Note from Sir Michael Marmot at the Beginning of the Review
People with higher socioeconomic position in society have a greater array of life chances and more
opportunities to lead a flourishing life. They also have better health. The two are linked: the more
favoured people are, socially and economically,the better their health. This link between social
conditions and health is not a footnote to the ‘real’concerns with health – health care and unhealthy
behaviours – it should become the main focus.Consider one measure of social position: education.
People with university degrees have better health and longer lives than those without. For people aged
30 and above, if everyone without a degree had their death rate reduced to that of people with degrees,
there would be 202,000 fewer premature deaths each year. Surely this is a goal worth striving for.
It is the view of all of us associated with this Review that we could go a long way to achieving that remarkable
improvement by giving more people the life chances currently enjoyed by the few. The benefits of
such efforts would be wider than lives saved. People in society would be better off in many ways: in the
circumstances in which they are born, grow, live, work, and age. People would see improved well-being,
better mental health and less disability, their children would flourish, and they would live in sustainable,
cohesive communities.
Executive Summary : key messages
1. Reducing health inequalities is a matter of fairness and social justice. In England,
the many people who are currently dying prematurely each year as a result of health
inequalities would otherwise have enjoyed in total, between 1.3 and 2.5 million extra
years of life.
2 There is a social gradient in health – the lower a person’s social position, the worse
his or her health. Action should focus on reducing the gradient in health.
3 Health inequalities result from social inequalities. Action on health inequalities
requires action across all the social determinants of health.
4 Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently.
To reduce the steepness of the social gradient in health, actions must be universal,
but with a scale and intensity that is proportionate to the level of disadvantage.
We call this proportionate universalism.
5 Action taken to reduce health inequalities will benefit society in many ways. It
will have economic benefits in reducing losses from illness associated with health
inequalities. These currently account for productivity losses, reduced tax revenue,
higher welfare payments and increased treatment costs.
6 Economic growth is not the most important measure of our country’s success. The
fair distribution of health, well-being and sustainability are important social goals.
Tackling social inequalities in health and tackling climate change must go together.
7 Reducing health inequalities will require action on six 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
8 Delivering these policy objectives will require action by central and local government,
the NHS, the third and private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies.
9 Effective local delivery requires effective participatory decision-making at local
level. This can only happen by empowering individuals and local communities.
Executive summary
3.3.6 The hunt for quick wins P.86
Reviews often look for new interventions, particular
policies that may help turn the corner or make significant
impact in improving service quality. However,
a stream of new initiatives may not achieve as much
as consistent and concerted action across a range
of policy areas. A social determinants approach to
health inequalities highlights how it is the intersection
between different domains that is critical
– health and work, health and housing and planning,
health and early years education. Success is more
likely to come from the cumulative impact from a
range of complementary programmes than from
any one individual programme and through more
effective, coherent delivery systems and accountability
mechanisms.
Key Policies Over the Life Course: Chapter 6
Pre-birth and early years (up to age five)
Give every child the best start in life Increase investment in early — years development
— Holistic support for families from before birth
— Priority for maternal health interventions
— Increase paid parental leave in the first year
— Evidence-based parenting support programmes, children’s centres, advice, assistance
— Provision of good quality early years education and childcare
— Improve quality of early years workforce
— Support the transition to school
Enable all children, young people and adults to maximise their capabilities and have control
over their lives
— Schools develop a ‘whole child’ approach with extended school services
Create fair employment and good work for all
— Better jobs suitable for lone parents, carers,people with mental/physical health problems
Ensure healthy standard of living for all
— Minimum income for healthy living
— Review systems to remove ‘cliff edges’ to facilitate flexible employment
Create and develop healthy and sustainable
places and communities
— Mitigate effects of climate change
— Improve active travel
— Improve access and quality of green and open spaces
— Improve the food environment
— Reduce fuel poverty
— Integrate local delivery systems to address social determinants of health
— Improve community capital and reduce social isolation
Strengthen the role and impact of ill health
prevention
— Increase investment in ill health prevention
— Reduce social gradient in obesity
— Focus public health efforts to reduce social gradient
Children and young people in full-time education (ages 5–16)
Give every child the best start in life Holistic support for families — from before birth
— Evidence-based parenting support programmes, advice and assistance
— Support the transition to school
Enable all children, young people and adults
to maximise their capabilities and have control
over their lives
— Reduce the inequalities in educational outcomes
— Schools develop a ‘whole child’ approach with extended school services
— Develop school-based workforce, working across school-home boundaries
— Increase access to lifelong learning, including work based learning and apprenticeships
Create fair employment and good work for all
— Better jobs suitable for lone parents, carers,people with mental/physical health problems
Ensure healthy standard of living for all
— Minimum income for healthy living
— Review systems to remove ‘cliff edges’ to facilitate flexible employment
Create and develop healthy and sustainable places and communities
— Mitigate effects of climate change
— Improve active travel
— Improve access and quality of green and open spaces
— Improve the food environment
— Reduce fuel poverty
— Integrate local delivery systems to address social determinants of health
— Improve community capital and reduce social isolation
Strengthen the role and impact of ill health prevention
— Increase investment in ill health prevention
— Increase availability and quality of drug treatment programmes
— Reduce social gradient in obesity, smoking, alcohol
— Focus public health efforts to reduce social gradient
Early adulthood (ages 17–24)
Give every child the best start in life Holistic support for families — from before birth
— Priority for maternal health interventions
— Increase paid parental leave in the first year
— Evidence-based parenting support programmes, advice and assistance
Enable all children, young people and adults to maximise their capabilities and have control
over their lives
— Reduce inequalities in educational outcomes
— Schools develop a ‘whole child’ approach with extended school services
— Develop school-based workforce, working across school-home boundaries
— Increase access to lifelong learning, including work based learning and apprenticeships
— Resources for 16–25 year olds on life skills, training and employment advice
Create fair employment and good work for all
— Intervene early with active labour market programmes
— Improve quality of work
— Workplaces adhere to equality legislation
— Effective prevention of physical and mental health problems at work
— Improve flexibility in employment.
— Better, more suitable jobs for lone parents, carers, people with mental/physical health problems
Ensure healthy standard of living for all
— Minimum income for healthy living
— Review systems to remove ‘cliff edges’ to facilitate flexible employment
— Implement progressive taxation
Create and develop healthy and sustainable places and communities
— Mitigate effects of climate change
— Improve active travel
— Improve access & quality of green & open spaces
— Improve the food environment
— Reduce fuel poverty
— Integrate local delivery systems to address social determinants of health
— Improve community capital and reduce social isolation
Strengthen the role and impact of ill health prevention
— Increase investment in ill health prevention
— Increase availability and quality of drug treatment programmes
— Reduce social gradient in obesity, smoking,alcohol
— Focus public health efforts to reduce social gradient
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