How much longer and further are health inequalities set to rise? The Office for Health Improvement and Disparities faces unprecedented challenges

The launch of the Office for Health Improvement and Disparities (OHID) is accompanied by the starkest evidence yet of the large, persistent and widening inequalities in life expectancy at birth in England. The divide takes many forms - north-south, rich-poor, male-female, London versus the rest of the country.

Although analyses often focus on recent years, a longer lens is more telling. Between 2001–3 and 2018–20 life expectancy in England increased by 3.2 years in males and 2.4 years in females. However, only 0.3 years of this improvement occurred after 2010–12 as increases in life expectancy stalled after decades of improvement. The reasons for this stalling are unclear and have been debated, but include widening socio-economic inequalities, a slowdown in improvements in cardiovascular disease mortality, and some exceptionally severe flu seasons.

Over these two decades, the north–south divide in life expectancy has amplified. We can see this if we compare the areas with the highest and lowest life expectancies nationally. In 2001-3, the gap in male life expectancy between Hart (South East) and Manchester (North West) was 8.2 years; by 2018-20 the gap had increased to 10.7 years between Westminster (London) and Blackpool (North West). Similarly, for female life expectancy the gap between Kensington and Chelsea (London) and Blackburn and Darwen (North West) was 6.6 years in 2001-3; by 2018-20 the gap had increased to 8.9 years between Kensington and Chelsea and Blackpool.

'...in 2018-20, 47 of the 50 local authorities with the lowest male life expectancy were in the three most-deprived deciles, and the figure was 49 for female life expectancy.'

The geographical divide in longevity reflects a deprivation divide.¹ For example, in 2018-20, 47 of the 50 local authorities with the lowest male life expectancy were in the three most-deprived deciles, and the figure was 49 for female life expectancy. Covid-19 has exacerbated the deprivation divide, increasing inequality in life expectancy between most- and least-deprived deciles from 9.3 to 10.2 years in males and 7.9 to 8.4 in females between 2019–20. Both the Prime Minister and the Secretary of State have drawn attention to the challenges facing Blackpool, which includes eight of the ten most deprived neighbourhoods in the country. The new data should give them further pause for thought - it shows that, since 2001-3, the gap in life expectancy between Westminster and Blackpool has doubled from 5.3 years to 10.7 years for males, and from 3.9 years to 8.1 years for females. Inequality in healthy life expectancy between most- and least-deprived areas is even greater – almost two decades in both males and females.

Although women continue to live longer than men, female life expectancy is further cause for concern. In some northern areas, among the most deprived nationally (Blackpool, Kingston upon Hull, Barrow-in-Furness), female life expectancy has increased by just 0.6 years since 2001-3, compared with 2.4 years nationally. Comparisons with European peers suggest there is significant potential for improvement - female life expectancy in the UK in 2020 is among the lowest in Western Europe and improvement in the preceding decade has been amongst the lowest.

There is another angle to inequalities - the distinctive pattern of London, where life expectancy in 2017-19, ie, pre-Covid-19 pandemic, was the highest among all regions. Life expectancy gains over the past two decades have been highest in many London boroughs, despite high deprivation levels, high proportions of ethnic minority residents, and the pandemic (which had a disproportionate impact on deprived and ethnic minority groups). For example, Lambeth, Southwark, Hackney, Newham and Tower Hamlets, all of which are both deprived and with about half or more of their populations being non-white, were among the 15 authorities with the greatest life expectancy improvements in both males and females since 2001-3. Tower Hamlets had the third highest increase in male life expectancy (of 7.1 years) since 2001–3 and sixth highest (of 4.5 years) in females.

'It's important to establish why London is distinctive and how it bucks deprivation effects, as it can potentially obscure the scale of inequalities and the factors driving them.'

Although people in ethnic minority groups had higher pre-pandemic life expectancy than people in the white group, it’s unclear what’s driving the greater improvements in these and other London boroughs. The explanations could include, for example, better access to and quality of health care, a younger population with healthier lifestyles, or selective migration with, for example, older, unwell residents moving out and younger, healthy people moving in search of employment. It's important to establish why London is distinctive and how it bucks deprivation effects, as it can potentially obscure the scale of inequalities and the factors driving them. However, even without London, inequalities are unacceptably wide and widening.

These inequalities have become institutionalised. They symbolise and are the product of wider socio-economic inequalities, with devastating impacts on individuals, their families and communities, and a waste of human and social capital. This must change. If the Secretary of State’s call that it is time to level up in health is to mean anything, the OHID will need to take a multifocal lens to addressing the many and cross-cutting dimensions of inequality, its challenges made greater by the fall in life expectancy to 2010 levels and exacerbation of inequalities caused by the Covid-19 pandemic. Reducing the gross health inequalities that continue to curtail the lives of too many in our society prematurely has never been a steeper mountain to climb.