For Cheshire and Merseyside, as with many Marmot Places, the COVID-19 pandemic sparked collective action across the region’s nine local authorities to address and tackle existing and deepening health inequalities.
Introduction
According to Professor Ian Ashworth, Director of Population Health for NHS Cheshire and Merseyside Integrated Care System, there was widespread recognition locally of acute levels of poverty and the related challenges of ill health and mounting demand on health services.
We see poverty more acutely in our part of the world.... a lot of the challenges to ill health and demand on health and care services comes from people having rubbish housing, rubbish jobs or rubbish things going on in their lives.” says Ashworth.
During the pandemic, the COVID-19 mortality rate in Cheshire and Merseyside was five per cent higher than the national average between March 2020 and April 2021 and, as in so many areas, exposed and amplified existing inequalities.
The Index of Multiple Deprivation (IMD) shows that Knowsley is the second most deprived borough in England, followed by Liverpool. Life expectancy in the region is below the average for England, except in Cheshire West and Chester. Women living in the most deprived areas live 12 years less than those in the least deprived, and for men, the difference is 13 years. Within individual council boundaries, there are even greater inequalities in life expectancy closely related to levels of deprivation.
Healthy life expectancy (how long one can expect to live in good health) is also below the national average in Halton, Liverpool, Knowsley, St Helens and for men in Wirral.
From recognition to action
The urgent need to address these inequalities coincided with the establishment of Integrated Care Boards (ICBs), says Ashworth. There was ‘buy in’ and strong support for the Marmot approach. “We wanted to work together as a unified front… so that’s why we brought in the Institute of Health Equity.”
The region’s journey toward becoming a Marmot Place has taken nearly two years, bringing together the nine boroughs, NHS organisations, housing associations and local and economic voluntary groups. It has been an invaluable journey in laying the groundwork for future actions that will be delivered to promote health equity.
Workshops held across each area helped to identify priorities for action. Each council within the region, working with their Health and Wellbeing Boards, developed its own Marmot data pack, highlighting issues which were considered critical to reducing health inequalities.
The IHE report has a set of 22 local indicators, co-created with Cheshire and Merseyside (including more than 100 stakeholders), aligned with the eight Marmot principles. It will be monitored by the Combined Intelligence for Population Health Action (CIPHA) programme.
Political leadership and collaboration
According to Ashworth, political leadership from Cheshire West and Chester Council leader, Cllr Louise Gittins, played a vital role in bringing people on this journey, despite there not being a national mandate to do so.
Cllr Gittins, who is also Chair of the Local Government Association, added,
By working collaboratively across sectors, we’ve brought together councils, health services, wider public sector, housing, and community, voluntary and faith sectors to create real, meaningful change.
“Prioritising our most disadvantaged communities not only improves health outcomes but also strengthens our local economy, making Cheshire and Merseyside healthier and more prosperous for everyone.
“Adopting a Marmot approach in Cheshire and Merseyside has allowed us to focus on the social factors that influence health, like housing, education, and employment, ensuring we tackle inequalities at their root." said Cllr Gittins.
The impact of implementing Marmot strategies
Cheshire and Merseyside’s Marmot report, All Together Fairer: Health equity and the social determinants of health in Cheshire and Merseyside provides an overarching framework that allows all sectors to keep the same narrative, collaboration and shared outcomes. The Integrated Care Partnership adopted the All Together Fairer (Marmot) report in whole as its Health and Care Partnership plan from 1 October 2024 for the next five years. The Partnership has embarked on a major programme on child and family poverty with widespread political and professional leadership and in line with Marmot principles.
Two specific strategies have been drawn up since working with the IHE: Physical Activity Strategy (All Together Active) and Sefton Child Poverty Strategy, both of which address most, if not all, of the Marmot eight principles.
All Together Active was commissioned by the Integrated Care System (ICS) Population Health Board and developed by Active Cheshire and Merseyside Sport (MSP) in conjunction with place-based and subregional partners who are able to improve physical activity levels at scale.
All Together Fairer has also already made a vast difference to local efforts. At a recent Population Health Board meeting, colleagues heard how Cheshire and Warrington’s Devolution Deal proposal will now incorporate health inequalities and Marmot’s recommendations, directly prompted by the event and the far-reaching coverage since the report was launched.
Input from the IHE has helped maintain the momentum and provides a check and challenge that enables colleagues across the borough to reflect and consider their plans. Marmot community leads in each of the nine boroughs share information and experiences of helping embed a Marmot approach in their areas, which as Ashworth says, helps ensure the work remains on track.