Democratising Health

27 February 2020

In this blog, John Hume discusses the Health Equity in England: The Marmot Review 10 Years On report and how the Trust has helped build the practical evidence on how to reduce inequalities.

Yesterday saw the launch of the Marmot Review 10 Years On. The messages were not good. Professor Sir Michael Marmot described it as a “lost decade”. Life expectancy flat-lined, the social gradient has increased, the life expectancy of women living in the most deprived 10 percent of areas has fallen, and people living in more deprived areas are spending more of their shortened lives in ill-health than those in less deprived areas. Not many reasons to be cheerful, but many reasons to hang our heads in shame.

Over the past eight years, we have funded over 3,000 neighbourhood-based organisations through £112m of funding. Our work focuses on those neighbourhoods which experience the sharp end of disadvantage across Great Britain today. At the core are the ideas of social connection and collective control. Our work came directly out of the 2010 Marmot Review and the work of Professor Jennie Popay and others.

In the early years of the Trust, together with local people, we theorised that short-term changes would be needed if local people were to act directly on the social determinants of health. These were around improved social connections; increased knowledge, understanding and skills; increased confidence and aspiration; a sense of purpose; control over money and resources; and the ability to have and exert influence.

Some of our funding, such as the Local Conversations programme, supports 19 neighbourhoods through long-term funding lasting up to ten years. In these neighbourhoods, we asked people to develop their priorities for improving health in their neighbourhood. The priorities for each neighbourhood were remarkably similar: 89% of areas said their immediate surroundings were a priority. The same percentage said that residents connecting was also a priority. 78% listed opportunities for young people, 50% said jobs and skills, and 28% highlighted community spaces.

What is interesting about this is that people know what it is that really makes them ill, and what can make them well. The starting point for communities who are at the sharp end is never ‘exercise more, eat better’ (as important as these things may be for us all). It’s their rent, their debt, their income, their jobs, and their access to green spaces, transport, affordable shops and ways to connect with others.

We have been evaluating our work over the past three years with New Economics Foundation and Leeds Beckett University. We found that people connected to our programme had stronger relationships with their neighbours, felt they belonged more to their neighbourhood and felt they could influence what happened in their neighbourhood to a greater extent, when compared to neighbourhoods experiencing similar disadvantage using the Community Life Survey.

You could be forgiven for wondering what social connections and control have to do with health inequalities. The answer is a lot – they are vital elements that protect health, noted in the first Marmot Review and cited in many other reports before and since. These findings are not just the ‘nice to haves’: they are the bedrock of highly involved communities. Communities which have often been ignored.

Over the past few years, there has been a fairly significant shift in rhetoric (and some practice) about ‘community-centred’ approaches to public health, all with different names and genuine intentions but, truthfully, the practice has a long way to go.

Our public services are asked to expedite. 'Need' trumps assets. The professional opinion rules. And this is set against a shrinking public sector workforce. It’s the perfect storm for actively ignoring the views of local residents and by doing so, squashing their agency and their confidence. It’s a symptom of a sick system: one which rewards speed and reaction to need, but doesn’t (and can’t) work well, particularly in prevention terms.

Social connections and collective control are critical foundations in being able to really support local people to play a very active role in addressing the social determinants of health within their neighbourhoods.

Unless you start to support stronger connections and control to build, you won't engage residents. If you don't have engaged residents, you cannot take this to the next level, which is deeper engagement leading to influence.

The Trust and its funded partners have achieved a lot in the last five years, but there is much more to do. There is a ceiling in terms of what can be achieved through the work of an organisation such as ours. The ultimate responsibility for health inequalities and for the social determinants which cause them rests with the government (national and local). We need some pretty radical reform, in England, of the priority that the government gives to the social determinants of health.

We need to see:

  • Prevention front and centre – including creating a health inequalities strategy for England.
  • Health democratised - we need to support the releasing of the skills of local people to determine what needs to be done, in collaboration with those who are paid to support.
  • Funding – we need to create a proper long-term funding settlement for our communities - such as that endorsed by the Community Wealth Fund Alliance
  • Quality work - we need to do it well and to expect that this will take time. Political short termism shouldn’t be curtailing the way we address horrific health inequalities.

If the last ten years has taught us anything, it’s taught us that if we are to have any real chance of addressing the real causes of health inequalities, we need a much more considered and much more deliberative approach.

 

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