Oct 6 / Dr Tom Ratcliffe

Rise up against the organisation of misery

Things must change, and change soon.

Anyone working in areas of poverty will tell you the same thing: many families are stressed out to the max, staring at the equation: income minus cost of housing minus food minus heat minus clothing and getting the same answer – the sums do not add up, the result is always negative.

And the result: charities supplying food so people do not starve, mattresses so children don’t sleep on the floor, people getting ill from cold, moldy homes and a generation whose health and wellbeing is irreparably damaged.

The facts and figures around destitution, defined as "poverty so extreme that one lacks the means to provide for oneself", are shocking. Millions of families in the UK now experience this as a day to day reality, according the latest report from the Joseph Rowntree Foundation. You may also want to refer back to our 2022 blog on the cost of living crisis.

Economic policy responses to destitution seem inadequate and, all too often, involve "tough choices" that are tough only for society's least affluent. The worst policies are cruel and seem designed to pile suffering on those who already have very little. Ending destitution does not appear to be being met with an adequately robust or urgent economic plan.

There was a time when people in poverty could depend on public services, the welfare state and the NHS for help. Now, if they do so, they will find that it is, quite literally, falling apart.
I work in a health centre that has been listed for replacement for over ten years, whose roof regularly leaks, whose toilets are often out of order and that, at one stage, had to be closed for rat infestation. Our local hospital’s roof has to be regularly inspected because it is made of aerated concrete and at risk of structural failure. Our computer systems are outdated and slow. This is all the direct result of one of the lower levels of capital expenditure on healthcare amongst comparable European countries since 2010.

Last month a colleague told me a story of when they were a trainee doctor in the 1990s. One of their jobs was to go through the waiting list for urology and check who had died whilst they were waiting for surgery. The waiting list was dubbed ‘the death list’. With the current delays in the health service, we are back there now.

Not only will people on the waiting lists die or become more seriously ill than might otherwise have been the case, but many are unable work, with significant economic implications. This is why investing in healthcare at the level of inflation in healthcare costs makes economic sense.

In primary care, the GP workforce is in decline and essential community services have been cut back, as a result of huge reductions in local authority and public health funding. Children’s centres, health visitors, school nurses, contraception and sexual health and drug and alcohol services have all been cut back. At the same time, we have failed to sort out social care, meaning that people with dementia, frailty, learning disability, severe mental health problems or physical disability, all receive care that is nowhere near as compassionate or effective as it should be.

So, when you read headlines about an epidemic of childhood mental illness, falling vaccination rates for serious illnesses like measles, rising numbers of cases of gonorrhoea and syphilis, rising deaths from drugs and alcohol, failures to safeguard children from abuse, older people suffering the indignity of substandard social care… then ask, why? You will need look no further that the disastrous short term money saving measures of the austerity era, the failure to reach a consensus around social care reform over the last two decades and the lack of a serious plan to put healthcare funding on a sustainable trajectory.

This adds up to a failure to protect and improve population health. At the turn of the century, Wanless and others told us that, if we followed this path, publicly funded healthcare would be unsustainable, and they were right . Yes, the Covid-19 pandemic had a big impact, but it has just acted to accelerate underlying trends: the present was always our destination.

Turning to the things that public health is traditionally concerned with… On the plus side, tobacco consumption continues its long term fall; on the minus side, rates of obesity, harmful alcohol use and mental health problems are rapidly rising , with a disproportionate impact on areas of high deprivation . At the same time we are beginning to appreciate the harmful effects of a new set of factors: air pollution, childhood trauma and adverse events, consumption of ultra-processed food and loneliness, gambling and pornography addiction to name but a few. Again, exposure to these is not equally distributed across society, with the poorest often most at risk.

Thinking about wider social determinants of health: schools are struggling, police forces face issues with tackling crime and anti-social behaviour and our communities, especially the less affluent, look increasingly run down, with empty high streets, declining leisure and library facilities, potholed roads and public spaces run down, unduly affected by crime or both.

Sadly, it turns out that, when it comes to the impact of these things on health, the experts are right. Neglect society and life expectancy and health go into decline. This is exactly what is happening for the first time in over a hundred years.

But, there is hope.

Many parts of healthcare, including primary care, operating in the most socioeconomically deprived neighbourhoods have innovated amidst this relative desolation. There are brilliant examples of health coaching, social prescribing and community development work being done to counteract what is happening in the public realm and offering an essential lifeline to struggling families. There is a growing evidence base about what to do about health inequalities – a clear message is to start with giving children the best start in life and reducing child poverty.

We are better able to use data and digital technology to target peoples’ ill health and interventions at the right groups. The voluntary and community sector has been incredible when it comes to helping communities with their health and wellbeing at grassroots level. There is a growing realisation that a greener future is a healthier future (and, for now, a broad political consensus to pursue this). And we have seen that public health measures (tobacco control, alcohol minimum pricing and “sugar taxes” ) can work.

A General Election is imminent. It is vital that the incoming Government addresses the huge problem of poverty and starts to restore the nation’s health and healthcare.

As a charity concerned with healthcare, we have set out what can be done in primary and community care to turn the tide, based on our experience of working in the most socio-economically deprived communities during an era of austerity and deteriorating public health. You can read our briefing here.