The UK is not doing well. Here's how the Marmot Principles could help Starmer turn things around

When he was a fresh, dynamic leader of the opposition, Keir Starmer frequently referenced and praised Marmot Principles on poverty, health and joined-up thinking to regenerate Britain. As inequalities grow, and government spending faces massive pressures, should he turn again? In our deep dive into what Marmot means, the creator Sir Michael Marmot lays out his vision, and the thinking behind the eight Marmot Principles.

Beveridge is alive and living in modern Britain. Not the man, but the social problems he identified, known as his five giants: idleness, ignorance, disease, squalor and want. It was Sir William Beveridge’s report in 1942 that laid the foundation for the welfare state in Britain. For a nation deep in war it presented a vision of a society that made the struggle worthwhile. The five giants had to be overcome.

Evidence shows that one of the giants, health and disease, is strongly influenced by the other four. That has been the thrust of our many ‘Marmot’ reports, which explain why unfair, avoidable health gaps (health inequalities) exist and suggest ways to fix them. So strong is the link between social conditions and health that the health of a society tells us how well that society is meeting the needs of its members. 

The UK is not doing well. Over the last 14 years, health stopped improving, inequalities in health increased and health for the poorest people deteriorated. We again need the kind of national renewal for which Beveridge called.

The health record is troubling. For close to a century life expectancy increased about one year every four years. Something changed in 2010. For a decade after 2010, the rate of increase slowed and nearly ground to a halt. The country was not in a good place to tackle the Covid pandemic. As such, Covid-19 amplified and exacerbated health inequalities.

From 2009 to 2023 life expectancy in the UK did not improve at all. The implied promise of living in a society such as Britain is that health will improve all the time. Society will improve all the time. That
promise had been broken. Fourteen years with no improvement in health.

Further, health is strongly linked to deprivation. In most regions of England outside London, life expectancy has been falling among people living in the most deprived areas, and self-reported health has got worse.

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Whatever pressure the NHS has been under, this grim picture of health in the country cannot be attributed to lack of access to health care. A precise figure is difficult, but it is estimated that variations in health care are responsible for no more than 20% of variations in health. The majority can be attributed to the social determinants of health, the other four giants.

It is also unlikely that, around 2010, large numbers of individuals were spontaneously seized by a desire to behave badly and overindulge in fast food, sedentary lifestyle, alcohol, drugs and tobacco. These behaviours are important for health. They tend to be the focus when people speak of prevention, but they are only part of the story. We have to look at the causes of the causes – and these make up the eight Marmot Principles.

It is difficult to escape the conclusion that austerity, imposed in 2010, has amplified the unfair health outcomes from which we now suffer. 

One million extra deaths

Last year, 2024, we published a calculation that I have long wanted us to do. We showed that if everybody in England had the low mortality rates of the people living in the least deprived 10% of areas, there would have been one million fewer deaths over the decade after 2009.

Commonly, we hear statements such as ‘the poor people in this area have life expectancy 15 years shorter than the rich’. It shows the scale of the tragic loss of life. But health inequalities are not confined to poor health for the poor and good health for everyone else. The reason for this is the social gradient: on every step up the social ladder – from the poorest to richest, least educated to most educated – people get healthier and live longer.

To make health outcomes fairer, government policies must therefore aspire to improve everyone’s health to the level of the top 10%. But instead, in the decade after 2009, one million people lived shorter lives than they should have. If governments care about the health of their population, they should work to flatten the social gradient.

There was a social gradient before 2010, but it was much flatter. Austerity made it substantially steeper and, as a result, my Institute of Health Equity (IHE) calculated it killed 148,000 people. Colleagues in Scotland calculated that the excess death figure in the UK, linked to austerity, was even higher. 

One way austerity harmed health is the regressive way central government funded local areas, with the most deprived areas receiving the greatest funding cuts. The IHE promotes the principle of ‘proportionate universalism’: providing universal services and support, with more help given to those in most need. But, the IHE found, post 2010, the opposite happened.

The IHE mapped life expectancy in 2010-12 for every local authority and looked at central government cuts in local authority spending up to 2020. The unhealthier the place in 2010-12, the more money was taken away by central government – an effort inversely proportionate to need. It is hardly surprising if this contributed to the increase in inequalities and the worsening health of people in the most deprived areas.

Read more:

• Covid exposed the brutal realities of UK health inequality – has anything really changed?
• Measles, whooping cough and infection: Why children’s health is getting worse in the UK
• Labour promised to reduce health inequality – here’s how they can deliver

The other Beveridge giants have loomed larger as obstacles to progress. Let’s look at two: child poverty and housing. A standard way of measuring poverty is living in a household at less than 60% of median income. In 2010, after housing costs are taken into consideration, 27% of children were living in poverty. This rose to 30% by the end of the decade.

Comparing countries in the OECD, the rich countries club, the UK had the fastest rise in child poverty of 38 countries. Child poverty actually went down briefly at the beginning of the Covid pandemic, given the chancellor’s welcome emergency actions, including a £20 a week uplift to universal credit. Central government policy can be powerful. 

When the chancellor removed the uplift, a further 200,000 children were thrown into poverty.

Giants strewn across the path

It is perhaps stretching the meaning of Beveridge’s ‘squalor’ to apply it to our current housing stock, often characterised by cold, damp and mould. With Friends of the Earth, we estimated that one-third of households in the UK had housing that was below energy conservation level C, insufficiently insulated, and were at the minimum income threshold – the realistic poverty line – or below.

The question of housing supply, quality and affordability looms large. Private renters who earn the national average or below are paying 40% of their income on rents. Anything over 30% is considered unaffordable. Then there is the desperate shortage of social housing. Where it is available, even that is often unaffordable for people on low incomes.

It is not these giants strewn across the path to a better society that excite my passion. It is tackling them and the inspiring examples of communities up and down the country banding together to make a difference that make me hopeful for the future. Coventry was the first to declare itself a ‘Marmot City’. You can look on their website and see how they are acting on the eight Marmot Principles.

The leadership came from the elected city politicians and officials in all the key sectors. Similarly
in Greater Manchester, mayor Andy Burnham set the tone. We worked with the 10 local authorities, the health sector, social services, other public services, the voluntary and community sector, the university with the charismatic leadership of the vice-chancellor.

We are now working with more than 50 places to develop as health equity Marmot Communities in the UK. Public Health Scotland convened us in a Collaboration for Health Equity Scotland, developing a national strategy and working with three Scottish Marmot Places: Aberdeen, North Ayrshire and South Lanarkshire. 

In Wales the five communities that make up Gwent have taken up the mantle. On a visit to Torfaen, one is greeted by the sign “Welcome to Torfaen, a Marmot Community”. The government of Wales has declared its intention to make Wales a Marmot Nation.

To add to my feelings of hope: Legal and General, an important insurance and financial services business, commissioned our report, The Business of Health Equity: The Marmot Review for Industry. L&G fund our Health Equity Network and have made available a fund of £3 million for community and voluntary sector projects to improve health equity around the country.

The Health Equity Network started in January 2023 with about six members. As of September 2025, the network has more than six thousand active users.

We have a movement. All around the country, areas are saying that we want to create a fairer, better society for the people who live there. It is an inspiring vision. And it is all being done despite the steep cuts to local government, the pressures on the health services and to the voluntary and community sector.

It would, of course, be helpful if central government could come in behind these activities and ensure that all communities can benefit, not just those that have declared themselves Marmot. What could be a more important social goal? Communities where all people can flourish, be educated, work productively and lead healthy lives.

Professor Sir Michael Marmot is a world leader on the causes of avoidable unfairness in health outcomes (health inequities). Over the last 50 years he has led numerous research studies for governments, UN agencies and NGOs on the main drivers of health and longevity. His Institute of Health Equity at University College London is the world’s leading global think tank on the subject.

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