Social Determinants of HealthInvestigating inequalities, research gaps and best practice

A Cumberland Lodge residential conference summary report

27 − 29th January 2014

Conference R

eport

Speakers

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Social Determinants of Health

Investigating inequalities, research gaps and best practise

Summary report written by Sandra Robinson,

Associate Director, Cumberland Lodge

© Cumberland Lodge June 2014

www.cumberlandlodge.ac.uk

Registered charity no.1108677

Speakers

Debbie Abrahams, MP for Oldham East and Saddleworth

Lawrence Ashelford, Director of Strategy, Policy and Planning, Cambridge University Hospitals NHS Foundation Trust

Councillor Sir Merrick Cockell, Chairman, Local Government Association

Dr Ann Marie Connolly, Director of Health Equity and Impact, Public Health England

Professor Dame Sally Davies, Chief Medical Officer for England

Dr Jeanelle de Gruchy, Vice President, Association of Directors of Public Health

Professor Michael Depledge, University of Exeter Medical School

Professor Anne Ellaway, Head, Neighbourhoods and Health Programme, University of Glasgow

Dr Tom Fowler, Locum Consultant Epidemiologist, Public Health England

Professor Peter Goldblatt, Deputy Director, UCL Institute of Health Equity

Dr Ann Hagell, Research Lead, Association of Young People’s Health

Professor Carol Jagger, AXA Professor of Epidemiology of Ageing, Newcastle University

Professor Yvonne Kelly, Lifecourse Epidemiology, UCL

Professor Tom Kirkwood, Associate Dean for Ageing, Newcastle University

Sir Jonathan Michael, FRCP, Chief Executive, Oxford University Hospitals NHS Trust

Emma Rigby,Chief Executive, Association of Young People’s Health

Duncan Selbie, Chief Executive, Public Health England

Julia Unwin, Chief Executive, Joseph Rowntree Foundation

Introduction

‘There is no wealth but life.’ John Ruskin 1819 – 1900

Public health has been defined as: ‘the science and artof preventing disease, prolonging life and promotinghealth, though the organised efforts of society.’ Anotherdefinition is that: ‘public health is what we as a societydo collectively to ensure conditions that ensure peopleare healthy.’ At the conference Professor Dame SallyDavies noted that according to these definitions publichealth is not the sole responsibility of the heath caresystem, nor is it only a matter of individual life stylechoices. The core tenet of public health today is theactive participation of the population, working togetherfor the common good. There needs to be a culture forhealth where healthy behaviours are the norm.Institutional, social and physical environments shouldpromote this mindset.Duncan Selbie went on to say that too often peopleconflate good health with the NHS: this is a mistake.Most countries say the health care system does notcontribute more than 20 percent to public health, whilethe British might say it is up to 25 percent:fundamentally, it is not what improves the length andquality of life. More important are our behaviours andchoices as individuals, and environmental factors such

as our employment status, accommodationarrangements, the quality of support for those withmental health problems, or criminal records, and theexistence of a network of friends.

Professor Tom Kirkwood pointed out that the healthservice is predominantly concerned with illnesseswhere age is the single biggest risk factor: the mainoverlap between the NHS and public health is inpreventing premature death. Even for illnesses whichdevelop from socio−economic disadvantage, the ageingprocess is the biggest deficit. Yet too often the needs ofthe elderly are overlooked.

Professor Peter Goldblatt said that health and ill healthaccumulate through life so to address inequalities youneed to take a life course approach, addressing thedeterminants of health at each stage: it is not enoughto focus only on ante−natal care and leave everythingelse in a child’s life to chance, similarly, although theelderly, as a group, experience the greatest amount ofill health, most of their health problems are betteraddressed earlier in the life cycle. An intergenerationalapproach is needed as poverty and ill health aretransmitted between generations. Work needs to bedone with the mothers and fathers of children at riskof growing up in poverty, and those who are madevulnerable by the multiple processes of exclusionoperating upon them.

Introduction

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Social Determinants of HealthInvestigating inequalities, research gaps and best practice

The Picture of Health Inequalities

1. Children

Health inequalities have their roots in early life and thenaccumulate, serving to widen the gap between thoseliving in poverty and the wealthy. The linguisticdevelopment of young children has a predictive effecton mental health, literacy, employment prospects andobesity. There are multiple spheres of influence on thedevelopment of children, with risks coming from factorssuch as not being breast fed, having a depressed mother,unemployed parents without educational qualifications,poor quality housing and a deprived residentialneighbourhood. Children with multiple disadvantages,seven or more, are generally far behind in terms ofreading scores, clinically relevant behavioural problemsand language development. The highest rate ofvictimization, 16.1 per 1000, occur in children who areyounger than three years old and those who have beenmaltreated from birth are at substantial risk ofexperiencing subsequent developmental problems. Theeffects of victimization are similar to poverty, but canbe more severe. There is extensive research on the benefits of breastfeeding, and rates have improved since the 1970s: now70 – 85 percent of mothers start with breast feeding.However it seems to be less well recognised that thelonger a child is breast fed, the lower the risk ofbehavioural problems. In addition, women in the mostadvantaged positions are twice as likely to breast feed as

those from poorer backgrounds. Similarly, there are ahost of reasons why getting adequate and regular sleepis important for children: it reduces behaviouraldifficulties, improves concentration, regulates theappetite and improves emotional resilience. However itis disappointingly difficult to make this academicresearch known more widely to those in political circleswho develop policy. (Professor Yvonne Kelly)

2. Young people

There are 11.5 million young people aged between 10and 24 years: they make up 19 percent of thepopulation. Emma Rigby said that this is a crucialperiod for establishing life−long healthy behaviours, yetthis age group is neglected by policy makers. There is alack of evidence about vulnerable, disadvantagedgroups, and more needs to be done to design servicesspecifically to meet young people’s needs. (EmmaRigby) One in ten, or 1,000,000 young people aged 10 – 19,have multiple deprivations and therefore need focusedintervention. There are 37,730 young people over tenyears of age looked after by local authorities, and theyhave extremely low levels of educational achievement.The number of long term unemployed youth in theUK has been increasing, and in 2011 it stood at 25percent of the total unemployed in the UK. As manyas 14 percent of 19 year olds are ‘not in employment,education or training’ (NEET). The collapse in theyouth labour market makes the UK levels ofunemployment among the worst in Europe. (Dr Ann

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Hagell)

3. Adults

Unemployment leads to increased risk of long termillness; increased mortality rates; and a two fold increasedrisk of mental health problems and suicide. The risk ofill health increases as the duration of unemploymentincreases. The unemployment rate, and rate of long termunemployment, are generally highest in the mostdeprived areas. The north south divide is evident, butthe West Midlands and London also have areas of highunemployment. (Professor Carol Jagger and Dr TomFowler] Research has also found that while in general work isgood for your health there is bad work. Insecure jobs,lack of reward for effort, bullying, poor pay,unpredictable work patterns and a lack of a sense ofcontrol all impact on employees’ health and wellbeing.Too much work sometimes causes musculo−skeletalproblems and repetitive strain injury. There has also beenincreasing awareness of presenteeism, when theperformance of individuals at work is affected bytiredness and stress. Presenteeism costs are said to dwarfthose of absenteeism. (Dr Ann Marie Connolly andProfessor Dame Sally Davies) How people perceive and experience their residentialneighbourhood is related to their health and wellbeing.The antisocial behaviour of neighbours and living inrun down, unkempt surroundings are particularlydetrimental to mental well being. Clearly, these are allamenable to change. (Professor Anne Ellaway)

4. Older People

People living in poverty die sooner. Research inScotland has revealed that there is little differencebetween socio−economic groups in death rates fromnon−preventable diseases like brain and ovarian cancer,but large differences in more preventable causes likealcohol−related deaths and heart disease. (LawrenceAshelford) Premature mortality due to liver disease is, on average,falling across the EU15 (our closest EU comparators)while the rate is increasing in England. The problem ofexcessive drinking needs to be addressed. In the northof England, premature deaths are mainly due toalcoholic liver disease and increasingly related to fattyliver disease: the combination is particularly serious. Inthe south premature death is mainly due to alcoholicliver disease but also hepatitis. The problem of excessivedrinking needs to be addressed. (Professor Dame SallyDavies) The variation in healthy life years between differentsocio−economic groups is much greater thaninequalities in life expectancy. The average age of onsetof disability is below 65 for 14 percent of localauthorities. The prospect of extending the retirementage in these areas will be a real challenge. (ProfessorCarol Jagger)

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The wider social context

1. What poverty looks like today

The lives of people in poverty are characterised byinsecurity, and their immediate worries can easily crowdout considerations of a healthy lifestyle. Julia Unwin described how it is not just theunemployed who are trapped into poverty. Thoseexperiencing poverty, today, might be those on benefits,and those who may or may not be in low paid work.Sometimes poverty affects families which have amember of the household in work. Casual work andzero hours contracts can be vicious forms ofemployment, making people’s lives precarious. The labour market is now a bifurcated one, with jobsavailable at the top for the highly skilled and at thebottom for the unskilled, but few opportunities inbetween. This means it is harder for those at the bottomto experience a sense of progression in their work: beingtrapped in a low pay job provides little incentive.In addition, the cost of food, fuel, transport and childcare have all increased, making it harder to achieve adecent standard of living. Borrowing is sometimes theonly way to purchase basic needs, but the cost of doingso might compound financial problems.

2. What the long life looks like

Julia Unwin noted that although medicalbreakthroughs mean more people are living longer andhealthier lives, this will accentuate social injustice. Thelong life will be hard on those who are in poverty,disabled and mentally ill. Low−paid manual jobsbecome more difficult for older people and they aremore likely to fall ill before they reach retirement age:they will have an extremely impoverished old age.

Professor Carol Jagger explained that as people areliving longer the retirement age has been extended, butto work longer we need to be healthy. Has there beenenough consideration given to increasing healthyworking life expectancy?

The needs of the older population also impact onyounger generations. The elderly may need help withmany aspects of daily living, and generally it is theirchildren, who may themselves be in their fifties orsixties, doing the caring. Those in full time work whoare also caring for an elderly relative are far more likelyto report poor health: are employers sufficiently flexiblefor those who are carers?

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The arguments for public health

1. Cost

Each year approximately 300,000 people leaveemployment and commence receipt of health relatedstate benefits. There are a range of reasons for this, themost frequent being mental and behavioural disorders,while the second highest category is diseases of themusculoskeletal system and connective tissue. Thenumber of working days lost to work−related illness orinjury has been decreasing for many years, and in2011/12 this accounted for 17 percent of sicknessabsence. The cost of the absence of employees to theeconomy is approximately £15 billion per annum. (DrTom Fowler)There is superb return on investment in child health,between 6 – 10 percent, yet the National Audit Officesays government spending on prevention is only 6percent, and in health care the figure is as low as 4percent. Sally Davies asked if we are putting the moneyin the right place. Treating children who suffer thetrauma of poisoning or injury costs the UK around£640,000 and £2.25 billion in long term health andsocial security costs. For every £1 spent on thermostaticmixers for taps etc. we would save £1.41 in burnsprevented. It is known that smoking contributes toprematurity: 7 percent of all births are premature, and4.2 percent of babies are born with severe disability. Ifwomen stop smoking in pregnancy we would havemuch better outcomes for those children as well as save£3 million a year on NHS costs.

Mental health costs 23 percent of the total ‘burden ofdisease’ (a composite measure of premature mortalityand reduced quality of life), and 11 percent of allspending of the NHS secondary health care budget.There is also the cost of informal care, worklessness,sickness absence and the inability to undertakevoluntary work. (Professor Anne Ellaway)

2. Human Rights

Professor Peter Goldblatt worked on the MarmotReview which was commissioned by the lastgovernment to look at health inequalities post−2010.The Marmot Review suggests we need a human rightsapproach to health. Public health is about social justice,the material and psychosocial empowerment of allpeople, particularly the poor, so individuals have controlover their lives. Health inequalities should be addressedthrough proportionate universalism: action needs to betaken for everyone in society, but at a levelproportionate to their social needs. The Coalition government accepted the life courseframework proposed by the Marmot Review andaccepted that they needed to tackle the wider socialdeterminants of health. The Marmot Review made sixpolicy recommendations: give every child the best startin life; enable all children, young people and adults tomaximise their capabilities and have control over theirlives; create fair employment and good work for all;ensure healthy standard of living for all; create anddevelop healthy and sustainable places andcommunities; and strengthen the role and impact of illhealth prevention. The current government has adopted

five of the policy recommendations, but did not agreeto a minimum income ensuring a standard of livingnecessary for healthy living. Several speakers emphasised the importance of goodevidence − biological, medical and social − of whatdisadvantage actually does to people’s healthy lifeexpectancy. We need to understand the nature of thechallenge, get evidence on what works, and understandhow ‘evidence’ is used to motivate behavioural change.

What should be done?

1. The political response

Professor Goldblatt explained that the Health and SocialCare Act 2012 was a landmark: for the first time it hasbecome a legal duty to address health inequalities. Mostof those duties were placed on the NHS. This actuallycreates an immediate tension, as the Act also transferredpublic health to local authorities: it will be challengingfor the NHS to have the legal responsibility foraddressing inequalities in health when the levers foraction on wider determinants of health lie with others. Lawrence Ashelford thought that the currentgovernment appears to be continuing work aroundsocial care: strengthening communities and families,providing assistance where needed, but ensuring this iscontingent on people accepting information, advice andguidance. Lawrence Ashelford suggested that althoughthis looks good, academic research has shown thattargeted welfare does not have the impact of universal

benefit. He noted that Scandinavian countries stand outas the most effective in reducing poverty and inequalitybecause they provide large, universal anddecommodified services. Debbie Abrahams MP said that the Labour partysupports the move of public health into localauthorities; however public health around the country,especially in the north west, has been undermined bythe current government. The Directors of PublicHealth do not have the same powers of protection asmany of the former Medical Officers of Health. Healthand Wellbeing Boards are important but have no powerover budgets. Routine and systematic monitoring ofhealth inequality is under threat, supposedly for costcutting reasons. While the Health and Social Care Act2012 professed to be about reducing health inequalities,what it is doing is contrary to the interests of publichealth and specifically to reducing health inequalities:it is a move to competition and privatisation as primarydrivers.

2. Local authorities

Councillor Sir Merrick Cockell said shifting publichealth to local authorities was probably the biggestchange in its responsibilities for the last five years.Where in the past a local authority could look andcomment, now it can act, addressing the health ofcommunities by improving housing and townplanning, providing better children’s services andeducation, tackling crime and improving leisurefacilities. In Blackburn and Darwin £1 million was

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transferred to a central pot and people were allowed tobid for the money for health−related projects. Thisprogramme, called Refresh, provided free access tocouncil leisure services. Already thirty coronary eventsand thirty premature deaths have been avoided. Everylocal authority in the country could do that. However, the Better Care Fund is not enough to addressthe financial challenges. It needs to be a catalyst for amuch larger pooling of health and social care fundingthat will bring the two sides closer together on locallyagreed plans. Getting social care right will alleviatepressure on the NHS.To be successful Health and Wellbeing Boards need tobe given wider commissioning responsibilities forprimary and some acute care. We need to ensure thatHealth and Wellbeing boards are made up of the rightpeople with appropriate expertise. There needs to beclarity from the NHS about the evidence base fordifferent reconfiguration options, so we can play ourpart in keeping the public informed. Through the Better Care Fund and the prospect ofreconfiguration we face a huge opportunity to improvethe lives of the most vulnerable in our society. But theyneed to be placed at the centre of their own care.Rewiring services around people’s individual needs,rather than on comfortable organisational silos, is crucialat this time when there are fewer resources and everincreasing demand. Duncan Selbie said we need to resist the myth thatpublic health can be dealt with in Whitehall. We needto understand that the local authorities do not have aduty to provide a public health service; their duty is to

improve the health of individuals and communities.Everyone has access to mobile technology: it should beused to reach people about their choices, for example,regarding food and exercise. Perhaps the public healthservice should be turned into the public health digitalservice! Dr Jeanelle de Gruchy felt that the next few years willbe critical to see if the shift of public health to localgovernment works well. Local authorities need to focuson developing healthy public policy, and engaging withcommunities in order to do this effectively.

3. The NHS

Duncan Selbie said that after six decades of universalaccess to the NHS, and obscene amounts of newmoney going into the health services, inequalities areas wide and widening. Why might this be? It is a myththat the NHS does not have enough money. It has lotsof money; it is about how it chooses to spend it. Thereis a wide gap between what is said about preventionand early intervention and how the NHS spends itsmoney. We have a broken system. For Sir Jonathan Michael the 2013 reforms to thehealth and social care system brought wide−rangingchanges, including to the relationship between theNHS and public health. These reforms have madecommissioning organisations more fragmented than inthe past. Now the NHS, public health and social careeach have a separate outcomes framework laying outpriorities, and different organisations commissionservices in line with each of these. Achieving common

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goals requires working across commissioning andprovider organisations: yet in practice the gaps are oftenbridged. Health care services are just one factor among manywider environmental determinants of health: the NHScan’t be expected to work in isolation. Yet public healthand prevention are at the core of the NHS. The leadingcauses of death and ill health, which are drivingincreased demand for NHS services, are largelypreventable. A focus on keeping people well, reducingtobacco and alcohol consumption, improving diet andincreasing physical activity, is crucial in this time ofausterity. The ways acute trusts are working to improvepublic health were described. (Sir Jonathan Michael)

4. Environment

Professor Michael Depledge considered environmentalinequality in terms of access to green and blue places.Policies should ensure access to aesthetically pleasing,environmentally safe, natural settings in urbanenvironments. The benefits of spending time outdoors,engaged in physical activity were discussed. Morebroadly, he made the point that many of the socialdeterminants of health are mediated by environmentalcircumstances, and that public health research andpractice should devote more attention to the intimateinterconnections between the environment, health andwellbeing in addressing health inequalities. (ProfessorMichael Depledge) Professor Anne Ellaway noted that how people perceiveand experience their residential neighbourhood is

related to their health and wellbeing, especially theantisocial behaviour of other residents and run downunkempt surroundings having a negative impact onmental well being. Investing in improving the local areathrough tackling anti−social behaviour andneighbourhood management may bring aboutimprovements in health. While it is important to have local facilities thatpromote health, such as sports centres, public swimmingpools, and green spaces, it is not enough to just putfacilities into place, resources are needed to supportpoorer groups, and safe routes to the sports venue areneeded. (Professor Anne Ellaway)

5. Employers

Dr Ann Marie Connolly suggested that work is themost important determinant of population health andhealth inequalities in advanced market democracies. Itis therefore important to ask how best to shape theavailability, access and distribution of work? Moreinterdisciplinary research is needed on access to workfor areas blighted by low employment and low wages. Do employers regard health as a valuable commodity?Dr Tom Fowler gave the example of Google: after ithad gained a reputation for fattening its staff with foodon demand, it decided to experiment with somehealthy eating initiatives. It reasoned that healthyemployers are more likely to be happy and thereforemore innovative and efficient. Why do more companiesnot ‘nudge’ employees about health questions? At the500−acre Olympic Stadium construction site it was

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noticed that accidents peaked in the one−hour periodbefore lunch, when workers were thinking more aboutwhat they would have for lunch than the job at hand.Bosses started offering bowls of porridge to giveemployees a ‘healthy start to the day’. The result wasbetter diets, lower accident rates and a general boost tohealth. Further examples were given. Given that theevidence is so clear that it is cost effective, and oftencost saving, to have good work place health policies,why are they not more widespread? What can we learnfrom looking at those that are good examples? (Dr TomFowler)

6. Advertising and business

Sally Davies said that we should look at marketmechanisms to attach extra value to healthy choices. Itis a problem that healthy foods are more expensive.Restrictions on cigarettes, alcohol and snack foodadvertising have the potential to reduce unhealthyconsumption. We also need to maximise thedisincentives for unhealthy behaviours. Taxation onsmoking and alcohol is known to reduce consumptionand could be extended to unhealthy foods. Restrictingthe availability of unhealthy foods in schools, leisure andsporting venues and other public places is alsoworthwhile. The example was given of an ASDA storewhich was placing discounted alcohol in a prominentposition, where everyone would walk past it. When thispractice was challenged the store agreed to put itsalcohol in a less obvious place, although doing so meantit lost money.

Dr Jeanelle de Gruchy also thought that we need tofocus on the commercial determinants of ill health.Alcohol related harm is a serious, wide−rangingproblem. As the price of alcohol has come down,alcohol usage has gone up. Since licensing laws werechanged in 2005, people have access 24 hours a day toalcohol. Similarly, the increase in child obesity is linkedto the rise and rise of fast foods. For Lawrence Ashelford it is not possible to look atdisease without considering the context of the food,tobacco and alcohol industries, energy costs, roads,medical education and the pharmaceutical industry.While the financial crisis seemed to present afundamental challenge to neo−liberalism, it seems tobe shrugging off this challenge. The reason for this isthat while neo−liberalism seems to be about freemarkets, in practice it is concerned with the dominanceof the giant corporation over public life. This has beenintensified, not checked, by the recent financial crisisand acceptance that certain financial corporations are‘too big to fail'.

7. Psychology

Professor Sally Davies said that public health can notbe imposed from the top: it needs to be valued by thepopulation at large. The aspirational value of healthneeds to be maximised by making it part of oureducation and culture. Local organisations should nothesitate to use nudge methods to promote healthybehaviours. How can we make it socially unacceptablefor individuals to drift into ill health? If better social

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engagement is the answer to improving public health,how do we do it? Professor Tom Kirkwood thought that a majorpsychological question that needs to be addressed is:how can more people be given hope for the future? Inour society immediate gratification too often trumpsany long term consequence. Having aspirations for thefuture is an important aspect of being willing to giveup unhealthy life−style habits, and working for deferredbenefits. At root, those living in poverty don’t have hopeto guide them into the future with positiveexpectations.

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About Cumberland Lodge

Cumberland Lodge is a house for ideas. It is a former royalresidence that has been an independent educational charitysince 1947, promoting ethical debate and cross−sectorcooperation on a range of matters affecting the developmentof society. Cumberland Lodge fulfils its mission by designingand facilitating a series of events which enable participantsto discuss ethical, moral and spiritual issues.

About

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www.cumberlandlodge.ac.uk

Cumberland Lodge ConferencesCumberland Lodge orchestrates a variety of events designed to promote the exchange ofideas, initiate fresh debate, influence policy, and foster learning and education at every lifestage. From conducting high profile conferences to mentoring university hopefuls, the Lodgeworks to produce a rich and diverse programme aimed at the betterment of society.www.cumberlandlodge.ac.uk

Cumberland Lodge StaffDr Owen GowerDirector, Cumberland Lodge Programme

Reverend Dr Edmund NewellPrincipal, Cumberland Lodge

Janis ReevesConference Co−ordinator, Cumberland Lodge Programme

Sandra Robinson (report author)Associate Director, Cumberland Lodge Programme

Natalie RussellKing George VI Fellow