Marmot review eleven years on – opportunities

10 March 2021

Eleven years ago, Professor Sir Michael Marmot, by invitation from the Secretary of State for Health, chaired an independent review to find the most effective strategies for reducing health inequalities in England.

The final report, Fair Society Healthy Lives, required action in six key areas:

1. Give every child the best start in life

2. Enable all children, young people and adults to maximise their capabilities and have control over their lives

3. Create fair employment and good work for all

4. Ensure healthy standard of living for all

5. Create and develop healthy and sustainable places and communities

6. Strengthen the role and impact of ill-health prevention.

Where are we now, a decade on? According to the Health Foundation: “In England, health is getting worse for people living in more deprived districts and regions, health inequalities are increasing and, for the population as a whole, health is declining.”

In short, despite a pivotal independent review to develop strategies to improve health inequalities, things have got worse, not better. What can we do to move on from this?

Long-term national strategy

According to the Institute of Health Equity, the biggest discrepancies in life expectancy are between the most deprived neighbourhoods in the north east and the least deprived neighbourhoods in London. In some deprived communities in the north of England, life expectancy has actually fallen.

Research shows that austerity and national funding cuts have meant that health inequalities haven’t been prioritised – including a lack of national strategy to tackle this issue. This has led to a significant decrease in funding for key services, for example a reduction in local authority available spend for children and young people of £3 billion between 2010-2018. The inherently affects those in the most socially deprived communities the most.

Long-term strategies to shift the approach to funding should be introduced to enable all citizens to have the same health and wellbeing outcomes. The aim of national policies should be to help those in the most deprived communities the most in order to deliver a proportionate and fair way to decrease health inequalities.

Board long-term support – be a part of healthy and sustainable communities

The recently published health and social care white paper had some focus on place, although it is not defined. A huge part of this is about local organisations, such as NHS providers and local authorities, working together to strategically provide the most needed services for local communities.

Collaboration between these bodies will bring “innovative and creative solutions, exploring the potential of digital and data”, according to the white paper. Data is such a strong force in this, with the power to join up care and understanding of communities to drive transformation. Boards should take this as an opportunity to understand inequality locally and find ways to work collaboratively to shift local inequalities.

Other long-term opportunities abound in the new integrated care model. ICS and provider organisation strategies could and should also consider the environment, climate change and air quality.

Having a proactive approach to building facilities on issues such as electricity use can shift green credentials while helping environmental outcomes. Air quality and related health risks have been seen as a major equity issue, with pollution levels worse in the most deprived areas. Public bodies have an opportunity to switch to greener energy resources and even consider new ways to approach building new facilities in the most environmentally friendly way possible.

Board short-term support – work with others

And what can boards of public sector organisations do to support a reduction in health inequalities in the immediate term?

The public sector is the largest employer in the UK, with the NHS famously known as the fifth largest in the world. With this brings opportunities for all public sector organisations to look after colleagues, who are also citizens, and support them where you can. Creating fair employment and good work for all is one of the key action areas, which will affect thousands of staff.

Investing in good quality policies with benefits for staff can reap huge benefits for health and wellbeing. Now, more than ever, when COVID-19 has affected so many, all boards should spend time ensuring that their organisational policies are right to support staff. Happy, healthy, supported staff can help drive reductions in health inequalities.

NHS boards should also work with local authorities and voluntary groups to better understand the causes of health inequalities in their areas. The collaboration built in to the new health and social care system creates opportunities to explore initiatives related to known health determinants – including foodbanks, job skills programmes, community projects and physical activities.

The systematic relationship between deprivation and life expectancy, known as the social gradient in health, shows that males living in the lead deprived areas can, at birth, expect to live 9.4 years longer. Many third sector organisations have taken the place of interventional and preventative services that local authorities and others used to run but can no longer afford to. Engaging, working together and investing early as a collective is key.


  • Collaborative use of data could transform the way in which inequalities within local communities are understood and therefore supported.
  • Long-term planning from public sector organisations can also help to reduce health inequalities, with a focus on communities and the environment.
  • Public sector organisations can take an immediate role by supporting and looking after colleagues.
  • NHS boards should look beyond health at socio economic factors – working with other local experts, such as local authorities and third sector providers, to truly understand and respond to local need.

If this Illumination prompts any questions or comments please call us on 07732 681120 or email

Prepared by GGI Development and Research LLP for the Good Governance Institute.

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