Marmot Principles

Professor Sir Michael Marmot

 

Professor Sir Michael Marmot is a world leader on the causes of avoidable unfairness in health outcomes, [health inequities]. Over the last 50 years he has led numerous research studies for governments, United Nations' agencies and NGOs on the main drivers of health and longevity. His Institute of Health Equity [IHE] at University College, London is the world's leading global think tank on the subject.

Sir William Beveridge's report in 1942 [referred to below] identified the five 'giants' of social problems in Britain: idleness, ignorance, disease, squalor and want. It was this hugely important document that laid the foundation for the Welfare State in Britain, presenting a tantalising future vision for a nation struggling to escape the seemingly endless horrors and deprivations of WW2. Evidence subsequently showed that one of these giants, health and disease, was strongly influenced by the other four and this explains the thrust of many Marmot reports which reveal why unfair avoidable health gaps, i.e. health inequalities, exist and suggests ways to remove them.

The situation in 2019 shows little variation in 2025.

Britain's health record is not impressive. Until 2010, life expectancy in the U.K. increased at the rate of roughly one year in every four years. Sadly from around 2010 for a decade, the rate of increase slowed then almost stopped and one recent result of this was the relatively ineffectual UK response to Covid which allowed Covid-19 to exacerbate health inequalities. From 2009 to 2023 life expectancy in the UK did not improve at all and this in a wealthy society which enjoyed the implied promise, the unspoken assumption, that life in general, particularly in health, would continue to improve.

Furthermore, as one might expect, health is seen to be strongly linked to deprivation. In most regions of England excluding London, life expectancy has been falling among people living in the most deprived areas. Ease of access to healthcare cannot be a major cause as estimates suggest that variations in health care are responsible for no more than 20% of the total. The main reason for this link can only be attributed to the social determinants of health, Beveridge's other four 'giants'. In 2024 the Institute of Health Equity published a calculation that if everyone in England had the low mortality rates of the people living in the least deprived 10% of areas, there would have been one million fewer deaths over the decade after 2009.

Between poor people living in deprived areas, and the rich living in greater affluence, there is a social gradient which means that at every step up, people get healthier and live longer. In the decade after 2009 one million people lived shorter lives than they could, or should have, which suggests that a Government which cares, must work to flatten the social gradient. Before 2009, the social gradient had been flatter but austerity made it substantially steeper and Marmot's IHE [Institute of Health Equity] calculated that 148,000 more people died as a result. One way in which austerity harmed health is the regressive way in which central government funded local government with the most deprived areas receiving the greatest funding cuts. The IHE promotes the principle of 'proportionate universalism', with most help going to those in most need but it discovered, post 2010, that the opposite had been happening.

Eight Marmot Principles.

These were developed for the first Marmot Review in 2010 and are based on evidence about the main drivers of health inequities found locally, nationally and globally.

1. Give every child the best start in life.

2. Enable everyone to maximise their capabilities with control over their lives.

3. Create fair employment and good work for all.

4. Ensure a healthy standard of living for everyone.

5. Create and develop healthy and sustainable places and communities.

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

7. Tackle racism, discrimination and their outcomes.

8. Pursue environmental sustainability and health equity together.

Andy Burnham, Mayor of Manchester

The first time I read the list above, I was both aghast and impressed at the extent of action demanded by Marmot, of local councils, government bodies, commerce, education, municipal endeavours, voluntary bodies. The breadth and depth of guidance offered by the Marmot Principles and the firm imperatives therein are superb but much education in this area is needed. However, arising from Marmot's ground-breaking work there are now over 50 places developing Marmot Communities in the UK. Public Health Scotland is working with IHE to develop a national health strategy and collaborating with three Scottish Marmot places: Aberdeen, North Ayrshire and South Lanarkshire. In Gwent, Marmot initiatives are underway, while the government of Wales has declared it is working to become a Marmot Nation. Legal and General are funding the Marmot Health Equity Network, making available £3 million for community and voluntary sector projects to improve health equity around the country. In Greater Manchester, under the inspiring leadership of the Mayor, Andy Burnham, IHE worked with ten local authorities, the health sector, social  services and the Vice-Chancellor of the University. At every level local, regional, national, it is inspiring to see the leadership provided by elected politicians and officials in establishing the Marmot Principles.