2. NHS priority setting for treatments – current approaches

Priority setting is familiar to NHS health authorities. In respect of medicines, local recommendations to commission NHS treatments still fall to health authorities (currently integrated care boards (ICBs)). Priority setting requires health authorities to comply with the NHS Constitution and, therefore, to explain their decision-making.Footnote ³ Many appoint ‘priorities committees’ or ‘medicines optimisation committees’ to assist them, guided by ethical frameworks of principles to take decisions and explain their reasons. For example, in common with many others, the South East Region health authorities engage an Ethical Framework which sets down a small number of general statements to guide decision-making, referring to principles such as equality, costs of treatment and opportunity costs, quality of clinical evidence and exceptional need.Footnote ⁴ Requests for funding for new treatments may be submitted by doctors, pharmacists, hospitals and health authorities based on their experiences of need within the local NHS. New treatment applications are assessed by reference to an ethical framework as a way of promoting fairness, consistency and transparency in decision-making (Newdick, Reference Newdick, Nagel and Lauerer2016a; Newdick, Reference Newdick, Flood and Gross2014).

Priorities committees offer advice only to ICBs and may also recommend not to commission a treatment, eg. because it is unaffordable within the local NHS or the evidence of efficacy is unpersuasive. Health authorities may, therefore, decide not to support the treatment except in cases of exceptional need. Of course, this is not an exact science and disagreements can arise between decision-makers. Nevertheless, certain components of the process are reasonably well-understood. Aside from these ethical principles, the focus is on the benefit to be gained from the ‘treatment’ of ‘patients’ by use of ‘healthcare’ having regard to the best clinical trials evidence and the impact of the costs of purchase on a finite budget (including reference to Quality-Adjusted Life Years). These ethical frameworks are an impartial starting point, a neutral explanatory tool against which applications are tested and assessed.

Decision-making tools of this nature are not simply desirable. They are essential to enable health authorities to demonstrate qualities vital in the law of judicial review, especially that policymaking is rational and proportionate. Frameworks of this nature assist fairness and consistency in decision-making. As a process for responding to patients (and judicial review), these frameworks have been reasonably effective. Crucially, however, they have not created substantive rights for patients, i.e. rights of access to particular care and treatment. They do no more than establish a model of procedural rights which seek to guarantee the ideal of a fair, equal and consistent process for decision-making, often referred to as ‘accountability for reasonableness’ (Daniels, Reference Daniels2008).

3. Health inequality priority setting – the new challenge

If this process has been helpful in relation to the allocation of resources for medicines to treat patients after they have fallen ill, to what extent is it relevant to measures concerned to reduce health inequalities more broadly? There are a number of significant differences.

Recall that the burden of these diseases falls disproportionately on those suffering greatest poverty. One reason for this is the familiar challenge of public policy, that measures intended to improve the position of those in most need tend to benefit most those who need it least (Mitton et al., Reference Mitton, Smith, Peacock, Evoy and Abelson2009). Whilst aggregate standards of health may improve, health inequality in the community continues to widen (House of Commons, 2008–09). Bear in mind too that from 2010, the Conservative-led government’s policy of public welfare austerity most significantly affected the most deprived members of the community (Ray-Chaudhuri et al., Reference Ray-Chaudhuri, Waters and Wernham2024). Thus, the public health budgets of those areas most in need have been diminishing precisely as public authorities have the potential to contribute most to the public health debate (Marmot, Reference Marmot2020).

If ethical frameworks are helpful for fairness, consistency and transparency, how should public health priorities committees approach the role of advising health authorities in relation to their health inequality duties? Crucially, this responsibility is concerned less with patients, and more with the needs of ‘people’ and the community in general. The tools at the disposal of directors of public health to respond to these needs are less about treatment, and more about creating preventative environments conducive to health, sometimes referred to as the ‘upstream’ determinants of health. Inevitably, from finite health authority budgets, decisions to commit resources to promote public health involve opportunity costs which impact on the resources available to (say) acute care in hospital or the notional drugs budget available to General Practitioners (GP) in primary care. In the competition for scarce resources, which commands greater priority; the need to restore the workforce lost to the NHS (estimated at 115,000 clinical staff vacancies) (Care Quality Commission, 2021), the urgent repairs required to the NHS estate (NHS Confederation, 2023b), or improved social care of babies at home and undernourished children in school? The tension is sensitive because investment in public health takes longer to yield results. Inevitably, we must balance the delayed benefit of longer-term investment with the immediate and pressing need to reduce waiting times today.

Unlike priority setting for medical technologies (e.g. drugs 20 and devices), these responses do not necessarily belong to a single health authority. Instead, they engage a range of public authority departments, including community care, education and housing and, indeed, central government itself. Various measures are available. In England, eg. we have a Soft Drinks Industry Levy, smoking in public spaces has been banned and graphic images of disease on cigarette packaging are now required. Scotland and Wales impose minimum pricing on units of alcohol. Powerful arguments are made to regulate ultra-processed food (House of Lords, 2024–25); so too the fluoridation of water supplies and improving improve air quality. And locally, how should integrated care system (ICS) compare policies to (say) improve children’s diets, the mental health of rough sleepers, or preventing falls at home? On what metric should these decisions be explained and differentiated?

Add to these challenges another significant difference, i.e. that the priority setting familiar to the NHS is neutral, procedural and reactive. Ethical frameworks for health technologies simply respond to the requests brought before them. By contrast, policies of the sort discussed above are political, substantive and proactive. The ambition of reducing inequality is political in the sense that it is concerned to redistribute rights, duties and power within the state (Coggon, Reference Coggon2012). It is inevitably contentious and proactive in the sense that it seeks to initiate measures to improve the position of particular groups of people by comparison to others. Clearly, ‘politics’ lies at the heart of many of these decisions concerning concepts such as autonomy, liberty, equality and paternalism (Newdick, Reference Newdick2017; Eskin, Reference Eskin2002); and crucially, whether health is a primary responsibility of government or of individuals (Daniels et al., Reference Daniels, Kennedy, Kawachi, Anand, Peter and Sen2000; Coggon and Kamunge-Kpodo, Reference Coggon and Kamunge-Kpodo2022; López and Gadsden, Reference López, Gadsden, Alexander, McBride Murry and Bogard2017). Acknowledging these challenges, the process still needs a procedural framework to ensure fairness, equality and consistency in population health policymaking. Public authorities must be capable of demonstrating that decision-making is robust by reference to the evidence considered, how it is weighed and balanced, and the reasonableness of its conclusions. Crucially, however, processes alone cannot measure and compare the potential benefits for particular social groups of substantive interventions across so many departments.

On what evidence, therefore, should decision-making as to the substantive issues be based and according to what criteria? These questions lack the relative certainties of procedural fairness. Recall that we started talking about health inequalities in 1979 with the Black Report on inequalities in health (Townsend and Davidson, Reference Townsend and Davidson1979). Even in 2006, the European Charter on Counteracting Obesity stated that ‘[t]he obesity epidemic is reversible… Visible progress, especially relating to children and adolescents, should be achievable in most countries in the next 4–5 years and it should be possible to reverse the trend by 2015 at the latest’. (WHO, 2006). Yet, today: ‘Despite the publication of 14 government strategies to tackle obesity between 1992 and 2020 containing 689 policies, no progress has been made’ (Food Foundation, 2024). Does this serve to strengthen the need for a coherent, consistent ethical framework to promote public health priorities? Or, on the other hand, does it only show that a coherent framework of priorities between so many variables of contested significance is a fruitless search for the holy grail?

4. Justice, intersectionality and ‘non-ideal’ approaches

We have emphasised the value of procedural fairness inherent in the NHS Constitution and local ethical frameworks, i.e. to encourage fairness, consistency and transparency in resource allocation in a way that is largely non-contentious. But this is not true of the social and commercial determinants of health which involve substantive interventions about which disagreement is endemic. For some, a response to this divisive challenge is to engage with ‘ideal’ theories of distributive justice to guide our thinking. Ideal approaches in health focus on establishing guiding principles to achieve an archetype of health equality, starting for example, with designing a perfectly just healthcare system, both as to the institutions responsible and the principles that govern them. Equality in access to healthcare services for all then becomes a benchmark or standard for all decision-making.

Rawls’ doctrine of liberal equality provides an ideal approach which has featured prominently in the framing of the ethics of resource allocation. His theory puts fairness at its core, suggesting societal rules be chosen by individuals unaware of their status and characteristics. This, he argues, would guarantee basic liberties for all, promoting equality, but also prioritising the least advantaged members of society (Rawls, Reference Rawls1971). His conception of justice certainly illuminates healthcare policy objectives and the moral case for more equal access to the NHS (Germain, Reference Germain2019). His theory has been criticised, however, for focusing on idealised principles which fail to grapple with contemporary structures which cannot readily provide achievable policy objectives (Valentini, Reference Valentini2010). Here we consider the shortcomings of ‘ideal’ approaches for reducing health inequality in order to uncover an approach capable of developing more pragmatic, ‘non-ideal’ solutions to the challenge for ethical frameworks for priority setting in public health. This, we argue, benefits from using an intersectional lens to address health inequalities.

5. The shortcomings of an ‘ideal approach’

‘Ideal’ responses to the complex question of health inequality seek to present a comprehensive and coherent framework of guidance. They however present difficulty because they distil general principles from a paradigm of justice which exists only under utopian circumstances. Rawls’ theory, eg. provides an abstract moral framework for theoretical beings (Coggon, Reference Coggon2012). To be realised, his ‘ideal approach’ necessitates distancing from complex social contexts and from the intricate network of individual circumstances (Coggon, Reference Coggon2012). This is because it aims principally to establish a framework to shape ‘perfectly just’ basic institutions for society, without addressing the causes of the shortcomings of existing ones (Sen, Reference Sen2009). The strict and unachievable conditions it mandates highlight the weakness of its pragmatism. Removing particularities to reach such a level of abstraction does not help promote equality (Coggon, Reference Coggon2012). By their essence, these issues cannot be reduced to single traits or properly understood by isolating one or a constellation of factors (Hankivsky, Reference Hankivsky2012). Identity categories, the classifications that individuals use to define themselves (e.g. race, gender, class or sexuality) are not only fluid and deeply influenced by location, but also entirely socially constructed. Framing an idea of justice in isolation from these factors cannot be conducive to the promotion of social equality (Ghasemi et al., Reference Ghasemi, Majdzadeh, Rajabi, Vedadhir, Negarandeh, Jamshidi, Takian and Faraji2021).

Like Coggon, we argue that a normative framework for reducing health inequalities cannot be designed in abstraction, away from the lives people actually live (Coggon, Reference Coggon2012). Environments and social factors need to be accounted for, as well as the dynamics of human experience, to achieve an ‘effective’ ideal (Larson et al., Reference Larson, George, Morgan and Poteat2016). This is more likely to address the complex of inequalities which arise from these intersecting contexts. Pristine images of ideally just institutions are less likely to serve that purpose (Stemplowska and Smith, Reference Stemplowska, Smith and Estlund2012). Indeed, their failure to provide workable solutions may even obstruct progress and perpetuate the status quo for failing to recognise the structural inequalities arising from positions of privilege (Wolff, Reference Wolff2007) and, in doing so, failing to achieve an ‘ideal’ approach (Pateman and Mills, Reference Pateman and Mills2007).

As a normative theory, an ‘ideal approach’ is simply too distant from the complexities that give rise to inequalities, particularly in health (Coggon, Reference Coggon2012). As previously discussed, they stem from multiple socioeconomic environments and affect people in very different ways (Yong and Germain, Reference Yong and Germain2022). If we are serious about tackling health inequality, we need to step away from ideal benchmarks and turn to a more practicable approaches that will allow for more agile frameworks to differentiate and chose appropriate options. To do so, the uniqueness of individual experiences needs to be accounted for, particularly in respect of marginalised groups with complex identities (Borras, Reference Borras2020). What we need, therefore, is a conception of justice that can help draw comparison among various propositions to support policy makers needing to balance competing issues (Stemplowska and Smith, Reference Stemplowska, Smith and Estlund2012). Justice should be considered on a comparative basis rather than a set benchmark according to which policy options are measured. It seems natural to suggest that procedures should also be developed to engage with communities most directly affected (Germain and Veronesi, Reference Germain and Veronesi2024). Only then will the complexities of the human experience and environment be adequately considered, and this will assist the design of an ethical framework that asks how we can positively advance equality in health, rather than develop a perfectly just healthcare system (Sen, Reference Sen2009).

6. Intersectionality and health inequalities

In addition to our caution against abstraction in framing unachievable ‘ideals’ to anchor an ethical framework for public health, we propose a more comprehensive perspective on inequality to encompass the complex ways in which social experience shapes health (Lapalme et al., Reference Lapalme, Haines-Saah and Frohlich2019). The concept of intersectionality offers a helpful way of doing so. Many health inequalities have remained hidden because of an over simplified picture of our society and the use we make of disaggregated data on a single identity axis to design laws and policies (Yong and Germain, Reference Yong and Germain2022). Social science research has contributed to these shortcomings by overlooking the upstream structures that play a crucial role in perpetuating inequalities (Lapalme et al., Reference Lapalme, Haines-Saah and Frohlich2019). This oversight, inherently linked to the idea of ‘epistemic injustice,’ has constrained our understanding of inequalities and the reasons for their persistence (Dunn, Reference Dunn, O’Campo and Dunn2012; Chung, Reference Chung2021).

Crenshaw’s theory of intersectionality (Crenshaw, Reference Crenshaw1989) offers a lens through which we can gain a more accurate understanding of society, allowing us to better account for the impact of the social and commercial determinants of health on individuals and communities. Intersectionality acknowledges the role of structural factors in creating and sustaining forms of disadvantage (Hankivsky et al., Reference Hankivsky, Daniel, Hunting, Giesbrecht, Fridkin, Rudrum, Ferlatte and Clark2014). As a context-informed approach, it unpacks the complexities of social stratification. Social stratifiers – such as age, class, ability, gender, geography, migration status, race, religion, sex, socioeconomic status – are criteria used to divide society into hierarchical categories. These stratifiers do not exist in isolation from each other, rather they are embedded within broader social systems including law, media, policy, religious institutions, and governments. These social categories also interact with structures of power such as ableism, ageism, colonialism, imperialism, patriarchy, racism, and xenophobia. Together, these systems and structures sustain inequalities by limiting consideration of the broader social determinants of health (Shannon et al., Reference Shannon, Morgan, Zeinali, Brady, Couto, Devakumar, Eder, Karadag, Mukherjee, Tourinho Peres, Ryngelblum, Sabharwal, Schonfield, Silwane, Singh, Van Ryneveld, Vilakati, Watego, Whyle and Muraya2022).

Intersectionality recognises these structural causes of inequalities and the social patterns that sustain them (Kapilashrami et al., Reference Kapilashrami, Hill and Meer2015). It also provides an entry point to understand empirically the mechanisms and power structures that have allowed social inequalities to endure (Lapalme et al., Reference Lapalme, Haines-Saah and Frohlich2019). Engaging this perspective, Crenshaw explains that individuals or groups with ‘intersecting’ identities (at the convergence of multiple axes) can experience unique forms of disadvantage (or privilege) in how they are treated, as a result of the way others (or institutions) perceive their complex identities (Crenshaw, Reference Crenshaw1989). Intersectionality highlights the compounding and unique effects that social identities have on individuals or groups. It does not adopt an additive approach to explain oppression (Hankivsky, Reference Hankivsky2012a). Instead, it offers a framing to understand how social locations and structural forces interact and shape the ‘marginalising’ experiences of some groups or individuals (Hankivsky, 2009). As an analytical tool, it helps us consider health inequality differently and more seriously, defying the notion of essentialism. Essentialism views human traits as innate, fixed and universally shared within groups (Philips, Reference Philips2011) and has, thus far, led us to wrongly consider social groups as homogeneous (Hankivsky et al., Reference Hankivsky, Cormier and De Merich2009; Hankivsky, Reference Hankivsky2012b). By contrast, through an intersectional lens, social groups’ multidimensionality becomes the focus. Attention is paid to social dynamics rather than fixed identity categories which help us better understand the complexity of health inequalities (Kapilashrami et al., Reference Kapilashrami, Hill and Meer2015).

An intersectional perspective to the design of an ethical framework for priority setting offers the most promising approach to the challenge of health inequality (Borras, Reference Borras2020). With this as a guide (Sen et al., Reference Sen, Iyer and Mukherjee2009), we will be more likely to identify the health vulnerabilities that have been camouflaged by ‘intersectional invisibility’ (Bastos et al., Reference Bastos, Harnois and Paradies2018).

7. Intersectionality and ‘non-ideal’ approaches

Social science research has broadened our theoretical understanding of the inequalities resulting from intersecting, social and commercial determinants of health by explaining how and why structural forces have created and reinforced them (Lapalme et al., Reference Lapalme, Haines-Saah and Frohlich2019). The challenge is now to move from research into policy to develop a framework for guiding public health decision-making. The ambition of an intersectional lens needs to be translated into an actionable framework to guide the development of practicable responses to priority setting in public health.

So far, the implementation of intersectional frameworks (Hankivsky Reference Hankivsky2012a) has not gathered significant policy traction, perhaps because of the challenges of giving it practical implementation, including of everyday politics (Ghasemi et al., Reference Ghasemi, Majdzadeh, Rajabi, Vedadhir, Negarandeh, Jamshidi, Takian and Faraji2021). Intersectionality’s focus on the uniqueness of lived experiences can make developing population level frameworks and policies difficult (Holman et al., Reference Holman, Salway, Bell, Beach, Adebajo, Ali and Butt2021). It seeks to bridge the gaps between the theoretical utopia of ‘ideal approaches’ and the political reality of health inequalities (Stemplowska and Smith, Reference Stemplowska, Smith and Estlund2012). Ideal approaches cannot achieve this objective (Stemplowska and Smith, Reference Stemplowska, Smith and Estlund2012); indeed, they may be counterproductive, distracting us from solutions to health inequality (Sen, Reference Sen2009). Instead, as Powers and Faden suggest,

… the questions of what inequalities matter most and of what constellations of determinants are most important, cannot be answered in abstraction. Empirical inquiry is required to identify both how well people are doing and what elements of the social structure are having the most profound effects on the different aspects of wellbeing (Powers and Faden, Reference Powers and Faden2006).

In other words, to improve health outcomes, we do not need to know which theories of distributive ethics are the best. Instead, we need to understand which interventions are available in our communities and how they compare in terms of impact and feasibility. This focuses more clearly on realising justice through feasible and practicable social arrangements (Gledhill, Reference Gledhill2014). So too, for the procedural components of decision-making, i.e. those who decide, their expertise and the public authorities involved. While not theoretically perfect, this ‘non-ideal’ path is better suited to respond to the realities that have constrained the achievement of health justice for many marginalised groups (Sayegh, Reference Sayegh2017). Even without a completely formed ‘ideal’ it can help to define targets and outline a path for action (Sreenivasan, Reference Sreenivasan2007). Crucially, the starting point is not theoretical, but an assessment of the range of currently available policy options, opportunities and their limitations.

8. Implementing an ethical framework for health inequality

Non-ideal solutions offer the most promising mechanism for responding to the challenge of health inequality while taking an intersectional perspective that accounts for structural forms of disadvantage.

Explaining the potential for doing so, we consider existing statutory structures to emphasise the duties on NHS bodies and local authority departments to work together. ICBs must integrate their services with other health-related and social care services to tackle health inequalities.Footnote ⁵ The 2022 reforms enhance the advisory role of local authorities and Health and Wellbeing Boards. For example, ICBs must obtain appropriate advice, including from Directors of Public Health.Footnote ⁶ They must ‘co-operate’ with local authorities,Footnote ⁷ publish strategies describing how their services could be integrated and consult local Health and Wellbeing Boards in preparing annual plans.Footnote ⁸ NHS and local authority bodies may pool their budgets to improve services,Footnote ⁹ (Knowsley Council, 2014; Bristol One City Approach), Health and Wellbeing Boards may ‘express an opinion’ to NHS England (and, after its abolition, the Department of Health and Social Care) whether its ICB has properly considered the local health and wellbeing strategyFootnote ¹⁰ and Overview and Scrutiny Committees, with persuasive powers to ‘champion’ population health (Campbell, Reference Campbell2010), maintain watchful eyes over the process (Local Authority, 2002; Local Authority 2013; Department of Health and Social Care, 2024b).

Yet, despite the clarity of the ambition, uncertainty surrounds the practical working of this structure. Shortly after taking office, the incoming 2024 Labour government appointed Lord Darzi to investigate and report on the state of the NHS after a decade of austerity funding. In respect of these statutory duties, the investigation found that some ICBs pursue a positive role by tackling the social and commercial determinants of health. Others confine their public health duties to the supply of healthcare. But some do neither, concentrating their focus simply on the performance management of hospitals (Department of Health and Social Care, 2024a). The new ICS intends, amongst other things, to ‘tackle inequalities in outcomes, experience and access’ (NHS England, 2023), but what is so plainly absent is a framework of principles and priorities to achieve this objective. As Patricia Hewitt, a previous Secretary of State for Health, said in her report to the Conservative Sunak government: ‘We have created ICSs but not yet the context in which they can thrive and deliver’ (Hewitt, Reference Hewitt2023). On the one hand, around ‘80% of health outcomes are determined by non-health-related inputs, such as education, employment, housing and the environment’ (Health and Social Care Committee, 2022–23) because they arise ’upstream’ from the NHS, within local authority responsibility. On the other, the dominant party within the integrated care system remains ICBs chiefly responsible for organising health care. As we have seen, local authorities must be consulted and have an enhanced advisory role, but ICBs retain ultimate decision-making authority. Inescapably, however, ICB capacity to ‘think creatively about longer-term solutions is likely to be highly limited…’ (King’s Fund, 2022–23).

Add to this that the ‘public health grant’ to local authorities, valued at around £3.5bn in 2023/24 (Deparment of Health and Social Care, 2023a), has consistently declined over the past 10 years and is now 10% less than in 2013/14 in real terms (King’s Fund, 2023). So, precisely when the statutory levers to tackle health inequalities convey most potential for integration, there is uncertainty as to their practical impact and mounting constraint on the capacity to respond. ICSs urgently need a framework to support partnerships (e.g., between ICBs, ICPs, HWBs, local authorities, voluntary and charitable organisations), including examples where co-operation is likely to help.Footnote ¹¹

There is an argument for significant central leadership, eg. from His Majesty’s Treasury to identify priorities and drive targets though the establishment of a new Prevention Investment Unit, with statutory powers under a new Public Investment Act, (Demos and the Health Foundation, 2025). However, in the absence of a model supplied centrally, the issue remains within the discretion of ICBs, together with their local authority partners.Footnote ¹² What is required is a generic approach with broad-based support around which ICSs can congregate. One such ‘non-ideal’ framework, sufficiently flexible to accommodate an intersectional approach, is offered by the Marmot Review of 2010. Sir Michael Marmot is Professor of Epidemiology at University College London and leads the Institute for Health Equity. Through his health inequalities work for, inter alia, the World Health Organization and the British government, Sir Michael has created an authoritative framework of recommendations to reduce health inequality, starting with a focus on children.Footnote ¹³ In 2010, he identified the following six policy domains, i.e.:

1. (1) Give every child the best start in life,Footnote ¹⁴

2. (2) Enable all children, young people and adults to maximise their capabilities and have control over their lives,

3. (3) Create fair employment and good work for all,

4. (4) Ensure healthy standards of living for all,

5. (5) Create and develop healthy and sustainable places and communities,

6. (6) Strengthen the role and impact of ill health prevention. (Marmot, 2010)

To this, two further areas were added in 2020 in the context of the SARS-CoV2 public health crisis:

1. (7) Tackle racism, discrimination and their outcomes,

2. (8) Pursue environmental sustainability and health equity together. (Marmot, Reference Marmot2020)

Each domain encourages a holistic perspective and provides an opportunity to take an intersectional approach to craft adapted solutions to more effectively account for complex experiences of health inequality. Now we need to develop the partnership arrangements required to support these objectives. These priorities have inspired over 40 local authorities across the UK to become ‘Marmot Places,’ which address health inequality by proactively engaging in programmes that embody the eight key areas. Practice varies as ICS’ respond to local circumstances. Each ‘Marmot Place’ plans interventions for its local population to foster sustainable systemic change in the long term, though no external financial support is provided for them to do so (Dean, Reference Dean2024). ‘Marmot Places’ and ‘Marmot Cities’Footnote ¹⁵ and, at a smaller scale, ‘Marmot Boroughs’ receive guidance from The Institute for Health Equity. The Institute supports local authorities to assess the extent of inequalities in their area and identify valuable existing initiatives and gaps in their programmes, to generate a plan for collaboration with local bodies (Dean, Reference Dean2024). Although recommendations vary in scale and scope, the focus is always on initiatives that go beyond the delivery of healthcare services to address the root causes of inequalities. Acknowledging that the NHS alone cannot tackle the complex issues affecting population health, the ‘Marmot Eight’ principles set out to ‘develop and deliver interventions and policies to improve health equity; embed health equity approaches in local systems and take a long-term, whole-system approach to improving health equity’ (Institute of Health Equity, 2024).

The ‘Marmot approach’ focuses on lived experiences to set priorities and build strong accountability locally and at the higher official echelons (Dean, Reference Dean2024). Whether by interventions which target environmental, socioeconomic or behavioural factors, or access to health care and outcomes, the foundation for action is not an abstract theory of distributive justice. Rather, priority is placed on responding to the inequalities suffered by the most deprived and marginalised parts of the community based on the principles of proportionate universalism which seeks to make the scale and intensity of action proportionate to the level of disadvantage (Albini, Reference Albini2024). For example, Coventry, a ‘Marmot City’ since 2013, has adopted policies that focus on reducing digital exclusion, making remote services more accessible, optimising transport for in person services, increasing pre-employment apprenticeships and work placements, and improving mental health, to specifically support young populations in its most deprived areas (Coventry City Council, 2024). Coventry’s local authorities want all residents, including its most vulnerable, to have the opportunity to benefit from ‘good growth’, something they believe will generate jobs, better housing and other benefits to the city (Coventry City Council, 2024).

‘Marmot Places’ are good examples of pragmatic, non-ideal solutions at a local level. They offer a helpful framework to guide priority setting to reduce health inequality. All Marmot areas seek to better integrate interventions to tackle health inequality by coordinating the work of local government, the NHS, the voluntary and community sectors, other public services (e.g., education, criminal justice and transport), and the business and private sector. They have the advantage of a flexible starting point about which there is widespread support and from which information about successes and failures can evolve.

9. Conclusion

ICBs have clear statutory duties as to health inequalities, so they must do something; the question is what? We have described how the NHS Constitution has promoted the notion of procedural fairness in priority setting. However, this is very different from the substantive duty to reduce health inequality. Certainly, the NHS and local authorities have a procedural duty to co-operate and integrate their services, but its potential for tackling health inequality is uncertain. In the absence of a national framework for action or coherent theoretical response, we endorse a pragmatic approach to the challenge of health inequality, grounded in the reality of the lives people actually lead. The ‘Marmot Eight’ principles offer a constructive response, at least for the present, not because they are ‘ideal’, nor because they are the only possible options. They are, however, manifestly plausible responses about which health authorities could unite and collaborate by sharing experience and learning.

Equally, we should acknowledge that corporate and mass media interests are always likely to resist change, arguing perhaps that interfering with individual lifestyle is an unwarranted, ‘nanny state’ infringement of liberty by ‘food fascists’ (Marmot, Reference Marmot2013; Le Grand and New, Reference Le Grand and New2015)? For example, ‘climate change, obesity, drinking, smoking, gambling, and abuse of pharmaceutical opioids are overwhelmingly framed as poor individual choices: the problem gambler; irresponsible drinker…’ (Gilmore et al., Reference Gilmore, Fabbri and Baum2023; Paetkau, Reference Paetkau2024). This may equally serve to deflect attention from governments’ own failures to invest in population health (Deaton, 2013; WHO, 2024; Joseph, Reference Joseph2013; Chadwick, Reference Chadwick2019). We have considered the position in England. In truth, however, the roots of deepening inequality are more widespread and lie in the power and influence arising from global structures that concentrate private capital and political influence in increasingly fewer hands (Picketty, Reference Picketty2020; Stiglitz, Reference Stiglitz2013; Newdick, Reference Newdick, Breau and Samuel2016b) and, correspondingly in the UK, the belief that austerity justifies faltering investment in public services relative to GDP (Ogden and Phillips, Reference Ogden and Phillips2023). Short of a Polanyian transformation in the narrative about the value of public services to social solidarity (Polanyi, Reference Polanyi1957; Wilkinson and Pickett, Reference Wilkinson and Pickett2010; Mazzucato, Reference Mazzucato2018; Atkinson, Reference Atkinson2015), productive policies to reduce health inequality will always face a steep uphill struggle.