THE MARMOT REVIEW AND SUBSEQUENT WORK Jessica Allen

1. THE MARMOT REVIEW AND SUBSEQUENT WORKJessica Allen UCL Institute of Health Equity www.instituteofhealthequity.org

2. Marmot Review 1 The Marmot Review – building evidence 2 Dissemination 3 impact and prioritising health equity 4 The institute of health equity 5 Building approaches – extending and developing • Future developments 7 What went well and what didn’t go so well

3. 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

4. Social justice Material, psychosocial, political empowerment Creating the conditions for people to have control of their lives Key principles www.who.int/social_determinants

5. Task groups set up to assess evidence and make recommendations. Also – indicators – measurement very important.

9. Key themes Reducing health inequalities is a matter of fairness and social justice Action is needed to tackle the social gradient in health – Proportionate universalism Action on health inequalities requires action across all the social determinants of health Reducing health inequalities is vital for the economy – cost of inaction Beyond economic growth to well-being

10. 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.

11. MACROLEVEL CONTEXT WIDER SOCIETY SYSTEMS • LIFE COURSE STAGES Accumulation of positive and negative effects on health and wellbeing Prenatal Early Years Working Age Older Ages Family building Perpetuation of inequities

12. Policy Objectives: The Social Determinants of Health • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives. • Create fair employment and good work for all • Ensure a healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill-health prevention

13. Policy Objective A Give 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

18. 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.

19. 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.

20. 3 Impact

21. 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

22. 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

23. 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…

24. 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

25. Measurement and Monitoring • Measurement is Radical • Monitoring is vital • Holding to account – political, delivery, organisational – health inequality duties.

26. 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.

27. Male life expectancy at birth, local authorities 2008-10

28. 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

29. GIVING EVERY CHILD THE BEST START IN LIFE:CHILDREN REACHING A GOOD LEVEL OF DEVElopment at age 5

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

31. Enable all children, young people and adults to maximise their capabilities and have control over their lives.

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

33. Create fair employment and good work for all:PERCENTAGE of Household in Receipt of means tested benefits

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

35. 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

36. Recession indicators • Piloted in 4 boroughs in London – likely to be rolled out 4 Domains EMPLOYMENT INCOME AND MIGRATION OF VULNERABLE FAMILIES HOUSING HEALTH AND WELLBEING

39. 4 UCL Institute of Health Equity (IHE) • IHE launched November 2011 • Director – Michael Marmot • Advisory Group – international experts • Steering Group

40. 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

41. 5 Building approaches – extending and developing

42. 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

43. 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

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

45. 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

46. 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.

47. 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.

48. 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.

50. Fuel poverty report