The Commission on Social Determinants of Health (CSDH) – Closing the gap in a generation 2008

Strategic Review of Health Inequalities in England:

The Marmot Review – Fair Society Healthy Lives 2009

European Review of Health Inequalities and

the Health Divide

2010-2012

Life expectancy and disability free life expectancy at birth, persons by neighbourhood income level, England, 1999-2003

45

50

55

60

65

70

75

80

85

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

Neighbourhood Income DeprivationSource: ONS (Population Percentiles)

Age

Life expectancy

DFLE

Pension age increase2026-46Poly. (DFLE)

Poly. (Life expectancy)

2

Life course

Prenatal Pre-school

School Training Employment Retirement

Family building

PreventionEarly Years Skills Development Employment and Work

Accumulation of positive and negative effects on health and wellbeing

Healthy Standard of Living

Sustainable communities and places

Life course stages

Areas of action

3

Inequality in Early Cognitive Development of British Children in the 1970 Cohort, 22 months to 10 years

0

10

20

30

40

50

60

70

80

90

100

22 26 30 34 38 42 46 50 54 58 62 66 70 74 78 82 86 90 94 98 102 106 110 114 118

months

Ave

rag

e p

osi

tio

n in

dis

trib

uti

on

High Q at 22m

Low Q at 22m

Source: Feinstein, L. (2003) ‘Inequality in the Early Cognitive Development of British Children in the 1970 Cohort’, Economica (70) 277, 73-97

High SES Low SES

4

Gaps in school readiness at 3 and 5 years by family income: UK

Ave

rage

per

cent

ile s

core

Waldfogel & Washbrook 2008 6

Per cent achieving 5+ A* - C grades inc Maths and English at GCSE by IDACI decile of pupil residence: England 2007

25.329.9

34.239.2

44.749.5

53.857.8

61.968.4

0

10

20

30

40

50

60

70

80

0-10% 10-20%

20-30%

30-40%

40-50%

50-60%

60-70%

70-80%

80-90%

90-100%

% achieving 5+ A*-C GCSEs inc Maths and English

Income Deprivation Affecting Children Index (IDACI) Least deprived

Source: DCFS 2009

Most deprived

7

8

The Conceptual Framework

Reduce health inequalities and improve health and well-being for all.

Create an enabling society that maximises individual and

community potential.

Ensure social justice, health and sustainability are at heart

of policies.

A. Give every

child the best start in life.

C. Create fair

employment and good work for all.

B. Enable all children, young people and adults to maximise

their capabilities and have control over their lives.

D. Ensure healthy

standard of living for all.

E. Create and develop

healthy and sustainable places and communities.

F. Strengthen the role

and impact of ill health prevention.

Equality and health equity in all policies.

Effective evidence-based delivery systems.

Policy objectives

Policy mechanisms

9

Key Messages

• Major health inequalities within and between countries.

• Social gradient in health• Health inequalities driven by

social inequalities • Action is needed across the

whole system ,health systems alone cannot reduce health inequalities.

• Systematic , sustained and universal action on the social determinants of health proportionate to disadvantage.

• Collate the evidence, develop capacity, build political commitment.

Local Democratic legitimacy

• Community Leadership in giving people voice.

• Place shaping building sustainable communities promoting health wellbeing and resilience.

• Extending participation and co-production of services

• Orchestrating local partnership working.

• Directors of Public Health leading local public health

• Use Council’s role as Commissioner, Service Provider and Employer.

Local determinants of health and wellbeing

Barton H and Grant M 2008

People and Places

• Critical linkage of health, wellbeing and resilience.• Evidence of linkage of low level stress, depression,

isolation especially in communities of multiple deprivation with significant barriers to participation.

“ You can see the deprivation, all you have to do is look outside. Its in your face every day, litter everywhere, rats and rubbish. It’s a dump……it feels like people around you have no meaning to life.I keep my curtains closed at times……….It doesn’t give you a purpose to do anything” (Focus group participant)• Many excluded areas are characterised by lack of

mutual trust, isolation and under developed social cohesion.

“I feel safe but there I places I don’t go” (focus group participant)

Developing Communities: building resilience

• Evidence participation and improving life skills ameliorates impact of health inequalities through developing social support networks. (Bynner and Parsons 2006)

• Impact of personal support critical“ I know I have got back up and that is a big thing” (Mari 2006)

• Learning and skill development impact positively and fosters community action. “ It was just getting worse and worse. The group then decided that we ought to be lobbying people that could help us MPs, local councillors, local members and the Police.” (Shirley)

• Social networks create the conditions in which people thrive“I don’t know what makes other people healthier. I know what makes me healthier and that’s being happy and having friends” (Suzanne 2006)

INDEX OF HEALTH AND SOCIAL PROBLEMS PLOTTED BY INCOME INEQUALITY

Wilkinson R and Pickett K.(2009) The Spirit Level; Why more equal societies almost always do better.Penguin Books London.

Impact of changes to tax and benefit system on net income in 2014 -2015 by decile: UK

Source: IFS 2011

YORK ALL AGE: ALL CAUSE MORTALITY RATES

Creating the conditions for individuals and communities to take control over their health and lives and have political voice.

www.ucl.ac.uk/marmotreview