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1/ As a medical student I was taught:

Less well off people die earlier than more well off people (Marmot)

Those that need our help are least able to access it. (Tudor-Hart)

I'm summarising #Marmot2020 with key graphs. Apologies if I've lost nuance here @MichaelMarmot. #FOAMed
2/ Too often in medicine we focus on 'direct' causes of disease: smoking, diet.

What drives these causes, i.e. indirect causes such as social/economic factors? #Marmot2020 #FOAMed

➡️ Spending on social protection, education, housing and environment has GONE DOWN as % GDP 📉 % of GDP on social spending has gone down over the last decade

➡️Council spending for people in the most deprived areas has been cut the most 📉
#Marmot2020 #FOAMed Council spending per person by quintile of Index of Multiple Deprivation average score, 2009/10 to 2017/18 has decreased the most for most deprived areas.
4a/ The more I consult with my patients, the more I see the impact of socio-economic factors:

The woman who smokes because she is lonely and stressed because she is on zero hours contracts, 2 children to bring up as a single parent and can’t keep up rent repayments. #Marmot2020
4b/ OR the man suffering with depression who is worried about being deported have fled civil war in his country of origin. #Marmot2020 #FOAMed

➡️ Your money does not go far if you are poor. Increasing percentage of families spending more than a one-third of their income on housing costs in the UK in 1996/97 compared to 2016/17 worse for the most deprived.

➡️ Life expectancy has slowed down for both men and women but affecting women in the most deprived areas the most.

#Marmot2020 #FOAMed Life expectancy has slowed down for both men and women since 2010Life expectancy has actually decreased for women in the most deprived decile comparing 2010-12 to 2016-18

➡️ Death rates are plateauing most notably for the 55-74 age group. Is this due to ‘deaths of despair’ (suicide, drugs and alcohol abuse) as seen in the USA?

#Marmot2020 #FOAMed Net decrease in death rate for those < 55 years of age but increase in last 2 yearsDeath rates are plateauing most notably for the over 55 age group

➡️ Big gradients continue to persist between the least deprived and most deprived populations in both men and women

The most deprived populations spend 12-15 years less health years compared to the least deprived populations. #Marmot2020 #FOAMed The most deprived populations spend 12-15 years less health years compared to the least deprived populations.

➡️ Worse quality of life for older people from ethnic minorities compared to those who are white British. #Marmot2020 #FOAMed Worse quality of life for older people from ethnic minorities compared to those who are white British.

➡️ Child poverty is on the rise whether you control for household income or not.

➡️ Good development for children with free school meals has stalled for a decade. Remember these children didn't choose this.

#Marmot2020 #FOAMed
After controlling for housing costs:

➡️ Increasing poverty rates for pensioners

➡️ Much higher poverty rates for the disabled people from minority ethnic background compared to white people

➡️ When you have less money, eating well is not possible. For the most deprived, eating well would cost 75% of the household income.

Then you have little choice but to buy cheaper unhealthy food: think Whitechapel, London:…

#Marmot2020 #FOAMed

Is poverty relative or absolute? Some say that poverty is relative as it is defined as compared to the population, e.g. having a TV now vs 50 yrs ago:…

But we are talking about not having enough food or somewhere to sleep. #Marmot2020 #FOAMed

➡️ People from most deprived backgrounds face more adverse childhood experiences (ACEs).

"ACEs elevate risk children... will experience damage to health/social outcomes, across the life course."

➡️ Marked decrease on spending for the most deprived.

#Marmot2020 #FOAMed

➡️ Decreasing school attainment as measured by GCSE for children from the most deprived backgrounds.


➡️ Increasing permanent secondary school exclusion rate for children from the most deprived backgrounds.

#Marmot2020 #FOAMed

➡️ Increasing people in employment - that's great really as people in jobs are generally happier

BUT this is crude as it doesn't measure the type and quality of work. #Marmot2020 #FOAMed

➡️ Average wages have fallen - albeit by a little bit


➡️ Increasing numbers of zero hours contracts (do not guarantee a minimum number of paid hours and associated with poor health)


➡️ Increasing work related stress/mental health problems

#Marmot2020 #FOAMed
12c/ I've seen increasing numbers of patients with mental health problems/stress and physical injuries in manual jobs relating to increasing workloads which I rarely saw as a trainee.

Could be availability bias from me as I currently see more patients now. #Marmot2020 #FOAMed

➡️ Increasing workers in poverty especially for those in full time employment and after correcting for housing costs.

➡️ No real increase in household incomes for the poorest in society which is difficult given rising living costs

#Marmot2020 #FOAMed

➡️ The rich have got richer at a rate far higher than the poorest in society

➡️ The richest 1% of the UK have increased their share of the wealth held

➡️ The rich are comparatively taxed less compared to the poorest in society

#Marmot2020 #FOAMed

➡️ Regional divides looking at median household incomes have increased

#Marmot2020 #FOAMed

➡️ Local authority spending has gone down.

➡️ Why does it matter? It affects people physical and mental health - think air pollution, crime, road collisions (see table)

#Marmot2020 #FOAMed

➡️ Increasing violent crimes over the last decade but higher rates in the most deprived populations

#FOAMed #Marmot2020

➡️ Worsening housing conditions over the last decade - think mould affecting asthma, cold houses due to poor insulation, mice carrying disease. @mhclg

➡️ No clear North-South divide when it comes to worse housing conditions

#FOAMed #Marmot2020
@mhclg @TheMarmotReview @HealthFdn 18/

➡️ Over the last decade, homelessness have been rising: increasing households in temporary accommodation and increasing numbers of rough sleepers

➡️ Increasing spending on crisis housing and decreasing spending on preventive housing

#FOAMed #Marmot2020
19/ Whilst there is a moral case there is huge financial cost to health inequality with up to £70 billion estimated in the 2010 @MichaelMarmot review.

Health spending is much higher for the most deprived populations looking at age and gender. #Marmot2020 #FOAMed

Is all this data right? Is this correlation not causation? #Marmot2020 #FOAMed

Inequality is linked to rising GDP but defenders of the free market have unsuccessfully debunked this:

BUT Inequality IS inevitable but over the last decade but...
21/ ...whilst living conditions have improved for a lot (esp middle classes) we have left increasing numbers behind.

As @MichaelMarmot said in "The Health Gap"

🗣️It's not poor choices that result in poverty BUT poverty that result in lack of or NO choice.

#Marmot2020 #FOAMed
22/ How do we move forward?

There are dozens of recommendations and case studies in the report. I've shown the macro and some relevant to primary care.

#Marmot2020 #FOAMed
23/ Running out of time:

📺 Do you learn by watching?

2 min @TheMarmotReview @HealthFdn video:

#Marmot2020 #FOAMed
24/ Running out of time:

📺 Do you learn by watching?

45 min @RCGPAC video:

#Marmot2020 #FOAMed
24/ Running out of time:

📚 Do you learn by reading? #Marmot2020 #FOAMed

@TheLancet editorial:…

25/ Running out of time:

🔊 Do you learn by listening? #Marmot2020 #FOAMed

Listen to the @fairhealthuk podcast:…
26/ We should be outraged by the results of the @MichaelMarmot report.

This is bigger than access to healthcare and health tech. It's about our social and economic values.

We must do better. We need change and we need it now for a better fairer society.

#Marmot2020 #FOAMed
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