The cost of population health

The cost of population health
© shutterstock/Ody_Stocker

We spoke to Dr Tammy Boyce, Senior Research Associate at UCL Institute of Health Equity about how increased levels of poverty are impacting population health in the UK.

In recent months, the effects of the COVID-19 pandemic have been compounded by rising living costs, the war in Ukraine and increasing fuel prices. Not only have these challenges been testing for an already struggling health system, but they pose short and long-term implications for public health. To discuss the wider effects of health and the health system on the economy and why governments and organisations must work together to address the cost-of-living crisis, Lorna Rothery spoke to Dr Tammy Boyce, Senior Research Associate at the UCL Institute of Health Equity.

To what extent can the healthcare crisis we are currently seeing be attributed to the effects of the COVID-19 pandemic?

For me, I think the real question is why recovery is slower in the UK compared to other nations. The causes of this crisis are complex, and I do not feel that the wider impacts are being adequately discussed by the media or politicians.

I was talking to a local authority representative recently and they told me that at the peak of austerity in the UK ten years ago, because of the banking crisis, they faced cuts of around £11-13m each year over three years. Yet, in 2023/24 this particular local authority is being asked to deal with cuts of £33m. Brexit has been compounded by the complexities of what happened during the pandemic; it has been an absolute nightmare.

We have been talking about what is causing poor population health since 2010 and now we are seeing the situation getting even worse.

What could be some of the long-term impacts on population health?

The truth is, we do not know, mainly because population health statistics can take a couple of years to collate. Before COVID-19 and the cost-of-living crisis, we would say on average, one in ten households were fuel-poor, now around one in two or three households are fuel-poor. We have not seen levels of poverty like this before, it is putting a lot of pressure on people and their incomes.

As an example, I have been working with local authorities in Wales looking at life expectancies for one of the country’s poorest areas. Since 2017, life expectancy in four of Gwent’s local authorities has been slowly declining, however, in an adjacent local authority, life expectancy is increasing. We were discussing five-year plans, taking into account the huge cuts that they are going to have and the changes that would need to happen, which could include laying off social workers and closing local leisure centres and public pools.

In areas that are already very poor, and where councils are facing huge pressures as well as an NHS that is still dealing with the effects of COVID,  there will be severe challenges. Without proper interventions, life expectancy will decline and population health will get worse; it will get worse for all of us but particularly for those on the lowest incomes. The picture is similar across Europe: inequalities in life expectancy are often very local, one street can have increasing life expectancy and around the corner, life expectancy can be decreasing.

In terms of the implications for those suffering from chronic diseases, as an example, Kidney UK recently did a survey about the impact of kidney disease on mental health and 67% of respondents said they experience symptoms of depression while 68% are not being offered mental health support and 27% have considered self-harm or suicide. A similar report from Kidney Care UK revealed 98% of people are worried about the rising costs of living, and of these, 60% worry about it all of the time. It is hard to isolate and measure the impact this crisis will have, particularly on people’s mental health, but I imagine it will be huge.

I spoke to a GP in October who said a woman, who did not have an appointment, had sat in the surgery’s waiting room all day because it was warm. We have not experienced this level of worry in the UK before, where people are worried about their incomes and about putting their heating on to stay warm. Poverty affects everything, including chronic diseases. Living with a long-term health condition often means increased costs, especially if a patient needs to travel to the hospital for treatment.

We talk about people in quintiles; often when it comes to disease outcomes and government budgets, it is usually those people in the poorest 20% of the population who are most affected. However, the rising costs are not just an issue for the poorest societal groups, whose health is going to get worse as a result of this crisis, it could be the bottom 60% of the population who will suffer. There will be people who have never been close to fuel poverty or used a food bank, for example, who will find themselves fuel-poor. Equally, those people who have been fuel-poor before will find themselves in a much graver situation.

© shutterstock/Monkey
We have not experienced this level of worry in the UK before, where people are worried about their incomes and putting their heating on to stay warm. Poverty affects everything including chronic diseases

Should more attention be paid at a policy level to the wider effects of the health system on the economy, how are the two interlinked?

We need people to be able to work for the economy to function better. However, what we are seeing post-COVID, and there is a great deal of attention on this, partly because migration is lower, is worklessness and more people quitting their jobs. The narrative being played out in the media, and reflected by politicians, is that the economy is suffering because more older people are retiring early, and while there is some truth to that, there are lots of people who do not want to work because they have a mild illness or mental health issues. If you are in a job that is poorly paid, what is the incentive to work?

We have to look at this correlation between health and the economy. In the UK, we have had so many cuts to government services that the NHS is mopping up the mess. If you do not fund social care, education, transport, and housing – all of the things that make our lives good – then the NHS is going to have to deal with the repercussions. The health system is having to spend its money on the causes of ill health and disease but it should not have to; this should be something that local governments can do if they are funded properly and that is why we have seen a decline in life expectancy that is steeper in the UK compared to other nations.

The UK Government has tried to implement measures to address the crisis including energy price caps, state pension increases and minimum pay rates, are these measures sustainable?

We often point out in our research and reports that the government has made the welfare benefits system so complex that millions go unclaimed because people are not claiming things like housing benefits, even though they have a right to.

One of the cost-of-living payments has gone via local authorities so I know that they have delivered that properly which is a positive step. So, why do we not do it like this all the time? We know from the number of strikes that are happening, people simply cannot afford to live, even people who have never been on strike before and do not want to be on strike like teachers, nurses and doctors, and lecturers.

Can we trust a government that has not funded the social determinants of health for the last 12 years? Can I trust them to make the right decisions for people on the lowest incomes? I have trouble thinking that they have these people at the top of their agenda and that they are thinking about what is best for them. Looking at their previous decisions, it seems they have other priorities. We need the media to be reporting more on the profits that are being made by the energy companies, there are huge inequalities, and we are not talking about them enough. At a structural level, that is what I want the media to cover, that absolute disinvestment in society that has led us to where we are now. On top of that disinvestment in society is a cost-of-living crisis and that is why the UK is suffering the most, because we have had 12 years of austerity, unlike other countries.

Everyone is exhausted, and we are going to get more tired. It will be bleak. I think we think it is tough now, but it is going to be much, much tougher by this point in April.

What is next for your efforts in this area?

We are working in a number of areas across England and Wales as well as internationally and with businesses. We are clear that there is no money in the system; we make recommendations, and what we have to do now is focus on systems working better together. When I talk to people on the ground, they all know that they can work better together. It is about getting the NHS to come and sit at that table, and not just when it is an emergency.

© shutterstock/1000 Words
We need people to be able to work for the economy to function better. However, what we are seeing post COVID is worklessness and more people quitting their jobs

We have been contacted by various organisations and people who want to effect positive change, which is promising. It takes a brave person at the top to say we need to do something different, even at this moment of crisis. For example, we were contacted by Blackpool Trust; Blackpool is an area of very high deprivation, and they can see that if they keep doing the same thing, they are going to get the same result.

The NHS in some ways has always been in a crisis, there have always been waiting lists, but unless we try and address some of these issues in partnership outside of the NHS, that revolving door is just going to get busier and busier, particularly as we age, but also as the cost-of-living crisis worsens. We used to talk about this in terms of ageing, but now we would say things are getting worse because of the cost-of-living crisis.

I have been interviewing people at the top leadership levels in the NHS about health inequalities. One of them was telling me about how difficult it was, and I asked them how they stay motivated given all these difficulties and budget cuts etc. They told me that when it works, it makes everything worthwhile because you can see the patients that you have helped. They are personally driven to help people. We have to try and help the system and work better together.

Dr Tammy Boyce
Senior Research Associate
UCL Institute of Health Equity

This article is from issue 24 of Health Europa Quarterly. Click here to get your free subscription today.

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