The Westminster government has consistently shown little sign that it understands the structural weaknesses underlying the worsening health situation

The message from British ministers is clear. 2020 may have been a terrible year, but that is behind us now. We can see the light at the end of the pandemic tunnel as the NHS and its partners have initiated one of the largest vaccination efforts in recent history. Boris Johnson has delivered on his promise to “get Brexit done.” There may be a few bumps in the road, such as questions about vaccine supply, difficulties moving food across borders, and unhappy fishermen (although happier fish). We are reassured by ministers that these are no more than teething problems that will soon be resolved. Now we can move forward, freed from the obstacles placed in our way by the European Union over four decades. Indeed, the speed with which we were able to approve the new vaccines was highlighted as testament to the ability of this once great country to realise its ambitions as a newly sovereign nation.

There are, however, a few problems with this narrative, not least the fact that the new vaccines were approved while the UK was still subject to EU rules. But we should not let details get in the way of a good story. What cannot be questioned is the ambition of this government to move forward. As Michael Gove wrote in The Times on Boxing Day, “The greatest prize, however, is the chance now to renew our country and help it to recover from the ravages of the covid-19 pandemic in a spirit of shared endeavour and solidarity. We have a duty to spread opportunity more equally across the UK. Outside the EU, with a good trade deal in place, we can tackle the injustices and inequalities that have held Britain back.” 

This government came to power on the promise that it would “level up” those parts of the country that had been left behind. Voters in constituencies that had been held by Labour for decades, the so-called red wall, shifted their allegiance. Their newly elected MPs and their constituents have high expectations. But will they be realised?

While there are many ways of measuring the progress of nations, the health of their populations is a good metric. In the 1980s, one of the first signs of the problems that would, within a few years, contribute to the collapse of the Soviet Union was an increase in death rates, something rarely seen outside war or natural disaster. Yet since the mid 2010s, this has been happening in many parts of the UK, driven in part by increases in the so-called “deaths of despair”. This cannot have been because we were held back by Europe as we competed with the United States, among industrialised nations, for bottom ranking in life expectancy gains. Rather, it reflected a prolonged policy of austerity that, among other things, created gaping holes in social safety nets, leaving the country poorly prepared for the covid-19 pandemic and undermining the very systems critical to an effective pandemic response and recovery. Those communities most affected by austerity were the same ones that have been hit hardest by covid. It is not surprising that the UK has experienced some of the highest death rates in Europe during the pandemic.

So what are the prospects for success in levelling up? While we share the view that we should try to be positive, especially as the UK has a strong research base to support progress, as public health doctors we have some serious concerns. 

First, the Westminster government has consistently shown little sign that it understands the structural weaknesses underlying the worsening health situation in recent years and the impact of covid. Although it can point to the billions spent in the covid response, vast sums have been wasted, for example on the procurement of equipment that was overpriced and, in some cases, unfit for purpose. Throughout, there has been the failure to engage with those who were affected by policies and who could have advised how this money could have been better spent. Directors of Public Health were ignored when the failing national contact tracing system was designed. Time and again, announcements were made at the last minute, even though the need to act was obvious. Headteachers have displayed unwavering commitment as they struggled to implement ever-changing guidance issued after successive policy U-turns. Community leaders and social and behavioural scientists were largely ignored when they repeatedly pointed out the lack of support for those who should be isolating, especially those, such as workers in the gig economy, who fell through the holes in the social safety nets. We will fail to level up the most disadvantaged communities if we fail to listen to them and resistance to extend the universal credit boost suggests a concerning lack of insight into the precarious lives many people live.

Second, Boris Johnson’s claim that the UK will “prosper mightily” outside the EU is simply implausible. As one group after another, most recently Scottish fishermen and some Northern Irish politicians, point out the yawning gap between what was promised and the unfolding reality, the economic damage will accumulate. Some groups are beginning to stage protests and Brexit supporters are engaging in mutual recriminations, while ministers downplay the severity of the situation or divert blame from the deal with the EU that they have just agreed. The disruptions will mean less money overall but, worse, it now seems that the most disadvantaged parts of the country, such as Cornwall and the North East, will get much less under the government’s Shared Prosperity Fund than they previously got from EU regional funds. Ironically, many parts of the country that voted for Brexit had benefitted disproportionately from EU funding, which compensated partly for decades of underfunding by Westminster.

Our third concern is more specific. To widespread incredulity, the government decided to abolish Public Health England (PHE) in the middle of the pandemic, adding job insecurity to staff under massive stress as they struggled to combat the spread of the coronavirus. But worse was to come, as it has become clear that the government has no formalised plan about what it will do with PHE’s health improvement work, tackling many of the determinants of the health inequalities the government claims to be levelling up. 

Although our concern is about health, we cannot ignore the wider political implications. The government risks dashing the hopes of those who have, for far too long, felt abandoned. History teaches us that this rarely ends well, especially when populist leaders exploit feelings of abandonment. This trajectory, however, is not inevitable, and a change of course is always possible. Inequities and injustices arise from political choices but so too can equity and justice—where there’s a will there’s a way.

Martin McKee, professor of European public health, London School of Hygiene & Tropical Medicine

May van Schalkwyk, NIHR doctoral research fellow, London School of Hygiene & Tropical Medicine

Competing interests: MMK is a member of Independent SAGE. MvS holds an honorary contract with Public Health England but writes in a personal capacity.