Marmot in Practice

1. Marmot in Practice Jim McManus, Joint Director of Public Health Birmingham City Council and NHS

2. The response to the JSNA took everyone by surprise.....

3. Cover • Introduction to context of Marmot • Relevance to Health & Social Care Integration • Relevance to JSNA • Examples of use in Practice • Over to you

4. Challenge – today’s version of sewerage as a public health task • The elements which make for a healthy society are multi-faceted • Our frameworks and systems are not • JSNA has an almost impossible task • Everyone knows what they want the Health and Wellbeing Strategy to do...nobody wants to do it • Need to plan across the lifecourse

5. Outcomes, outcomes,everywhere

6. Forward Comrades! The JSNA has solved all our problems!

7. Birmingham’s use of Marmot • 1. Adopt the Outcomes • Starting well • Developing well • Living well • Working well • Ageing well • 2. Add an objective “dying well” • 3.Cut our JSNA and Strategy across the Lifespan • 4. Use as “golden thread” (still under construction) • For Health Inequalities Action • For JSNA • For Health and Wellbeing Strategy • For Integration • As a lifecourse approach to human ecology Activities Framework

8. Examples of Marmot in practice • Lifecourse approach using Marmot • Early development • Mental health problems onset • Tasks for each lifestage • Community and Public Sector tasks • Interdependencies • Use of Marmot Framework across lifecourse • Tasks for adult social care and older adult social care elucidated • Incorporation into third sector contracts with third sector • Preventive workstream LGBT MENTAL HEALTH PREVENTION

9. Areas of action Sustainable communities and places Healthy Standard of Living Early Years Skills Development Employment and Work Prevention Life course Accumulation of positive and negative effects on health and wellbeing Prenatal Pre-school School Training Employment Retirement Family building Life course stages

10. The Conceptual Framework Reduce health inequalities and improve health and well-being for all. Create an enabling society that maximises individual and community potential. Ensure social justice, health and sustainability are at heart of policies. Policy objectives A. Give every child the best start in life. C. Create fair employment and good work for all. E. Create and develop healthy and sustainable places and communities. B. Enable all children, young people and adults to maximise their capabilities and have control over their lives. D. Ensure healthy standard of living for all. F. Strengthen the role and impact of ill health prevention. Policy mechanisms Equality and health equity in all policies. Effective evidence-based delivery systems.

11. Inequality in Early Cognitive Development of British Children in the 1970 Cohort, 22 months to 10 years Socio Economic Status High SES Low SES High Q at 22m Low Q at 22m Source: Feinstein, L. (2003) ‘Inequality in the Early Cognitive Development of British Children in the 1970 Cohort’, Economica (70) 277, 73-97

12. Gaps in school readiness at 3 and 5 years by family income: UK Average percentile score Waldfogel & Washbrook 2008

15. Key themes from the evidence Reducing health inequalities is a matter of fairness and social justice – inequality is avoidable. Action is needed to tackle the social gradient in health – Proportionate universalism Action on health inequalities requires action across all the social determinants of health avoiding lifestyle drift Reducing health inequalities is vital for the economy – cost of inaction A move beyond economic growth to well-being of society: sustainability and the fair distribution of health

16. Implications of the gradient Without health inequalities in England – Each year, if all had the mortality rate of 1) those with university education: • Prevent 202,000 people aged 30+ dying prematurely (40 % of deaths); • 2.5 million life years gained; 2) those in most affluent 10% of areas: • 2.8 million extra years of life free from limiting illness or disability Estimates calculated for Marmot Review based on ONS data

17. 1) Give every child the best start in life. • Priority objectives • Reduce inequalities in the early development of physical and emotional health, and cognitive, linguistic, and social skills. • Ensure high quality maternity services, parenting programmes, childcare and early years education to meet need across the social gradient. • Build the resilience and well-being of young children across the social gradient. • Focus Group respondent – Single Parent in Manchester: • “I’m not mentally ok because I’m doing too much, but then how am I helping my children?”

18. 2) Enable all children, young people and adults to maximise their capabilities and have control over their lives. • Priority objectives • Reduce the social gradient in skills and qualifications. • Ensure that schools, families and communities work in partnership to reduce the gradient in health, well-being and resilience of children and young people. • Improve the access and use of quality lifelong learning across the social gradient. • Focus Group Respondent ,Birmingham • “If there is no education, there are no jobs these days, so it really is worrying. If your children don’t get a good education then what’s going to happen to them”

19. Monitoring progress • Life expectancy (Years of Life) • Health expectancy (quality of years) • Wellbeing. (when developed) • Readiness for School • Young People not in education or unemployment. • Increase in proportion of households with an income sufficient for healthy living.

20. 4. Lovely, so how do you use Marmot in Practice? • JSNA (Birmingham, Lincolnshire, E Mids, Mcr) • Health Inequalities Strategy (London, • Tracking Progress (LHO, Wales) • Sustainable Community Strategy (Birmingham) • Health and Wellbeing Strategy (Bham) • Pragmatism • What works for you • Bridging framework • Analysis tool • Outcomes tracker • Strategic Tool • A way to getting to lifecourse commissioning An overview Principles

21. “The Golden Thread” - assumptions • Marmot gives us the best possible statement of evidence on the challenges of health inequalities • Evidence appraisal leads to outcomes and Policy Objectives • Marmot as Bridging Framework

22. Birmingham’s use of Marmot • 1. Adopt the Outcomes • Starting well • Developing well • Living well • Working well • Ageing well • 2. Add an objective “dying well” • 3.Cut our JSNA and Strategy across the Lifespan • 4. Use as “golden thread” (still under construction) • For Health Inequalities Action • For JSNA • For Health and Wellbeing Strategy • For Integration • As a lifecourse approach to human ecology Activities Framework

23. The Elements • Adoption of Framework by HWBB and LSP • The JSNA is constructed according to outcomes • Prioritisation being developed according to Marmot Outcomes • Health and Wellbeing Strategy using Marmot • Marmot Group – Joint NHS and LA Group on the “what of health inequalities work”

24. Examples

25. What have we done • JSNA refresh in draft • HWBS in drafting process • Commissioning for older people • Prevention programme • LGBT Health Strategy • Faith Community Strategy • Joint Health Inequalities Plan • Vision for Public Health Reorganisation

27. 5. Over to you... Thank you! Jim.mcmanus@birmingham.gov.uk