Marmot Review Team

Jessica Allen and Mike Grady

University College London

National Stakeholder Forum: background material

16th July 2009

The Strategic Review of Health Inequalities in England post-2010:

The Marmot Review

• Secretary of State for Health in England asked Sir Michael Marmot to lead a review, based on the best global evidence, on “how we can do more to tackle health inequality in this country.”

• Timeline– Announced November 2008– Preparatory work November to December 2008– Meetings January 2009 to September 2009– Report to Department of Health in December 2009

The Strategic Review of Health Inequalities in England post-2010:The Marmot Review

• Secretary of State for Health in England asked Sir Michael Marmot to advise on the future development of a health inequalities strategy based on the best global evidence

• Objectives– Identify for the health inequalities challenge facing England

and the evidence most relevant to underpinning future policy and action.

– Show how this evidence could be translated into action.– Advise on possible objectives and measures, building on

the experience of the current targets on infant mortality and life expectancy

– Publish a report that will contribute to the development of a post 2010 Health Inequalities Strategy addressing short, medium and long term issues.

CSDH

Commission on the Social Determinants of Health

• Chaired by Professor Sir Michael Marmot

• Commissioned by World Health Organisation,

• 2005-8• Comprised leading

academics, politicians

CSDH - Key message

• "(The) toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible….Social injustice is killing people on a grand scale."

Translating the CSDH means:

1) Social justice runs though our narrative2) Need to make a global report locally

relevant3) Ensure a focus on the “causes of the

causes”4) Make practical recommendations that will

improve peoples lives5) Involve and engage as wide a range of

stakeholders as possible

Working Committee 1 Jan - June

• Collecting new evidence about interventions Collecting new evidence about interventions which are successful in reducing inequalities in which are successful in reducing inequalities in particular social determinants – and are likely to particular social determinants – and are likely to translate into changes in health inequalities translate into changes in health inequalities across the gradient across the gradient in the short (2012-15), in the short (2012-15), medium (2016-2019) and long-term (2020 and medium (2016-2019) and long-term (2020 and beyond). beyond).

Task groups – Areas for Action

- Early child development and education- Employment arrangements and work conditions- Social protection- Built environment- Sustainable development- Social exclusion and social mobility- Priority public health conditions- Economic analysis - Delivery systems

Task groups – Areas for Action

- Early child development and education- Employment arrangements and work conditions- Social protection- Built environment- Sustainable development- Social exclusion and social mobility- Priority public health conditions- Economic analysis - Delivery systems

Inequality in Early Cognitive Development of British Children

Feinstein, Economica, 2003

Average rank of test scores at 22, 42, 60 and 120 months, by Socio-Economic Status of parents

Income and Educational Outcomes

0

10

20

30

40

50

60

70

0-10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 FSM Non FSM All PupilsDecile of Area Deprivation

Per

cent

age

atta

inin

g 5

A-C

(In

c E

nglis

h an

d M

aths

)

Most Deprived Least Deprived

Low Skills = Low Employment Rate

Source: HM Treasury (2006) Leitch review of Skills

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NoQualification

(14%)

Below Level 2(19%)

Level 2 (21%)

Level 3 (20%)

Level 4 (21%)

Level 5 (5%)

Qualifications (% with in parentheses)

% W

ork

ing

Ag

e P

op

ula

tio

n

Inactive

Unemployed

Employed

Level 2 - e.g 5 GCSEs A-C, NVQ Level 2Level 3 - e.g.A-Levels, NVQ Level 3Level 4 - e.g.First Degree, NVQ Level 4, HNDLevel 5 - e.g.Postgraduate degree

Key questions

• What would a Sure Start system look like that was truly transformative for children and contributed to reducing inequalities?

• What kind of workforce would support families and children in the early years and help reduce inequalities?

• What are the enduring structural barriers to educational equality and how might they be tackled?

• How do we promote more effective positive pathways for young people at risk of social

exclusion?

Task groups – Areas for Action

- Early child development and education- Employment arrangements and work conditions- Social protection- Built environment- Sustainable development- Social exclusion and social mobility- Priority public health conditions- Economic analysis - Delivery systems

Work Matters

• Long-term unemployed: double the mortality risk• Job instability (e.g. downsizing): around 40 studies document

elevated morbidity and a few indicate elevated mortality• Involuntary temporary employment: around 30 studies document

elevated morbidity and a few indicate elevated mortality

Good Work Matters

• Poor psychosocial quality of work (high demand/low control; high effort/low reward) among 15 to 30 per cent of the workforce

• Substantial morbidity and mortality risk (e.g. with increase in cardiovascular diseases and drepression)

• Gain in physical and mental health through improved quality of work

Key Questions

• What is a “good work place” and how can better work be extended to reduce the social determinants of ill health?

• How do we ensure that critical determinants of health including job security and stability, employment conditions, flexibility, and autonomy in the workplace are less socially stratified?

• How can we ensure that people with disabilities, ill health and other vulnerable groups are best able to access and remain in sustainable employment?

Task groups – Areas for Action

- Early child development and education- Employment arrangements and work conditions- Social protection- Built environment- Sustainable development- Social exclusion and social mobility- Priority public health conditions- Economic analysis - Delivery systems

Key Questions

• How do we ensure sustainable livelihoods for those on the fringes of the labour market or reliant on social security?

• What will be the impacts of increased conditionality regimes?

• What are the financial, attitudinal, and demographic constraints we face looking forward?

Task groups – Areas for Action

- Early child development and education- Employment arrangements and work conditions- Social protection- Built environment- Sustainable development- Social exclusion and social mobility- Priority public health conditions- Economic analysis - Delivery systems

Proportion of homes measured as non-decent by tenure: England

0

10

20

30

40

50

60

70

1996 2001 2003 2004 2005 2006

Private rented Social rented Owner occupied

Source: www.poverty.org.uk from English House Condition Survey

The Quality of your neighbourhood environment depends on where you live

0

5

10

15

20

25

30

35

40

45

Poore

st Dec

ile 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Riches

t Dec

ile

Superoutput areas: Vintile on Income Indicator Score (IMD 07)

Ave

reag

e o

f sc

ore

on

Qu

alit

y o

f L

ivin

g E

nvi

ron

men

t

Average Living Environment Score

Highest Qualiity Living Environemtn

Lowest Qualiity Living Environemtn

Key Questions

• How can the environment better promote good health and wellbeing?

• What is a “good place to live” and how can better housing, urban and suburban environments be planned and designed to reduce the social determinants of ill health?

• Can existing housing and neighbourhoods be changed through regulation, incentives or other means?

• What is the role of architecture, urban design and planning policy in promoting good health and wellbeing?

Critical policy areas / issues to resolve

• The Recession / Economic Outlook

• Prioritisation and approach to evidence

• The role of well-being

• Thinking and acting beyond silos

The Recession / Economic Outlook

• Immediate Individual effects– Unemployment – Changing patters of health behaviours

• Impact on services– Increased demand– Projected cuts

• An opportunity for a rethink – sustainable, healthy futures?

UK unemployment (ILO)

Source: cesi.org.uk

Prioritisation and approach to evidence

• Challenge set by health select committee - lack of evidence of what works?

• No silver bullets to be unearthed

• Economic reality will sharpen debate about evidence

What does success look like?

• Adoption of policies and priorities across Government;

• …and by opposition parties;

• SDH approach supported by public agencies and civil society;

• International relevance

Emergent Themes

• Reducing Material Inequalities• Enhance individual/Family, social and community

capital• Sustainable neighbourhoods, transport and food

systems• Quality and flexibility of work and security of

employment.• Protecting vulnerable groups• Public Sector performance and responsibility• Strengthening the approach to evidence based

policy.• Strengthening universal preventive activity on health

CHALLENGES FOR THE REVIEW

1 Reducing the gradient

2 Beyond mortality: Inequalities in “being well” and “well being”

3 Concepts of equity and inequality

4 The role of resilience

5 Public services – creating the conditions that foster change

6 Prioritising recommendations

7 The role of regulation

Some key questions

1. Are the principles and values of Social Justice the right approach to addressing the Social Determinants of Health?

2. Are the themes those most relevant or are there alternatives?

3. What are your views on the cross-cutting challenges?

4. Are there examples of good practice and successful interventions that should be included?

5. How do we empower local population and other groups to ensure action on health inequalities is prioritized?

6. What are the implications of future fiscal policy for Government post 2010?

7. Are the current systems for delivery the most appropriate ? What would improve delivery?

Thank You.

For further information, please visit

www.ucl.ac.uk/gheg/marmotreview