209: Health Inequality

Chris Sandel: Welcome to Episode 209 of Real Health Radio. You can find the show notes and the links talked about in this episode at seven-health.com/209.

At the beginning of September, we’re going to be starting with new clients again. This will be the last time that we start with clients in 2020. Client work is the core of the business and is the thing I actually enjoy the most. After working with clients for the last decade, I feel confident in saying I’m very good at what I do.

When I reflect on the clients that have sought out Seven Health over the last couple years, there’s a handful of areas that come up most. One of the biggest is helping women get their periods back, so recovery from hypothalamic amenorrhea, or HA. This is often a result of undereating and over-exercising and is almost always connected with a fear of weight gain and a focus on being ‘healthy’. I’ve had clients regain their period after being absent for 10 or even 20 years, often after being told it would never happen again, or clients becoming pregnant who had almost given up hope of it happening.

We work with clients along the disordered eating and eating disorder spectrum. Many clients wouldn’t think to use the term ‘disordered eating’ to describe themselves; they just know that things aren’t right. With these clients, there are symptoms that are commonly occurring – water retention, poor digestion, always cold, peeing all the time (especially waking multiple times in the night), no periods or bad PMS, low energy, poor sleep, low thyroid. There’s also common mental and emotional symptoms – a compulsion for exercise, a fear of certain foods, anxiety, low mood or depression, poor body image, and a fear of gaining weight.

At Seven Health, we believe in full recovery. We’ve had many clients who’ve had multiple stays at inpatient facilities where nothing worked, but through working with us, they got to a place of full recovery.

Many clients come to Seven Health because they want help transitioning out of dieting and so they can finally start to listen to their body. They’ve had years or decades of dieting, and it hasn’t worked, but they’re struggling to figure out how to eat without dieting. Many clients experience feelings of body shame and hatred. They’re determined to be a particular size, and they feel frustrated or even angry by what they see in the mirror. They want to get past this and to be able to be present and stop putting life on hold.

In all these scenarios, we use the core components of what Seven Health is about, which is science and compassion. We focus on both physiology and psychology, so understanding how the body works and how to best support it and also understanding the mental/emotional side and uncovering someone’s identity and values and priorities and traits and beliefs, and looking at how these are helping or hindering with the change process.

It’s these kind of clients that make up the bulk of the practice, and I’m very good at helping people get to places with their food and their body, and even with their life, that feel out of reach.

If any of these scenarios sound like you and you’d like help, then please get in contact. You can head over to seven-health.com/help, and there you can read about how we work with clients and apply for a free initial chat. This will be the last time we start with clients in 2020, so if you would like help, then please reach out. The link, again, is seven-health.com/help, and I’ll also include it in the show notes.

Hey everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. Today I’m back with a solo episode, which is well overdue. The last one of these I did was back in April time when I did the two-parter on sleep.

Today’s show is on health inequality, and it’s a podcast I’ve been wanting to do an episode on for a while now. If you a regular listener, it’s a subject I’ve touched on before. In Episode 129, I did a show on life expectancy, and then in Episode 163, I covered the complexity of health. In both of these episodes, I made reference to the Marmot Review. This was a report that was published first back in 2010, and it was called ‘Fair Society, Healthy Lives’ and was chaired by Professor Sir Michael Marmot, which is why it’s often just called the Marmot Review. The basis of the report was to make recommendations for the government for reducing health inequalities across England. It identified six main areas of the government to focus on.

At the start of this year, in February time 2020, a new report was released called ‘Health Equity in England: The Marmot Review 10 Years On’. This report, as the name would suggest, looked at what has happened in the area of health inequality since the original review came out. Have things got better, have things got worse? That is what this review was addressing.

This is what this podcast is based on. I read through the full 172-page review and wanted to talk about the findings and the topic of health inequalities.

00:05:24

Why health equity is so important

There’s a handful of reasons why I think this is important. One is the bubble that the health and wellness field seems to be living in. There’s such a huge focus when we talk about health to mention things like food and movement and sleep and meditation and many of the other levers that we believe people have in their power to change. For many practitioners and people working in this field, this is somewhat true for their target market and for the clients that they regularly work with. They’re working with people who have the means and the ability and have control in their life over these things.

I shouldn’t just say ‘they’; this is true for myself too. For the vast majority of clients I’m working with, they do have a level of ability and access and means that most others don’t.

But where I see this becoming a problem is by making the assumption that what works for your client base or my client base will work for the population at large. I’m going to get into this in much more detail when I go through the review, but what struck me so much with the Marmot Review, especially the 10 years on – in both of them, actually – is how little time is spent talking about diet and exercise. They do come up, but it is a small part.

The reason for this is because this review is much more interested in the causes of the causes. It’s trying to intervene at an earlier point. They can see that the most affluent of society at the population level are living much longer, and if these people are eating better, it’s not because they simply have more knowledge or are smarter or feel it’s more important. There are other factors that make this so, and that’s what the report is looking at.

This is important because in the health and wellness industry, there is such a focus on personal responsibility and on changing the food system and on getting people to move more. But as the review points out, there’s a much bigger and more systemic issue that has more of an impact on health than focusing solely at this level.

While my focus here has been talking about those working in the health and wellness field, the same is true of those who are consumers of this information, so participants in this movement. I’ve had so many conversations with clients who are struggling with say orthorexia and are worried about having to eat the exact right thing for their health, or someone who is restricting and fearing what will happen if they loosen their reins, or someone who is following a diet where there is this real prescriptive list of ‘good’ and ‘bad’ foods, and they don’t even want to eat the ‘good’ foods.

The fears here have been really stoked by the notion of personal responsibility and the importance of diet and exercise for health. They see that life expectancy is getting worse for large sections of the UK population or the U.S. population, and the belief is that this is solely about an individual’s poor choices. They’re worried that if they start making different choices than they are now, that this is where they’re going to end up.

I think these kind of fears are always going to be part of an eating disorder or disordered eating, but it’s disproportionately magnified by the simple answers that are offered, which largely focus on individual choice and not by looking at the causes of the causes that are outlined in the Marmot Review.

If you are suffering with an eating disorder or disordered eating or struggle with dieting and have these real rigid thoughts around food and you’re thinking, “Okay, maybe this podcast isn’t going to be so relevant for me,” I actually think it is. It can change the way that you think about health at the population level and see the holes in many of the recommendations being made.

00:09:25

How COVID has effected weight stigma

The second reason for wanting to do this podcast is because of the coronavirus. In many ways, the virus has been indiscriminate with who has been affected and the outcome of this, wherein there are plenty of young, healthy individuals who become sick and have lost their lives. But so much of the focus is on pointing out the deadliness of the virus related to preexisting conditions.

Again, in the health and wellness space, so much of that talk is then about how many of these preexisting conditions are a matter of lifestyle choices and are avoidable, and that if people cared more about their health and make it a priority, they wouldn’t find themselves in this position. The Marmot Review is great at pointing out the absurdity of this position. At the population level, the likelihood of having a preexisting condition or your overall health is largely dumb luck connected to the household you were born into, the area you live in, the opportunities in that area, etc.

Connected to this has been the focus on body weight and its connection to COVID. In the UK, Prime Minister Boris Johnson was in hospital with coronavirus and has subsequently recovered, but he is now talking about how his weight made him more susceptible and how he has started dieting, and there’s now lots of photos of him regularly out running. Off the back of this, he’s now leading a push for an increased focus on reducing weight across the UK.

With this strategy, they’re talking about how to use weight loss as a way to beat COVID and how using weight loss is a way to protect the NHS, and the ideas that they’re suggesting as part of this are to ban TV and online adverts for foods high in fat, sugar, and salt before 9 p.m., to end deals like ‘Buy one, get one free’ on products that they deem unhealthy, for calories to be displayed on menus to supposedly help people make healthier choices when eating out.

For me, this is hugely disheartening, and there’s a couple of reasons. The first is the connection between weight and coronavirus is weak. Christy Harrison has written a number of pieces addressing this. She did a really great article for Wired looking at this. I’ll link to that in the show notes.

But the second reason is that we have this Marmot Review that is explicitly telling the government how to improve health and reduce health inequalities, and yet they’re now focusing on the ideas of banning TV advertising and putting calories on menus – things that may have some impact; I can’t say for sure that it won’t do anything, although there are clearly issues in doing things this way – but more fundamentally, it’s not addressing the real root cause of the health issues. It’s once again putting the focus on personal responsibility.

00:12:35

Racial/socioeconomic inequality and health

The final reason that I want to go through this topic is because of the death of George Floyd, the increased prominence of Black Lives Matter, and the subsequent ripple effect that this has had around the world. I want to share a quote from David R. Williams, who’s a professor at the Harvard School of Public Health. The quote is talking about the U.S. rather than England, but undoubtedly something similar is happening over here.

He said, “Every 7 minutes, a black person dies prematurely in the United States. This means over 200 black people die every single day who would not die if the health of blacks and whites were equal.”

Systemic racism is a problem, and so is the issue of income inequality and wealth inequality, because this leads to inequalities in health, in life expectancy, in healthspan – which is the amount of one’s life that they live disease-free and healthy. As we’ll see as we go through this review, ethnicity is connected with health outcomes, and for many ethnic minorities in England, the outcomes are pretty depressing.

But being poor regardless of ethnicity is bad news, and this review really demonstrates just how much socioeconomics, probably more than any other factor, is your best predictor of health. If we care about health of a society, we have to be addressing the income and the wealth inequalities and the subsequent health inequalities that this then produces.

I think as humans, we aren’t always the best at perspective taking. We aren’t great at imagining what it would be really like to be in someone else’s shoes and living their life. This review really cuts through that and simply allows the data to tell the story, because even if you believe that if you were living in some part of North England, that you’d be the one that was going to make it out and make a great living and live to 100, the data clearly doesn’t show at the population level this is what is happening.

I want it to be the case that when people in the field of health and wellness talk about health at the population level, what is contained in this report is what they mention. Not green smoothies, not stress management, not organic food. If you’re going to talk about population level health, we need to understand the real drivers for what is going on.

My statements here are drawing on the work of FrameWorks Institute. I’m going to quote here from the recent Marmot Review. When FrameWorks’ research looked into the UK public’s thinking on poverty and health and homelessness and child development and the economy, it revealed that there were three common beliefs. One is individualism, so the idea that success or failure in life is solely determined by each person’s choices and hard work and determination. The second is ‘them and us’ thinking, so the idea that other people and communities have problems and deficiencies that are built into their culture and that we lose out and they gain something. Three is fatalism, the idea that certain challenges are too entrenched to ever be addressed.

It goes on to say: “Those wishing to actually shift the public focus away from health care and health behaviours towards structural drivers of health inequalities, we should:

(1) Balance urgency with efficacy by talking about how things should be and could be as well as highlighting where and how major problems are not being addressed.

(2) Highlight and explain structural solutions, so talk about how systems can and must be redesigned to meet needs and tackle problems;

(3) Highlight the impact of health inequality on children, being clear that all children should have the opportunity to be healthy, no matter where they live.

(4) Include evidence and statistics that refer to the contexts as well as the individuals – so access to services, access to things that make us healthy.

(5) Make a moral case for addressing poverty based on shared values of compassion and justice.

(6) Avoid talking about choices and lifestyles and physical activity and instead talk about options and opportunities and places.

(7) Avoid talking about education and awareness campaigns because these perpetuate the idea that individuals should simply get educated to get healthy.”

This is really what I want to address as part of this episode, going through all the systemic and the structural reasons for poor health and the health inequalities in our society. Most of this episode is going to be direct quotes and statistics taken from the most recent Marmot Review that came out in February 2020, so to save me constantly saying “and I quote,” you can just assume that anything said after this point is a direct quote.

It could be very easy for an episode like this to be incredibly dry because there are so many statistics and so many issues that are reduced simply to numbers, so I’m going to try my best to avoid it feeling like this dry report of a podcast. If I fail in that endeavor, my apologies. But if anything, I do hope that you’ll take from this how complex this is and that to make one change that is going to be some kind of silver bullet just isn’t going to happen.

I’m going to link to both of the Marmot Reviews in the show notes, so if you do want to read them in their entirety yourself, you can.

00:18:27

The Marmot Review 2020: Overview

To start off with, I just want to share an overview from the start of the most recent review looking at how things are right now.

“England is faltering. From the beginning of the 20th century, England experienced continuous improvements in life expectancy but from 2011 these improvements slowed dramatically, almost grinding to a halt. For part of the decade, from 2010 to 2020, life expectancy actually fell in the most deprived communities outside of London for women and in some regions for men. For men and women everywhere, the time spent in poor health is increasing.

“Put simply, if health has stopped improving, it is a sign that society has stopped improving. Evidence from around the world shows that health is a good measure of social and economic progress.

“Austerity has taken its toll in all the domains set out in the Marmot Review, from rising child poverty and the closure of children’s centers to declines in education funding and increases in precarious work and zero hours contracts to a housing affordability crisis and a rise in homelessness to people with insufficient money to lead a healthy life and resorting to food banks in large numbers to ignored communities with poor conditions and little reason for hope. And these outcomes, on the whole, are even worse for minority ethnic populations and people with disabilities.

“We neither desire nor envisage a society without social and economic inequalities, but the public thinks that inequalities have gone too far and evidence from across the world suggests that the level of health inequalities seen in England is unnecessary.”

That gives you a bit of a flavour of how the review sees the current situation. The original Marmot Review from 2010 coined the phrase ‘proportionate universalism’. They looked at health follows a social gradient. Everyone that is below the top gradient or the top people have the greatest risk of worse health than those at the top, so we need to be sensitive to this gradient and respond proportionately to need. “A proportionate universalist approach ensures that interventions and resources are universal and available for the whole population but are developed with an intensity proportionate to need, to raise and flatten the gradient.”

In layman’s terms, government spending and intervention should happen across the board and support everyone, but more spending should be happening for those in a worse situation.

This is really a guiding principle. When the 2020 review looks at say increases in government spending or changes in taxation or cuts to government services, it’s looking at this from a proportionate universalist approach and looking at how this affects the people who have the greatest power, how it affects the people who have the least power. The spoiler is things have been moving in the wrong direction.

For example, government spending has not only declined in key social determinants of health, but it’s now allocated in less equitable ways, meaning that spending allocations are less weighted towards deprived areas and communities than previously. Government spending as a percentage of gross domestic product declined by 7 points between 2009 and 2018. It went from 42% down to 35%. The more deprived an area with greatest need had the greatest reduction in per-person spending.

00:22:00

How socioeconomic inequality impacts life expectancy

The review begins by looking at the statistics around life expectancy, health expectancy, the amount of time spent in ill health, and some of the reasons for these figures.

This is actually a topic I touched on before – not just touched on before, but did a whole episode on before called ‘Life Expectancy’. It’s Episode 129. I looked at this both for the UK and the U.S. because both have had declining life expectancy over recent years. I wanted to include some of this information here because it’s relevant to this episode and the idea of health inequalities, but if you want to hear more specifically about the topic of life expectancy with me going into more detail, then please check out the separate podcast episode. I’ll link to it in the show notes.

Most of the statistics in the review look at the least deprived areas compared to the most deprived areas, with them breaking everything down into deciles, so 10 groups representing 10% of the population. Here are some of the statistics on this.

In England, the difference in life expectancy at birth between the least deprived and the most deprived is 9.5 years for males and 7.7 years for females, and that was in 2016-2018. It used to be 9.1 years for males and 6.8 years for females in 2010-2012. So those have got worse over this time.

There are growing regional inequalities in life expectancy. Life expectancy is lower in the north and higher in the south. It’s now the lowest in the northeast and the highest in London. But people living in affluent areas in every region are living longer, so it matters little for life expectancy where those areas are in the country. Regions matter much more for people living in deprived areas. This can be illustrated by comparing London with the northeast region. The health disadvantages of living in the northeast increase much worse with levels of deprivation because of that area of residence.

In 2015-2017, females in the most deprived decile spent 34% of their life in ill health compared to just 18% for those in the least deprived areas, and among males it was 30% versus 15%. Only people in the least deprived 20-30% of areas will be eligible for a state pension before they can expect to develop a disability, with those in the most deprived areas spending many years with disability prior to reaching state retirement age.

Compared with other OECD nations (OECD stands for the Organisation of Economic Corporation Development, and it contains 37 nations), the slowdown in life expectancy in the UK had been marked. Between 2011 and 2017, the UK as a whole had experienced lower rates of improvement annually than any other OECD country except the U.S. and Iceland.

Importantly, these lower levels of improvements aren’t because the UK has the highest peak life expectancy. There’s many other countries that have higher levels of expectancy and continue to improve at a much faster rate than the UK. The U.S. has experienced decreasing life expectancy since 2014, and this decrease is largely explained by rising mortality for middle-aged, lower educated white people who suffered social, cultural, political, and economic exclusion and loss of status. The big contributor of deaths here is from accidental poisoning, opiates, suicide, and alcohol, which have been labeled as ‘deaths of despair’. This is something I go into in much more detail in the episode on life expectancy.

There’s a term called ‘avoidable mortality’ which refers to deaths that could’ve been avoided if there’d been timely and effective healthcare or public health interventions or both, and this is what David R. Williams was referring to in the quote I mentioned earlier about the difference between white and blacks in the U.S.

In the UK, the risk of avoidable mortality is at least three times higher for women and men living in the most deprived areas compared to the least deprived areas, and inequality in avoidable deaths increased markedly in the last 10 years, and in the most deprived areas in England, an increase by 8% for females and 17% for males. That’s a really sharp increase.

Again, many of these are deaths of despair, like is occurring in the U.S. Suicide and suicidal behaviours, so self-harm, are really common in more deprived areas than wealthier areas, and it’s more common for men than it is for women. Factors that contribute to suicide include unemployment and job insecurity, unmanageable debt and lack of support services, all of which are occurring more in the most deprived deciles.

Broadly speaking, poorer communities, women, and those living in the north have experienced little or no improvement since 2010. What we’re seeing in the figures around health is somewhat similar to other countries that have experienced political, social, or economic disruption and a widening of social and economic inequalities. So while this kind of thing is normally what you would see with a civil war or economic implosion, like what happened with the breakup of the Soviet Union, this is happening in the UK and in the U.S. and they’re just managing to do this all on its own.

Obviously, this is a podcast, so it is an audio only experience, but the graphs in the report really paint this so starkly. You can see so clearly as you move along from less deprived to more deprived, how drastically things change.

As part of the review, it makes recommendations on six different areas of six different domains. These recommendations appeared in the original review from 2010. The review from 2020 is assessing how these areas have been traveling for the last 10 years.

The six domains are: (1) give every child the best start in life; (2) enable all children, young people, and adults to maximize their capabilities and have control over their lives; (3) create employment and good work for all; (4) ensure a healthy standard of living for all; (5) create and develop healthy and sustainable places and communities; and (6) strengthen the role and impact of ill health prevention.

The government at the time in 2010 agreed to tackle five of these. For some reason, it wasn’t interested in looking at ensuring a healthy standard of living for all.

The review explained why it picked these areas. It states, “The approach we take is to address the causes of the causes. It is poverty that leads to unhealthy choices, and the poorer health of those lower down the social hierarchy results from restricted range of options available to those on low incomes as well as the direct heath impacts associated with stress and the poor conditions which result from poverty.”

I want to go through each of the domains, as these are really the crux for how the report sees making improvements to health and health inequality. Obviously I can’t cover everything in the review, so I’m just going to give you a snapshot of things that most jumped out at me as I went through it.

00:29:59

Domain 1: Give every child the best start in life

Starting with Domain 1, give every child the best start in life. The 2010 Marmot Review had three objectives for this early years area. One was to reduce inequalities in the early development of physical and emotional health and cognitive, linguistic, and social skills. Two, ensure high quality maternity services, parenting programs, childcare, and early years education to meet needs across the social gradient. Three, build the resilience and wellbeing of young children across the social gradient.

What has happened since 2010? Rates of childhood poverty, which really is a critical measure of early childhood development, have increased over the decade and there’s now 4 million children who are affected. The more deprived areas have lost more funding for children and youth services than less deprived areas, even as their need has increased.

On average, 1 in 5 children, so 22%, are living in poverty before housing costs, and this then increases to 30% when we take in housing costs. This is a really high percentage. 47% of children living in lone parent families are in poverty in the UK after housing costs. 43% of children living in families with three children or more are living in poverty. 45% of ethnic minority children live in families in poverty after housing compared to just 20% of children in white British families in the UK.

These children experience cumulative effects of the intersection between poverty and exclusion and discrimination, which really harms health and life chances from this really early age. The most deprived 10% of children are nearly twice as likely to die as the most advantaged 10% of children, and children in the most deprived areas are more likely to face serious illnesses during childhood and have long-term disability.

These percentages are devastating what should be a really thriving first world country, to have such high percentages of children living in poverty is really unconscionable.

There are reasons that the Marmot Review focused so much on the early years. First, inequality in the early years has such a lifelong impact. Second, it is the period of life when interventions to disrupt inequalities are most effective. Thirdly, and really related to the first two, is interventions at this early stage have been shown to be cost-effective, and they yield a significant return on investment. So people who are worried about the money side of things, it pays to actually put money in.

Less positive experiences in early life, particularly things like adverse childhood experiences, relate closely to many negative long-term outcomes – poverty, unemployment, homelessness, unhealthy behaviours, and poor mental health and physical health.

The national cost of late intervention, so not intervening when kids are kids, but doing it later on through benefits and other services that are required when people have difficulties later in life, is estimated at 16.6 billion. Funding for local authority services for children and young people fell by 3 billion over 10 years, so there was a 29% reduction.

There’s been a clear shift away from support for low-income families. In 2007 and 2008, 45% of all government spending on the early years and childcare was targeted explicitly at low-income families, but by 2018, that share was now 27%. The northeast, which is typically the area that has been hit the hardest, had the steepest decline – a 34% reduction in that 10 years.

Looking more directly at education, we can see the same kinds of economic disparities. Strong communication and language skills in the early years are linked to success in education, in high levels of qualifications, higher wages, better health. Socioeconomics inequality in child development, you can already see this by the second year of life, and it has an impact by the time children are entering school and then persists and deepens as school goes on.

In the UK, we have a scheme called the Free School Meals. These are means tested, and to qualify you usually have to be receiving some form of other government assistance. Focusing on free school meals really lets you see the people who are typically the most deprived, and those who are eligible for free school meals are reaching considerably lower levels of development than their peers of the same gender. Boys receiving free school meals had the lowest level of development.

Interestingly, poor children appear to thrive better in poor areas than rich areas. Among children who are eligible for free school meals, those in the most deprived deciles achieved a better level of development at the end of reception – that’s 5 years old – than those children eligible for free school meals in the least deprived areas. There’s a possibility that this is because being a poorer child among more privileged children may lead to feelings of exclusion or lack of self-esteem, which makes sense, but I think it equally could be about developmental level and how they stack up against others in their class.

I remember from Malcolm Gladwell’s book David and Goliath, when he looked at school, he noticed that being in the bottom third of your class is detrimental. And it doesn’t matter what school you’re at. You can be the smartest kid in your whole area, and then you go off to Harvard or you go off to Cambridge or you go off to some elite school; if you’re then in the bottom third of the students, you struggle and you feel dumb. And by comparison to everyone else in your class, it’s right in a sense to feel that way. Even if at the population level, you are at the top 0.01% in molecular physics, when you’re sitting in that classroom, you’re not likely to feel smart.

Gladwell found that being in this lower third really has a negative impact on performance. You’re likely to drop out of your major, you’re likely to change your major or your chosen degree, and how smart you are in comparison to others in your classroom is often much more important than just how smart you are in comparison to the national average.

Maybe this is happening because in these classrooms, the poorer kids in the more affluent areas, by comparison, feel like they’re in the bottom third, and this is less about exclusion and self-esteem and more about developmental level. When someone is receiving free meals in a poorer area, there is less of a developmental difference, and it means they’re not necessarily going to be in that bottom third.

The review also looks at adverse childhood experiences, or ACEs. This is something I’ve done a whole podcast on before. It is Episode 85. If you want to learn more about that, you can check out that show. Adverse childhood experiences are traumatic events that occur before the age of 18, and ACEs include all types of abuse and neglect as well as parental mental illness, substance use, divorce, incarceration, domestic violence.

What the review found is that children who grow up in deprived areas, in poverty, and those in lower socioeconomic positions are more likely to be exposed to ACEs compared with their more advantaged peers. The World Health Organisation estimates that in 21 of the countries they studied, 30% of adult mental illness could be attributed to ACEs.

Given the connection, then, between socioeconomics and ACEs, reducing them really necessitates moving families out of poverty and proportionately increasing income among those in the lower end of the social gradient, particularly lone mothers.

In this domain of “give every child the best start in life,” things have gotten much worse over the last decade, and these changes are going to affect the trajectory of the kids that were there in 2010 who are then going to become adults. From a national health and health inequalities perspective, this is really not good news.

00:39:19

Domain 2: Enable children + adults to maximize their capabilities

Domain 2 is looking at “enable all children, young people, and adults to maximize their capabilities and have control over their lives.” There were three main objectives to reduce inequalities during this period of life. One was reduce the social gradient in skills and qualifications; two, ensure that schools, families, and communities work in partnership to reduce the gradient in health, wellbeing, and resilience of children and young people; and three, to improve the access and use of quality lifelong learning across the social gradient.

Again, there is a clear social gradient with educational attainment. We saw this in the last domain with young children when I talked about reception and being age 5, and this simply continues on. The higher level of deprivation, the worse GCSEs that are received. For those not aware of the UK schooling system, GCSEs are tests that are taken around age 16 years old. Likewise, if you’re a low-income student that is eligible for free school meals, you perform better in your GCSEs if you’re in a more deprived area than being in a more affluent area.

Since 2010, there’s been a significant increase in the rate of exclusions from schools, and this is both in the primary and secondary schools. Again, there’s clear socioeconomic inequalities in the risk of being excluded. Exclusions are also higher by ethnic group, or break down differently by ethnic group. If you’re Bangladeshi or Chinese or Indian, you are half as likely to be excluded in comparison to white British children, and then children from other ethnic groups are more likely to experience exclusion, in particular Black, Caribbean, gypsy, roamer, and traveler children, and peoples of mixed background.

One of the reasons for the increases in exclusion is the pressure on schools to achieve high grades and also a good OFSTED score or rating. For those not in the UK, OFSTED stands for the Office for Standards in Education, Children’s Services and Skills. They give schools ratings. There’s four options. You can be an outstanding school, a good school, requiring improvement, or an inadequate school. OFSTED ratings matter a lot to schools, and schools also worry about the grades that kids receive because that also impacts on how their school is perceived.

If there are students that are difficult or are having poor grades, it’s much easier to remove them through exclusion so they aren’t included as part of your scores. When there are cuts to school funding like there have been, this just becomes the school’s easiest option.

Pupil numbers have risen, but funding has decreased by about 8% per pupil, and the steepest declines have been for ages 16 and over, so post sixth form, and for further education. There’s also been a cut in youth spending by 66% in real terms. This is going to have a really big impact on kids of this age.

Youth crime is another area that the review looked at, and violent crimes and particularly knife crime has increased significantly among young people over the last decade. But again, this is much more looking at areas of deprivation. Being a perpetrator or a victim of crime is closely associated with deprivation, but also closely associated with exclusion. Again, in this domain, things are worse than a decade ago.

00:43:19

Domain 3: Create fair employment + good work for all

Domain 3 is “create fair employment and good work for all.” In the 2010 Marmot Review, there were three priority objectives for employment. One was to improve access to good jobs and reduce long-term unemployment across the social gradient. Two was to make it easier for people who are disadvantaged in the labor market to obtain and keep work. Three was to improve the quality of jobs across the social gradient.

Unemployment, particularly long-term unemployment, really contributes significantly to poor health, and poor quality work is also a major driver of inequalities with physical and mental health. As part of the review, they define what they mean by good quality work and poor quality work.

Good quality work is characterised by features including job security, adequate pay for a healthy life, strong working relationships and social support, promotion of health, safety, and psychosocial wellbeing, support for employee voice and representation, inclusion of varied and interesting work, a fair workplace, promotion of learning, development, and skills use, a good effort-reward balance, support for autonomy, control, and task direction, and a good work-life balance. Poor quality of work is essentially just the opposite of all of these features.

Since 2010, employment rates have increased, but this really doesn’t tell the real story because there’s been an increase in poor quality work, including part-time work and insecure employment. The number of people who are doing zero hours contracts has increased significantly since 2010. Zero hours contracts are contracts that don’t guarantee a minimum number of paid hours. The incidence of stress caused by work has increased since 2010. Real pay is still below 2010 levels, and there’s been an increase in the proportion of people who are living in poverty who are working. So there’s now more people in poverty who are in work than are out of work. Automation is leading to job losses, and this is particularly in low paid, part-time work, and the north of England is being particularly affected by this.

Despite the fact that there’s been an increase in employment since 2010, being unemployed, and particularly long-term unemployed, is still highly unequal between different groups. White people, married men, people with no disabilities, and those with the highest qualifications have the highest rates of employment, and then minority ethnic groups, women, lone parents, and people with disabilities have the worst outcomes.

The highest employment rates at the end of 2019 were found in the southwest, followed closely by the southeast and then the east of England, and the lowest employment rates were seen in the northeast and Yorkshire. Again, there’s this north/south divide where north is disproportionately worse off.

In the 2010 review, they said getting people off benefits and into low paid, insecure, and health-damaging work is not a desirable option. Unfortunately, this is exactly what has happened. Young people are increasingly citing mental health problems as a reason for work absence. In 2009, it was 7.2%, and by 2017 this has risen to 9.6%.

As I said before, the average weekly earnings are worse in real terms than they were before. In September 2019, they were only 5 pounds better than 2008. When you then take in inflation, they’re worse. Between 2017 and 2018, the UK has experienced negative growth.

I mentioned zero hours contracts and that they’ve increased. There’s now 900,000 of those compared to back in 2010, when there was 168,000 of them. Zero hours contracts are highly insecure forms of work, and this insecurity is really harmful to health, and particularly for those who are on low pay and with low socioeconomic status. Workers from minority ethnic groups are more likely to be on zero hours contracts than white workers. 1 in 24 minority ethnic workers is on a zero hours contract compared to 1 in 42 workers who are white. Minority ethnic workers are more likely than white workers to also be on agency contracts.

There’s also an age-related difference with this as well in terms of zero hours contracts. There’s large numbers of people who are between the age of 16 and 24 and there’s large numbers of people who are over 65 than any other age groups.

There’s been a push by the government over the last decade to get people off benefits. There’s a benefit in the UK called Employment and Support Allowance that you can receive if you have a disability or if you have a health condition that affects how much you can work. To get this, you receive an assessment from a doctor or a nurse and they determine if you meet the requirements for Employment and Support Allowance or if they instead deem that you are fit for work. Between October 2017 and 2018, there were over 5,500 people who died within 6 months of being deemed ‘fit for work’. It was also found that half the doctors and nurses who’d been employed in the private sector to assess fitness for work had not actually completed adequate training. It’s then no wonder that disabled adults have faced some of the highest risks of poverty and the highest increases in poverty.

Again, in this domain, things are getting worse and have got worse over the last decade. Worse job opportunities and conditions, higher levels of stress and poverty, and more difficulty getting benefits for those who need it. Again, this is affecting those in poorer areas more than those in well-off areas.

00:49:49

Domain 4: Ensure a healthy standard of living for all

Domain 4 is “ensure a healthy standard of living for all.” The priority objectives for this domain in the 2010 Marmot Review were: one, to establish a minimum income for healthy living for all people; two, to reduce the social gradient in the standard of living through progressive taxation and other fiscal policies; and three, to reduce the cliff edges faced by people moving between benefits and work.

Remember, this was the domain that the government said they weren’t going to work on. Given all the other domains so far, it should be no surprise how this one is going to end up.

Life is worse for people lower down the socioeconomic hierarchy, and having resources to live a healthy life is central to improving health. Children living in poverty are more likely to suffer from poor health and are over three times more likely to suffer from mental health problems than children who are not poor. One of the issues with this is scarcity. Scarcity is having too little of anything – too little money, too little food, too little time. It affects mental processes. It affects the narrowing of mental bandwidth. This results in people making decisions that go against their long-term interests because they’re focusing on coping in the short term rather than planning for the future.

Tax and benefit reforms really have widened the income and health inequalities. Between 2010 and 2015, tax and benefit reforms overall had a negative impact on the poorest 50% in the UK. The poorest 20% saw the most negative impacts. Meanwhile, benefit changes were positive for the top 40%, and tax changes were beneficial for the top 30%. So really, those at the top are doing better and those at the bottom are doing worse.

In 2019, 9 out of 10 NHS mental health trusts in England reported that changes in benefits had increased the number of people with anxiety and depression and other conditions that increase demand of the mental health services.

Wealth inequality is something that is being talked about a lot more, and wealth inequality increased faster in the UK than any other OECD country except for the U.S. In the Office for National Statistics’ definition for wealth, there’s four components. There’s property, there’s financial wealth, there’s private pensions, and then there’s physical wealth, so the valuables that you have in your households, your cars, vehicles, that kind of thing.

Wealth, rather unsurprisingly, is associated with good health, both directly and indirectly. It provides a buffer for economic shocks, for insecure work. It gives a sense of security. It’s hugely beneficial for mental and physical health.

In Great Britain, over 2014 to 2018, net wealth increased by 13%. That sounds good, but the increase in wealth wasn’t felt by everybody. Between 2016 and 2018, the top three deciles held 76% of all the health, and the bottom three deciles held 2% of the wealth. Interestingly, in the years since 2010, London has become the richest region in Northern Europe, but the UK more generally contains 6 of the 10 poorest regions in Northern Europe. This makes the UK Europe’s most geographically unequal economy.

People in persistent poverty are at particularly high risk of having poor physical and mental health, and this is true for children as well. This breaks down unevenly across ethnic backgrounds. The percentage of individuals living with less than 60% of the median household – this is really basically talking about people in poverty – if you’re white, after housing costs it’s 20%. If you’re Asian or Asian-British, it’s 36%. If you’re Indian, it’s 23%. If you’re Pakistani, it’s 46%. Bangladeshi, 50%. Chinese, 33%. Then Black, African, Caribbean, Black-British is 42%.

Changes in pension age has also created a problem, especially for women. Pension age is rising and has risen from age 60 to age 66, and this has penalized those who were nearing that pension age and had the pension age increased. Older women’s poverty has increased by 6% because of this.

Children who grow up in food insecure homes are more likely to have poor health and worse educational outcomes. Food insecurity is defined as a household level economic and social condition of limited or uncertain access to adequate food. Food insecurity has risen from 28% to 46% from 2004 to 2016 for low-income adults.

What I regularly hear from those in the health and wellness space is that healthy food is cheap, that if people just spent more time cooking at home, they could eat a lot healthier and save money. This is just not true. The NHS has an Eat Well Guide, and this is the recommendation of what a balanced diet should largely look like. It includes five portions of fruit and vegetables a day, having starchy carbs be a third of what you eat, having a portion of oily fish each week, etc.

I know there are plenty of people who rally against this guide in the same way they did the old food pyramid. Especially, this is true with the low carb movement, with the paleo movement. But let’s put those arguments to the side for now because from a financial standpoint, living on a low carb diet or living on a paleo diet isn’t going to be any cheaper than the Eat Well Guide, and at this stage, that is largely what we are focusing on.

The poorest 10% of the English households would need to spend close to three-quarters of their disposable income to meet the guidelines of the NHS Eat Well Guide, so 86% of their weekly earnings just on food. This is compared to then only 6% of income for households in the richest decile. This is an enormous difference between those two ends of the spectrum. If you’re spending all or nearly all of your money on food, there is just nothing else left for anything else, so people don’t do that.

Unsurprisingly, being in arrears with debt repayments is highly concentrated among the lowest income households in the UK, 16% of those in the lowest incomes versus 1% of those in the highest deciles. It’s then those in the lowest positions who are more likely to have to fund essential living costs like eating through debt. It’s them who are most impacted upon by the health implications of being in debt because the stress levels resulting from falling into arrears with housing payments and with debt payments are comparable to those caused by being unemployed. So if you are also in arrears and unemployed, then this is a terrible situation.

Interestingly, it’s become a lot more common to have welfare and debt advice services situated in GP surgeries over here. Legal problems also have an impact on health, and those are also appearing more in GP surgeries. There was a survey done of 1,000 GPs, and they found that close to 1/5, 19% of their consultation times, were spent on non-clinical issues – issues around legal problems, issues around debt, etc.

Social mobility in England has stalled, and this is partly because of stagnating wages, poverty, inequalities in wealth – all the things I’m going through here. It’s also a result of the economic inequalities in experiences in the early years and in education and in the labor market. In more socially mobile countries like Denmark and Finland and Norway and Sweden, people’s economic status is less strongly related to their parents’ than in other OECD countries.

In Denmark, it can take an individual born to a low-income family two generations to reach the average national income, and in other Scandinavian countries it’s more like three generations. In contrast, in the U.S. and in the UK, it’s five generations. The average span between one generation is 25-30 years, so we’re talking about 125-150 years for a family to move from low income to average national wage. You can talk about you want bootstrapping and you want people to pull themselves up, but the statistics just don’t show that that is what is happening at a population level.

This means that unfair and widening inequalities in health are really related to social and economic status, and these are stark and they’re persistent, and they’re transmitted down through generations. This is referred to as intergenerational transmission of inequity.

Again, in this domain of healthy standards of living for all, things are worse than before.

01:00:20

Domain 5: Create + develop healthy, sustainable communities

Domain 5 is “create and develop healthy and sustainable places and communities.” The 2010 Marmot Review had two objectives in relation to communities and places. One was develop common policies to reduce the scale and impact of climate change and health inequalities, and two was to improve community capital and reduce social isolation across the social gradient.

There are many communities and places that have been labeled as left behind, where they have multiple forms of deprivation, and this deprivation has persisted for many years, and there’s little prospect of this changing. So left behind areas are more likely to have higher rates of unemployment, so more than double the national average with child poverty and lone parent families.

They are in worse health, so have worse rates of work-limiting injuries or illnesses, lung cancer, worse prevalence of coronary heart disease, diabetes, higher blood pressure, kidney disease. They have a smaller working age population, lower population growth, and lower levels of skills and formal qualifications, and they’re less likely to have residents that are pursuing higher education. There’s lower levels of home ownership, with residents more likely to live in social rented housing. They’re more likely to be of white British background, and they have lower levels of funding per head for local government services despite the higher levels of need.

The thing that stands out for me in this list, really above everything else, is that these are largely areas of white British background. Just like with the rise of Trump in the U.S., there’s been a rise of populism in the UK, as we saw with the Brexit vote, and people have lost confidence in their communities and the institutions. They feel that their voices no longer matter, and they feel cut off from other places because of economic inequality and the precariousness of their own communities.

There’s a real difference in levels of control that they have in their life related to income and education, and in general, those in lower income groups perceive themselves as having lower levels of control, and those in lower educational attainment perceive themselves as having lower levels of control versus those with higher educations or those with higher income. Low control is associated with poorer health outcomes. It’s associated with greater levels of stress and anxiety, with lower engagement in health-promoting behaviors.

Social cohesion and a sense of trust and belonging are all components of this sense of control. For many people, they’re looking around and they’re not seeing that this is going on where they’re living. The cuts have deeply affected their sense of identity and control in their communities and in the places they live. People want a sense of control, and they’ll find it in some way, even if it is a mirage of control or an illusion of control. For a lot of people, populism is that way to get that feeling back, to find a community, to have someone to blame.

Since 2009-2010, net expenditure per person in the most deprived local authorities has fallen by 31% compared to a reduction of just 16% in the least deprived areas. This has such a big impact on those areas. The Local Government Association calculated the funding gap that is going to be facing the government, and they expect it to be 3.1 billion in the year 2021 and 8 billion in years ’24 and ’25. There’s going to need to be this real substantial, long-term increase in local government funding to restore areas and services to levels so that communities and places are going to thrive.

Since 2010, crime rates have declined in England, but violence against individuals has increased. The gap in terms of the likelihood of being a victim of this type of crime is widening between being in the most deprived or the least deprived areas. In comparisons to households on income above 50,000 pounds, household incomes below 10,000 pounds are twice as likely to suffer violence or injury, twice as likely to be burgled, three times as likely to be robbed or mugged, three times as likely to suffer rape or attempted rape, and six times as likely to be victims of domestic violence. These are all things that are affecting people who are further on down the socioeconomic gradient.

Pollution levels are on average worse in the areas of highest deprivation compared to areas of the lowest deprivation. In London, the 46% of areas in the most deprived deciles have concentrations above the EU limit for nitrogen oxide compared to just 2% in the least deprived areas.

The review contains this wonderful table that looks at the features of an unhealthy High Street that I find really illuminating. It lists the features; it then looks at the inequalities between the best and the worst areas, and then says how this impacts on health both directly and indirectly. This is probably the clearest example of how inequality is impacting on health.

I’m going to go through it. I can’t go through all of it, because it would be a ton of repetition, but the features that they look at – one is a lack of diversity in retail offer on the High Street. It says high density of payday loan, alcohol, gambling, and fast food outlets in areas of deprivation, and this impacts on less mobile populations disproportionately. It then looks at both the health impacts directly and indirectly and things like diabetes, cardiovascular disease, cancers, addiction, alcohol-related harm. The list just goes on.

The next feature of a High Street is lack of green infrastructure. Deprived inner city areas have five times less the amount of good quality green spaces and higher levels of pollution than other urban areas. The next one is noise and air pollution. Areas of deprivation have a greater exposure to air pollution and noise than wealthier areas. Litter and area degradation. Deprived areas experience poorer local environments overall, including higher levels of graffiti, of fly-tipped waste and litter associated with low levels of crime and antisocial behavior.

There are more road traffic collisions. Rates of fatal and serious injuries for 5- to 9-year-olds are nine times higher than the average in the 20% most deprived areas than in the least deprived areas. Cycling fatalities are higher in the 20% most deprived areas than in other areas. Risk of injury varies depending on employment status and ethnicity appearance, creating further inequalities.

There’s then crime and fear of crime. Higher levels of crime are found in poorer areas, and greater fear of crime is found in inner city areas. Greater fear of crime is also found in Black and minority ethnic communities, with young people, older people, and with women, and disproportionate victimisation is experienced by young Black men, people with disabilities, and LGBT people.

Then cluttered pavement and non-inclusive design. Older people, people with physical disabilities, people with reduced mobility and parents with young children are affected the most by cluttered pavements and non-inclusive design, reducing opportunities for physical exercise, social interaction, and access to health-promoting goods and services.

In each of these different areas, it looks at how this directly and indirectly impacts health. One aspect of the unhealthy High Street that they talk about is fast food outlets. The poorest areas in England have five times more fast food outlets than the most affluent areas, and the number of fast food outlets has increased by 8% over a 10-year period. The problem with this isn’t about fast food outlets per se or on their own; it’s that these then become the only options available. In the poorer areas, it’s not fast food outlets plus all these other healthy options; it’s just fast food outlets.

In England, the wealthiest 10% of the population receive almost four times as much public spending on transport compared to the poorest 10%. Poor public housing is another issue that comes up. Poor housing and poor quality impacts on health because of the damp and the cold and the mould and the noise, and it impacts on poor physical health and poor mental health. For a lot of people, there’s just no way of avoiding this. They have no other alternative.

In the review, they talk about the idea of a non-decent home. A non-decent home lacks three or more of the following: a reasonably modern kitchen, 20 years old or less; a kitchen with adequate space and layout; a reasonably modern bathroom, 30 years or less; an appropriately located bathroom and flush toilet; adequate isolation against external noise; and adequate size and layout of common areas if you’re in a block of flats.

Again, there are clear regional differences in the proportion of non-decent homes. In the West and East Midlands and in Yorkshire, more than 1 in 5 homes fail to meet the decent home standards. This drops down to just 16% in the southeast and just 11% in the northeast.

In 2018, the average home in England cost eight times more than the average annual pay, and since 2006, the proportion of 35- to 44-year-olds who own a home has really dropped. It’s dropped by 20%. It went from 72% down to 52%, and this is equal in the proportion of people who are private renters in this age range. It went from 11% up to 29%. At a time when historically, nearly three-quarters of people used to own a home, this is now just above 50%. Despite the government’s repeated commitments that they’re going to build more housing, expenditure on new home buildings was cut by 44% in real terms between 2009 and 2013.

Overcrowding in homes is also a problem. This is something that is experienced more by minority ethnic groups, really in all socioeconomic – wherever they are on the gradient. Only 2% of white British households are overcrowded compared to 30% of Bangladeshi households or 15% of Black African households. There’s risks associated with overcrowding – increased rates of intestinal and respiratory infections. There’s the risk to mental health from frequent sleep disturbances if adults are sharing a bed or bedroom with children.

In 2016, the Health Charity Shelter found that 1 in 3 working families were a single paycheck away from homelessness. This has really come to fruition, because homelessness and rough sleeping has significantly increased. There’s been a 165% increase from 2010 to 2017. The number of households in temporary accommodation has increased. The number of people in hidden homelessness has increased. Hidden homelessness is people who have arranged their own temporary accommodation and are staying with friends and family.

There’s 69% more children in homeless families living in temporary accommodation now than in 2010, and a rather sobering statistic is that if you’re a rough sleeper, you’re going to die on average 30 years earlier than the general population.

So once again, in Domain 5, things are worse than they were a decade ago and health is suffering.

01:13:43

Domain 6: Strengthen the role + impact of ill health prevention

Domain 6, the final domain, is “strengthen the role and impact of ill health prevention.” In this final domain, there’s less a review of the last decade – although that does happen – but instead it more looked at the recommendations moving forward. What would be the recommendations to really tackle health inequalities?

It looked at the last time that the government really did focus on reducing health inequalities in a serious way. There was a program called Tackling Health Inequalities: A Program for Action, and this ran between 2003 and 2010. During this time, the gap in life expectancy between the most deprived local areas and the rest of the country decreased. So the program was working. But prior to this, from 1983 up until the program starting, inequality was increasing, and then after this program stopped, from 2013 onwards, as I’ve gone through extensively today, inequality has been widening again.

There was a recent review of public opinion across the EU, and this was done by the World Health Organization of Europe, and they found that health and social security ranks as the second most important national issue for EU citizens overall after unemployment. But there were 10 EU countries where it ranked first instead of unemployment, and the UK was one of them.

Health and social security is the number one most important issue for those in the UK, according to this poll. This just shows how in the wrong direction things have been going, because if this is meant to be the most important thing, this is really failing.

The Marmot Review from 2010 really looked at the economic costs of this health inequality per year. There’s productivity losses of between 31 and 33 billion. There’s taxes and higher welfare payments of between 20 and 32 billion, and there’s additional NHS healthcare costs in excess of 5.5 billion. I think it’s useful to look at these figures this way because too often, the focus is on how much obesity is costing the NHS or how much lifestyle diseases are costing the NHS. But as we’ve seen with this review, so much of this can really be explained through health inequalities. Rather than simply blaming the individual, we need to look at the systemic causes of what’s going on that is driving these costs.

The review makes a recommendation for how you could set up a health system based on ill health prevention and health equity and what that would involve. There’s a number of things. One is a focus on preventing ill health and supporting good health as well as treating ill health, so a move away from reactive services that focus solely on treatment for people who are already ill and more towards services that help to improve conditions in which people live, which in turn will improve their health.

A focus on place, so looking at small areas and influencing the environment and social and economic conditions of places in order to improve the health of residents, especially for the most disadvantaged areas.

Looking at cross-sector collaboration between multiple organisations and sectors, reaching beyond healthcare and public health and social care. This could include housing and early years services and training and education, because as we’ve gone through, these all have an impact.

There’s understanding the local population health and the health risks of that population. This requires health assessments that include the broader social and economic drivers of health as well as a focus on inclusion of particular communities that are at greater risk of poor health.

Action on social determinants of health as well as medical treatment. There’s much that the health profession and healthcare organisations can do to take action on social and economic and environmental factors that would significantly drive improvements to health outcomes and health inequalities, so really getting in front of these problems.

And then development of proportionate universal approaches. Additional resources and actions need to be given to the more deprived communities and areas – approaches that focus on improving health equity. These may look different to those that just focus on improving average population health, as the responses would be different and they’d be putting greater levels of focus on the areas that have the greatest need and have the highest risk of poor health.

Those are the recommendations of how you would actually tackle this at a population level. They go on to say that despite the growing consensus on the importance of social determinants of health, really we give way too much focus to healthcare services and access to healthcare services and having improved equitable services and quality of services – which is fine, but again, this is a lot more of the ‘after the fact’ situation. What we really need to be focusing much more on is how to stop this in advance.

A focus on individual choices is not the solution. Our health is not entirely down to the government, that is true. A focus on individual choices, though, really overlooks the role that is played by the environment in which we live, and many drivers of health are outside individuals’ control, and the choices we make are constrained. We have this strong public view on the importance of individual responsibility, and that’s a concern because public opinion will often drive public policy and will drive policy choices. It means that a lot of the public policy then focuses on individual choices because that’s what the public is talking about.

But what this review highlights is even if that is what the public is talking about, they’re only talking about it because they’re unaware of what is really driving the situation. Looking at individual health behaviours is really largely a distraction.

One thing they do talk about is the idea of social prescribing. This is an example of an approach that tackles the social determinants of health and is a way for local agencies to refer people to a link worker, and that link worker then gives people time, focuses on what matters to them, takes more of a holistic approach to people’s health and wellbeing, and they connect people to community groups and statutory services for practical support, for emotional support. It can involve things like volunteering, it can involve arts activities, group learning, gardening, befriending, cookery, healthy eating advice, and a range of activities and sports. It’s one of the things that has come up a lot more, and there’s a lot of evidence to support that it is helpful – although, again, it is just one piece of the puzzle.

01:21:57

Conclusion: Why is this so important?

That is it for the six domains. The 10 years on report that I’ve just gone through really shows in England that health is getting worse, and it’s getting worse for people living in the most deprived districts and regions, and health inequalities are increasing. For the population as a whole, health is declining. The data that this report brings together just shows that for almost all the recommendations made 10 years ago, the country has moved in the wrong direction.

I know this isn’t the cheeriest way to end the podcast, but I do really think that this is an important thing for people to realise. I was actually looking at a program for health coaching while putting together this podcast. It’s a U.S.-based program, and the focus is on the fact that the U.S. healthcare system is broken, or that’s the focus that this course takes, and how 1 in 3 Americans have diabetes, and that today is the first generation of kids that will live a shorter lifespan than their parents, and that 7 in 10 deaths are caused by chronic disease.

This course states that the reasons for this and the reasons for the chronic disease are poor food choices and too much sitting and not sleeping enough, and that doctors don’t have long enough time to spend with patients, and when they do, they’re not focusing on the chronic disease end of the spectrum; they’re focusing too much on the symptoms and not the root cause.

I understand that what I was looking at is a sales page, and that this is copy that is meant to be inspiring people to want to become health coaches, and the issues that they’re talking about are issues that these coaches can then tackle with people. But when looking at health at the population level, we have to be talking about the systemic issues that are covered in the Marmot Review. These are really the causes of the causes. Otherwise, all that’s going to happen is the least deprived will continue to increase their health and their lifespan while everyone else gets left behind.

This isn’t just about health. It’s about creating a better, stronger, more cohesive society. Investment in improving early childhood development and reducing exposure to adverse childhood experiences reduces antisocial behaviour and crime, in addition to the beneficial effects on mental health and physical health and children not going through adverse experiences. Improving education will lead to more capable citizens as well as a more qualified workforce. Creating healthy environments will be good for meeting climate change targets. Reduction of poverty is a good thing in and of itself, but in addition, it’s going to have a benefit on reducing health inequalities.

So really, a more equal, cohesive society is simply a better, healthier place to live, and this should be what we’re striving for.

That is it for this week’s solo episode. I hope it was informative. I hope I managed to keep it interesting and not too dry.

As I mentioned at the top, Seven Health is now taking on new clients. If you’re interested in working together or finding out more, you can head over to seven-health.com/help. That is it for this week. I will be back next week with another new episode. Stay safe, and I will catch you then.

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