Title: Update paper on ‘Gwent: Marmot Region’

Paper sponsor:

Dr Sarah Aitken, Executive Director of Public Health and Strategic Partnerships, ABUHB

Paper authors:

Richard Lewis, Principal Public Health Practitioner, PHW

Stuart Bourne, Consultant in Public Health, ABUHB

Date: 30^th June 2022

1. Introduction

1.0 At its meeting on 10^th March 2022, Gwent Public Services Board (PSB) formally agreed to become a ‘Marmot Region’, and to work in partnership with the Institute of Health Equity (IHE) to address the social determinants of health. It was also agreed to align the ‘Health and Well-being/Inequalities’ theme of the PSB Well-being Plan Response Analysis with the Marmot Principles.

1.1 The purpose of this paper is to up-date Gwent PSB partners on progress in establishing a Marmot Region programme, and to seek PSB endorsement to establish a sub-group of the PSB to lead and coordinate this work. This paper also provides a summary of recently published data on childhood obesity and life expectancies which adds to the body of data highlighting the importance of addressing health inequalities in Gwent.

2. Background

2.0 Under the leadership of the Director of Public Health (DPH), Aneurin Bevan Gwent Public Health Team (ABGPHT) is coordinating the implementation of the Marmot Region proposal. The proposal paper agreed by Gwent PSB on 10^th March 2022 can be accessed here: https://www.gwentpsb.org/wp-content/uploads/2022/03/03-Proposal-Gwent-Becoming-a-Marmot-Region.pdf

2.1 Development of the implementation plan is being undertaken in consultation with Gwent PSB members, Gwent Strategic Well-being Action Group (GSWAG), Gwent PSB Engagement Group and PSB Secretariat.

2.2 On 7^th December 2021 Gwent PSB agreed to adopt the six Marmot Principles as the framework for action to reduce health inequalities across Gwent as part of the forthcoming Gwent PSB Well-being Plan. The health and well-being / inequalities response analysis paper is aligned to the Marmot Principles for approval separately on the 30^th June 2022 PSB agenda.

The six Marmot Principles 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 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

3. Latest data on health inequalities in Gwent

3.0 Childhood obesity (& overweight) has both immediate and long-term consequences. Increasingly, obese children are being diagnosed with a range of health conditions previously seen almost exclusively among adults such as diabetes, high blood pressure, bone, joint and respiratory problems.  Overweight or obesity in childhood can also result in serious psychological difficulties due to bullying and low self-esteem. Some of these problems can persist into adulthood, resulting in longer periods of poor health and a shorter life expectancy compared with children of a healthy weight.¹

3.1 Public Health Wales has recently released the first set of data on children’s weight since 2018/19.² The figures for 2020/21 demonstrate a significant rise in the average rate of obesity among 4-5 year old children in the Gwent (Aneurin Bevan University Health Board) region, up from 11.8% in 2018/19 to 18.3% in 2020/21. This 6.5 percentage point increase means that, in 2020/21, an estimated 1,097 4-5 year olds in Gwent started school already obese.

3.2 There is wide inequality in the rate of childhood obesity at local authority level in Gwent (Figure 1). When the figures are analysed by socioeconomic status, the extent of the gap is even wider. There is an almost eight percentage point difference in child obesity rates between the most and least deprived population quintiles in Gwent (Figure 2).

3.3 In June, Public Health Wales published new data on the inequality gap in life expectancy and healthy life expectancy in Gwent.³ For both men and women, the inequality gap in life expectancy has remained unchanged, and there continues to be a seven year gap for men and a six year gap for women (Figure 3). The gap in healthy life expectancy is also largely unchanged for men (13 years), but it has widened for women such that the gap is now 20 years (Figure 4).

Figure 1: Percentage of children aged 4 to 5 years with obesity, Gwent local authorities, 2020/21.

Source: Public Health Wales

Figure 2: Percentage of children aged 4 to 5 with obesity, deprivation fifths, Aneurin Bevan University Health Board, Child Measurement Programme, 2020-21

Source: Public Health Wales

Figure 3: Life expectancy at birth (years), most vs least deprived quintiles, Aneurin Bevan University Health Board area, 2011-13 to 2018-20

Source: Public Health Wales

Figure 4: Healthy life expectancy at birth (years), most vs least deprived quintiles, Aneurin Bevan University Health Board area, 2011-13 to 2018-20Source: Public Health Wales

4. Marmot Region Programme Governance

4.0 The fact that the inequality gap in life expectancy and healthy life expectancy has, at best, persisted unchanged in Gwent throughout the last decade reinforces the PSB’s decision to become a ‘Marmot Region’ to enable a concerted, whole system response to address this issue. The widening of the inequality gap in health life expectancy for women is particularly concerning, with women resident in the most deprived parts of Gwent living, on average, just 48 years of life in good health.

4.1 This paper proposes the establishment of a Gwent Marmot Region Programme Leadership Group to provide leadership and partnership coordination in implementing the Marmot Region programme. The Group will consist of PSB members with the delegated authority to make decisions on behalf of Gwent PSB relating to programme implementation, including communications and engagement. It is needed to maintain the pace of work in 2022/23 with IHE as they help Gwent to establish itself as a Marmot Region in the next twelve months. A draft Terms of Reference for the Leadership Group are included in Annex 1 for Gwent PSB approval.

4.2 The Leadership Group will be supported by a programme team within the Aneurin Bevan Gwent Public Health Team (ABGPHT) under the leadership of the Director of Public Health. Three fixed term posts have recently been put out to advert to support this work in 2022/23.

4.3 Since the 10^th March PSB meeting, a contract has been signed between IHE and ABUHB to formally establish IHE’s role working with Gwent PSB to develop its plan to address each of the Marmot Principles. A Service Level Agreement is also due to be signed, which will formalise the work-packages in the proposal.

4.4 A working timetable has been developed for the delivery of the work packages with IHE so that work can commence from IHE’s start in June. This is included in Annex 2 for information. Preparatory meetings with IHE have been taking place since 10^th March to shape these outputs. A briefing of Wales/Gwent specific data sources is being prepared by the ABGPHT programme team to assist IHE with its data analysis.

4.5 The PSB’s Engagement Group will support the building of the stakeholder invitation list to support participatory events in Gwent. Planning of the events is being informed by the approach and lessons learnt from the involvement programme that followed publication of the ‘Building a Healthier Gwent’ DPH Annual Report in 2019.

4.6 Learning from the experience of the Cheshire and Merseyside ‘Marmot Community’, there is a need to strengthen business sector involvement and collaboration in the Marmot programme in Gwent. The business sector has a key part to play in improving the social conditions that affect health and health equity, including employment conditions, goods and services, and wider impacts.⁴ Engagement with this sector will be progressed via the Marmot workshops in the autumn, to which representatives of Cardiff Capital Region, South Wales Chamber of Commerce, CBI Wales and FSB (Federation of Small Businesses) in Wales will be invited.

5. Additional Marmot Principles

5.1 In May 2022, IHE published its final report ‘All Together Fairer: Health Equity and the Social Determinants of Health in Cheshire and Merseyside’.⁵ It presents recommendations across the ‘Marmot 8’ Principles and system-wide recommendations.

5.2 The ‘Marmot 8’ Principles include the addition of two new additional Marmot Principles to the original six, which are:

· ‘Tackle racism, discrimination and their outcomes’

· ‘Pursue environmental sustainability and health equity together’.

5.3 As a consequence, this paper proposes Gwent PSB extends its decision to adopt the Marmot Principles to include these two additional principles. The latter principle is consistent with Gwent PSB’s theme of ‘Environment (Climate and Nature emergencies)’ in its Response Analysis.

5.4 As an indication of the recommendations that may arise from adopting the 8 Marmot Principles as the framework for the Gwent Marmot Region programme, the system-wide recommendations arising from the Cheshire and Merseyside Marmot Region programme are:

1. Increase and make equitable funding for social determinants of health and prevention.

2. Strengthen partnerships for health equity.

3. Create stronger leadership and workforce for health equity.

4. Co-create interventions and actions with communities.

5. Strengthen the role of business and the economic sector in reducing health inequalities.

6. Extend social value and anchor organisations across the NHS, public services and local authorities.

7. Develop social determinants of health in all policies and implement Marmot Beacon indicators.

6. Marmot Region Communications and Engagement Strategy

6.0 A draft communications and engagement strategy is being developed to promote Gwent PSB’s decision to become a Marmot Region and to illustrate how people can get involved. Development of the strategy is being co-ordinated by ABUHB’s Strategic Head of Communications, Population Health.

6.1 This paper proposes in principle, the Gwent Marmot Region communications and engagement strategy should:

· Follow the Chartered Institute of Public Relations’ communication principles of Transparency, Support, Honesty and Trust, and Accessibility

· Be developed collaboratively with the PSB’s Engagement Group and Secretariat

· Be informed by the experience of other Marmot local approaches, particularly Cheshire and Merseyside

· Develop an evidence based narrative on the action needed to reduce inequalities, particularly the move from individual responsibility towards collective, whole-systems responsibility

· Tailor its key messaging and tone of voice to a variety of professional and community audiences.

7. Recommendations

Gwent PSB is asked:

7.1 To NOTE the recent data on childhood obesity and life expectancies in Gwent and the widening inequalities in both measures (Section 3)

7.2 To AGREE to the establishment and terms of reference for a Gwent Marmot Region Programme Leadership Group (para 4.1 & Annex 1)

7.3 To AGREE to include the two additional Marmot Principles as the framework for action to reduce inequalities across Gwent, bringing Gwent into line with current approach of eight Marmot Principles (para 5.2)

7.4 To AGREE the principles for the Marmot Region communications and engagement strategy (para 6.1)

7.5 To NOTE the timetable of work (Annex 2)

References

1. https://post.parliament.uk/research-briefings/post-pn-0640/

2. https://phw.nhs.wales/services-and-teams/child-measurement-programme/cmp-2020-21/child-measurement-programme-report-2020-2021/

3. https://phw.nhs.wales/news/inequalities-in-life-expectancy-on-the-increase-in-wales/

4. The Business of Health Equity: The Marmot Review for Industry - IHE (instituteofhealthequity.org)

5. Champs | Public Health Collaborative (champspublichealth.com)

Annex 1: Gwent Marmot Region Programme Leadership Group – DRAFT Terms of Reference

Gwent Marmot Region Programme Leadership Group

Terms of Reference (v0.4)

Role:

The role of the Gwent Marmot Region Leadership Group (‘the Group’) is to provide leadership and partnership coordination to establish Gwent as the first ‘Marmot Region’ in Wales. The Group will consist of PSB members with the delegated authority to make decisions on behalf of Gwent Public Services Board relating to matters of establishing the Gwent Marmot Region programme in 2022/23. This will provide a mechanism to ensure that work progresses at pace and in a way that is coordinated across Gwent partner organisations.

The eight Marmot Principles 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 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

· Tackle racism, discrimination and their outcomes

· Pursue environmental sustainability and health equity together

Approval of the eventual recommendations and actions to address the Marmot Principles will sit with Gwent Public Services Board. The focus of the Leadership Group is the quality of the process that develops the recommendations.

Responsibilities:

· To make decisions relating to the development of a Gwent-wide response to the eight Marmot Principles, ensuring the process to develop an action plan is robust and valid.

· To agree and oversee delivery of all aspects of the Marmot Region programme plan for 2022/23.

· To agree and oversee delivery of all aspects of the Marmot Region communications and engagement strategy for 2022/23.

· To ensure actions are delivered on time and in accordance with the programme plan and communications and engagement strategy in 2022/23.

· To oversee the development of a set of recommended actions arising from the Gwent Marmot programme for consideration and agreement by Gwent PSB.

· To monitor any risks to delivery and provide a forum to resolve escalated issues.

· To receive and note Marmot Region up-date papers from the Gwent Marmot Region Programme Team (ABGPHT) in advance of each meeting of Gwent PSB.

Membership

Chief Executive, Monmouthshire County Council (Joint chair)

Chief Executive, Torfaen County Borough Council (Joint chair)

Chief Executive, Tai Calon Community Housing

Chief Executive, Gwent Association of Voluntary Organisations

Executive Director of Public Health and Strategic Partnerships, Aneurin Bevan University Health Board

Deputy Director - Prosperous Futures Division, Welsh Government (Observer)

Officers from the Gwent Marmot Region Programme Team (ABGPHT) will be in attendance. Secretariat will be provided by Aneurin Bevan Gwent Public Health Team (ABGPHT).

Governance:

The Gwent Marmot Region Leadership Group will take the form of a sub-group of Gwent Public Services Board with a specific remit to lead work to agree a set of recommended actions for Gwent PSB to address the eight Marmot Principles.

The Group will report on progress to Gwent Public Services Board at each meeting during 2022/23.

Frequency:

Meeting frequency and how the Group meets will be decided by the Group members, but is anticipated to be at least monthly and to continue up to June 2023.

Date of review of terms of reference: December 2022.

Annex 2: DRAFT working timetable for the delivery of the work packages with Institute of Health Equity (v10)

Please see the Excel spreadsheet attached.