Transcript of Module 1 Public Hearing on 16 June 2023

(10.00 am)

Lady Hallett: Yes, Ms Blackwell.

Ms Blackwell: Good morning, my Lady. The evidence today will begin with me calling Professor Clare Bambra and Professor Sir Michael Marmot, who are present in the witness box. May they be sworn, please.

1. Professor Sir Marmot and Professor Clare Bambra

PROFESSOR SIR MICHAEL MARMOT (affirmed).

PROFESSOR CLARE BAMBRA (sworn).

Questions From Counsel to the Inquiry

Ms Blackwell: Thank you both. May I begin by thanking you both for the assistance that you’ve given to the Inquiry so far, and for agreeing to come and give evidence to the Inquiry today.

During the questioning, please keep your voices up and speak into the microphones so that the stenographer can take a note. If I ask you a question that isn’t clear, please ask me to repeat it.

If you need a break at any time, please just indicate. We will have a break part-way through your evidence, but if you want one before that, please just say and we will rise.

My Lady, the report that has been jointly prepared by Professors Marmot and Bambra is at INQ000195843. It’s currently on the screen. My Lady, you can see that it’s signed at the foot of each page by each of the professors, confirming that it’s their own work. Please may we have permission to publish the report?

Lady Hallett: You do, thank you.

Ms Blackwell: Thank you.

We can take that down.

I’m going to begin by providing an introduction of your professional backgrounds and areas of expertise.

Turning first to you, Professor Bambra, you are a professor of public health in the Population Health Sciences Institute, at the Faculty of Medical Sciences at Newcastle University. You have extensively researched health inequalities, including the unequal impact of the Covid-19 pandemic. In 2013, you were elected as a fellow of the Academy of Social Sciences and in 2022 you were awarded senior investigator status with the National Institute for Health and Care Research academic college.

You are an academic co-director of Health Equity North and a member of the World Health Organisation Europe’s scientific advisory group on health equality.

Professor Sir Michael Marmot, you are a professor of epidemiology and public health at the Institute of Health Equity, University College London. You are an elected fellow of the Faculty of Public Health at the Academy of Medical Sciences, an honorary fellow of the Royal Society of Public Health, and the British Academy, and a foreign associate member of the Institute of Medicine.

In 2000 you were awarded a knighthood, and in 2023 made a companion of honour for services to public health. In 2008 you chaired the World Health Organisation Commission on Social Determinants of Health, and you led the seminal UK Government-commissioned Marmot Review, Fair Society Healthy Lives, in 2010, as well as the Health Equity in England: The Marmot Review 10 Years On in 2020, and Build Back Fairer: The COVID-19 Marmot Review in the same year.

Hot off the press, recently announced last week, you will co-chair the Global Council on Inequality, AIDS and Pandemics, researching and asks the questions: do inequalities drive pandemics, and what is the impact of pandemics and inequalities in health?

The report that you have prepared is split into topics, and we will deal with your evidence along the same lines, covering health inequalities, the health inequalities landscape in the UK, health inequalities in pandemic planning, the consequences of failing to take account of health inequalities, and the recommendations which lie at the end of your report.

May we put on the screen, please, page 4 of the report, and highlight paragraph 2. You begin your report in this way: explaining that:

“Health inequalities are the systematic, avoidable differences in health which exist between different social groups … Health inequalities exist between different socio-economic groups (measured using indicators of socio-economic status, including income, education, occupation or area-level deprivation), by ethnicity, and are also experienced by other social minorities (such as ‘inclusion health groups’, or members of the LGBTQ+ community, or people with disabilities). The term health inequalities includes both (a) inequalities in health outcomes (eg mortality rates, life expectancy etc) as well as (b) inequalities in access to healthcare and inequalities in the outcomes of healthcare.”

Please can you explain to the Inquiry what is meant by inequalities in health outcomes as compared to inequalities in access to healthcare, and how do these relate one to the other?

Professor Marmot: Inequalities in health outcomes commonly we measure by mortality, life expectancy, healthy life expectancy, or some specific measures of morbidity. There’s been intense debate in the scientific field as to how much of the systematic inequalities between social groups in those health outcomes that I’ve just described can be attributed to inequalities in access to care.

Ms Blackwell: Yes.

Professor Marmot: When the Commonwealth Fund has looked at health systems in 11 countries, consistently until – maybe not anymore, but consistently until very recently, the NHS always ranked number one on equity of access. Which means that, by and large, most of the inequalities in health that we see are not directly related to inequalities in access to healthcare.

In the United States, for example, there’s enormous interest in inequalities in access to healthcare because they are huge.

Ms Blackwell: Yes.

Professor Marmot: But in a way we’re the control country. Because we’ve done such a good job of getting equity of access to healthcare because of our National Health Service, by and large, the majority of the inequalities in health that we see are not attributable to inequalities in access to care.

Ms Blackwell: Right. There are several social, economic and environmental factors which impact on people’s health and can give rise to inequalities; is that right?

Professor Marmot: It’s what we call the social determinants of health. I don’t want to divert the Inquiry, but we have another term that we use. You introduced me, I’m the director of the Institute of Health Equity, and the reason we’ve introduced that term, WHO tends to use it, it’s these avoidable differences in health which are judged to be avoidable and are not avoidable, are unfair, hence inequitable.

Ms Blackwell: Right.

Professor Marmot: That’s why we tend to talk in terms of health equity, social justice, which is a judgement call, whereas what Clare – forgive me if I refer to my colleague as Clare rather than Professor Bambra – what Clare and I are looking at is the evidence of avoidable health inequalities, and they’re avoidable, because we understand the social determinants of these systematic differences, and we’ve laid them out.

Ms Blackwell: Yes.

The World Health Organisation in 2005 set up the global Commission on Social Determinants of Health to examine the social factors leading to ill health and health inequalities, and the commission was led by you, Professor Marmot, and culminated in the United Kingdom Government in 2008 commissioning you to conduct your review.

Was that review conducted only in relation to England and not the other three nations?

Professor Marmot: Yes, because health is a devolved matter –

Ms Blackwell: Yes.

Professor Marmot: – for the other nations, so although we think that our report for England clearly applies in Scotland, Wales and Northern Ireland, as well as England, but officially it was England. I’ve had quite a lot to do with the Welsh Government based on my English report, and they’re very interested in it, so they clearly think the conclusions apply. But because health is a devolved matter, it was set up for England.

Ms Blackwell: Do you know if any similar reviews were set up to deal with Northern Ireland, Wales and Scotland?

Professor Marmot: In the wake of my 2020 review, Health Equity in England: The Marmot Review 10 Years On, the Health Foundation convened a review in Scotland – I was on the advisory board for that review – and it was very much along the same lines of my 2020 report.

Wales hasn’t done it in the same way. They’ve had the Future Generations Act, which has been very important to thinking in Wales, but they haven’t quite done it in the same way.

Ms Blackwell: And Northern Ireland?

Professor Marmot: Northern Ireland hasn’t. I’ve, from time to time, talked to government people, public health people, in Northern Ireland, but they haven’t done it in the same systematic way.

Pleasingly – drop that word. No, pleasingly, there’s good collaboration in public health between Northern Ireland and the Republic of Ireland. That is pleasing that there’s good collaboration. Because public health crosses borders and we talk to each other all over the place, and there’s good collaboration, and the Republic of Ireland has been intensely interested in my review, and there’s quite a lot of cross-border discussion, collaboration on the island of Ireland.

Ms Blackwell: Thank you.

So social determinants of health inequalities are the conditions in which we are born, grow, live, work and age. I’d like to look at some of those individually, please.

If we can highlight paragraph 3 of your report. Thank you.

“Inequalities in health by social economic status are not restricted to differences between the most privileged groups and the most disadvantaged: health inequalities exist across the entire social gradient … Consistently, the finding has been that the lower the socio-economic position the worse the health, the higher the age-specific mortality rates and the shorter the life expectancy … The social gradient in health runs from the top to the bottom of society and ‘even comfortably off people somewhere in the middle tend to have poorer health than those above them’ … We first demonstrated the social gradient in health in the Whitehall Studies of British Civil Servants: the higher the grade of employment the longer the life expectancy … By way of further example, on average, people in the highest occupational groups … have better health outcomes than those in mid-ranking occupations … who in turn have better health outcomes than those in the lowest occupational groups … Similarly, people with a higher income or university-level education – on average – have better health outcomes than those with a lower income or no educational qualifications …”

The key finding, then, is that the lower a person’s socio-economic position, the worse their health, the higher the age-specific mortality rates and the shorter their life expectancy. Is that right? I can see you both nodding.

Professor Marmot: Yes.

Professor Bambra: Yes.

Ms Blackwell: You explore socio-economic geographical inequalities in the United Kingdom at paragraphs 8 to 13 in your report. We don’t need to look at them.

And we can take that down, please.

In summary, is it correct that those in more deprived areas have shorter lives and lives with more ill health?

Professor Bambra: Yes.

Ms Blackwell: And that – in terms of healthy life expectancy, are you able to give a definition of what that means in terms of inequality?

Professor Marmot: Yes, I mean, we tend to look at life expectancy, it’s an artefact, it’s not predicting how long an individual will live, it’s a way of summarising the current age-specific mortality rates. So it’s saying if somebody born today was subject to today’s age-specific mortality rates, that’s how long they would live. But it’s not predicting what the age-specific mortality rates will look like 50 years, 60 years, 70 years from now. So it’s a summary. We tend to use it because everybody counts deaths, all over the world, and you can get good comparisons. Not because we think length of life is the only thing that matters, but it’s available, and it’s pretty systematic and comparable.

Healthy life expectancy in one sense is much more important, because it’s quality of life as well as length of life. But it’s less readily available, and it’s less comparable, particularly between countries within – we are blessed in Britain – I affirmed, I don’t know where I got “blessed” from. But we’re fortunate in Britain to have brilliant statistics, which is why we know as much as we know, pre-pandemic, and why we knew what we knew during the pandemic.

Ms Blackwell: Yes.

Professor Marmot: So we can look at healthy life expectancy. There are various ways of doing it, but it’s asking people about disability or about good health, and that tends to come from the census, and then doing a calculation.

Ms Blackwell: Yes.

Professor Marmot: What’s striking is that the social gradient in life expectancy is steep, the social gradient in healthy life expectancy is even steeper.

Ms Blackwell: I don’t want to interrupt you, but we’re going to look at those figures now.

Professor Marmot: Okay.

Ms Blackwell: So could we have on screen, please, the subparagraphs of paragraph 12 in the report. Thank you. Could we just scroll down a little. Thank you.

So here are some of the figures, Professor Marmot, that you have just been explaining to us. Looking at paragraph 12.1 and dealing with the four nations separately:

“12.1. In England, healthy life expectancy at birth amongst men living in the 10% most deprived areas was 52.3 years in 2017-2019, compared with 70.7 years among those living in the 10% least deprived areas.”

Now, I’ve had my calculator out overnight, my Lady, and that is a difference of 18.4 years.

“Women in the most deprived areas could expect to live 51.4 years in ‘Good’ health compared with 71.2 years in the least deprived areas …”

A difference of 19.8 years.

Moving down to Scotland:

“12.2. In Scotland, healthy life expectancy at birth amongst men living in the 10% most deprived areas was 47.0 years in 2017-2019, compared with 72.1 years amongst those living in the 10% least deprived areas.”

Which is a difference of 25.1 years, so that’s almost a third of the healthy life expectancy:

“Women in the most in the most deprived areas could expect to live 50.1 years in ‘Good’ health compared with 71.6 years in the least deprived areas.”

Which is a difference of 21.5 years.

“12.3. In Wales, healthy life expectancy at birth in 2017-19 for men was lowest in the 10% most deprived areas at 51.8 years and highest in the least deprived 10% of areas at 68.6 years, a difference of 16.9 years. Similarly, healthy life expectancy at birth for women in the most deprived areas was 50.2 years compared to 68.4 years in the least deprived areas …”

Which is a difference of 18.2 years.

“12.4. In Northern Ireland, the healthy life expectancy inequality gap between the 20% most and least deprived areas was 13.5 years for men and 15.4 years for women [over the same time period] … The data presented here for Northern Ireland is by quintile (20% bands) whereas [the difference] is by decile (10% bands) for the other three countries. This reflects cross-national differences in how the data is published.”

Is that right?

Professor Bambra: Yes.

Ms Blackwell: Right. Thank you, we can take that down, please.

In relation to inequalities arising from ethnicity in health, you explain that there has historically been a lack of routine data linking ethnicity to mortality records, explaining an absence of official regular information on life expectancies for different ethnic groups; is that right?

Professor Bambra: Yes, that’s right. There are complexities around calculating life expectancies by ethnicity, which we go into in detail in the report.

Ms Blackwell: Yes. What’s the importance of data collection in respect of protected characteristics and other axes of inequalities, including the importance of disaggregated data?

Professor Bambra: Yes, as Michael said, we have brilliant data when we’re looking at area-level disadvantage in England and the other devolved nations, but when it comes to other groups that suffer from health inequalities, such as ethnic minorities, people from LGBTQ or inclusion health groups, then it’s like a contrast of riches in terms of data compared to almost no or sparse data, where it mainly has to come from cohort studies conducted by individual universities and so on.

The issues are that if you don’t have any data, you don’t know sufficiently what the health needs are of different populations in your community.

Ms Blackwell: But despite the absence of data, in your report you say that there is some evidence that ethnic minority people may have much poorer health, that is morbidity, than white people in England.

Professor Bambra: Yes, there’s better data for the various groups, including minority ethnic groups, when it comes to morbidity as opposed to mortality.

Ms Blackwell: Right.

Professor Bambra: Obviously it’s something that you can do on a survey basis, it’s less complicated to measure and, yes, it varies obviously by different minority ethnic group, but there are certain conditions that are more likely to be worse in some groups than others. And certainly for indicators such as self-reported health or mental health, it’s particularly poor in certain ethnic minority groups, yes.

Ms Blackwell: Is the pattern in terms of the data or lack of data similar one in Scotland and Wales?

Professor Bambra: Yes, that’s correct, and there’s even less data available in Northern Ireland.

Ms Blackwell: Minority ethnic groups in England, Scotland and Wales experience substantial inequalities in the social determinants of health, and so you said, Professor Marmot, in your 2020 report.

Could we display paragraph 28 of their report, please.

All right, now, there are a series of inequalities in the social determinants of health in relation to minority ethnic groups set out in subparagraphs of paragraph 28, starting with the:

“28.1. Educational attainment at GCSE and degree levels [which] is highest for … Chinese and Indian ethnic groups [but] Gypsy and Irish Travellers have the lowest level of qualifications at both levels …”

If we could move over the page, please, we can see that:

“28.2. White and Indian minority ethnic groups are more likely to be in employment, with unemployment highest among Black and Bangladeshi/Pakistani populations …”

And that your review, Professor Marmot:

“28.3 … noted that … people from ethnic minority groups are ‘more likely to be in low-paid, poor quality jobs, with few opportunities for advancement, often working in conditions that are harmful to health. Many are trapped in a cycle of low-paid, poor-quality work and unemployment’.”

And that:

“28.4. ‘Workers from minority ethnic groups are more likely to be on zero-hours contracts than White workers: 1 in 24 minority ethnic workers is on a zero-hours contract compared with one in 42 White workers, and minority ethnic workers are more likely than White workers to be on agency contracts …”

“28.5. Bangladeshi, Pakistani, Chinese and Black groups are about twice as likely to be living on a low income, and experiencing child poverty, as the White population … In Wales, for example, there is a 29% likelihood of people whose head of household came from a non-white ethnic group living in relative income poverty compared to a 24% likelihood for those whose head of household came from a white ethnic group …”

And so it goes on.

I want to just divert slightly to ask you both: what is the impact that racism can have on health inequalities?

Professor Bambra: There are different types of racism.

Ms Blackwell: Yes.

Professor Bambra: At the interpersonal level, institutional level or at the structural level. A lot of the research that’s been conducted has been done on interpersonal racism, so that’s harassment, discrimination, and violence. Those studies obviously find significant impacts particularly on mental health but also on general health, and that that lasts across people’s life course.

In terms of institutional and structural racism, there has been less research done in the UK on that, although we do know from studies, for example in America, the impacts that structural racism, so the way in which society is organised, and how that is embedded within laws and cultural norms, we know that that can have an impact, for example in America, in terms of infant mortality rate gaps, and when certain laws were changed to become more inclusive of ethnic minorities there, then you see an improvement in infant mortality rates amongst those groups.

Ms Blackwell: Right. So, taking that together with what we see set out in the subparagraphs of paragraph 28 of your report, what is your conclusion in terms of how race might affect health determinants?

Professor Bambra: People from minority ethnic groups are much more likely to be living in deprivation, so everything that Professor Marmot outlined in terms of the health impacts of poverty, housing and so on applies kind of even more so, it’s amplified for people from minority ethnic groups.

So, for example, 50% of Bangladeshi and Pakistani households are in the 20% most deprived neighbourhoods, compared to 17% of the white population.

Ms Blackwell: Thank you.

Professor Marmot: If I could add?

Ms Blackwell: Yes, please.

Professor Marmot: I think of it in two ways. One exactly as Clare has just described, that racism leads to social disadvantage, but the second is what Clare was describing earlier, the direct psychosocial effect of racism. It’s pretty miserable to be discriminated against.

And we’ve got – this is emerging since Clare and I prepared our report – we’ve got emerging evidence that if you look at school performance, early childhood, minority ethnic groups do well. Poor Bangladeshi kids do better than poor white kids in school. The discrimination and the prejudice seems to happen afterwards, when they go into further education or into employment.

So exactly what we’ve documented here of the employment disadvantage of belonging to a minority ethnic group, it’s almost as if something happens after early education.

So, I think – we’re in agreement on this – there are two ways to think about it: racism leads to social and economic disadvantage, but there may be direct psychosocial effects of racism.

Ms Blackwell: Thank you.

I want to turn away from racism and race for a moment and look at what are described as “inclusion health groups”.

Can we please display paragraph 33 of the report. Thank you. Could we highlight paragraph 33. Thank you very much.

“According to NHS England … inclusion health groups are people who are socially excluded ‘who typically experience multiple overlapping risk factors for poor health, such as poverty, violence and complex trauma’. Inclusion health groups include ‘people who experience homelessness, drug and alcohol dependence, vulnerable migrants, Gypsy, Roma and Traveller communities, sex workers, people in contact with the justice system and victims of modern slavery’. People belonging to inclusion groups tend to have poor health outcomes, negative experiences of healthcare and a lower average age of death … For example, a systematic review of over 300 scientific studies conducted in high-income countries (including the USA, Australia, Sweden, Canada and the UK) which was published in The Lancet found that mortality rates were significantly higher amongst people with a history of homelessness, imprisonment, sex work, or substance use disorder than amongst the general population, particularly for deaths due to injury, poisoning, and other external causes … Research suggests that the adverse health experiences of inclusion health groups result from stigma, trauma, social exclusion, discrimination and victimisation.”

That’s quite a wide description of various factors that might affect someone’s life. But is the analysis of the level at which their lives are affected, in terms of the lower average age of death and negative consequences of healthcare, quite common amongst those groups?

Professor Bambra: Yes, as it’s stated there from the scientific evidence.

Ms Blackwell: Yes.

Can you explain to us what is meant by intersectionality, please?

Professor Bambra: Yes, intersectionality is a way of thinking about how people have different aspects of social identity, so, for example, I’m a women but I’m also white and I’m also LGBTQ, and so I would get certain advantages in life, for example, from whiteness, but I might get disadvantages from being a women. So I experience the social world and therefore the health consequences of that in different ways, from a privilege or subordination.

Ms Blackwell: Thank you.

Finally on this topic, could we highlight paragraph 34, please:

“LGBTQ+ groups (lesbian, gay, bisexual, transgender, and queer or questioning), also experience health inequalities. Whilst data is lacking in terms of mortality, life expectancy or physical health, there is strong evidence of higher prevalence of mental health issues amongst LGBTQ+ people … For example, a review of UK studies found higher rates of mental health problems amongst LGBTQ+ people including attempted suicide, self-harm, anxiety and depression … This review also found evidence of higher substance (alcohol and tobacco) abuse amongst LGBTQ+ people. Mental health services were perceived to be discriminatory by LGBTQ+ people. Researchers have suggested that this increased morbidity is potentially a result of stigma, social exclusion, discrimination and victimisation …”

Thank you.

I’m going to move on now to ask about the health inequalities landscape in the United Kingdom, and begin, please, with what is described in your report as a slowdown in health improvement.

Could we display, please, paragraph 36 at page 15:

“Until 2010, life expectancy in the UK had been increasing at about one year every four years. This trend had continued for all of the 20th century, with small deviations. In 2010/11, there was a break in the curve. The rate of improvement slowed dramatically and then stopped improving. One question this raises is whether we have simply reached peak life expectancy; the rate of improvement has to slow some time. However, comparisons with other countries answer this question. The slowdown in life expectancy growth during the decade after 2010 was more marked in the UK than in any other rich country, except Iceland and the USA …”

Is it right that the only G7 country with lower life expectancy going into the pandemic than the UK was the United States?

Professor Marmot: That’s correct.

Ms Blackwell: Yes.

Are you able, Professor Marmot, to give us a picture of how the healthcare situation, the state that it was in at the time that the pandemic hit, not only in terms of healthcare but also in terms, for instance, of vacancies in hospitals or the situation in which nurses found themselves, and give us a full complexion of what that picture looked like?

Professor Marmot: As I said earlier, most of the health differences that we see are not attributable to healthcare, but to health. Let me make two comments about this slowdown in improvement in health post-2010. The first is close to unprecedented – it’s hard to overstate how important this is: that we were used, as a country, based on the evidence, to expect health to get better every year. Fewer babies would die, fewer old people would die, health would improve year on year and that’s what the history of the 20th currently led us to expect. And in 2010 that rate of improvement slowed dramatically, more marked in the United Kingdom than in any other rich country except Iceland and the United States. That’s really dramatic. It slowed in many countries, but nowhere near to the extent that that improvement in life expectancy slowed in the UK.

Second – we’ve described the social gradient in health – the social gradient got steeper, so the inequalities got bigger, and, particularly for people from the northeast, what we saw was a decline in life expectancy. A decline. Not just a slowdown in improvement, a decline in life expectancy for people in the bottom 10% of deprivation, the most deprived, in every region of the country except London.

So the regional inequalities got bigger.

If you were lucky enough to be in London, then the consequence of deprivation for your health was not as bad as if you were deprived in the northeast or the northwest.

Ms Blackwell: I’m going to display some charts now which I hope you can take us through that demonstrate the evidence you’ve just given, Professor Marmot.

Could we have on the screen, please, paragraphs 39 and 41. Thank you very much.

What do we see here, Professor Marmot or Professor Bambra? We can see that the title of the figure is “Life expectancy at birth by sex, four countries of the UK”, so that’s between 2010 and 2012 to 2016 to 2018.

Professor Marmot: Well, I say to my Welsh colleagues, “You look like England, only more so” – which they don’t like much – because the slowdown was more marked in Wales and Scotland than in England. Now, there may be a number of reasons for that. One might be that England is the wrong comparator for Wales, maybe it should be northeast or northwest England, because of post-industrial effects on poverty and the like. But what we see is this slowdown in improvement in all four countries of the United Kingdom.

Ms Blackwell: Let’s look, please, briefly at each of the countries separately, starting with Scotland, at paragraphs 40 and 41. Next page, please.

(Pause)

Ms Blackwell: Figure 3 on page 20, please. Yes, thank you.

Professor Marmot: So, Scotland, when I said Wales is like England only more so, Scotland is like the northeast and northwest of England, only more so. Look at the decline in life expectancy in the most deprived group.

Ms Blackwell: Which is at the bottom of each of these figures, yes.

Professor Marmot: So this is using an index of multiple deprivation, the same index across the UK, and you can see the improvement in life expectancy in the least deprived quintile –

Ms Blackwell: Yes.

Professor Marmot: – and going up a bit in the next two quintiles, you can see it declining after 2010 in the second poorest quintile, and declining quite markedly in the poorest quintile. So the inequalities are getting bigger and life expectancy for the bottom 40% – earlier I said the bottom 10% – the bottom 40% is getting worse.

That’s really – I mean, I can’t overstate it, it’s really shocking to those of us in the health field, as well as to ordinary people: the idea that it’s no longer the case that you can look forward to better health year on year, it’s actually getting worse.

Ms Blackwell: Just to confirm, the top figure relates to males and the bottom figure relates to females, but the patterns are pretty much the same.

Professor Marmot: The patterns are pretty much the same. There is a consistent phenomenon in the data globally – well, amongst high income countries – that if you look at life expectancy, the variations tend to be bigger for men than for women. When you look at ill health, the variations tend to be bigger for women than for men. And Clare may have a better answer to that than I do, but if I say I don’t know the reason for that, I can then speculate, but it’s troubled all of us for a very long time that women seem to have more morbidity, more ill health, and in fact, with what happened post-2010, we saw a particular impact on ill health in women going up. So the life expectancy figures, it’s both genders, but particularly reported ill health was going up for women.

Professor Bambra: The life expectancy for women in the most deprived areas has had declines in some cases as well. So, for example, in some of the areas of the northeast, it’s lower than it was ten years ago.

Ms Blackwell: Thank you.

May we go to figure 4 on page 21, please. We can see the same information plotted on figures for Wales, and is this a similar pattern to what we have seen in the previous two –

Professor Marmot: Yes.

Ms Blackwell: – charts? Thank you.

Then, finally, can we go to Northern Ireland, please, which is on page 22, figure 5.

Professor Marmot: Look at the dramatic decline. There you can actually see for the bottom 60%, the most deprived 60%.

Ms Blackwell: In relation to both men and women?

Professor Marmot: Yes.

Ms Blackwell: Yes.

Professor Marmot: So you asked me – I hadn’t finished answering your question –

Ms Blackwell: Sorry, I interrupted you.

Professor Marmot: – where we were up to 2019.

Ms Blackwell: Yes.

Professor Marmot: In my 2010 review, drawing both on the World Health Organisation Commission on Social Determinants of Health, which I chaired, and the work of nine task groups, expert task groups that we set up to bring the evidence together, we made six domains of recommendations: give every child the best start in life; education and lifelong learning; employment and working conditions; number four was everyone should have at least the minimum income necessary for a healthy life; number five was healthy and sustainable places in which to live and work; number six, taking a social determinants approach to prevention.

We said: if you follow these six domains of recommendations, health will improve and health inequalities will diminish.

So then we get to – notice we didn’t say anything about healthcare, for the reasons that I said earlier, that the National Health Service delivered great equity of access to healthcare, and in fact – a slightly complicated point – in a way, it goes the other way. What we see is that the usage of the healthcare system follows the social gradient in that the more deprived the area the greater the usage of the healthcare system. Not because people are overusing it, but because they’re sick. There’s more illness. So it’s actually inequalities in health that are putting the burden on the healthcare system, not the healthcare system that’s responsible for inequalities in health. It actually goes the other way.

That said, we do need a healthcare system when we get sick, and where we were pre-pandemic, if you look at funding for the healthcare system – and we put this in the report, adjusting for the size of the population and the ageing of the population – if you’ve got more people, you need to spend more money on healthcare; if you’ve got more older people, you need to spend more money on healthcare. Older people get sick, that’s the nature of it. So just looking at a blanket figure for spending doesn’t tell you enough. And we drew on figures from the Nuffield Trust that said during the government from 1979 to 1997, healthcare spending went up about 2% a year, after you adjust for the size of the population and the ageing of the population.

Ms Blackwell: Yes.

Professor Marmot: In the government from 1997 to 2009, it went up at 5.7, 5.8% a year. 2010, it went up by minus 0.07%, and then the next five years, minus 0.03%.

So, adjusting for the size of the population and the ageing of the population, the increase was negative after 2010.

Now, we know, even after adjusting for population size, you need positive growth because of new technology, which is expensive and so on. So the funding of the healthcare system was inadequate post-2010.

If you take January 2009 the number of people waiting for NHS treatment as a benchmark, it was at the – in 1997 it was about 2.3 times what it was at the low level of 2009. By 2019 it had doubled compared with 2009. So pre-pandemic the number of people waiting for NHS treatment was twice as high as it had been in 2009.

There were already vacancies climbing in –

Ms Blackwell: Vacancies of clinicians –

Professor Marmot: Oh, doctors and nurses.

Ms Blackwell: Yes.

Professor Marmot: Climbing. I can’t give you the figures for 2019. The most recent figures suggest 150,000 vacancies of doctors and nurses, but there were already vacancies, which puts great pressure on the existing staff. Then we know there were real problems of morale. There had been the first doctors’ strike in the 2010s. There was real concern over pay for doctors and nurses, which was part of the concern over public sector pay in general. But before the cost of living crisis, nurses’ pay had gone down by 5% over the period from 2010.

I’m not going to get into the intricacies of the doctors’ calculations of which is the right figure, but doctors’ pay had clearly gone down.

So pay and conditions, vacancies, morale, were really adverse in 2019 before the pandemic.

Ms Blackwell: The figures that you gave a moment ago relate to funding the NHS in England. What about social care?

Lady Hallett: Sorry, before we go on, I think there are two separate issues. We have had the graphs on life expectancy and we’ve now moved on to funding of the NHS. Can I just go back to the graphs for a second.

Professor Marmot: Sure.

Ms Blackwell: Of course.

Lady Hallett: Forgive me for interrupting, Ms Blackwell.

Ms Blackwell: Not at all.

Lady Hallett: I confess a lack of understanding of graphs on occasion – I used to describe to colleagues I had graph blindness – so forgive me if I don’t really follow. But could we go back to the graph which is on the screen at page 22.

The funding point is obviously really important and we will get back to it, I promise.

But, as I understand it, graphs – the way in which you can get lines going like that or going like that can depend a lot on the extent of space you give to your differences, to your various criteria.

So when we look at the bottom graph, females, am I reading it correctly, one or both of you, the vertical graph, the vertical line axis is 78, 81, 84 years of age. Is that right?

Professor Marmot: That’s correct.

Lady Hallett: So between 78 to 81 we have got 79, 80, so if we roughly fit it in, the graph seems to start, in 2015-2017, at the age of 80, have I got that – no, it’s probably about 79.5. It’s hard to say.

Professor Marmot: Yes.

Lady Hallett: Then it goes along and then it comes down, and I’m going to guess it comes down to about 79.

Ms Blackwell: My Lady, are you looking at the female chart?

Lady Hallett: I’m looking at the female chart, the most deprived.

Professor Marmot: Yes.

Lady Hallett: So I get from the graphs the significant difference between the most advantaged and the most deprived. At the moment what I’m not getting – and that’s why I’m asking for your help – is a dramatic decrease in life expectancy if you take into account what – the line really is reflecting what ages. So we’re going from roughly 79.5 to about 79, and so my question is: is that a dramatic decrease?

Professor Marmot: Yes. Forgive me for this comment, I think you understand the graph perfectly well. I don’t think you’ve got graph blindness at all.

Yes, it is dramatic. Half a year doesn’t sound like much, but if you think that the history had been increasing one year every four years, half a year means we’ve just lost two years of improvement. So it doesn’t sound like a lot, but it’s actually a lot.

I mean, one year every four years, if you say to somebody, you know, “Run round the block three times a week and you’ll add to year to your life expectancy”, they would probably say, “The game’s not worth the candle. A year, who the hell cares?” Because it’s the nature of the measure, it’s not very informative, it hardly seems worth running round the block just to get another year, from 79 to 80. But it’s a summary measure. So half a year is really quite a lot, it’s quite a great deal.

I mean, your point is well taken. If we had, as we’re taught in first year, to put the zero and – you wouldn’t be able to see any difference, because it would all be clustered up the top. So, to that extent, we’ve disobeyed the rule of always putting it at zero, so you could actually see the differences.

So your question is perfectly appropriate, but the comparison is not: well, what does half a year mean? It’s: we expect one year every four years, and we got half a year drop. That’s really quite a dramatic difference.

Professor Bambra: And if I could just add, it’s in this historical trend of increasing life expectancy over the 20th century, with the exception of World Wars, so a fall like this – and we’ve also seen a corresponding increase in infant mortality rates in the lead-up to the pandemic – are historically unprecedented from a public health perspective.

Ms Blackwell: As we have seen, the downward trajectory, the pattern is the same, for women and for men, in all four nations.

Professor Marmot: In all four nations. And, as I said earlier, in England we see a bigger fall in northern parts of the country than we do in London and the southeast.

Ms Blackwell: Well, before we leave this area of evidence, may we put up figure 6 at page 24, please. This is the figure for life expectancy at birth by sex for the least and most improved deciles in each region between 2010 and 2016 or 2018.

What do we see here, Professor Marmot?

Professor Marmot: The first thing we see is, if you look at the least deprived decile, the regional differences are relatively small. If you’re rich, it matters less which part of the country in which you reside and I think that’s quite important. The poorer you are, which is actually in figure 7, but the poorer you are, the more it matters where you live.

Ms Blackwell: Well, let’s look at figure 7, please, because I think that is of greater interest to what you’re saying. Here we see “Life expectancy at birth by sex and deprivation deciles in London and the North East”, and this is what you were talking about before, the stark difference between the area in the country that you live, in which you live.

Professor Marmot: And it’s really terribly important, because this is a national index of multiple deprivation, so it’s the one index that’s being applied, and if you’re deprived, it’s worse to be in the north, if you’re in the north it’s worse to be deprived. I mean, it’s almost intersection in the way –

Professor Bambra: Yes, intersection of place, yes.

Professor Marmot: – Clare was describing it before.

Ms Blackwell: What do we see in these charts at figure 7, please?

Professor Marmot: So the greater – for both London and the northeast, the greater the deprivation, the shorter the life expectancy. The gradient is steeper in the northeast than it is in London. So, as I was describing, the consequences for life expectancy are bigger if you’re in the northeast and deprived than if you’re in London and deprived.

Then, crucially, if you look at the dotted line – look at London and look at the dotted line and the solid line. So the dotted line –

Ms Blackwell: Is the earlier period, isn’t it?

Professor Marmot: The dotted line is 2010 to 2012, and the solid line is 2016 to 2018. Look at London. You see at every point along the gradient life expectancy improved. Now look at the northeast. Life expectancy – and particularly you see it more clearly for women. Look at the bottom graph for women. Life expectancy fell in the poorest decile. It fell marginally in the next poorest decile. It didn’t improve for the bottom six deciles. It’s only in the top 40% that you get an improvement. And you see it more clearly for women, it’s a similar picture for men, but more clearly.

So if we then go back to figure 6, if we may, it’s not just the northeast, it’s every region virtually outside London. If you’re in the least deprived 10%, life expectancy went up a bit, the regional differences were relatively small. If you’re in the most deprived 10%, the regional differences are much bigger, and life expectancy went up in London and went down in virtually every region outside London.

Ms Blackwell: Is that more pronounced in the bottom figure here for females? We can see it very clearly.

Professor Marmot: Yes, it is, and – I’m sorry if I’m jumping ahead to your next question.

Ms Blackwell: Not at all, no, please.

Professor Marmot: But I said that I can’t explain the male/female differences. When we published these figures in our 2020 report, it was put to me that the burden of austerity fell on women to a much greater extent than on men. The various cuts had a bigger impact on women’s lives than on men’s lives. And when that was put to me – we didn’t put it in our report – I had to say, “Yes, that sounds credible to me”. So I hadn’t put it in my 2020 report, but it’s at least a credible explanation for what’s going on here.

Ms Blackwell: Thank you.

So we’ve looked – we can take that down now, thank you very much – at life expectancy, we’ve looked at NHS funding, and I was coming on to ask you about social care funding and what happened to social care funding. What was the effect of it over the course of the ten years leading up to the pandemic?

Professor Marmot: If you look at social care funding per person by local authority, the spend per person by local authority, for the least deprived 20% of local authorities, social care spending per person went down by 3%, and then the greater the deprivation of the area, the steeper the cuts in social care spend. In the most deprived 20%, it went down by 17%.

Now, arguably the greater the deprivation, the greater the need. The greater the need, the greater the reduction in spending and it was part of the settlement to local government spending in general.

If you look at spending per person, total spending per person by local authorities, in the least deprived 20% the spending per person went down by 16%, and then the greater the deprivation, the greater the reduction. In the most deprived 20%, it went down by 32%.

Now, if you were in government and worked on the assumption that everything local government does is a waste of space, then you can cut and not expect any adverse consequences. If you’re not of that view, and I and Clare are not of that view, what local government does is quite important, like adult social care, like amenities, like childcare and all the good things that local government does.

If you cut in that regressive way – and I’ve shown these figures to economists who say, “You’re making this up, I’ve never seen such neatly regressive settlements”, but these are the government figures, the graph I’ve got comes from these two fiscal studies but it’s based on government figures; the greater the deprivation, the greater the need; the greater the need, the greater the reduction in local authority spend in general, and on adult social care specifically – that will damage the health of people, other things equal, and will contribute to inequalities in health.

Ms Blackwell: Thank you.

I want to draw all this together now, please, and have a look at your expert opinion as you’ve set out in the course of your report.

First of all, may we look at paragraph 57. That’s at page 29. Thank you.

“The overall impression that UK government austerity policies post-2010 had an adverse effect on health inequalities is also supported by analyses of England showing that health inequalities narrowed in the period of high public expenditure from around 2000 to 2010, and began to widen again post-2010 … “

As you have outlined in your evidence.

“Scientific research has found that between 2000 and 2010, geographical inequalities in life expectancy, infant mortality rates and mortality amenable to healthcare were reduced in England … In contrast, these inequalities have increased since 2010 …”

The next paragraph, please:

“Substantial systematic health inequalities by socio-economic status, ethnicity, area-level deprivation, regime, socially excluded minority groups and inclusion health groups existed during the relevant period.”

The relevant period being between 2010 and the onset of the pandemic.

“There is evidence that such health inequalities increased during the relevant period. The majority scientific view is that the underlying causes of health inequalities are the social determinants of health: the conditions in which people are born, grow, live, work, and age. It is plausible that adverse trends in these social determinants of health since 2010 led to the worsening health picture in the decade before the onset of the pandemic. In short, the UK entered the pandemic with its public services depleted, health improvement stalled, health inequalities increased and health among the poorest people in a state of decline.”

Does that accurately reflect your conclusion in this area?

Professor Bambra: Yes.

Professor Marmot: Yes.

Ms Blackwell: Thank you.

My Lady, I’m about to move on to health inequalities and pandemic planning, and I wonder whether that would be a suitable time to take our mid-morning break.

Lady Hallett: Certainly. I shall return at 11.20.

(11.06 am)

(A short break)

(11.20 am)

Ms Blackwell: Thank you, my Lady.

We’re now going to consider the extent to which inequalities were taken into account in pandemic planning by the United Kingdom Government and the devolved administrations. I think, Professor Bambra, it falls to you to answer most of the questions in relation to this topic.

You were good enough to consider a wealth of documentation which was provided to you, most of which has been obtained by the Inquiry during the course of its preparation for these public hearings, including a series of National Security Risk Assessments and National Risk Register processes.

Am I able to summarise the position in relation to the NSRA and NRR documents in this way: that up to very recent editions of those assessments, there has been no mention at all of consequences, risk consequences on any vulnerable groups?

Professor Bambra: Yes, the risk registers pre-pandemic that we reviewed had very little by way of vulnerability other than clinical risk factors or age in some cases, and there was certainly nothing in terms of, for example, minority ethnic groups, deprivation, other things which we know are major factors in the Covid pandemic.

Ms Blackwell: More recently, however, and post pandemic, the documents that you have considered and analysed do tend to begin, at least, to consider those with vulnerabilities and health inequalities; is that right?

Professor Bambra: Yes, there has been an improvement and a broadening of what the term “vulnerable” means within the risk registers, which is to be welcomed.

Ms Blackwell: Thank you.

You also looked at the Civil Contingencies Act of 2004, and a series of both statutory and non-statutory guidance that is relevant to that Act of Parliament.

What did you find in relation to those bodies of work in terms of reflection on vulnerabilities and inequalities?

Professor Bambra: Obviously these documents refer to all different types of civil emergency, so it could be a flood, a terrorist act, or indeed a pandemic. So the definition of vulnerability used within those documents is often quite narrow, such as, you know, people who might have difficulties helping themselves in the event of an emergency, very narrow and somewhat outdated, and doesn’t really apply across when we think about it from a public health or a pandemic perspective.

Ms Blackwell: On that point, may we display paragraph 97 of your report, please. I’m afraid I don’t have a page number for that.

Lady Hallett: 40?

Ms Blackwell: I think it might be page 40, thank you.

The previous page, thank you.

Here, just to underline the point – thank you – you are referring to the glossary of the Civil Contingencies Act and you say:

“… vulnerability is defined as ‘the susceptibility of individuals or a community, services or infrastructure to damage or harm arising from an emergency or other incident’ …”

What comment do you have upon the description there and the definition?

Professor Bambra: I think from a health perspective we’d obviously define vulnerability differently, as we did in our earlier comments about the different types of health inequalities.

Ms Blackwell: Yes. All right.

I’d like now to look, please, at a different document. It’s the witness statement of Mark Lloyd, who is the chief executive of the Local Government Association. It’s at INQ000177803.

Can we go, please, to page 43, which is paragraph 160.

Just to put this in context, one of the non-statutory pieces of guidance which you looked at to the Civil Contingencies Act is the emergency response and recovery guidance; is that right?

Professor Bambra: That’s right.

Ms Blackwell: Thank you.

It’s page – thank you. Now, paragraph 160 of Mr Lloyd’s statement reads as follows:

“There is an expectation that in formulating emergency plans, LRFs and individual agencies including local authorities will take into account the needs of vulnerable people. Vulnerability is not framed in government guidance in terms of protected characteristics, nor is it clearly, or narrowly, defined, but instead includes broad references to children and young people; faith, religious, cultural and minority ethnic communities; and elderly people and people with disabilities. Previous research from the British Red Cross … published shortly before Covid indicates different practices on whether vulnerability is defined in local plans, and on whether this is seen as a responsibility of the [local resilience forum] or of councils. However, the [Local Government Association] understands that there is very limited direction and no specific requirement from Government as to the issues for which councils and [local resilience forums] should test and exercise, even where these could be identified as national level rather than local issues.”

Does that reflect what you found in your analysis of the relevant guidance?

Professor Bambra: I think I’d slightly disagree with the list of – you know, saying there’s broad references to these different groups, because the balance, in my reading of the 40 or so documents, is that predominantly it would be children, older people, sometimes people with disabilities, and on very rare occasions would you get mention of faith or minority ethnic communities, you know, literally like once or twice, and often in the context of perhaps adherence or responses to behavioural messaging, rather than in a: how can we help people in an emergency?

Ms Blackwell: Does this demonstrate that there was, certainly in amongst the legislation and the guidance that you have considered, no common definition of vulnerability, and those suffering from health inequalities and matters of that nature?

Professor Bambra: Yes.

Ms Blackwell: And is it important, in your view, that there should be a common understanding and definition of these terms?

Professor Bambra: Yes, I think part of the problem with some of the work that we reviewed is that because the Civil Contingencies Act, as I said, is for all different types of emergency –

Ms Blackwell: Yes.

Professor Bambra: – they’re either going to have a very broad definition or, you know, potentially a narrow one. But when we’re thinking specifically about pandemic planning as an emergency, then obviously, for the reasons that Michael and I outlined earlier, it’s very important you think about which groups are going to have the highest health risk and that, of course, could differ completely from people who might be most affected by a flood or terrorism. We have much better data on being able to predict and ascertain which social and economic groups would be most impacted by a pandemic, and that needs to be reflected in these types of guidance when they’re thinking about a pandemic.

Ms Blackwell: Thank you.

You also looked at the Dame Deirdre Hine review from July of 2010, which was brought about as a result of the swine flu in 2009, the H1N1 pandemic response.

What did you discover about the level of consideration within that review to vulnerable groups?

Professor Bambra: Yes, the Hine review was the independent inquiry into H1N1 and, again, vulnerability was largely defined in terms of clinical risk factors: age, pregnancy, that sort of thing. Nothing in terms of a broader definition of thinking about health inequalities. And there is, as we present in the report, evidence that there were socio-economic and ethnic inequalities in the swine flu pandemic in England and Wales.

Ms Blackwell: So did it surprise you that there was little, if any, reference to those within the report?

Professor Bambra: The report pre-dates the research studies by a few years. However, the research studies use official government data, so I would be surprised if the government didn’t have access to that data before the researchers.

Secondly, we know about seasonal flu, the inequalities we see in that replicate the inequalities we see in swine flu, for example, and also other respiratory tract infections, which, for example, are higher in some British Asian groups. So yes, I was very surprised that the 2010 report didn’t think about the health inequalities that had happened within that small pandemic.

Ms Blackwell: Just to set out what some of those inequalities were, and we don’t need to put this up now, but these are set out in paragraphs 174 through to 176 in your report, the mortality rate in the most deprived 20% of England’s neighbourhoods, in relation to swine flu, was three times higher than in the least deprived 20%, and a study of ethnic inequalities in mortality from the swine flu in England found people from some minority ethnic groups experienced an increased mortality risk compared to the white population during the pandemic, with the highest risk of death being in those of Pakistani ethnicity and the lowest in the black minority ethnic group.

Professor Bambra: That’s correct.

Ms Blackwell: Thank you.

You also looked at the United Kingdom influenza pandemic preparedness strategy for 2011, and what did you find in relation to any reference to vulnerabilities or inequalities in that document?

Professor Bambra: That reflected the Hine review and was an update of the previous 2007 flu strategy. Again, as with the other documents, clinical risk factors and age are the only references to vulnerability or inequalities.

Ms Blackwell: Nothing –

Professor Bambra: Nothing in terms of socio-economic status or minority ethnic groups, for example.

Ms Blackwell: There was also an additional document connected to that strategy, entitled “Analysis of Impact on Equality” report. Did you look at that as well?

Professor Bambra: Yes, I looked at that, it was an equality impact assessment that they needed to do under the Equality Act.

Ms Blackwell: What are your concerns, if any, about the way in which that was carried out?

Professor Bambra: Again, it’s limited in terms of – it’s trying to think about how the flu strategy might have unequal effects, and I think it’s very limited in terms of how it conceives that, and thinking about how different groups might be differently affected is not thought about within that, that exercise.

Ms Blackwell: If that document, the strategy, was still in place in the run-up to the pandemic – which we know it was – and had not been updated, what do you have to say about the fact that that document had very little, if any, consideration of the effect of a pandemic on those with health inequalities and vulnerabilities?

Professor Bambra: So the 2011 document was updated, for example, after Exercise Cygnus in 2016, but again it still did not have any references to the health inequalities we’ve talked about.

Ms Blackwell: Yes.

Professor Bambra: So the concern from that point of view would be that there would be no anticipation or planning or thinking about how different groups, different communities, different parts of the country, could potentially be more at risk and more affected by a pandemic.

Ms Blackwell: You reviewed the material generated by several exercises, Winter Willow, Taliesin, Valverde, Alice, Silver Swan, Broad Street, Cerberus and Pica.

Were health inequalities examined in any of those exercises?

Professor Bambra: No, they were not.

Ms Blackwell: You also considered the material surrounding Exercise Cygnus, to which you’ve just made reference, in 2016. Does the Cygnus report mention planning for local surges? I think this is set out in paragraph 137 of your report where you say it does mention local surges:

“… but the potential role of area-level deprivation or other community characteristics (eg the ethnic composition of the population) in leading to local surges is not discussed [at all].”

Professor Bambra: Yes, so thoughts about where you might get local surges or where you’re more likely to get them because of the risk profile of the community is not thought about.

Ms Blackwell: Yes, finally on this topic, may I ask that the following document is displayed: INQ000192271, at page 4, paragraph 15.

This is the witness statement provided to the Inquiry by Sir Christopher Wormald, Permanent Secretary of the Department of Health and Social Care, which of course, as you know, was the lead government department for pandemic risk.

If we can highlight paragraph 15, please:

“In terms of how the Department [that’s the Department of Health and Social Care] approaches its duties in respect of equalities, any such impacts are routinely assessed and taken into account during the formation of policies and the decision-making process, which generally takes place in the usual Government fashion [that is] by the provision of submissions to the decision-maker(s).”

Based upon the evidence that you have seen and the wide range of documents that you have considered, does it appear that equality impacts have been routinely assessed and taken into account in the formation of policies relating to pandemic preparedness?

Professor Bambra: In the documents that we looked at, there was only the one equality impact assessment, which we’ve just discussed, so out of a whole body of work there was only one from 2011, so I don’t think we could see that as routinely assessed in regards to the planning.

Ms Blackwell: Thank you.

We can take that down, please.

You were asked by the Inquiry team to address the following question: did the specialist structures concerned with risk management and civil emergency planning allow for the proper consideration of structural racism and its impact?

Did you find that there was no mention of structural racism or its potential impacts in any of the planning documents reviewed under this topic, nor were there any considerations of other causes of health inequalities in the documents, such as social determinants of health or austerity?

Professor Bambra: No, there was no mention of health inequality, so there was certainly no mention of any of the causes of the health inequalities.

Ms Blackwell: Are you able to give the Inquiry an example of how structural racism might have been utilised during the course of the preparation of these documents? How it might have appeared?

Professor Bambra: I think having a knowledge of who was most likely to be at risk and why that might be the case would be the way that you would think about using that within a planning document. But, as I said, there is kind of no reflection on which groups might be at risk. So it would be quite difficult for them then to think about why they might be at risk when they’re not thinking about them at all.

Ms Blackwell: So let’s move, please, to look at paragraph 149 of your report. In fact we don’t need to display this, I’m able to summarise it in these terms: did you both conclude in relation to this topic that, with some exceptions, the specialist structures concerned with risk management in civil emergency planning did not properly consider societal, economic and health impacts in light of pre-existing inequalities and the UK Government and the devolved administrations and relevant public health bodies did not systematically or comprehensively assess pre-existing social and economic inequalities and the vulnerabilities of different groups during a pandemic in their planning for risk assessment processes?

Professor Bambra: That’s correct, that’s our expert opinion.

Professor Marmot: Yes.

Ms Blackwell: Thank you very much.

Turning, then, please, to the consequences of failing to take account of health inequalities, you describe, Professor Bambra, the Covid-19 pandemic as syndemic. Can you explain to us, please, what you mean by that?

Professor Bambra: Yes, it’s because Covid acted synergistically with existing socio-economic and health inequalities to exacerbate and amplify the impacts of the pandemic but also the impacts of those existing inequalities.

Ms Blackwell: Within the report you outline five key pathways through which existing inequalities in the social determinants in health result in higher mortality and morbidity from an infectious respiratory virus. Could you take us through those, please.

Professor Bambra: Yes, the first one is about how people are unequally exposed to the virus. So if we think, for example, of key workers, many of whom were from minority – disproportionately from minority ethnic groups and from low paid employment sectors, then they were more likely to be exposed because they were still going in to work when a lot of office workers were working from home.

The second pathway is about unequal transmission. So once you have an infection within a community, if people are in an urban area or if they’re in a smaller property, more overcrowded property, then it’s much more likely to spread. If they’re less likely to self-isolate because of, for example, low payments for being off sick during the pandemic, then that could increase spread, again a risk that is higher in more deprived areas and amongst minority ethnic groups.

The third one is the unequal vulnerability, and so this is thinking about pre-existing health conditions. So, for example, if you have diabetes or a heart condition, then you’re more vulnerable if you get the illness.

The fourth one is the unequal susceptibility. So this is thinking about actually, as Professor Marmot’s work has shown, people have lower immune responses from the result of the chronic stress of psychosocial factors, so we can think about that, that links across to what Professor Marmot was saying about the psychosocial impacts of racism and being in a social hierarchy, so you have a suppressed, compared to someone more affluent, for example, immune system, so again, you’re more vulnerable to an adverse event as a result of your infection.

The final pathway would be about unequal treatment, so in terms of, for example, access to antivirals or the vaccine. Of course, in the UK case, that inequality is there, we can see that in the vaccine uptake, for example.

Ms Blackwell: Thank you.

So did you conclude in relation to this topic that:

“The UK entered the pandemic with increasing health inequalities and health among the poorest people in a state of decline. [That you] knew from previous pandemics and research into lower respiratory tract infections that people from lower socio-economic backgrounds, people living in areas or regions with higher rates of deprivation, and people from minority ethnic groups and people with disabilities, are much more likely to be severely impacted by a respiratory pandemic. Lack of consideration of pre-existing social and ethnic inequalities in health in our pandemic plans may have meant that our responses were unable to mitigate the disproportionate impact experienced by minority ethnic, low socio-economic status and other socially excluded communities.”

Professor Bambra: Yes.

Ms Blackwell: Thank you.

Before we turn to your recommendations, I just have a couple of questions to ask you about what is contained in section 6 of your report under the topic whole-system catastrophic shocks. To what extent do whole-system catastrophic shocks expose or amplifies pre-existing health inequalities, please?

Professor Marmot: Building on what Clare has just laid out in relation to infectious disease, if you plot on a graph – I know this is Module 1, but if you plot on a graph mortality from Covid, now plot on a graph childhood obesity by deprivation, it looks the same. The more deprived, the greater the childhood obesity. It looks the same. We don’t think childhood obesity is caused by a virus. Now, plot a graph and look at dental caries in children by deprivation. Looks the same.

So, in other words, social and economic inequalities are increasing risk to whatever the threat is going to be. So then when you get a big external shock, a pandemic, of course, a hurricane, a tsunami, civil unrest, it is entirely predictable, and that’s exactly what happens: the lower the socio-economic position, the greater the deprivation, the greater the consequences of this big external threat.

So we know in Puerto Rico, when Hurricane Maria hit, the excess mortality, over predicted, was highest in people of low socio-economic position, middle in people of socio-economic position, and lowest in people of high socio-economic position.

I was in New Orleans a year and a bit after Hurricane Katrina. We had a workshop there and, as my colleague said, Katrina – the reason for the workshop was not to hit the US Government round the head because of their mismanagement of the hurricane and its consequences, but it exposed the fault lines in American society.

The people who were affected by Katrina were poor and African American, overwhelmingly. In the Lower Ninth Ward, which was flooded, coming back, what was left were liquor stores, no health clinics, no place to buy groceries, nothing normal. If you were sick, you couldn’t get treatment a year and a half after Katrina.

So you get these big external shocks and that’s why we say they expose the underlying inequalities in society and amplify them.

Now, I don’t think of dental caries as a big external shock, but the reason I started with that was to show that, whatever’s happening, we see your social position determines your susceptibility to that big shock.

Ms Blackwell: Thank you.

Going back some time to the Spanish flu and when that hit in England and Wales, have you, Professor Bambra, considered a case study that demonstrates strong geographical inequalities, even at that time, in terms of who was affected and the manner and severity with which they experienced the pandemic?

Professor Bambra: Oh, yes, and it reflects what Michael was saying about the social patterning. When you look at what happened in 1918 Spanish flu, then you find there were socio-economic inequalities. We can see that from data, historical data from different European countries and from North America, there were racial inequalities in the mortality. Higher amongst people with disabilities, for example, in a Norwegian study. And in England and Wales, higher in urban compared to rural areas and also higher in the north and parts of Wales than in the south of England.

Ms Blackwell: Thank you.

So moving, then, please, to your recommendations.

Can we display, please, page 82 of your report, and begin at paragraph 199. Thank you.

If we read through this together, please. You begin your recommendations in this way:

“Based on the research and analysis conducted within this report, [you] make the following recommendations:

“199.1. Reduce health inequalities so that the health of all communities across the UK is better placed to withstand future pandemics. This requires different actions in each of the four UK nations but in each case, it should be based on …”

I’m sorry, my screen has gone off – there we are, it’s back on, mid-sentence.

I’ll start from the beginning of that sentence again:

“This requires different actions in each of the four UK nations but in each case, it should be based on key learning from the Marmot Reviews of 2010 and 2020 which set out the following six evidence-based areas for policy action …”

Now, Professor Marmot, you’ve made reference to this already, but would you please take us through these subparagraphs.

Professor Marmot: “Give every child the best start in life.”

We know that early child development is actually crucial to what happens to children in school. What happens in school is crucial to what happens post school, in the world of work, which is important for income, where you live, and in terms of health and health inequalities. So it all starts at the beginning of life. Not just because of health of children, but because of the consequences of early child development for what happens later. And we know that adverse childhood experiences have a dramatic impact on mental health subsequently and, increasingly the evidence shows, on physical health.

So good early child development has the positive component of nurturing, supporting and so on, and the negative of adverse childhood experience, and both of those follow the social gradient, the greater –

Lady Hallett: I apologise for interfering. There is a limit to what I can do in conducting this Inquiry, and as noble as this recommendation and aim may be, I think it may be stretching beyond my terms of reference or what it’s possible for me to recommend and achieve.

Ms Blackwell: I take that into account, my Lady.

Professor, in terms of the key learning that was set out in your review and what you’re expressing and explaining now, are there specific matters which you can draw together in order to explain how it affects risk management and pandemic planning?

I appreciate that you’re setting out the principles behind what lies in your review in terms of giving every child a start in life and creating fair employment and good work, but are you able to draw that together and bring it back to what her Ladyship has to consider in terms of recommendations in this module of the Inquiry?

Professor Marmot: Yes. My general view is that if you look at the evidence from previous pandemics, including the current one that we’re considering –

Ms Blackwell: Yes.

Professor Marmot: – that the impact of the pandemic is very much influenced by pre-existing inequalities in society, including inequalities in health.

Ms Blackwell: Yes.

Professor Marmot: So action – it’s not just specific pandemic planning, it’s not just whether there’s a report somewhere in government about planning for a pandemic; you’ve got to plan for better health, and narrow health inequalities, and that will protect you from the pandemic.

Ms Blackwell: Thank you.

Professor Marmot: So that’s the general point.

Ms Blackwell: That’s the point.

Let’s move, then, please, to paragraph 199.3, because here I think you do draw together the health equity lens and the pandemic planning and preparation that my Lady needs to consider in her recommendations.

“Pandemic planning and preparation should integrate a health equity lens across all aspects of the process. It should consider if, in future pandemics, additional social groups should be added to those based on age or clinical risk. This could lead to prioritising access to testing, PPE, vaccines, and antiviral medications. Public communication messages about risk and mitigating actions should be both universal for the whole population and targeted to specific at-risk communities. Suitable PPE equipment should be stockpiled in advance and distributed according to relative occupational risk. Enhanced testing should be conducted within at risk communities. Inequalities between and within communities (eg Local Authorities, voluntary sector and NHS capacity) in terms of the ability and capacity to respond to pandemics needs to be addressed. A ‘universal proportionalism’ strategy should be applied in future pandemic planning so that mitigations are delivered for the whole population (universalism) but enhanced for those most in need (proportionalism).”

So, planning, taking into account all of the vulnerabilities and health inequalities, but also enhancing preparations, resources, for those who are most at need?

Professor Bambra: Yes, this reflects what we looked at in terms of the planning documents and the lack of regard for different types of social inequality, so we’re suggesting here that these, ethnicity, deprivation and so on, should be added as risk factors in terms of pandemic planning, and then of course this has implications. It’s not just about having a plan, like Michael says, but what does that plan mean, for example in terms of public communications? Having it translated into minority ethnic languages, for example, would clearly be a strong recommendation.

Ms Blackwell: So it’s all well and good having a set of documents that purport to have considered these issues, but what really matters are the practicalities that need to be in place for when the next pandemic hits?

Professor Bambra: Yes, what does it mean and what do we need to do differently and better, and we’ve made some suggestions, my Lady, as a way to start off thinking about this, yes.

Ms Blackwell: Thank you very much.

Well, my Lady, those are my questions.

Professor Marmot: Can I –

Ms Blackwell: Would you excuse my back, please, whilst I just take instructions on who is going next?

Lady Hallett: Of course.

Ms Blackwell: Thank you.

(Pause)

Ms Blackwell: My Lady, as with other witnesses, you have given a provisional indication that those representing the Covid-19 Bereaved Families for Justice UK are entitled to ask questions on a particular topic, and I think Ms Munroe King’s Counsel is ready to step up and ask her questions now, subject to your Ladyship’s permission.

Lady Hallett: Certainly. Yes, please, Ms Munroe, thank you.

Questions From Ms Munroe KC

Ms Munroe: Thank you, my Lady.

Good morning, Professor Bambra, good morning, Professor Marmot. My name is Allison Munroe and I represent the Bereaved Families UK, and I just have a very few questions to ask you on the topic of data capture, surveillance monitoring.

Ms Blackwell King’s Counsel very helpfully raised the issue and introduced it earlier this morning, and in answer to a question from her regarding the paucity of data and statistics for certain groups in the population, Professor Bambra, you said:

“The issues are that if you don’t have any data, you don’t know sufficiently what the health needs are of different populations in your community.”

Are you able to explain why there has historically been this lack of routine and reliable data, firstly in relation to ethnicity?

Professor Bambra: Yes. So we’re very reliant on the census in terms of, for example, thinking about calculating life expectancy, but the census doesn’t actually capture everyone. So the response rates are much lower, for example, in some minority ethnic groups. So that means you don’t necessarily have a clear concise knowledge of the population size. We also have difficulties in recording mortality, so the deaths, in terms of whether ethnicity is coded or not.

Putting those together, and obviously it’s more complicated that I’ve alluded to here, and we go through some of the further issues in the report, it means you haven’t got the numbers correct either in terms of population size or deaths in order to make accurate estimates, for example of life expectancy, and we also have migration patterns where people come in and go out, and so you find different results in terms of life expectancy for British minority ethnic groups who are British-born compared to more recent migrants, for example.

So there are complexities. The ONS has produced what they call experimental statistics, and that’s because of these complexities in the calculation to do with the data, what data is available.

As to why we don’t try to have better data in terms of minority ethnic groups and other socially excluded populations, I’m afraid I don’t have an answer for that one. But clearly the health and public health community need to do better in terms of making sure that we record people, because if there’s no data, there’s no problem, we don’t see the health needs, we don’t see the disparities.

Ms Munroe: Thank you.

Likewise, are you able to assist with this question: the paucity of, again, reliable, regularly reported data in respect of other marginalised communities, such as the LGBTQ+ community, disabled people?

Professor Bambra: Yes. So could in a way be seen as kind of hidden populations, so it’s only in the most recently census that there has been questions asked about, for example, people’s sexual identity. But again, you wouldn’t necessarily have that recorded at the mortality point. So it’s about how much data you want to record and how much data people are happy to share. But certainly that’s why there’s less.

There is more in terms of survey data, for example, hence we know quite a bit about mental health, but there is less when we’re looking at mortality or causes of death.

Ms Munroe: Would it be correct to say that during the relevant period that this Inquiry is concerned with, that you both are of the view that there was an obvious need for a national system of data capture based upon race, ethnicity and the other marginalised groups that we’ve been discussing this morning?

Professor Bambra: I think if we had had that, with the caveats that I’ve outlined, then we certainly would have had more knowledge of who was most likely to be impacted, their specific health needs, and so on. However, because of looking at the planning documents, I’m not sure that would have been taken into account in planning, even if we had had such a robust data capture system.

Professor Marmot: If I could add, I lamented in my 2020 review the lack of routine data on minority ethnic groups. I’m pleased to say that the Race and Health Observatory, the NHS Race and Health Observatory, is now set up with the explicit mission of redressing that problem, of making sure that we do get regular data by minority ethnic status.

Ms Munroe: Professors, when one talks about national systems, are we talking about a UK-wide data capture or does it need to be broken down into the constituent parts of the UK?

Professor Bambra: Currently the data – because health is devolved, then the data is set up by each nation, so if that process would continue then each country would need to do that, yes, and then it would be up to them if they wanted to harmonise that across the UK.

Ms Munroe: What, in your opinion, has been the impact of the lack of data with regards to pandemic planning and preparedness, for example, modelling and tracking the pandemic disease? What has been that impact of the lack of data?

Professor Bambra: So, again, if you’re not – when you’re thinking of modelling what the pandemic might look at and you’re only looking at average or overall effects, you’re obviously missing, then, whether it’s going to affect some groups of people, some areas, more than others, so that might influence your decisions about what you’d do. So if you had health inequalities embedded in your modelling, in your data collection processes, then you could feed that in to how you think about resource deployment, for example, in the early stage of the pandemic.

Ms Munroe: Should that data gathering, and specifically we’re talking about minority ethnic groups, other marginalised groups within the population, disabled people, LGBTQ community, should such data gathering reach beyond healthcare?

Professor Marmot, you’re nodding.

Professor Marmot: Yes, very much so. I mean, if – the whole thrust of what we have been doing is about the social determinants of health, and so we need to understand ethnic differences in all the key determinants.

Saving my Lady’s patience, I won’t go through them all, but we do need to understand not just socio-economic differences but ethnic differences in those social determinants. So it means we need to have them across all those domains.

Ms Munroe: Ade Adeyemi, who is from the Federation of Ethnic Minority Healthcare Organisations, FEHMO, who will in due course be giving evidence to the Inquiry, he has described the absence of a national system of data capture regarding race and ethnicity as being perhaps one of the most egregious and the biggest system failures in emergency planning to be exposed by the pandemic.

Would you concur with his observations there?

Professor Bambra: I guess there were quite a few flaws, in the planning that we’ve talked about today, with regard to health inequalities and groups not being considered within, for example, the risk register or the contingencies and civil emergency planning. And certainly the lack of data is also an important hindrance, yes.

Ms Munroe: And you’ve talked about the lack of data and how that impacts upon planning, modelling, tracking the disease. Would you agree that it’s also important in terms of laboratory and case studies, in epidemiological studies in any event?

Professor Bambra: Yes, absolutely, as Michael was outlining, we would need to have more data, not just in studying pandemics and planning, but in studying all other issues of health and disease as well.

Ms Munroe: Finally, if we can just go back to your conclusions, if we could have it up, please, my Lady, at page 83 of the report.

Lady Hallett: Sorry, which of the questions you were going to ask is this one, Ms Munroe?

Ms Munroe: Yes, it is, my Lady, it’s the last. I’ve changed the order slightly. I think that’s …

Thank you. If we could look at paragraph 199.6, that’s your very final paragraph, where you’ve identified the need for robust data surveillance and monitoring of health – healthcare inequalities in respect of protected characteristics, other minority and marginalised groups in the UK, as a whole.

Dr Marmot, I think it was you who said, just before I stood up, that reducing health inequalities means better health, and that means protection from pandemics.

So is it fair to say that a robust data surveillance and monitoring system is also crucial in order to identify, assess and, importantly, mitigate against health inequalities generally?

Professor Marmot: Absolutely. I said earlier that we have excellent statistics, routine statistics, available in this country, much better than most other countries, but a lack has been the one that we have just been discussing, the routine data available for minority ethnic groups, which is absolutely crucial to understanding health, health inequalities, and the likely impact of a pandemic.

Ms Munroe: Thank you very much, Professor Marmot, Professor Bambra. Thank you, my Lady.

My Lady, before I sit down, before I stood up actually, I think – I may be wrong – that Professor Marmot looked as if he had his hand up to say something else. I don’t know if that’s right.

Professor Marmot: I did, but that was long past.

Lady Hallett: You can’t remember now? I have had that feeling before now.

Thank you very much indeed, Professors Marmot and Bambra, you have been extremely helpful, if some of the stuff you have had to tell me has been rather depressing. But anyway, thank you very much indeed for all that you’ve done.

Professor Marmot: Thank you.

Ms Blackwell: Thank you, my Lady, and that concludes their evidence.

I think we are ready to go straight on to the next witness, Katharine Hammond. It just needs a quick change around in the witness box. I don’t think, my Lady, you need to rise. Thank you very much.

(The witnesses withdrew)

Mr Keith: Yes, if the oath or affirmation could be put, please.