Ten years since the publication of the original Marmot Review, for the first time in more than 100 years life expectancy has failed to increase across the country, and for the poorest 10% of women it has actually declined. Over the last decade health inequalities have widened overall, and the amount of time people spend in poor health has increased since 2010.
Health Equity in England: The Marmot Review 10 Years On confirms an increase in the north/south health gap, where the largest decreases were seen in the most deprived 10% of neighbourhoods in the North East, and the largest increases in the least deprived 10% of neighbourhoods in London.
The 10-year on review discounts the theory that the slowdown in life expectancy increase can be solely attributed to severe winters or flu, and is that it is more marked in the UK than in most European and other high-income countries, except the USA.
Earlier this month, the Secretary of State for Health and Social Care addressed the All-Party Parliamentary Group for Longevity at the launch of their longer, healthier lives strategy: The Health of the Nation – A Strategy for Healthier Longer Lives, published by the All-Party Parliamentary Group (APPG) for Longevity. It found that women in the UK are living for 29 years in poor health and men for 23 years: an increase of 50% for women and 42% for men on previous estimates based on self-reported data.
The APPG concluded: 'We need more urban design that supports healthy living, opportunities for walking and cycling – bearing down on the 40% of car journeys that are less than 2 miles – low-crime neighbourhoods, action on the environment and cross-governmental work on air quality'
In a related move, The King's Fund has published a new strategy for the next five years. The strategy focuses on three strategic priorities: building healthier places and communities; tackling the worst health outcomes; and supporting people and leaders working in health and care.
One quarter of the UK’s greenhouse gas emissions come from transport and road transport is the largest contributor to poor air quality. In 2016 the Government set the target to double cycling rates and increase the number of children (aged 5-10) walking to school by six percent. However, between 2010 and 2018 the percentage of children in England (aged 5-16 years) who walked to school has not changed, while the number who cycle to school increased by one percent. More positively active travel for adults has increased but inequalities have widened. There was a 5 percent increase in walking trips per year for those on the lowest incomes and 14 percent increase for those on the highest incomes between 2010 and 2018.
Air quality and related health risks have emerged as a major equity issue since 2010. Pollution levels are, on average, worse in areas of highest deprivation compared with areas of lowest deprivation.
Health harm from climate change is increasing, and will likely affect more deprived communities most.
The unhealthiest high streets are likely to be located in more deprived areas; and have the highest number of fast food outlets, betting shops, more littering and fouling, noise and air pollution, unhealthy retail outlets, crime and fear of crime and road traffic accidents.
The government’s prioritisation of road and train travel over buses has widened inequalities in access to essential services, employment and social interactions. Current travel policies benefit those on higher incomes, as those on lower incomes tend to travel more on buses. Between 2010 and 2017 funding for bus travel reduced by 45 percent.
The more deprived the area, the shorter the life expectancy. This social gradient has become steeper over the last decade, and it is women in the most deprived 10% of areas for whom life expectancy fell from 2010-12 and 2016-18.
There are marked regional differences in life expectancy, particularly among people living in more deprived areas.
Mortality rates are increasing for men and women aged 45-49 – perhaps related to so-called ‘deaths of despair’ (suicide, drugs and alcohol abuse) as seen in the USA.
Child poverty has increased (22% compared to Europe’s lowest of 10% in Norway, Iceland and The Netherlands); children’s and youth centres have closed; funding for education is down.
There is a housing crisis and a rise in homelessness; people have insufficient money to lead a healthy life; and there are more ignored communities with poor conditions and little reason for hope.
Despite the cuts and deteriorating outcomes, some local authorities and communities have established effective approaches to tackling health inequalities. The practical evidence about how to reduce inequalities has built significantly since 2010. There is considerable technical and practical experience about how to reduce health inequalities learned from some local areas, such as Coventry and Greater Manchester, and other countries.
In Coventry, for example, all the original policies recommended to support the objective to create and develop healthy and sustainable places in the 2010 Marmot Review have, since 2017, been adopted into the Coventry Local Plan: a comprehensive and statutory document outlining plans for development of the city.
This section outlines the influence that the Marmot Review and other forces have had an action across place-based determinants such as air quality and active travel, housing, fuel poverty, green space, the food environment and community regeneration. There is strong evidence of using local powers, such as licensing and planning, to promote healthy communities and of using the strong partnerships that exist in Coventry to mitigate the effects of austerity.
In the Marmot Review the following policy recommendations were made to support this objective:
Promote active travel, create good quality open space, improve the food environment, improve energy efficiency of house across the social gradient.
Fully integrate the planning, transport, housing, environmental and health system to address the social determinants of health in each locality.
Support evidence-based community regeneration programmes that remove barriers to community participation and reduce social isolation.
As the benefits of cleaner air and more active lifestyles become better communicated, they assume a greater importance both for national policy and for health equity interventions.
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