What are health inequalities?

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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.

Figure 1 Inequalities in life expectancy (persons) by neighbourhood deprivation level 2015-19

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.

Figure 2: Life expectancy at birth (female) by local authority, 2017-19

 

Figure 3: Life expectancy at birth (male) by local authority, 2017-19

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.

  • 1The terms ‘ethnic minority’ or ‘ethnic minority groups’ refer to people belonging to ethnic groups that are in the minority in the context of the population of England.

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.

Figure 4: Mortality rate per 100,000 population from avoidable causes by local authority 2017-19

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).

Figure 5: Attended contacts with community and outpatient mental health services, per 100,000 population, England, 2018/19

 

Figure 6: Inpatient stays in secondary mental health services, per 100,000 population, England, 2018/19

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.

  • 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.

Equity and endurance: how can we tackle health inequalities this time?

Here we draw out what can be learnt from past attempts to tackle health inequalities and make the case for a long-term approach that endures.

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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

SectorExamples
IncomeIncome determines people’s ability to buy health-improving goods, from food to gym memberships. Living on a low income is a source of stress, and emerging neurological evidence suggests that being on a low income affects the way people make choices concerning health-affecting behaviours.

Children from households in the bottom fifth of income distribution are over four times more likely to experience severe mental health problems that those in the highest fifth.
HousingPoor-quality and overcrowded housing conditions are associated with increased risk of cardiovascular and respiratory diseases, depression and anxiety.

Households from minority ethnic groups are more likely than white households to live in overcrowded homes and to experience fuel poverty.
EnvironmentAccess to good-quality green space is linked to improvements in physical and mental health, and lower levels of obesity. Levels of access to green space are lower on average for people from ethnic minority communities and people living in areas with lower average incomes.

Exposure to air pollutants is estimated to cut short 28,000–36,000 lives a year in the United Kingdom. Differential levels of exposure are associated with both deprivation and ethnicity.
TransportThose living in the most deprived areas have a 50 per cent greater risk of dying in a road accident compared with those in the least deprived areas. Children and young adults in the most deprived areas are more likely to be killed or injured on the road than those in wealthier areas.
EducationOn average among 26 Organisation for Economic Co-operation and Development countries, people with a university degree or an equivalent level of education at age 30 can expect to live over five years longer than people with lower levels of education.
WorkUnemployment is associated with lower life expectancy and poorer physical and mental health, both for unemployed individuals and their households. In 2019/20, employment rates in the least deprived decile were 81.5 per cent, compared to 68.4 per cent in the most deprived decile.

The quality of work, including exposure to hazards and job security, determines the impact that work has on health. People from minority ethnic backgrounds experience higher levels of work stress than those from white groups.

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 for women grew by 1.0 years and for men grew by 1.1 years, with gaps in 2021 of 8.7 years for women and 10.4 years for men.

The pandemic has also had an unequal impact on different ethnic groups. Up to December 2021, Black and Asian groups experienced Covid-19 mortality rates that were 2.1 times higher than for the white group and, up to March 2022, also experienced the highest cumulative mortality rates for deaths from all causes (which includes deaths involving Covid-19). 

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 educationunemployment 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.

To find out more about current policy and opportunities for action on health inequalities, you can read further content from The King’s Fund on:

Comments

Pearl Baker

Position
Carer/Independent Mental Health Advocate and Adviser,
Organisation
Carer/Independent Mental Health Advocate
Comment date
03 January 2022

As a Carer of (many) within the family group: Dementia, Autism, Mental Illness: knowledge is what you need to ensure the CARER can Deliver what is rightfully theirs by legislation and the LAW. Equality Act 2010 lists 'severe disabilities' Schizophrenia is one: this GROUP is not supposed to be contacted by DWP to complete ESA questionnaire: In LEGISLATION, but IGNORED. AUTISM is another area: leaving School at 19 you have the right to specialist Residential College, funded by LA, after three years it is possible for Carer to organize 24 hour Care in the Community FULLY FUNDED by the LA. Personal Budgets are also Mandatory, but ignored. We have a Health & Social Care system that ignores what they know to be right in order to exploit the 'Vulnerable' to save their money, but to WIN your case, you need WEALTH, because it nearly also ends up in COURT? or the LA withdraw at the last minute. I hope the KingsFund print this, because i have gained my knowledge over 40 years and put it to the test in a Court of Law and WON.

Lucia Igbinovia

Position
support worker,
Organisation
futuredirectionscic
Comment date
02 March 2021

Long-term health condition can effect a patient day to day life activities do to lack of physical disability like going out, that is if their mobility is bed or shorting down.

Johnson Tunde …

Position
Helalthcare Support worker,
Organisation
MSI HEALTHCARE LTD
Comment date
02 March 2021

I think that patients has the right to choose the nature and type of care that they want. But it is the of the responsibility of the support workers to help and assist in the area of making the right choice. Health inequality differs a responsibility and can be measured in divers range. For instance a homelessness may find it difficult to make the right decision he needs. Bearing in mind that their wellbeing remain pour priority. Assisting in getting shelter , like the assistance for getting asses to good healthcare, the notification of the red army, regardless of the sociological believe or the colour of skin.
As such, the challenge of facing social difficulties has be removed on gradual basis as that can affect their mental illness. Thus, bearing in mind that every patients count. And together we shall safeguard patients.

Mayowa Ayodele

Position
Student,
Organisation
Nottingham Trent University
Comment date
02 March 2021

The gap in health status can only be bridged and reduced through a systematic long-term process. One quick solution cannot fix this as evidenced by the limited success of health-care intervention only. This process must put into consideration, factors such as: Gender equality, racism, ethnicity, wider-determinant of health, economy, and so on.

Philip Barber

Position
Consultant Respiratory Physician,
Organisation
MFT
Comment date
14 December 2020

The demonstrations of geographic variation in LE and disability-tree LE are striking. Two major issues are largely absent from this otherwise excellent piece - and from many other similar presentations. The first is Smoking, mentioned only briefly as an 'example', contrasting prevalence in deprived vs wealthy demographics. The truth is that smoking accounts by itself for over half the excess mortality in deprived populations, is a uniquely preventable risk factor, and one where prevention is uniquely cost-effective, The second is a specific smoking related disease, now the commonest cause of premature death (not just cancer death) in urban populations, which remains largely under the radar, despite being uniquely preventable, increasingly predictable, and eminently curable if caught early. This almost completely preventable mass killer is Lung Cancer. When looking at practical steps which can be taken to reduce health inequalities, and in doing so save hundreds of thousands of lives, a determined assault on smoking, and on the early detection and treatment of lung cancer, should be paramount. As things stand, they are almost entirely neglected, and the NHS has actually disinvested in smoking cessation, leaving it in the hands of cash-strapped local authorities who are in no position to deliver an effective service. The benefits of tobacco control fall biggest and earliest to the NHS, and that link needs to be restored by empowering our healthcare institutions to take direct advantage of it. Cui Bono? is a good principle, and one which needs to be deployed in this area, to create a 'virtuous cycle' of health and cost benefit.

Linda Sanday

Position
Thyroid patient activist/retired,
Comment date
15 November 2020

I also like the document, and the comments from the respondents. With a grandson with autism spectrum I can attest to him having no contact with anyone official regarding his well being apart from his family for the whole of the 6 years since he was diagnosed. His school off-rolled him within months of him being diagnosed.
From a thyroid treatment point of view NICE block the pathway to effective treatments, condemning those who cannot be made well by the standard treatment to a life of campaigning for better treatment. And guess what, the treatment is there, just a lack of willingness by Gov.uk to make it available, and by endocrinologists stuck in a mindset and quashed by both CCGs and GMC in being allowed to prescribe as they would wish.

Dipen Gadhia

Position
Advocacy and Improvement - Patient Choice,
Organisation
NHSE/I
Comment date
07 October 2020

Related to Mathew Barker's comment, patients have a right to choose the provider of the care at the point of referral from a GP for all elective consultant led services and in mental health, for all health care professional led services. I wonder if any work has been done to show whether greater promotion of patient choice, enabling patients to access services, irrespective of where they live, can improve some health inequalities?

Matthew Baker

Position
Patient Activist,
Organisation
Hypersomnolence UK
Comment date
11 September 2020

On a separate track on inequalities, I'm rare of a rare disease group, who, through the lack of a diagnostic and treatment pathway have a major inequality in care in the UK. With some hospitals, mainly in London, there is a better, but not huge range of medication options, and informed consultants, whereas in other places the medication choice is limited to one drug which can have bad side effects or limited use. This inequality can be seen even within a particular hospital which makes it impossible to complain or campaign for better treatment, in case overall treatment is reduced. NICE appear to be a block in the road towards better care, plus change is slow because we are not a "popular" illness to campaign for, and I am uncertain if these inequalities will ever change in my lifetime.

Laura Brown

Position
Community Dietitian,
Comment date
24 July 2020

The comments on learning disabilities echoes my thoughts exactly. I accessed this article to look for some hard evidence of the inequality that I see in my work and was very surprised there was no specific mention of the well known and evidenced inequalities in health and health service provision encountered in this area

Marion Rogerson

Position
Chair / Sensory Integration Practitioner,
Organisation
SENSORY PEOPLE ( Charity)
Comment date
29 June 2020

Most helpful and informative document - thank you; however, a mention of health inequalities In relation to People with Learning difficulties /conditions such as - Dyspraxia, ADHD, Autistic Spectrum disorders would perhaps add to the contents.

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