The Challenge of Marmot

Photo by Flickr user Roadsidepictures

In a recent appearance before the Education Select Committee the Secretary of State, Michael Gove is reported as saying that he wanted to be “deliberately controversial” when questioned about the role that schools play in helping pupils avoid risky behaviours.

He said:

“if you look at the way in which we can encourage students not to indulge in risky behaviour, one of the best ways we can do that is by educating them so well in a particular range of subjects that they have hope in the future.

“There is a direct correlation between how well students are doing overall academically and their propensity to fall into risky behaviour.”

For those of us pressing for compulsory health education this comes across as short sighted and complacent; how is this compatible with the promise to prioritise prevention as outlined in the Social Justice Strategy just published?

We point to the evidence that a number of programmes have shown good impact on risky behaviours, we argue that these programmes can help improve educational outcomes, that they’re cost effective, and that young people should have an entitlement for good health and wellbeing education.

But, a new publication from the Institute of Health Equality (IHE) (which was launched in November 2011 to build on the work of the Marmot Review) asks us to think again.  They suggest that the approach to public health is too often ‘downstream’ of the things that make a real difference to health inequalites.

While downstream interventions do have a mitigating impact and can reduce the extent of health problems, they usually fail to address the root of the problems. This will be best addressed by tackling the causes of the causes further upstream and using a whole system approach to delivering interventions effectively and according to an area’s needs.

 This may sound like music to the ears of those of us in the prevention field, but the Institute are quite clear that school based prevention programmes (for example) are an ‘upstream’ intervention.

They use the phrase ‘lifestyle drift’ to describe how public health practitioners are drawn back to intervening in behaviours rather than addressing the social determinants of health (SDH) (the causes of the causes).  This happens for a number of reasons:

  • Behaviours are easy to identify and easy to design interventions around (even if they’re not effective).
  • National policy is designed and analysed around behaviours.
  • It takes a really long time to see the effect of SDH.

 So, a school programme that tries to develop the life skills of young people in order to effect drug or alcohol use addresses behaviour, while what is really needed is to address the causes of the causes. And it is hear that we return to Michael Gove and the strategies that being pursued by the government to address school failure, tackle truancy, improve academic outcomes, and to tackle youth unemployment.

There is little doubt that the IHE would see these national government policies as being of much more importance for the future of public health than the delivery of evidence based programmes in schools.  Which may be why we see a public health outcomes framework that includes indicators such as school readiness, truancy rates, the number of young people not in education, employment or training, and first time entrants to the youth justice system.

Whilst it would be a foolish thing to argue that tackling the causes of the causes shouldn’t be something that Health and Wellbeing Boards focus on there may be good reasons that they should have a slightly wider view which encompasses trying to the causes of ill health too.

However, the challenge that the report sets us is to think more deeply about whether our efforts to prevent substance misuse can be drawn in a way that can add value to tackling the ’causes of the causes’ that a social determinants of health approach might indicate.


The report also sets out some principles for Health and Wellbeing Boards when commissioning services that look really useful.  They are:

  1. Address the area’s wider needs (Intervention likely to impact on the greatest needs of the population as identified in the JSNA, regardless of what sphere the intervention takes place in and allowing for the fact that the timescale needed for an impact on health outcomes might be long)
  2. Is universal and addresses the social gradient in health (Intervention likely to impact on the whole population, but provides more intense support to those in greater need, with less socio-economic resources, or living in areas of greater economic or environmental deprivation)
  3. Is aligned with other local and national policies (Intervention does not interfere with other policy objectives, e.g. sustainability, and is likely to have positive impact on other social outcomes and performance indicators)
  4. Is backed-up by evidence of efficacy (Intervention considered because there is evidence strong evidence base that it is likely to have an impact on the SDH and on health inequalities)
  5. Is cost-beneficial (Intervention likely to positively impact on long term costs to health and social services, and to provide significant social gains for its cost)
  6. Takes advantage of existing assets and resources (Intervention makes efficient use of existing service infrastructure and enhances the availability and quality of community resources)
  7. Provides the population with control over their lives (Interventions devised on the basis of clear community priorities as stated by consulted stakeholders and users; intervention engages the public in decision-making and delivery)
  8. Falls within one of the following unifying themes:
    1. The importance of improving the physical, social and economic environment of deprived areas.
    2. Early intervention and the long term public health benefits of intervening early in the life course particularly for prevention.
    3. Looking at the close interplay between physical and mental health when designing strategies to reduce health inequalities.
    4. The use of fiscal and financial policy instruments to enable deprived populations to live healthier lives.

One thought on “The Challenge of Marmot

  1. Pingback: BMA – Delaying initiation and minimising the use of illicit drugs | Mentor Thinks

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