The Marmot Review is a series of reports on health inequality in England, led by Professor Sir Michael Marmot. The reports focus on the social determinants of health—the conditions into which people are born, grow, live, work, and age. They argue that addressing health inequalities is a matter of social justice and that health is profoundly shaped by societal fairness, not just lifestyle choices or healthcare access. Commissioned to propose evidence-based strategies for reducing these inequalities, the reports provide a framework for understanding how social and economic factors create disparities in health outcomes.
The 2010 Fair Society Healthy Lives Report
The first Marmot Review, “Fair Society, Healthy Lives,” was published in February 2010. It analyzed the causes of unequal health outcomes, moving the focus beyond the healthcare system to the broader social and economic landscape.
A central finding was the “social gradient in health.” This concept describes how health outcomes improve at each step up the social and economic ladder. The lower a person’s socioeconomic status, the worse their health is likely to be. This gradient runs across the entire population, meaning even those in the middle experience worse health than those at the top.
The report emphasized that these inequalities are not inevitable and can be reduced. It framed the issue as a matter of fairness and social justice, arguing that everyone should have the opportunity to lead a healthy life. Evidence showed people in deprived areas die sooner and spend more of their lives with a disability, an average difference of 17 years in disability-free life expectancy. The report concluded that action was needed across all sectors of society, not just health.
The Six Policy Objectives
To address the social gradient in health, the “Fair Society, Healthy Lives” report outlined six policy objectives. These recommendations provided a framework for action across national and local government and other organizations.
- Give every child the best start in life by supporting parents and providing high-quality early years education.
- Enable all children, young people, and adults to maximize their capabilities and have control over their lives through access to good education and training.
- Create fair employment and good work for all, ensuring jobs are safe, secure, and pay a living wage.
- Ensure a healthy standard of living for all by addressing income inequality, fuel poverty, and access to affordable, healthy food.
- Create and develop healthy and sustainable places and communities, including quality housing and safe, green spaces.
- Strengthen the role and impact of ill-health prevention by shifting the health system’s focus from treatment to tackling the social determinants of health.
The Marmot Review Ten Years On
In February 2020, a follow-up report, “Health Equity in England: The Marmot Review 10 Years On,” assessed progress since the original review. The findings revealed a reversal of previous positive trends. For the first time in over 100 years, the rate of increase in life expectancy in England had stalled, a trend more pronounced than in most other high-income countries.
The 2020 report found that health inequalities had widened, and the slowdown in life expectancy gains was not evenly distributed. For the poorest 10% of women, life expectancy had declined between 2010-12 and 2016-18. The health gap between the most and least deprived areas grew, with the largest decreases in life expectancy in the most deprived parts of the North East.
The review also highlighted that people were spending more of their lives in poor health. It linked these negative trends to the social and economic policies of the preceding decade, particularly austerity measures that resulted in significant funding cuts to public services. These cuts disproportionately affected more deprived areas, worsening the conditions that lead to poor health.
Proportionate Universalism Explained
A core principle of the Marmot Review’s recommendations is “proportionate universalism.” This principle advocates for universal actions that help everyone, but with a scale and intensity proportionate to the level of need. Support should be available to the entire population, with additional resources directed toward the most disadvantaged.
This approach tackles the social gradient in health by improving outcomes for everyone while narrowing the gap between the best and worst off. It recognizes that focusing only on the most deprived would not address the full spectrum of inequality. The goal is to “level up” by bringing the health of those lower on the social ladder closer to the health of those at the top.
An example of proportionate universalism is a universal early years education system open to all children, but with additional funding targeted at children from low-income families. This ensures that everyone benefits from the service, but those with the greatest need receive extra help. The approach aims to create a fairer system that improves overall population health and reduces health inequalities.