NHS and the whole of society must act on social determinants of health for a healthier future

Shorter lives spent in poorer health

People in the UK are dying earlier. Life expectancy can be calculated at any age and provides an estimate of the average age a person would live if the current mortality rates were applied over their lifespan. Since 2010, the long history of improvements in life expectancy have plateaued and, for some groups, declined.1213141516 As of early 2024, the latest figures from the Office for National Statistics show that the combination of slow improvements for the past decade and the covid-19 pandemic have decreased overall life expectancy, returning to 2010-12 levels for women and below the 2010-12 level for men, and falling in all four nations for 2020-22 compared with 2017-19.17 Furthermore, people are spending less of their lives in good health. Health Equity in England: The Marmot Review 10 Years On reported that healthy life expectancy has reduced for women since 2010, and the proportion of life spent in poor health has increased for both sexes.14 A 2024 report found 9.6 million households are living on incomes below the minimum income standard and in some of the least well insulated, cold, damp homes in industrialised countries,18 with negative consequences for the health of children and adults.19

The decline in health shows marked inequalities across factors such as ethnic group, race, sex, and deprivation, many of which intersect with each other. Life expectancy and healthy life expectancy are closely linked to deprivation: the greater the deprivation, the shorter the life expectancy. Those living in deprived areas spend more of their shorter lives in poor health.14 This relation represents a social gradient: each increase in socioeconomic level results in an increase in health and lower mortality rates. Health Inequalities: Lives Cut Short found that that one million lives were cut short between 2011 and the start of the pandemic in 90% of areas in England.20Figure 1, from the Marmot Review 10 Years On, shows how deprivation and region overlap, with regional differences greater in the most deprived group (divided by deciles) than in the least deprived group.14 In every region outside of London, life expectancy has fallen in the most deprived group. Acknowledging the overlap and intersections in the groups affected is important. Those living in the most deprived areas are often affected by multiple factors, such as structural racism and the consequences of the climate emergency, and are often more likely to lack the resources to mitigate the subsequent health consequences.

Fig 1

Life expectancy at birth by sex for the least and most deprived groups in each region, England, 2010-12 and 2016-1814

• Download figure
• Open in new tab
• Download powerpoint

Health is deteriorating from the cradle to the grave

Older women were among the first groups to have an unprecedented fall in life expectancy.1521 Older people have been particularly affected because of a greater reliance on a functioning health and social care system. The golden generation, those born between 1925 and 1934, saw remarkable improvements in mortality throughout their lifetimes,22 but the remainder of their lives were cut short since 2010.23 Over time, in more and more groups, health has worsened and lives have been shortened,1213 including a rise in deaths of despair in middle age, reflecting the US experience, of deaths from suicide and from causes related to alcohol and drugs.24 These findings are reflected across Scotland,252627 and in Northern Ireland, life expectancy in men has been declining since 2016-18, with increased mortality in those aged 30-39 years making the greatest contribution.28

Of particular concern is the “appalling decline” in both physical and mental health of children aged <5 years, detailed in the 2024 report from the Academy of Medical Sciences. The report described children as being “betrayed” by a failure to be provided with a healthy start in life.2930 The accompanying statistics include that infant mortality increased between 2014 and 2017, with the UK ranking 30th out of 49 OECD (Organisation for Economic Cooperation and Development) countries; child vaccination levels are currently below WHO coverage targets; and a quarter of all children aged 5 years are affected by preventable tooth decay, the main reason for hospital admissions in children aged 6-10 years. These problems are entirely preventable and disproportionately affect the most deprived communities.

Figures 2 and 3 show that infant and child death rates increased between 2020 and 2023, with infant deaths almost three times as high for black/black British babies than white babies, and marked regional inequalities in child deaths.31 Similar trends have been seen in the rates of stillbirths, with increasing rates linked to worsening areas of deprivation and ethnic groups.32 Other inequalities in early child development exist: cognitive, linguistic, emotional, and behavioural.14 These inequalities are important because they are correlated with behavioural problems in children and predict the subsequent development of health inequalities. Another marker of poor health in children in the UK is height. In 1985, the height of boys and girls aged 5 years in the UK was lower than in 68 other countries. Height in children aged 5 years increased more slowly in the UK than in many other countries. By 2019, in the UK, boys ranked 102 and girls ranked 96. The average height of children aged 5 years fell from 2015 onwards, suggesting that austerity, which began in 2010, might have had an effect.33

Fig 2

Estimated infant death rate per 1000 live births by ethnic group31

• Download figure
• Open in new tab
• Download powerpoint

Fig 3

Estimated child death rate per 100 000 population, by region. Population is children aged 0-17 years31

• Download figure
• Open in new tab
• Download powerpoint

Rising poverty, worsening health

A wide body of evidence has indicated a link between deterioration in health in the UK and cuts in public spending through austerity policies introduced in 2010, policies that are continuing into 2024.1213142325343536 The effect of austerity on poverty in the UK has been so great that two successive United Nations special rapporteurs on extreme poverty have called on the government to take action on the problem.37 The first, Philip Alston, visiting in 2018, called the policies of austerity “punitive, mean spirited, and callous” and the levels of child poverty both a disgrace and an economic disaster.38 The second, Olivier de Schutter, visiting in 2023, commented that the warning signs his predecessor had given had not been acted upon, that universal credit was too low to protect people from poverty, and that “There’s a huge gap, which is increasingly troubling, between the kinds of indicators the government chooses to assess its progress on one hand, and the lived experience of people living in poverty.”39 Currently, government policy does not provide enough money for people to live healthily.4041

How do social determinants of health cause ill health?

The WHO Commission on Social Determinants of Health synthesised the evidence on social determinants of health.42 Building on this global body of work, in 2010, Fair Society Healthy Lives: the Marmot Review, re-examined the evidence as it applied to England.43 The review categorised the determinants of health inequality into six domains: early childhood, education, employment and working conditions, having enough money for a healthy life, environmental and living conditions, including housing, and health behaviours. Health Equity in England: the Marmot Review 10 Years On, published in 2020, indicated the health picture summarised above and showed worsening in most of these six domains, the likely cause of which was austerity.14 Relative child poverty, after housing costs, increased from 27% to 30%, and 1000 Sure Start Children’s Centres closed; spending on education per pupil was reduced by 8%; the gig economy increased; poverty increased, as summarised above; little was done to solve the housing crisis; and spending to improve the thermal property of housing was reduced. Looking at one key marker of future ill health, inequalities in childhood obesity increased.

Each of these domains was made worse by the pandemic and the cost-of-living crisis. For example, the Joseph Rowntree Foundation defined destitution as doing without two or more of six essential items: housing, heat, light, food, clothing, and toiletries.44 In the UK in 2022, 3.8 million people, including one million children, were destitute. The figure for children increased by 2.9-fold since 2017. Food poverty and food insecurity rose, linked to austerity,4546 including for children, with the number of children in food poverty doubling between 2022 and 2023 to four million.47 Between April 2022 and March 2023, the Trussell Trust’s network of food banks delivered almost three million emergency food parcels (a 37% rise compared with the same period the year before); one million food parcels went to children.48 The lack of these essential items will damage health and increase health inequalities. Living in these conditions has a huge social, emotional, and psychological effect, which will in turn affect mental and physical health.

Much has been reported on the commercial determinants of health.49 A review of how industry can affect health and health inequalities summarised the evidence into three areas: employment and working conditions, unhealthy goods and services, and the wider effect on society and communities, including procurement, employment, and the environmental and social impact.50 The 2010 Marmot review developed the concept of proportionate universalism: universal policies with effort proportional to need. Spending by local government in the decade after 2010 was regressive, showing effort inversely proportionate to need. The greater the deprivation of the area, the greater was the reduction in spending per person. Spending was reduced by 17% in the least deprived 20% of areas (quintile) and by 32% in the most deprived areas (quintile). Spending on adult social care was also regressive, with a reduction of 3% in the least deprived areas and 16% in the most deprived areas. Evidence indicated that the greater the reduction in local authority spending, the worse the mortality trends after 2010.12

Action on social determinants of health improves health

Recognising that the action needed to improve the health of the population is outside the provision of health services is not new, but some political factions reject such action, favouring an individualistic approach more consistent with a libertarian ideology. The great health gains made during the 19th and early 20th century were not because of the therapeutic revolutions of modern medicine but more a result of the sanitary and social reforms that provided people with better living conditions, such as uncontaminated food, clean water, waste disposal, improved housing, and education of children. The marked improvements in life expectancy in the 1940s and 1950s were thought to be a result of a combination of improved housing and nutrition after rationing during the second world war, which improved understanding of the importance of childhood nutrition, free secondary education for all (Butler Education Act of 1944), advancement of public health measures, including in sanitation and access to clean water, introduction of antibiotics and immunisations and, eventually, the introduction of the NHS in 1948. Although the NHS was established after the initial acceleration in improving life expectancy, substantial health gains have been made since, thanks to greater access to effective care that it enabled.

Improving health is a political choice

Ten years ago, in 2014, experts wrote an open letter in the Lancet to the then prime minister, David Cameron, highlighting concerns about food poverty.51 Since then (and before then), multiple reports, research papers, and editorials have called for government action on rising infant mortality rates, child poverty, and growing inequalities.615213652 Many other reports on these problems exist, spanning over a decade, all indicating that the state of health in the UK in 2024 is not unexpected, has not happened without warning, and could feasibly have been prevented. More research is not needed; action is needed. Action to reduce poverty can be taken almost immediately. For example, the decision by the then chancellor, Rishi Sunak, to reverse the temporary increase of £20/week in universal credit during the covid-19 pandemic, which had helped 400 000 children out of poverty, returned the number of children living in poverty to levels before the pandemic of 4.2 million.53 Notably, fewer children are living in poverty in Scotland than in England,54 where child benefit payments for more than two children in a family have been maintained, and the Scottish child weekly payment was raised to £25 for any child aged <16 years in a household receiving benefits, a move the children’s commissioner in Wales is advocating to replicate.5556 Child poverty in the UK is a political choice.

The economic decline of the UK, exacerbated by Brexit, must be confronted. The Institute for Fiscal Studies has forecast that real household disposable income will not return to pre-pandemic levels before the next election in 2024, after “another terrible decade” of poor economic growth.57 The number of people signed off sick from work has tripled in the past decade, because Britain is sicker than it was a decade ago.58 Investing in the social determinants of health will improve health, productivity, and thus economic growth. The move from health in all policies to health for all policies acknowledges that progress and improvement in health and health outcomes has substantial benefits for other sectors.59 We cannot afford inaction.

We know what to do

Focused, evidence based recommendations exist on how to improve health in the UK. The 2010 Marmot review called for action on six policy objectives (the first six in box 2), and publication of a framework of indicators and economic analysis followed one year later.43Inequalities in Health: the Black Report was commissioned by a Labour government and published under Margaret Thatcher’s Conservative government. The report detailed inequalities in poor health and mortality in Britain.60 Similarly, the Marmot review was commissioned by a Labour government and published under the Conservative-Liberal Democrat coalition government. The coalition focused on implementing austerity, “doing more for less,”61 and the recommendations were not acted upon.

From 2020 onwards, the covid-19 pandemic intensified and increased the existing inequalities. The UK fared comparatively badly, in part because of the condition of the country before the pandemic.6263 The Build Back Fairer: COVID-19 Marmot Review detailed short, medium, and long term actions needed on each of the six Marmot principles to reduce inequalities and improve health to build, or rebuild, a healthy society.64 The profound effect of structural racism on the outcomes of covid-19 led to the addition of the seventh Marmot principle, and the eighth was added in consideration of the climate emergency (box 2).65 These additional principles are based on empirical observation, but regrettably are often politically partisan. Although central government has failed to act on the robust evidence available, some local governments have acted decisively66; for example, Coventry and Manchester are Marmot cities, acting on the Marmot principles to improve health.6768

Challenging individualism and the nanny state

Two related areas of political ideology, individualism and accusations of the nanny state, act as powerful rhetoric against public health interventions intended to improve the health of the population. Every day, people make decisions that affect their health and wellbeing, but not under conditions of their own choosing. The individualistic approach to health assigns blame to those who show behaviours associated with ill health, and is a convenient mechanism for those in and with power, and wider society, to abrogate responsibility for creating the conditions for a healthy society. Instead, those with the worst health are blamed for their conditions. For example, during the peak of the covid-19 pandemic, people from lower income households, frequently with frontline roles, were unable to work from home and had greater loss of income during quarantine when infected with the virus.6269 People infected with the virus, including those who died, were frequently blamed for not taking adequate precautions or having weaker immune systems or pre-existing conditions (also linked to deprivation) rather than the wider social context being acknowledged. The pandemic is just one example.

Low income, racial, and sex discrimination, commercial exploitation, poor housing (or lack of housing), and lack of access to high quality education are some of the social conditions that diminish the ability of people to live healthy and fulfilling lives. Action to improve these social and economic conditions can and will improve health and reduce the burden on healthcare.

If public health is seen as simply instructing people on how to behave, then accusations of the nanny state are understandable. But what is necessary for public health is ensuring that people have a roof over their heads, have sufficient money to buy food to feed their families, can afford heating when the weather turns cold, and can face the weeks and months without fear of eviction, which is different from instructing people on how to behave. Disputes at the margin, however, are inevitable. Some will see Prime Minister Sunak’s ambition for a smoke-free generation as a bold step towards improving the public health (although a substantial health problem is looming from the growth in vaping, now shown to markedly increase risks of cardiovascular disease70). Others will see it as a step too far. We should see the key social determinants of health as the responsibility of government and other social actors, not simply individual responsibility. Asking individuals to make choices that their circumstances do not allow almost guarantees persisting health inequalities.

Weakening of the public health system across UK

Because of the political climate, at least in part, the public health system across the UK is now arguably weaker than at any point in history, going back as far as the 1870s, with substantial reductions to public health budgets and staffing levels. Northern Ireland and England have seen significant changes, with the functions of public health severely weakened at local, regional, and national levels.

In England, the abolition of the regional tier of government has seen the end of regional development agencies, regional assemblies, strategic health authorities, and government offices for the regions, among other subnational infrastructure. The abolition of regional emergency planning and response functions, which had worked effectively during crises, such as foot and mouth disease and the fuel tanker drivers’ action, was a weakness in the poor response to covid-19 in the UK. The role of public health has been curtailed, with major reductions in resources and expertise, and changes in the role of directors of public health. The abolition of Public Health England and creation of the UK Health Security Agency as an executive component of the Westminster government’s Department of Health and Social Care not only saw the disappearance of the term public health but cast the new and undefined function of health security as part of the country’s security system. This change has been accompanied by attempts to replace the term health inequalities with the ill defined and obscure health disparities.

In Northern Ireland, local director of public health posts have disappeared entirely, and the public health function has been severely weakened. The absence of a functioning government for several years has created something that resembles a failed state.71 The re-establishment of the Northern Ireland Executive offers a mechanism to begin to deal with these problems, and the current health minister is familiar with his brief. The legislative agenda is enormous, however, and health might not be a priority. Northern Ireland’s unique position with regard to the European single market is a further advantage as it limits the ability of the government at Westminster to enact health damaging policies, such as relaxation of restrictions on harmful chemicals.72 The Good Friday Agreement also offers opportunities to learn from and expand joint programmes with Ireland, where in marked contrast with the UK, life expectancy is improving.

Restore, revitalise, and prioritise the public health system in the UK

We recommend urgent restoration of the public health system across all four nations of the UK. The evidence base for what needs to be done to improve population health continues to strengthen, as we have highlighted, even while the capacity in the UK to carry out the necessary actions to improve health is depleted. The deterioration in health and the social determinants of health, such as housing, have been accompanied by the dismantling and the imposed disorganisation of the public health system, particularly in England and Northern Ireland. Thus, we recommend that the government should restore the public health grant to at least 2015-16 levels73 and re-establish Public Health England.

Dealing with the population health crisis in the UK requires urgent, in-depth consideration and substantial commitment to creating a system that can deliver all WHO defined essential public health functions. One way to engage in this task would be the formation of a cross party task force accountable for public health, enabling non-partisan consideration of the necessary actions. The task force should cover the whole of the UK and seek to learn from the positive experiences of public health structures in Wales and Scotland. Because of the long term nature of public health change, there would also be value in creating this cross party task force as a standing body so that it could review the implementation of its recommendations and measure the results.

Role of the NHS

The NHS is predominantly focused on providing clinical care and support to those needing treatment for health conditions. It is because of its role in the delivery of care that the NHS can do much more as both a health service provider and the country’s largest employer74 to ensure that fewer people are burdened with poor health and that many more enjoy healthy lives.

What individuals working in the NHS can do—Recognising that improving the social determinants of health will improve health, and thus reduce the burden on healthcare, those working in the NHS might consider the effect they can have as individuals. Box 3 shows some examples.

What the NHS can do as a health system—Leaders of NHS organisations and systems can act on the social determinants of health: firstly, as an employer, considering their staff as a key population; secondly, on staff recruitment, development, and training, working towards self-sufficiency in the workforce; thirdly, as important social partners within local communities; fourthly, as a procurer of goods in its supply chain; and finally, in reducing its environmental impact (box 4). These actions are linked to recommendations to enhance the NHS’s role as an anchor institution (ie, an institution that can positively contribute to the wellbeing of the population it serves and the communities it is based in).77 Healthcare leaders might draw inspiration from the East London NHS Foundation Trust, which is working with University College London Institute of Health Equity to become the first Marmot Trust, exploring how trusts can work upstream to tackle the drivers of poor health and implement the Marmot principles (box 2).78

Role of policy makers

The health crisis cannot be solved by the NHS alone. Action on the social determinants of health requires changes in policies and political support from local and central governments. We know what to do. The political will to implement the recommended measures has, so far, been missing. The UK lost a decade between the government commissioned 2010 and 2020 Marmot reviews; the findings and recommendations were not acted upon by successive governments.79 Since then, the covid-19 pandemic has worsened the crisis,64 and life expectancy has regressed to 2010-12 levels.17 Time is of the essence.

We are not recommending further reviews, research, or commissions; these processes would delay urgently needed action. Instead, from the Marmot reports,14194364 we highlight three recommendations (box 5): implement policies to tackle poverty so that individuals and families can lead healthy lives; invest in housing that is compatible with good health; and prioritise children and young people. These recommendations are, of course, related. Reducing child poverty and improving child health will, in turn, improve the physical and mental health of families, strengthening the workforce and productivity, as well as reducing costs to the NHS. Although managing poverty does not level the social gradient, proportional universalism does, and a focus on housing and childhood can help deal with the gradient, as will further action on the Marmot principles (box 2). Similarly, by dealing with key policy areas, such as working and housing conditions, people experiencing intersecting factors are most likely to benefit, because the data consistently show that they are over-represented in these areas.

Implement policies to tackle poverty so that individuals and families can lead healthy lives—Poverty causes poor health.80 Treating people in a health service that returns them to conditions that are making them sick is futile. Policies to deal with poverty will, evidently, improve health.

Invest in sustainable housing compatible with good health—The standard of housing in the UK is poor, and homelessness is rising to record levels. Cold, energy inefficient homes cause poor health and cost billions a year, directly and indirectly, through costs to the NHS of associated health problems, energy bills, lost productivity from poor health, and carbon emissions.19

Prioritise children and young people, giving every child the best start in life—The government must act immediately to reduce child poverty and improve child health, with proportionate universalism, ensuring that those doing worst receive appropriate support. This approach requires acknowledgment of racial, ethnic, and geographical inequalities, as well as their interaction. In addition to the recommendations in box 5, the government should remove the two-child restriction on child benefit and benefit cap, increase child benefit for lower income families, and extend free school provision for all children in households that receive universal credit, as set out in the Build Back Fairer review.64

For any recommendations to be meaningful, an acknowledgment that the UK has a problem is crucial. Thus we call on the leaders of all political parties to recognise the scale of the problem and the need for action, and to commit to acting on the available evidence (box 6). Support for this initiative must come from an informed, unified general voting population, who are also considering those who cannot vote (eg, those who are too young to vote).