Social Determinants of Health – framing the future of health care in Europe

Michael Marmot UCL The Future of Healthcare in Europe Conference 13 th May 2011

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 Health Inequalities and the Health Divide 2010-2012

CSDH Conceptual Framework SOCIOECONOMIC & POLITICAL CONTEXT Governance Policy Macroeconomic Social Health Cultural and Societal norms and values Social Position Education Occupation Income Gender Ethnicity / Race Material Circumstances Social Cohesion Psychosocial Factors Behaviours Biological Factors DISTRIBUTION OF HEALTH Health Care System SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES

The broad European context Health divide

Life expectancy at birth – women, WHO EURO

WHO EURO Health for All database

Life expectancy at birth – men, WHO EURO

WHO EURO Health for All database

Healthy life years and life expectancy at birth, 2008

Males Females

• Health inequalities between and within countries: the social gradient in health

Life expectancy and disability-free life expectancy at birth by neighbourhood income deprivation, 1999-2003

Absolute inequality in males death rates by level of education

Mackenbach et al 2008

Fair Society, healthy Lives: 6 Policy Objectives

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 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

Fair Society, healthy Lives: 6 Policy Objectives

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 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

Minimum Income Standard by family type as a percentage of median income, April 2008

Context matters

Percentage shares of equivalised total gross and post-tax income, by quintile groups for all households, 1978 – 2007/8

Gini coefficients of income inequality, mid-1980s and late 2000s: OECD countries Source: OECD 2011

Inequality of market income and disposable (net) income in the OECD area, working-age persons, late 2000s

Note

: OECD average excludes Greece, Hungary, Mexico and Spain Source: OECD 2011

10 12

Annual growth in health expenditure and GDP, 2000-2008

SVK 8 6 4 2 IRL KOR POL TUR GRC CZE PRT ITA LUX NZL USA MEX DNK CAN BEL NLD ESP GBR

OECD

SWE AUS FRA CHE AUT JPN NOR DEU ISL FIN CHL HUN 0 0 1 2 3 4 5

Real annual growth in per capita GDP, 2000-2008 (%)

6 7 Notes: 2000-2006: Luxembourg and Portugal. 2000-2007: Australia, Denmark, Greece, Japan and Turkey. 2000-2009: Iceland.

Source:

OECD Health Data 2010

.

8

Cost-Related Access Problems in the Past Year, by Income (Adjusted) percent experienced at least one of three problems**

Note: Percentages adjusted based on logistic regression to control for health status, age, and —in the U.S.— insurance status.

* Indicates significant within-country differences with below-average income (p < 0.05).

** Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.

Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Relation between social welfare spending and all cause mortality in 18 EU countries, 2000 Stuckler, D. et al. BMJ 2010;340:c3311

Copyright ©2010 BMJ Publishing Group Ltd.

Marmot Review: 6 Policy Objectives

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 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

• Only 4 per cent of NHS funding is spent on prevention

Average weekly alcohol consumption by sex and socioeconomic class, GB: 2008

Mean number of units a week ONS General Lifestyle Survey 2008

Alcohol-attributable hospital admissions by small area deprivation quintile in England, 2006-07

Action on the wider determinants - to tackle health inequalities

• “Every sector a health sector” action across the whole of society • Local authorities, Health and Social Services, Voluntary Sector have a key role to play at local level • Empower individuals and communities – create the conditions for people to take responsibility www.marmotreview.org

Role of the medical profession

1. Put own house in order: – Access – Health promotion – Prevention 2, Be advocates/work with other key sectors 3. Knowledge, monitoring, evaluation

Good Society?

1. Health inequalities

Health and the distribution of health as social accountant

2. The causes of the causes

Every Minister a Health Minister

3. Fundamental drivers

• Health inequalities are not inevitable or immutable

SMRs by cause, all ages: Glasgow relative to Liverpool & Manchester

All ages, both sexes: cause-specific standardised mortality ratios 2003-07, Glasgow relative to Liverpool & Manchester, standardised by age, sex and deprivation decile Calculated from various sources 350 300 250 229.5

248.5

200 150 131.7

168.0

126.7

112.2

111.9

100 50 0 All cancers (malignant neoplasms) Circulatory system Lung cancer External causes Suicide (inc.

undetermined intent) Alcohol Drugs-related poisonings Source: Walsh D, Bendel N., Jones R, Hanlon P. It’s not ‘just deprivation’: why do equally deprived UK cities experience different health outcomes? Public Health, 2010 from H Burns, CMO, Scotland

Health improvement in difficult times

• A major element of the excess risk of premature death seen in Scotland is psychosocially determined • Study evidence of low sense of control, self efficacy and self esteem in population in these areas Source: H. Burns, CMO Scotland

Age standardised mortality rates by socioeconomic (NS SEC) in the North East and South West regions, men aged 25-64, 2001-03

A Fair Society

Conditions in which individuals &communities: Have control over their lives and Participate fully in society Website www.marmotreview.org

UCL Health and Society Summer School 4-8 July 2011

Information: www.ucl.ac.uk/healthandsociety