Pillar 1: The wider determinants of health

The main cause of health inequality is social inequality, that is the variation across the population in income, employment, education, and access to health care. In England, health inequalities were already worsening before the COVID-19 pandemic. The report Health Equity in England: The Marmot Review 10 Years On (2020) showed that life expectancy in England had stalled and the impacts of austerity policies had damaged health and increased health inequalities. The 2021 report Build Back Fairer: The COVID-19 Marmot Review demonstrated that these inequalities had worsened the impact of the COVID-19 pandemic for those on the lowest incomes and would widen health inequalities in the longer term as a result of widening inequalities in key wider determinants of health.

Despite the deteriorating national and regional context, there is still scope for local areas to make a real difference. For example, in 2021, the Cheshire and Merseyside Champs Public Health Collaborative and the Population Health Board of the Integrated Care System commissioned the Institute of Health Equity (IHE), to support work to reduce health inequalities in Cheshire and Merseyside. The aim of the programme is to take action on the social (wider) determinants of health and to build back fairer from COVID-19. The final report, All together Fairer: health equity and the social determinants of health in Cheshire and Merseyside will be launched on 26 May 2022 and will include a wide range of recommendations and actions for us to consider. This provides added focus and priority to existing work on health inequalities in the sub-region and will help develop new momentum and recommendations for effective action in the context of the COVID-19 pandemic. Cheshire West is part of the Cheshire and Merseyside Marmot community and is fully committed to taking action on the recommendations outlined in the report.

The development of the Integrated Care System (ICS) in Cheshire and Merseyside (see Pillar 4 below) with its nine Places (on Local Authority footprints) presents a real opportunity to forge an action-based, accountable system which will generate greater health equity in the region based on partnerships with other sectors. The ICS is also supporting the reduction of health inequalities through the national Core20PLUS5 programme. CORE20 refers to the most deprived 20 per cent of the national population. PLUS refers to the population groups in Cheshire and Merseyside that experience poorer than average health access, experience and/or outcomes who may not be captured in the CORE 20 alone and would benefit from a tailored healthcare approach. For example, certain ethnic minority communities, rural communities, people experiencing drug or alcohol dependence, or Gypsy, Roma Traveller Communities. 5 refers to five key clinical areas of health inequalities:

• Maternity
• Severe mental illness
• Chronic respiratory disease
• Early cancer diagnosis
• Hypertension case finding

The CORE20PLUS5 Programme is:

• Developing a list of high impact actions in partnership with local systems which will provide a practical menu of options for engaging with the defined communities.
• Driven by quality improvement methodologies to ensure measurable and sustained improvement.
• Working closely with Local Authorities, communities, and the Community Sector in tackling health inequalities.

This ambitious programme of work will run alongside wider efforts to reduce health inequalities. Local work on health inequalities is important. Whilst Cheshire West is generally thought of as an affluent borough, the overall picture masks stark gaps between areas of prosperity and deprivation. The median (average) local household income is £28,525 per year but 15 per cent of local households have an annual income of less than £15,000. Some 24,670 local people live in neighbourhoods ranked in the most deprived 10 per cent in England and 9,003 local children lived in low-income houses during 2019/20. Whilst female life expectancy in the borough continues to rise, for men it has started to fall. The inequality in both male and female life expectancy at birth has shrunk. Male life expectancy across the borough varies by up to 9.8 years for men and 7.8 years for women.

To address inequalities, investment should be targeted to where need is greatest, an approach known as proportionate universalism. Long term investment in a life course approach can limit ill health and the accumulation of risk throughout life. Altering policies, environments, and social norms to reduce inequalities will benefit all our residents, as well as future generations. Therefore, this approach can provide high returns for health and contribute to social and economic development. A holistic approach to investment is required, focusing on preventing health risks and reducing their cumulative effect throughout life and across generations to mitigate the economic burden of health costs.

We will:

• Agree which recommendations in the All Together Fairer Marmot Report are priorities for Cheshire West and include them in our action plan and outcomes monitoring framework.
• Increase community engagement to build trust, understand needs and incorporate lived experience into appropriate planning and service delivery, brokered by the Community Sector and Poverty Truth Advisory Board, with a focus on underrepresented groups including Romany Gypsy, Traveller and Boating communities. This includes better representation in our nine Care Communities (see Pillar 4: An integrated health and care system).
• Build on the West Cheshire Anchor Network to maximise social value opportunities and community wealth building.
• Address food poverty via increased access to healthy, affordable, and culturally appropriate food – shifting from food banks/emergency provision to social supermarkets integrated with welfare advice and service signposting, rooted in dignity and fairness.
• Adopt a proportionate universalism approach, where universal policies and interventions are developed to be more intense where need is higher.
• Adopt Cheshire and Merseyside’s Marmot indicators into local organisations including NHS, Cheshire West and Chester Council, businesses, and the Community Sector during 2022-23
• Work in partnership with the Integrated Care System to support the CORE20PPLUS5 programme locally
• Integrate wider determinants of health in all policies and in all work commissioned. All Council and local NHS strategies and decisions to be assessed for wider determinants of health impacts.
• Ensure our local poverty and other strategies includes commitment to reducing digital exclusion.
• Work in partnership with local communities to assess digital exclusion priorities.
• Assess the budget for addressing the social determinants of health in the NHS and local authorities in 2022/23.
• Work with Community Sector to include their contributions to addressing the social determinants of health.
• Extend the anchor organisation approach within the NHS, and to all other stakeholders e.g., public services, academic institutions, police.

Implement and enforce a 15 per cent social value weighting mandatory in all NHS procurement.