Health In All Policies Inequality Public Health

Marmot 10 years on



Launched this week – This is a (detailed) briefing on key points in three parts – 1) what does it say, 2) some reflection, 3) some thoughts on where next.


Acknowledgement – Paul Hayes, Wakefield MDC, Jeanelle De Gruchy, ADPH President, and many who commented on the launch of the report on social media


1            What does it say

Each chapter gives a detailed commentary on what has happened over the last 10 years in a structure broadly similar to the original report. There is a huge amount of material on the themes Marmot set out 10 years ago


Short summary of key points

‘if health has stopped improving it is a sign that society has stopped improving’. Goes to the heart of the purpose of government.

The 2010 report amassed the biggest collection of scientific evidence on health inequalities in years. Ten years on from the first report, health inequalities have worsened and life expectancy has stalled.


There is an argument that the causes of what we are seeing now has it’s roots in macro economic and social policy of the 1980s, combined with the economic stagnation of the 2010s and the policy choices made by Government. This is a view put forward by the Resolution Foundation among others. Poverty is the most important determinant of health. Currently 4.1m children in the UK are living in poverty. Marmot argues this is the consequence of political choices.


Key points:

1. Poverty matters

2. Place matters

3. Gender differences are stark

4. Healthy life expectancy declining

5. Slowdown in health improvement more rapid and severe in the U.K.

6. More data needed on ethnicity

7. inequalities in health not inevitable

8. we know what to do

8. a strategy is needed to coordinate cross govt action key. Led by No 10, not DHSC


The findings reinforce:

1. Strong local economies that provide good work for all

2. Tackling the housing crisis and homelessness

3. Giving every child the best start in life

4. Support local decision making & programmes

5. Place wellbeing at the centre of all policies



overarching recommendations, with specifics in each area

Develop a national strategy for action on the social determinants of health with the aim of reducing inequalities in health.

Ensure proportionate universal allocation of resources and implementation of policies.

Early intervention to prevent health inequalities.

Develop the social determinants of health workforce.

Engage the public.

Develop whole systems monitoring and strengthen accountability for health inequalities.


A set of recommendations against Marmot Principles, with specifics for each:

Giving every child the best start in life

Enabling all children, young people and adults to maximise their capabilities and have control over their lives

Creating fair employment and good work for all

Ensuring a healthy standard of living for all

Creating and sustaining healthy and sustainable places and communities.



2            Some points of reflection as I read it

In many respects it reads a lot like my draft DPH report – the 10 year impact of austerity   – beaten by another publication ahead of us. Louise and I are trying to write this as we speak


a)           There is no good news in Marmot but we DO know what to do

Worth a historic reflection on when there HAD been success. Since Marmot 2010, the research around the evaluation of the past national strategy (admittedly under a labour govt) has been started to be published. The Ben Barr evaluation research highlighted that the prior national strategy, spearhead PCTs (a lot of investment), a focused approach, with implementation and new services demonstrably led to a closing of the gap. Lesson = it can be done.


b)           There is no shortage of policy prescriptions, but take care with a cookie cutter approach

It is worth a thought on the never ending search for the perfect policy list.

there are many reports with specific recommendations. See appendix for a full(er) list. It is worth noting that many of these evidence based recommendations have been implemented in many ways over the years.

We all want nice clean simple answers. A 6 word plan would be “implement the Marmot Report recommendations, please”.

There are dangers inherent in the evidential model and the viewpoints of different constituencies. Lynch and Marmot make the point about avoiding medicalisation and medical model answers (see his points re poverty vs methadone (better “evidence” for methadone, but may lead us the wrong way). That said short term impact interventions in a medical context CAN and DO have significant impact – inclusion health, CVD risk management, smoking cessation.

There aren’t “three big things” (see a 170 page report from Marmot) and we don’t have the capacity to programme manage 500 projects. There is a need to be mission driven.


c)           There may be a push toward “lifestyle choices” in the Gov response. This must be resisted.

It is fair to say that the response to Wanless and Marmot 2010 (for eg Govt response to Wanless in 2004 (John Reid), The NHS Long Term Plan and Five year view, and many others) continued to focus on lifestyle, and within that individual lifestyle choice.

I would have liked to have seen see more emphasis in Marmot report placed on the damage caused by the over commercialisation of our environment – traditional CDOH etc – hammer the food and drink industry in terms of sugar, salt, fat and alcohol, gambling advertising

The most deprived decile households would spend 75% of their disposable weekly income to meet the healthy eating guidelines. How do you make healthy choices when there’s rent to pay? Hence a focus on enabling environments, addressing the CDOH and a focus on root causes.

Often disproportionate coverage to solutions  oriented in individual behaviours, personal responsibility, often at the expense of changing the context in which people live. The evidence is crystal clear in many different spaces and areas that whilst interventions focused on behaviour change is important what really makes biggest impact, and is most equitable, is addressing the upstream context and environment in which that behaviour happens. There is a general concept issue there, as well as specific policy propositions in certain areas (stop smoking services vs HMT tax policy).


d)           Communities

In my view Marmot report underplays the narrative around an asset vs deficit oriented model. There is an opportunity to build on this locally with a place, community & people oriented approach, not (only) service oriented approach.

There is an opportunity to put into practice the asset based approaches being developed in Wigan(Kings Fund here), proposed by the New Local Government Network (NGLN Community Paradigm / NGLN Community Commissioning), and others.

We often talk about asset based approaches, but then falls into trap of “designing services around user need”. We have an opportunity to make good on approaches focused around communities, community capability and capacity.


e)           Tie it up with other political and other processes and narratives

Devo Opportunities to link to / greater cross reference with some of the big political processes – devolved models of governance and finance.

Push the interface between inequality and economy, but economy in a bigger context (public, social AND private sector economy – and how they interact and are inter dependant. Why does “inequality” in “health” matter for GDP etc. continued pressure for shift away from neoliberal economic model.

Kerslake – UK 2070 commission  on spatial and economic inequalities. Worth reading this thread also.

financial exclusion – Maybe needs a bit more coverage on debt and financial exclusion? Some practical and tangible things we can / are doing on this space. Locally advice services, nationally maybe something about making such things statutory??

Well being in all policies. Could do with a lot more cross ref to the efforts of various govts to do well being as part of all policies – Scotland, Wales, NZ, Iceleand.

Social mobility. Would be good to emphasise the link to social mobility agenda – especially in terms of helping poorer kids to university/technical college, apprenticeships etc. There’s also something about bridging the gap between finishing formal education/training and getting your first proper job and somewhere to live.

APPG – Longevity and ageing. Also good to link to the APPG Longevity report

Deaton – what is coming from Deaton Review –

education – inequalities in educational attainment have life-long impacts and deepen as children progress through school – the right education approaches can break the link between poverty and poor attainment

climate justice. There are also plenty of opportunities to link “health” inequalities to notions of climate justice. The extent to which we need to re-nationalise some of basic social infrastructure – start with the buses? promote the green economy (especially with the North leading the way on this); local produce in local services; tax discounts for hybrids and solar panels

IFS spending on local govt. Putting into this the IFS review of local gov finance and equity implications inherent in their review of local gov finances. The areas of big cuts are basically social determinants . These cuts have been inequitably spread. We know from this IFS analysis and plenty of other (eg NEF analysis) that from individual, family, community, place level those with most need been hit hardest.


f)            Framing and language

The language of inequality is arguably over technical and professional, and actually not “angry” enough.  The human experience is rather different from what the data actially says, and as experience in many of our communities shows there continues to be merit in the human to human conversation, invest in their ideas & make health about having hope & confidence in our futures & having fun with our families and friends

There is merit in continuing to frame “H Ineq” away from “health” more towards unusualness in life chances and opportunities. Folk continue to see it as a health thing (and thus see it through lens of doctors and NHS etc). This is well trod territory, but needs continual push. NB Hanckock’s initial response was about NHS. If its “health” might (I think does) limit the constituencies that see it as “theirs”

Few understands the words around equality and equity, or inequality, it may be worth framing the approach around poorer life chances (from birth), poorer health, shorter lives.


g)           How to appeal to the right politically speaking, needs thought

Marmot clearly can easily be interpreted as criticism of the right and a call to action for the left. There is more thought needed for how the frame the language and the response in a way that makes clear inequality is a social responsibility regardless of political leaning. This may include a need for thought on whether to focus on equality of opportunity or outcomes, levelling up v redistribution.

Marmot has exposed the deeply entrenched structural inequality in our society has been exposed. It remains to see what ‘levelling up’ means, and how it is delivered. Brexit and all its repercussions and consequences will likely have a profound impact on the nation’s health and wellbeing over the next decade.

Stigltz argues we wont get near solving the economic growth problem until we solve the economic inequality problem. One might extend this to a health outcome context – we wont solve the population health issue (and thus health & social demand as a subset) until we make progress in the health inequality space

h)           Balance between local and national

There is a delicate balance between national and local and whether to ask for a national health inequalities strategy vs something about fundamental principles of government that entrenches (or alleviates) inequalities vs “localising” it entirely (ie making it an issue for local gov only)

There is a really strong focus in the report on local systems and examples (inc well known ones to us such as GM, Coventry and Cheshire and Merseyside), to show what is possible and what is going well.  The trick is to balance this with, ‘but it could be so much better’ and what is the national and local asks.

Many, including me, argue that place oriented response is only way of bringing everything together. There are obvious tensions between national top down / sector specific and place oriented, especially if fully assed based model.


3            what response?

It is likely the “response” to the Marmot report will be a DHSC response to the consultation on the Prevention Green Paper. I am hearing the response is more likely to be a “statement of intent” rather than a White Paper.


I am anticipating being disappointed by this (narrowly constructed and framed, not cross government, DHSC not HMT or no 10 led, oriented around genomics, predictive prevention and “lifestyle choices” / personal responsibility – see above point on lifestyle choice vs social and commercial determinants).


Marmot sets out the case for an ask on different govt depts.- HMT, DfE, DfT, DCMS, DHCLG, HO, DWP – what are EACH of the other depts doing. This also plays out locally, and underscores the importance of place based responses. Each govt department needs to take responsibility for the impacts their policies have on human health and wellbeing. This requires leadership from MPs and pressure from the public and civil society.


The Health Foundation have suggested some national potential priorities for the next 5 years

1. Economy and productivity

2. Promote equity within budgets

3. Strengthen regional productivity

4. Focus on improving HLE

5. Maximise opportunities from devolution

6. Cross-govt and cross-sector action


Local response – my thoughts

Under governance may well be an issue for us. Marmot highlighted this nationally.


The HWBB should hold the ring on the governance on HI


This should have the effect of widening the perspective, the understanding, ownership of the need for response into domains well beyond “public health” narrowly defined or something that is perceived must be (only) owned by the NHS.


Ingredients for Sheffield  – Stakeholders in Sheffield have discussed this extensively over recent years. There are approximately ten recurring themes that keep coming up

1.       Not just about deprivation & geography – gender, ethnicity, disability, mental illness, layered disadvantage

2.       Disproportionate distribution of resources, services and assets to meet disproportionate need

3.       The earlier the better. Health of the working age population

4.       economic impact of inequality. GVA vs social value.

5.       Community capacity and approach.

6.       Shift of hospital to primary care.

7.       focused effort on CVD risk factors.

8.       Lifestyle “choices” vs commercial determinants health

9.       Inequality and poverty are obviously inextricably linked.

10.   Participation in education and generating aspiration is important


But more than specific topics – build the right machinery

There is merit in building mechanisms that builds action to redress inequality into the machinery of our organisations more squarely. We need to be building the right approach into the wiring – institutional (performance system, financing, expectations re outcome, professional practice, targets. Some suggestions:

1.       It is broadly agreed our Health and Well Being Strategy is essentially a health inequalities strategy. There is merit in reflecting on the findings and recommendations of Marmot in the context of our strategy and adapting our approach as a board to reflect this.

2.       Test progress locally against multiple reviews & recommendations (not an insignificant exercise)

3.       EVERY paper (to HWBB and constituent partner agencies) should directly address a point about positive impact on health inequalities. Treat inequality with the same gravity as financial balance?

4.       Extend the role of EqIA to encompass inequality?

a.       Shift EqIA away from defensive post hoc activity focused on groups with protected characteristics towards upfront at question forming stage. far broader including aspects of socioeconomic deprivation and multiple layer disadvantage.

b.      Can’t pass or go to cabinet until done – compulsory to publish EqIA with any paper to board / cabinet or equivalent where decision might be needed.

c.       May not need to be a FORMAL EqIA but paper be very clear that equality considered at question stage onward.

d.      With some form of objective measure as to what is “good enough”.

e.       Performance measures may include number of staff trained (need to develop the training package), post hoc audit of equality impact assessments completed and lessons learnt

5.       Proportionate universalism – For all blocks of funding and service deliver, build and enact the principal of differential funding and model of delivery. Redevelop a policy of distribution of the funding streams we CAN control according to some measure of proportionate universalism

6.       Culture – As well as the machinery we look at the mission and culture and the narrative (we won’t address improvement in population outcomes until we narrow the gap and we need to know the gap by lifting the floor).

7.       Focus on cohorts. Ask all services for a definitive focus on the bottom 20% and a very laser like focus on specific cohorts

8.       Building measurement of the gap into the performance framework for every indicator (technically difficult), or greater use of the PHE Marmot indicatrors or similar on Fingertips




Appendix – policy recommendations

I often use this to marshal together my thoughts and this slide set

There are many evidence reviews giving specific policy prescriptions – I once tried to summarise


NHS oriented

1.       PHE Place Based HI Reports and Tools Also this is the Chris Bentley Stuff reborn. I have my own views on the Bentley model. Downstream ish. Necessary. Needs focus on implementation

2.       Primary care oriented stuff here

3.       Liz Walton once wrote this

4.       The Buck 8 from Kings Fund

5.       Thoughts on resource allocation, funding and demand in here

6.       Public Accounts Committee 2010  and NAO

7.       Luchenski – what works for those who are excluded


8.       Picket – Population reduction of health inequalities

9.       of course Marmot 1

10.   Smith et al – what kind of policies do health researchers support

11.   British Adademy – if there was one thing

12.   Fran Baum – beyond social determinants. A manifesto

13.   NHS Scotland modelling the impact of income policy interventions

14.   Healthy, prosperous lives for all: the European Health Equity Status Report. Major new report on health inequality

15.   McAuley – modelling approaches to inform investment in reducing inequalities

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