England & Wales, Scotland Health and social care

A step backwards: Marmot ten years on?


“The principal objective of the public health department of a local authority is the provision of a healthy environment in order to ward off sickness and ill-health from the inhabitants of its district. Although the provision of hospitals are included among their powers, our local councils are more concerned with the prevention of illness than with their cure.

“Slums are demolished and new houses built; public swimming baths, maternity and child welfare services… these are only some of the tangible achievements of local government, which have revolutionised the health and welfare of the whole population as compared with their grandfathers.”  Walter Elliot, Minister of Health — responsible for local government The ABC of Local Government, C Kent Wright, 1939

These words are as relevant today as they were in 1939. The health of our society, citizens and communities depends as much, I would say more, on the homes we live in, the environment around us, and the wider services we have access to. Of course, 1939 was prior to the NHS, but preventing ill health and encouraging good health and wellbeing is still the objective we need to focus on. And local government is fundamental to that.

2010 was a significant year for public health and for health inequalities. The (then Labour) government proposed to transfer public health responsibilities to local authorities in England – to bring them back, of course, from those pre-NHS days, albeit in a different form.

‘Fair Society Healthy Lives’, the final report of the Marmot Review, was published in 2010. Sir Michael Marmot had been commissioned to analyse the causes and extent of health inequalities in England and identify what could be done to improve health.

The structures are different in Scotland and are about to change again with the establishment of Public Health Scotland by 1 April this year. The challenges, however, are no different to those in Wales and England. Life expectancy, and healthy life expectancy, – the years we live in good health – varies significantly across Scotland. The joint priorities of the Scottish Government and Scottish local government echo those in the Marmot Review and its update.

2020 then, is a good year to reflect on progress.

I just reread my report All’s Well that Ends Well: the LGiU had been commissioned by the Department of Health in 2010 to consider the role of local government in supporting health improvement and tackling health inequalities. There isn’t space here to assess how well local government dealt with the challenges posed by their new role, but it is clear that the themes it highlights are still critical today – such as the need to focus on prevention, the essential role of partnership working, and the importance of engaging communities in promoting health and wellbeing.

What is the position on health inequalities in 2020? The Health Foundation’s report, Health Equity in England, provides an update on health inequalities ten years after the original Marmot review. It describes what has happened to the “causes of the causes” of health inequalities. The stark conclusion is that in five priority areas health is “worse for people lower down the socioeconomic hierarchy”. They encompass a wide area – children’s life chances, realising everyone’s potential, ensuring everyone has a healthy standard of living, creating fair employment for all, and developing healthy and sustainable places. Our recent briefing gives a summary of the Health Foundation’s report.

The inequalities between overall affluent areas, particularly London and the South East, and regions with major areas of deprivation, particularly in the North is clear. Our briefing asks whether austerity is a cause of worsening health inequality or just a correlation. But adds the point that ‘we are living in a country where too many people live needlessly hard lives, and there are evidence-based measures we can take to improve this, which, furthermore, will bring social and economic benefits to the whole country’.

We know that councils are doing excellent work to tackle the social determinants of health and, as important, are empowering communities to take action themselves. But we also know that the pressures on finance mean hard decisions have had to be taken. The report highlights that sustainable funding would allow local government to do so much more.

There needs to be a reinvigorated debate about policy responses to the growing health inequalities gap – it was a high profile issue after the 2010 Marmot report but it seemed to lose impetus since – there has been more focus on personal responsibility for changing lifestyles and on specific initiatives such as the ‘sugar tax’ on soft drinks. What is needed – as it was in 2010 – is the recognition of the underlying causes of health inequalities and the ways in which individual lifestyles are influenced by the wider physical, social and economic environment — “the interdependence of places and people”, as described by Professor Danny Dorling. Local government is in a unique place to bring together the two strands.


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