The cost of mounting inequality

The socialist thinker and academic Raymond Williams once observed that ‘to be truly radical is to make hope possible, rather than despair convincing’.

It is a maxim and mindset Professor Sir Michael Marmot (pictured above) subscribes to, even if he readily concedes there is plenty to despair about when it comes to the state of health equity and social inequality in the UK in 2023.

A former president of the BMA, and global authority on the determinants of health and the role of social justice in wellbeing, Prof Marmot is the author of the landmark 2010 study Fair society, healthy lives: the Marmot review, with this seminal piece of work itself revisited and reappraised in 2020’s The Marmot Review 10 Years On

It was with these credentials in mind that Prof Marmot was invited to present the second instalment of the Victor Horsley lecture at this year’s BMA annual representative meeting in Liverpool, in which doctors and medical students had the opportunity to hear Prof Marmot dissect the factors which have contributed to disparities in health outcomes. These include the fact that UK life expectancy, which until 2010 had been increasing around one year every four, has now shrunk by 0.9 years in women and 1.2 years in men.

Poor indicators

Meanwhile health and physical development among UK children has been similarly stunted, with the average height of five-year-olds in the UK now ranked 101 out of 200 similar nations, having been 69th in 1985.

‘Our five-year-olds are now seven centimetres shorter than fiveyear-olds in the Netherlands,’ explained Prof Marmot.

‘The genes didn’t change in that time. Genes determine the heights of individuals. It’s nutrition, infection, poverty, stress [that determine the heights of groups].

‘What we can say is [between 2010 and 2020] we [the UK] had the slowest improvement in health equity of any rich country except Iceland and the USA.

‘I’m concerned with health and the determinants of health, particularly now that the healthcare system is under such threat [and] there have been three huge recent challenges to health inequalities; the decade of austerity, the COVID pandemic, and the cost-of-living crisis.’

COVID co-efficient

While the role of social status in determining an individual’s health outcomes is not a recent observation, understanding the complex interplay of how global events and subsequent government policy have a direct effect in shaping these outcomes is not always straightforward.

Around the time he was publishing his 10 years on review, Prof Marmot had made clear that the then unfolding COVID-19 pandemic would expose and exacerbate existing health and social inequalities.

The antecedents, however, go back much further, and in many cases are the logical conclusions of political choices and government policies enacted since 2010, with Prof Marmot pointing out that public sector spending had been 42 per cent of GDP in 2009/10 shrinking to 35 per cent by 2019/20.

He said that having recently listened to an interview with George Osborne in which the former chancellor asserted that austerity had helped to drive growth and make the UK’s economic model one that other countries had sought to emulate, he found it laughable.

‘The pandemic is a crisis, but I would argue that the magnitude of health inequalities we had in 2010 should have been a crisis, and yet we chose to cut public expenditure and make things worse,’ Prof Marmot said.

‘George Osborne was the architect of the austerity, I was listening to him on a podcast while I was out for a morning walk today [and] was so annoyed I got a blister.’

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That which we call a rose…’ Shakespeare so often has the right words for a situation, but there was one debate at the BMA annual representative meeting in July, where Juliet’s famous line on names not mattering would simply not have cut it.

That which we call a ‘junior doctor’ feels vile esteemed by the title, and they would argue it entirely fails to capture the weight of responsibility required.

Staffordshire foundation year 1 Sai Ram Pillarisetti told the ARM: ‘This title of junior doctor has proven misleading and indeed demeaning to the general public, it may imply lack of experience or competence, creating a misunderstanding about the work we do and the qualifications we hold.’

There was nothing junior about their responsibilities, he said, adding that the title failed to distinguish between doctors with differing levels of experience.

‘Every day these so-called junior doctors act as the first point of contact for sick and unwell patients on the ward, they’re in theatre operating on your loved ones, and they’re leading teams across various specialties in our health service,’ he said.

This has been a subject of debate for some time.

Consultant orthopaedic surgeon Scarlett McNally was asked last year to write a report by Health Education England. A survey conducted for the report found more than three-quarters found the term ‘junior doctor’ inappropriate and almost half thought ‘trainee’ should be avoided.

Professor McNally recommended four titles – foundation year ones, central doctors, registrars and consultants.

‘Central doctors’ would generally be within five years of qualification, and largely occupy the ground previously held by senior house officers.

Unwanted title

The difficulty inherent in any renaming exercise was acknowledged at the ARM by East of England anaesthetics trainee Ciaran Scott who said that attempting to educate the public about the capabilities and responsibilities of junior doctors might be a better use of time.

Recognising the challenges highlighted by Dr Scott, Manchester medical student Noor Al-Saffar said, however, that abandoning the ‘junior’ title was a correct and important step in redefining the way doctors were perceived.

‘There have been several anecdotal studies which have shown that junior doctors have experiences where patients have asked for a senior doctor because they don’t believe in the competency of these doctors,’ she said.

The motion urged the BMA to discontinue the use of the terms ‘junior doctor’ in all forms of communication, and use ‘doctor’ instead.

What was clear from the debate is that experience comes thick and fast to doctors, and that there is nothing ‘junior’ about what any doctor has to do.

As Shakespeare said, perhaps more helpfully: ‘Experience is by industry achiev’d, And perfected by the swift course of time.’

AL-SAFFAR: