Transcript Document

THE MARMOT REVIEW AND
SUBSEQUENT WORK
Jessica Allen
UCL Institute of Health Equity
www.instituteofhealthequity.org
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
6
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
Key principles
• Social justice
• Material, psychosocial,
political empowerment
• Creating the conditions
for people to have
control of their lives
www.who.int/social_determinants
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 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
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.
MACROLEVEL CONTEXT
WIDER SOCIETY
SYSTEMS
LIFE COURSE STAGES
Accumulation of positive and negative
effects on health and wellbeing
Prenatal
Early Years
Working Age
Family building
Perpetuation of inequities
Older Ages
Policy Objectives: The Social Determinants of
Health
A. Give every child the best start in life
B. 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 all
D. Ensure a 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
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
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
Life expectancy
(years)
86
84
82
80
78
76
74
72
70
0
30
60
90
Local authority rank - based on Index of Multiple Deprivation
120
150
Inequalities in male life expectancy within
local authority areas, 208-2010
Largest inequalities
Smallest inequalities
Westminster
Stockton-on-Tees
Middlesbrough
Wirral
Darlington
Newcastle -u-Tyne
Barking & Dagenham
Newham
Isle of Wight
Herefordshire Cty UA
Wokingham
Hackney
16.9 (84)
15.3 (78)
14.8 (76)
14.6 (77)
14.6 (77)
13.7 (77)
Figures in parentheses show life expectancy of the area
5.2 (77)
5.0 (76)
4.9 (79)
4.8 (79)
3.5 (82)
3.1 (77)
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
Good level
of development
at age 5
%
80
75
70
65
60
55
50
45
40
0
30
60
90
120
Local authority rank - based on Index of Multiple Deprivation
150
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
Not in education
employment or training
%
14
12
10
8
6
4
2
0
0
30
60
90
Local authority rank - based on Index of Multiple Deprivation
120
150
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
Households on means
tested benefits
%
35
30
25
20
15
10
5
0
0
30
60
90
Local authority rank - based on Index of Multiple Deprivation
120
150
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 Domains
EMPLOYMENT
INCOME AND MIGRATION OF
VULNERABLE FAMILIES
HOUSING
HEALTH 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
Male life expectancy – WHO
European Region
Country
Life
Year expectancy
Highest
Israel
Iceland
Sweden
Switzerland
2009
2009
2010
2007
80
80
80
80
Lowest
Ukraine
Republic of Moldova
Kyrgyzstan
Belarus
Kazakhstan
Russian Federation
2010
2010
2009
2009
2009
2009
65
65
65
65
64
63
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
45 p20 = probability of living to 65 yrs when aged 20 yrs
0.7
University
45 p 20
0.65
0.6
0.55
0.5
Less than secondary
0.45
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
0.4
Source: Murphy et al 2006
Calendar year
Child poverty rates <60%
median before and after
social transfers 2009
Iceland
Norway
Denmark
Slovenia
Cyprus
Finland
Sweden
Czech Republic
Austria
Germany
Netherlands
Belgium
France
Slovakia
Ireland
Switzerland
Estonia
Malta
United Kingdom
Hungary
Luxembourg
Portugal
Poland
Spain
Greece
Italy
Lithuania
Bulgaria
Latvia
Romania
0
Source: EU SILC
10
20
30
40
50
Poverty rate
Before social transfers
After social transfers
60
Social Protection
Each 100 USD per
capita greater social
spending reduced the
effect on suicides by:
0.38%, active labour
market programmes
0.23%, family support
0.07%, healthcare
0.09%,unemployment
benefits
Source: Stuckler et al 2009 Lancet
Spending> 190 USD no effect of
unemployment on suicide
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