Build Back Fairer: The COVID-19 Marmot Review Institute of Health Equity


Worst in Europe: UK must ‘Build Back Fairer’ warns new Marmot Review

New generation of children & young people risk worsening health & shorter lives

A generation of children and young people risk worsening health and shorter lives post COVID-19 pandemic, according to Professor Sir Michael Marmot, Director, UCL Institute of Health Equity in his new landmark report, published today in his new landmark report.

Build Back Fairer: The COVID-19 Marmot Review notes that in England the excess death rate linked to COVID-19 is higher than anywhere else in Europe. Pandemic containment measures (lockdowns, tier systems, social isolation) have harmed children and young people’s well-being and has damaged everyone’s prospect for improved long-term health.

The new review builds on the UCL Institute of Health Equity’s Health Equity in England: The Marmot Review 10 Years On, published in February this year. England entered the pandemic already in a poor state of health; improvement in life expectancy was slower than in almost every other rich country, and the numbers of people in poor health was risking; inequalities in health between socioeconomic groups and regions were rising; and life expectancy for people living in the most deprived areas was actually going down. Child poverty had increased and public services had been cut, in an unfair way: steeper cuts in poorer areas. A decade of austerity had damaged the nation’s health.

The COVID-19 Marmot Review highlights the UK’s lack of social cohesion – everyone working together for the common good – as an additional reason for the country’s current poor state of health. And it implores government not to choose between our health and the economy. Countries that had more effectively managed the pandemic had less of an economic hit and, as a result, less likelihood of containment measures causing long-term harm to health and health inequalities (see Editor’s Notes for more details).

The mantra of Build Back Better must become Build Back Fairer Sir Michael urges to reduce widening social, economic, environmental and health inequalities, level up differences in health between Regions, and mitigate against increasing regional inequalities and a new generation of children and young people’s mental and physical health declining further, risking shortening their lives.

The COVID-19 pandemic has shown us how highly valued our health is, and how closely it is linked to the functioning of society and it would be a tragic mistake to attempt to re-establish the status quo that existed before the pandemic – a status quo that saw the UK as the worst in Europe, marked by stagnation of health improvement and widening health inequalities.

There is an urgent need to do things differently, to build a society that functions to meet the needs of its members; to build a well-being economy that puts achievement of health and well-being at the heart of government strategy, rather than narrow economic goals; to build a society that responds to the climate crisis at the same time as achieving greater health equity.”

Key findings – why we need to Build Back Fairer: 

  • England’s excess death rate linked to COVID-19 highest in Europe because of failures to control the pandemic alongside the UK’s ‘lost decade’ in health pre-pandemic
  • The pandemic has had an adverse impact on young people’s social and emotional development; the closing of early years settings is likely to make early child development worse; and closure of schools has contributed to an already wide educational gap
  • Containment measures and resulting social/economic impacts e.g., reduced family income, reduced employment/training and increases in poverty, harming young people’s physical & mental health as well as training/employment prospects, widening inequalities long term
  • The more deprived the local authority, the higher the COVID-19 death rate, with North of England worst hit, mirroring the pre-pandemic widening health and social determinants inequalities between Regions
  • Overcrowded living conditions and poor quality housing are associated with high COVID-19 deaths (housing conditions had deteriorated for many in the previous decade), which are shockingly high for ethnic minority communities
  • Systemic disadvantages among ethnic minority communities, including living conditions and exposure to the virus at work and at home, result from structural racism
  • Being a key worker, unable to work from home and being in close proximity to others all higher risk, with managers living in deprived areas higher risk than elementary workers living in least deprived areas
  • Close association between underlying health, deprivation, occupation, ethnicity & COVID-19 accelerating regional inequalities, particularly NW and NE England, which were underminded by pre-pandemic regressive cuts, made worse by differing pandemic containment measures
  • New health crisis created by pandemic-associated behaviour changes including increasing alcohol consumption, smoking & obesity inequalities & declines in mental health, all made worse by pre-pandemic deterioration of working & living conditions


Short-term key recommendations to reduce inequalities exposed and amplified by the pandemic:

  • Early Years: Increase early years funding to prevent closures & improve access to parenting programmes
  • Education: Provide laptops & urgently roll out catch-up tuition in full for students in more deprived areas
  • Children & Young People: Remove ‘two child’ benefit cap & fund additional training for young people
  • Working & Living: Enforce minimum wages; increase furlough to 100%; end five-week wait for UC
  • Sustainability: Increase local government COVID-19 grants & housing allowance; remove council tax cap
  • Prevention: Public health core to tackling new health crisis; Increase funding to 0.5% of GDP from current 0.15% level (2.5% of NHS budget)


Medium-term key recommendations to overcome deterioration in socioeconomic conditions caused by the pandemic and associated societal response (lockdown & decreased economic activity):

  • Early Years: Improve availability & quality of early years services; increase spending to OECD average
  • Education: Restore school per-pupil funding to 2010 levels; address deteriorating mental ill health
  • Children & Young People: Reduce child poverty to 10%; increase apprenticeships & in-work training
  • Working & Living: Ensure living wage for healthy living; make UC £1000/year increase permanent
  • Sustainability: Reduce road traffic air pollution in deprived areas; build sustainable affordable homes
  • Prevention: Health interventions to improve health behaviours must focus living and working conditions


Long-term key recommendations to create a cohesive society prioritising a well-being economy through a national inequalities strategy, led by the Prime Minister, to tackle inequality and climate crisis:

  • Early Years: Government should prioritise reducing inequalities in early years development
  • Education: Attainment to match best in Europe & put equity at heart of education policy & funding
  • Children & Young People: Reverse mental health declines; all u21s in education, employment or training
  • Working & Living: Health equity & wellbeing heart of economic planning; consider four-day week
  • Sustainability: Ensure 100% of housing is carbon neutral & aim for net zero GHG emissions by 2030
  • Prevention: Public health system prioritising deteriorating living & working conditions to improve health

Editor’s Notes:

For media enquiries please contact Felicity Porritt f.porritt@ucl.ac.uk, 07739 419219 or Rowan Walker, UCL Media Relations Team on rowan.walker@ucl.ac.uk or +44 (0) 7986 463767

For those interested in more analysis, a jointly hosted IHE/Health Foundation Webinar will be held on Tuesday 15th December, 9.00-10.30am, to explore the impact and long-term implications of the Pandemic on socioeconomic and health inequalities. In addition to Sir Michael, speakers include:

  • James Banks, Senior Research Fellow, Institute for Fiscal Studies
  • Andy Burnham (TBC), Mayor of Greater Manchester
  • Angela Donkin, Chief Social Scientist, National Foundation for Educational Research
  • Kevin Fenton, London Regional Director, Public Health England
  • Richard Horton, Editor, The Lancet
  • Fozia Irfan, Director of Children and Young People at BBC Children in Need
  • Polly Mackenzie, Chief Executive at Demos
  • Liz Sayce, Visiting Senior Fellow, London School of Economics & former CEO, Disability Rights UK
  • Dame Clare Moriarty, Chair, Health Foundation COVID-19 impact inquiry advisory panel

Build Back Fairer: The COVID-19 Marmot Review was commissioned by the Health Foundation as part of its COVID-19 impact inquiry


The COVID-19 crisis, the pandemic and associated social and economic response, have made action set out in the UCL Institute of Health Equity February 2020 report Health Equity in England: The Marmot Review, 10 Years On even more important. The aim of Build Back Fairer: The COVID-19 Marmot Reviewis:

  1. To examine inequalities in COVID-19 mortality. Focus is on inequalities in mortality among members of BAME groups and among certain occupations, alongside continued attention to the social-class gradient in health – the more deprived the area, the worse COVID-19 mortality tends to be.
  2. To show the effects that the pandemic, and the societal response to contain the pandemic, have had on social and economic inequalities, their effects on mental and physical health, and their likely effects on health inequalities in the future.
  3. To make recommendations on what needs to be done.


Lack of widespread testing means the Review has not been able to assess infection rates and severity of disease. Build Back Fairer does not analyse factors such as government communication/decision making, fatal delays in supplying PPE, or mistakes that put people in care homes at such risk. It does though recognise these will all have played a part in UK’s high COVID-19 death rate.

The COVID-19 Marmot Review is to protect England from the inequitable health impacts of the pandemic and containment measures, and build on recommendations in the 10 Years On and Marmot 2010 reports:

  1. Give every child the best start in life
  2. Enable all children, young people and adults to maximise their capabilities and have control over their lives
  3. Create fair employment and good work for all
  4. Ensure a healthy standard of living for all
  5. Create and develop healthy and sustainable places and communities
  6. Strengthen the role and impact of ill health prevention


Build Back Fairermakes recommendations for urgent action in the short, medium and long-term to: level up inequalities in the risk of mortality from COVID-19; inequalities as a result of containment measures for children in the early years and for young people; during working lives and impacts on income, living conditions and health; and in public health for ill-health prevention.

The early signs for the Government’s spending review in autumn 2020 present a mixed picture. There will be a permanent scarring effect on the economy – an estimated 3% smaller than expected by 2025, meaning it will take longer for the average family to recoup their losses.

Amid welcome dedicated spending made necessary by the pandemic, there will be a reduction of £10 billion in ‘normal public sector spending’ next year (2021). Public sector pay outside the NHS will be frozen, and the temporary boost of £20/week to Universal Credit is not set to continue beyond March 2021.

The measures will be insufficient to reduce the inequitable impacts of the containment measures – from widening inequalities in early years development, educational attainment and prospects for young people, to rising unemployment and low pay and increasing poverty, to deepening deprivations in certain communities and regions and deteriorating public health. All these are harbingers of a long-term health and health equity crisis in England.

The recommendations to Build Back Fairer recognise the challenges and realities of public finance but prioritise a more equitable, socially cohesive and healthy society. Recommendations are relevant to the management of the pandemic and to Building Back Fairer in each of the key social determinants of health. The Government must start by aiming for significant reductions in societal, economic and health inequalities. A vital step is an Inequalities Strategy for England that lays out that ambition and provides practical steps to achieve it (see Executive Summary for more detailed recommendations).

About the UCL Institute of Health Equity

Our mission is nothing less than a fairer, healthier society. The Institute of Health Equity was established in 2011 and is led by Professor Sir Michael Marmot at University College London. The aim is to develop and support approaches to health equity and build on work that has assessed, measured  and implemented approaches to tackle inequalities in health - works such as the ‘WHO Commission on Social Determinants of Health’ and ‘Fair Society Healthy Lives’ (The Marmot Review).


Since 2011, the Institute has led and collaborated on works to address the Social Determinants of Health and improve health equity. These works include the PAHO Commission on Equity and Health Inequalities in the Americas, a Review of Social Determinants of Health and the Health Divide for the WHO European Region, Indicators for Local Authorities in EnglandHealthy Places, Healthy LivesSocial Determinants of Mental Healthlocal practice resources for public health.


Professor Sir Michael Marmotis Professor of Epidemiology at University College London, Director of the UCL Institute of Health Equity, and Past President of the World Medical Association. Professor Marmot has led research groups on health inequalities for over 40 years. He chairs the Commission on Equity and Health Inequalities in the Americas, set up in 2015 by the World Health Organizations’ Pan-American Health Organization (PAHO/ WHO).  He was Chair of the Commission on Social Determinants of Health (CSDH), which was set up by the World Health Organization in 2005, and produced the report entitled: Closing the Gap in a Generation in August 2008. At the request of the British Government, he conducted the Strategic Review of Health Inequalities in England post 2010, which published its report 'Fair Society, Healthy Lives' in February 2010. This was followed by the European Review of Social Determinants of Health and the Health Divide, for WHO Euro in 2014.  Professor Marmot served as President of the British Medical Association (BMA) in 2010-2011, and is President of the British Lung Foundation and in 2000 was knighted by Her Majesty The Queen, for services to epidemiology and the understanding of health inequalities. 

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Felicity Porritt
Head of Communications
Institute of Health Equity


Tel: 07739419219