Social gradient in health and vulnerability Peter Goldblatt

- People are in vulnerable situations when they experience multiple processes of exclusion - Data on excluded populations are extremely hard to obtain

The review identified four broad themes in which action needs to be taken The lifecourse – from before birth, through early years and education, employment, family building and at older ages. In the wider society - social protection, vulnerability, minimum standards of living, gender equity, community engagement and empowerment, sustainable and equitable local environmental policies The macro-level context - taxes and public spending priorities, , sutainable development plans Systems to support a strategic approach to equity – local, regional and national partnership working, health care systems and transparent scrutiny of inequities and the strategies to address these.

Life expectancy and disability-free life expectancy (DFLE) at birth, males by neighborhood deprivation, England, 1999–2003 and 2009-2013

Expected years from birth with disability, males by neighbourhood deprivation, England, 1999–2003 and 2009-2013

Expected years from birth with disability, females by neighbourhood deprivation, England, 1999–2003 and 2009-2013

Percentage smoking by difficulties experienced in paying bills, 2012

Life-course pathway from early life origins to inequality in mortality mediated by smoking Giesinger I, et al. J Epidemiol Community Health 2013

Psychosocial environment of work Stress arises from: Demand-control imbalance Effort-reward imbalance Organisational injustice Employment precariousness

What enhances my wellbeing and health What is detrimental to my wellbeing and health What enhances my wellbeing and health Lack of interesting activities in winter Recycling facilities Green spaces that I can use Poor local job prospects Affordable healthy food Poor street lighting and uneven pathways Affordable transport Here is an example of a ‘fictional’ citizen’s view on what ‘enhances’ and ‘frustrates’ their wellbeing and health. It is an example of looking through both an asset and a deficit ‘lens’. Spending time with my neighbours Soaring fuel bills and poor insulation

The Role of Health Professionals in Tackling Health Inequalities: Workforce Education and Training Working with Individuals and communities NHS organisations - Working in Partnership Workforce as Advocates

B. Primary and Community Care Indicators of health care access, quality and outcomes - all stages of the patient pathway A. Home Primary care Supply Primary Care Quality 4. Preventable hospitalisation 3. Hospital waiting time 5. Repeat hospitalisation B. Primary and Community Care C. Hospital 7. Amenable Mortality 6. Dying in hospital D. Die

Association between average performance and deprivation: preventable hospitalization

Health is a human right Do something Do more Do better Michael Marmot Source: WHO Review of Social Determinants and the Health Divide in the European Region