Inequalities in life expectancy over time: the importance of place and devolution

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Last week we published a new report, Inequalities in life expectancy: changes over time and implications for policy. So what were the take-home messages?

First, the relationship between income deprivation and life expectancy changed between the late 1990s and late 2000s. As the figure below shows, not only did life expectancy improve, but areas with higher income deprivation tended to improve faster than areas with lower income deprivation. The gap in life expectancy got smaller.

Relationship between income deprivation and life expectancy

Second, this has implications for how we properly assess the impact of government policies – health and other wider policies – on inequalities during the first 10 years of the 21st century. Until recently, the narrative was broadly, ‘tried hard, targets missed, didn’t work’. As a result, the coalition government swapped targets and performance management of the NHS for incentives (the health incentive premium) and more transparency (the outcomes frameworks). But, as we said some time ago, tackling inequalities in health means using all the tools in the toolbox, not dropping one set and picking up another.

We go on to look at how these findings could inform current and future policy. We argue that ‘integration’ needs to have a focus beyond health and social care services for older people – embracing the role of wider public services for working-age and younger populations, with reducing inequalities a core goal. Our findings reinforce the role that housing, employment, older people’s deprivation and behaviours like binge drinking and diet play in the differences in life expectancy between areas and so we call for a stronger emphasis on holding wider government policy to account for its impact on health.

We find ‘place’ has a very strong role in inequalities; some areas do better or worse than predicted on life expectancy, above and beyond the contribution of the factors above. Our analysis allows us to pinpoint some of these areas but not to explain these effects. For that, a much more nuanced and local understanding of each place is required which cannot be divined by any high-level analysis such as ours.

Some have concluded that our report strengthens the case for devolution since it is consistent with the role of local public services in influencing the wider determinants of health and because of the local knowledge required to act.

This is potentially true, but tackling persistent inequalities requires consistent, sustainable action and intervention, which in turn requires stable, committed system leadership with a focus on population health systems. Devolution could deliver that, but as we have recently set out, greater political participation in health decision-making in local areas is a double-edged sword. While it can confer more control over the wider determinants of health, there is a danger that local electorates could use their local voice – and vote – on the basis of saving the iconic hospital down the road, rather than taking account of the complexity and interplay of the factors that drive inequalities in life expectancy and health more generally. These factors are not easily reducible to political soundbites. Avoiding this pitfall will be one of the greatest challenges for local system leaders.