Weakened by a decade of austerity: why the UK’s covid-19 inquiry is right to look at policies since 2010
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* Martin McKee
* Lucinda Hiam
* Danny Dorling

Any concerns that the UK’s covid-19 inquiry would give ministers an easy ride seem to have been dispelled by the determination with which its chair, Heather Hallett, has pursued information held by former prime minister Boris Johnson.1 The government, likely alarmed by the risk of disclosing similar information from current ministers, fought back with a judicial review of her action.2 Inevitably, this unprecedented measure has dominated media coverage, diverting attention from an equally important development: reports that the inquiry will take evidence from former prime minister, David Cameron, and former chancellor of the exchequer, George Osborne.3 Given the pandemic began in 2020 and both men had left office four years previously, some may ask what interest their testimony can be to the inquiry.

In fact, the decision to invite them sends out a very important message. Much attention has, rightly, focused on the events during the first few weeks of the pandemic. The release of the questions sent by Heather Hallett to Boris Johnson, a consequence of the government’s legal action, has revealed her interest in why the then prime minister seemed so disengaged from what was happening, and in particular why he failed to attend briefings.4 However, her interest in what political leaders from previous administrations have to say shows that she is also interested in earlier decisions that left the UK weakened, contrary to an independent assessment that suggested that it was well prepared.5

It has almost become a cliché to say that the pandemic shone a light on the fractures in society, picking out communities where many lived precarious lives and where social safety nets had been shredded.6 Yet, in the UK, it is arguable that this illumination should have been unnecessary. The signs were already visible for all to see. Since 2014 the Office for National Statistics (ONS) have repeatedly revised down their population projections,7 with one estimate that a million lives will end earlier than anticipated by 2058 as a result.8 Indeed, we and others had done what we could to draw attention to them.9101112

Over more than a century humanity has achieved remarkable progress in improving health. This has accelerated over the past two centuries, for reasons that include improved living conditions and, most recently, advances in healthcare. There have been declines in some places and at some times, but usually for reasons that were obvious, such as wars, famines, and pandemics.13 Consequently, any evidence that this progress is being interrupted for reasons that are, at least initially, unclear should give pause for thought. One such decline occurred in the Soviet Union in the 1980s, something we now know was the earliest sign of a failing state.14 Hence, when the first signs emerged that progress in life expectancy, for some groups, was stalling in the UK in the 2010s, those in power should have at least asked why.15

It is almost never the case that patterns of mortality in a population have a single cause. Public health scholars recognise the importance of causes and the “causes of the causes.” Responsibility for the sinking of the Titanic can easily be attributed to the iceberg but further insights are needed to explain why the death rate was so much higher for third class passengers compared with first class passengers.16 An earthquake in a country with high and rigorously enforced building standards will kill fewer people than one of the same magnitude where the construction industry is beset by corruption.17 Similarly, while the immediate cause of the covid-19 pandemic was obviously the SARS-CoV-2 virus, those looking from a public health perspective ask why some countries fared worse than others and, within them, why some groups suffered more than others.18

Seen from this perspective, it is entirely understandable that Hallett will want to talk to political leaders from the 2010-2016 governments. Faced with a global financial crisis, the coalition government chose to adopt a package of extreme austerity measures. This brought the nascent recovery occurring under the previous Labour government to a halt, unlike in other countries that adopted policies to stimulate the economy.19 They included decisions to shrink the role of the state, reducing expenditure across government. By the late 2010s the impact on health was apparent, with the UK falling further down the global ranking of life expectancy,20 competing with the United States, where the term “deaths of despair” was already entering the policy lexicon.

Yet even then, when the UK’s poor performance could no longer be disputed, it seemed impossible to get anyone in a position of authority to take any notice. When they did, it often seemed that their focus was on any reasons other than the effects of austerity that could explain it.2122 But if anyone had been counting the rising numbers of premature deaths that would not have occurred if the UK had made similar progress to its European neighbours, the alarm bells may have rung.

Many of us suspect strongly that it was the cumulative consequences of austerity policies initiated by the Coalition Government after 2010 that created the conditions that allowed covid-19 to do so much more damage in the UK than in many of its neighbours.23242526 A greatly depleted civil service struggled to respond. A weakened public health system was often marginalised. Millions of people who had been just about managing were struggling with the public health measures needed to interrupt transmission of covid-19. While our focus is on the poor health of the population and the reasons behind it, the TUC has also highlighted unsafe staffing levels in public services, diminished public service capacity and resource, the weakened social security system, and loss of health and safety protections at work.27 It is therefore entirely appropriate that Heather Hallett should want to hear from the architects of the policies that gave rise to this situation.

## Footnotes

*   Competing interests. MMK is president of the British Medical Association and as a member of Independent SAGE he was requested to submit written evidence to the covid-19 inquiry and has done so.

*   Provenance and peer review: not commissioned, not peer reviewed.

## References

1.  UK COVID-19 Inquiry. What is the UK Covid-19 Inquiry? 2023. [https://covid19.public-inquiry.uk/](https://covid19.public-inquiry.uk/) (accessed 2nd June 2023)
    
    

2.  Allegretti A, Walker P. Government to take legal action against Covid inquiry over Johnson WhatsApps. [inews.co.uk](http://inews.co.uk), 2023. [https://www.theguardian.com/uk-news/2023/jun/01/government-to-launch-legal-action-in-attempt-to-retain-johnson-whatsapps](https://www.theguardian.com/uk-news/2023/jun/01/government-to-launch-legal-action-in-attempt-to-retain-johnson-whatsapps) (accessed 2nd June 2023)
    
    

3.  Waugh P. George Osborne summoned to Covid Inquiry over impact of NHS austerity cuts on pandemic. [inews.co.uk](http://inews.co.uk), 2023. [https://inews.co.uk/news/george-osborne-summoned-covid-inquiry-nhs-austerity-cuts-2369223](https://inews.co.uk/news/george-osborne-summoned-covid-inquiry-nhs-austerity-cuts-2369223) (accessed 2nd June 2023)
    
    

4.  Chaplain C. Covid inquiry: 12 major new questions facing Boris Johnson from the documents. [inews.co.uk](http://inews.co.uk), 2023. [https://inews.co.uk/news/politics/boris-johnson-questions-covid-inquiry-documents-2382183](https://inews.co.uk/news/politics/boris-johnson-questions-covid-inquiry-documents-2382183) (accessed 2nd June 2023)
    
    

5.  Nuclear Threat Initiative. Global Health Security Index Web Site. Baltimore: Johns Hopkins Center for Health Security & The Economist Intelligence Unit, 2019.
    
    

6.  McNamara CL, McKee M, Stuckler D. Precarious employment and health in the context of COVID-19: a rapid scoping umbrella review. Eur J Public Health2021;31(Supplement_4):iv40-9. doi:10.1093/eurpub/ckab159 pmid:34751369
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1093/eurpub/ckab159&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

7.  Hiam L, Dorling D. The end of great expectations?BMJ2022;377:e071329. doi:10.1136/bmj-2022-071329 pmid:35512810
    
    [FREE Full Text](https://www.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjE5OiIzNzcvbWF5MDVfOS9lMDcxMzI5IjtzOjQ6ImF0b20iO3M6MjM6Ii9ibWovMzgxL2Jtai5wMTI4OC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

8.  Dorling D, Gietel-Basten S. Life expectancy in Britain has fallen so much that a million years of life could disappear by 2058 – why?: The Conversation, 2017. [http://theconversation.com/life-expectancy-in-britain-has-fallen-so-much-that-a-million-years-of-life-could-disappear-by-2058-why-88063](http://theconversation.com/life-expectancy-in-britain-has-fallen-so-much-that-a-million-years-of-life-could-disappear-by-2058-why-88063) (accessed 3rd June 2023)
    
    

9.  Hiam L, Dorling D, McKee M. Things Fall Apart: the British Health Crisis 2010-2020. Br Med Bull2020;133:4-15. doi:10.1093/bmb/ldz041 pmid:32219417
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1093/bmb/ldz041&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=32219417&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

10. Hiam L, Dorling D, Harrison D, McKee M. Why has mortality in England and Wales been increasing? An iterative demographic analysis. J R Soc Med2017;110:153-62. doi:10.1177/0141076817693599 pmid:28208027
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1177/0141076817693599&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=28208027&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

11. Hiam L, Harrison D, McKee M, Dorling D. Why is life expectancy in England and Wales ‘stalling’?J Epidemiol Community Health2018;72:404-8. doi:10.1136/jech-2017-210401 pmid:29463599
    
    [Abstract/FREE Full Text](https://www.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiamVjaCI7czo1OiJyZXNpZCI7czo4OiI3Mi81LzQwNCI7czo0OiJhdG9tIjtzOjIzOiIvYm1qLzM4MS9ibWoucDEyODguYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

12. McCartney G, Walsh D. Stalled improvements in mortality and life expectancy predate the pandemic. BMJ2023;380:493. doi:10.1136/bmj.p493 pmid:36868567
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1136/bmj.p493&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=36868567&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

13. McMichael AJ, McKee M, Shkolnikov V, Valkonen T. Mortality trends and setbacks: global convergence or divergence?Lancet2004;363:1155-9. doi:10.1016/S0140-6736(04)15902-3 pmid:15064037
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1016/S0140-6736(04)15902-3&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=15064037&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 
    
    [Web of Science](https://www.bmj.com/lookup/external-ref?access_num=000220595500026&link_type=ISI) 

14. McKee M. Commentary: the health crisis in the USSR: looking behind the facade. Int J Epidemiol2006;35:1398-9. doi:10.1093/ije/dyl237 pmid:17085454
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1093/ije/dyl237&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=17085454&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

15. Hiam L, Dorling D, McKee M. Rise in mortality-when will the government take note?BMJ2018;361:k2747. doi:10.1136/bmj.k2747 pmid:29941609
    
    [FREE Full Text](https://www.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjE3OiIzNjEvanVuMjVfMS9rMjc0NyI7czo0OiJhdG9tIjtzOjIzOiIvYm1qLzM4MS9ibWoucDEyODguYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

16. Dorling D. Health Inequalities: From Titanic to the Crash.Policy Press, 2013.
    
    

17. Ambraseys N, Bilham R. Corruption kills. Nature2011;469:153-5. doi:10.1038/469153a pmid:21228851
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1038/469153a&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=21228851&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

18. Larsen T, Bosworth ML, Ayoubkhani D, et al. Inequalities in SARS-CoV-2 case rates by ethnicity, religion, measures of socioeconomic position, English proficiency, and self-reported disability: cohort study of 39 million people in England during the alpha and delta waves. BMJ Med2023;2:e000187. doi:10.1136/bmjmed-2022-000187 pmid:37063237
    
    [Abstract/FREE Full Text](https://www.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NjoiYm1qbWVkIjtzOjU6InJlc2lkIjtzOjExOiIyLzEvZTAwMDE4NyI7czo0OiJhdG9tIjtzOjIzOiIvYm1qLzM4MS9ibWoucDEyODguYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

19. McKee M, Karanikolos M, Belcher P, Stuckler D. Austerity: a failed experiment on the people of Europe. Clin Med (Lond)2012;12:346-50. doi:10.7861/clinmedicine.12-4-346 pmid:22930881
    
    [Abstract/FREE Full Text](https://www.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTI6ImNsaW5tZWRpY2luZSI7czo1OiJyZXNpZCI7czo4OiIxMi80LzM0NiI7czo0OiJhdG9tIjtzOjIzOiIvYm1qLzM4MS9ibWoucDEyODguYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

20. Hiam L, Dorling D, McKee M. Falling down the global ranks: life expectancy in the UK, 1952-2021. J R Soc Med2023;116:89-92. doi:10.1177/01410768231155637 pmid:36921623
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1177/01410768231155637&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=36921623&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

21. Hiam L, Dorling D, McKee M. When experts disagree: interviews with public health experts on health outcomes in the UK 2010-2020. Public Health2023;214:96-105. doi:10.1016/j.puhe.2022.10.019 pmid:36528937
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1016/j.puhe.2022.10.019&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=36528937&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

22. Hiam L, Dorling D, McKee M. Austerity, not influenza, caused the UK’s health to deteriorate. Let’s not make the same mistake again. J Epidemiol Community Health2021;75:312. doi:10.1136/jech-2020-215556 pmid:33004658
    
    [FREE Full Text](https://www.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiamVjaCI7czo1OiJyZXNpZCI7czo4OiI3NS8zLzMxMiI7czo0OiJhdG9tIjtzOjIzOiIvYm1qLzM4MS9ibWoucDEyODguYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

23. McCartney G, McMaster R, Popham F, Dundas R, Walsh D. Is austerity a cause of slower improvements in mortality in high-income countries? A panel analysis. Soc Sci Med2022;313:115397. doi:10.1016/j.socscimed.2022.115397 pmid:36194952
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1016/j.socscimed.2022.115397&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

24. Walsh D, Wyper GMA, McCartney G. Trends in healthy life expectancy in the age of austerity. J Epidemiol Community Health2022;76:743-5. doi:10.1136/jech-2022-219011 pmid:35667853
    
    [Abstract/FREE Full Text](https://www.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiamVjaCI7czo1OiJyZXNpZCI7czo4OiI3Ni84Lzc0MyI7czo0OiJhdG9tIjtzOjIzOiIvYm1qLzM4MS9ibWoucDEyODguYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

25. Loopstra R, McKee M, Katikireddi SV, Taylor-Robinson D, Barr B, Stuckler D. Austerity and old-age mortality in England: a longitudinal cross-local area analysis, 2007-2013. J R Soc Med2016;109:109-16. doi:10.1177/0141076816632215 pmid:26980412
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1177/0141076816632215&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=26980412&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

26. Alexiou A, Fahy K, Mason K, et al. Local government funding and life expectancy in England: a longitudinal ecological study. Lancet Public Health2021;6:e641-7. doi:10.1016/S2468-2667(21)00110-9 pmid:34265265
    
    [CrossRef](https://www.bmj.com/lookup/external-ref?access_num=10.1016/S2468-2667(21)00110-9&link_type=DOI) 
    
    [PubMed](https://www.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmj%2F381%2Fbmj.p1288.atom) 

27. TUC. Austerity left UK “hugely unprepared” for the Covid pandemic – TUC. 2023. [https://www.tuc.org.uk/news/austerity-left-uk-hugely-unprepared-covid-pandemic-tuc](https://www.tuc.org.uk/news/austerity-left-uk-hugely-unprepared-covid-pandemic-tuc) (accessed 5th June 2023)