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Peter Goldblatt, Senior Advisor, UCL Institute of Health Equity, continues our guest blog series responding to our 'You Only Had To Ask' report on what people with multiple conditions say about health equity.

There are substantial inequalities in health in England, particularly in long-term chronic conditions. These inequalities in health are a result of the conditions in which people are born, grow, live, work and age and inequities in power, money and resources – the social determinants of health (1). Because these social determinants are associated with a range of ill-health conditions, those living in more deprived conditions have a much greater chance of developing multiple conditions than those living in less deprived circumstances.

In addition, developing long term health conditions increases the chances of experiencing further inequalities as these frequently limit life chances and, if not properly managed, lead to further health complications. All these sources of inequalities are “avoidable by reasonable means” (1). Addressing the causes of social inequalities would reduce the initial incidence of many long-term conditions; better management of these conditions will prevent avoidable deterioration and the development of additional conditions; and, reasonable adaptations for those with multiple conditions will reduce the socially disabling effects of multiple health problems.

The fact that this constellation of mutually reinforcing causes of health inequalities exists today in England for among those with multiple health conditions was highlighted in the Taskforce on Multiple Conditions report You only had to ask (2). In a series of case studies, this report highlights how every aspect of this vicious circle of social and health disadvantage manifest itself in the lives of people with multiple conditions:  

“Many people were facing socially determined circumstances that made it harder for them to prioritise their health and access the care and support they needed. These included the type of work they did, the area they lived in, financial troubles, the other people they interacted with and their beliefs about the world around them……....Self-management of conditions – a key assumption of NHS care models - was also made more challenging by people’s living situations, either in poor quality housing or being far from the provision of key services.”  (2)

The “reasonable means” by which social determinants of health inequalities can be addressed both to reduce the unequal incidence of ill-health conditions and their contribution to this vicious circle are well documented [refs]. In particular, in 2010 the Marmot Review made recommendations for actions in six domains (3), each of which covers different aspects of lifetime experiences which, in the report You only had to ask, were identified as factors leading to inequalities among those with multiple conditions:

• Give every child the best start in life

• Enable all children, young people and adults to maximise their capabilities and have control of 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. (3)

While the 2010 Public Health White Paper accepted five of these recommendations (4), the recent report, Health Equity in England: The Marmot Review 10 Years On (5), presented data to show that government spending not only declined in key social determinants of health, a consequence of austerity, but that it is now also allocated in a less equitable way – meaning that spending allocations are less weighted towards deprived areas and communities than previously [ref].

In order to respond to this widening gradient in ill-health – whereby the lower people are in the social hierarchy and the more deprived they are, the greater is the threat to their health – the 10 Years On report emphasised the importance of responding proportionately to need across the whole of society. To achieve this levelling-up, the recommendations in the report updated the actions proposed under the Marmot Review’s six domains to take account of the main factors contributing to widening inequalities.

Based on these recommendations and those in the report You only had to ask, there are clear and reasonable actions that can and should be taken to prevent inequalities in the development of multiple conditions and enable everyone “to lead a life they have reason to value” (6).


1. CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva : WHO, 2008.

2. Revealing Reality. You only had to ask: what people with multiple conditions say about health equity. London : The Richmond Group of Charities, 2021.

3. Marmot, M, et al. Fair Society, Healthy Lives: The Marmot Review. London : The Marmot Review, 2010.

4. HM Government. Healthy Lives, Healthy People: Our strategy for public health in England. CM7985. London : The Stationery Office, 2010.

5. Marmot, M, et al. Health equity in England: The Marmot Review 10 years on. London : Institute of Health Equity, 2020.

6. Sen, A. Development as freedom. New York : Alfred A. Knopf, 1999.

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