Summary of the impact

In November 2008, Professor Sir Michael Marmot and his team at UCL were asked by the Secretary of State for Health to chair an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England. The Marmot Review, published in 2010, has fundamentally shifted discourse on health inequalities in the UK and internationally. It has shaped public health services across England and around the world, guided government and international policy, and has given rise to a new commitment from service providers and health professionals to reducing health inequalities and addressing the social determinants of health.

Underpinning research

Research by Professor Michael Marmot and colleagues over the last 20 years has investigated the role of social inequalities in health.

The Whitehall II study was established in 1985 by Marmot and his UCL team to investigate the importance of social class for health by following a cohort of 10,308 working men and women. Research on this cohort has continued throughout the period 1993-2013 with funding from the MRC, British Heart Foundation and NIH, and to date over 500 research papers have been published based on data collected from the study. The initial aims were to investigate the causes of inequalities in disease during the working life, such as the inverse social gradient in cardiovascular disease in Britain. In addition to the contribution of unhealthy behaviours and traditional risk factors (such as high blood pressure) in heart disease and diabetes, the Whitehall II study showed the importance of psychosocial factors such as work stress, unfairness, and work-family conflict to socio-economic inequalities [1, 2].

Marmot was Chair of the Commission on Social Determinants of Health set up by the World Health Organization in 2005 to support tackling the social causes of poor health and avoidable health inequalities. The final report, entitled Closing the Gap in a Generation was published in 2008 [3].

At the request of the British Government, Marmot then chaired an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England. The Review was tasked with identifying relevant evidence, showing how this could be translated into policy, and advising on indicators and targets. The UCL secretariat team set up nine task groups in topic areas relevant to the review (e.g. the built environment, early years, employment and work). Each was made up of academic and practitioner experts in their area. The task groups produced evidence-based reports and proposals for action. These reports provided a basis for the final report, which was also informed by focus groups, consultation responses, policy dialogues and meetings with professionals. The final report was therefore able to bring together and draw conclusions from a wide range of up-to-date, expert research and data. Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010 was published in February 2010 [4] and had six main policy objectives, based around the social determinants of health:

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 a 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.

Following publication there has been an intensive phase of supporting implementation of the proposals at national and local level to ensure the review is built on and taken forward. In November 2011, the UCL Institute of Health Equity (www.instituteofhealthequity.org) was launched to support this phase. The new Institute is supported by the Department of Health, UCL and the BMA. The team have carried out further research work to implement the findings of the Marmot Review and have published on issues relating to the social determinants of health, continuing to build the evidence base for practitioners and policy makers — for instance in relation to alcohol, obesity and smoking, the early years, fuel poverty, cardiovascular disease (CVD), the impact of the economic downturn, mental health, advice for local government, healthy hospitals, chronically excluded groups [5].

References to the research

[5] Publications from the Institute of Health Equity:

• Early years: https://www.instituteofhealthequity.org/projects/an-equal-start-improving- outcomes-in-childrens-centres

• Fuel poverty: http://www.instituteofhealthequity.org/projects/the-health-impacts-of-cold- homes-and-fuel-poverty

• CVD: https://www.instituteofhealthequity.org/projects/a-social-determinants-based- approach-to-cvd-prevention-in-england

• Impact of the economic downturn:
https://www.instituteofhealthequity.org/projects/demographics-finance-and-policy-london- 2011-15-effects-on-housing-employment-and-income-and-strategies-to-reduce-health- inequalities

• Healthy Hospitals: http://www.instituteofhealthequity.org/projects/barts-and-the-london-nhs- trust---health-promoting-hospitals-strategy

Details of the impact

The findings of the Marmot Review and subsequent work conducted through the Institute of Health Equity (IHE) have contributed to the shaping of England's health policy. Health inequalities are at the centre of the new health system in England. In December 2010, the government's White Paper "Healthy Lives, Healthy People: Our strategy for public health in England" stated that it "responds to Professor Sir Michael Marmot's Fair Society, Healthy Lives report and adopts its life course framework for tackling the wider determinants of health" [a]. In 2011, the Department of Health's Public Health Outcomes Framework set out the strategy for achieving this with the intention to follow the Review's life course framework for tackling the wider social determinants of health, stating that: "In improving the wider determinants of health, we have included a range of indicators that reflect factors that can have a significant impact on our health and wellbeing. These indicators are in line with those recommended by Sir Michael Marmot in his report Fair Society, Healthy Lives in 2010, and focus on the "causes of the causes" of health inequalities. Wherever possible, the indicators will follow the formulation published by the Marmot Review team and the London Health Observatory" [b]. The principles set out in these documents were then followed by inequalities duties - introduced for the first time by the Health and Social Care Act 2012. As part of democratic scrutiny of these policies, members of the team have given oral and written evidence to several Select Committees [c].

The Institute has worked with the Department of Health and other national and local bodies, including NHS bodies and local government to help embed a social determinants approach to health inequalities throughout the health system in England, including advising and influencing national organisations such as the Department of Health, local authorities, Clinical Commissioning Groups, health sector and public health professionals. The IHE's work has had measureable and important impacts across England, including influencing national and local government, the NHS, third and private sector organisations.

The shape of national health services has been influenced by our work. Public Health England (PHE) was established in April 2013, bringing together specialists from more than 70 organisations into a single public health service. The organisation reports that "the recommendations of the [Marmot] report have informed the design of PHE in general, and the Health and Wellbeing directorate in particular" [d].

Over 70% of local authorities are now working to embed `Marmot principles' in their approaches to improving health and reducing inequalities [e]. For example, Coventry Council describe its approach as follows:

"Coventry is a Marmot City, and the aim of the Health and Well-being Board is to improve health and well-being levels in Coventry so they match the best in the Country. The Health and Well-being Strategy is based around the six Marmot Themes which were identified in February 2010 by Professor Michael Marmot in his report "Fair Society, Healthy Lives" (link below). These themes identify the wider social determinants of ill-health and have been adopted by the Coventry Health and Well-being Board" [f].

The Institute is engaged in a high profile programme of activity to encourage and support health professionals to tackle health inequalities. The programme has been enthusiastically supported by Royal Colleges, the British Medical Association (BMA) and other relevant organisations who have provided many practical ideas for action and made commitments to embed them over the next few years. For example, the Royal College of General Practitioners (RCGP) committed to: "ensuring that health inequalities are taken into account across all areas of RCGP activity and policy" and the Royal College of Nursing committed to "developing the workforce in terms of emphasis on the awareness of public health and social determinants of health in pre and post registration training" [g].

We have also been commissioned internationally to expand the impact of this work. The WHO Regional Office for Europe commissioned us to lead a review to support the development and implementation of the new common health policy framework for Europe: Health 2020. It was carried out to answer demands from policy makers and public health advocates for practical guidance on identifying "policies that work" to reduce the inequities in health¹ between and within low-, medium- and high-income European countries [h]. The European Commission awarded a contract for IHE to lead a consortium to review progress made by its Member States in reducing health inequalities action and recommend action by Governments and the EC [i]. IHE has established international partnerships to support implementation of work on social determinants, including a sub-network of WHO European Health Cities network [j]. IHE has also worked with the Pan American Health Organisation (PAHO) to embed social determinants of health in its five year strategy, as shown in its recent update to Health in the Americas [k].

Sources to corroborate the impact

[a]https://www.gov.uk/government/publications/healthy-lives-healthy-people-our-strategy-for- public-health-in-england

[b] Public Health Outcomes Framework for England 2013 to 2016: Part 1A.
https://www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes- and-supporting-transparency

[c] Health Select Committee corrected transcript of oral evidence, Session 2010-12:HC 1048-iii:
http://www.publications.parliament.uk/pa/cm201012/cmselect/cmhealth/c1048-iii/c104801.htm Public service and demographic change committee evidence volume 2 Pages 168-189: http://www.parliament.uk/documents/lords- committees/Demographicchange/PublicServiceVol2.pdf
Communities and Local Government Committee - The role of local authorities in health issues:
Tackling the causes of the causes of poor health:
http://www.publications.parliament.uk/pa/cm201213/cmselect/cmcomloc/694/69407.htm

[d] Public Health England equality analysis https://www.gov.uk/government/publications/equality- analysis-public-health-england

[e] The Joint Strategy Needs Analysis or Health and Wellbeing Strategy of every local authority in England was reviewed for alignment with the objectives of Fair Society, Healthy Lives. Only those local authorities specifically referencing the Marmot Review as underpinning their approach are included in the figure of 70%. A copy of these data are available on request. Examples include:

• http://www.walthamforest.nhs.uk/Global/Team_folders/communications_and_engagem ent/NHSWF_Health-Inequalities-strategy_2011-15.pdf
• http://www.marmotreview.org/AssetLibrary/local%20examples/Sheffield%20Action%20 Plan.pdf
• http://www.london.gov.uk/sites/default/files/LondonHealthInequalitiesStrategy.pdf

[f] http://www.coventrypartnership.com/group-members/healthandwellbeing

[g] Over 19 royal colleges and other professional organisations made commitments to action, which are summarised here:
https://www.instituteofhealthequity.org/Content/FileManager/healthprofs/all-commitments-by- theme.pdf

[h] Review of social determinants and the health divide in the WHO European Region. Final report http://www.euro.who.int/en/publications/abstracts/review-of-social-determinants-and-the-health- divide-in-the-who-european-region.-final-report

[i] Commission staff working document on "Report on health inequalities in the European Union" http://ec.europa.eu/health/social_determinants/docs/report_healthinequalities_swd_2013_328_ en.pdf

[j] Information on our networks is at: http://www.instituteofhealthequity.org/Networks

[k] See for example, the PAHO page on Determinants of Health, which references our work: http://www.paho.org/hq/index.php?option=com_content&view=article&id=5165&Itemid=3822&l ang=en

---

¹ The term "inequities in health" is used to describe unfair systematic differences in health between social groups that are avoidable by reasonable means.