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Michael Marmot: Build Back Fairer

Put Equity of Health and Well-being at the Heart of All Government Policy 

“Each morning, as they read the newspapers over breakfast, one of them would share an item … and they would sigh or go silent. On some days, while reading out an item of news, Katia would say that this was the worst yet, only to be corrected by Erika, who would have found something even more outrageous”. Could be describing Britain in the years up to 2022, and the Tory leadership election. In fact, it is from Colm Toibin’s brilliant novel, The Magician, based on the life of Thomas Mann. Mann, Germany’s most famous writer, is a target of the Nazis. He, his wife Katia and daughter, Erika, are exiled in Switzerland, watching impotently as things go from bad to worse in Germany. 

Not Nazi Germany, but in Britain in 2022, the bad news we pass from hand to hand, is still outrageous. Of all the problems besetting Britain, the one that exercises me the most, and the one least discussed by the government and prime minister-to-be, is the state of the nation’s health – health, not the NHS. Health is important for at least two reasons. First, everyone is concerned with health, for themselves, their family, and their community. It is part of the reason that the NHS has such an important place in Britain’s values. But population health is only in part dependent on access to effective health care. Far more important are the social determinants of health: the conditions in which people are born, grow, live, work and age; and inequities in power, money and resources that give rise to inequities in conditions of daily life. This insight leads to the second reason health is so important. So close is the link to health of social determinants of health that health is a measure of how well we are doing as a society. It captures so many of the other crucial areas of society. If health has stopped improving, it implies that society has stopped improving. If health inequalities are increasing inequalities in society are increasing.  

Health inequalities did increase after 2010, and health in the most deprived areas got worse. Further, health and health inequalities got worse during the pandemic. Now health equity is severely threatened by the cost of living crisis; see our UCL Institute of Health Equity (IHE)report Fuel Poverty, Cold Homes and Health Inequalities. The idea that tax cuts are the solution to this, and all other problems is dangerous, for reasons that I will set out. My analyses are based on two reports we, at IHE, produced: Health Equity in England: the Marmot Review 10 Years On and Build Back Fairer: the Covid-19 Marmot Review. We set out what went wrong with health, and why, and what we should be doing to improve health and achieve greater health equity.   

We know what needs to be done. In those two reports we laid out six domains of recommendations: 

  • Give every child the best start in life 
  • Education and life-long learning 
  • Employment and working conditions 
  • Everyone should have at least the minimum income needed for a healthy life 
  • Healthy and sustainable places in which to live and work. 
  • A social determinants approach to prevention 

To these six, we have now added two: 

  • Tackle discrimination, racism and their outcomes 
  • Pursue environmental sustainability and health equity together 

There it is. That should be the vision and the agenda for creating a society with greater equity of health and well-being. It is the way to Build Back Fairer. Let’s not confuse means and ends. Discussions of the kind of society we want should not be degraded into what the level of taxation should be. 

Britain did the experiment, launching a decade of austerity in 2010. UK public expenditure went from 42% of gross domestic product (GDP) in 2010 to 36% of GDP by the end of the decade. Plausibly, regressive cuts in public spending after 2010 were responsible for an increase in health inequity and life expectancy falling for the poorest people. I want to ask ideological tax cutters: why are they not prepared to come out and say that damaging the public health and creating greater inequities of health and wellbeing is the price society has to pay to meet this obsession? The tax-cutting zealot might note that the UK is not a high-tax country. Data from the International Monetary Fund show government revenue as a share of GDP to be 52% in Finland and France, 50% in Sweden, 46% in Germany, and only 36% in the UK. The USA lags at 31%. 

To build back fairer along the lines of the recommendations above – the Marmot 8 – we need to examine what happened in the decade of austerity, what needs to be put right. 

In the decade after 2010, child poverty after housing costs in England rose from 27% to 30% (poverty defined as <60% median income), as a direct result of changes to tax and benefits. Other countries do things differently. UNICEF’s Report Card 16 highlighted what factors shape child wellbeing; in 41 mostly high-income countries, average child poverty in 2018 was 20%. Ranked 1–4, the countries with the lowest poverty at 10–11% were Iceland, Czechia, Denmark, and Finland. Ranked 40 and 41, with child poverty at 32–33%, were Romania and Turkey. The UK ranked 31 out of 41, with child poverty at 24% (a different mode of calculation to the 30% I mention above); the USA, with 30% of children in poverty, ranked 38 out of 41. Before redistribution through tax and benefits, child poverty in Finland was higher than in the USA. It is government policy in Finland to use fiscal and social policy—tax dollars—to reduce child poverty. 

It can also be government policy to increase expenditure on good child development. The average spend on children aged 0–5 years in countries in the Organisation for Economic Co-operation and Development is about US$6000 per child. In Norway, it is a little over $12 000. In the UK, it is around $4000, but not as low as in the USA at closer to $3000. We are limping along, not the worst, but below average. Is that where we want to be as a country? 

Per pupil spend on education in England went down by 8% in the decade after 2010. Cut taxes to cut it further?  

There were regressive cuts to local government spending: 16% reduction in the least deprived fifth of local authorities, a shocking 32% in the most deprived fifth. Cut local services even more?  

Public sector pay did not keep up with inflation. Make public sector workers even poorer? If someone becomes unemployed in Denmark they receive 90% of their previous salary, in the Netherlands 75%, and in Germany 60%. In the UK, Universal Credit is 14% of median pay. Immiserate the unemployed even further? 

Funding of the NHS, with an annual increase of about 1% a year since 2010, fell below the historical trend since 1997 of about 3·8% a year, despite the population increasing and getting older. Cutting taxes would surely result in an even bigger shortage of the health workforce and longer waiting lists. 

It was as relatively low-taxed countries, with high levels of social and economic inequality, and threadbare public services that the UK and USA faced the COVID-19 pandemic. And these two countries did really badly. In England, a comparison of life expectancy in 2018–20 with the previous triennium showed a fall in the most deprived 40% of areas. A reasonable interpretation is that the pandemic led to worse health overall and increased health inequality. Among 20 high-income countries, the USA had the biggest fall in life expectancy in 2020 and 2021, followed by Scotland, Northern Ireland, Germany, and England and Wales. My speculation is that the link between poor health performance pre-pandemic and poor management of the pandemic works at four levels: poor governance and political culture, high levels of social and economic inequalities, low and diminished spending on public services, and poor health that predisposes some people to more severe COVID-19. 

Suppose that we agreed that equity of health and wellbeing is a worthwhile social goal that our political and social arrangements should deliver. The UK, along with the USA, are rich countries with relatively low levels of taxation and relatively high social and economic inequalities. Evidence on the social determinants of health provides ready explanations for why their population health has been relatively poor and health inequities have increased. A degraded discussion about taxation levels should not be the currency of political debate. Surely, a more worthwhile debate is how to increase and sustain health equity and wellbeing. In short, to build back fairer.


  • Michael Marmot

    Professor Sir Michael Marmot is Professor of Epidemiology at University College London, Director of the UCL Institute of Health Equity, and Past President of the World Medical Association. Marmot Michael

Michael Marmot

Professor Sir Michael Marmot is Professor of Epidemiology at University College London, Director of the UCL Institute of Health Equity, and Past President of the World Medical Association.

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