Last week I was at the WLGA conference in Swansea, where for the third time in a year I found myself listening to Sir Michael Marmot presenting his eight principles for health equity and sharing the statistics that show the growing health inequity across our regions. In June 2025, the last Welsh Government announced Wales will become the world’s first ‘Marmot Nation‘ with a continued priority on tackling the root causes of health inequity within the new government’s Programme for Government. We are good at these bold statements and commitments in Wales. But what does this really mean in practice? How will it make tangible, everyday differences to the lives of people across Wales facing the deep-seated inequalities these ‘Marmot Principles’ set out to address?
At the WLGA conference local action was raised as the answer, however little was shared within Marmot’s speech about how this will actually happen, particularly in shifting public sectors systems and processes that currently maintain the status quo of shocking growths in health inequity.
What are the Marmot Principles really saying
The eight Marmot Principles, from giving every child the best start in life, to tackling racism and pursuing environmental sustainability, rest on a simple idea that health is not primarily made in hospitals. It is shaped by where people live, what work they do, how they are treated, and whether they have real control over their lives.
As Marmot himself said, “healthcare matters, but social circumstances matter more. Health equity must be a priority for all services, not just the NHS.”
This isn’t radical. Anyone working in our communities has long seen the direct impact of safe housing, fair wages, education and clean environments on wellbeing. Advocates for climate action, disability rights, and racial equality have spent decades sharing evidence and campaigning against systemic discrimination to improve collective quality of life. It is welcome news that prevention and social determinants are now on the agenda, but it must go beyond stark data charts and a convenient structural framework. It requires long term investment and action working with the communities that have the knowledge and experience to make a difference.
If health is shaped by the conditions of people’s lives, then the people living those lives must be partners in changing them, not passive recipients of strategies designed without them. This is a democratic argument as much as a public health one, about who is listened to and who is involved in making change.
The shift required of local governments
It was thoroughly refreshing to hear Ellis Cooper from Merthyr Tydfil County Borough Council remind the room during a fringe event that behind every dataset are real people living through these persistent experiences of health inequity. Far too much of the current institutional focus remains stuck on public bodies speaking to other public bodies about data trends rather than engaging directly with the individuals most affected. While cross-agency collaboration is certainly valuable, communicating between institutions is not the same thing as co-production.
On day 2 the Joint Chief Executive of Blaenau Gwent and Torfaen Councils, Stephen Vickers’s reflections on the “BGT way” pushed the question further, what are the capabilities that enable local government to work differently with their communities? Not a programme, not a Marmot label to adopt, but an understanding of how to work together. Outlining a shift towards a learning culture, sharing power with communities to act, thinking across silos to find who can actually drive change, and giving people permission to do things. At root, this is about power and relationships and seeing communities as partners, not recipients.
This requires a coherence of purpose strong enough to shift organisational behaviour, because in times of crisis and scarcity, institutions get pulled towards what’s immediate, manageable and controllable, focusing on ticking the boxes of strategic requirements, managing risk, protecting budgets. The focus ends up on what we do, rather than on what we need to change. This aligns with evidence from our report ‘Putting the Five Ways of Working to Work’, which highlights how public sector engagement is “very good at going out and saying what we can provide and what we can do to help, without asking what people need”.
That report, drawn from our work with Public Services Boards across Wales, sets out four enablers of this shift: embracing learning cultures that tackle the fear of failure and support responsible risk-taking; empowering change makers who exist at every level but need training and supportive cultures to thrive; targeted investment, since asking people to work differently requires specialist expertise and seed funding that long-term savings justify; and involving people always and everywhere, through genuine, ongoing relationships rather than formal engagement alone.
Co-production and the Marmot Principles
The Marmot Principles tell us what needs to change. Co-production is about how that change happens sustainably, genuinely shaped by the communities with the experience and knowledge of what matters. Principle two calls for enabling people to maximise their capabilities and control their lives. That is co-production. Principle five calls for creating healthy, sustainable places, you cannot do this to communities, only with them. The same holds across all eight, each requires that people most affected are involved not as subjects of action, but as its architects.
Where the Co-production Network for Wales comes in
The Co-production Network for Wales exists precisely to support organisations to work this way. We offer training, consultancy, facilitation, and a community of practice spanning the public and third sectors across Wales. Whether you are a Public Services Board working on a local well-being assessment, Regional Partnership Board designing integrated services, or a public body trying to understand what genuine community involvement looks like in practice, we can help.
As national and local governments look to implement their health equity ambitions, co-production is not an optional extra. It is the methodology that makes the difference between a framework on paper and change people actually feel. Both the Social Services and Well-being Act and the Well-being of Future Generations Act already place involvement at the heart of how public bodies must work, with health equity it is time to make this commitment a reality through embedding co-production as the framework for action.
If your organisation is working on health equity, get in touch. We’d love to think with you about what meaningful co-production could look like in your context.