LONDON CATALYST

‘Health Inequalities in London:

developing joint solutions to achieve
better health outcomes’
Jessica Allen
UCL Institute of Health Equity
www.instituteofhealthequity.org
Inequalities in health

Between and within countries – the social class gradient in

health

Inequalities in life expectancy and healthy life expectancy

The social determinants of health and action to reduce

inequalities

London – inequalities in health and recession impact

Male life expectancy – WHO
European Region
Life
Country Year expectancy

Highest
Israel 2009 80
Iceland 2009 80
Sweden 2010 80
Switzerland 2007 80

Lowest
Ukraine 2010 65
Republic of Moldova 2010 65
Kyrgyzstan 2009 65
Belarus 2009 65
Kazakhstan 2009 64
Russian Federation 2009 63

Source: WHO HFA database

 Sweden: Life Expectancy at age 30 by
56 level of education,1986 – 2003, women +3.0

54 +1.8

52 +0.7

50

48

46

44
1986 1988 1990 1992 1994 1996 1998 2000 2002

Compulsory Upper secondary Post-secondary

Source: SCB
 Trends in probability of survival in men by
education: Russian Federation
45 p20 = probability of living to 65 yrs when aged 20 yrs
0.7
University
0.65
0.6
45 p 20

0.55
0.5 Less than secondary

0.45
0.4
8 9 90 91 92 93 94 95 96 97 98 99 00 01
19 19 19 19 19 19 19 19 19 19 19 20 20
Calendar year
Source: Murphy et al 2006
Strategic Review of
Health Inequalities in
England:
The Marmot Review –
Fair Society Healthy
Lives 2010
English Review
• Following publication of CSDH
• 2008 Michael Marmot commissioned to produce
report to:
• describe health inequalities
• describe drivers of health inequalities
• and propose action to monitor and to reduce health
inequalities .
• Reported in 2010
Why Commissioned

Frustration that, despite actions and some

investment, health inequalities in England continued
to widen.

Signal that this a government priority.

Commissioned by a Labour Govt, reported to a

Conservative govt.
• Reviewed the Evidence Base
• 13 task groups to support this process

• Described health inequalities and the evidence

linking social determinants of health and health
inequalities

• Made proposals for action and monitoring.

Life expectancy and disability-free life expectancy at birth
by neighbourhood income deprivation, 1999-2003
Prevalence of any common mental disorder
by household income, England 2007
Health inequalities

• Social justice – the greatest inequality of all.

• the conditions in which we are born, grow,

live, work and age

• Creating the conditions for people to have

control of their lives
Key themes

Reducing health inequalities is a matter of fairness and

social justice
Action is needed to tackle the social gradient in health
– Proportionate universalism
Action on health inequalities requires action across all
the social determinants of health
Reducing health inequalities is vital for the economy –
cost of inaction
Cost of Inaction
Human cost
In England, dying prematurely each year as a result of
health inequalities, between 1.3 and 2.5 million extra years
of life.

Financial Cost of doing nothing

Economic benefits in reducing losses from illness
associated with health inequalities.
Each year in England:
– productivity losses of £31-33B
– reduced tax revenue and higher welfare payments of £20-32B
and
– increased treatment costs well in excess of £5B.
 Fair Society, Healthy Lives:
6 Policy Recommendations
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
Every sector is a health sector
Early years

Education

Housing

Environment

Planning

Work

Social protection etc etc.

Universal proportionate action

• To raise and flatten the gradient

• For most excluded, particular, specific focus.

• Focus on the processes of exclusion

To prioritise politically and ensure
implementation
• Evidence
• Practical
• Cost efficacy
• Public support
• Wider system and cross government support
• Measurement and monitoring
• Accountability
• Leadership, leadership, leadership
Cited obstacles to further prioritisation and
implementation – nationally and locally
• We don’t know what to do
• It’s not our role and remit (health care sector,
national government role)
• Investment is difficult, no money available
• Difficult to prioritise – not high on the political or
public agenda
• No clear accountability incentives, enforcements
• Lack of data and information
 Learn from best performing local authorities by
deprivation level.
Life expectancy and healthy life expectancy at Life expectancy and healthy life expectancy
birth females 2010-12, by IMD deprivation at birth, males, 2010-2012, by IMD depriva-
quintile tion quintile
90 85.0
85 80.0
80 75.0
75 70.0
70 65.0
65
60 60.0
55 55.0
50 50.0
45 45.0
40 40.0
0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 0 1 2 3 4 5

Healthy life expectancy at birth - females Life expectancy ar birth -males

Linear (Healthy life expectancy at birth - females) Linear (Life expectancy ar birth -males)
Female LE at birth Healthy life expectancy at birth - males 2010-12 years
Linear (Female LE at birth) Linear (Healthy life expectancy at birth - males 2010-12 years)

Deprivation Best performing local Healthy life Deprivation Best performing local Healthy life
level authority-females expectancy at authority-males expectancy at
birth- females birth- males

1 – most Greenwich 63.3 1 – most Brent 63.2

deprived deprived

2 Brighton and Hove 66.5 2 Enfield 64.4

3 Kensington and Chelsea 67.5 3 Kensington and Chelsea 66.7
4 Barnet 69.9 4 Barnet 68.9
5 – least Wokingham 71 5 – least Richmond Upon Thames 70
deprived deprived
Give every child the best start in life – key
points
• Inequalities evident from a young age
• Not just genetic variation
• Inequalities accumulate
• An equal start details outcomes that need to be improved to improve
children’s life chances – children’s development, parenting and the
context in which families live
• Can start reducing inequalities BEFORE birth
• Adverse circumstances linked to poor health and other outcomes,
multiple adverse circumstances particularly harmful
• Physical or sexual abuse in particular has long lasting impacts
• Evidence that you can improve the gradient
• RESOURCE See IHE evidence review on parenting interventions,
home to school transition, An Equal Start and Measuring What
Matters
 Percentage of 5-year-olds achieving good
development score* in Birmingham Local Authority,
the West Midlands region and England.
Percentage

* in personal, social and emotional development and communication, language and literacy. Source: Department of Education.

Early Years
ENABLE ALL CHILDREN,
YOUNG PEOPLE AND ADULTS
TO MAXIMISE THEIR
CAPABILITIES AND HAVE
CONTROL OVER THEIR LIVES.
 B. Enable all children, young people and adults to maximise their
capabilities and have control over their lives.
• Educational attainment is a
predictor of health outcomes.

• Higher educational attainment is

associated with healthier
behaviour.

• There is a gradient in limiting

illness by level of educational
attainment.

• There is a gradient in mortality by

educational attainment.

Education and Skills

 Proportion of Year 11 school leavers known to
be NEET in 2004 - 2010

Education and Skills

 Swansea and Wrexham NEETs
NEETs reduced by 68% over 5 years, in Swansea from 12.2% in
2004 to 4.2% in 2010 – well below the Welsh average.

• Strategic focus (priority at strategic level; clear targets set;

resources shifted; work intensified; earlier intervention)
• Identifying target groups within the population of young people
(Careers Wales advisers and school staff working together to
identify pupils in Year 11 at risk of becoming NEETs)
• Partnership working and information sharing (Local Authority,
Careers Wales, JobCentre Plus, head teachers, teachers,
Learning Coaches, Youth Workers, and Education Welfare
Officers)
• Provision & support (change in core service provision, greater
emphasis on summer months, skills building provision, flexible
start dates for training, work placement through project partners)
• People (enthusiastic and committed staff)

Education and Skills

Improving skills and reducing inequalities

• Equal access to excellent schools and lifelong learning that

is not associated with income or wealth.
• Careers advisors in secondary schools, school nurses
• Apprenticeship schemes and valued and genuine
alternatives for non academic children - early identification
of NEETS and structured programme
• Health literacy and empowerment classes – limit risky
behaviour
• See also: IHE evidence briefing - building resilience in
schools, Structured programmes for adolescents to reduce
risky behaviour. (Early intervention Foundation)
CREATE FAIR EMPLOYMENT
AND GOOD WORK FOR ALL:
MORTALITY
C. Create fair employment and good work for all: mortality
What works
• Ensure employers comply with HSE stress management guidelines
• Encourage permanent contracts, with clear progression
• Autonomy in how work is done
• Good health and safety regulation
• Support workforce to accommodate older workers
• Fair effort/reward balance
• Careful handling of shift work
• Use LEPs/Social value act to create more high quality jobs
• Skills audit and skills progression to match training to work available
A MINIMUM INCOME FOR
HEALTHY LIVING
 Data derived from analysis by Matt Padley and Donald Hirsch, Households Below a Minimum Income Standard 2008/9 to 2011/12, JRF

 In 2011/12, 23% of households studied (which covers 2/3rds of household types in England)
did not receive enough income to reach an acceptable Minimum Income Standard (MIS).
 In London, where costs are higher, one in four households (29.3%) did not receive enough income.
• There has been a deterioration in living standards, with the proportion of people living in households
below MIS increasing by a fifth between 2008/9 and 2011/12 from 3.8 million to 4.7 million households
Effects on health
• Lower incomes associated with worse health.
• 29% of household in London have insufficient income.
• 34% of families with children in UK have insufficient
income
• Many ethnic minorities fair worse
• Insufficient income – poor, cheap diets not conducive to
weight regulation, inadequate intake of vitamins – e.g iron,
lack of resources for clothes, social interaction, good
quality housing.
• Stress effect of debt can lead to addiction
• Stress/depression as a result of debt can lead to sub
optimal parenting
What works
• Increase wages/reduce prices
• Implement the living wage within the council and through supply chain (see
Islington for example)
• Try to negotiate for cheaper prices for housing and essential services (follow
up on Coventry on whether they managed to get utility bills down)
• Utilise social value act
• NB. Food banks saw a tripling of use last year – without them situation could
be worse.
• Resource: see IHE evidence review on implementing the living wage
System alignment and other relevant levers

• HI duties in Health and Social Care Act

• Integration duties
Summary, Social Value is…

• An opportunity to improve health and reduce inequalities

in social determinants
– Locally AND nationally
• An opportunity to ‘work’ the economic power of public
procurement. In 2012-13 over £230 billion spent on
public sector procurement of goods and services.
• An opportunity to align with other priorities and
obligations – win wins
• A legal obligation!
needs?
• National and local system leadership

• Public Awareness

• Non government support – third sector

• Cost case

• Evidence

• Cross government sector action and mechanisms

• Monitoring

• Accountability

• Levers

• Other sectors and workforce