Two years ago, East London NHS Foundation Trust and the UCL Institute of Health Equity (IHE) teamed up to develop the “Marmot NHS Trust” approach, based on the ground-breaking 2010 report, ‘Fair Society, Healthy Lives’, by the IHE’s director, Professor Sir Michael Marmot. The report recognised that disadvantage and subsequent poor health starts before birth and accumulates throughout life.

Sir Michael originally set out six policy objectives – two more have been added since then – that would need action on to reduce health inequalities. The principles are:

• giving every child the best start in life;
• enable all children, young people and adults to maximise their capabilities and have control over their lives;
• create fair employment and good work for all;
• ensure a healthy standard of living for all;
• create and develop healthy and sustainable places and communities;
• strengthen the role and impact of ill health prevention;
• address structural racism; and
• tackle climate change.

Several towns and cities have since adopted these principles and become Marmot Cities. East London NHS Foundation Trust (ELFT) is now working to become the first Marmot Trust in the country.

Writing in the BMJ last week, Sir Michael, Una Geary, public health specialty registrar at the Royal Free London NHS Foundation Trust, and Angela Bartley, former director of population health at ELFT, described how the latter had made improving population health a strategic priority and integrated the Marmot principles into its five-year strategy for 2021-26.

The commentary advocates that NHS trusts should go beyond the clinic walls and their traditional remit of healthcare provision, by addressing the upstream social causes of ill health in their communities, since this work will often have a greater impact on health than healthcare services.

Health inequalities in England have widened over the past decade and more. Recent analysis by the IHE for the period 2011-2019 showed that more than 1 million people in England died earlier than they would have if they had lived in the richest 10 per cent of areas.

“The lives of people in the most deprived parts of England are being cut short by about ten years, and they are spending nearly 20 fewer years of their shorter lifespans in good health, compared to people in the most affluent areas,” says the commentary. “The NHS as a sector has considerable power and potential to go some way towards rebalancing the scales of social justice in a society in which the poorest have been hit hardest by a troika of government policies of austerity, the Covid-19 pandemic, and, most recently, the cost-of-living crisis.”

Covering East London, Luton, and Bedfordshire, ELFT serves some of the most deprived communities in the country. In East London, Tower Hamlets has the highest child poverty rate in the UK, with more than half of children living in poverty, and Newham has the highest rate of households in temporary accommodation of all London boroughs, at nearly 50 per 1000 households.

The Trust has taken several actions in addressing the social determinants of health, including piloting the provision of welfare and financial advice in its children’s clinical services; developing a training offer for employers in Luton to promote good quality work through better pay and conditions; and supporting service users and other local people who face barriers to finding work access employment opportunities through the Trust. Indeed, in Newham and Luton, ELFT has linked up with the local councils’ employability programmes to recruit healthcare support workers and administrative workers. It has also made it mandatory in all new contracts for suppliers that they pay their staff at least the real living wage. The trust aims to have every one of its suppliers – new and existing – complying with this mandate by 2025.

Concluding, the authors write: “Tackling the social determinants of health is not only morally imperative; it also represents a pragmatic approach to reducing demand on our services. Undertaking this work is by no means an easy task, given the crisis conditions the NHS faces, but going beyond the hospital walls to improve population health is exactly what we need to do if we are ever going to bring our services back from breaking point.”

They add: “There is much that NHS trusts can do to tackle the social determinants of health, as demonstrated by ELFT’s Marmot NHS Trust approach, which serves as a model for other trusts to use the Marmot principles as a strategic framework to guide such work.”