In November 2008, Professor Sir Michael Marmot was asked by the health secretary to chair an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England from 2010.
The strategy will include policies and interventions that address the social determinants of health inequalities.
The Fair Society, Healthy Lives review had four tasks, including the identification of relevant evidence; demonstrating how this evidence could be translated into practice; advising on possible objectives and measures, building on the experience of the current PSA target on infant mortality and life expectancy; and, the publication of a report of the review’s work that will contribute to the development of a post-2010 health inequalities strategy.
A summary of the key messages:
1. Reducing health inequalities is a matter of fairness and social justice. In England, the many people who are currently dying prematurely each year as a result of health inequalities would otherwise have enjoyed, in total, between 1.3 and 2.5 million extra years of life.
2. There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health.
3. Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health.
4. Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. This is called proportionate universalism.
5. 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. These currently account for productivity losses, reduced tax revenue, higher welfare payments and increased treatment costs.
6. Economic growth is not the most important measure of our country’s success. The fair distribution of health, well-being and sustainability are important social goals.
7. Tackling social inequalities in health and tackling climate change must go together.
8. Reducing health inequalities will require action on six policy objectives: give every child the best start in life; enable all children young people and adults to maximise their capabilities and have control over their lives; create fair employment and good work for all; ensure healthy standard of living for all; create and develop healthy and sustainable places and communities; strengthen the role and impact of ill health prevention.
9. Delivering these policy objectives will require action by central and local government, the NHS, the third and private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies. Effective local delivery requires effective participatory decision-making at local level. This can only happen by empowering individuals and local communities.
Marmot Review conclusions
Social justice is a matter of life and death. It affects the way people live, their consequent chances of illness and their risk of premature death.
This is the opinion of the Commission on Social Determinants of Health set up by the World Health Organisation. Theirs was a global remit and we can all easily recognise the health inequalities experienced by people living in poor countries, people for whom absolute poverty is a daily reality.
It is harder for many people to accept that serious health inequalities exist here in England. We have a highly valued NHS and the overall health of the population in this country has improved greatly over the past 50 years.
Yet in the wealthiest part of London, in one ward in Kensington and Chelsea, a man can expect to live to 88 years, while a few kilometres away in Tottenham Green, one of the capital’s poorer wards, male life expectancy is 71.
Dramatic health inequalities are still a dominant feature of health in England across all regions. But health inequalities are not inevitable and can be significantly reduced.
They stem from avoidable inequalities in society: of income, education, employment and neighbourhood circumstances.
Inequalities present before birth set the scene for poorer health and other outcomes accumulating throughout the life course.
The central tenet of this review is that 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. The health and well-being of today’s children depend on us having the courage and imagination to rise to the challenge of doing things differently, to put sustainability and well-being before economic growth and bring about a more equal and fair society.
Reaction to the review
Professor Mike Kelly, director of the Public Health Excellence Centre at NICE, said: “Public health interventions are extremely good value when compared with the costs of clinical interventions. We need to shift the emphasis away from medical interventions that treat existing illnesses to interventions to prevent those illnesses developing in the first place, but it needs political support and system change to make this happen.
“A modest switch in resources to public health, to invest in those interventions which have been shown to be effective and cost effective by NICE, would from a societal point of view and a social justice point of view, be an important investment for the future.”
The King’s Fund acting chief executive Dr Anna Dixon said: “The problems that contribute to health inequalities are complex and longstanding. It is clearly the role of the NHS to help everyone improve their chances of living longer and healthier lives. But the health service cannot eradicate these inequalities on its own.
“The onus is on government to address health inequalities as a cross-departmental issue and to support not just NHS efforts but programmes that address the wider determinants of health – like housing, working conditions and early childhood education.
“The political obstacle is that cash invested in initiatives to tackle health inequalities doesn’t produce instant returns. It’s imperative that politicians continue to support the reduction of inequalities as a goal, even if the outcomes might not be achieved until after they have left office.”
Read the full review.