.

Inequalities in health are intrinsically linked to inequalities in economic outcomes.

Many people and organizations have commented that the way in which the economy has developed has left people behind and often exacerbated poverty. There is a strong research base on this, and this has led to the establishment of terms like “inclusive economy”, which describes an effort to ensure the economy works for everyone. Given that health inequality is essentially driven by wealth inequality this underscores the importance of our efforts around creating an inclusive economy as important for reducing inequalities in health and wellbeing.

Multi-morbidity

Multi-morbidity (having more than one condition) is more common than having a single illness. It is more common in working age adults than old adults, and (you guessed it) is very unequally spread across our population. As more than half of over 60s have two or more long-term conditions this makes preventing, and delaying and treating, those conditions a quality of life and an economic issue. And as more deprived areas have more people out of work due to long-term health conditions for more of their working lives, economic growth in these areas is that much more difficult. 

The Sheffield Example

Illness costs the Sheffield economy an estimated £1bn (as a comparator, the NHS spend in Sheffield is £1.1bn) every year! 100,000 working days are lost a year to mental illness, and a similar number for musculoskeletal conditions… to name just a couple of examples.

So what does this all mean and what can we do about it?

Simply, a healthier population is likely to be more economically productive (and to need less spending on healthcare and health-related benefits). This is a two way link as a more prosperous society is likely to be healthier. Just as HS2 is seen as an investment in the economy, so is investment in a healthy population.

We should consider health as a balance sheet asset, not a cost.

What we measure and value is important. This is one of the things that underpins calls to widen the measure of economic growth from solely gross value added to a wider measure that includes social benefit. It would be easy, in narrative terms at least, to also include resilience and cohesion into the things we value in our economy.

Health and wellbeing should be a central component of economic strategy. The above issues are not issues that will be (only) solved by more, or better health care services. That is necessary but not sufficient. Poor health has a direct and indirect impact on the economy at an individual and societal level. So the central “health” challenges – stalling healthy life expectancy, and inequalities of that – aren’t just a problem for the NHS, they are a problem for the whole economy. Keeping people well is a major national infrastructure project. A bit like HS2. With those kind of timeframes. How seriously are we really taking this?

Once we start to treat health as a linchpin to community and economic development, we can begin to insist on different investment decisions and improve our programmatic approaches to power boost results.

References

See here for some references to support the above.