Health equity in England – ten years on from the Marmot review
It is now ten years on from the original report into health inequalities by Sir Michael Marmot and in the recent review of what has happened since, the picture it revels is stark, with life expectancy stalling in England and actually declining for women in the poorest 10 per cent of areas. CIH's senior policy and practice officer Sarah Davis takes a look at the review's findings.
The landmark report in 2010 highlighted the importance of improving the social and economic determinants of health and called for a joined-up approach to tackle six priority areas:
• Give every child the best start in life
• Enable all children, young people and adults to maximise their capabilities and take control of their lives
• Create fair employment and good work for all
• Ensure a healthy standard of living for all
• Create and develop healthy and sustainable places and communities
• Strengthen the role and impact of ill-health prevention.
Housing is a more significant factor now than 10 years ago
Housing was an important factor in the original report, with an impact across all the priorities. The review, however, acknowledges it as a significant driver in the widening of health inequalities, becoming even more acute due to the impact of austerity. In particular, the unaffordability of housing, poor housing condition and lack of security are all raised, demonstrating how far the problems have increased, with severe impacts for people’s physical and mental health and wellbeing.
Housing costs and rising poverty
In highlighting the rising numbers of households in poverty, including those in work, the report points to increasing housing costs as critical; while nearly 9 million were in poverty before housing costs, that rose to 12 million – 22 per cent of England’s population – after housing costs were taken into account. 45 per cent of minority ethnic children and 47 per cent of children in lone parent families are growing up in poverty after housing costs. Given that poverty experienced in childhood harms health not only then but into the rest of life, this raises real questions about what health problems will emerge in the future from the lack of investment in secure, decent and affordable homes now.
The lack of available social housing also gets a mention, including CIH’s analysis of the loss of 165,000 of these homes, as do the increased rents even within this more affordable sector. The housing affordability crisis, as the report terms it, is directly affecting people’s mental health. It points to the cuts in housing benefit introduced in 2011 having a statistically significant link with rises in mental health problems where people are affected by the changes.
Poor housing conditions
The report explores the way that poverty in turn restricts people’s ability to control and address other factors impacting health, such as moving to better housing, heating their homes or eating healthy foods. The longer people live in poor housing conditions that are strongly associated with poor health, such as cold and damp homes, the greater the impact on their health and wellbeing. 21.5 per cent of the excess winter deaths are attributed to cold homes.
And looking forward, the report points to housing conditions and climate change, recognising that this risks further negative impacts for people’s health in multiple ways, with older people more susceptible to extremes of heat and cold and poorer families at greater risk of being housed in poor homes in vulnerable locations and unable to modify their homes to cope with changing environmental conditions. Arguably the capacity of councils to help to mitigate this is also reduced – planning and housing are identified as areas that have experienced the greatest cuts in spending per person.
Targeting help where it is most needed
Overall the conclusions of the report are far from positive - in terms of housing, the situation has significantly deteriorated. Identifying that the greatest cuts have fallen in areas with highest needs, the review calls for proportionate universalism in response, with greater investment as a priority to be targeted at those areas that have lost the most and are in greatest need.
This reinforces CIH’s long-standing call to government to shift the focus of investment in housing from the private market into more affordable homes, which only receive 21 per cent of existing investment. We need 145,000 affordable homes a year, of which 90,000 need to be for social rent. It isn’t simply a matter of numbers, but the right homes in the right places. The impact of poor housing conditions means we need to be building new homes to higher standards, notably around energy efficiency and accessibility, and we need to look at how we invest in retrofitting the homes we have to support people’s health and wellbeing alongside resilience to the challenge of climate change.
Housing has increased as a negative impact on health since the first report, so it is now critical that investment is directed to ensure that housing becomes a driver of improvement in the population’s health and wellbeing in the future.