In early January I highlighted three things related to the public’s health coming in the next three to six months. Two of those are now here: the All-Party Parliamentary Group (APPG) for Longevity’s report, The health of the nation: a strategy for healthier longer lives, which covers what the government needs to do to meet its own ambition of an extra five years of healthy life for every individual by 2035 plus narrowing inequalities; and Health equity in England: the Marmot review 10 years on, an assessment of progress on health inequalities and the wider determinants of health 10 years after Fair society, healthy lives.
The ‘Marmot plus 10’ review is a tour de force: marshalling facts and evidence across five of the six themes of the original review. It calls for a national cross-government health inequalities strategy – as the Fund and others have – and many specific actions (see Greg Fell’s blog for a summary). The APPG report makes key recommendations, consistent with Marmot plus 10 in many areas, but with more on what needs to be done on health behaviours, the NHS and business. However, it’s what happens next that’s most important when it comes to having an impact. In particular two issues: how these reports reach those with the power to act; and the balance between national and local action and responsibility.
First, people with the power to make change need to act on the reports’ recommendations. For that to happen, in my view, three things are needed. Number one, a narrative that connects and convinces national government to act; currently, in England, that narrative is ‘levelling up’. There is a political imperative to address the lower life expectancy and healthy life expectancy experienced by people in the seats that the Conservatives took from Labour in the north of England and the Midlands (the so-called ‘red wall’) when compared with other Conservative seats. Number two, the public need to better understand the core drivers of health, politicians will then be more likely to act on these drivers. Polling shows that almost eight in ten people think that free health care has a very large impact on health, compared to fewer than three in ten thinking the same about education or having a job, when the evidence tells us the contrary. The Health Foundation and UK Public Health Network recognise this and are working to change the public narrative about ‘what causes health’. Number three, reports like these need to be relevant to – and challenge and support – both local and national policy- and decision-makers. Both make some headway on this: Marmot plus 10 recognising the significant role of local government and its partners (with case studies of Coventry and Greater Manchester published alongside the main report) and the APPG recognising that most activity around delivering the government’s goals will happen locally, drawing on Greater Manchester’s experience in particular.
Second, there’s a need to consider the balance between national and local action and responsibility. The lesson from experiences under a Labour government was that a national strategy with specific health inequalities targets, funding and action did make a difference to inequalities in life expectancy between areas, it’s core goal. But we have also seen more devolution in England since 2010, and innovation and signs of improving health outcomes in some of those areas that are the most deprived, so there is clearly a role for learning from local areas.
However, there is still lots of variation between local areas that is hard to explain, and understanding and tackling this will be key to achieving the objectives in both reports. This is illustrated by one of the many charts in Marmot plus 10 (see Figure 1).
The slope tells the all too familiar tale of people in places with higher deprivation benefiting from fewer years of healthy life; the fundamental message of the Marmot reports. However, there is a large amount of scatter around this relationship. This scatter reveals that many of the most deprived local authorities (left-hand side of the Figure) are doing better than you might expect (because they are above the line), and many of the least deprived are doing less well than you might expect (and are below the line). Therefore, while a cross-government national strategy is essential to co-ordinate and direct government policy (across all the drivers of health, from the NHS through to levelling up economic growth and employment ) doing this alone is not enough. Any national strategy needs to address local variation. This means being better at both recognising where local action and powers will be more effective in tackling variation and ceding more control as appropriate, but also being stronger on unjustified variation, and expecting more action from local areas to address this variation themselves . Public Health England, as the government body with the most expertise on what drives health and inequalities and whose role it is to support local government and advise national government on health, could have more of a role here.
This brings me back to the third thing coming down the track, the promised government response to Theresa May’s government’s ‘Green Paper’ on prevention. This will be an early test of how far the Marmot plus 10 and APPG for Longevity narratives are ‘getting through’ and give an insight into the government’s position on balancing the national and local response.
It is encouraging that this discussion is once more being taken into the public domain....just like the evidence has been for the past 30 years from Black, Acheson and more latterly Marmot. This is not new, as you point out, and there have been attempts at improving the situation which have shown promise. I worked in a Spearhead Local Authority in the early years of the 21st century which met the targets set for closing the gap in all areas identified. A Health Inequalities National Support Team headed by Chris Bentley, was working to scale up good practice. We were building the evidence for what works. We then have Sir Michael Marmot in 2010 identifying a range of interventions in 6 key areas that, if implemented, will start to narrow the gap.
I suppose my key point is that we have the evidence for why we should act, we have a wide range of interventions under Marmots 6 key themes that will make a difference, let’s do something rather than talking about it. I started in Public Health around the time when Black published his report, I would like to be finishing my career in 6-8 years feeling that we are heading in the right direction and levelling up is no longer an ambition but a reality.