One year on...

Recently, I was asked one of those standard questions: what most keeps you awake at night? The question that has nagged away at me since starting as chair of the WHO Commission on Social Determinants of Health, and continued with our Review of Health Inequalities in England Fair Society, Healthy Lives, is: what would success look like? Engaging the best scientists and practitioners to help in producing the Marmot Review a year ago is great for the quality of the report, but can hardly be counted as success. In the longer term, of course, reduction of health inequalities is the only success that matters. But short of that, what would success for the movement on social determinants of health and a fair distribution of health look like?  

I asked that question of a friend who is a professor at one of the leading public policy schools in the US. His answer: rarely do you see a one-to-one-to-one link between a report, policy and outcomes. Success is having your report and recommendations become part of the policy debate.

About 90 people helped us put together Fair Society, Healthy Lives. There is objective evidence that they can be pleased that their efforts have been amply repaid with success:

• In the first year after publication of Fair Society, Healthy Lives the team here gave approximately 200 invited presentations - more than four a week, allowing for summer and Xmas breaks. The sheer numbers attest to the amount of interest the Review generated in the UK and globally.
• 22 local areas in England have active plans for implementation of the Review.
• Several others have it on their agenda; Birmingham, for example, has "Marmot Champions" (don't think I can write that without cringing) representing each of the six domains of our recommendations.
• Wales and Northern Ireland have declared their interest in pursuing this agenda. Scotland, under the leadership of CMO Harry Burns is pursuing similar plans

Readers with long memories will remember the Black Report on health inequalities. Commissioned by a Labour government, Sir Douglas Black and his colleagues reported soon after Mrs Thatcher became Prime Minister and his report was buried. It had huge impact on the scientific community and, indeed, Fair Society, Healthy Lives built on Black and Acheson, but Black was rejected by the government of the day. Health Inequalities were off the government's agenda. Many observers muttered darkly that history would repeat itself and Marmot would follow Black.

It hasn't. The Government's Public Health White Paper is an explicit response to Fair Society, Healthy Lives. The Public Health White Paper gives prominence to public health and does three important things: it puts reduction of health inequalities in centre place; it emphasises the life course; and has explicit recognition of actions needed on social determinants of health. The White Paper takes up five of our six recommendations - notably, the one excluded is minimum income for healthy living - and it endorses our call for proportionate universalism (read the report).

I was installed as President of the BMA in June - it lasts a year. It was put to me that I may be the first BMA President with an agenda and mine was to ask what the medical profession could do on social determinants of health and health inequalities. The BMA has been very supportive in a variety of ways, including a conference held yesterday to mark one year on from publication of the Review. The BMA has also helped in engaging the Medical Royal Colleges, and we have been embraced enthusiastically by the Royal College of Nursing.

With BMA support, I chair a small working group of the World Medical Association to address this agenda. Picking up one of the recommendations of the WHO Commission on Social Determinants of Health, WHO and the Brazilian government are organising a global summit on Social Determinants of Health, in Rio in October 2011.

The Regional Director of WHO Euro, Dr Zsuzsanna Jakab, has invited me to lead a Review of Social Determinants and the Health Divide. Peter Goldblatt and Jessica Allen, central players in the English Review, are co-leading the European Review.

I have several times been moved to quote Don Quixote: the dogs are barking, Sancho, it's a sign we're moving.