What are health inequalities?

Health inequalities are avoidable, unfair and systematic differences in health between different groups of people. There are many kinds of health inequality, and many ways in which the term is used. This means that when we talk about ‘health inequality’, it is useful to be clear on which measure is unequally distributed, and between which people.

What are health inequalities?

People experience different combinations of these factors, which has implications for the health inequalities that they are likely to experience. This means that people grouped according to one factor, such as disabled people or people from a particular ethnic background, will not be homogenous – there will be variation in health profiles and risks within any given population group. The way these factors combine and interact with each other also influences the health inequalities people experience. This is often referred to as ‘intersectionality’. For example, women experiencing homelessness have distinct health risks and needs compared to men experiencing homelessness.

This explainer provides an overview of how health inequalities are shaped and experienced in England’s population. We focus on data up to 2019 in most of what follows, and then look at the impact of the Covid-19 pandemic towards the end.

Inequalities in life expectancy

Life expectancy is a key measure of a population’s health status. Inequality in life expectancy is therefore one of the foremost measures of health inequality.

Life expectancy is closely related to people’s socio-economic circumstances. The most common summary measure of these circumstances across a population is deprivation. The index of multiple deprivation is a way of summarising how deprived people are within an area, based on a set of factors that includes their levels of income, employment, education and local levels of crime.

In England, there is a systematic relationship between deprivation and life expectancy, sometimes known as the social gradient in health. In 2017–19, women living in the least-deprived 10 per cent of areas could, at birth, expect to live to 86.4 years old, whereas women in the most-deprived 10 per cent of areas could expect to live to 78.7 years – a gap in life expectancy of almost 8 years. For men, this gap was even wider, with a difference of 9.4 years between the life expectancy for those in the least-deprived 10 per cent of areas (83.5 years) and the most-deprived 10 per cent of areas (74.1 years). In recent years, inequalities in life expectancy by deprivation have widened.

This social gradient relationship holds true across the whole population – health inequalities are experienced by everyone, not just those at the very bottom and top. Figure 1 shows how, during 2015–19 in England, rising levels of neighbourhood deprivation were linked to falling levels of life expectancy.

There are also geographical inequalities in life expectancy. in 2017–19, the North East of England experienced the lowest life expectancy at birth for both men and women across England’s regions, followed by the North West. Life expectancy in the four most southerly English regions was higher than the England average, whereas in all other regions, life expectancy was lower than the England average.

The north of England has a higher concentration of deprived neighbourhoods than the south of England, and therefore a greater proportion of communities where life expectancy is likely to be lower based on their levels of deprivation. But in addition to this, for any given level of deprivation, life expectancy in the north of England is lower than in the south of England.

The maps below illustrate differences in life expectancy at birth in 2017–19 by local authority areas. For women, the gap between the area with the lowest life expectancy (Blackpool, at 79.5 years) and the area with the highest (Westminster, at 87.2 years) is 7.7 years. For men, the gap is 10.5 years, also between Blackpool (74.4 years) and Westminster (84.9 years).

Hover over each local authority to see the average life expectancy at birth.

Some population groups have significantly shorter life expectancy than the general population. For example, based on 2018–19 data, women with a learning disability had a life expectancy at birth of 67 years – 17 years less than females in the general population. Men with a learning disability had a life expectancy at birth of 66 years, which was 14 years younger than men in the general population.

Inequalities in life expectancy exist between ethnic minority and white British groups, as well as between different ethnic minority groups.¹ The picture of health inequalities by ethnicity in general is both complex and limited by a lack of high-quality data. In terms of life expectancy, 'experimental’ ONS statistics suggest that in 2011–14, life expectancy at birth among men and women of white and Mixed groups was lower than in all other ethnic groups. This may be due in part to the ‘healthy migrant effect’, whereby people who migrate tend to be in good health, as well as lower rates of smoking and alcohol consumption in ethnic minority groups compared to white groups.

Inequalities in healthy life expectancy

Another key measure of health inequality is how much time people spend in good health over the course of their lives, given how crucial good health is to quality of life and people’s ability to do the things that they value.

A widely-used measure for this is healthy life expectancy. This estimates time spent in ‘good’ or ‘very good’ health, based on how people perceive and report on their general health.

The gap in healthy life expectancy at birth by deprivation is stark. In 2017–19, people living in the least deprived areas could expect to live almost two decades longer in good health than those in the most deprived areas. People in the most deprived areas spend around a third of their lives in poor health, twice the proportion spent by those in the least deprived areas. This means that people in more deprived areas spend, on average, a far greater part of their already far shorter lives in poor health.

Again, geographical inequalities exist in this measure. In 2017–19, healthy life expectancy at birth for women in the North East of England was 59.0 years, compared to 65.9 years for women in the South East, a gap of 6.9 years. For men, this gap was 5.9 years.

Inequalities in avoidable mortality

Deaths are considered avoidable if they could have been averted or delayed through timely, effective healthcare (known as ‘treatable mortality’) or wider public health and preventive interventions (known as ‘amenable mortality’). In 2019, almost 140,000 (roughly one in five) deaths in the UK were considered avoidable.

Differences in rates of avoidable mortality between population groups reflect differences in people getting the help that they need to address life-threatening health risks and illnesses. In England, in 2019, women in the most deprived areas were 3.5 times more likely to die from an avoidable cause than those in the least deprived areas. Men in the most deprived areas were 3.6 times more likely to die from an avoidable cause than those in the least deprived areas.

Figure 4 shows avoidable mortality by local authority area between 2017 and 2019. Darker blue areas have higher rates of preventable mortality. Blackpool had the highest rate at 405.1 deaths per 100,000, almost three times higher than the lowest area, which was Hart at 138.0 per 100,000.

Hover over each local authority to see the mortality rate per 100,000 population from avoidable causes.

Inequalities in long-term health conditions

Long-term conditions are a major cause of poor quality of life in England. People in lower socio-economic groups are more likely to have long-term health conditions, and these conditions tend to be more severe than those experienced by people in higher socio-economic groups. Deprivation also increases the likelihood of having more than one long-term condition at the same time, and on average people in the most deprived fifth of the population develop multiple long-term conditions 10 years earlier than those in the least deprived fifth.

People from ethnic minority groups are more likely than white British people to report limiting long-term illness and poor health, with those identifying as white Gypsy and Irish Traveller reporting the poorest health.

Inequalities in the prevalence of mental ill-health

Assessing differences in the prevalence of mental illness between social groups is challenging and complex, because rates of recognition, reporting and diagnosis are likely to vary between groups. Existing evidence is patchy and inconsistent, but data from a range of sources highlights a range of differences in how mental illness and treatment for mental illness is experienced.

First, data suggests that demand for mental health services is higher among more deprived communities. Figures 5 and 6 show that in England in 2018/19, both the rate of attended contacts with community and outpatient mental health services and the rate of inpatient stays in secondary mental health services were higher among more deprived populations. Data also shows that between 2010–17, suicide rates among the most deprived decile were consistently around double the rates among the least deprived decile (although the correlation between deprivation decile and suicide rate is only seen among working-age adults).

Second, existing evidence suggests that inequalities in various types of mental ill-health exist across a range of protected characteristics, including sexual orientation, disability, sex and ethnicity.

• People in the United Kingdom who identify as lesbian, gay, bisexual or transgender (LGBT), for example, experience higher rates of poor mental ill-health and lower wellbeing than those who do not identify as LGBT.

• In 2019-20 in England, disabled people experienced poorer recovery outcomes in Improving Access to Psychological Therapies (IAPT) services than non-disabled people.

• The 2014 Adult Psychiatric Morbidity Survey found that women in England were more likely than men to report experiencing a common mental health disorder, with 19 per cent of women reporting symptoms compared to 12 per cent of men.

• The Adult Psychiatric Morbidity Survey also showed disparities in mental ill-health by ethnicity in England. For example, rates of psychotic disorder experienced by Black men (3.2 per cent) and Asian men (1.3 per cent) were higher than among white men (0.3 per cent), although for women no significant difference by ethnicity was observed.

Several socially excluded groups have been shown to experience higher rates of mental ill-health than the general population. For example, more than 80 per cent of people experiencing homelessness report having a mental health difficulty, and in 2019 people in this group were 14 times more likely than those in the general population to die by suicide. Asylum seekers and refugees are also at increased risk of experiencing depression, post-traumatic stress disorder and other anxiety disorders.

There is also substantial evidence of ethnic differences in pathways into psychiatric care across England. For example, in 2018/19, rates of detention under the Mental Health Act among the Black or Black British group were more than four times higher than the white group. In addition, access to mental health services through general practice has been found to be less likely for people in the Black group compared to people in the white group. This has been linked in part to higher rates of serious mental illness in this group as well as to racism and discrimination within services.

Inequalities in access to and experience of health services

Access to health services refers to the availability of services that are timely, appropriate, easy to get to and use, and sensitive to user choice and need. Inequitable access can result in particular groups receiving less care relative to their needs, or more inappropriate or sub-optimal care, than others, which often leads to poorer experiences, outcomes and health status. Access to the full range of services that can have an impact on health includes access to preventive interventions and social services, as well as primary and secondary health care.

Inequitable access might mean that a group faces particular barriers to getting the services that they need, such as real or anticipated discrimination or challenges around language. It can mean that information is not communicated in an easily understandable or culturally sensitive way. These issues are often reported for asylum seekers and refugees and Gypsy, Roma and Traveller communities in particular.

Access can be measured in terms of service availability and uptake. More deprived areas tend to have fewer GPs per head and lower rates of admission to elective care than less deprived areas, despite having a higher disease prevalence.

Different social groups might also have systematically different experiences within the services that they use, including in terms of the quality of care they receive and whether they are treated with dignity and respect. A recent review commissioned by the NHS Race and Health Observatory, for example, found evidence of women from ethnic minority backgrounds experiencing ‘stereotyping, disrespect, discrimination and cultural insensitivity’ when using maternal and neonatal healthcare services. To take another example, in a 2018 study by Stonewall, 13 per cent of LGBT respondents reported experiencing unequal treatment from health care staff because they were LGBT, with this number rising to 32 per cent for people who are transgender and 19 per cent for LGBT people from ethnic minority backgrounds. The differences between groups in this latter example demonstrate how using intersectional lenses gives us a more precise picture of health inequalities.

Pathways to health inequalities

The examples above show systematic differences across various measures of health for different population groups in England. This section explores differences in the likelihood of engaging in healthy or unhealthy behaviours and differences in the wider determinants of health. Both involve differences in the health risks that people are exposed to and in the opportunities they have to lead healthy lives.

Behavioural risk factors

People’s behaviour is a major determinant of how healthy they are. Smoking, poor diet, physical inactivity and harmful alcohol consumption are leading risk factors that drive preventable ill health and premature mortality in England. Behavioural risks to health are more common in some parts of the population than in others. The distribution is patterned by measures of deprivation, income, gender and ethnicity, and risks are concentrated in the most disadvantaged groups. For example, in England in 2019, the proportion of adults who were smokers in the lowest income quintile was 27 per cent, compared to 10 per cent in the highest income quintile.

Higher-risk health behaviours also tend to cluster together in certain population groups, with individuals in disadvantaged groups more likely to engage in more than one risky behaviour. The prevalence of multiple higher-risk behaviours varies significantly by deprivation. In 2017, the proportion of adults with three or more behavioural risk factors was 27 per cent in the most deprived fifth, compared with 14 per cent in the least deprived fifth.

Health-related behaviours are shaped by cultural, social and material circumstances. For example, recent analysis suggests that the poorest 10 per cent of UK households would need to spend, after housing costs, 74 per cent of their income on food in order to follow the government’s official guidance on a healthy diet – compared to only 6 per cent of income for the richest 10 per cent of households.

Furthermore, evidence suggests that some people’s circumstances make it harder for them to move away from unhealthy behaviours, particularly if they are worse off in terms of socio-economic factors such as debt or poverty. This is compounded by differences in the environments in which people live – for example, in 2017 deprived areas in England were likely to have many more fast food outlets per person than less deprived areas. This indicates that interventions aimed at changing behaviours need to be able to adapt to the reality of people’s lives, addressing the contexts in which behaviours take place and recognising the challenges of achieving behavioural change under conditions of stress.

The wider determinants of health

The wider determinants of health are the social, economic and environmental conditions in which people live that have an impact on health. They include income, education, access to green space and healthy food, the work people do and the homes they live in. It is widely recognised that, taken together, these factors are the principal drivers of how healthy people are, and that inequalities in these factors are a fundamental cause of health inequalities. Addressing these wider socio-economic inequalities is therefore a crucial part of reducing health inequalities.

Table 1 provides some examples of health impacts relating to a range of wider determinants. The examples focus on individual determinants, but these determinants are often experienced together and cumulatively over time. Particular groups can be disadvantaged across a number of factors, and these disadvantages can be mutually reinforcing. Deprived areas have, for example, on average nine times less access to green space, higher concentrations of fast food outlets and more limited availability of affordable healthy food.

Table 1 Selected impacts of wider determinants on health inequalities

Interactions between the factors driving health inequalities

Our health is shaped by a complex interaction between many factors. These include the accessibility and quality of health and care services, individual behaviours and, most importantly, wider determinants such as housing and income. Health inequalities exist as a result of systematic variations in these factors across a population.

Inequalities in these factors are inter-related. First, disadvantages are concentrated in particular parts of the population. For example, as noted above, lower socio-economic groups tend to have a higher prevalence of higher-risk health behaviours, worse access to care and less opportunity to lead healthy lives than higher socio-economic groups.

Second, these factors can reinforce each other to compound and magnify the health risks and challenges that disadvantaged groups face. Unemployment, for example, as well as being associated with a direct negative impact on health, can harm future earning potential, thereby affecting other determinants of health such as income and poverty – which in turn can impact on health behaviours and decision-making processes.

Policies and interventions undertaken to tackle health inequalities need to reflect the complexity of how these inequalities are created and perpetuated, otherwise they could be ineffective or even counterproductive.

The impact of Covid-19 on health inequalities

Covid-19 has had an unequal impact on different population groups and has exacerbated existing health inequalities in England.

Mortality rates from Covid-19 have been higher in more deprived areas than in less deprived areas. Up to March 2022, the Covid-19 mortality rate was 2.6 times higher for the most deprived decile in England than for the least deprived decile. This contributed to widening inequalities in life expectancy between the most and least deprived areas: between 2019 and 2021, the gap in life expectancy grew by 0.7 years for women and by 1.1 years for men, with gaps in 2021 of 8.6 years for women and 10.4 years for men.

The pandemic has also had a disproportionate impact on ethnic minority groups. The picture is complex and differs between ethnic groups and over time. Overall, ethnic minority groups have experienced higher mortality from Covid-19 than the White British group, and Covid-19 mortality rates have been highest in the Bangladeshi, Pakistani and Black Caribbean groups. From the beginning of the pandemic up to February 2022, overall mortality rates from all causes were higher for men and women in the Bangladeshi group, and men in the Black Caribbean and Pakistani ethnic groups, compared with the White British group. In other ethnic minority groups, all-cause mortality during the pandemic remained, as before the pandemic, lower than or similar to the White British group, despite higher Covid-19 mortality.

Disabled people experienced a greater risk of dying from Covid-19 than non-disabled people. Up to March 2022, the risk of death involving Covid-19 was 1.6 times greater for disabled women who consider their daily life to be ‘limited a lot’  (based on self-reported disability status in the 2011 census) compared to women without a disability, and was 1.4 times greater for disabled men who consider themselves ‘limited a lot’ compared to men without a disability.

Covid-19 restrictions and the reprioritisation of health care services to manage demand associated with Covid-19 also affected some groups more than others. Disabled people were more likely than non-disabled people to report both that Covid-19 restrictions had a negative impact on their lives and that their medical treatment was disrupted during the pandemic.

The longer-term impact of the pandemic is likely to widen health inequalities even further unless urgent and significant action is taken. Recent analysis by The King’s Fund has shown inequalities in the elective care backlog, with waiting lists in the most deprived fifth of areas growing by 55 per cent, compared to 36 per cent in the least deprived areas. Health inequalities are also likely to be exacerbated by growing disparities in the wider determinants of health linked in part to the pandemic, including around education, unemployment and financial insecurity.

Tackling health inequalities

Based on factors outside of their direct control, people in England experience systematic, unfair and avoidable differences in their health, the care they receive and the opportunities they have to lead healthy lives.

Health inequalities are not inevitable and the gaps are not fixed. Evidence shows that a comprehensive, multifaceted approach to tackling them can make a difference.

Concerted, systematic and sustained action is needed to address the multiple and overlapping web of factors that drive health inequalities – from differences in experiences and quality of healthcare through to the wider determinants of health. This includes, but goes well beyond, the health and care system. It requires working in partnership across services, sectors and communities, at local, regional and national level.