Michael Marmot and Jessica Allen: Building back fairer in Greater Manchester

Covid-19 mortality was 25% higher in Greater Manchester than in England as a whole, finds new report by Michael Marmot and colleagues

A question that has exercised so many of us, made more pressing by the impact of the covid-19 pandemic, is where will there be action on social determinants of health in order to improve health equity. We know the problem of health inequalities. At the UCL Institute of Health Equity, we are even confident enough to conclude that we have the evidence on what needs to be done, as laid out in our 2010 Marmot Review. [1] It would appear that, at a national level, the evidence has been overlooked. It is not fanciful to posit a link between failure to pursue policies on social determinants of health and England’s poor state of health before the pandemic. From 2010, the rate of increase in life expectancy slowed markedly; health inequalities increased, linked to deprivation and region; and life expectancy for the poorest people outside London declined. This worsening health picture, we suggest, is related to policies of austerity and regressive cuts to spending during that period. [2] 

If inaction, or worse, at national level has been the bad news, the good news has been real interest in social determinants of health at local authority level. After our 2010 report, Coventry declared itself a Marmot City. On 30 June 2021, the Institute of Health Equity published the results of its work with Greater Manchester. [3] The work with Greater Manchester, to inform and support action on health inequalities, began in 2019. It was already the case that health in Greater Manchester, along with the rest of the North West, had suffered more than areas of England in the South during the decade of austerity and regressive funding allocations. Then came the pandemic, and made it all worse: exposing the underlying inequalities in society and amplifying them. [4] Covid-19 mortality was 25% higher in Greater Manchester than in England as a whole, and the social gradient in mortality from covid-19—a close link between deprivation and mortality—was  steeper in Greater Manchester. The effect of the pandemic was dramatic. During 2020, life expectancy fell by 1.2 years in women in the North West and 1.6 years in men; compared to a fall in England of 0.9 and 1.3 years.

The Institute of Health Equity produced a national Build Back Fairer report, in December 2020. [4] The evidence was that the status quo before the pandemic was not where the nation should be heading, given the relatively poor state of health. Build Back Fairer had recommendations of what needed to be done nationally, by government, business, the health and care system, and the voluntary and community sector. Build Back Fairer in Greater Manchester builds on our 2020 national report and makes recommendations that are concrete and can be put into action now. 

We propose a Build Back Fairer framework for Greater Manchester built around six key themes: future generations—improving equity in the prospects for young people; resources—compensating for the cuts to public services of the last decade; standards—improving living and working conditions important for health equity; institutions—both businesses and public sector to develop as “anchor” institutions with positive impacts on the community; monitoring and accountability—working with colleagues in Greater Manchester we have developed 24 Marmot Beacon Indicators; greater local power and control—continue the process of devolution in GM.

These key themes are accompanied by specific recommendations in six areas, that build on the recommendations in our previous English reports: communities and places; housing, transport, and the environment; early years, children and young people; income, poverty and debt; work and unemployment; public health.

Greater Manchester has deep-seated problems of poverty and relative disadvantage that damage health and health equity. There are two key positives. First, the UCL Institute of Health Equity was invited in. The significance is that we worked in partnership with colleagues across Greater Manchester in different sectors. Second, Greater Manchester’s plans for the future, to make Manchester quite the best place to be born, grow, live, work, and age—our description of social determinants of health—means that Greater Manchester’s aspirations have the potential to be transformational.

Build Back Fairer in Greater Manchester can be seen not only as a contribution to improving health and health equity in Greater Manchester, but a demonstration to national government as to what they need to do, if serious about levelling up. If levelling up includes greater health equity, there is an urgent need to build a society based on principles of social justice, narrower inequalities in wealth and income, prioritising equity of health and wellbeing, while responding to the climate crisis. There is a great deal that Greater Manchester can do. It will take commitment from national government, too.

Michael Marmot, Institute of Health Equity, Department of Epidemiology and Public Health UCL.

Jessica Allen, Institute of Health Equity, Department of Epidemiology and Public Health UCL.

Competing interests: none declared.


  1. Marmot M. Fair society, healthy lives : the Marmot review ; strategic review of health inequalities in England post-2010: [S.l.] : The Marmot Review; 2010.
  2. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health Equity in England: The Marmot Review 10 Years On. London UK: Institute of Health Equity, UCL; 2020.
  3. Marmot M, Allen, J., Boyce,  T., Goldblatt, P., Morrison, J. . Build Back Fairer in Greater Manchester: Health Equity and Dignified Lives. London: Institute of Health Equity; 2021.
  4. Marmot M, Allen, J.,  Goldblatt, P., Herd, E., Morrison, J. Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity; 2020.