22. 02. 2010

The Marmot Review: health and inequality in the spotlight once more

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I spent last Friday at the launch conference for the Marmot Review – a report on health and equality and what we should be doing about them here in the UK.

It’s a really good report and powerfully reminds all those who see themselves as active in the ‘sustainable development community’ of the overlap with the public health/health and equalities community, and the importance of working much more effectively together than we’ve sometimes been able to in the past.

I won’t bang on about those synergies, two graphics in the Review illustrate these well. (See Fig 4.6 on cycling on page 127 or Fig 4.7 on green spaces on page 130 of the Review)

Some people say that this is all old hat. The Black Report, the Acheson Report, the Wanless Report. And now the Marmot Report. Same old, same old.

In some instances, that’s true. But there are many completely new insights in this report, building on new evidence. For instance, the principal recommendation (‘give every child the best start in life’) is based on new research looking at what happens between birth and the third year of any child’s life.

Just looking at the difference between the most advantaged and the least advantaged on indicators like birth weight, post-natal depression for mothers, regular bed times, being read to every day, breastfeeding and so on, you can see why this is the critical point of intervention. After the age of three, a lot of future interventions may well be far less impactful. And by the age of five, brighter, poorer kids have been overtaken by less bright kids from families that are better off.

Intriguingly, the most inspiring talk of the day came from the Deputy Chief Fire Officer from Merseyside. The Fire and Rescue Service on Merseyside has been running a community engagement and advocacy programme for the last 10 years, providing advice in the first instance on fire prevention, but then helping local residents think much more about all those things that exacerbate health inequalities (smoking, alcohol, drugs, poor quality housing, poor diets and so on), whilst simultaneously increasing fire risk – if only indirectly. His officers are now putting out 50% fewer fires than 10 years ago.

The Deputy Chief Fire Officer didn’t bring this out explicitly, but his presentation provided a powerful analogy for the whole day. Shift the effort (and the investment) upstream – into prevention and brilliant public service interventions in people’s lives – and the downstream costs can be progressively reduced. But if you don’t do that, there’ll be no reductions downstream.

The vast majority of health practitioners are well aware of that. But the truth of it is that after 30 years of talking about prioritising prevention and public health, practically nothing has been done about it. Just 4% of total health spending in the UK goes on prevention and public health.

The Marmot Review doesn’t make a particularly strong case on that score. But the truth of it is that all its recommendations may well make no more progress than the recommendations of its predecessors unless that imbalance is addressed.

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23. 02. 2010
Tess Green

This is interesting but also depressing. 30 years ago I worked in a Social Services project with very disadvantaged children and their families, using similar intervention to that reported by the Merseyside Fire Service. Although it was successful in terms of improving school attendance and performance and reducing offending behaviour, sometimes dramatically,for those children and families so that much more expensive intervention later was avoided, the service has been progressively reduced by funding cuts since.

27. 02. 2010
vik mohan

Thank you for a very helpful insight into the Marmot Review. As a practicing GP and Population, Health and Environment practitioner I am desparate to know how we can better communicate the power of these syngeries, and the effectiveness of focussing our efforts "upstream". Hopefully the International Symposium on Monday, addressing Population Dynamics, Reproductive Health and Climate Change will highlight these issues for us.

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