Intended for healthcare professionals


Sajid Javid must promote health across government

BMJ 2021; 374 doi: (Published 14 July 2021) Cite this as: BMJ 2021;374:n1783
  1. Michael Marmot, director,
  2. Jessica Allen, deputy director
  1. Institute of Health Equity, Department of Epidemiology and Public Health, University College London, UK
  1. Corresponding author: M Marmot m.marmot{at}

Key determinants of health lie outside the health and care systems

The task for the new secretary of state for health and social care in England is daunting: the nation’s health is poor and marked by large inequalities.1 It was poor before the pandemic, and our handling of the pandemic has made it worse. In England, as in most countries, health is much better in the 2020s than, say, the 1920s. But that is not the most telling comparison. Where should we be now, with respect to the nation’s health?

Three indicators measured before the pandemic show the extent of the challenge. In 2019, child mortality in England ranked 22 of 23 “western” European countries; on child wellbeing at age 15, the UK ranked 27 of 38 rich countries in the Organisation for Economic Co-operation and Development; and in the decade after 2010, improvement in life expectancy was nearly the slowest of any rich country.1 It is cold comfort that on each of these three measures the US performed worse than the UK.

The other way to judge the nation’s health is by looking at the extent of inequality in each of these three indicators. In the decade after 2010, health inequalities increased and life expectancy declined for people living in the most deprived 10% of areas outside London.1 Infant and child deaths show a steep social gradient—if the infant death rates of the most deprived 80% of the population were to fall to the levels of the least deprived 20%, half of infant deaths would be prevented.2 Degree of deprivation is also a potent predictor of child wellbeing.3 If health is not improving and health inequalities are getting worse, society is not improving and is becoming more unequal.

A conventional view of the challenges for the new health secretary focuses on the healthcare system: challenges posed by the virulent delta variant of SARS-CoV-2; a backlog of operations and patients with untreated cancer; a potential flu epidemic with accompanying strains on the care system; an exhausted healthcare workforce; appointing a new chief executive of the NHS; a white paper on (yet another) NHS reorganisation; recognising there is no longer a carpet big enough under which to sweep the unsolved crisis in adult social care.

These are all substantial challenges, but a secretary of state for health has responsibility for the population’s health (the clue is in the title) not just the health and social care systems. The key determinants of health lie outside these systems, and our 2010 Marmot Review emphasised the importance of six domains: early child development, education, employment and working conditions, having enough money to lead a healthy life, healthy and sustainable communities, and taking a social determinants of health approach to healthy behaviours.4 All have been under threat since 2010, when UK governments, of which the new health secretary was latterly a minister, pursued policies of austerity.

Last year, our Build Back Fairer report noted that inequalities in health, now including a social gradient in covid-19 mortality and ethnic inequalities, were amplified by the pandemic.5 In addition, and perhaps linked, the UK had the highest excess mortality of any rich country in the first six months of the pandemic. That report listed four ways in which the poor state of health before the pandemic and high excess mortality during the pandemic could be linked: quality of governance and political culture; increased social and economic inequalities; disinvestment in public services; and the direct link between poor underlying health and risk of death from covid-19.

Good governance means putting equity of health and wellbeing at the heart of all government policy. If the government is serious about levelling up, this has to be its prime focus. By contrast, the UK government elected in 2010 had austerity and rolling back the state as its central mission. It was quite successful in that mission: public sector expenditure went down from 42% of gross domestic product in 2009-10 to 35% by 2018-19, and cuts to local government expenditure were made in a sharply regressive manner—the poorer the area the steeper the cuts, with a 32% reduction in spending per person in the most deprived fifth of local areas. Plausibly, the costs of that “success” were the failure of health to continue to improve at its historic rate, the rise in health inequalities, and a decline in health among the poorest people.

When the new health secretary Sajid Javid left the Treasury, he expressed regret that he had not been able to enact further tax cuts. Why? How would tax cuts have improved health and reduced health inequalities? A different approach was taken by the New Zealand Treasury, the stated mission of which, before the pandemic, was to put wellbeing at the heart of government policy.6

If any health secretary is to fulfil their role to improve population health, they must advocate for policies to improve health and reduce inequalities right across government. It is the health secretary who should be held to account when the government fails to undertake its fundamental responsibility: to create the conditions for greater equity of health and wellbeing across the whole population.


  • Provenance and peer review: Commissioned; not peer reviewed.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

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