Wales has a challenge to address health inequalities – from cradle to the grave – and take action on the social determinants of health. In this piece from the Bevan Commission Opinion series, Professor Sir Michael Marmot (a Bevan Commissioner) and colleagues Dr Angela Donkin and Dr Frances Macguire from the Institute of Health Equity, look at how Wales can make a positive change through policy, education and advocacy.


It is good news that for Wales, more people are expected to live longer, and indeed the population of 75s and over is projected to increase by 50% between 2014 and 2030.  There are, however, two important points to note. Firstly – life expectancy has not been increasing as quickly in Wales as it has in England, and secondly, along with the rest of the UK, there are marked health inequalities, with approximately a 10 year gap between the life expectancy of those living in deprived and those living in less deprived areas in some areas in Cardiff.   

This is not just a social injustice, but health inequalities are also estimated to cost £3-4 billion annually through higher welfare payments, productivity losses, lost taxes, and additional illness.

Unequal from birth

A focus on life expectancy only presents some of the picture, and tends to place our focus on older people.  At the other end of the spectrum,  health indicators for children show similar trends, for example childhood obesity varies between most and least deprived communities. Some 28.4% of children living in the most deprived areas are either overweight or obese compared to 20.9% in the least deprived areas.  

Twice as many children living in Merthyr Tydfil, for example, are obese compared to those living in the Vale of Glamorgan (14.7% Merthyr Tydfil, 7.3% Vale of Glamorgan). Instances of childhood injuries and tooth decay show similar patterns.

Although infant mortality rates have declined in recent years in Wales, neonatal and infant mortality rates are still highest in the most deprived areas of the country, almost 50% more than in the least deprived areas. Children living in the most deprived areas are twice as likely to be of low birth weight and half as likely to be breast fed compared to children in the least deprived areas.

Addressing health inequalities, from birth, and throughout the life-course is essential.

Local and national action

Addressing health inequalities in Wales needs a combination of evidence-based politics and a spirit of social justice, invoking the legacy of Aneurin Bevan. The Marmot review undertaken at the Institute of Health Equity (IHE) identified six policy objectives.

Public Health Wales has set out a related array of mechanisms to reduce ill health and inequalities. While there is more of a focus on behaviour here there is the clear recognition of the need to reduce poverty.

The policy objectives are clearly not all within the traditional remit of government health ministeries. To achieve success and move forward, combined action with buy in across government departments, is required.  It is therefore extremely encouraging to note that the Welsh Government is at the forefront of thinking regarding this.  Two landmark Welsh laws have recently been passed. The Social Services and Well-being (Wales) Act 2014 and the Wellbeing of Future Generations (Wales) Act 2015 require public bodies to work together for the long-term sustainability of Wales and its people.

In addition, central to making change, are local authorities, and committed leaders. Local individuals may also drive positive change through community interest companies. These can be used to set up local sports clubs or health and wellbeing groups which increase people’s connectedness and access to physical activity.

Change is possible

Since the review in 2010,  IHE have continued to build the evidence base on health inequalities, and driven by demand, have written a number of reports to aid implementation of these recommendations.  Central to this work was a strong commitment from public health officials to improve the social determinants of health, both nationally in the health agencies, and locally. 

The annual indicator work that we conduct monitors progress across all areas on each of the policy objectives, and it is clear that there are some areas, for each indicator, that given a certain level of deprivation are doing better than expected.  For example, we also looked at  the best and worse performers in terms of the gap in attainment at age 5 between all and those who would be eligible for a free school meal.  On average in England there is a 15.6 percentage point difference, but in Hackney, it is only a 4.2 percentage point difference, whereas in Bath and Somerset, it is nearly a 30 percentage point difference.  Clearly Hackney is doing something right.  Spreading best practice from the better performing areas should be a key policy prioirity.

The English government did not take on all the recommendations from the Marmot review, and was famously silent on the issue of having a minimum income for healthy living. Evidence from the EU Statistics on Income and Living Conditions (EU-Silc) illustrates that material deprivation is a stong predictor of self reported ill health, much more so than income itself or education. 

Ensuring that people have sufficient income to be healthy should be a policy priority led by central government,  not least because insufficient income will transfer to greater costs to the health services at a later stage.  We know that in Sweden levels of material deprivation are the lowest in Europe, unsurprising therefore that they have small inequalities in health compared to the UK.  Local areas may struggle to counter economic austerity, but might want to push through a requirement to pay the real living wage in public bodies and might try to incentivise local private employers to do the same. 

Moving forward with the health profession

Heath professionals have an important and often under-utilised role in reducing health inequalities. The health workforce is well placed to develop services that impact on the wider social determinants of health and reduce inequities through:

  • Workforce education and training
  • Practical actions to be taken during interactions with patients
  • Ways of working in Partnership
  • Advocacy.

Given that illness arises from the conditions in which people are born, grow, live, work, and age – the social determinants of health – it’s clear that all agencies have a role in reducing the causes of illness and, indeed, the causes of the causes. Action on the social determinants of health should be a core part of health professionals’ business, as it improves clinical outcomes, and saves money and time in the longer term. But, most persuasively, taking action to reduce health inequalities is a matter of social justice and all sectors of society have a role in reducing inequalities.

A call to action

Social injustice is killing on a grand scale. We know that improved health equity can be delivered through action on the social determinants of health by taking a life course approach and following best practice that is already available.  Of course, there is always room for improvement and new initiatives should be encouraged, and evaluated, but there is the possibility to positively change outcomes: now.

Professor Sir Michael G Marmot, Dr Angela J M Donkin, Dr Frances AS MacGuire, The UCL Institute of Health Equity.

This article originally appeared in the Bevan Commission Opinion series and is a shortened version of the chapter ‘Addressing Health Inequalities in Wales’ which features in the book ’70 years on – what next? Personal reflections on the NHS in Wales from the Bevan Commission’.