Building fairer towns, cities and regions: Insights from Marmot Places

I am delighted to introduce this important report on Marmot Places and the transformative work being carried out across towns, cities and regions to address health inequalities.

The ground-breaking publication of the 2010 Marmot Review, and its follow-up in 2020, have been key to shaping our understanding of the social and economic costs of health inequalities. These landmark reviews not only highlighted the urgency of addressing these disparities, but also provided a robust and well-evidenced business case for concerted national and local action. They continue to serve as a blueprint for creating a fairer society and improving health outcomes for our communities. 

The Marmot approach, grounded in the social determinants of health, offers a powerful framework for tackling the root causes of health inequalities. It is not just about delivering better health outcomes, but about creating equitable communities where everyone has the opportunity to thrive.

This report highlights the innovative and collaborative work of councils and their partners, who have embraced the Marmot principles and turned them into meaningful action. From leading the way with new initiatives in housing and employment to embedding health equity across policies and practice, these case studies showcase the determination of local government in adapting and innovating, despite funding pressures and lasting impacts from the pandemic.

However, this work cannot stop here. The progress achieved so far must inspire ongoing commitment, both locally and nationally. Addressing health inequalities requires sustained effort, robust partnerships and an unwavering resolve to ensure that everyone, regardless of their background, has the opportunity to live a healthy and fulfilling life. Let this report be a call to action for all sectors to redouble their efforts and build on the foundations already laid.

That is why we believe this report must also serve as a call to action for a new national health inequalities strategy. National leadership is vital to match the local ambition we see in these case studies. By working together across sectors, regions, and all levels of government, we can build on the progress already made and move closer to a more equitable society where everyone has the opportunity to thrive.

Marmot Places came into existence after the significant 2010 report Fair Society, Healthy Lives was published. This independent review, commissioned by the then government and led by Professor Sir Michael Marmot, identified the most effective evidence-based strategies for reducing health inequalities in England.

The review concluded that reducing health inequalities would require action on six policy principles. Two additional principles have been added in recent years (see box). Subsequent reports and guidance including Marmot indicators – a framework of measures to assess performance delivery of Marmot principles - have followed, such as the influential Marmot Review 10 years on.

More than 50 local areas across England, Wales and Scotland have signed up to be Marmot Places; 37 of them are local councils. Coventry City Council was the first, 11 years ago, Oxfordshire County Council is one of the most recent.

What is a Marmot Place?

A Marmot Place recognises that health and health inequalities are shaped by the social determinants of health (SDH) and takes action on these social determinants. Sometimes called the building blocks of health, these social determinants are the conditions in which people are born, grow, live, work and age, such as education, employment and housing, and lead to wide differences in people’s health and in their life expectancy.

To develop as a Marmot Place, the UCL Institute of Health Equity (IHE), headed by Professor Sir Michael Marmot, works with an area to:

• understand local inequalities and existing work
• strengthen the health equity system
• based on analysis and evidence, it develops recommendations for action across the eight Marmot principles, with associated monitoring and evaluation.

The combination of the independence of the report and the unifying nature of the vision enables a systematic approach to health equity across all stakeholders in a place.

There is added interest, kudos and sometimes funding for interventions from stakeholders and partners when the IHE declares an area a Marmot Place. 

The challenge that the IHE sets is for areas to embed evidence-based action to improve the health of the poorest the fastest (proportionate universalism). It calls for a system for health equity, with multiple partners, stakeholders and collaborations, to both facilitate and drive forward a reduction in health inequalities. It sets out transformational processes to be embedded in a system to ensure greater equity.

How Marmot Places operate

How each area takes that work forward differs. Most seek internal ownership of next steps, a work plan or implementation plan but the emphasis within each place can differ. Some ensure most programmes are shaped by the Marmot approach. Others take a less visible but nevertheless embedded Marmot approach, driving from within rather than leading from the front. 

There is no direct funding from the IHE to support areas becoming a Marmot Place, so it is essential that there is leadership and some resource within a council, to reinforce and lead the Marmot approach and to ensure the principles are embedded across the organisation.

Based on these eight principles, Marmot Places develop and deliver interventions and policies to reduce health inequalities and embed health equity approaches in local systems by taking a long-term, whole-system approach. Becoming a Marmot Place provides a unified framework and shapes how everyone will work together, in partnership, on a shared journey to deliver a cohesive and robust programme of work for better health and health equity.

Sir Michael’s impact on health equity 

Professor Sir Michael Marmot is a world-renowned authority on health equity. He has been the Advisor on Social Determinants of Health to the World Health Organisation (WHO) Director-General and is the recipient of the WHO Global Hero Award. He is the author of The Health Gap: the challenge of an unequal world and Status Syndrome: how your place on the social gradient directly affects your health. 

Sir Michael remains very much in touch with what is happening nationally and locally across England. He and the UCL Institute of Health Equity (IHE), of which he is director, have this year reported a widening of health inequalities across the country. He recognises that action taken by councils to try and improve health equity in their areas can make a difference, despite reduced local government funding.

As part of that local action, more than 50 areas are signing up to become Marmot Places, looking to the IHE to support and steer their work on the social determinants of health.

Marmot has become the byword for action to improve health equity. Places have been leading the charge in developing this action," said Sir Michael.  

Sir Michael says that both positive and negative factors have driven local government to push ahead with Marmot inspired work. He says the government commissioned and welcomed the 2010 Marmot Review, Fair Society, Healthy Lives that he delivered but action happened locally rather than nationally. “Although the government elected in 2010 produced a white paper on public health, which appeared to be a positive response to our 2010 report, in practice, what they did - as we documented in our 2020 report - was go in the opposite direction,” he says.

Local councils deliver many of the services that are the backbone of the social determinants of health, such as housing, education and social care. Reduction in local government funding over recent years has led to a tightening of how much support councils can offer beyond their statutory commitments. In England’s Widening Health Gap: Local Places Falling Behind, the IHE found that reductions in funding to local government were highest in areas with lower life expectancy and greater health inequalities. 

Sir Michael says, “The shorter the life expectancy in 2010, the steeper the reduction in funding up to 2019 to 2020.” But he says despite that, councils have continued to focus on improving health equity. 

There is real enthusiasm from local places. They're not saying, ‘there's nothing we can do, our funding settlement is too terrible…they’re saying we want to act right now.” said Sir Michael.

The importance of all eight Marmot Principles 

The eight Marmot principles can seem daunting but Sir Michael is adamant that there is not one principle that supersedes another: “I do have a priority list,” he says, “Do the eight! We very consciously did not order them in priority.”

He cites Leeds who are into their second year as a Marmot city, as an example of how doing all eight principles fits together:

They said to us when we started, we have two priorities, children and young people, and housing. I said, we’re very happy to work with your priorities…Now, think about children and young people, so…you need services for early childhood. But you need to reduce child poverty, so you've now got recommendation one and four. 

“Well, if we're thinking about young people, that's probably recommendation two as well. Education, what we want young people to achieve, whether in employment, education, or training - relates to recommendation three. So now we've got one, two, three and four. 

“Housing is vital to children's health and wellbeing. We've produced reports on cold homes and fuel poverty, so now we've got one, two, three, four and five…

“Well, what about healthy eating? If you're going to focus on young people, surely you want to do something about child obesity? So now we've got one, two, three, four, five and six. Well, you wouldn't want young people from different ethnic groups to have different life chances, so now we've got seven and that's all got to be done in the context of saving the planet – bringing us to eight.” said Sir Michael.

Combatting racism was the seventh Marmot principle added in 2022 to the original six. Most Marmot areas embed this principle in all their programmes, rather than standalone because racism can affect each of the other principles and these have cumulative impacts throughout life. Structural Racism, Ethnicity and Health Inequalities in London is the IHE’s most recent publication and highlights the importance of racism as a public health issue.

A health equity national approach?

Sir Michael is hopeful that the new government will start to steer a health equity approach at a national level. He said that while in opposition, Labour had referenced Marmot cities in a technical document it produced to support its health mission. Since winning the election, he has met with public health minister Andrew Gwynne who has supported the Marmot approach, wanting to build on the initiatives of Greater Manchester, Manchester and Coventry. Sir Michael says that Gwynne has said more than once that “they plan to make England a Marmot country”.

Becoming a Marmot Place requires action across three inter-related areas: across the eight Marmot principles; system change and culture shifts; and transformational processes. Being granted Marmot Place status by the IHE has proven to galvanise and unite people in a way not experienced by other partnerships or collaboration, in pursuit of health equity. 

Professor Sir Michael Marmot

Professor of Epidemiology, University College London (UCL)

Director, UCL Institute of Health Equity