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: catherine.conroy@ucl.ac.uk

UCL Health and Society Summer School8-12 July 2013

www.ucl.ac.uk/healthandsociety/