The UK is the sick man of Europe. Since 2010, improvements in healthy life expectancy have stalled, health inequalities have been increasing and health for people living in the most deprived areas has been getting worse. The country has been struggling with three big challenges: a decade of austerity, the Covid-19 pandemic and a cost-of-living crisis. Each of these has exposed a grim fact: Britain is an unhealthy place to be poor, even relatively poor. A tottering NHS has not been the cause of these threats to health but, increasingly, it is not there when we need it. People have noticed. Satisfaction with the health service among the general population was at 34% in 1997. This picked up, reaching 70% in 2010 after Labour began its reforms and markedly increased funding. It has been downhill since, reaching a new low in 2022 with just 29% of people satisfied. People have good reason to be dissatisfied. One key indicator is the number of people waiting for NHS treatment. Waiting lists in England were low in January 2009 – take that as a benchmark. In 1997, the end of 18 years of Conservative government, the waiting list was 2.3 times the 2009 level. After 2010, it began a steady rise, had doubled by 2019, and increased to three times by 2021. Labour’s shadow health secretary, Wes Streeting, set out his vision for the NHS on Friday: the emphasis is not on more money, but reform. I’m sure about the need for reform – we must have a different approach to improving the nation’s health and it must be more than organisational change within the NHS but include a focus on the causes of ill-health. But funding is important: the NHS has been starved of cash and it’s difficult to see how it can be saved without restoring some of the losses. A reasonable approach would be to bring the spending up to the average of peer countries in Europe. To understand the funding position, it is best not to listen to what the government is saying: the problems cannot be simply attributed to the pandemic, the war in Ukraine, or “greedy” doctors and nurses. The problems began in 2010. Health spending per person, adjusted for demographic change, grew at 2% a year under the Conservatives from 1979 to 1997; at 5.7% a year under Labour from 1997 to 2010; at -0.07% from 2010 to 2015; and at -0.03% from 2015 to 2021. In other words, even Margaret Thatcher, who declared there’s no such thing as society, increased NHS funding at a higher rate than the Conservatives in the 2010s. David Cameron declared he wanted to create a “big society”, and he and George Osborne reduced NHS funding per person. Cameron also said that there would be no more top-down reorganisation of the NHS and then, with his health secretary Andrew Lansley, did exactly that. It marked what Chris Ham, former head of the King’s Fund, described as the political failure that led to the decline of the NHS. Other European countries have taken a different approach. If the UK had increased its healthcare expenditure from 2010 to 2019 as much as France did, we would have increased our current spend by 21%, and by 39% if we had matched Germany. The NHS needs more money. It would help in filling the 150,000 vacant full-time posts. Paying doctors and nurses appropriately would help. But we do need reform as well. The reform that is needed is to act on the conditions in which people are born, grow, live, work and age – the social determinants of health that lead to illness in the first place. Poor people use the health service more because they have more illness. In Scotland, for example, people living in more deprived areas had 64% more preventable hospital admissions than those living in the least deprived areas. If everyone in Scotland had the hospital use of the least deprived cohort, it would save about 10% of hospital bed capacity. Similarly in England, we must reduce inequalities in health to reduce the burden on the health service. The NHS can be a partner in actions to improve the quality of people’s lives and hence reduce their risk of premature illness. In the 2010 Marmot review, we laid out six domains of recommendations to improve health and reduce health inequalities between rich and poor. They covered: early child development, education, employment and working conditions, having enough money for a healthy life, healthy and sustainable places in which to live and work, and taking a social determinants approach to prevention. In 2020, we revisited these domains. Almost all had got worse. Child poverty had risen, childcare had become more unaffordable, spending on education per pupil had gone down, there were sharp cuts in spending on adult social care – the more deprived the area, the steeper the cut. The reduction in total per person spend by local government was, similarly, sharply regressive. Housing is a crisis. Universal credit only pays about 70% of the amount of money needed to cover essentials. As an illustration of the grim fact that poor people in Britain fare worse than those in many European countries, we can look at home energy use. In France, as in Britain, people in the top decile of income pay about 6% of their income on energy costs. In Britain, people in the poorest 10% spend nearly 18% of their income on energy; in France it is 10%. Why? Why have governments since 2010 been active participants not only in undermining the NHS, but making the key social determinants of health worse? It seems to be part of a package of failure to recognise the public good, to recreate private affluence amid public squalor, to quote the economist John Kenneth Galbraith. If a new government wants to reverse this trend it must give priority to the health and wellbeing of the population, to make Britain a place where all can flourish. Michael Marmot is professor of epidemiology at University College London, director of the UCL Institute of Health Equity and past president of the World Medical Association