Working for Health Equity: The Role of Health Professionals
Michael Marmot
BMA18th March 2013
The Commission on Social Determinants of Health (CSDH) – Closing the gap in a generation
Strategic Review of Health Inequalities in England:The Marmot Review – Fair Society Healthy Lives
European Review of
Social Determinants
and the Health Divide
2010-2012
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 livesC. Create fair employment and good work for allD. Ensure healthy standard of living for allE. Create and develop healthy and sustainable places and
communitiesF. Strengthen the role and impact of ill health prevention
Fair Society, Healthy Lives:6 Policy Recommendations
1. Workforce Education and Training2. Working with Individuals and Communities3. NHS Organisations4. Working in Partnership5. Workforce as Advocates6. The Health System – Challenges and
Opportunities
1. Workforce Education and Training2. Working with Individuals and
Communities3. NHS Organisations4. Working in Partnership5. Workforce as Advocates6. The Health System – Challenges and
Opportunities
Life expectancy and disability-free life expectancy at birth by neighbourhood income deprivation, 1999-2003
Social determinants of health across the lifecourse
The best start in life:Early Child Development (ECD)
• ECD means: physical, social/emotional, language/cognitive development
• ECD is socially determined and, in turn, is a determinant of health across the life course
Socio-emotional difficulties at age 3 and 5:Millennium Cohort StudyAge 3 Age 5
Kelly et al, 2010 Fully adjusted = for parenting activities and psychosocial markers
Working age people in England at high risk of mental illness by social class
9
15
12
17
5
10
15
20
Men Women
Social classes I-IIINM Social classes IIIM-V
% w
ith H
igh
GH
Q12
sco
re
Source: Health Survey for England, DH; the data is the average for 2004 to 2006; England; updated June 2008
Prevalence of obesity, by region and deprivation quintile, children aged 10-11 yrs
Circulatory Disease death rates at ages under 75, by local ward deprivation level
Cancer Death Rates at ages under 75, by local ward deprivation level
Alcohol attributable hospital admissions by small area deprivation quintile
Social Isolation and Loneliness
• Social isolation and loneliness is associated with 50% excess risk of CHD
Systematic literature review and meta-analysis of prospective cohort studies published up to December 2011 in CHD-free populations (nine studies) reported in Steptoe & Kivimaki 2012
Percentage of those lacking social support by deprivation of residential area, 2005
1. Workforce Education and Training2. Working with Individuals and Communities3. NHS Organisations4. Working in Partnership5. Workforce as Advocates6. The Health System – Challenges and
Opportunities
Stress at work• Two models
– Demand-control model: high job strain is characterised by high job demands and low job control, or decision latitude
– Effort/reward imbalance: efforts at work are not adequately rewarded by pay, esteem, job security or opportunities for career advancement
• Socially isolated – (no supportive co-workers or supervisors)
• Stress at work is associated with a 50% excess risk of coronary heart disease
Kivimäki M, Virtanen M, Elovainio M, Kouvonen A, Väänänen A, Vahtera J. Work stress in the etiology of coronary heart disease—a meta-analysis. Scand J Work Environ Health 2006;32(6 special issue):431–442.
The association of civil service grade with job control, Whitehall II study, 1985–88
High Low
Job control
Employment Grade
Chandola et al. BMJ 2006
ODDS RATIO* OF METABOLIC SYNDROME BY EXPOSURE TO ISO-STRAIN: WHITEHALL II PHASES 1 TO 5
0
0.5
1
1.5
2
2.5
3
No exposure 1 exposure 2 exposures 3 or moreexposures
Odds Ratio
Exposure to Iso-strain
Chandola, Brunner & Marmot, BMJ, 2006
*Adj. for age, employment, grade and health behaviours
1. Workforce Education and Training2. Working with Individuals and Communities3. NHS Organisations4. Working in Partnership5. Workforce as Advocates6. The Health System – Challenges and
Opportunities
Living in cold homes: effect on adolescents% children with four or more negative outcomes*
Overcrowded
Poor state of repair
Inadequately heated
All children
0 5 10 15 20 25 30
4
4
4
9
11
9
9
16
283-5 years1-2 years0 yearsAll children
*i)A long-standing illness or disability, ii) to go without regular physical exercise, iii) in trouble for smoking, drinking or taking drugs, iv) bullied in or out of school, v) expelled or suspended from school, vi) does not see friends and does not attend organised activities, vii) has been in trouble with the police, viii)below average in key academic subjects, ix) family cannot afford an annual holiday, and, x) family in income poverty. Source: Barnes et al 2008
% children with four or more negative outcomes*
Number of previous5 years child has lived in theseconditions
Risk of fuel poverty according to household income
Proportion of NEETs in London Boroughs by rank on the Index of Multiple Deprivation
Birmingham Brighter Futures• Aims to improve the lives of all the city's children
and young people;• Focus on improving children’s physical health,
literacy and numeracy, behaviour, emotional health, social literacy, and job skills.
• Specific programmes relevant to early years include: Family Nurse Partnership (FNP), Incredible Years Parenting Programme, Promoting Alternative Thinking Strategies (PATHS), Triple P Parenting Programme.
Per cent 5 year olds achieving ‘good development score’,* Birmingham LA, West Midlands & England
*in personal, social and emotional development and communication, language and literacy
Source: Department for Education: preliminary data
%
1. Workforce Education and Training2. Working with Individuals and Communities3. NHS Organisations4. Working in Partnership5. Workforce as Advocates6. The Health System – Challenges and
Opportunities
Projected relative AHC income poverty rates under current policies and without the coalition government’s tax and benefits reforms: UK
IFS 2010
Neighbourhoods affordable to Housing Benefit Recipients in 2011 and 2016
1. Workforce Education and Training2. Working with Individuals and Communities3. NHS Organisations4. Working in Partnership5. Workforce as Advocates6. The Health System – Challenges and
Opportunities
Health and Social Care Act 2012
• Legal duties to reduce health inequalities, for the first time
• Public Health in Local Authorities• Health and Well Being Boards in LAs• Platform for joining up health services,
social care services and health-related services at local level
www.instituteofhealthequity.org
A Fair Society
Creating conditions in which individuals and communities have control over their lives
INTERNATIONAL INSTITUTE FORSOCIETY AND HEALTH
For further information email: [email protected]
UCL Health and Society Summer School8-12 July 2013
www.ucl.ac.uk/healthandsociety/