Same storm, different boats: can the UK recapture improving life expectancy trends?

The COVID-19 pandemic has led to devastating loss of life and livelihood across the world. It has resulted in falls in life expectancy, a widely used summary measure of contemporary age-specific mortality rates, in most European countries. In England and Wales, life expectancy has fallen by 0.9 and 1.2 years for women and men, respectively, when compared to 2019. These falls are, however, part of a longer-term trend that began long before the COVID-19 pandemic. For the past decade, life expectancy in the UK has been stalling, and falling in some regions and social groups, and inequality in age at death has been rising. In this piece, we consider the health of the UK population before the pandemic, compare this to the health of the populations in the USA and Japan, as investigated in a recent paper, and ask if it is possible to recapture previous improving life expectancy trajectories.


Health in Britain before 2020
The pandemic arrived in the UK after a decade of austerity and declining health outcomes: stalling life expectancy, rising infant mortality rates and widening health inequalities. 4,5 Spending on health and social care did not keep pace with rising demand, leading to declining service access and outcomes. 4,6 A phenomenon first described in the USA of rising mid-age mortality (aged 45-54 years) from 'deaths of despair' -that is deaths from suicide, drug and alcohol overdoses, and alcoholic liver disease -has now been observed in England and Wales 7 and in Scotland, 8,9 with growing evidence that an increase in mortality at mid-age is contributing to a widening of inequalities in the age of death in the UK. 3,10 This alarming loss of life did not occur suddenly. In 2015, when the UK saw one of the largest increases in year-on-year deaths since World War II, alarm bells were sounded but the government response was not one of national crisis. 11 Health outcomes continued deteriorating in the years that followed, and many began to suggest the declines could be a result of austerity policies that were resulting in the slowing down or cutting of government expenditure on health, social care, education, welfare and housing. The Cameron government, which believed austerity was good economic policy, refuted this link and ignored widespread concern from public health experts. 12 While other causes may also have played a role in the poor state of population health in the UK prior to the pandemic, such as reductions in improving cardiovascular disease mortality (which may itself be related to austerity), 13 the evidence on the contribution of austerity policies on health outcomes is overwhelming. 14 As a result, the UK 'limped into the pandemic . . . an unhealthy population marked by growing inequalities and a worsening of the conditions in which people are born, grow, live, work and age'. 15

Same storm, different boats
Japan and the USA -two countries with very different experiences of the COVID-19 pandemic -entered the pandemic with very different population health patterns. The USA had seen unprecedented falls in life expectancy every year since 2015, preceded by rising lifespan variation, 16 representing increasing inequality in the age at death. Japan, in contrast, had sustained increases in life expectancy and reductions in lifespan variation, with no worsening of health inequalities, despite a decade of low economic growth. 3,17 Several factors, including government policy during the pandemic, determine the severity of COVID-19 in any given country. There appears to be, however, an observable difference between the high-income countries examined that entered the pandemic with deteriorating population health and growing inequalities, such as the UK and USA, and high-income countries where health is more equally distributed across the population, such as Japan. 18 Could it be that countries that entered the pandemic on a 'healthy trajectory', with stable or improving health outcomes across the population, were more resilient to the pandemic?
The road not taken In the past year, life expectancy in England and Wales has fallen, 2 superimposed on a worsening trend before the pandemic. 3,4 Without urgent intervention, the UK is unlikely to recapture the trajectory of health in countries like Japan.
For decades, public health practitioners and academics have been calling for greater action on the wider determinants of health, such as education, employment and housing. 19 The recently established Office for Health Promotion, 20 with a much overdue cross-government ministerial board, aims to operationalise a 'step change in public health policy'. It remains to be seen if this is substantial or symbolic, but it is clear the Office will fail to meet the Conversative Party pledge to increase healthy life expectancy by five years by 2035, 21 if it does not explicitly consider the role of socioeconomic deprivation in shaping health.
In order to recapture improving life expectancy trends, public services -including health and social care services -need investment and reform, not least to handle the COVID-19 aftershocks. The Institute for Public Policy Research has called for an average £12 billion per annum uplift to NHS, 22 social care and public health services expenditure, while the LSE-Lancet commission has called for an average £10.2 billion per annum for the next decade. 6,22 Instead, analysis of November 2020 and March 2021 Budgets by the Institute for Fiscal Studies reveals austerity policies by stealth in several government departments, most notably in funding for local government which is facing a 3% real-terms cut in 2022-2023. 23 The Institute for Fiscal Studies concluded 'if [the proposed figures] are adhered to then many public services are due a second, sharp dose of austerity'. 24 Japan and the USA are taking different approaches. Both have adopted more Keynesian responses to the economic crisis brought about by the pandemic and have significantly increased government expenditure. This is in keeping with a shift in macroeconomic consensus, with even eminent institutions of fiscal discipline such as the International Monetary Fund and the Organisation for Economic Co-operation and Development, advocating a sizeable debt-financed fiscal stimulus. 25,26 The UK's spending plans in response to the COVID-19 pandemic are less than half of the USA's and one-third of Japan's, adjusted to the size of the economy. 27 President Biden has since committed to a further $4tn spending over the next decade, which includes significant investment in health and social care, child care, education and housing. 28,29 It will be of great interest to observe the impact this has on the current declining life expectancy trends in the USA.

Conclusion
As we wait for an official COVID-19 inquiry, the question remains: how prepared was the UK for a pandemic? The health of the population was deteriorating before 2020, with a loss of previous improving trends in life expectancy. It is not certain what role this played, but what is abundantly clear is the impact of the poor and unequal distribution of health in the UK prior to the pandemic: COVID-19 has not just fed on these inequalities, it was amplified by them.
The road to recovery for health, including life expectancy trends, requires an ideological change in social and economic policy making. It requires coordinated and collaborative action across local and national government, and greater investment in public services and welfare. Health is a public good -it must now become a marker of societal progress.

Declarations
Competing Interests: None declared.
Ethics approval: Not applicable.

Guarantor: LH
Contributorship: LH conceived the first draft which PP significantly edited and added to.