The Marmot Review, officially titled Fair Society, Healthy Lives, is a landmark 2010 public health report commissioned by the UK government to address persistent differences in health outcomes across the population. Led by Professor Sir Michael Marmot, the independent review provided a strategy to reduce health inequalities in England post-2010. The report identified the underlying social factors that drive these differences and proposed evidence-based actions. Its findings demonstrated that achieving better health requires looking beyond the healthcare system to the conditions in which people live. The review established a framework for policy interventions that would improve health and reduce the gap in life expectancy between the most and least advantaged groups.
Understanding the Social Gradient of Health
The Marmot Review is founded on the concept of the “social gradient in health,” which describes how health outcomes systematically worsen at every step down the social ladder. This pattern affects the entire population, meaning people with slightly lower social standing tend to have worse health than those just above them. This gradient applies to both overall life expectancy and the number of years a person can expect to live in good health.
The review provided evidence that an individual’s health status is strongly linked to their socioeconomic position, determined by factors like education, employment, income, and housing quality. People in the most deprived neighborhoods not only die earlier but also spend a greater proportion of their shorter lives in ill-health compared to those in affluent areas. This pattern highlights that health inequalities are rooted in the conditions of daily life, which the report calls the social determinants of health. These determinants encompass the circumstances in which people are born, grow, live, work, and age, requiring action outside the health sector to effect change.
The Six Policy Objectives for Reducing Inequality
To address the deeply embedded social gradient, the Marmot Review proposed six interconnected policy objectives. The first objective, “Give every child the best start in life,” recognizes the profound influence of early years on lifetime health, calling for investment in high-quality early childhood education and care. This aims to maximize developmental potential.
The second objective, “Enable all children, young people and adults to maximise their capabilities and have control over their lives,” centers on education and lifelong learning, emphasizing that greater personal control over one’s life is linked to better health. The third objective, “Create fair employment and good work for all,” targets the workplace, advocating for quality jobs, fair wages, and healthy working conditions.
The fourth objective, “Ensure a healthy standard of living for all,” focuses on reducing poverty and ensuring adequate income, as financial security is a direct determinant of health through access to good housing, nutrition, and warmth. The fifth objective, “Create and develop healthy and sustainable places and communities,” highlights the importance of the physical environment, recommending improvements in housing, transport, and access to green spaces.
The sixth objective is to “Strengthen the role and impact of ill-health prevention.” This objective aims to make prevention a central function across all public services, rather than solely relying on the healthcare system to treat existing illness. These six areas form a comprehensive strategy that targets the root causes of health inequality.
Implementation and Measuring Progress
The Marmot Review’s framework was widely adopted by local authorities and public health bodies across the UK as a blueprint for local strategies. Its recommendations led to the development of the “Marmot Indicators,” a set of metrics used to monitor progress on the social determinants of health at a local level.
Subsequent reports, such as The Marmot Review 10 Years On (2020), assessed the progress made since the original 2010 publication. This follow-up revealed a worrying deterioration in health outcomes and a widening of health inequalities. Life expectancy improvements had stalled across the country, and for the poorest 10% of women, life expectancy actually declined between 2010 and 2018.
The lack of sustained national prioritization and cuts to funding for key social determinants—like housing, education, and social care—had undermined the progress made by local initiatives. The social gradient had become steeper, with the gap between the most and least deprived areas increasing. Failure to implement the review’s recommendations fully led to preventable worsening health, cementing the review’s ongoing relevance as a standard for assessing policies that affect social justice and public health.