Foreward from Marmot Review 10 Years On

England is faltering. From the beginning of the 20th century, England experienced continuous improvements in life expectancy but from 2011 these improvements slowed dramatically, almost grinding to a halt. For part of the decade 2010-2020 life expectancy actually fell in the most deprived communities outside London for women and in some regions for men. For men and women everywhere the time spent in poor health is increasing.

This is shocking. In the United Kingdom, as in other countries, we are used to life expectancy and health improving year on year. It is what we have come to expect. The UK has been seen as a world leader in identifying and addressing health inequalities but something dramatic is happening. This report is concerned with England, but in Scotland, Wales and Northern Ireland the damage to health and wellbeing is similarly nearly unprecedented.

Put simply, if health has stopped improving it is a sign that society has stopped improving. Evidence from around the world shows that health is a good measure of social and economic progress. When a society is flourishing health tends to flourish. When a society has large social and economic inequalities there are large inequalities in health. The health of the population is not just a matter of how well the health service is funded and functions, important as that is: health is closely linked to the conditions in which people are born, grow, live, work and age and inequities in power, money and resources – the social determinants of health.

The damage to the nation’s health need not have happened.

When, in 2015–16, statistics from the Office for National Statistics and Public Health England first showed that the increase in life expectancy had nearly ground to a halt, we at the UCL Institute of Health Equity were cautious, in the usual academic fashion. We were reluctant to attribute the slowdown in health improvement to years of austerity because of difficulty in establishing cause and effect – we cannot repeat years without austerity just to test a hypothesis. The fact that austerity was followed by failure of health to improve and widening health inequalities does not prove that the one caused the other. That said, the link is entirely plausible, given what has happened to the determinants of health.

The evidence we compile in this ‘ten years on’ report, commissioned by the Health Foundation, explores what has happened since the Marmot Review of 2010. Austerity has taken its toll in all the domains set out in the Marmot Review. From rising child poverty and the closure of children’s centres, to declines in education funding, an increase in precarious work and zero hours contracts, to a housing affordability crisis and a rise in homelessness, to people with insufficient money to lead a healthy life and resorting to foodbanks in large numbers, to ignored communities with poor conditions and little reason for hope. And these outcomes, on the whole, are even worse for minority ethnic population groups and people with disabilities (1). We cannot say with certainty which of these adverse trends might be responsible for the worsening health picture in England. Some, such as the increase in child poverty, will mostly show their effects in the long term. We can say, though, that austerity has adversely affected the social determinants that impact on health in the short, medium and long term. Austerity will cast a long shadow over the lives of the children born and growing up under its effects.

Given the strength of evidence on social determinants and health inequalities, it is not an act of hubris to speculate that had the Government acted on all the recommendations in the Marmot Review, health would have continued to improve and health inequalities not have grown larger (2). Certainly, a report we subsequently prepared in 2012 warned of the risks to health from austerity policies.

We endorse today what we wrote in the Marmot Review 10 years ago:

Health inequalities are not inevitable and can be significantly reduced… avoidable health inequalities are unfair and putting them right is a matter of social justice. There will be those who say that our recommendations cannot be afforded, particularly in the current economic climate. We say that it is inaction that cannot be afforded, for the human and economic costs are too high (3).

In this ‘10 years on’ report, we rely on updated evidence but we use the same framework of analysis as the 2010 Marmot Review. In support of that judgement, we cite the Royal Society for Public Health, which surveyed its members and a panel of experts on their views on the major UK public health achievements of the 21st century to date (4). The top three were the smoking ban, the sugar levy and the 2010 Marmot Review. We cite this as an indicator that the public health community judges that we got the evidence, approach and proposals broadly right. This review, therefore, looks at what has happened, or is new, in five of the six domains that we judged to be crucial for improvement of health and reduction of health inequalities, and makes recommendations for what needs to be done now (4).

Globally, actions to address inequalities have moved on since 2010. We are reporting in the era of the UN Sustainable Development Goals, or SDGs. At least 11 of the 17 SDGs can be seen as key social determinants of health. The twin problems of social inequalities and climate change have to be tackled at the same time. Addressing each is vital to creating a society that is just, and sustainable for the current and future generations. New Zealand has shown the way a government can reorder national policies. The government there has put wellbeing, not growth, at the heart of its economic policy: enabling people to have the capabilities they need to lead lives of purpose, balance and meaning.

The question we should ask is not, can we afford better health for the population of England, but what kind of society do we want? The recommendations we made 10 years ago, and those that we make here, will create conditions for all members of society to lead flourishing lives, to achieve their full potential, and to enjoy levels of good health currently experienced by people who live in the most advantaged circumstances. Every society will have some level of economic and social inequalities. What we can envisage, and work towards, is a society that creates the conditions for everyone to be able to lead lives they have reason to value (5). That we do not have such a society at the moment is shown by the slowdown in life expectancy improvement, deteriorations in physical and mental health and widening health inequalities.

Michael Marmot (Chair)

Health Equity in England

The Marmot Review 10 Years On

As a part of the Institute of Health Equity's collaborative work with The Health Foundation, which will see the publication of The Marmot Review 10 Years On, in Feb 2020, Professor Sir Michael Marmot wrote a blog piece about the importance of the work, in the context of declining life expectancy and increase in inequalities in health.

'There can be no more important task for those concerned with the health of the population than to reduce health inequalities'

Read the blog in full at The Health Foundation website.

The NHS, health inequalities, and the Social determinants of health

There has been a contradiction at the heart of recommendations for action on health inequalities. No one is more concerned with health than those of us in the health sector. But the key determinants of health inequalities lie outside the health care system. It is not so much what doctors do, or don’t do, for patients that cause health inequalities, but the conditions in which people are born, grow, live, work and age.

This understanding informed our 2010 Marmot Review, in which we set out principles and recommendations to reduce health inequalities in England. We made recommendations, not for the NHS, but on early child development, education, employment, income support, housing, transport, environment and on the social determinants of healthy, and unhealthy behaviours.

Since the Marmot Review, we have continued to build evidence, developing clear programmes for action on health inequality across all these sectors. We have also focussed on what health professionals can do. Omitted has been the potential role of NHS organisations in acting on social and economic drivers of ill health.

Recognising that the NHS could do far more to support good health as well as treat ill health, I went to see Simon Stevens. We agreed that the NHS should be developing a stronger platform of activity in health equity and health improvement. The resource we have published today, 19th September 2018 ‘Reducing Health Inequalities through New Models of Care’ is the outcome of these discussions.

In the report we make the case for the NHS to take more action on social determinants of health and, drawing on discussions with several vanguards and NHSE staff, we assess exactly what these actions might be. We develop principles for a health system which is based on prevention and health equity.




We developed a diagram to show how vanguards can use existing strategic, system and resource levers, which are available to them, to develop a strong focus on health inequalities – working towards developing and embedding a local health system focused on prevention and health equity.



Our approach is based on discussions with several local vanguards – all of whom are trying to use mechanisms at their disposal to reduce health inequalities. They provided plenty of good examples of local actions which several NHS organisations are taking in collaboration with other sectors to implement programmes and activities to drive reductions in health inequalities; and they demonstrate a real appetite to do more.

They suggest that a better understanding of population health needs, and sharing information on social determinants underpins development of a healthy and equitable health system. To this end we worked with Tower Hamlets Vanguard to establish an integrated local data system – a whole systems dataset (follow link to the dataset) - which combines social determinants, health outcomes and health care utilisation data at small area level. The next stage is to analyse and use the data to drive strategies and service development to tackle poor social determinants at local level.

We also discussed the importance of legislative requirements and in particular the benefits of equality and health inequality assessments, appropriate equity focused evaluations, use of the social value act in commissioning and social prescribing as ways of driving forward action on social determinants and health equity.

Vanguards also highlighted inherent risks to equity – expanded use of technology and inconsistencies in care home service provision for instance. Our report describes all these elements, and urges the development of an ambitious local health system – which focusses on population health needs and good health for all as well as provision of treatment and services.

We must learn from the efforts of these vanguards and strengthen and embed them right across England. As the Five Year Forward View pointed out, rising demand and costs have put the NHS and workforce under immense strain – improving health and reducing inequalities is more important than ever. And, of course, improving health equity is central to the mission and work of the NHS and all those working in it.

NCDS, health equity and social determinants of health

Remarks in opening expert plenary session at NCD conference in Montevideo

18 October 2017

Michael Marmot

UCL Institute of Health Equity

NCDs are a global health problem. One purpose of our meeting here in Montevideo is to plan for an NCD summit to be held in at the UN in New York in September 2018. If you attend that summit and, while there, go to Central Park for a little exercise in green space – good for mental as well as physical health –  you may find your life at risk. Mown down by hordes of high-income joggers.

Much as I applaud people taking responsibility for their health, these high-income New Yorkers are atypical. Globally, the burden of NCDs is in middle-income and, increasingly, low-income countries. Within countries, the so-called diseases of affluence are no longer; the lower people are in the social hierarchy, the higher the risk of NCDs. We cannot deal with NCDS, without dealing with the social determinants of health inequities.

There is a rumour going around that poor people are poor because they make poor choices; and that poor people are unhealthy because they make unhealthy choices. This rumour is a myth. It has the causal connection backwards. More accurately, it is not mythical that the rumour exists – I read it in the press nearly daily – but the evidence points the other way. It is not poor choices that lead to poverty, but poverty that leads to poor choices. An Indian villager is more likely to invest in longer term strategies if the harvest has been good. If it has been poor, he will focus on how to get calories for his family tomorrow, not on strategies for future prosperity. A single mother may respond to the admonition to read bed time stories to her children – it’s good for their long-term future – that she would if she could be sure that they would have a bed, let alone a book.

So it is with healthy choices. Change circumstances and people of low income are more likely to adopt the choices that are good for health. Having time to think about exercise is a luxury that people at the economic margins may not have, quite apart from lack of amenities; healthy food may be beyond a household budget. The stress of marginal employment would be happily forgone if better jobs were available.

Globally, to take effective action on NCDs, we need to address inequities in NCDs, and this entails action on the social determinants of health. What can we do?

In the wake of the WHO Commission on Social Determinants of Health, I was invited by the British Government to conduct a review to answer a question: how can we apply the findings of your global Commission to one country, England. In the Marmot Review, Fair Society Healthy Lives, we identified six domains of recommendations necessary for reducing avoidable health inequalities, promoting health equity:

·         Give every child the best start in life

·         Education and life-long learning

·         Employment and working conditions

·         Minimum income for healthy living – every one should have at least the minimum income that would enable them to live a healthy life

·         Healthy and sustainable places and environments in which to live and work

·         Taking a social determinants approach to prevention. Not just looking at smoking and unhealthy diet, for example, but looking at the causes of the social distribution in these behaviours – the causes of the causes.

As I have but a few minutes I encourage you to read the Marmot Review, or my book, The Health Gap. I will, though, touch on how these six are relevant to prevention of NCDS.

Early child development sets a basis for everything that follows in the life course. Good early child development, leads on to better educational outcomes, better jobs on graduation, more income, better living conditions, and longer lives. People in these favoured conditions are more empowered to make the healthy choices that will reduce the burden of NCDs.

Education is a step on this life-course journey. There has been emphasis on health literacy, very welcome, but we should not forget literacy, more generally. Better educational outcomes give people the life skills not just to negotiate the health system but to negotiate life.

Employment and working conditions are vital not just because work earns money that enables other things to happen. But conditions at work may influence stress pathways that change NCD risk, in addition to influence on healthy behaviours.

Minimum income for healthy living. Universal basic income is on the agenda. It is a health issue. Do I need to make the case for why people need enough money to live healthy lives? The Minister of Finance may have more influence on health equity than the Minister of Health.

Healthy environments. Housing, of course. Working conditions, too. But we now have estimates for the millions of deaths globally caused by air pollution, respiratory and cardiovascular deaths principal among them. Increasingly, environmental pollution is an equity issue.

Social Determinants and prevention. Alcohol is a good example. We know, in general, that the higher the mean alcohol consumption of a country, the greater the frequency of alcohol-associated problems. One strategy, then, must be to aim for lower mean consumption in the population. It is often said that we should find ways to collaborate with the private sector. But we are on a collision course with industry. The brewers don’t want to reduce mean consumption.

When we turn to inequalities and alcohol, we need a further strategy. In the UK, and other countries, the higher the socioeconomic position of people the higher their mean alcohol consumption. Harm goes the other way. The lower the socioeconomic position, the higher the risk of alcohol-related hospital admissions and alcohol-associated deaths. We need, then, to address the social causes that put people at progressively higher risk the lower they are in the social hierarchy; as well as pursuing the first strategy of reducing population mean consumption.

Increasingly health inequity means inequity in the burden of NCDs. Therefore, to address NCDs, we must address health inequity, and that means concerted action on the social determinants of health. Cross government action is a priority.

The rise of life expectancy in the UK is slowing

19 July 2017

There is cause for alarm. Something has happened to slow health improvement in the UK. It is entirely reasonable to think that health just gets better and better. Indeed, over the last century, in the UK, life expectancy showed a steady increase: about 1 year every 3.5 years in men; about 1 year every 5 years in women. As you think about it, such improvement is quite remarkable: every 24 hours male life expectancy increased nearly 7 hours. Since 2010, this rate of increase has halved. Indeed, the increase has more or less ground to a halt.

What’s going on? The first thing to say is that we have not reached peak life expectancy. A levelling off is not inevitable. In the Nordic countries, in Japan, in Hong Kong, life expectancy is greater than ours and continues to increase. There must, inevitably, come a point where levelling off occurs, but we are not there yet

In considering reasons for this stalling, there is another part of the picture that claims attention: inequality. Since we published Fair Society Healthy Lives, the Marmot Review, in 2010 we have been monitoring health inequalities and their social determinants. In our July 2017 publication, we showed the longest life expectancy in the country was in the richest borough, Kensington and Chelsea: 83 for men and 86 for women. By contrast, the lowest life expectancy was in the North: Blackpool, 74 for men; Manchester, 79 for women.

Even more dramatic than these regional inequalities are the inequalities within local areas. In Kensington and Chelsea, life expectancy was 14 years shorter among the most disadvantaged compared to the best off. Alarming, but perhaps not surprising. Kensington and Chelsea may be the richest local area in the country, it is also the most unequal economically. The average salary in Kensington and Chelsea is £123,000. But the median is £32,700; i.e half the earners have £32,700 or less. There are some very high earners in the borough. Parenthetically, no prize for guessing correctly that Grenfell Tower, the tower block that went up in flames, is in the poor part of the borough.

In the Marmot Review, we identified six domains that cause health inequalities and where action is required to reduce them: early child development, education, employment and working conditions, minimum income for healthy living, healthy and sustainable places to live and work, and taking a social determinants approach to prevention.

Each of these raises cause for concern. To illustrate, our fourth recommendation was that in a rich country such as Britain everyone should have at least the minimum income necessary for a healthy life. The Joseph Rowntree Foundation monitors the minimum income standard – akin to our minimum income for healthy living. In 2008/9 about 25% of people lived in households with incomes below the minimum income standard. By 2014/15 this had risen to 30%. Not just the very poor, but the just about managing simply do not have sufficient income to lead a healthy life.

Inequalities in these social determinants provide potential explanations for a slowing of improvement. It is worth, though, thinking about the elderly, specifically.

The majority of deaths occur after age 75. Here, as well as effects from earlier in life, it is possible that spending on social care and health care could have much more immediate effects. Spending on adult social care has been reduced by more than 6%, since 2009/10 at a time when the population aged 65 and over increased by a sixth. Given that we show a big increase in deaths with dementia written on the certificate, and given the growth in the number of people aged 85+, there will be an increase in the need for social care. With cuts in funding, it is likely that there are unmet needs.

Similarly, funding of the NHS, which historically increased at about 3.8% a year since the late ‘70s, has, since 2010 been increasing at about 1.1%. And the spending per person is projected to go down.

It is tempting to link policies of austerity since 2010 to the slowing in increase in life expectancy since 2010. So far, I have resisted that temptation. What I would conclude, though, is that less generous spending on social care and health will have adverse impacts on quality of life of the elderly. It is urgent to determine whether austerity also shortens lives.

Professor Sir Michael Marmot is Director of the UCL Institute of Health Equity www.instituteofhealthequity.org and author of The Health Gap: The Challenge of an Unequal World

Michael Marmot's blog posts can also be found at: www.huffingtonpost.co.uk/michael-marmot

Universities in a post-fact political world

One of my colleagues in Trondheim admitted that as he gets older the tears seem to come more readily. They did on Friday 18 November. Perhaps I should explain.

NTNU, Norwegian University of Science and Technology, in Trondheim awarded me a doctorate honoris causa, their 91^st. The ceremony was a wonderful mixture of Nordic pomp, clockwork precision and Norwegian informality. Apart from two honorary doctors, twice a year approximately 150 students get their doctorates. Impressive.

Like all graduations it was a moving occasion. Certainly, I was moved. My short acceptance speech was along the following lines:

I love graduations. You, dear doctoral graduates, have worked so hard and now you are to be rewarded. You will go out into the world and use your knowledge and skills to make the world a better place.

I find this this graduation occasion special for three reasons. The first, not so important, is that it makes us happy. I work at UCL. The auto-icon of Jeremy Bentham sits in box outside the office of the University President and Provost. Bentham emphasised that social progress should aim at the greatest good for the greatest number. By each of us graduates being happy we add to the world’s utility. But I am not really a Benthamite.

A second more important reason why today is special is because it is a wonderful celebration of what we do in Universities like this one. It stands in stark contrast with what is going on in the world of politics at the moment. With Brexit, far right parties in Norway, Sweden, Denmark and across Europe, the US election, some politicians have declared war on truth, logic, consistency, reason and social justice; not to mention the assault on statistics. What we stand for in universities is all those things: truth, logic, consistency, reason and social justice. We have a vital role to play in standing up for these civilised and civilising values.

The third reason for my valuing this occasion so highly is because I take the award to me as an award to the field in which I work: social justice and health. What I do relies on evidence-based policies and social justice. I am chairing a new Commission on Equity and Health Inequalities in the Americas. At a recent meeting in Washington DC I walked in the Mall and found myself in the area devoted to Martin Luther King Jr. Dr King said:

Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly affects all indirectly.

The world’s problems are our problems, your problems, my dear new doctors.

My colleagues here in Trondheim asked me if I am optimistic, given all the bad things happening in the world, as I have just laid out. Yes, I am optimistic because I do believe that evidence-based policies and social justice will win out. Martin Luther King said it better.

I believe that unarmed truth and unconditional love will have the final word in reality. This why right, temporarily defeated, is stronger than evil triumphant.

Another Norwegian professor, as if accounting for his colleague’s tendency to shed a tear, said: you spoke from your heart to our hearts. I shed a tear.

Read more about the event.

World Medical Association General Assembly, Taipei 2016

Welcome Message: Michael Marmot

It is my special pleasure and privilege to welcome you to our WMA General Assembly Taipei 2016 and 204th/205th Council Sessions. And to thank our hosts in Taiwan for their gracious hospitality and splendid arrangements.

It is tempting to say that this has been a tumultuous year – when were they ever different? There is, though, evidence to support this contention. The Global Peace Index looks at three broad themes: level of safety and security in society; the extent of domestic or international conflict; and the degree of militarisation.

2016 shows the level of peace in the world to be declining and the gap between the most and least peaceful countries continues to widen. Not just peace, but economics, too. Inequalities of income have been increasing in many if not most countries. Globally the gap in wealth is enormous. Oxfam reported this year that the richest 62 billionaires have the same wealth as the poorest half of the global population. The 62 could just about fit into a red London double decker bus. Not so the 3.5 billion people with the same cumulative wealth.


Added to concerns of security and economic inequality there is the slow burn of climate change that threatens major changes to way of life, particularly in low income countries. All three of these – conflict, economic insecurity and climate events such as floods, drought and famine – drive migration. According to the UNHCR we are now witnessing an unprecedented number of people driven from their homes – 65 million worldwide. Among them are over 21 million refugees, half of whom are under the age of 18. The top hosting countries for displaced people are Turkey, Pakistan, Lebanon Iran, Ethiopia and Jordan, but there are big impacts in Europe, Africa, the Americas, and Asia and the Pacific.

Each of these dramatic trends affects us as medical professionals. We deal with the health consequences of conflict and insecurity, economic inequality, climate events and large scale displacement of people. Our freedom to deliver medical care to the needy has, in some countries, been compromised unconscionably. And, at our best, we are active in addressing the causes of these challenges to the health or our patients and the communities of which we are part.

As we come together to debate these big issues we, representing doctors from all parts of the world, bring the highest ethical principles and commitment to the health of our populations. We have important roles to play within the World Medical Association, our National Medical Associations, and in the society at large.

More, we enjoy the company of colleagues from round the world. What we share is so much bigger and more important than what divides us. We gain so much from each other. A heartfelt thank you to all.

Michael Marmot
President
World Medical Association