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Coventry – a Marmot City

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Coventry – a Marmot City COVENTRY – A MARMOT CITY An evaluation of a city-wide approach to reducing health inequalities Alice Munro Public Health Specialty Registrar February 2020 CONTENTS Executive Summary ................................................................................................................................................................................................................... 2 Glossary ........................................................................................................................................................................................................................................... 4 1. Introduction....................................................................................................................................................................................................................... 5 2. Methods ............................................................................................................................................................................................................................... 7 3. Becoming a Marmot City ........................................................................................................................................................................................... 10 3.1 Context ............................................................................................................................................................................................................................ 10 3.2 Motivations for becoming a Marmot City ........................................................................................................................................................ 11 3.3 Developing the Marmot City Approach in Coventry ................................................................................................................................... 14 4. Governance of the Marmot Approach ................................................................................................................................................................. 15 4.1 Developing an Approach to governance as a Marmot City ...................................................................................................................... 15 4.2 Measuring impact ....................................................................................................................................................................................................... 17 4.3 Views on governance ................................................................................................................................................................................................ 19 4.4 Proportionate Universalism .................................................................................................................................................................................. 20 4.5 Workforce and Public Engagement .................................................................................................................................................................... 21 5. Delivering Marmot: Action on Social Determinants in Coventry ............................................................................................................ 23 5.1 Give every the child the best start in Life ........................................................................................................................................................ 23 5.2 Maximising Capabilities of Children and Young People ............................................................................................................................ 28 5.3 Create Fair Employment and Good Work for All .......................................................................................................................................... 33 5.4 Ensuring Healthy Standard of Living for All ................................................................................................................................................... 38 5.5 Create and Develop Healthy and Sustainable Places .................................................................................................................................. 40 5.6 Strengthening Ill-health Prevention .................................................................................................................................................................. 46 6. Strategic and Population Impacts ......................................................................................................................................................................... 50 7. Lessons from Coventry .............................................................................................................................................................................................. 52 Acknowledgements ................................................................................................................................................................................................................. 54 Appendix 1 - 2013-16 Steering group indicators ...................................................................................................................................................... 55 Appendix 2 - Logic Model developed for Coventry by PHE, 2016 ..................................................................................................................... 58 Appendix 3 - Indicators agreed for this report ........................................................................................................................................................... 63 References ................................................................................................................................................................................................................................... 65 1 EXECUTIVE SUMMARY Social determinants of health are often understood as ‘the causes of the causes’ of ill health, and encompass the range of social, environmental, political and cultural differences that directly or indirectly impact the health of individuals and populations. They are now globally recognised as a core dimension of public health policy and practice and central to action on health inequalities. In 2008, Sir Michael Marmot was asked by the Department of Health to review the evidence regarding the causes of health inequalities in England and recommend action to reduce them. The Marmot Review Fair Society, Healthy Lives was published in 2010, and heavily influenced the 2010 Public Health White Paper and Public Health Outcomes Framework.(1) The Review found that there is a social gradient in health: the lower a person’s social position, the worse his or her health. Factors that were found to affect the social gradient are termed social determinants of health: experiences in the early years of life and during education; income and quality of employment; environmental exposures such as air pollution and poor housing; experiences in later life; and individual characteristics such as gender and ethnicity. These in turn are influenced by social, political and cultural contexts. All of these profoundly influence health behaviours and health outcomes. Recommendations for action therefore focused on reducing inequalities in health by addressing the social determinants of health and doing so in a way which is proportionate to need. The six policy objectives recommended in the Marmot Review to reduce the social gradient in health are often referred to as the ‘Marmot Principles’ and include: • 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 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 The overarching approach to delivery recommended across all these policy areas is proportionate universalism, the idea that services should be provided universally but with a scale and intensity that is proportionate to the level of disadvantage. Reducing inequalities in health and in the social determinants is viewed by many as a social good, a matter of fairness and social justice. More instrumentally, relative equity across social determinants is viewed as an economic asset, a public good which increases social cohesion and productivity. In Coventry both these sets of considerations played a role in the decision in 2013 to become a Marmot City, and develop a whole systems approach to reducing inequalities in health via action on social determinants. Coventry is a city with significant inequalities in health and healthy life expectancy between the most and least deprived areas of the city. In 2010-12, inequality in male life expectancy at birth was 11.2 years between the highest and lowest income deciles whilst, using the same data, inequality in female life expectancy at birth was 8.4 years. Publication of the Marmot Review was followed by the Health and Social Care Act in 2012, which legislated for the move of public health functions in England from the NHS to local government. In 2013, being aware of local inequalities, and as it took on its new public health duties, Coventry City Council decided to adopt the title of Marmot City and sought to
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