Role of healthy places and sustainable communities in reducing health inequalities Peter Goldblatt

COMPLETED 3 REVIEWS : GLOBAL COMMISSION CLOSING THE GAP IN A GENERATION. ENGLISH REVIEW FAIR SOCIETY HEALTHY LIVES AND IN OCTOBER WE WILL FORMALLY PUBLISH THE EUROPEAN REVIEW OF THE SDH AND THE HEALTH DIVIDE. CONSISTENCY OF MESSAGE FROM THE EVIDENCE: HEALTH INEQUALITIES VARY CONSIDERABLY BETWEEN AND WITHIN COUNTRIES,ACROSS REGIONS AND ACROSS CITIES THOSE INEQUALITIES ARISE FROM SOCIAL INEQUALITIES IN THE CONDITIONS IN WHICH PEOPLE ARE BORN, GROW, LIVE,LEARN, WORK AND AGE AND IN INEQUALITIES IN POWER,MONEY AND RESOURCES THESE CONDITIONS LEAD TO AN ACCUMULATION OF BOTH DISADVANTAGE AND HEALTH HAZARD THROUGHOUT LIFE WITH EARLY CHILDHOOD EXPERIENCES HAVING THE MOST PROFOUND LIFELONG EFFECTS AS SET OUT I N GRAHAM ALLENS REVIEW OF EARLY YEARS. THIS PERSISTENT INEQUALITY OF SOCIAL CLASS IS INTERWOVEN AND OVERLAID WITH DISADVANTAGE OF GENDER, ETHNCITY, SEXUAL ORIENTATION, DISABILITY, AGE RELIGION AND BELIEF. THE EVIDENCE IS THAT SOCIALLY COHESIVE SOCITIES WITH DEVELOPED WELFARE STATES,HIGH QUALITY EDUCATION AND HEALTH SERVICES HAVE CREATED THE CONDITIONS WITHIN WHICH PEOPLE HAVE FREEDOM TO THRIVE AND FLOURISH. THE GLOBAL RECESSION AND NATIONAL ECONOMIC CRISIS IN THE UK HAS EXACERBATED THE GAP AND EXPOSED STARK SOCIAL AND ECONOMIC INEQUALITIES. A HUMAN RIGHTS APPROACH SUPPORTS PRIORITY TO IMPROVING HEALTH AND NARROWING THE GAP AS A MATTER OF SOCIAL JUSTICE. INEQUALITIES IN HEALTH ARE WIDESPREAD,PERSISTENT,UNECCESSARY,DTRIMENTAL TO US ALL AND UNJUST. THE EVIDENCE IS CLEAR WITH THE RIGHT CHIOCES OF POLICY PROGRESS CAN BE MADE.THIS IS OUR CAUSE. 2

Key principles Social justice Material, psychosocial, political empowerment Creating the conditions for people to have control of their lives www.who.int/social_determinants 3

Life expectancy and disability-free life expectancy at birth by neighbourhood income deprivation, 1999-2003

Fair Society: Healthy Lives: 6 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 Health system is well placed to work with all these. AT END OF REVIEW HAD 1000 PAGES OF EVIDENCE AND 157 RECOMMENDATIONS. DH ASKED FOR ONE!! DISTILLED THESE 6 FROM THE EVIDENCE ALL 6 ARE NECESSARY BUT TIME FRAMES DIFFER CONSIDERABLY IF HAD GONE WITH ONE IT WOULD BE GIVE EVERY CHILD THE BEST START BECAUSE IF THAT WERE AHIEVED REDUCES THE REMEDIAL BURDEN AND BUILTS INTO SUSTAINABLITY

Healthy and sustainable places and communities - policy recommendations Prioritise policies and interventions that both reduce health inequalities and mitigate climate change Fully integrate systems to address the social determinants of health in each locality Support locally developed and evidence-based community regeneration programmes that remove barriers to community participation and action social isolation

Reduce health inequalities and mitigate climate change Across the social gradient: Active travel Access to safe, good quality open space Improved food environment locally Improved energy efficiency of housing

Principles in reducing health inequalities Health inequalities result from social inequalities - ‘causes of the causes’ – the social determinants Address the social gradient in health through ‘proportionate universalism’ Life course approach Intergenerational focus Address processes of exclusion Develop strategies based on assets, resilience, capabilities and strengths. Human Rights framework

KEY MESSAGE FROM THE REVIEW WHICH RUNS COUNTER TO MAIN POLICY DIRECTION IN THE PAST 20 YEARS IS THE ISSUE OF PROPORTIONATE UNIVERSALISM. FOCUSING SOLEY ON THE BOTTOM OF THE GRADIENT WILL NOT ALTER THE SLOPE INDEX SUFFIENTLY TO NARROW THE GAP NEED INVESTMENT ACROSS THE GRADIENT PROPORTIONATE TO THE LEVELS OF DISAVANTAGE OF COURSE INVEST MORE AT THE BOOTOM BUT ALSO IVEST DiFFDERNTIALLY LATEST KINGS FUNE REPORT BY DAVE BUCK AND FRANCESCA FROSINI HIGHLIGHTS THAT THE PROPORTION OF THE POPULATION ENGAGING IN THE 4 KEY UNHEALTHY BEHAVIOURS HAS DECLINED FROM AROUND 33% TO 25% BY 2008. REDUCTIONS MAINLY AMONGST THOSE WITH HIGHER SOCIA ECONOMIC AND EDUCATIONAL GROUPS.POOREST AND THOSE WITH LEAST EDUCATION BENEFIT LEAST WIDENING INEQUALITIES AND AVOIDABLE PRESSURE ON THE NHS. MANY UNIVERSALIST SERVICES NHS,EDUCATION AND SERVES AS MODELS UNDERPINNING COLLLECTIVE PROVISION AND RESPONSIBILITY KEY MESSAGE FROM THE EVIDENCE IS THE SOCIAL GRADIENT NEEDS TO BE ADDRESSED.FOCUSSING ONLY AT THE BOTTOM MEANS TACKLING ONLY PART OF THE PROBLEM. EVEN IF THE INTERVENTION IS SUCCESSFUL IT WILL HAVE FAILED TO ADDRESS INEQUALITIES WHICH EXIST FOR OTHER GROUPS ON THE GRADIENT OR THE IMPACT WILL BE INSUFFICIENT TO REDUCE THE OVERALL GARDIENT.

Fully integrated approach to health inequalities MACROLEVEL CONTEXT WIDER SOCIETY SYSTEMS LIFE COURSE STAGES Accumulation of positive and negative effects on health and wellbeing Prenatal Early Years Working Age Older Ages Family building Perpetuation of inequities

People and Places Critical linkage of health, wellbeing and resilience People and Places Critical linkage of health, wellbeing and resilience. Evidence of linkage of low level stress, depression and exclusion are barriers to participation: “ You can see the deprivation, all you have to do is look outside. Its in your face every day, litter everywhere, rats and rubbish. It’s a dump……it feels like people around you have no meaning to life. I keep my curtains closed at times….It doesn’t give you a purpose to do anything” (Focus group participant) Many communities are characterised by lack of mutual trust, isolation and under developed social cohesion. “ It is a deprived area ,there are no jobs , people are stressed out family and partner relationships and all things like that are going wrong” (June) EVIDENCE SHOWS CRTICAL IMPORTANCE AND INTERLINKAGE OF HEALTH WELLBEING AND RESILIENCE. LYNNE FREIDLI WORK FOR WHO EUROPE IS PARTICULARILY SIGNIFICANT MENTAL HEALTH,HEALTH INEQUALITIES AND RESILIENCE. SO TOO DANNY DORLING ACTION ON SPACIAL SEGREGATION OF OUR CITIES WITH GHETTOS OF SOCIAL HOUSING AND THE IMPACT ON HEALTH INEQUALITIES PLACE,SPACE AND ENVIRONMENT HOLD GRAET IMPORTANCE ON HEALTH AND WELLBEING ACTIVITY PSYCHSOCIAL WELLBEING AIR QUALITY NOISE INJURIES SUSTAINABLE HOUSING AND ENERGY. FEELING GOOD ABOUT WHERE WE LIVE = 200% LESS LIKELY TO BE IN LOWEST GROUP FOR MENTAL HEALTH

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

Partnership with individuals and communities- an asset based approach. FOCUS HAS BEEN ON A DEFICIT MODEL SINCE BEVERIDGE CONCENTRATION ON NEEDS PROBLEMS AND CITIZENS SEEN AS PASSIVE RECIPIENTS OF WELFARE AND PROGRAMMES JOHN MCNIGHT ORGANISED CHICAGO NEIGHBOURHOODS IN 60S EMPOWERED COMMUNITIES ARE THOSE THAT IDENTIFY,CONNECT AND UTILISE THEIR OWN RESOURCES START WITH ASSETS AND COMMUNITY LEADERSHIP DEVELOPMENT IDENIFY STRENGTHS FOCUS ON COMMUNITIES AND SOCIAL CAPITAL PEOPLE AS CITIZENS WITH TALENT AND RESOURCE   CREATE THE CONDITIONS WHICH ALLOW PEOPLE TO TAKE CONTROL AND THRIVE IMPROVE LIFE CHANCES FOSTER POWER AND VOICE. EXAMPLES INCLUDE WAKEFIELD ABCD (2001) CHESHIRE EAST THINKING IT THRU AS PART OF JSNA. I&DeA A Glass half-full:how an asset approach can improve community health and wellbeing.

Health, wellbeing and resilience Evidence participation and improving life skills ameliorates impact of health inequalities through developing social support networks. (Bynner and Parsons 2006) Learning and skill development impact positively and fosters community action. “ I have learned ..I use my counselling skills with my family. I listen more and I know my daughter will say I am really proud of what you are doing ,Mum “ (Jane) Social networks create the conditions in which people thrive “ I would say that people in the group have more confidence. At one poInt they would have been sat at home doing nothing ,now they are out and are involved. Once you get there it ‘s amazing to see how far you can go.” (Joyce)

Coventry City Council Deficit Asset Start with assets of communities Identify opportunities and strengths Invest in people as citizens Emphasise civil society Focus on neighbourhoods and common good Citizens as co producers People take control People are the answer Start with deficiencies and need externally defined Respond to problems Provide services for users Focus on individuals Clients as consumers Passive recipients Fix people with programmes as the answer

participate fully in society Creating conditions in which individuals and communities have control over their health and lives and participate fully in society 16