Wider Determinants

Wider Determinant


In his review of health inequalities, one of Sir Michael Marmot’s key messages is that “Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health.”  The review identified six policy objectives which require action to reduce health inequalities.  These are:

  • Give every child the best start in life;
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives;
  • Create fair employment and good work for all;
  • Ensure healthy standard of living for all;
  • Create and develop healthy and sustainable places and communities; and
  • Strengthen the role and impact of ill-health prevention.

The topics within this theme are important contributors to the social determinants of health.  This summary attempts to identify the most important issues contained within each topic and, from these, highlight those which are the most important for action in addressing health needs and inequalities in Middlesbrough.

What are the most important messages from each topic?



  • Alcohol consumption is linked to 44% of offences, creates problems at weekends and in particular locations, and is associated with antisocial behaviour.  It is common to three of the four commissioning priorities about offenders, troubled families and location of crime.
  • There is a common thread in the commissioning priorities that data and information systems are not used to their full potential.



  • There is a problem with school readiness for children and adults.  There is a particular need for readiness for primary school for both children and parents, but readiness is also needed for the transition to secondary school, working for GCSE and other qualifications, and going on to further and higher education.
  • We need to create a population that values education by understanding both the opportunities it can bring and the barriers presented by a lack of qualifications.



  • There is a need to get young people (aged 18-24) working.  In particular there seems to be a lack of employment for young men, and high rates of unemployment in the north and east of Middlesbrough.



  • Middlesbrough must create an environment that supports health and wellbeing, including both physical and emotional wellbeing.



  • A high proportion (40%) of private rented housing is of low quality, contributing to fuel poverty, winter mortality and affecting illness.
  • The housing needs of vulnerable and disadvantaged groups are not always being met.
  • Homelessness prevention.



  • There are between 11,500 and 16,300 people in Middlesbrough who are not claiming benefits that they are entitled to.  If all of these benefits were claimed, this could be worth between £17million and £28million to the people and economy of Middlesbrough.  A systematic approach to maximising rightful benefit uptake would help the most vulnerable and disadvantage people.
  • The educational attainment of disadvantaged children is worse than that of other children, perpetuating a cycle of poverty.



  • Too many people are killed or seriously injured in road traffic collisions.  Children in the 10% most deprived areas in England are three times more likely to be pedestrian casualties than those in the least deprived areas.  41 of Middlesbrough’s 88 LSOAs are in the most deprived 10% in England, with a total population of 65,700.
  • Opportunities for physically active transport (walking and cycling) in the relatively compact town of Middlesbrough need to be maximised to help both physical and mental health.
  • Cuts to public transport limit people’s access to employment in the early morning and may isolate some residents from public services and could affect mental health by limiting access to social opportunities in the evening.

What should be the highest priorities for commissioners? 

Short-term (1 to 2 years)

  • Tackling alcohol-related crime.  This would help relieve weekend pressures on A&E services, reduce domestic violence, and tackle location-based hotspots.
  • Develop a systematic approach to maximising benefits claimants, improving the lives of disadvantaged people and boosting the local economy.

Medium-term (3-5 years)

  • Ensuring school readiness of children and parents.
  • Improving the quality of housing in the private rented sector, including thermal efficiency.
  • Optimise opportunities for job creation for all, but with a focus on young people in the north and east of Middlesbrough.

Long-term (over 5 years)

  • Develop transport infrastructure to maximise physically active travel and minimise injury and death.
  • Create an environment which supports health and wellbeing.


Summary authors

Heidi Douglas
Specialty Registrar Public Health
Middlesbrough Borough Council

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service