I read an article this week on health inequality. Health inequalities are essentially differences in the status of people’s health, but can also be the differences in care that people receive and the opportunities that they have to live a healthy life. Health inequalities can, therefore, involve differences in:
- Health status (e.g. life expectancy and prevalence of health conditions).
- Access to care (e.g. availability of treatments).
- Quality and experience of care (e.g. levels of patient satisfaction).
- Behavioural risks to health (e.g. smoking rate).
- Wider determinants of health (e.g. quality of housing).
You can loosely group the differences in health to groups of people. In England, health inequalities are often analysed and addressed by policy across four factors:
- Socio-economic factors (e.g. income).
- Geography (e.g. region or whether urban or rural).
- Specific characteristics including those protected in law (e.g. sex, ethnicity or disability).
- Socially excluded groups (e.g. people experiencing homelessness).
Looking first at life expectancy, which is a key measure of a population’s health status, we see that it is closely related to people’s socio-economic circumstances. 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, known as the social gradient in health. Males living in the least deprived areas can, at birth, expect to live 9.4 years longer than males in the most deprived areas. For females, this gap is 7.4 years. This relationship has become known as ‘the Marmot curve’ because of its prominence in Sir Michael Marmot’s report ‘Fair society, healthy lives’.
In recent years, in addition to growth in life expectancy stalling in the population as a whole, inequalities in life expectancy by deprivation have widened. Between 2012–14 and 2015–17, the gap in life expectancy at birth increased by 0.3 years for males and 0.5 years for females. Life expectancy for females in the most deprived areas fell by almost 100 days during this period.
There are also geographical inequalities in life expectancy. 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. 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.
Not only does deprivation affect life expectancy, but it also has an effect on the rate of avoidable mortality. In 2017, more than 140,000 (almost a quarter) of deaths were considered avoidable (delayed or averted through timely, effective care – amenable mortality, or wider public health interventions – preventable mortality). In England, in 2017, males in the most deprived areas were 4.5 times and females 3.9 times more likely to die from an avoidable cause than males in the least deprived areas.
In addition, 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.
Mental illness has a few more factors at play. This is a challenging one to measure because rates of recognition, reporting and diagnosis are likely to vary between groups. Existing evidence, although in many cases patchy and inconsistent, suggests a number of important patterns. Evidence suggests that inequalities in various types of mental ill-health exist across a range of protected characteristics, including sexual orientation, 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 health, including depression, anxiety and self-harm, than those who do not identify as LGBT. Furthermore, women were found to be more likely than men to report experiencing a common mental health disorder, with one in five women reporting symptoms compared to one in eight men. But both alcohol and drug dependence were found to be twice as likely in men as in women. Disparities in mental ill-health by ethnicity have also been found. For example, rates of psychotic disorder experienced by Black men (3.2%) and Asian men (1.3%) were higher than among White men (0.3%), although for women there was no significant difference by ethnicity. Several socially excluded groups have also been shown to experience higher rates of mental ill-health than the general population. For example, more than 80% of people experiencing homelessness report having a mental health difficulty, and people in this group are 14 times more likely than those in the general population to die by suicide.
People’s behaviour is a major determinant of how healthy they are. Public Health England’s 2020–25 strategy identifies smoking, poor diet, physical inactivity and high alcohol consumption as the four principal behavioural risks to people’s health in England today. 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, smoking prevalence in the most deprived fifth of the population is 28%, compared to 10% in the least deprived fifth, and evidence suggests that some people’s circumstances make it harder for them to move away from unhealthy behaviours. In addition, recent estimates suggest that households in the bottom fifth of income distribution may need to spend 42% of their income, after housing costs, on food in order to follow Public Health England’s recommended diet.
Other wider determinants of health:
- Transport (those living in deprived areas have a 50% higher chance of dying in a road traffic accident).
To conclude, based on factors often outside 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. Interventions to tackle health inequalities need to reflect the complexity of how health inequalities are created and perpetuated, otherwise, they could be ineffective or even counterproductive. For example, efforts to tackle inequalities of health status associated with behavioural risks (such as poor diets) should address the wider network of factors that influence these behaviours (such as access to affordable healthy food, marketing and advertising regulations) and the impact that these behaviours have on health outcomes (such as access to clinical services).