Fair society, Healthy Lives Michael Marmot UCL Institute of Health Equity Stockholm July 2012

Fairness at the heart of all policies. Health inequalities result from social inequalities – requires action on all the social determinants; the causes of the causes Focusing solely on the most disadvantaged will not reduce inequalities sufficiently – action is needed across the social distribution.

The health sector acting alone cannot tackle health inequalities Action is needed across the whole of government and the whole of society Health is an issue for all social workers, not just those working in health settings Recipients of social care services are likely to be the most socially disadvantaged and most will have a long-term illness or disability… over 50s age group are largest users of health and social care (Marmot Review p 159)

Social determinants of health across the lifecourse

A.Give every child the best start in life B.Enable all children, young people and adults to maximise their capabilities and have control over their lives C.Create fair employment and good work for all D.Ensure healthy standard of living for all E.Create and develop healthy and sustainable places and communities F. Strengthen the role and impact of ill health prevention Fair Society, Healthy Lives: 6 Policy Objectives

A.Give every child the best start in life B.Enable all children, young people and adults to maximise their capabilities and have control over their lives C.Create fair employment and good work for all D.Ensure healthy standard of living for all E.Create and develop healthy and sustainable places and communities F. Strengthen the role and impact of ill health prevention Fair Society, Healthy Lives: 6 Policy Objectives

Early child care and education Parenting and family support –Perinatal services –Care before and during pregnancy –Help for new mothers Pre-school education and care Primary, secondary and tertiary education and training

Links between socioeconomic status and factors affecting child development, Source: Department for Children, Schools and Families

Gaps in school readiness at 3 and 5 years by family income: UK Average percentile score Waldfogel & Washbrook 2008

Country ranking: equality in child wellbeing - material, education, and health Source: UNICEF Report Card 9, ranking 24 OECD countries by their performance in each of three dimensions of inequality in child well-being ScoreCountry 8Denmark, Finland, Netherlands, Switzerland 7Iceland, Ireland, Norway, Sweden 6Austria, France, Germany, Poland, Portugal 5Belgium, Czech Republic, Hungary, Luxembourg, Slovakia, Spain, United Kingdom 3Greece, Italy

Children aged months that do not attend any form of early education programme in selected CIS and CEE countries Source: Unicef/MICS 2007

A.Give every child the best start in life B.Enable all children, young people and adults to maximise their capabilities and have control over their lives C.Create fair employment and good work for all D.Ensure healthy standard of living for all E.Create and develop healthy and sustainable places and communities F. Strengthen the role and impact of ill health prevention Fair Society, Healthy Lives: 6 Policy Objectives

Unemployment in EU 27 countries,

Unemployment associated with poor mental and physical health

Mortality* of men aged by social class and employment status at the 1981 census 1981 LS Cohort. *England & Wales: mortality * adjusted for age and salary Social class Standardised Mortality Rate I II IIIN IIIM IV V Employed in 1981 Unemployed in 1981

Unemployment and Mortality 1% rise in unemployment associated with: - 0.8% ↑Suicide - 0.8% ↑Homicide - 1.4% ↓Traffic death No effect on all- cause mortality Source: Stuckler et al 2009 Lancet

Changes in adult unemployment and in age- standardised suicide rates (age 0–64 years) in old (pre- 2004) and new European Union Member States (Stuckler et al Lancet 2011) 2007 is the index year, and y-axis values represent proportional change relative to that year Unemployment Suicides

Occupational stress in European countries

A.Give every child the best start in life B.Enable all children, young people and adults to maximise their capabilities and have control over their lives C.Create fair employment and good work for all D.Ensure healthy standard of living for all E.Create and develop healthy and sustainable places and communities F. Strengthen the role and impact of ill health prevention Fair Society, Healthy Lives: 6 Policy Objectives

Social protection policies make a difference Social and health benefits

Social Protections Help… Each 100 USD per capita greater social spending reduced the effect on suicides by: 0.38%, active labour market programmes 0.23%, family support 0.07%, healthcare 0.09%,unemployment benefits Spending> 190 USD no effect of unemployment on suicide Source: Stuckler et al 2009 Lancet

Copyright ©2010 BMJ Publishing Group Ltd. Stuckler, D. et al. BMJ 2010;340:c3311 Relation between social welfare spending and all cause mortality in 18 EU countries, 2000

Responses to economic crisis and child poverty: UK

Projected relative AHC income poverty rates under current policies and without the coalition government’s tax and benefits reforms: UK IFS 2010

Social protection policies can mitigate intergenerational effects

Child poverty rates (% living in households <60% median income) before and after social transfers 2009 Source: EU SILC

Health inequalities are not inevitable or immutable

SMRs by cause, all ages: Glasgow relative to Liverpool & Manchester Source: Walsh D, Bendel N., Jones R, Hanlon P. It’s not ‘just deprivation’: why do equally deprived UK cities experience different health outcomes? Public Health, 2010 from H Burns, CMO, Scotland

Health improvement in difficult times A major element of the excess risk of premature death seen in Scotland is psychosocially determined Study evidence of low sense of control, self efficacy and self esteem in population in these areas Source: H. Burns, CMO Scotland

Health inequalities and policy strategies Health inequalities are not inevitable; Not just a responsibility of the health care sector; Whole of society, whole of government

A Fair Society