Using Marmot principles to tackle health inequalities and COVID-19, 23 June 2020

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Sue Woolley:

Okay, well, good day, everyone. I don't know whether to say good morning or good afternoon. I'm Councilor Sue Woolley and I'm a member of the LGA community well being board, and I'm also chair of Lincolnshire's health and well being board. I'd like to welcome you all here today. We've got an enormous audience and I think it's for one reason only and that's certainly not me. We will be using this opportunity [inaudible 00:04:27] about using Marmot principles to tackle health and equalities in Covid-19. The hashtags for this webinar are #lgainequalities and #lgamarmot.

Sue Woolley:

The coronavirus pandemic and subsequent measures to control the virus have brought forth existing health inequalities into sharp and painful focus for many of us. People facing the greatest deprivation are experiencing a higher risk of exposure to Covid-19 and existing poor health puts them at greater risk of more severe outcomes if they contract the virus. Local government leaders have been doing their utmost to support the vulnerable and keep all of their communities safe during this pandemic and we will hear some examples of the excellent work already under way shortly. However, we know that in the difficult days and months to come, we will need to do as much to tackle the disproportionate long-term impacts of Covid-19.

Sue Woolley:

We want to take this opportunity to build a fairer healthier society by focusing on the social causes of ill health such as early years development, education, and employment opportunities and improving services for older people. A few days before Covid-19 hit the UK, Sir Michael Marmot published a review of his landmark research revealing that since 2010 the health gap had widened and improvement to life expectancy had stalled and in fact, declined for the poorest.

Sue Woolley:

It is now more pressing than ever that we understand the reasons for the growing gap and how we can mitigate against it. We're very grateful to Sir Michael Marmot for agreeing to speak directly to local leaders and play shapers today. This webinar builds on our previous event with Professor Kevin Fenton on Covid-19 and ethnicity and is part of our on-going work to support councils in their commitment to ensuring that no one in their communities is left behind by the effects of this truly dreadful disease.

Sue Woolley:

I'd now like to welcome our first speak, Professor Sir Michael Marmot, director of the UCL Institute of Health Equity, who conducted the strategic review of health inequalities in England post 2010 and published its report Fair Society, Health Lives in February of that year. He is also the author of the Health Equity in England: the Marmot Review 10 Years On published in February of this year. Over to you, Sir Michael. Thank you.

Sir Michael Marmot:

Thank you. It's an absolute pleasure to speak at this gathering because I see local government as my natural allies. People working in local government have a keen appreciation of the lives of individuals in communities, and my experience with local government is political party counts for much less than it does in Westminster because you're in touch with the reality of people's lives. And exactly as our chair just said, my 2020 report I think is highly relevant to Covid-19 and building back. So, what I'm going to do is to run through the key elements of the 2020 report because we're now engaged in an exercise of looking at the impact of Covid-19 and the lockdown on the elements that I identified in the 2020 report and how it will impact on health and health inequalities and be highly relevant to the whole issue of building back.

Sir Michael Marmot:

So this was the report, the 10 Years On report. And I said in commenting, "We've lost a decade. And it shows." I see everything through the prism of health and health inequalities. This is the decade we lost. Life expectancy had been increasing for females and for males. I had taken this back here to 1980, but if we went back to 1890, life expectancy was improving about one year every four years. And then it slowed dramatically in 2010, 11; it slowed dramatically and stopped increasing at the same rate and just about ground to a halt.

Sir Michael Marmot:

If we look at the social gradient of health inequalities by deprivation, what you see for males and for females a social grading, and the steepness of that grading increased. ONS has been very good data regularly on Covid-19 mortality and the social grading for Covid-19 mortality looks almost the same as the social grading for cause mortality, which means we're dealing with the same set of social determiners that cause health inequalities that cause inequalities in Covid-19 with one big difference: the excess mortality in BAME populations from Covid-19, which we did not see anything like the same extent more generally. I don't think that means that deprivation is unimportant, quite the contrary; deprivation is part of the explanation for the excess mortality in different BAME populations.

Sir Michael Marmot:

It's not just length of life, but quality of life. This is the gradient for life expectancy by deprivation and this is the gradient for disability-free life expectancy and you can see that the grading is steeper. We drew a horizontal line over of retirement age, pension age, and you can see that if pension age becomes 68, something like two thirds of the population do not have disability free life expectancy as long as 68, the bottom two thirds based on level of deprivation. If we want people to work longer, we go to do something about inequalities in health.

Sir Michael Marmot:

And the healthy life expectancy is really rather important. For males, years in poor health went from 15.8 to 16.2 and for females, it went from 18.7 to 19.4, so healthy life expectancy for women actually went down a little bit. That's not a very good record. We expect health to get better every year; that's what we've come to expect, and life expectancy to increase, but over the last 10 years that's slowed dramatically and that really should not happen. Something went terribly wrong.

Sir Michael Marmot:

And if we look by region, for the least deprived, there are relatively small regional differences. They exist, but they're relatively small. For the most deprived, there are dramatic region differences, and you can see the improvement for the most deprived 10% in London, but for virtually every other region outside London, it's declined. So, if you're in the least deprived 10%, doesn't matter much where in the country you live. The more deprived you are, the more it matters. So if we compare London with the North East, there's the gradient by level of deprivation. The gradient's steeper in the North East. In other words, the more deprived the area in which you live, the more it matters which reason of the country you live in, and we can see that in the North East life expectancy actually declined for women in the bottom 10%. Went down! Getting worse! That's not right.

Sir Michael Marmot:

In 2010 the Marmot Review, we had six domains of recommendations which became the basis for work in Coventry and in other local authorities: give every child the best start in life; education and lifelong learning; fair employment and good work for all; having enough money to live on is number four; healthy and sustainable places and communities; and strengthen the role and impact of ill health prevention. In the 2020 report we focused on the first five of these. We spent less time on the sixth for this reason. This is looking at the healthy eating guidelines and how much money household would have to spend to follow the healthy eating guidelines.

Sir Michael Marmot:

The households in the bottom 10% of household income, they would have to spend 74% of their income on food to eat healthily. It's all very well saying eat more fruit and vegetables, eat healthily but if you just spent 74% of your income, who's going to pay the rent? And if somehow you could pay the rent and eat, who's going to heat the house, the flat? So, we didn't spend too much time in 2020 report on lifestyle because if you get the other five right, lifestyle will look after itself.

Sir Michael Marmot:

The government in 2010 had a stated aim to reduce public expenditure and by golly, they achieved it. They went down from 42% of GDP to 35% of GDP. That's a dramatic rolling back of the state, but they did it in a very regressive way. This is level of deprivation, council spending per person, and all of the people listening to this know this. So, if you look at total local authority spending per person, in 20% most deprived areas, it went down by 32%. In the 20% least deprived areas, it went down by 16%.

Sir Michael Marmot:

We're worried about care homes and social care. Adult social care went down by 7% overall from 2010, went down by about 3% in the least deprived 20% and went down by 16% in the most deprived. The greater the need, the bigger the reduction, so it wasn't just austerity, but austerity applied in a regressive way. I showed this figure at a WHO meeting I'm chairing, commissioned in the Eastern Mediterranean, and one WHO economist looked at this and said, "You made it up." No, no these are real figures. "I've never seen anything quite so regressive as that," said this WHO. Well, this was government policy.

Sir Michael Marmot:

And if the idea of that government policy was to get the economy back on its feet, it didn't work. This is real wage growth from 2007 on in OECD countries. Greece minus 18%, Mexico, and then the UK. We had the third worst wage growth. We had negative wage growth throughout this whole period whereas all these countries had positive wage growth. So if the rational for austerity was to get the economy in good shape, certainly in terms of salaries, it didn't work.

Sir Michael Marmot:

Children living in poverty before and after housing. I always like to look at the after housing costs because housing's so important. Children 27% in poverty went up to 30%. Remarkably... Occasionally, I take to Twitter and I was moved to take to Twitter yesterday: remarkably, in parliament last week, the prime minister said that poverty went down. 400,000 children or families were taken out of poverty. I thought where on Earth did he get that figure from? Poverty went up. And in fact, the children's commissioner did an inquiry into those statements. He said the prime minister was wrong; it's a false statement. Poverty went up. Parenthetically, it did occur to me that if you want to level up and you can't tell the difference between up and down, then you'll succeed whatever you do, but I didn't say that on Twitter. I didn't say that now either, by the way.

Sir Michael Marmot:

If we look at children living in poor households by family type, for lone parent not working child poverty went up from 62% to 70%. Work was supposed to be the way out of poverty. For lone parent in full-time work, child poverty went from 18% to 30%. Work was not the way out of poverty, and increasingly, it was not the way out of poverty.

Sir Michael Marmot:

And the number of workers in poverty increased. So being in work was not the way out of poverty. And if we look at the tax and benefit changes that were introduced in 2015, let's look at working age families with children. The people in the bottom 10% of household income, the predicted effects of the changes to the tax and benefit system would be that the bottom 10% would lose 15% of their income. The next [inaudible 00:20:59] would lose 12% and then the richer you were, the less you would lose.

Sir Michael Marmot:

I sat with a former minister in the conservative government. I showed him this graph and said, "Your government's policy was to increase child poverty," and he said, "Well, it wasn't our explicit policy," and my response is, "They're very clever people in the treasury. They must have said to the chancellor the predicted affect of the policy will be to make poor people poorer." And this former minister looked uncomfortable and I hasten to add and I'm very careful in my Tweet about the prime minister not telling the truth about this that I don't approach this in a party political way. I approach this, we need the evidence of what's going on. We need to examine policies with respect with the impact on health and health equity.

Sir Michael Marmot:

For what it's worth, this is the effect of taxation on the amount people pay in tax. Now, the way ONS does these calculations, they tax is a percent of original income. That original income is the income you get in the market, and people in the bottom 10%, and tax is direct and indirect taxation, so people in the bottom 10% pay about 90% of their income in taxation. People in the top 10% pay just under 35%. Now, tax as a percent of gross income. Gross income is original plus benefits. Well, benefits approximately double the income of the bottom 10%, so they quote only pay 45% of their income in tax and the top 10% pay 35.

Sir Michael Marmot:

My guess is pre-lockdown if I went out into the street and asked somebody, "Do we have a progressive taxation system in this country?" I'd probably get arrested if I was stopping people in the street, but assuming I could ask, people would say yes. We don't. It's hugely regressive. I'm no economist, but I don't think that's fair.

Sir Michael Marmot:

And housing. Spending more than one third of your income on housing is one measure of difficulties and in each decile, housing had gone up as a proportion of income, but in the most deprived decile, it had gone up to about 38% of families were having to spend more than one third of their income on housing and they'd have to spend 74% of their income if they wanted to eat healthily.

Sir Michael Marmot:

Temporary accommodation has gone up, people sleeping rough. Now, this one's really interesting. This could be solved overnight as it was done in Covid-19. Pandemic, get people off the streets, find temporary accommodation and it can be done overnight. We just haven't wanted to do it. We just allowed rough sleepers to go up.

Sir Michael Marmot:

And young people: that was supposed to be a youth center for young people. We closed youth centers because we stopped funding local government and problems with education and the like. Guess what? Violence increased. The more deprived the area, the higher the rate of violence and we wring our hands and say, "Oh gosh, isn't this terrible? Knife crime and so on. Yeah, but we know the causes and it starts with early childhood and education and funding abuse centers and you stop doing those things and guess what? Rates of violence go up and they follow the social [inaudible 00:25:33].

Sir Michael Marmot:

Wanted to finish because in thinking of building back better, we need to put the climate crisis and inequalities on the agenda together. So, this is PM10 concentration. The more deprived the quintile, the higher the air pollution in all these English cities. And we said in our report in trying to bring climate change and health equity together 100% of new housing should be carbon neutral by 2030 and for net zero greenhouse gas emissions, ensuring inequalities do not widen as a result.

Sir Michael Marmot:

As we think about building back better, I've been intrigued by this: a wellbeing approach can be described as enabling people to have the capabilities they need to live lives of purpose, balance and meaning for them. Where might that quote have come from? Philosopher, Nobel prize winning economist, Amartya Sen? Well, it could be. But no, it was the New Zealand treasury. In 2019, this was the goal for the New Zealand treasury. As we think of building back better, let's put not growth of GDP at the heart of what we're trying to achieve, but a wellbeing approach enabling people to have the capabilities they need to live lives of purpose, balance and meaning for them then health will improve and health inequalities will diminish. Thank you.

Sue Woolley:

Thank you, Professor Marmot. We're not going to hear from colleagues at Coventry Cit Council: Councilor Kamran Caan, cabinet member for public health and sport and Liz Gaulton, director public health and wellbeing.

Kamran Caan:

Hi, thank you chair, Councilor Sue Woolley. I want to thank you for all the work you're doing and thank you for the invitation. I also want to give a special thanks to our colleagues in the NHS and all key workers who have really, really supported us during this difficult time and it's quite an emotional moment in our history. Many people are facing massive challenges due to Covid-19, and I finally just want to give a special, special thanks to the great Sir Michael Marmot. I've been a fan of his and I've sort of grown up watching him because quite early when I came into this role I was introduced to Sir Michael and from that day he's been a hero of mine because he has clearly allowed us to do some of the work we've done in our great city quite easily because I can always rely on his evidence to back some of the political decisions that we've made.

Kamran Caan:

I think it's important, I probably do start off with a couple of examples of the things that I can contribute to Sir Michael's support and his work. One of them was we invested approximately city-wide about 100 million overall, but we personally invested about 60 million into leisure facilities over the last couple of years, and one of the great things I want to mention is we've always had a service called passport to leisure. This service was about allowing people in vulnerable communities and in difficult situations to have discounted access to these services. Through that work of Sir Michael, we managed to roll that out massively and now these great facilities that are world class level, all these community members who are facing vulnerable and difficult situations, they can access these facilities at a greatly reduce cost. So I want to obviously credit him with that.

Kamran Caan:

And then just finally, we done fitness in the parks. This has been very, very popular in some of the most vulnerable and most difficult areas of the city where we have put these markings. One of the parks we've seen over 1000% increase in usage and we've also seen a massive amount of, for example, working class people who would never actually been able to take up running, cycling or just walking and keeping themselves fit, and especially some of the most vulnerable groups, age 10 and 11, obesity, young children, so I think we've had a massive impact there. So, I think I want to just thank Sir Michael Marmot amongst many others; I haven't got the time to actually list them.

Kamran Caan:

Coventry clearly is a really vibrant and diverse city. It's a beautiful place to live and work. We generally got quite a young population and I'm very proud to call this home and bring up my young family. I think there's many reasons why we will flourish and we are seeing it flourish. It's the ninth largest city in England and it's always had diversity and rich ethnically diverse communities and a young community. One third of the population are from minority ethnic groups and the city has experienced a high rate of population growth in recent years particularly amongst 18 to 29 year olds. These factors have actually secure the city status as the UK city of culture, 2021, something that we're very, very excited about and we know we're going to reap some great rewards in tackling inequalities and supporting people's mental health throughout that year.

Kamran Caan:

Some of improvements in Coventry's relative deprivation, there has been over the last few years, but it clearly masks some of the significant health inequalities between wards across the city, and I think to help, the city's always been very, very honored to work alongside Professor Sir Michael Marmot and the University College of London. I think as a Marmot city since 2013, I was the deputy cabinet member for public health at the time, I think the city has take some massive steps as I previously mentioned in reducing inequality, but clearly there's a lot more we need to do and we need to stay focused on increasing healthy life expectancy across all our communities, something that can actually be measured, not easily, but it is very, very possible. So we measure that quite clearly, but we know there's a lot of work that we need to do to support that.

Kamran Caan:

I think we also know it's not the only area where you live that has a massive impact on your health. Reducing health inequalities, one of the key responsibilities in the work I do in public health on the team, but these reductions are only going to continue to be achieved through our partnership with public, private and voluntary sector services, so it's very important that we continue our great partnership working. And our health and wellbeing board, which I am the chair of, we actually had some fantastic success and people speak very, very highly of the partnership working that we are actually undertaking and continue to undertake.

Kamran Caan:

I think all agencies will have an important part to play and it's been very evident during these extraordinary events, the Covid-19 outbreak as earlier mentioned. I think in recent months, organizations, businesses and the voluntary and community sector in Coventry have stepped up to help address the impact of the pandemic with determination and compassion and I think I've seen some eye witness accounts that community members have been in tears, staff members have been in tears because they've been so overwhelmed with the work that has actually been done on a voluntary basis by many of us.

Kamran Caan:

And I think as a result of the pandemic, people are no facing serious financial uncertainty. We have to accept that, and it's massive hardship, and I'm very, very worried and I know many of our colleagues are. The mental health concerns clearly need to be addressed and we need to be on the front foot, but we also need to understand why many of the BME groups have been particularly over-affected of Covid-19 and these issues need to come out and we need to actually see why this has actually happened.

Kamran Caan:

And I think, just moving on to probably the final phase of what I would like to say, I think we clearly recognize the pandemic is going to have a massive impact negatively, unfortunately, on health inequalities and it's even more important that we work with the work and the scientific proof we've got of Sir Michael Marmot and his great team doing this great inequalities work that we can actually accelerate our defense and I think we really, really must accelerate the work we're doing because a lot of this information is readily available now. We know what's causing us problems in our communities for many years now, so we got probably less of an excuse not to do little, but more of an excuse to do more. And I think, our particular in Coventry, our efforts in driving down the numbers of Covid cases means that we are now re-establishing and reconnecting people to health services, but while clearly recognizing this virus is a very key threat to the community and it's still unfortunately not over.

Kamran Caan:

And across Coventry, we are securing and channeling funding and commissioning services exactly where they need to be and where they will support health and wellbeing most of all for all our citizens, and we want to ensure people stay in good health, become more active and support some of their travel patterns that they've actually had to choose recently and we want to support their travel patterns and there's much work that we are doing.

Kamran Caan:

Test and trace, which I clearly believe from day one is the key to our success is now clearly being, it is established. It's still in its infancy unfortunately, but clearly, Coventry is proud to become a beacon for the outbreak control plans in partnership with our neighbors in Warwickshire and [inaudible 00:36:16]. We are working together to ensure local outbreak control plans are consistent as the city continues to recover. And our local plans have added focus on community engagement and participation and I'm pleased to see that the community is becoming, first and foremost, the most important point of contact. And also the inequalities that we know are going to come from this. So, we face massive challenges, but I think we got massive opportunities. We've seen the best of our city, and of our region, and of our country throughout the community and I think it's very, very pleasing to see that.

Kamran Caan:

But I think now is the time to be very, very bold and innovative in our approach to support this work of inequalities, to make a difference to the lives of all residents.

Kamran Caan:

I'm just going to pass over to who I feel is probably one of the best DPH's in the country, Liz Gaulton, to continue with a presentation to give you a bit more facts and information. Thank you.

Liz Gaulton:

Thank you, Councilor Caan. It's Liz Gaulton, Director of Public Health and Wellbeing for Coventry City Council. I've got some quite detailed slides and I've only got five minutes, but that's absolutely find because what you'll be able to do is look at the slides later and they will provide you a lot of the detail and context around the story that Councilor Caan has essentially just told if I just talk you through the slides very quickly. Okay, that's working.

Liz Gaulton:

So, Coventry has been very happy to work with Sir Michael Marmot since 2012 and this really explains the journey we've been on over those years. In terms of where we are now, we re-engaged every couple of years to check that a Marmot city is absolutely where Coventry wants to be and it is. The DPH annual report last year focused on inequalities and also, we did a full evaluation in terms of what Marmot as a city has meant to Coventry and that [inaudible 00:38:17] will soon be available as well.

Liz Gaulton:

This slides essentially talks about the journey we've been on from that Marmot city right through to working across Coventry, Warwickshire, our year of wellbeing, which really engaged the whole community's wellbeing, and the work we've done around the Kingston population health model and the One Coventry approach, which is now how we're working with all the communities and stake holders. I'll come back to our health and wellbeing model in a few slides time.

Liz Gaulton:

So, our population health framework which I've talked about in terms of our model very much embeds the wider determinants work and the work we've done as a Marmot city in everything that we do. And then of course Covid happened, so it gave us a chance to take stock, to actually think about how we mobilize some of the brilliant stuff we've done already in terms of Marmot, but also how we make that real in the background of actually, what's been very, very challenging times for us. So, as well as what every other city has done in terms of lockdown and in terms of protecting the most vulnerable, we think Coventry really focused on our more deprived communities and built on the work we'd already undertaken in terms of Marmot because we have the existing partnerships and it always feels very strange to talk about Marmot when you got Sir Michael in the room with us, but essentially, that is the short hand we use all the time in Coventry.

Liz Gaulton:

So, some examples here: we've established food networks, we've been really innovative with data sharing and mapping the [inaudible 00:39:40] council's hospital primary care, which had helped us identify vulnerable communities et cetera; we've established community networks, working with local volunteers; we've moved people out of their day job and actually put them into these community networks to help support community very quickly if the pandemic hit; we've utilized migrant health champions to support communities and disseminate messages to some of our communities which perhaps this has been even more difficult to understand; and worked with places of worship and faith groups to make sure they're safe settings and used them as well to send messages out.

Liz Gaulton:

Of course, we worked with temporary accommodation and rough sleepers and I know that has been across the country, but I think we did a really good job of that in Coventry as well. And as Councilor Caan talked about the work we're doing around test and trace [inaudible 00:40:25] Warwickshire, but a real focus on inequalities and disparities within that work as well, so it isn't just about test and trace.

Liz Gaulton:

In terms of resetting wellbeing, this rather complex and colorful slide show how we'd approach that across the city council, but in terms of the working with wider communities and new social economies, that's really important in terms of how we reset the work across the council as is the work around health and wellbeing and this is exemplified on this diagram. We've put those as equal importance to regeneration and the economy, all of which clearly has to happen in unison because all of them are equally important to have a thriving city, which of course is where we want to be.

Liz Gaulton:

So, in terms of our approach to resetting health and wellbeing, I'll flick right on to the next slide given the time pressures. So this again, is our population health model and here we've mapped the things we can do to reset health and wellbeing as we move out of the first initial stage of Covid and start to think about some of the lessons we've learned. And just some of the lessons on here that we've pulled out and really want to work with very quickly now are things like sustainable travel, workplace wellbeing, all things that have really been turned on their head in the last three months, but actually we need to take that opportunity. Other examples would be general health protection, immunization, vaccinations, really making the most of the fact that people may be keener than ever to have their vaccinations done, to have their children vaccinated. And things about mitigating the impact on specific groups. I'll talk in a little, there's a slide in a little while in terms of the recent PHE report and its disparities, but we really need to take that seriously in all communities, but particularly in areas such as Coventry. And of course, air quality; we've seen benefits in air quality due to less people commuting et cetera and how do we build on that as we go forward?

Liz Gaulton:

So in terms continuing to support our most vulnerable communities, and this is my last slide so hopefully I have done it in the time allocated, so a real focus on inequalities and disparities around Coventry place, and we are taking into account, taking very seriously, the PHE report into disparities and risks and outcomes around Covid and actually opportunities that gives us to really work in a closer way with some of those communities and to really emphasize those messages in terms of long-term health conditions such as diabetes, et cetera.

Liz Gaulton:

Our local outbreak control plan includes an emphasis on inequalities and disparities. And we're also undertaking alongside Warwickshire who are our close neighbors an impact assessment on Covid-19 and looking on how it's impacted on some of those health and inequalities we talked about. A focus on residents with protected characteristics, the economy and transport. We've made Equality impact assessments for all our services to understand both residents and staff, how Coventry, the impact Covid's had. And we've added a section to equality impact assessments around deprivation and we've been doing that for a couple of years now actually and that's actually called the Marmot element of our equality impact assessments and really helps embed it within all the work across the city council.

Liz Gaulton:

We have health and wellbeing as a key theme across the whole council's approach to reset and recovery. It's just all on the diagram I showed earlier and really want to continue to work in partnership to reduce the long-term health and inequalities caused by Covid. So I know that was a whistle-stop. I'll stop there. I'll stop sharing screen as well, but that information will be available on the website. I'm happy for people to come back to me individually, and I'll respond to questions. Thank you.

Sue Woolley:

Many thanks, Liz, and you may now breathe. Thank you too to Kamran. We're now going to move very quickly on to Councilor Asher Craig who is the deputy mayor for communities, equalities and public health at Bristol city council. Thank you.

Asher Craig:

Hello, can you hear me? Okay, all right, apologies. Thank you again for inviting me to make a presentation today about the work that we're doing here in Bristol. I may stick up a slide at the end just to give you an overview of the kind of numbers that we're dealing with, but I'm really today going to provide some reflections from Bristol on the impact of Covid-19 and health inequalities on our local community and what our place leadership [inaudible 00:45:00] and actions have been.

Asher Craig:

I want to first start off pre Covid and what was going on. As we know, England has lost a decade. That's the point that Professor Sir Michael made in his review report. And we know that the longevity and intensity of austerity that has been imposed by the government over the last decade has meant that we have utterly failed to address the link between deprivation and health inequalities. Some of the key findings into the Michael's review makes for deeply uncomfortable reading, particularly for national policy makers and Sir Michael set these out in his earlier presentation, which we should all believe is a social injustice.

Asher Craig:

The report sets out clearly how poverty deprivation affects people's health and to put it bluntly, when we've got plot differences in life expectancy and health outcomes against deprivation one trend becomes really clear: poverty kills.

Asher Craig:

This is not just an issue of social justice, but an unequal, fragmented and unwell population means that an unequal, fragmented and unwell workforce will happen. It's bad for the economy; it's bad for democracy. The original Marmot Review challenged public services, community groups, and local and national leaders to reduce health inequalities. And where leader from national government has been found wanting, [inaudible 00:46:36] has stepped up.

Asher Craig:

Sir Michael' praise for many of our local authorities like ourselves is all the more remarkable given that we have delivered this under a government that has imposed austerity, have generated the conditions that have driven demand, and in the place of crippling budget cuts, political instability which constantly undermines our own ability to plan for the long-term.

Asher Craig:

So Bristol has put the principles for a healthier population at the heart of everything that we do. So delivering affordable, high-quality and sustainable homes in balanced communities across the city, investing in the dramatic transformation of our transport network to connect people to people, people to jobs, people to opportunity. We've kept all of our children's centers open, all 21 and we've been safe guarding the future of all of our library services and supporting feeding Bristol to provide nutritious meals so families don't go hungry in school holidays. We preserved all our green spaces and developing opportunities to take up more sport and physical exercise which we have seen completely blow up since Covid. And most importantly, we have brought city partners and the city's citizens together to harness the whole city's energy to agree and achieve the vision of Bristol's One City plan.

Asher Craig:

So, these are all the steps that we have taken to unlock inclusive economic growth, empower people and communities, and to shake off the entrenched poverty, and improve health outcomes so people can enjoy longer, healthier and more independent lives.

Asher Craig:

So what has been the impact of Covid-19 here in Bristol? Well, we know that national PHE published their review recently on the impact of Covid on the ME communities, but we didn't wait for Public Health England's report to be published, and myself and the mayor commissioned a rapid review report from the national institute for health research. That came out on the 25th of May into the impact of Covid-19. That made, quite clearly, the links between the [inaudible 00:48:58] Marmot key principles, health inequalities, social determinants and set out quite clearly a set of actions that we needed to take. We shared those findings with community leaders and key stakeholders across the city, and as a result of that, we put together a Covid-19 BME steering group with the community so that we can implement the findings, not only of that report, but any additional recommendations that the community feels we need to take to address these issues.

Asher Craig:

Obviously, in terms of our own emergency response, and I suppose it's been said about Coventry, and I would say it, but I think our response has been second to none. I'm just heaping praises on all the staff involved in delivering our emergency responses. So we managed several volunteering schemes. We set up 22 community hubs across the city. Within 48, 72 hours we had over eight and a half thousand sign up to our [inaudible 00:50:16] Bristol volunteering website and as a result of that, nearly 4000 of those volunteers over the past 2, 3 months are shopping, doing prescriptions, walking dogs, supporting people who are self-isolating and shielding. We've got phone buddies reaching out to people who are feeling lonely and I think by the end of May, we were already doing nearly 1300 regular shopping visits, nearly 900 prescription collections, nearly 1000 people telephone befriending, dog walking, et cetera.

Asher Craig:

In terms of food distribution, it is absolutely been phenomenal and the kindness, and the generosity of spirit that has been shown by the citizens of Bristol has blown everybody away. The explosion of mutual aid support, local level in local neighborhoods has been absolutely outstanding. We have been working closely with Feeding Bristol, which is an umbrella organization that coordinates and supports the network of community and voluntary groups providing foods to those in need. Working alongside our key partner which Fair Share Southwest, we have been bringing a huge amount of food into the city supplying about 100 projects and in addition to that, we also through representations made by black, asian, minority ethnic communities, that project had to step up a gear and ensure that many of the food parcels that we were also providing were culturally appropriated to represent the range of communities here in our city.

Asher Craig:

So we also established four new emergency community food banks were opened and this has tripled the number of referrals for residents who have been struggling financially. The food club network now has 16 clubs each supporting 50 families each. We've got pop-up food distributions. I have to, again, I praise our pubs, our restaurants who have turned their businesses into pop-up food distribution sites and I must say that our homeless community must be the most well-fed community in Bristol with three course meals coming from of our [inaudible 00:52:50] chefs, well-known chefs in the city. It's actually been amazing and it's also changed their mindset as we enter recovery about the way in which they are going to be continuing to support the effort going forward.

Asher Craig:

On mental health, we've got Are You Okay? campaign led by ourselves on behalf of the Keeping Bristol Safe partnership. This will initially focus on three priority areas: safeguarding of adults and children, domestic abuse, and mental health and we'll encourage people to contact support services if they [inaudible 00:53:23] or someone they know that needs help.

Asher Craig:

It also works to highlight the hidden effects of Covid-19 and how to spot the signs of concern and remind everyone of the help available and where to find it. BME community based mental health services have a remained open for existing and new clients throughout the lockdown. Statistics have shown that a proportion of the ME communities are much more reluctant to seek support form services because of being unaware of what's available or they may feel that they will not be fully understood. So currently, fears are still very much heightened through many of the media reports of the impact on our communities and the very, sometimes confusing, messages about how to stay safe. And I think I call it the Cummings' effect because I think from that day all hell broke loose and people decided that, for all intents and purposes, they felt in some instances, lockdown was over. But anyway, we've been trying to manage that.

Asher Craig:

I think in terms of our Bristol planning for recovery, as I said, we have something called the Bristol One City plan that sets out our vision to 2050 and our mayor, Marvin Rees, published the plan back in January, 2019 and it sets out the challenge and aims to bring the city together around our common causes and our ambition is to make Bristol a much more equal, aspirational and resilient city.

Asher Craig:

Like Coventry, we work very closely with our city partners and this means at city organizations work together on priority issues, an approach that has been vital during coronavirus and as we plan how the city recovers. And our commitment to achieving the UN sustainable development goals has been central to this approach and underpins the work that we're doing alongside Marmot principles.

Asher Craig:

We have six One City boards within the city, one of them which is our health and wellbeing board. We have an economy board, environment, homes and community, learning and skills, and connectivity. Each of those boards convene as a multi-board to find solutions for the complex and multiple problems such as air quality and tackling persistent inequality which is now taking center stage as we climb down out of this pandemic.

Asher Craig:

In terms of health and wellbeing, Bristol Public Health, we're working collaboratively across the council to ensure that we're tackling health inequalities in all aspects of the council's work: a targeted stop smoking service; we're delivering Alive Bristol, it's our whole-city approach to healthy weight and requires a collection action across the local authority, the NHS and others to address these issues. The benefits obviously to the city include reducing obesity, food poverty, inequalities in health.

Asher Craig:

Mental health and wellbeing is another key priority for Bristol and has been for several years. In 2019 we launched Thrive Bristol, which is a 10 year program to improve the mental health of everyone in the city, and as a result of that work, we've actually set up a number of Covid-19 cells, one of which is our cell around mental health.

Asher Craig:

I could go on, but I won't because I'm conscious of everyone's time and I'm sure people want to ask questions, but finally, what I would say is that we're taking all the steps that we need to take to address these issues even in the face of austerity. The reality is that we in local government have been grappling [inaudible 00:57:27] for the paste decade and know that poverty, austerity engenders bad health, but we are working collectively with our partners to ensure that no one is left behind. So, I'll leave it there. Thank you.

Sue Woolley:

Very many thanks, Asher, and you too can have a bit of a breather. We're going to go to questions and answers, but you'll actually be relieved to know that the first three questions are for Professor Marmot, so I'm going to kick off.

Sue Woolley:

Professor Marmot, I'm going to offer you all three questions in one go if that's okay with you. If you find it too much, then shout at me.

Sue Woolley:

The first question: does Professor Marmot believe that the decline in life expectancy observed coincides with changes to benefit system, so universal credit, PIP, et cetera?

Sue Woolley:

The second question: London seems to have done better on health of deprived communities. Does Professor Marmot or other panelists have thoughts on how this has been achieved? So we'll share that with somebody else.

Sue Woolley:

And thirdly: does Michael have a view on how we can tackle health inequalities in access to testing for Covid-19 and access to appropriate healthcare?

Sue Woolley:

Over to you.

Sir Michael Marmot:

In trying to decide what course to slow down in improvement in life expectancy and the increase in inequalities, we said, fairly clearly I hope, that we can't say which specific change did it and we don't have a neat controlled experiment. What I've said is that in 2010 we thought that based on the evidence from the 80 or so experts that helped us compile the evidence that we were pretty clear about our understanding of health inequalities and over the next decade, most of those got worse and health stopped improving and health inequalities got worse.

Sir Michael Marmot:

It's highly likely that those changes, the rolling back of the state, the increasingly regressive nature of public expenditures, it's highly likely they play a role, but which ones? It's difficult to say. Now, child poverty is very bad for children and for their subsequent health and wellbeing, but child per se, the increase in child poverty, probably didn't cause the slowdown in life expectancy. It will some years from now, some decades from now, but not right now.

Sir Michael Marmot:

On the other hand, increasing poverty might well, and so the question about changes to the benefit system: yeah, it might well have made a difference in the immediate term rather than the longer term, but we can't say exactly which change led to the effect and that's why we've said, in general, the rolling back of the state and the regressive way that was done is likely to have played a key role in increasing inequalities.

Sir Michael Marmot:

The question of why London as seemed to escape the decline in life expectancy for the poorest 10% of women is difficult. Within the research field, there's been an active debate: if you're poor, are you better off or worse off to be in a rich area or a poor area? And the argument is well, if you're poor surrounded by rich people, that must be even worse because of relative inequality, so you're better off to be surrounded by poor people. That's one argument.

Sir Michael Marmot:

The other argument is, now hang on a minute, if you're in a richer area, the streets get cleaned, the schools are better, the amenities are better. So,[inaudible 01:01:57] of the data show, in general my view of the evidence, is the data show that if you're poor, it's even worse for your health to be in a poorer area. A poor person living in a richer area does not have their health damaged by knowing there's rich people around, they probably have their health improved by the better standard of services and amenities that are all around, and likewise, if you're a poor kid in a poor school surrounded by lots of other poor kids, you probably don't do as well as if you're a poor kid in a mixed school with a whole range of deprivation, ability and the like. I think the evidence is on that quite clear.

Sir Michael Marmot:

So, London, in general, is a much richer part of the country than the midlands, north east and north west, and that's why it's always been the case since we started working at the data that deprivation seemed to be less bad for damaging health in London than in the north of the country. So with the decade of austerity, the damage was probably less in London than in the rest of the country. So, it's sort of what we predicted, the long answer, but if you're poor, it's worse to be in a poor area than a rich area.

Sir Michael Marmot:

I think I'm going to pass over to my colleagues on the third one about access to testing for Covid-19 and appropriate healthcare.

Sue Woolley:

Okay, thank you [inaudible 01:03:44] for that, Professor Marmot. So, panelists, as far as the testing is concerned, your views please. What about, Liz, do you have a view on the testing? And I'll just reread the question to you: how can we tackle inequalities in access to testing for Covid-19 and access to appropriate healthcare?

Liz Gaulton:

Okay, thank you. So, test and trace clearly really important around Covid, but when the local outbreak control plan outline came out, if you like, asking councils to have their plans in place by the end of the month, there was to me a glaring omission in that and that was about community engagement and building trust and participation with our communities as [inaudible 01:04:31] we go along. So certainly in our own plan we put that in as an additional priority because test and trace will only work if people are supportive of it, believe in it, think it's worthwhile for them. It has massive implications as we're trying to get the economy working again to encourage people to take notice if they're asked to isolate, et cetera. And we need to work with local businesses on that as well.

Liz Gaulton:

I'm really conscious of a number of people in low paid work who may be reluctant to take time off and isolate if they're asked to do so when they're just starting to earn money again, so we really need to land those messages right in terms of inequalities, but also in terms of the breadth of communities we have in cities such as Coventry and Bristol and elsewhere, so that the messages are both timely, culturally sensitive, understood and adhered to. So, yeah, big piece of work to be taken by local councils in addition to what's been driven forward nationally.

Sue Woolley:

Thank you, Liz. And what about you, Asher? How are you finding the [inaudible 01:05:29] testing?

Asher Craig:

I think the jury is still out on there. I think with certain communities as well. I think it's about all of the mixed messages. So, we will be working with the communities as we have done through Covid to translate a lot of the information and get that out into our biggest communities: Polish, Somali, Bangladeshi, Indian communities. We held a meeting actually last week, myself and the DPH, with Imams from across all of the mosques in Bristol as well and actually what was really encouraging was that one of the Imams was suggesting, obviously going through GDP, that in the absence of proper test and trace that they were going to seek permission from many of their mosque-goers to provide their information and data so that they can help us with the track and tracing in the absence of not using. So, the communities themselves are being quite innovative.

Asher Craig:

I think there is a bit of an issue about are feeling quite suspicious, the way in which how track and trace has actually been introduced or not introduced because even I, quite surprisingly, my daughter called me yesterday and said, "Mom did you know you have something on your phone in relation to this?" So, it just sets conspiracy theories growing and in certain communities, it's much heightened than anywhere else, but we will do everything that we can. Like I said, we now have the engagement group that we are setting up as part of the test and trace. We have identified key community business and other leaders to be part of that group so that we are consistently sending out information in all languages and also using Facebook, social media platforms. That's been really, really helpful for us in Bristol.

Sue Woolley:

Thank you for that, Asher. Right, well, we'll move quickly on to the next three questions and the first one is, does the panel believe local authorities will use the Covid-19 inequalities data to develop strategies to build Marmot-based recoveries? Are there other examples of major successes and lessons learned from directors of public health across the country? So if I may, Professor Marmot, is that something you would like to see? But then we can see if there's any evidence from Liz with her colleagues as other DPHs across the country. So firstly to you, Professor Marmot.

Sir Michael Marmot:

Thank you. I want to draw attention to two things that have come out of Covid-19. First, the high risk in BAME populations and that's coincided with time with Black Lives Matter and that's very important. And the second, I'll come back to the first one in a moment. The second is front line workers. I've been asked a lot lately, "Are you optimistic about the future?" And my response was what a Brazilian colleague said to me who had a better grasp of English than I do. When I describe myself as an evidence-based optimist, he said, "No, you're not an optimist. You're hopeful." I said, "Go on." He said, "An optimist believes things will get better. You're hopeful that things will get better. You don't necessarily believe they will." And a very important distinction. I'm not predicting that things will get better, but we've got evidence now. That means that if we all work together, we can be hopeful that things will get better.

Sir Michael Marmot:

So the current [inaudible 01:09:45] of Black Lives Matter and the recognition of the high risk of BAME populations to Covid-19 should provide a hopeful [inaudible 01:09:56] that we can do things better in a different way. We've almost never discussed racism in Britain. I was on Radio 4. I don't wish to be critical, he said, being critical. But the secretary of state said, "Yeah BAME populations should wash their hands and indulge in social distancing." And I said, "And we should address structural racism." Washing your hands is good advice, social distance, good advice. And then I was asked, "Yeah but what do we do today, tomorrow?" We address structural racism today, right now. We don't say, "Oh, we'll put it off while we deal with the crisis." No, we do it right now because it's causing the problems right now. And it [inaudible 01:10:49] a moment. If we miss this moment and if we ignore it, we make a huge mistake. We do have a history of racism. It's not an American phenomenon. It probably was born in Britain, and we need to recognize and [inaudible 01:11:09].

Sir Michael Marmot:

And that brings me to the second one which is related to the BAME [inaudible 01:11:15], is the vital role that frontline workers play in our society. I tried to get recent figures; the figures I got were 2018 for the salary differentials between chief executives in the FTSE 100 and the average wage in Britain, so if the ratio is about 110, the ratio with the minimum wage is more like 200. Care workers in social care earn a minimum wage, if that. So they're earning one two hundredths of what a CEO in a FTSE 100 company earns. Does that reflect our views of the social value of these two people, the one looking after older people in care homes or at home and the one as a CEO of a FTSE 100?

Sir Michael Marmot:

I think most people in Britain, and the evidence suggests this, would say that the CEO of a FTSE would earn more than a care worker. That is what most people in Britain would say. And in fact, the evidence is they think perhaps 12 times would be an appropriate ratio, not 200 times. So as we go forward, and we recognize that we can't survive without cashiers at the checkout at supermarkets, without delivery drivers, without care workers, without NHS workers. These are vital people to our society and we don't value them and we pay them miserably, so as we build from Covid-19, let's learn those two lessons: the fundamental people and some structural racism and dealing with it and valuing all members of society for the contributions they make to the public [inaudible 01:13:22].

Sue Woolley:

Thank you, Professor Marmot. Liz, the second part of that question was around have you been able to pick up any elements of good practice or successes from directors of public health elsewhere in the country or do you feel it's a little too early at the moment?

Sir Michael Marmot:

Thank you. So, firstly just to echo Sir Michael in that actually Covid has shone a light on inequalities and health and wellbeing like never before and we absolutely mustn't lose that moment. In terms of my own workload and capacity over the last three months, it just had to be very focused on health protection in terms of the response to Covid and that will be the same for every pubic health in the country and rightly so, but there's a sort of slight frustration in me that actually there's a bigger issue here around inequalities and that we haven't quite got to it yet as you say, so it is a little bit early. I think the pictures I put up earlier in terms of the slides do tell the story of some of the examples and opportunities we've identified locally. I think DPHs need to be collating that information together now. I'm absolutely sure that we're all doing it locally, but we need to be telling the story, actually the inequalities around this as well as the health protection element. Can I just give one example which reflects on what Sir Michael said, but I personally found quite shocking? I think as a DPH, I'm pretty grounded and pretty close to what's happening in the city, but whilst Covid was causing mayhem in our care homes and many, many very tragic deaths, I was quite shocked to find that care home staff who were off sick, often because they were isolating, weren't getting full pay in our city and some of our care homes. Now, that might be naïve of me, but no wonder people were coming into work when they felt unwell, or possibly felt unwell, because they weren't getting paid if they weren't and that is very different to our staff working in the NHS. So, it's just a very local example of those inequalities that came home to me and something that we absolutely have to address on a system level.

Kamran Caan:

Chair, can I just mention something on care workers?

Sue Woolley:

Oh, please do.

Kamran Caan:

Just very briefly. I think Sir Michael Marmot raised a very, very important point and I think this is something often we are probably demotivating much of our country because we are brought up in a culture where our elders are our heartbeat. They're basically everything to us. It really hurts me that our older population is treated in this manner, especially the care workers were doing so great work, so Godly work, that they are not supported correctly. And really giving the impression to many members of our communities that as you get older you are worthless. You do not have any value even though you work day and night all your life to build this great nation and I think it's time that people genuinely, and I say this directly to government and I want the support of colleagues as well, the government of the day has the responsibility of the day and they really need to recognize that these people work all their life breaking their backs for our country.

Kamran Caan:

This is the time we should be giving them everything and more, not just thinking that they're a burden and a cost and it feels this way. And somebody who's maybe slightly younger, I say I still fear so much for our older population and it's something very close to me even though it might not be applicable for a little bit of time, but it's so close to my heart and I can't accept that and I want to really drive a campaign to recognize the work that they've done for our great nation. It seems like it's forgotten in minutes sometimes and it's very, very painful.

Sue Woolley:

Thank you, Kamran. Well, unfortunately time is really, we're up against the wall here, so I'm going to leave with a final question and it is to Sir Michael and for everybody else who may be listening in, please have, well once upon a time pens and paper, right? Maybe you need to be typing fast. The final question, Professor Marmot, can Sir Michael give us five high impact changes we can realistically make at our local upper tier local authority level to make a real difference and do it quickly, not over 10 years? Over to you, Sir Michael.

Sir Michael Marmot:

I would, wouldn't I, go back to my 10 years on report. It was February, so not that long ago, but it feels like another era, like another geological age, but was February, and we had five domains of recommendations: early childhood, by the way, I was delighted to hear that Bristol has kept all of its 21 children's centers open. Wow. I was muted. I was cheering silently.

Sue Woolley:

Big thumbs up though.

Sir Michael Marmot:

And you kept all 21 of your children's centers open. So, early child development. And what about the 7% per capita reduction in funding for education. That can be changed tomorrow and given... Sorry, let me depart from my five for a moment. Many people including me have commented on. We were presented in 2010 with austerity as if there was no alternative and it was a moral crusade [inaudible 01:19:05] collapse, God knows. The nation's maxed out on its credit card. Garbage, complete utter sheer economic illiteracy and it's showed to be economic illiteracy by most economists. In 2020, what won't we tell whatever it take? What happened to austerity as a moral crusade? Gone out the window. Whatever it takes. The government has essentially instituted universal basic income for 9 million workers on furlough schemes. Wow, this is a complete and utter change, so I never ever want to hear again, "No, we can't afford it."

Sir Michael Marmot:

So to come back to my five, it would be the five in my report: early childhood development; spending properly on education; looking at employment and working conditions; getting young people into meaningful green jobs as they leave school, high priority. It's part of the building back better, the green economy, the green new deal.

Sir Michael Marmot:

The forth, that's pretty easy: income, making sure people have enough money to live on. Now, that's hard at the local authority level. That depends on central government, but we're the most important people in the country, the [inaudible 01:20:33] of local government. Put pressure on central government to do the right thing.

Sir Michael Marmot:

The fifth, which is [inaudible 01:20:41], about healthy and sustainable places to live. When you see a picture of Milan, that's converted tens of kilometers of car use to cycling and pedestrian use overnight. So, this summer Milan will become much more of a pedestrian city. We can do that straight away, just decide we're going to have pedestrian cities. Dealing with the housing crisis is longer term. We could start tomorrow; we can't finish it tomorrow, but you can be looking at sustained transport.

Sir Michael Marmot:

And again, I love Bristol. What did you just tell us? You preserved your libraries and your green space. Absolutely vital. We don't live by bread alone. We need bread, that's why the food banks are so important, but we need libraries and we need green space and we need children's centers. So, in other words, the one thing I would say is take my 2020 report and let's do it right now.

Asher Craig:

Can I just finally say, Sir Michael, thank you so much. I am a fan and we too are following in the footsteps of Milan and this summer, we're pedestrianizing the whole of Bristol old city, so we're changing.

Sir Michael Marmot:

Fantastic.

Sue Woolley:

Well, on that note, thank you all. And I'm afraid we have run out of time. I think we could have gone on all afternoon and the questions kept coming and coming. I want to thank all of our speakers for their contributions. They have been fascinating and as usual, there's never enough time at these sorts of events. I want to thank you all for joining us and we hope that you've found it useful. The webinar's being recorded and it will be available on the LGA's events page as to all the presentations that the speakers have given. There is going to be a short survey, and I promise it is a short survey, and it's really helpful and useful if you can complete it and on that very final note, thank you and stay safe. Goodbye.

Kamran Caan:

Thank you.

Sir Michael Marmot:

Bye.

Sue Woolley:

Thanks all.

 

Download the presentations from this webinar

Liz Gaulton, Director of Public Health and Wellbeing, Coventry City Council Professor

Sir Michael Marmot, Director, UCL Institute of Health Equity