Abstract
Sir Michael Marmot, the ‘founder of social epidemiology’ delivered the eponymous John Hunt Lecture at the 2019 RCGP annual conference. He described his career exploring the effects of ‘Social Justice, Health Equity and the Social Determinants of Health' on the wellbeing of the UK population. The implications for day-to-day general practice are colossal; however, GP resources depicting strategies to overcome socioeconomic inequality in health are limited. The following lecture review considers how the lessons learned could influence our practice.
The predisposing factors for sickness and health
Sir Michael Marmot’s pioneering work in the 1970s explored how rates of heart disease were higher in Japanese migrants in Hawaii and California. Given the comparable population genetics, social factors, in this case a graded association with adoption of a westernised diet and lifestyle, were to blame for an increased rate of heart disease (Marmot and Syme, 1976). Sir Michael Marmot observed a similar graded pattern of health outcomes within the UK civil service, with higher positions within the employment hierarchy associated with better health and life-expectancy. He concluded that the conditions in which people are born, grow, live, work and age, have a profound impact on their health and life expectancy. This creates an ethical challenge for health professionals: ‘Why should we treat people, simply to send them back to the conditions which made them sick?’
Overall life expectancy in England has risen by 1 year for every 4 years over the past century. This increase stopped in 2011 (Office for National Statistics (ONS), 2018). Sir Michael Marmot raised his concerns with the then Minister for Health, Jeremy Hunt: ‘You should take this slowdown in life expectancy as seriously as you do a winter bed crisis’; and he did, he ignored them both (Marmot, 2019).
The Fair Society, Healthy Lives review (Marmot and Bell, 2012) and subsequent update (Marmot et al., 2020) explored this slowdown. First, compared with lower increases in life expectancy across Europe (2006–15), the UK impact was particularly marked. Despite the global financial crisis and policies of austerity, countries possessing a higher life expectancy than the UK, e.g. Switzerland and Finland, experienced further gains in life expectancy over this period. The UK socio-political environment may have contributed to a lost decade in life expectancy improvement.
Second, the stall in UK life expectancy was not uniform. Life expectancy increased for the most affluent, with a graded stagnation or worsening in the lowest three socioeconomic deciles i.e. the poorer the individual, the worse their health and life expectancy. Increases in mortality were observed within young- and middle-aged sectors of society. Increased suicide rates illustrate the importance of psychosocial pathways to physical illness. Such cases are not unique to the UK, with examples of disempowerment and resultant poor health outcomes described within the USA and Australia. Sir Michael Marmot summarised, saying that: ‘health tells us how well society is meeting the needs of its citizens - If health is not improving, then something is going wrong within a society’.
Confronting the social determinants of health
Sir Michael Marmot chaired the World Health Organisation commission for the social determinants of health, reporting that ‘social injustice is killing on a grand scale’ (WHO, 2008). Recommendations emphasised the need to empower individuals, communities, and whole societies, through adequacy of material (accommodation, food, resources), psychosocial (‘control over your life’) and political (‘having a voice’) resources. Achievement would have profound implications for the conditions in which people are born, grow, live, work and age. The report has six key domains:
Giving every child the best start in life Providing opportunities for education and lifelong learning for all Secure and fair employment and working conditions Ensuring each person has enough money to live and meet their needs Promotion of health and sustainable communities in which to live and work Taking a social determinants approach to prevention of poor health, through confronting predisposing factors e.g. smoking and obesity
Sir Michael Marmot explored these recommendations within the UK context, justifying intervention across the life course. Early life development predicts school attainment, qualifications achieved, job options, and overall health outcomes. Around 60% of UK children aged 5 years achieve a ‘good’ level of development. The more affluent a locality, the higher the attainment of the average child. Around 20% of UK children are impoverished i.e. household income <60% of the UK median. The majority of these children live within a household where at least one person is working. Inadequate income affects ability to pay for life essentials, including food and accommodation. To adhere to Public Health England’s healthy eating advice, individuals within the lowest socioeconomic decile would have to spend 74% of their household income on food. Trade-offs between accommodation, heating, and food are common. The rate of Adverse Childhood Experiences (ACEs), including parental incarceration, drug, sexual, alcohol abuse and parental death increases as an individual descends the socioeconomic gradient. Individuals with a history of four or more ACEs have higher rates of youth sexual activity, teenage pregnancy, smoking, binge drinking, and being a victim or perpetrator of domestic violence (Bellis et al., 2014).
To reinforce this point, Sir Michael Marmot quoted one mother’s account of family poverty in London: ‘Nobody falls into this on purpose, because your whole life is going to be a trap, and then you’ll see yourself living a life you never thought you would’.
For the same degree of socioeconomic deprivation, significant variations in child attainment are observed. The degree of disparity affects outcomes, with greater socioeconomic inequality leading to deprived children doing less well in affluent areas. Similarly deprived children in Hackney have better outcomes than those in Bath. As such, ‘Poverty need not equate with destiny’.
Application to general practice
The lecture demonstrated the significant impact that social determinants have on the health of our patients as they are born, grow, live, work and age. Applying the principles raised to individual consultations highlights the importance of exploring patients’ concerns within their social context (childhood, home situation, community environment, employment and income adequacy). Recognition of underlying and deep-seated social or economic problems may shed light on perceived complexity within the consultation, allowing achievable management options within an individual’s life circumstances. Effective follow-up and continuity of care can reduce secondary care overuse by frequent healthcare users, while improving patient and staff experiences of general practice (Barker et al., 2017).
Knowing our communities will support effective social prescribing through in-consultation signposting to local and online support organisations. Community link workers offer another avenue to counter the effects of deprivation through financial advice groups, accommodation services, work preparation schemes, food banks, women and children's centres (Skivington et al., 2018).
Furthermore, GPs can be advocates for the marginalised and socioeconomically disadvantaged. On an individual level, GPs can support health literacy and provide documentation to ensure health or status does not compromise employment or accommodation rights. At a practice level, GPs can ensure that individuals are not disadvantaged by structural aspects of care, including appointment booking, clinic times and locations, and prescribing practices (Hutt and Gilmour, 2010). The surgery can be a vehicle for community empowerment through patient participation groups, promotion of community events, and supporting community stakeholders. On a local and national level, GPs can provide a voice through engagement in political activities that push for greater equality in healthcare access and provision, and more broadly for steps to challenge the social factors which determine health outcomes.
ORCID iDs
Dr Aaron Poppleton https://orcid.org/0000-0002-3435-6721
Paul Pascall Jones https://orcid.org/0000-0002-5799-4363