Intended for healthcare professionals


We know what we need to do to improve health and reduce inequalities, now we need politicians to act

BMJ 2024; 384 doi: (Published 15 January 2024) Cite this as: BMJ 2024;384:q93

Linked Opinion

The next government must put health at the heart of all policies

  1. Michael Marmot, director
  1. UCL Institute of Health Equity, UCL Department of Epidemiology and Public Health

In this election year, politicians must give us hope for a better future, writes Michael Marmot

“Hope is an orientation of the spirit … an ability to work for something because it is good…. It is not the same as optimism. It is not the conviction that something will turn out well, but certainty that something makes sense regardless of how it turns out.”1

So said Václav Havel, playwright, dissident, and President of post-communist Czechoslovakia. He had been through it all before he played a key part in his country toppling communism and emerging blinking into the light. The UK in 2024, and at the beginning of an election year, is experiencing dark days of a different sort: population health has stopped improving and health inequalities are increasing. That means that the conditions in which people are born, grow, live, work and age have stopped improving or are deteriorating.

Demoralisation and pessimism about prospects for improvement abound, with versions of: the problems are too deep-seated, politicians are all the same, the Tories don’t care, Labour is too cautious. Austerity, the covid-19 pandemic, and cost of living crisis have given little cause for hope. Against this despair, there is a great deal of evidence to suggest we can make a difference to the social conditions that will lead to better health. It is being acted on in places all across England and Wales. With an election looming, leaders of our political parties, please, get in touch with your inner Václav Havel and inspire us with a vision of a more hopeful future. The country needs hope and it needs tangible action. We have the evidence to show how to take practical steps to create a fairer, healthier society.

I want to start, though, with the issue that most urgently needs to be tackled: the dismal state of our health and health inequalities. Many of us, myself included, focus on poverty and its many effects in explaining health inequalities.2 The obverse is to focus on those least deprived. Not sympathy for the rich, but using them as a benchmark for what level of good health is possible. At the UCL Institute of Health Equity (IHE) we have shown consistently that there is not a clear divide: bad health for the poor, good health for everyone else. It is a graded picture: the greater the level of deprivation of where people live, the shorter their life expectancy. It is a social gradient that runs from the top, least deprived, to the bottom, most deprived. Even more striking is the gradient in healthy life expectancy.3

What if everyone had the good health of the least deprived 10% of the population? There would have been 1 million fewer deaths in England in the period 2012 to 2019.3 Of these, 148 000 can be linked to austerity. In 2020, the first year of the covid pandemic, there were a further 28 000 excess deaths.4

In addition to this quite extraordinary excess death rate linked to deprivation, made worse by austerity, levels of healthy life expectancy have been getting worse. Healthy life years, a measure of the length of time someone lives free of ill health, has worsened in the UK compared with the average of the 27 countries in the European Union. In 2014, men and women in the UK had a higher average number of healthy years than those in the EU 27. By 2017 this had stagnated for men and fallen for women, but had increased by two years for both sexes in the EU27.5

To any political leader who says that health is only one concern, among so many others, I have three responses. Firstly, what can be more important than one million excess deaths over fewer than 10 years? Secondly, the evidence that we have compiled in global and national reviews shows that many of the other things that should concern you—the economy, education, housing, environment, the causes of crime, inequalities—are the causes of this excess mortality.67 They are the social determinants of health. Act on these and you will have a better, fairer, healthier society.

Quoting analyses by John Burn-Murdoch in the Financial Times, Britain is a poor country with some rich people.8 Our analyses show that it is poor sick country with some rich healthy people.4 Reduce the gap in income, wealth and general social conditions, between the richest 10% and everyone else, and the 90% will have better lives and health inequalities will diminish.

Thirdly, action is already happening in cities, regions, and boroughs all around the country.

Coventry was the first. They declared themselves a Marmot City in 2013. (Embarrassed disclaimer: it was not my intention or wish to call these places after me. But once Coventry did it and Greater Manchester picked it up, it had become a brand.) In our 2010 Review, Fair Society Healthy Lives, we had six domains of recommendations: give every child the best start in life; education; 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; take a social determinants approach to prevention.7 Coventry made these six recommendations the basis of their planning as a city and developed a Marmot monitoring tool to assess progress.9

Greater Manchester followed, as did 40 other places, along with businesses, public sector organisations and community and voluntary sectors. The causes of health inequalities lie outside the health sector, but the NHS can be active in tackling social determinants of health. Our work with East London NHS Foundation Trust is such an approach for taking action on the social determinants of health. We have now added two more recommendations to our six: tackle racism, discrimination and their outcomes; pursue environmental sustainability and health equity together.

So, to repeat, my answer to political leaders who say that they have other things to do, is that cities and places all around the country are already doing what they can to improve the quality of people’s lives and thereby reduce health inequalities. Such local action is vital, but they need help with national policies that will make a difference.

As Raymond Williams, a Welsh writer, academic and novelist said: “to be truly radical is to make hope possible rather than despair convincing.”10


  • Competing interests: none declared.

  • Provenance and peer review: not commissioned, not externally peer reviewed.