Fair Society, Healthy Lives


Owl has tracked down the sources of the recent press comment on declining health and health inequality.This post places these on the record, with summaries below. (Serious read, not for the faint hearted).

In 2010 Sir Michael Marmot’s strategic review of health inequalities in England post- 2010 was published under the title “Fair Society, Healthy Lives” . In the review, recommendations were made in six domains:

  • Give every child the best start in life 
  • Enable all children, young people and adults to maximise their capabilities and have control of their lives
  • Create fair employment and good work for all
  • Ensure a healthy standard of living for all 
  • Create and develop healthy and sustainable places and communities
  • Strengthen the role and impact of ill health prevention


This February a “ten years on”  report has just been published which shows that, 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. The data that this report brings together also show that for almost of all the recommendations made in the original Marmot Review, the country has been moving in the wrong direction. 



Report Conclusions and Summary of Recommendations

In 2008 the Commission on Social Determinants of Health, with Sir Michael Marmot as chair, published Closing the Gap in a Generation. The title was meant to reflect the fact that the Commission’s assembled evidence showed that, if acted on, the health gap – inequalities in health within and between countries – could indeed be closed within a single generation. The cover of the report read: “Social injustice is killing on a grand scale”. It was the Commission’s firm view that not acting on the evidence was deeply unjust to the billions of people whose health was made worse by social conditions they had no part in creating.

It was in this spirit that the Marmot Review team approached the task of assembling the evidence to show how the conclusions of the Commission on Social Determinants of Health could lead to recommendations for reducing health inequalities in England. Because we judged that social justice should be at the heart of policies to improve health, we gave the 2010 Marmot Review the title, Fair Society, Healthy Lives. Put fairness – social justice – at the heart of all policy-making and health would improve and health inequalities diminish.

This ’10 years on’ report shows that, 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. The data that this report brings together also show that for almost of all the recommendations made in the original Marmot Review, the country has been moving in the wrong direction. In particular, lives for people towards the bottom of the social hierarchy have been made more difficult. Some of these difficulties have been the direct result of government policies, some have resulted from failure to counter adverse trends such as increased economic inequalities or market failures. 

The purpose of this report is to show what can be done, in a spirit of social justice, to take action on the social determinants of health to reduce these avoidable health inequalities. It is not enough for the Government simply to declare that austerity is over. Actions are needed in the social determinants to improve the lives people are able to lead and hence achieve a greater degree of health equity and better health and wellbeing for all. While our approach emphasises the social determinants of health, there is much that the NHS can do to address the social needs of patients. Similarly, Public Health England should be taking a lead not only in action on traditional public health concerns but on the causes of inequalities that we have highlighted in this report.

But efforts to reduce health inequalities will require more than the NHS and Public Health England. Experience shows that action, across the whole of society, will require the commitment of the Prime Minister and the whole of government. The justification for whole-of-government action is that it is the route to reduction of health inequalities. There are two further reasons for the whole of government to act. First, as we said at the outset, health and health inequalities are good measures of how well society is doing: how well it is creating the conditions for people to lead lives they have reason to value. Second, there will be other benefits from the actions we recommend here. Investment in improving early child development, and reducing exposure to adverse child experiences, will reduce antisocial behaviour and crime in addition to its beneficial effects on mental and physical health. Improving education will lead to more capable citizens as well as a more qualified workforce. Creating healthy environments will be good for meeting climate change targets. Reduction of poverty is a good thing in itself, quite apart from its beneficial effect on reducing health inequalities. A more equal, cohesive society is simply a better, healthier place to live.

Although we have had much to say on the increasing levels of poverty in England – in some areas of England more than one child in two is growing up in poverty – the social gradient in health must remain in focus. The gradient has become steeper. Action must be taken not only to improve living conditions for the worst off, but also for those who are relatively disadvantaged. The aim of all policies should be to level up, for everyone to enjoy the good health and wellbeing of those at the top of the social hierarchy – hence our reiteration of proportionate universalism: universalist policies with effort proportionate to need. We extend this to include investment – over the last decade government allocations of funding have declined most in poorer areas and this must be reversed. Funding should be allocated in a proportionate way – those areas that have lost the most and are more deprived must receive renewed investment first and at higher levels. 

We repeat: we neither desire nor can envisage a society without social and economic inequalities. But the public thinks that inequalities have gone too far, and evidence from across the world suggests that the level of health inequality we see in England, is unnecessary. We welcome action from local and regional governments to tackle social determinants of health. More action of the type we have described here will be necessary. It is not, though, a matter of action by either central government or local government: we need both and we need leadership. If we leave this for another 10 years, we risk losing a generation. 

Our main recommendation is to the Prime Minister – to initiate an ambitious and world-leading health inequalities strategy and lead a Cabinet-level cross-departmental committee charged with its development and implementation. We suggest that the new strategy is highly visible to the public and that clear targets are set.

As we write the final words of this report, the world is demanding urgent action on climate change. It is of grave concern that such actions to mitigate climate change should not lead to wider socioeconomic inequalities. We need to bring the agendas of climate change and of social determinants of health and health equity together.

In effect, this report is calling for a reordering of national priorities. Making wellbeing rather than straightforward economic performance the central goal of policy will create a better society with better health and greater health equity. [Owl’s emphasis]

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