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Page last updated: Mon, 13 Feb 2012 11:37:17 GMT

Health Inequalities

The London Health Observatory (LHO) has a national lead role on behalf of the Association of Public Health Observatories on health inequalities. Public Health Observatories provide support to local and regional agencies addressing health inequalities by providing access to tools, intelligence and other resources.


What are health inequalities?

Health inequalities are unjust disparities in health outcomes between individuals or groups. They arise from differences in social and economic conditions that influence people’s behaviours and lifestyle choices, their risk of illness and actions taken to deal with illness when it occurs 1. Inequalities in these social determinants of health are not inevitable, and are therefore considered avoidable and unfair. The different life chances of life expectancy at birth, illustrated in Figure 1, is an example of inequity or unfairness – an inequality that cannot be accounted for by a difference in need.

Figure 1: Taking the Jubilee Line Route to Health Inequalities

Some health differences are unavoidable and to be expected. For example, the risk of physical ill health increases with age, so people in older age groups are more likely to become ill and can be expected to have a greater need for health services. Providing equal quantities of health and social care services for all groups is therefore not the prime objective, and access to services must be assessed in relation to need. If health services were distributed equally among all groups, those with greater need would be denied the amount of care they require, which would be unjust.

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Dimensions of health inequality

Inequalities may be found between many types of community or population groups. For example, there are disparities by gender, age, sexuality and ethnicity. Figure 2 summarises the many dimensions in which inequalities in health can be found.

Figure 2: The Health Inequalities Umbrella

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Types of health inequality

Throughout the health system, inequalities exist from determinants to outcomes, and include inequalities in:

  • socio-economic and environmental factors, including: income, employment, housing, occupation and education. Eg. The proportion of babies born each year who have a low birth weight varies according to the social class of the father. In 2008, 8% of babies born to fathers of manual social backgrounds had a low birth weight compared with 6.5% for babies of fathers from a non-manual background. 2

  • lifestyle and health related behaviours, such as smoking, diet and levels of physical activity. Eg. In 2006-2008, the estimated smoking prevalence between English local authorities ranged from 10.2% in Chiltern, in the South East, to 35.2% in Blackpool, in the North West. 3

  • access to services, such as health care. Eg. The Maternity Survey (2006) found that women from Black and Minority Ethnic groups in England accessed antenatal care later than White women (8.6 weeks compared to 7.7 weeks) 4

  • health outcomes, such as the differences in life expectancy, or rates of death or disease. Eg. People in more disadvantaged areas not only die sooner, they will also spend more of their lives with a disability. In England, the health expectancy (disability-free life expectancy) for people living in the poorest neighbourhoods is 17 years lower than for people living in the richest neighbourhoods. 5

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Social determinants of health and the social gradient

The World Health Organization defines the social determinants of health as 'the circumstances in which people are born, grow up, live, work and age, and the systems put in place to prevent and treat illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics' 1. In order to reduce health inequalities, action is required across all the social determinants of health, not just within the health system or health care.

In general, the more affluent a person is, the better their health; conversely, the poorest are more likely to have the worst health of all. Figure 3 provides an example of the social gradient using the Slope Index of Inequality, which is a single score, in this case representing the gap in years of life expectancy between the best-off and worst-off within a local authority 6. The graph shows male life expectancy in the London Borough of Enfield by deprivation group, based on the Index of Multiple Deprivation (IMD). The blue dot towards the left of the graph shows that for men in the most deprived 10% of the population in Enfield, life expectancy is 74.7 years. I n contrast, life expectancy for the least deprived 10% is 82.3 years.

This social gradient in health, which runs from the top to the bottom of the socio-economic spectrum, means that health inequalities affect the whole of society, not just the most disadvantaged.

Figure 3: Life Expectancy by Deprivation Deciles, showing the Slope Index of Inequality, Enfield London Borough, Males, 2005-09

Life expectancy

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Key facts

Inequalities by geography

There are geographical inequalities in England in early years’ development, which is a key social determinant of health. In 2010, an average of 55.7% of children achieved a good level of development at age 5. However, figures ranged between local authorities, from 41.9% to 69.3%. 7

Inequalities by level of deprivation

Life expectancy for both men and women is strongly associated with level of deprivation. In England, the difference in male life expectancy at birth between those living in the most deprived areas and those living in the least deprived areas was 8.8 years in 2005-2009. In females, the difference was 5.9 years. 7

Obesity levels amongst children in England increase as deprivation increases. Among children in Year 6 in 2009/10, 13.6% of the least deprived were classified as obese. In comparison, 23.5% in the most deprived group were classified as obese. The link between deprivation and childhood obesity was evident throughout the groups; the five least deprived groups in Year 6 had obesity prevalence that was significantly lower than the national average, whilst the four most deprived groups had obesity prevalence that was significantly higher than the national average. 8

Inequalities by socio-economic group

Infant mortality rates in England and Wales show a distinct gradient by socio-economic class. In 2007-09, the rate was higher than average for babies with fathers in routine and manual occupations (5.0 deaths per 1,000 live births compared with 4.5 deaths per 1,000 live births). However, at 6.8 deaths per 1,000 live births, the rate was highest for the ‘Other’ group, which comprises a mixed group of babies with fathers who have never worked, are long term unemployed or students, or whose occupational details could not be classified. The rate was lowest for babies with fathers in managerial and professional occupations (3.2 deaths per 1,000 live births). 9

The infant mortality rate for births registered by the mother alone, at 6.2 deaths per 1,000 live births, was higher than the rate for all births registered jointly by both parents (4.4 deaths per 1,000 live births) in England and Wales in 2007-09. 9

Encouragingly, infant mortality rates have fallen across all socio-economic groups over recent years, with larger falls in the Routine and Manual group, resulting in a narrowing of the social gradient. Between 2002-04 and 2007-09, the rate fell by 16% in the Routine and Manual group, compared with 6% in the Managerial and Professional group. 9

The prevalence of smoking in England varies markedly by socio-economic classification. In 2009, 28% of adults in routine and manual occupations smoked cigarettes compared to 15% in managerial and professional occupations and 21% in England overall 10.

Inequalities by ethnicity

The infant mortality rate in England varies substantially by ethnic group. In 2005-06, the infant mortality rate among the Black groups (8.0 deaths per 1,000 live births), as well as the Asian groups (6.9 deaths per 1,000 live births), was significantly higher than that of the White ethnic groups (4.4 deaths per 1,000 live births). 11

There are inequalities in GCSE achievement amongst pupils by ethnic group in England. In 2008/09, the percentage of pupils achieving five or more GCSEs was significantly better amongst pupils from both the Chinese and Other ethnic group (56.8%) and the Asian ethnic group (54.0%) compared to those in the White group (50.8%) and the Mixed ethnic group (51.5%). GCSE achievement amongst pupils in the Black ethnic group was significantly worse (45.2%). 12 13

Inequalities by disability

Young people with learning difficulties and disabilities are more likely to be unemployed or not in education or training than young people in general. In England, 7.0% of all young people in England were not in education, employment or training (NEET) in 2009/10. However, the percentage of young people with learning difficulties and disabilities who were NEET, at 13.7%, was almost double the national average. 14

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Review of health inequalities in England - the Marmot Review

Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010, published by the Marmot Review Team in 2010, discusses the health inequalities challenge facing England and proposes the most practical, evidence-based strategies relevant to future policy and action. The independent review, chaired by Professor Sir Michael Marmot, was commissioned by the UK government in response to The World Health Organisation’s report, Closing the Gap in a Generation (2008). This latter report showed that countries with more equitable policies and more just societies were healthier. It argued that there was a need for nation-specific strategies to combat health inequalities and achieve good health globally.

Fair Society, Healthy Lives emphasises the "causes of the causes" of health inequalities, and the need to address these wider determinants. To tackle inequalities and reduce the steepness of the social gradient, the Marmot Review recommends actions of sufficient scale and intensity to be universal but also proportionately targeted. Strategies need to target those at the lower end of the gradient as well as throughout the whole of society, according to the level of disadvantage.

The report specifically proposes action on six policy objectives:

  • Give every child the best start in life;
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives;
  • Create fair employment and good work for all;
  • Ensure a healthy standard of living for all;
  • Create and develop healthy and sustainable places and communities;
  • Strengthen the role and impact of ill health prevention.

As well as being a matter of fairness and social justice, achieving health equality would bring clear economic and social benefits, such as improved productivity, lower welfare payments and healthcare costs, and increases in revenue.

The Review suggests some indicators to support monitoring of the overall strategic direction in reducing health inequalities. Six indicators, which relate to improvements in social inclusion, health outcomes and child development across the social gradient, have been proposed

  • The Review suggests some indicators to support monitoring of the overall strategic direction in reducing health inequalities. Six indicators, which relate to improvements in social inclusion, health outcomes and child development across the social gradient, have been proposedHealth expectancy (to capture the quality of those years);
  • Readiness for school (to capture early years development);
  • Young people not in education, employment or training (to capture skill development during the school years and the control that school leavers have over - their lives);
  • Household income (to capture the proportion of households that have an income sufficient for healthy living).

The Review also recommends an indicator of wellbeing, once one is developed that is suitable for large-scale implementation.

The London Health Observatory and the Marmot Review Team have now produced baseline figures for some key indicators of the social determinants of health, health outcomes and the social gradient that correspond, as closely as is currently possible, to the indicators proposed in Fair Society, Healthy Lives. These are available for all upper-tier local authorities in England.

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Policy context

In recent decades, there have been a number of government documents examining health inequalities. The Black Report (1980) showed that although improvements in health had been made overall, there were widespread inequalities in health outcomes, as well as in access to health services. The review highlighted differences in health related to social class.

A programme of addressing inequalities in health was further propelled in England by the Acheson report Independent Inquiry into Inequalities in Health (1998). The report triggered a series of key policy documents that brought health inequalities forward as a national priority, such as Saving Lives: Our Healthier Nation (1999), Tackling Health Inequalities: A Programme for Action (2003) and Choosing Health: Making Healthy Choices Easier (2004).

The Wanless Report: Securing Good Health for the Whole Population (2004), an independent report to Government, focused on prevention and the wider determinants of health in England and the cost effectiveness of action that could be taken to improve the health of the whole population and to reduce health inequalities.

The Department of Health’s Tackling Health Inequalities: 10 Years On (2009), examines developments in health inequalities since the publication of the Acheson report. The report, developed with the oversight of a reference group chaired by Professor Sir Michael Marmot, reviews a range of key data sets, including social, economic, health and environmental indicators. It sets out lessons learnt and challenges for the future.

The Government has recently released two White Papers which outline proposed changes to the NHS and the long-term vision for public health in England: Equity and Excellence: Liberating the NHS (2010), which includes major reforms to the health system, such as moving health improvement responsibilities to local government, and Healthy Lives, Healthy People: Our strategy for public health in England (2010) responds to the challenges laid out by the Marmot Review Team in Fair Society, Healthy Lives. Strategies to tackle health inequalities include: the creation of a national ‘wellness’ service, Public Health England; shifting power to local communities; ring-fencing health improvement budgets; and providing financial incentives that will reward progress on specific public health outcomes.

The Public Health Outcomes Framework consultation, which will run until 31 March 2011, has been explicitly designed to tackle inequalities. It aims to improve and protect the nation’s health in its broadest sense, and to improve "the health of the poorest, fastest". It proposes several indicators that cover the wider determinants of health, requiring the combined efforts of all public services.

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Health inequality analytical tools

The Health Inequalities Gap Measurement Tool for England provides detailed information on the nature and extent of health inequalities across England. It shows inequality gaps in mortality rates within and between areas by grouping local populations according to relative levels of deprivation. Results are available for all Local Authorities and Primary Care Trusts (PCTs), as well as for Strategic Health Authorities, Government Office Regions and England as a whole.

The Health Inequalities Intervention Tool helps local authorities and PCTs understand the causes of their local life expectancy gap and predicts the impact of a number of evidence-based interventions that can reduce the gap in areas with the worst health and deprivation indices in England. It also allows all local authorities to understand inequalities within, as well as between areas, and model the impact of these interventions on the life expectancy gap within their area.

Local Basket of Indicators (LBOI) supports local action to reduce inequality gaps in life expectancy and infant mortality. Aimed at the NHS, local authorities, Local Service Providers and partner organisations, it allows comparisons to be made between local areas or with England as a whole. Local areas can choose which indicators to use and monitor over time based on locally agreed priorities.

The Slope Index of Inequalities (SII) is a single composite score based on life expectancy for deprivation deciles. The SII represents the gap in years of life expectancy between the least deprived and most deprived within an area, based on a statistical analysis of the relationship between life expectancy and deprivation scores across the whole area. Local authority data have been recently updated to include 2005-2009. Data for 2001 to 2008 are available here.

Health Profiles present a set of key health indicators that give a snapshot overview of health for each local authority and region in England compared to the national and regional average. Highlighting the considerable variation in health between areas, the health profiles are designed to help local government and health services make decisions and plans to improve local people's health and reduce health inequalities.

APHO General Practice Profiles are designed to assist GPs, consortia and PCTs to ensure that they are providing and commissioning effective and appropriate healthcare services for their local population. They bring together indicators from various sources, including deprivation score (Index of Multiple Deprivation 2007).

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Health inequalities – LHO and APHO resources
Date Title Format
3 Mar 2014 Socio-economic determinants of health during the economic downturn Icon representing a aspx filetype Download resource icon
24 Jan 2014 Understanding inequalities in London’s life expectancy and healthy life expectancy Icon representing a pdf filetype Download resource icon
12 Jul 2013 Trends in all-cause mortality by NS-SEC for English regions and Wales 2001–03 to 2008–10: London summary Icon representing a pdf filetype Download resource icon
28 Sep 2011 Health Inequalities Gap Measurement Tool Icon representing a aspx filetype Download resource icon
28 Mar 2011 Fair London, healthy Londoners? Datapack 2011 Icon representing a xls filetype Download resource icon
23 Mar 2011 Fair London, healthy Londoners? Icon representing a pdf filetype Download resource icon
14 Dec 2010 European regional health profiles Icon representing a php5?rid=851 filetype Download resource icon
30 Sep 2010 Regional Health Profile for London 2010 Icon representing a aspx?RID=95272 filetype Download resource icon
6 Sep 2010 Celebrating a decade of public health intelligence. London key fact 7: health inequalities Icon representing a pdf filetype Download resource icon
13 Aug 2010 The spirit level: summary of a debate held at the Royal Society of Arts on 22 July 2010 Icon representing a pdf filetype Download resource icon
17 May 2010 Updated - Local Basket of Indicators Data Retrieval Tool Icon representing a aspx filetype Download resource icon
9 Mar 2010 Health Inequalities Intervention Toolkit Icon representing a aspx filetype Download resource icon
29 Jan 2010 Health profile for London 2009 Icon representing a aspx?RID=85386 filetype Download resource icon
4 Jan 2010 World class commissioning health inequalities indicator: analysis of the slope index of inequalities in life expectancy in London PCTs Icon representing a pdf filetype Download resource icon
3 Dec 2009 London's Spearhead areas: progress towards the health inequalities national target Icon representing a pdf filetype Download resource icon
26 Jul 2007 Choosing health. Born equal? A briefing on inequalities in infant mortality in London Icon representing a pdf filetype Download resource icon
13 Jul 2007 Choosing health. Born equal? A report on inequalities in infant mortality in London. A technical report Icon representing a pdf filetype Download resource icon
2 May 2007 Health in London - 2006/07. Review of trends, progress and opportunities: full report Icon representing a pdf filetype Download resource icon
31 Mar 2007 Health in London 2006/07: looking back, looking forwards Icon representing a pdf filetype Download resource icon
16 Nov 2006 The London health inequalities forecast: a briefing on inequalities in life expectancy and deaths from cancers, heart disease and stroke in London Icon representing a pdf filetype Download resource icon
16 Nov 2006 The London health inequalities forecast: technical document Icon representing a doc filetype Download resource icon
28 Jun 2006 Commissioning for equity. A briefing on inequalities in access to revascularisation in the NHS and in the independent sector among London residents Icon representing a pdf filetype Download resource icon
28 Jun 2006 Commissioning for equity. Inequalities in access to revascularisation in the NHS and in the independent sector. A technical report Icon representing a pdf filetype Download resource icon
25 Oct 2005 Indications of public health in the English regions 4: ethnicity and health. Executive summary Icon representing a pdf filetype Download resource icon
25 Oct 2005 Indications of public health in the English regions 4: ethnicity and health. Full report Icon representing a pdf filetype Download resource icon

Health inequalities – London Health Inequalities Network - Resources

Key organisations
References and Sources