THE MARMOT REVIEW AND SUBSEQUENT WORK

Jessica Allen

UCL Institute of Health Equitywww.instituteofhealthequity.org

Marmot Review

1 The Marmot Review – building evidence 2 Dissemination 3 impact and prioritising health equity4 The institute of health equity 5 Building approaches – extending and developing6 Future developments

7 What went well and what didn’t go so well

1 The Marmot Review

• Commissioned following CSDH by English Labour Government.

• To analyse health inequalities and propose effective strategies to reduce them.

• Aware that health inequalities were not decreasing, in fact increasing

• Social justice• Material, psychosocial,

political empowerment • Creating the conditions

for people to have control of their lives

www.who.int/social_determinants

Key principles

Task groups set up to assess evidence and make recommendations.

Also – indicators – measurement very important.

Key themes

Reducing health inequalities is a matter of fairness and social justiceAction is needed to tackle the social gradient in health – Proportionate universalismAction on health inequalities requires action across all the social determinants of healthReducing health inequalities is vital for the economy – cost of inactionBeyond economic growth to well-being

Cost of Inaction• In England, dying prematurely each year as a result of

health inequalities, between 1.3 and 2.5 million extra years of life.

• Cost of doing nothing• Action taken to reduce health inequalities will benefit

society in many ways. It will have economic benefits in reducing losses from illness associated with health inequalities. Each year in England these account for:– productivity losses of £31-33B – reduced tax revenue and higher welfare payments of £20-32B

and – increased treatment costs well in excess of £5B.

Prenatal Early Years Working Age Older Ages

Family building

Accumulation of positive and negative effects on health and wellbeing

LIFE COURSE STAGES

MACROLEVEL CONTEXT

WIDER SOCIETY SYSTEMS

Perpetuation of inequities

Policy Objectives: The Social Determinants of Health

A. Give every child the best start in lifeB. Enable all children, young people and adults to maximise their

capabilities and have control over their lives.C. Create fair employment and good work for allD. Ensure a healthy standard of living for allE. Create and develop healthy and sustainable places and communitiesF. Strengthen the role and impact of ill-health prevention

Policy Objective AGive Every Child the Best Start in Life

Recommendations• Increase proportion of expenditure allocated to

early years• Support families (pre and post natal, parenting,

parental leave, transition points)• Quality early years and outreach

2 Dissemination• Post marmot review – ‘left over funding’

• Travelled – locally and internationally• Every local authority• Other sectors, policy

All government departments – cross government working group and expert group.

EVIDENCE to policy, measurement and other sectors• Evidence linking health to other policy areas• Made links explicit – not health imperialism but

health core concern and business of all government

• Win Wins• Recommended joint approaches and

interventions, partnerships, indicators• Advocacy with OGDs, other sectors.

3 Impact

Marmot Review: NATIONAL IMPACT:• Public Health Outcomes Framework• Public Health White Paper – based around Marmot

Review• Membership of groups: DWP health advisory group, DH

expert obesity group, oftag, Census Health Advisory group, Fuel Poverty Advisory Group, , Inclusion Health Board

• Marmot indicators – additional to phof• Evidence presented: Health select committee, CLG

select committee• Input/advice National Commissioning Board, PH England,

DH CVD strategy, Breast screening Review, Inclusion Health programme, Cabinet Committee meeting on public health

BUT…

• Cross party support – how meaningful?

• policies still widening inequalities• OGDs losing interest• Health perceived as wealthy – where the rewards

go• Cross sector work (and finance) increasingly hard

and fragmented

LOCAL IMPACT:• Local authorities

– 75% of local authorities have been significantly influenced by Marmot, evidence by their HWB and JSNAs 

– We have worked directly with 40 plus local authorities• English Partnership Local government

partnership between IHE and 7-8 local authorities until 2014/15 – intensive working to develop SDH approach to health inequalities. Disseminate findings – build evidence

• Local politics – resources, ideology, experience…

What to do:• Political prioritisation of health equity

– Advocacy – persuasion, evidence, facts, - it CAN be done

– Leadership – build capacity – all sectors

• Development of REALISTIC policies and interventions – push on open doors, align agendas

• ways of assessing benefit (social, value added)• Measure and monitor

Measurement and Monitoring

• Measurement is Radical

• Monitoring is vital

• Holding to account – political, delivery, organisational – health inequality duties.

Monitoring progress: Marmot Indicators

The indicators at local authority level are: • life expectancy at birth; • children reaching a good level of development at age five; • young people not in employment, education or training (NEET); and, • percentage of people in households receiving means tested benefits.

In addition there is an index showing the level of social inequalities within each local authority area for: • life expectancy at birth; • disability free life expectancy at birth, • and percentage of people in households receiving means tested

benefits.

Male life expectancy at birth, local authorities 2008-10

0 30 60 90 120 15070

72

74

76

78

80

82

84

86

Local authority rank - based on Index of Multiple Deprivation

Life expectancy (years)

Inequalities in male life expectancy within local authority areas, 208-2010

Largest inequalities Smallest inequalities

Westminster 16.9 (84) Barking & Dagenham 5.2 (77)

Stockton-on-Tees 15.3 (78) Newham 5.0 (76)

Middlesbrough 14.8 (76) Isle of Wight 4.9 (79)Wirral 14.6 (77) Herefordshire Cty UA 4.8

(79)Darlington 14.6 (77) Wokingham 3.5

(82)Newcastle -u-Tyne 13.7 (77) Hackney 3.1

(77)

Figures in parentheses show life expectancy of the area

GIVING EVERY CHILD THE BEST START IN LIFE:CHILDREN REACHING A GOOD LEVEL OF DEVELOPMENT AT AGE 5

Children achieving a good level of development at age five, local authorities 2011

0 30 60 90 120 15040

45

50

55

60

65

70

75

80

Local authority rank - based on Index of Multiple Deprivation

Good level of development

at age 5%

ENABLE ALL CHILDREN, YOUNG PEOPLE AND ADULTS TO MAXIMISE THEIR CAPABILITIES AND HAVE CONTROL OVER THEIR LIVES.

Young people not in employment, education or training (NEET), local authorities 2008

0 30 60 90 120 1500

2

4

6

8

10

12

14

Local authority rank - based on Index of Multiple Deprivation

Not in education employment or

training%

CREATE FAIR EMPLOYMENT AND GOOD WORK FOR ALL:PERCENTAGE OF HOUSEHOLD IN RECEIPT OF MEANS TESTED BENEFITS

People in households in receipt of mean-tested benefits, local authorities 2008

0 30 60 90 120 1500

5

10

15

20

25

30

35

Local authority rank - based on Index of Multiple Deprivation

Households on means tested benefits

%

Next steps

• Possibility to extend ‘Marmot indicators’, to encompass wider set . For example:

- Within school gradients in levels of attainment.

- Numbers below the minimum income for healthy living relevant to their life cycle circumstances

Recession indicators• Piloted in 4 boroughs in London – likely to be

rolled out

4 DomainsEMPLOYMENT

INCOME AND MIGRATION OF VULNERABLE FAMILIESHOUSINGHEALTH AND WELLBEING

4 UCL Institute of Health Equity (IHE)

• IHE launched November 2011• Director – Michael Marmot• Advisory Group – international experts• Steering Group

Institute Remit and Role • Influencing and developing policy at the local, national and

global levels

• Supporting those who are working to address health inequalities through training and workshops to spread the knowledge and widen the expertise

• Building evidence through partnerships on research and evaluation, and monitoring progress in taking action 

• Developing a wider global network to support development and implementation

5 Building approaches – extending and developing

WORKING FOR HEALTH EQUITY: THE ROLE OF HEALTH PROFESSIONALS

• What doctors, nurses, health visitors, midwives, etc can do to tackle SDH.– Practice– Advocacy– Organisationally/partnerships

• 2 year plus implementation programme - – 19 organisations

Areas for outcomes:• Development

– Cognitive– Communication & language– Social & emotional– Physical

• Parenting– Safe and healthy environment– Active learning– Positive parenting

• Parent’s lives– Mental wellbeing– Knowledge & skills– Financially self-supporting

• Report on impact of demographic change, recession and welfare reform on health inequalities in London and production of indicators to monitor and measure impact.

Evidence from previous economic downturns suggests that population health will be affected:

• More suicides and attempted suicides; possibly more homicides and domestic violence

• Fewer road traffic fatalities• An increase in mental health problems, including

depression, anxiety and lower levels of wellbeing• Worse infectious disease outcomes such as TB +

HIV• Negative longer-term mortality effects• Health inequalities are likely to widen

The report specifically looks at the impact of the recession on income, employment and housing:• The economic downturn is causing a rise in unemployment,

a fall in income for many households, which in turn may cause housing problems for those who experience lower incomes. – London unemployment up from 6.7% (Q2 2008) to 10.1% (Q1 2012)– There is a shortage of affordable homes in London. The number of

homeless people and those living in overcrowded homes has risen.• Unemployment, low incomes and poor housing contribute to

worse health. • These problems are more likely to occur among particular

groups within the population and among those already on low incomes.

Impact of the welfare reforms• £18 billions welfare savings• Intended to strengthen incentives to work, but there is a

shortage of jobs.• Many households face reduced benefits – lower incomes,

harder to cover housing costs.• Affects low-income households, in particular:

– Workless households and those in >16 hours/ week low-paid work– Households with children– Lone parents, possibly also women in couples– Larger families– Some minority ethnic households– Disabled people who are reassessed as ineligible for the Personal

Independence Payment– Private rented tenants.

Households unable to afford current accommodation will need to find an alternative solution, e.g. – Take up paid employment– Re-negotiate rent– Rent arrears, leading to repossession or non-renewal of tenancy– Become homeless– Become overcrowded– Compromise on housing conditions– Move to a less expensive area of the capital or out of London.

• London should expect significant migration within and between boroughs as more areas become unaffordable.

• Likely widening of socioeconomic health inequalities.

Fuel poverty report

Europe

• Publication and dissemination of WHO European Review of social determinants of health divide

• Launch of regional networks (southern Europe, Nordic and possibly UK)

• Healthy Cities sub equity network – working closely with 8+ cities across Europe

• EU Report

Life expectancy in countries in the WHO European Region, 2010 (or latest available)

Source: WHO Health for all database, 2012

Country YearLife

expectancy

HighestIsrael 2009 80Iceland 2009 80Sweden 2010 80Switzerland 2007 80

LowestUkraine 2010 65Republic of Moldova 2010 65Kyrgyzstan 2009 65Belarus 2009 65Kazakhstan 2009 64Russian Federation 2009 63

Male life expectancy – WHO European Region

Source: WHO HFA database

Years of life spent free of disability, women in selected European countries 2009

Source: EC health indicators

Trends in probability of survival in men by education: Russian Federation

0.4

0.45

0.5

0.55

0.6

0.65

0.7

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

Calendar year

45 p

20

45 p20 = probability of living to 65 yrs when aged 20 yrs

University

Less than secondary

Source: Murphy et al 2006

0 10 20 30 40 50 60

Romania Latvia

Bulgaria Lithuania

Italy Greece

Spain Poland

Portugal Luxembourg

Hungary United Kingdom

Malta Estonia

Switzerland Ireland

Slovakia France

Belgium Netherlands

Germany Austria

Czech Republic Sweden Finland Cyprus

Slovenia Denmark

Norway Iceland

Poverty rate

Before social transfers After social transfers

Child poverty rates <60% median before and after social transfers 2009

Source: EU SILC

Social Protection

Each 100 USD per capita greater social spending reduced the effect on suicides by:0.38%, active labour market programmes0.23%, family support0.07%, healthcare0.09%,unemployment benefits Spending> 190 USD no effect of

unemployment on suicide

Source: Stuckler et al 2009 Lancet

Summary Health inequalities are costly• Lives lost prematurely, and health lost

prematurely – costs to individuals and society• Financial costs – health service, social protection

and lost revenues, potential• Social costs – costs to social cohesion, crime

and other life chances – education, employment

ACTION TO REDUCE HEALTH INEQUALITIES THROUGH ACTION ON SDH WILL HAVE MULTIPLE SOCIAL AND FINANCIAL BENEFITS and benefit other sectors

6 future Development

Developing approaches• Life course• Intergenerational transfer of

inequities• Resilience – communities• Processes of exclusion• Human rights and governance• International mechanisms

Health equity in all policies

• HIAP - Tools exist, but to be effective, need strong leadership, prioritisation and not burden

• Intergenerational transfers of inequity – development of tools and culture and political discourse.

Older people

Mental health

NCDs

Employers – private sector

Public Health professionals?

Other plans – 5-10 years• Global network• Continuing to prioritise and influence health

inequalities strategies• Work with and influence national and local

governments, third sector and engage private sector

• Evidence gaps, evidence base and • Support delivery systems

7 What went well, and what didn’t• We have a lot of evidence and still gaps• We know political leadership is crucial – ways of

achieving that – even in current climate (existing assets – workforce, private sector)

• Advocacy• Coverage – national and local and across sectors• Infiltrate

Harder• Political prioritisation• Political cycles• Other policies pulling different ways • Maintaining focus – especially ogd

• Ideological opposition• Reorganisation

Local delivery• Delivering effective partnerships• Involving community• Competing priorities – budget competition and

delivery demands• Reorganisation public health and NHS• Health service still dominates – and under threat

even more so – and politically• Individual responsibility very strong

Evidence• We have a lot• Still need more and new• People want type of evidence that very rare

• We have to push action even where evidence weak or not evaluated because we know it will work

Need• Effective leadership

– Political and public health and health care leadership– And other sector– And local leadership

• Social movement – public support

• Strong accountability

• Proper integration with behaviour change• Long term ambition • No silver bullets

• Strong brave public health (reorganisation is all consuming and screening and social marketing)

• Keep infiltrating others agendas – eg NCDs, eg early years, eg health professionals.

Need• Greater support from other sectors

– Employers – private sector

– International finance system, trade negotiations, human rights legislation, MDGs etc.

AMBITION AND REALISM

Rewards are immense – fairer healthier society

Institute website:www.instituteofhealthequity.org