Building back fairer: Manchester’s marmot approach

COVID-19 exposed and exacerbated these inequalities, particularly in relation to economic and social deprivation, the pandemic’s disproportionate impact on ethnic minority groups and the role of systemic racism, as a fundamental cause and driver of adverse health outcomes. 

As a result, IHE’s work with the region refocused on gathering the evidence of the nature and extent of inequalities caused by the pandemic and making actionable recommendations to reduce them.

Its report, Building Back Fairer in Greater Manchester, provided a framework for change. Its recommendations focus on putting health equity at the centre of governance, including how resources are allocated across the region and gearing policies towards achieving greater health equity.

Manchester City Council, one of ten councils in the Greater Manchester region, pulled together a group of leaders from across the public sector, academia, and community organisations to represent Manchester’s ‘population health system’ to respond to the IHE Review with an action plan for the city.

Launched in 2022, Making Manchester Fairer (MMF) is a five-year action plan and long-term ambition to address health inequalities in the city focussing on the social determinants of health. The plan identifies heart disease, stroke, cancer and lung disease as the four leading causes of premature death in the city - driven predominantly by three behaviours: tobacco use, poor diet and physical inactivity. 

Cordelle Ofori, Director of Public Health for Manchester City Council, highlighted the city’s stark inequalities at a recent Health Equity Network Conference. Manchester is the sixth most deprived borough in England, with 47.9 per cent of children living in poverty and 52 per cent of the population from racially minoritised communities.

Life expectancy at birth for Manchester residents fell by an estimated 3.1 years for men and 1.9 years for women in 2020 compared to previous years. In contrast, the decline for England was 1.3 years for men and 0.9 years for women. Men in the most deprived areas live eight years less than those in the least deprived areas, while women face a six-year gap.

Describing the eight Marmot principles as themes, Dr Ofori says: “How we tackle those eight themes is more important than what we do.” 

The Making Manchester Fairer plan underpins the themes with six principles of its own in order to add value to existing work:

The work needs a system approach to connect the Marmot themes and to be effective, says Dr Ofori. Three areas are particularly important:

• community power
• tackling poverty
• addressing structural discrimination and racism.

A vital element of the plan is ensuring that residents’ voices are heard. The council recruited 16 people from the local community whose demographic reflects that of Manchester’s residents.

Participants were recruited through a variety of communication methods, asking if they identified with a particular group, for example people who were carers, or ex-armed forces, and if they were interested in attending monthly community forum meetings to provide feedback based on their personal knowledge and experience. These individuals, paid for their time and reimbursed for travel, provide feedback rooted in their lived experiences.

Engaging with residents is crucial to finding solutions to reduce health inequalities. Those consulting with them recognise they need to build trust with people and that communication is two way, so feedback on progress is important.

The council’s anti-poverty strategy (produced in 2023), now integrated into MMF, exemplifies this approach. For instance, initiatives such as “poverty-proofing the school day” remove barriers to education for children from disadvantaged backgrounds.

“Poverty cuts across everything,” says Ofori. The anti-poverty strategy will implement interventions to positively impact residents’ lives over the medium to long-term whilst MMF will provide the system changes needed to tackle poverty.  An example of this is the work being done to poverty-proof the school day by removing the barriers that pupils might face in accessing education due to poverty.

The city intends to develop an educational programme to tackle structural discrimination and racism, which can be rolled out across the system. Leadership and accountability, particularly in recruitment, will be key to its success in ensuring barriers are removed. The city’s focus on community engagement will have a key role for marginalised communities and young people.

Improving housing is a cornerstone of Manchester’s Marmot work, and the city plans to build 10,000 affordable homes over the next 10 years. Ensuring homes are also healthy environments is key. 

The MMF focus has been on developing pathways that ensure that when a child is seen with respiratory illness, the risk of damp and mould is addressed. Whether through the council or the housing provider, action is taken to deep clean the house. Houses need to be accessible, affordable, safe, secure, and of good quality.

Where we live is how we live,” said Ofori.