Why the middle class need to demand reductions in health inequalities

By 2025, more than a third of the UK’s population will be over 55. By 2014, projections suggest, over-65-year-olds will overtake the under-16s. With an increasingly ageing population, high national debt and significant public spending commitments, many European countries are seen to be at extreme ‘fiscal risk’ compared to younger country populations across the globe.

This is because, it is argued, an ageing population will place increasing pressure on public expenditure such as pensions and health care, while a shrinking working-age population means less productivity and less tax revenues to support public spending and debt payments.

In response to this perceived growing dependency ratio problem, the UK coalition government’s 2011 Pensions Bill proposed that the state pension age for women rise from 60 to 65 by 2018, and then increase to 66 for both sexes by 2020 – the eventual target pension age being 68. The Labour government was planning to make similar changes, but with a much longer timescale reaching 66 by 2026.

Seems reasonable – but from a public health perspective, these macro social and economic policies are deeply flawed. This is because they do not take into account the fiscal, social and political consequences of health inequalities.

The 2010 Marmot Review below highlights the problem.

Source: Marmot Review (2010).

Every dot is a lower super output area (about 1,500 people) with the horizontal axis showing income deprivation by percentage (most deprived 1% on left) and age on the vertical axis. All measures are aggregates for that 1,500 population/neighbourhood. The light green scatter of dots at the top are for life expectancy – the dark green for ‘disability free life expectancy’ (the age up to which you live without a diagnosis of a life- limiting disability).

The analysis shows that the least wealthy have considerably lower life expectancy – but the difference in ‘disability free life expectancy’ is even greater between rich and poor.

The dark green band across the middle – at age 68, is the age at which pensions are set to eventually rise under current proposals.

When this happens, the poorest 75% of the population on current projections all have at least one (and most likely more than one) life-limiting disability. They will in large part be unable to work or be able to only do limited work and thus require substantial ‘out of work benefits’ by age 68. This will leave 25% of the population – the healthier (but already wealthier) middle class – to work up to 68 supporting an ever-growing volume of the newly defined welfare-dependant population who are unable to contribute fully (or at all) to state taxation.

So… how long do we think will it take for the middle class to get fed up with that?

Whatever they feel about it, it is not going to be the answer to reducing dependency ratios – raising the pensions age will actually increase the dependency ratios in the UK. The policy will achieve exactly the opposite of its intent and most likely raise challenging political and social cohesion issues.

The real fiscal solution is to develop more effective social interventions to reduce social and health inequalities that increase the disability free life years of the poorest 75% of the population who have largely preventable long-term conditions.

Reducing inequalities in health through more effective and better funded public health interventions may be the best economic development strategy the government can adopt if it wants to solve the fiscal challenge of rising dependency ratios.

In their own interests – and in the interest of social justice – the middle class should be demanding improvements in health inequalities now.