The health of those living in the north is worse than those living in the south, and this inequality is reflected in the comparative economic performance as well. The regional inequality in economic performance is prominent throughout the United Kingdom. In this blog, Dr Luke Munford and Professor Clare Bambra explore the links between health inequalities and economic inequalities across the UK. They also consider the impact that the COVID-19 pandemic has had on health and economic performance. Considering an array of variables, they suggest investing in place-based public health, a more holistic approach to improve outcomes in the labour market and promoting health and prevention services across care systems.

• Health is an important pre-requisite for economic performance, and therefore, a stronger focus on health must be adopted in order to ‘Level Up’.
• The north experiences lower levels of economic activity rates, implying higher rates of unemployment and economic inactivity.
• Over the last 50 years, over 1.5 million northerners died earlier than if they had experienced the same lifetime health chances as those in the rest of England.
• The central government can focus on mitigating health inequalities by investing in place-based public health, improving labour market participation and job retention, increasing NHS funding in the north, implanting an inclusive, green industrial strategy, and developing health promotion and prevention services.

The renewed effort to ‘Level Up’ England is essential, as there are deep-rooted and persistent regional inequalities. People living in the north of England typically perform less well than those living in the rest of England on many important metrics. Crucially, the health of people living in the north is lower and so is their economic performance, often through no fault of their own. Previous policy has advocated for economic reforms with the hope that health will improve too. Here, we argue that health is an important pre-requisite for economic performance, and therefore, there needs to be a bigger focus on ‘Levelling Up’ health.

Regional differences in economic productivity and wealth before COVID-19

Pre-COVID-19, there was a £4 per-person-per-hour difference in productivity (measured using average Gross Value Added; GVA) between people living in the north of England and the rest of England; the average GVA per-worker in the north was £28 per-hour, compared to £32 nationally.

Based on these estimates, if Levelling Up the regions of the UK increases the productivity in the north to match the UK average, it would equate to a potential £44 billion real term gain to UK GDP.

The north experiences lower levels of economic activity rates, implying higher rates of unemployment and economic inactivity. Job density is lower too; for every 100 people looking for a job in the north, there are only 79 available – in London, the corresponding figure is 102. Even when in employment, the average annual earnings in the north are 10% lower than the rest of England.

Regional differences in health before COVID-19

People who live in the north tend to have lower levels of health than elsewhere and there is a two-year gap in life-expectancy. Over the last 50 years, over 1.5 million northerners died earlier than if they had experienced the same lifetime health chances as those in the rest of England.

There are also marked differences in the quality of health in the north. The ‘Due North Inquiry’ into health equity reported that a baby boy born in Manchester can expect to live 17 fewer years in good health than a baby boy born in Richmond upon Thames. A baby girl born in Manchester can expect to live 15 fewer years in good health than a baby girl born in Richmond.

The relationship between health and productivity before COVID-19

In a 2018 report funded through the Northern Health Science Alliance (NHSA), we asked “Are these things connected? If we reduce the regional differences in health, will we benefit from higher productivity?”

We showed overwhelmingly that they were. Large economic benefits will follow from the improvement of the health of those living in the north of England. This entails the improvement of employment rates, wages, and in turn, productivity. Potential channels through which health can improve productivity and economic performance include a healthier workforce, who are more likely to be employed and stay employed. Healthier people are also more productive in their job, through a combination of increased happiness and fewer ‘sick days’.

We also examined how much of the ‘productivity gap’ could be explained by lower levels of health in the north. Around 30% of the productivity gap (of £4 per-person-per-hour, or £44 billion per-year) can be directly attributable to worse health in the north. If we were to eradicate this gap and truly ‘Level Up’ health, we estimated that a further £13.2 billion per-year could be added to the UK GDP. This was likely a conservative underestimate as health also indirectly affects productivity through education, training and skills.

What happened during COVID-19

Analysis of data showed that the north was harder hit by the COVID-19 pandemic than other regions of England. The COVID-19 mortality rate was 17% higher in the north as a whole (38% higher in Greater Manchester and 59% higher in Manchester). All-cause mortality was much higher in the north, and we estimated that over two-thirds of the excess northern mortality – or about 100 deaths per 100,000 population, equivalent to around 15,500 deaths in total in the north – could potentially have been prevented if pre-pandemic health and deprivation was the same in the north as in the rest of the country. The prevalence of mental health conditions also rose sharply in the north, in part explained by more exposure to stricter localised lockdown measures.

The economy of the north was also harder hit. Unemployment rates were higher, and they rose much faster; the average unemployment rate of the north was 10% above that of the rest of the country during the pandemic. Wages of people in the north fell too.

We estimate that the increased mortality in the north of England could cost the national economy up to £7.3 billion in lost productivity. This will also likely to be a conservative underestimate given the north’s economy has also been hardest hit.

It is paramount to place health at the centre of all Levelling Up agendas. There needs to be a recommitment to a ‘health in all policies’ position and there to be a national strategy to target and reduce both between and within regional inequalities. The central government can focus on mitigating health inequalities by addressing an array of issues.

Firstly, it should improve health in the north by increasing investment in place-based public health. Local communities are in a much better place to know what works and why. For example, a key component of New Labour’s English health inequalities strategy was area-based interventions (such as Health Action Zones), and this led to a reduction in health inequalities.

Secondly, it should work with employers to improve labour market participation and job retention amongst people with health conditions in the north. For example, people who have long-term conditions could be given extra assistance to enable them to maintain their job. This could include different working arrangements, easier availability of necessary equipment, and greater flexibility.

The central government should also increase NHS funding in the north to be spent on prevention services and health science research. The increases in spending could be brought about by, for example, giving a higher weighting to deprivation measures.

Fourth, by implanting an inclusive, green industrial strategy, the economic inequality between the north and the rest of England can be reduced.

Our last suggestion for government is health remains a key part of the Levelling Up and Regeneration Bill. The commitment to increase healthy life expectancy was good to see, but more details on how it plans to do this would have been welcomed. In terms of northern, local, and regional stakeholders, we recommend the development of health promotion and prevention services. This can be done through via Health and Wellbeing Boards and the emerging NHS integrated care systems. We also recommend that Local Enterprise Partnerships, local authorities and devolved northern regions should develop locally-tailored programmes in partnership with the local NHS and third sector providers to promote ‘health-first’ programmes. Finally, local businesses should be encouraged by government initiatives to support job retention and health promotion interventions across the northern workforce and northern city regions.

Policy recommendations

• Improve health in the north by increasing investment in place-based public health. Local communities are in a much better place to know what works and why. For example, a key component of New Labour’s English health inequalities strategy was area-based interventions (such as Health Action Zones), and this led to a reduction in health inequalities.
• Work with employers to improve labour market participation and job retention amongst people with health conditions in the north. For example, people who have long-term conditions should be given extra assistance to enable them to maintain their jobs. This could include different working arrangements, easier availability of necessary equipment, and greater flexibility.
• Health must remain a key part of the Levelling Up and Regeneration Bill. The commitment to increase healthy life expectancy was good to see. In terms of northern, local, and regional stakeholders, we recommend the development of health promotion and prevention services. This can be done through via Health and Wellbeing Boards and the emerging NHS integrated care systems.

This article was originally published in On Productivity, a collection of thought leadership pieces and expert analysis addressing the gaps in economic performance across the UK, published by Policy@Manchester.

Policy@Manchester aims to impact lives globally, nationally and locally through influencing and challenging policymakers with robust research-informed evidence and ideas. Visit our website to find out more, and sign up to our newsletter to keep up to date with our latest news.