Fairness at the heart of it: putting proportionate universalism into practice

With health and care resources stretched, we need to put Marmot’s proportionate universalism into practice, writes Public Voice CEO Dan Rogers.

Health and care systems are under growing pressure from rising demand, entrenched inequalities and tighter budgets. So how do we make limited investment go furthest, and keep it fair? More than a decade ago, Professor Sir Michael Marmot offered an answer that still holds today. 

In his 2010 review, Fair Society, Healthy Lives, Marmot set out the idea of proportionate universalism. Support should be there for everyone, but its scale and intensity should match the level of need. Extra investment should go where disadvantage runs deepest. 

The thinking behind it is that health follows a social gradient. Anyone can be affected, but every step down the socioeconomic ladder brings poorer health on average. Closing that gap means acting across the whole population while doing more where the need is greatest. 

Making scarce resources count 

This matters more than ever as Integrated Care Boards (ICBs), which hold significant responsibility for commissioning local health services, work through major organisational change, with less capacity and ever larger areas to cover. Choices about where to invest are getting harder. Proportionate universalism offers a useful guide, helping ICBs avoid spreading resources so thinly that they make little difference, or focusing them so narrowly that wider inequalities go unaddressed. 

You can already see the principle at work in many Neighbourhood health initiatives. Community Health and Wellbeing Worker programmes offer something to everyone in a defined neighbourhood, while giving more support to the people facing the toughest health challenges. At their heart are trusted relationships and a focus on the wider factors that shape health, so people can get help before problems escalate. 

Public Voice has taken a similar approach in Haringey through the Thriving Community Zone Challenge Fund. The Fund is delivered through the Haringey Community Collaborative and funded by NHS West and North London ICB. It concentrates investment on Northumberland Park, one of the most deprived wards in London and in the country. Residents there have long faced the effects of poverty, economic inactivity and debt, alongside poorer health. 

The Fund backs grassroots voluntary and community organisations that are already part of the neighbourhood. It invests in what is already there: projects that improve health and wellbeing and bring people together. Grants come with capacity building support from the Haringey Community Collaborative team, helping organisations become more sustainable and make a lasting difference. 

Starting with community strengths 

Central to this approach is handing power and trust to community organisations themselves. They know local priorities, have established relationships, and are often best placed to reach people who feel disconnected from formal services. Instead of expecting communities to fit around the system, the system works through trusted local organisations that meet people where they are and open up routes into support. 

Throughout the funded projects and capacity building, local organisations will also meet and swap ideas with health and care leaders. This will strengthen relationships and could lead to future collaboration to better reach and support residents. 

It reflects a growing understanding that health and care services cannot tackle inequalities alone. Lasting change depends on investing in community infrastructure and treating communities as essential partners in building a healthier future. 

Proportionate universalism is about balancing fairness with effectiveness. By investing more where need is greatest while keeping support open to all, systems can stretch scarce resources further and achieve more. The Thriving Community Zone Challenge Fund is a fresh way of putting that principle into practice, and of building the community strengths that healthy Neighbourhoods rely on.