Health Inequalities – the Marmot Review – Some thoughts.

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The Marmot Review on health inequalities was released last week and is available at: http://www.ucl.ac.uk/marmotreview/ named ‘Fair Society, Healthy Lives’. I attended a lecture on it given by Prof. Peter Goldblatt which sought to details some of the process, evidence and outcomes that arose from the review. I will aim to briefly outline the nature of the report before sharing a few thoughts I had that arose from the session.

The report develops from a previous Marmot report called “Closing the Gap in a Generation” commissioned by the WHO. This report details the neccessity for Social Justice; Material, psychosocial and political empowerment; and, critically, the need to create conditions for people to have control over their lives. Health inequality is the situation in which different social classes can expect to have different health outcomes, the following graph from the Marmot Review demonstrates just this; that there is a social gradient in health from most deprived to most advantaged and that there is evident stratification between those that are healthy and those with Limiting Long Term Illness.

Life expectancy and disability-free life expectancy (DFLE) at birth, persons by neighbourhood income level, England, 1999–2003

It is interesting to note that the report is using the Index of Multiple Deprivation (I assume 2004) at MSOA (not LSOA) to define the axis ‘Neighbourhood Income Deprivation’. It is notable that the social gradient of health inequality in terms of life expectancy is greater for those with disabilities than without. Other graphs in the Marmot review confirm that the social gradient in health inequalities is not closing. Additionally there is also evidence for regional gradients. It is not just within the quantitative data that these gradients exist, but there is further evidence that social gradients in health inequalities are evident even in subjective questions in the Health Survey for England (HSE).

Having made health inequalities most evident, the review sought to collate as much evidence as possible, investigate measurement, indicators and targets that would be useful to this end, and finally suggest a strategy for implementing a reduction in health inequality. To this end it is important to note that the review was written under a philosophy of ‘progressive universalism’ – the authors believe in intervention across the social gradient, but put a greater focus on the least well-off areas. The review’s impetus is to create a greater sense of social justice and lower health inequalities by creating an enabling society; one in which there exists a sense of ‘Health Equity’ in all policy and in which benefit systems are used properly so as to maximise links between health and social protection and hence provide an adequate minimum income for healthy living. The 6 major recommendations, aimed at intervening along the entire life course, but specifically targetted at earlier stages where more good can be done, are:

  • 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 a healthy standard of living for all.
  • Create and develop healthy and sustainable places and communities
  • Strengthen the role and impact of ill-health prevention.

It is clear from even a basic summary of the review that it is far reaching, this is the nature of my first observation: health no longer simply means an absense of disease as dictated by a Doctor, rather it is an incredibly complex, multi-dimensional concept. Health has seen a shift from something that is solely related to the body and the mind in terms of illness and mental health, to something that is far more pervasive. We now talk of the health of society- a collective health, the ‘wellbeing’ of people – a broader social aspect of health, the presence of healthy places – places that promote health, and the differential effects of health needs and access to healthcare. The Marmot review deals more with social conditions that with health per se, as such the report is reminiscent of the attitudes of Victorian philanthropists and social reformers advocating the clearing of slums and publishing on the state of the poor and the need for social uplift. The breadth of the question of health really calls into question how such recommendations as noted above could be adequately implemented, despite the fact that the Department of Health is one of the most well funded government departments, many of the recommendations of the Marmot review are multi-disciplinary in the sense that they seek to act on aspects of society as a whole through diverse channels at multiple levels.

I’ve previously commented on the nature of policy to develop interventions at the local/community/neighbourhood/place level without having an adequate definitions of what these levels constitute. I think it is clear that, again, this review picks up these current tendencies in government policy without really stopping to ask what they actually are, or why they are important. Health geographers talk a lot about health and place, and often the meaning behind this is very nuanced. This is something which is is very difficult to account for in policy which is quantitatively driven, or requires concrete indicators of performance and success, and a universal toolkit applicable nationally, even regionally.

Finally, I pick up the comment about ‘Health Equity’. Asthana and Gibson (2008) define both health equity and healthcare equity. Health equity is the condition of equal “opportunity to be healthy” whereas healthcare equity is more targeted than health equity, specifying “equal opportunities of access to healthcare for equal needs” (2008 p.4). Health Equity is a deficient term because it supposes a uniformly distributed population across space, essentially it fails to account for the spatial dimensions of health. When one considers the one-dimensional space of healthcare inequalities in which inequalities are dictated by universally applicable socio-economic characterisitics such as social class or wealth is is easy to see how a logical conclusion to reach would be health equity, but this is because the inequalities of access to health and the patterns of environmental quality are not adequately assessed. Distribution of people over space is an implicit indicator of likely health inequalities that is most evident in the persistence of ‘postcode lotteries of care’.

Reference

Asthana S and Gibson A 2008 Health care equity, health equity & resource allocation: Towards a normative approach to achieving the core principles of the NHS. Radical Statistics 96: 4-28

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