The Five Health Frontiers: A New Radical Blueprint

The Five Health Frontiers

‘A brilliant exposé of how the political left in Britain is unaware of, and can start to begin to address, the effects of ever-increasing opting-out from public health and care services by those who can.’

—Danny Dorling, Professor of Geography, University of Oxford

‘The boldest blueprint for public health since Bevan.’

—Sonia Adesara, NHS Doctor and Campaigner

‘The ideas in this book are as significant and radical as the birth of the NHS, it shows a new, fairer vision for improving the health of the nation and a comprehensive plan for how to do it.’

—Shirley Cramer, former CEO of the Royal Society for Public Health

‘A vital book that shows just how broken the health status quo truly is. Thomas’s work will arm campaigners to demand a better, more just public health system – and to defend human life against corporate exploitation.’

—Dr Aseem Malhotra, author of A Statin-Free Life and Founder of Public Health Collaboration

‘A well-argued plan to bring together health, social and economic justice.’

—Andy McDonald MP

The Five

Health Frontiers

A New Radical Blueprint

Christopher Thomas

First published 2022 by Pluto Press

New Wing, Somerset House, Strand, London WC2R 1LA

www.plutobooks.com

Copyright © Christopher Thomas 2022

The right of Christopher Thomas to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

ISBN 978 0 7453 4393 8 Hardback

ISBN 978 0 7453 4392 1 Paperback

ISBN 978 0 7453 4395 2 PDF

ISBN 978 0 7453 4394 5 EPUB

This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental standards of the country of origin.

Typeset by Stanford DTP Services, Northampton, England

Simultaneously printed in the United Kingdom and United States of America

Contents

Abbreviations

List of Tables

Acknowledgements

Preface

Introduction

1. The NHS Frontier

2. The Social Justice Frontier

3. The Economic Frontier

4. The Social Care Frontier

5. The Sustainability Frontier

6. The Public Health New Deal

Epilogue: Labour’s Medicine

Notes

Index

‘Salus Populi Suprema Lex Esto’

The health of the people should be the supreme law

Marcus Tullius Cicero

To Alex

Abbreviations

List of Tables

1.1 Five Shifts to Realise Universalise the Best in the NHS

3.1 Proposed Powers for a New Government Public Health Unit

4.1 Location of Deaths, Selected European Countries and the UK

5.1 Description of a Sample of EIDs of Significant Concern

5.2 The Safe Operating Space for Humanity, Global Public Health

6.1 Costing the NHS Frontier

6.2 Costing the Social Justice Frontier

6.3 Costing the Social Care Frontier

6.4 Total Investment for a Public Health New Deal

6.5 Under 75 Mortality Rate per 100,000 Population, England, by Region

E.1 Labour Lead on Healthcare Ahead of Election

Acknowledgements

It’s not always easy to write a book about health during a health crisis. Combining a day job researching health and care with evenings and weekends spent thinking and writing about the implications of the pandemic could at times be oppressive. There were moments I wanted nothing more than to stop, hide away and think about anything else. But this has been a universal experience for many of us over the last 15 months, each witness to the deadly nature of the pandemic and the personal cost of failures in government policy.

In other moments, I felt incredibly privileged. Privileged to have had the opportunity to channel my fear and frustration into the catharsis of imagining what radical change must now follow – and might just become possible. There are few better coping mechanisms.

I could not be more grateful to Pluto Press for publishing this book. Neda Tehrani was an immediate champion for my book from the proposal. She has pushed it in ambition, scope and relevance ever since, for which I’m hugely grateful. Others have made huge contributions throughout the writing process. I appreciate the feedback given by my parents, by Harry Quilter-Pinner at the IPPR on an early draft, and from many others who read chapters or who listened to me read it out loud.

This book would not have been possible without the immense work from the academic and policy community. I am lucky to be able to draw from such a large base of fascinating research and scholarship – it’s a book built on the shoulders of giants. I hope what follows does some justice in translating our fantastic evidence into big policy ideas.

Most of all, though, my thanks to Alex – who has managed to be my partner while I dedicated weekends, evenings and early mornings to writing this book over the last 18 months. There is an irony that the health consequences of stress, overwork and burnout are covered in some detail – but she helped ensure I got through all these experiences safe and sound. Sometimes there has been joy, and sometimes it has been a dark and frustrating process. For being there and sharing in both, thank you.

Preface

The idea for this book came well before Covid-19. For a few years, I’d had a half-written book proposal saved in an out-the-way part of my computer. It emerged from my growing sense that there was something deeply wrong with how our public health system works – a fundamental discordance between health today and the democratic socialist ideals upon which the National Health Service (NHS) was founded in 1948.

Often, we chalk ‘health’ up in the left-wing win column. We talk lovingly about the UK’s system of universal care, based on need rather than identity, income, or ability to pay. But the brutal reality is that our public health system still distributes the best health to the people with the most money or power, and the worst health to the poorest and most marginalised.

Today, the most disadvantaged people in our country struggle most to access the healthcare that they need, and experience substantially worse outcomes when it comes to both length and quality of life. These injustices were not eradicated by the advent of the NHS – and they have been observed both in periods in which the health service has had plenty, and in periods where it has been starved of funding.

When news first broke of a new infectious disease spreading across the world, in the first days of 2020, I remember feeling confident we’d be okay. The UK was in an incredibly privileged position. We’re an advanced economy, we’re an island, we had a well-regarded infectious disease surveillance system, we have universal healthcare, people aren’t denied tests, vaccines, or treatments as a rule, and we have an influential role in the global health system.1

It quickly became clear that any such confidence was misplaced. To the horror of most in the health, medical and scientific communities – as well as the public – almost everything that could go wrong, did go wrong. Communication was poor and action was often lagging. In March 2020, large sporting and music events carried on, even as infection rates climbed. Lockdowns were repeatedly implemented too late. ‘Test and Trace’ was established, cancelled, re-announced and then outsourced to disastrous consequence and cost. All the while, tens of thousands of people died.

In an article on The Plague, Jacqueline Rose describes Albert Camus’ presentation of ‘the pestilence’ as both ‘blight and revelation’.2 My revelation from this pestilence was that, while exasperated by bad policy decisions during the pandemic itself, many of the problems we faced weren’t new. Rather, Covid-19 exposed and exploited structural problems that already existed, only now at a huge scale. In many cases, those structural problems were the same as the ones I had written of in my half-written book proposal.

In some parts, this book tells a story of the discrepancy between the NHS as it exists today, and the intentions and principles set out by Nye Bevan when he founded the service in the late 1940s. But it is quite a different story to the one told in the health books that have come before it. Often, interventions that cover the health service only take aim at the failures of neoliberals, libertarians, conservatives and right-wingers – usually, by sounding the alarm about privatisation. By contrast, this book is just as interested in taking a critical look at the left’s strategies to ‘save’ our NHS. Specifically, it asks why the stories we tell – and the perennial rear-guard action we employ to defend against the wrecking ball of privatisation – are no longer proving either effective or sustainable.

And while it would be difficult to write a book on health without talking about the NHS, I am of the strong opinion that this book is most important when it doesn’t talk about the health service at all. Our love of the NHS – ‘the closest thing the English people have to a religion’, to quote Nigel Lawson – has led to what I call an ‘NHS-centrism’ on the left. ‘NHS’ and health have become nearly synonymous among the public, politicians, journalists and activists. But if our goal is to advance health improvement and address health justice, this is far from optimal.

Though it’s not a recent finding, it still surprises people I talk to just how much of our health is defined outside of brick-and-mortar hospitals and Accident and Emergency (A&E) departments. Just 10 to 20 per cent of the disparities between people’s health outcomes are explained by differential access to healthcare. The other 80 to 90 per cent are explained by factors like our environment, our socio-economic status, or the places that we live in – that is, by our material conditions. This brings into scope agendas and policy levers far beyond the NHS or the Department of Health and Social Care.

To really get to grips with the big questions in health – why life expectancy is stalling, why health inequality is widening, why pandemics are breaking out, why the global health system is increasingly vulnerable and why policy doesn’t seem to be making a blind bit of difference – the left needs to expand the passion we have for our universal health service to the other key pillars of the public health system. We need to look at how we’ve failed to inoculate people against the health consequences of social injustice, and the way poverty expresses itself on our bodies as ill health. We need to look at how we have allowed businesses to profit at the expense of our health, without penalty or shame. We need to look at how a nationalistic approach to health placed us at risk of major health shocks and how it continues to do so. Each of these points is covered by a chapter in this book.

In some cases, the book adds value by highlighting new evidence on key aspects of health improvement or health justice. But, while I have aimed to give attention to drivers of poor and unequal health that traditionally receive less attention, I realise that the evidence on the drivers of poor health is very well established elsewhere, too. This book owes a clear debt to the writers on health inequalities that have come before: Kate Pickett, Richard Wilkinson, Michael Marmot, Lee Humber, David Stuckler, Sanjay Basu, Danny Dorling and others. There are perhaps, then, two places where this book adds value in places less well covered by other works. First, it applies a distinctly radical framing. A key objective here is to bring public health within the scope of the left’s wider search for a cogent, coherent and compelling political project that is built around justice.3 Too often, I find, the health sector and the progressive sector have very separate conversations, using disparate languages – and this book helps to bridge the gap between the two in a post-pandemic moment when our ambitions are broadly aligned.

Second, this book recognises that for all our evidence there is a poverty of radical, left-wing policy thinking in health. The sad truth is that there hasn’t really been an exciting health policy since the 1948 National Health Service Act and – for pockets of promising work – health has not hosted the same levels of creativity and ambition as agendas like economic, climate and criminal justice. Now more than ever, we desperately need exciting ideas that explain why public health is important, and why it can be a keystone in a compelling vision of a better future.

In line with that ambition, this book adopts the broadest possible definition of ‘public health’. For some, public health means a limited array of local and community services, funded out by a small ring-fenced grant. But in this book, it refers to everything that contributes both to the aggregate health of the population and the way that stock of health is shared out. Public health in this book is therefore not a single arm of the welfare state, but rather a comprehensive and distributive system (akin to the economy). Defined in this way, public health can provide an anchor for a holistic vision for our society and economy – perhaps even an alternative to GDP more suited to the left’s goals and agenda.

In thinking about how the left achieve change, I often refer to progressive, left or otherwise grassroot social movements. A key reason for writing this book is to undertake a constructive exploration of the state of the thinking, politics and campaigning around health on the left. Given that, I want to be clear from the outset: I realise the progressive movement is creative, diverse and often in productive disagreement with itself. I therefore realise that when I talk about the ‘mainstream’, it might lead me to overstate the homogeneity – and that for any critique I put forward, there will be grassroot exceptions. I’ve aimed to counterbalance this by pointing out a selection of the great examples of activism that do exist in the grassroots. But my main interest is with the mainstream: which left health arguments and topics receive the most bandwidth, the most attention, the most voluntary time and the most funding. Far from erasing the places that are good, my hope is this contribution strengthens the best of the vital work going on in the grassroots.

Another phrase I use regularly throughout the book is ‘health justice’ – a lesser heard term within the health sector today. More often, we use the language of ‘health inequality’, ‘inequity’, or ‘the social determinants of health’. We could get lost in semantics here, and I have seen whole programmes of what could have been worthwhile work derailed by an inability to pick a term. I’ve chosen health justice as it feels better aligned to one of my core propositions: that when it comes to health, we need to be more interested in how power operates, and more cognisant of how we align to other movements focused on radical change and societal justice.

The overwhelming message is one of optimism. I believe that through collaboration, the destruction wreaked by Covid can be the ashes from which the phoenix of better health rises. While we cannot dodge the brutal reality of fundamental problems with the health status quo, this book seeks to provide a new, radical blueprint – one through which public health and care can provide the foundation for a fairer society for all.

Introduction

In February 1928, George Orwell – or Eric Blair as he was then still known – arrived in Paris. He was not alone in yielding to the allures of the city of lights. It was then home to a number of his literary contemporaries – Gertrude Stein, T.S. Eliot, Jean Rhys, Ernest Hemingway and Ezra Pound all among them.

For many, the draw of Paris was the hedonistic ‘café culture’ of the inter-war period – an appropriate environment for the cultivation of literary bohemianism and high-minded modernist prose. This was not to be Orwell’s experience. Instead, his stay in the city would be defined by the shock of a sudden and severe illness.

This experience of ill health would stay with Orwell throughout his life. In the immediate aftermath, the experience informed the semifictional Down and Out in Paris and London (1933).1 Twenty years later, he returned to the period, this time in the non-fiction essay How the Poor Die (1946). The latter stands as a definitive, blow-by-blow account of the treatment he received during his two-week spell at L’Hôpital Cochin.2

HOW THE POOR DIE

L’Hôpital Cochin offered Orwell nothing short of torture. Upon arrival, he was met with an aggressive and unpleasant interrogation by the hospital’s receptionist – lasting a full twenty minutes and which, given his feverish temperature of ‘around about’ 103 degrees Fahrenheit,3 tested his ability to stay conscious.4 Next, Orwell was given a hot bath: ‘a compulsory routine for all newcomers, apparently, just as in prison or the workhouse’.5

His clothes were stowed and replaced with the hospital’s uniform of a linen nightshirt and blue dressing gown. In this scanty clothing, he was led barefoot through the open air – on a brisk February evening, and with suspected pneumonia – to the main hospital building. Inside, dim light illuminated rows of beds, each just a few inches, and a ‘foul smell, faecal and yet sweetish’ filled his nose.

Orwell was humiliated, disgusted and frightened on the ward. The experience led him to conclude that there is a substantial difference between how the poor and the rich die:

In the public wards of a hospital you see horrors that you don’t seem to meet with among people who manage to die in their own homes, as though certain diseases only attack people at the lower income levels.6

The most affluent of Orwell’s contemporaries could expect to expire in relative comfort. Most of them would pay for a doctor to deliver care in their own home. If they did need to visit hospital, they would book a private room – with better care, nicer food, more focused attention, in short: more dignity. The poor could expect a far more brutal, undignified and painful experience in tightly packed wards. The institution of the hospital, for them, was of the same genre as the prison block or the torture chamber.

Orwell’s story is not just about France. It’s not pure travel writing, nor is it designed to simply make his British readers grateful for what they have by comparison. Rather, it’s a story that epitomises the growing demands in the 1940s for major improvements to the country’s health system, and which captures the growing public distaste for the health inequalities present in mid-twentieth century Britain.7

It was within this context that the country elected the radical Attlee government, promising a system of universal healthcare. After a long and contested legislative process, the National Health Service was born on 5 July 1948 – with the explicit objective of providing everyone with the healthcare they needed: regardless of class status, income, religion, home address, or place of birth. It was meant, once and for all, to solve the kind of injustices about which Orwell had written.

THE GREAT EQUALISER

The sheer existence of the NHS gives rise to a pervasive idea today that we are all equal in the face of disease. This was certainly an idea that commentators looked to push in the early stages of Covid-19.

The Sunday Express published an official leader to this effect on March 15 2020.8 In the same month, John Harris wrote in the Guardian that ‘Coronavirus means we really are, finally, all in this together’.9 In between the two, the Evening Standard declared that ‘London Stands Together’.10 Madonna, broadcasting from a marble bathtub sprinkled with rose petals, recorded a video message calling the virus ‘the great equaliser’.11

The actual experience of Covid couldn’t be in starker contrast to these early proclamations. The disparities became clear from the moment we first learned the identities of the people dying from the disease. The national media took particular interest in the fate of NHS workers. And as they began to contract the virus, and tragically began to die, it was not uncommon to see their faces lined up on the front pages of the morning papers. Displayed in this way, something became clear: very few of the faces were white.

On 2 June 2020, anecdote was backed by evidence when Public Health England (PHE) published data on the pandemic’s inequalities.12 Compared to previous years, excess deaths among white men had doubled. But among Asian men, they had tripled. And among Black men, they had quadrupled.13 The report found similar patterns of mortality by ethnicity among women as well.

The same PHE report also implicated class in Covid’s injustices, and subsequent data has revealed this relationship yet more clearly. Official statistics now show the occupations with the highest Covid-19 mortality rates in 2020 were, in descending order: bakers, publicans, butchers, police officers, vehicle valets and cleaners, restaurant managers, hairdressers, care workers and home carers, metal working machine operatives, bank clerks, food and drink process operatives, chefs, taxi drivers and chauffeurs, security guards, roofers, waiters, ambulance staff, nursing assistants, catering and bar managers, hospital porters, caterers, and nurses.14 Every occupation on this list had a Covid mortality rate at least double the average (and as much as twenty times larger).15 And the clear pattern is that these most vulnerable professional groups predominantly fill jobs that are low paid and unable to offer work from home, but which are vital to maintaining the country.

‘Long Covid’ – a particularly serious form of the virus, with as many as 200 symptoms according to researchers at University College London16 – has a similar epidemiology. According to estimates from the Office for National Statistics (ONS), about a million people in the UK had long Covid as of July 2021.17 Of that million, health and care workers, people aged 35 to 69, women and those with a disability made up a disproportionate number of cases.18 Moreover, people living in the most deprived parts of the country – a measure obviously related to class and occupation – were also more likely to report having long Covid at the time of the analysis.

So strong is the link between job, class and long Covid, that there have been calls for the illness to be categorised as an ‘occupational disease’ – to ensure sufferers are eligible for Industrial Injuries Disablement Benefit (IIDB) payments.19 Despite this, there has been little in terms of recognition, support, or compensation.

INJUSTICE AT SCALE

Severe health disparities are not unique to the pandemic. In fact, the inequalities observed run along the same lines as health injustice before it. Recent estimates put life expectancy for men in the most deprived parts of the country at nearly ten years less than those in the least deprived. Among women, the gap is 7.6 years. The inequality in healthy life expectancy20 was twice as high – 19.0 years for men and 19.3 years for women.21 Compared to people in the least deprived parts of the country, those living in the most deprived communities are two times more likely to be diagnosed with lung cancer, and 1.5 times more likely to be diagnosed with prostate cancer.22 Similar figures can be found for almost every major physical and mental health condition.

That means that while Covid-19 was defined by inequality, and enacted injustice at massive scale, it was not the pandemic that put the conditions in place for this injustice. Covid simply exposed and exploited the existing structural vulnerabilities in the country’s health system. The conclusion we must level with is that despite the landmark democratic socialist achievement of a National Health Service in 1948 – and the work done since to solidify and protect those gains – we still have a public health system that disproportionately distributes good health