Health Inequalities - Health Committee Contents

2  Health inequalities - extent, causes, and policies to tackle them

The extent of health inequalities

16. The last ten years have witnessed large improvements in health for everyone.

Life expectancy at birth for men & women in social class I (professional), social class V (unskilled manual) and all, 1972-2005, England & Wales

  Men Women

Source: Professor Hilary Graham[6]

The figure above shows that although life expectancy increased for all social groups between the periods 1972-6 and 2002-05, health inequalities—gaps in life expectancies between social groups—have persisted.

The widening mortality gap between social classes
Standardised Mortality Ratios, indexed to 1930-32

Source: Office for National Statistics (see References Section)

Life expectancy at birth by social class and sex, 1997-99, England and Wales[7]

17. In fact, since the baseline period when the Government began to measure progress towards its target to reduce health inequalities (1995-97), the gap between the 'routine and manual' groups and the population as a whole has widened. The gap in men's life expectancy in the period 2005-07 was 4% wider than the baseline period, while for women, this gap was 11% wider. From 2005-07, infant mortality in routine and manual groups was 16% higher than in the population as a whole, compared to 13% in the baseline period.[8]

18. The UK is not alone in suffering from pervasive health inequalities, which have been defined as 'systematic differences in health status between different socio-economic groups'.[9] The following graphs show the relative inequalities[10] in mortality, by level of education, across European countries:

Relative inequalities in total mortality by level of education in Men

Source: Eurothine report 2007

Relative inequalities in total mortality by level of education in Women

Source: Eurothine report 2007

19. Unsurprisingly, the major causes of mortality, including coronary heart disease, also follow a socio-economic gradient:

Age-standardised death rates for CHD and stroke, adults aged 15 to 64, 1993 to 2003, England and Wales

Source: British Heart Foundation[11]

20. The following data from ONS demonstrates that there are differences in England not only in life expectancy, but in health—with women in the most deprived wards on average succumbing to poor health on average 13.6 years earlier than their counterparts in the least deprived wards. Years of healthy life expectancy are dark shaded and years of poor health are light shaded:

Years of healthy life expectancy (LE) and poor health by deprivation level

Source - HI 101, Professor Kay-Tee Khaw

For infant mortality, the picture is similar. The infant mortality rate has fallen significantly throughout the twentieth century in response to improved living conditions, availability of healthcare and other factors—even the last 30 years have seen dramatic improvements (in 1978 the infant mortality rate was 13.2/1000, compared with 4.8/1000 in 2007).[12] Despite this, differentials still exist by father's socio-economic status, birthweight, marital status of parents and mother's country of birth. For babies registered by both parents, the infant mortality rate is highest for babies with fathers in semi-routine and routine occupations—5.4/1000 compared to the national average of 4.9/1000. Moreover, the decrease of 5% in the infant mortality rate for this group between 1994 and 2002 was far smaller than the 16% fall in the overall infant mortality rate.

21. Health inequalities can be defined as either absolute or relative. Absolute inequalities are calculated by subtracting one figure or rate (e.g. deaths or death rate in social class 1) from another (e.g. deaths or death rate in social class 5). Relative inequalities are calculated by dividing one number or rate by another. Thus, absolute inequalities are simple arithmetic differences, while relative inequalities are ratios.

22. In England, health inequalities are generally measured in terms of socio-economic class, and action is targeted towards tackling this specific aspect of health inequalities. But there are many other dimensions of health inequalities, which are arguably just as valid candidates for measurement and targeting.

23. There are differences in health between ethnic groups. In April 2001 Pakistani and Bangladeshi men and women in England and Wales reported the highest rates of both poor health and limiting long-term illness, while Chinese men and women reported the lowest rates. The figure below shows the percentages of people in different ethnic groups suffering from poor health and limiting illness in 2001.

Age-standardised limiting long-term illness: by ethnic group and sex, April 2001, England and Wales

Source - ONS[13]

  • South Asian people are reported to have high rates of heart disease and of hypertension;
  • Black Caribbean people are reported to have high rates of hypertension, but not of heart disease;
  • All ethnic minority groups are reported to have high rates of diabetes, but low rates of respiratory illness;
  • Black Caribbean people, particularly young men, have high rates of admission to hospital with severe mental disorders (psychosis).[14]

24. It is claimed that inequalities in health exist between young and old, and that the old receive poorer treatment and are denied access to certain procedures.[15]

25. Gender inequalities also exist. The Men's Health Forum argue that men's life expectancy is more severely affected by deprivation than that of women, and point out that gender inequalities exist in many different health outcomes:

  • Three quarters of all suicides are by men.
  • 67% of men are overweight or obese compared to 58% of women.
  • Men are almost twice as likely to develop and to die from the ten most common cancers that affect both sexes.[16]

26. Those suffering from a range of physical and intellectual impairments and disabilities also experience poorer health outcomes than other parts of society. Those with schizophrenia are 90% more likely to get bowel cancer, 42% more breast cancer, have higher rates of diabetes, coronary heart disease, stroke and respiratory disease, and on average die 10 years younger than counterparts without mental health problems.[17]

27. Health outcomes also vary by geographical area—there is a substantial but not complete overlap with social class, with some evidence of the impact of place independent of other factors. There is some evidence that poorer people living in a deprived area suffer worse health than those in a mixed community.[18]

Measuring health inequalities

28. While the statistics presented above provide a broadly accurate view, it should be noted that measuring health inequalities is a complex and inexact science. This section discusses some of the difficulties associated with it. These difficulties do not negate the importance of collecting these data, but serve to illustrate why such measurements need to be treated with caution.

29. Data on socio-economic status and health are available from a number of sources, including the decennial census, government-sponsored household surveys, and birth and death records. Some of the most important information comes from an ONS longitudinal cohort which represents 1% of the population of England and Wales. The class to which individuals are allocated is determined by their job. In longitudinal data the individual's earliest known point of employment is used for this purpose, supplemented if necessary by the socio-economic status of other household members.

30. Most statistics on inequalities are disaggregated by age and gender. National figures on inequalities by disability and ethnicity are not easily available. ONS publishes limited figures on inequalities at regional and local authority levels, while PCTs and other organisations sometimes monitor these aspects of health inequalities at a local level.

31. Life expectancy is one of the target areas chosen by government; for geographical breakdowns it is measured by place of residence at death. We did hear concerns about the impact of population mobility on life expectancy calculations, but as the great majority of moves are within a local authority area, this is unlikely to have a large impact. The exception to this may be with recording and targeting health inequalities related to ethnicity, where large-scale migration, and the loss to studies of individuals who have left the country, might be a factor.

32. Infant mortality is the other aspect of the Government's health inequalities target. The first problem with this is that the measure of infant mortality only takes account of children born to parents where the father's occupation can be registered. Where a mother registers as a sole parent, that baby falls into another category which lies outside the target, and as sole-registered births have higher infant mortality rates even than those babies born to fathers who are in the manual and routine occupations, this means that current measures of infant mortality are likely to underestimate the true scale of inequalities in this area.[19]

33. As numbers of infant deaths are now so low, it is very difficult to discriminate between areas in a statistically sound way, as only a couple of random occurrences of infant deaths are needed to alter the picture.[20]

34. Comparing health inequalities internationally is also fraught with difficulty. This is because different countries may use different data sources that are not comparable: there may be differences in recording health statistics and differences in recording socio-economic status, with some countries using different measures altogether; education, for example, is commonly used in Europe. The best source of data for international comparisons remains the Eurothine project[21] but the caveats listed above apply to this as well.

Causes of health inequalities

35. While health inequalities are generally described in terms of socio-economic class, it is also possible to consider health inequalities using the 'Human Capital' model: each individual is born with a certain amount of "physiological stock", which is affected by genes, and by antenatal factors. This stock depreciates over the course of an individual's life, and can be augmented or not over life by lifestyle behaviours (including diet, stress, smoking, exercise).[22] The inter-generational causes of health inequalities are also crucial. Inequalities in health are passed from one generation to the next. This is not only to do with genetic factors, but the mothers' health behaviours during pregnancy and circumstances and behaviour as they raise their children.[23] Equally, health behaviours may be learnt by children from their parents at a young age.

36. This section considers lifestyle factors, and then their underlying causes socio-economic causes. But first we consider what role is played by access to health care in causing health inequalities.


37. Some specific aspects of inequalities in health are attributed to differential access to, and standards of, health care. These matters are considered more fully in Chapter 6. The most compelling concern is about access related to age-related inequalities.[24] However most of our witnesses agreed with Margaret Whitehead, Professor of Public Health at the University of Liverpool, that "inadequate access to health services is only one of many determinants of the observed inequalities in health, and a relatively minor one at that".[25]


38. The lifestyle factors which influence health inequalities are sometimes referred to as the "proximate" causes of health inequalities, because they are the immediate precursors of disease, as opposed to the 'distal', 'upstream' or 'wider determinants', such as poverty, housing or education. They include:

39. As the figures below show, lifestyle factors such as smoking, nutrition and obesity follow the same socio-economic gradient that is evident in the distribution of mortality and of the major causes of mortality.

Smoking prevalence and socio-economic disadvantage


Fruit and vegetable consumption by sex and socio-economic group, 2001, England
—   —  Socio-economic group of household reference person
—  Fruit and vegetable consumption —  Managerial & professional occupations —  Intermediate occupations —  Small employers & own account workers —  Lower supervisory & technical occupations —  Semi-routine & routine occupations
—  (portions per day) —  % —  %—  % —  %—  %
—  Men
—  None —  5—  8 —  8—  9 —  12
—  All with 5 portions or more —  28 —  24—  25 —  22 —  18
—  Women
—  None —  —  4 —  6—  6 —  8
—  All with 5 portions or more —  35 —  25—  27 —  26 —  21

Source: British Heart Foundation

Trends in Obesity Prevalence 1993-2004 by Social Class I and V

Source: Foresight Tackling Obesities: Future Choices—Modelling Future Trends in Obesity and Their Impact on Health

40. The potential for behavioural changes to affect health inequalities is borne out by research described to us by Kay-Tee Khaw, Professor of Clinical Gerontology at the University of Cambridge, which indicates that certain health behaviours, irrespective of socio-economic grouping, have an impact on health outcomes:

In EPIC-Norfolk, we observed that men and women who had four health behaviours—not smoking; not being physically inactive, moderate alcohol intake (more than 1 and less than 14 units a week: a unit is half a pint of beer or a glass of wine); and eating five servings of fruit and vegetables a day as estimated using blood vitamin C level—had a quarter the subsequent death rate and survival equivalent to men and women 14 years younger who did not have any of these behaviours. This relationship was consistent irrespective of age, social class or obesity. These behaviours are entirely achievable: 30% of this free living population were already practising all four behaviours.[26]


41. However, these lifestyle-related causes of health inequalities reflect what are frequently referred to as the underlying causes—income, socio-economic group, employment status and educational attainment. There are many reasons why the poorest in society are less likely to adopt beneficial health behaviours. Firstly, information about how to behave healthily may not reach some groups of society; secondly, they may lack the material resources to live healthily, and the environments in which they live may make this doubly hard; behaviours such as smoking tend to be more heavily entrenched in those from lower socio-economic groups which makes positive change harder; and finally, for people living difficult lives, who may be faced with pressing problems with income, employment or even personal safety, changing health behaviour is unlikely to be a major priority.

42. Sir Michael Marmot, Professor of Epidemiology and Public Health, University College London, and Chairman of the Commission on Social Determinants of Health, set out for us in simple terms why having sufficient resources is essential for health:

Professor Jerry Morris, I think after his 90th birthday, calculated the minimum income for healthy living for a pensioner and he did it by consensus. He went round to the various experts and said, "How much does it cost to eat a healthy diet?", and, "Is it reasonable to expect people to buy presents for their grandchildren and make visits to friends and so on? How much would all that cost?", and he summed it up. Then he looked at what a single pensioner gets with the state pension and there is a huge gap. People who rely on the state pension who are pensioners do not have enough money to lead a healthy life. That is the clear judgment and it is the same for a couple. They do not have enough money to live a healthy life. We can give all the health education we like. If people cannot actually afford to do the things they need to do to remain healthy then they are not going to be healthy. That has to be a key issue in inequalities and we have not solved that one.[27]

43. Socio-economic circumstances can also have a negative effect on health behaviour as future health is not a high priority for people who face much more immediate and serious problems, such as crime and unemployment:

Smoking is not a key issue for people living in relative poverty when they have a number of other key issues that concern them more immediately …If you look at Washington DC, young black men have a life expectancy of 57. Young black men also have a one third probability of being incarcerated for drug dealing between the ages of 18 and 24, so they are either going to die early or they are going to be put in prison. You go to those young men and say, "You know, you really shouldn't smoke because you might get lung cancer when you are 60" … I do not think you would get a very welcome reception. That is an extreme case but I think some of that goes on if people have multiple problems and smoking does not rank so highly on their list of problems that they are willing to do something about it.[28]

44. Richard Wilkinson, Professor of Social Epidemiology at the University of Nottingham, expanded on this point, arguing that 'health-related behaviour is all about resolutions to give up the things you do not want to give up and to do the things you do not want to do. You cannot do that, you cannot make the resolutions and stick to them, unless you are feeling on top of life."[29]

45. But socio-economic factors appear to go beyond the direct influence socio-economic circumstances may have on lifestyle, as these graphs demonstrate, which reveal that people from high socio-economic classes who smoke live longer than those from lower socio- economic classes who smoke:

Smokers survival by social class



Source - Gruer et al[30]

46. Much debate has centred on whether health problems are more common in lower socio-economic groups because they are absolutely poorer—as in Professor Marmot's example of a pensioner who could not afford to live a healthy life—or because they are relatively poorer. According to Professor Marmot, relative differences are also crucial:

Relative differences matter because even though our children all now have enough to eat they do not all have the latest Nike trainers or latest mobile phone, which is really very important. That is not trivial, that is central. If a kid does not have what the other kids have, even though he has got all the basic material provisions he needs, that is really terribly important, he is on the outside, and the evidence is that he is relatively deprived in the space of income but absolutely deprived in the measure of what he can do, of his capability to lead a healthy, flourishing life.[31]

47. There is also a hypothesis, called 'competing causes of death', which argues that irrespective of advances in health care and lifestyle the poor will continue to die earlier than the rich unless 'fundamental' or 'upstream' causes of inequality like income inequalities are tackled. In the 1930s the main cause of inequalities was infectious diseases; now it is chronic diseases arising from lifestyle factors, such as cancer and coronary heart disease. The consequence of eliminating the present major causes of death, such as heart disease or lung cancer, will be that the poor will continue to die earlier than the rich but from other causes which will inevitably replace today's major diseases.[32] In other words, it is argued that inequalities in health between rich and poor persist irrespective of the diseases which happen to be currently most prevalent. There is a large research literature referring to this phenomenon, but, while this literature discusses the fact that when one cause of death becomes less prominent, others take its place, there is no published research on the social class distribution of this phenomenon.

48. Although associations between socio-economic inequalities and health inequalities are apparent, controversy remains in this area, as seen by a recent publication in Health Economics which did not find a highly significant relationship between socio-economic inequalities and health inequalities.[33] Moreover, while the view that reducing relative income inequalities was the key to reducing health inequalities has many enthusiastic proponents, we did not see any conclusive evidence that suggested changing tax and benefit policies to reduce income inequalities would lead to a reduction in health inequalities. Such claims tended to centre on theoretical assertions rather than be supported by robust evaluative evidence. We note that the Government has commissioned research, to be carried out by Professor Sir Michael Marmot, into the evidence about these wider determinants of health.

49. Health in the UK is improving, but over the last ten years health inequalities between the social classes have widened—the gap has increased by 4% amongst men, and by 11% amongst women. Health inequalities are not only apparent between people of different socio-economic groups—they exist between different genders, different ethnic groups, and the elderly and people suffering from mental health problems or learning disabilities also have worse health than the rest of the population. The causes of health inequalities are complex, and include lifestyle factors—smoking, nutrition, exercise to name only a few—and also wider determinants such as poverty, housing and education. Access to healthcare may play a role, but this appears to be less significant than other determinants.

6   Ev 172, Professor Hilary Graham Back

7   Source - ONS -  Back

8   Tackling Health Inequalities: 2005-07 Policy and Data Update for the 2010 National Target, DH, 2008;  Back

9   Levelling Up: 'Social inequalities in health concern systematic differences' in health status between different socioeconomic groups', Dahlgren and Whitehead, WHO, 2007  Back

10   The relative index of inequality is a summary measure comparing the risk of death between different socioeconomic groups Back

11  Back

12   Source - ONS -  Back

13   Source - ONS -  Back

14   HI 120 - Professor James Nazroo Back

15   Ev 194-196 Back

16   Ev 72 Back

17   Ev 302-304; Q 477 Back

18   Neighbourhood deprivation and health: does it affect us all equally?, Stafford M, Marmot M, International Journal of Epidemiology, 32 (3), 357-366 Back

19   Q 117 Back

20   HI 143 Back

21   Tacking health inequalities in Europe: an integrated approach, Eurothine, Rotterdam 2007 Back

22   "The human capital model", Michael Grossman, Handbook of Health Economics, volume 1 A, chapter 7, pages 367-408 edited by AJ Culyer and JP Newhouse North Holland-Elsevier, 2000, Amsterdam, Oxford and New York Back

23   Fetal origins of adult disease, DJP Barker(ed), BMJ Books , London 1992 Back

24   Age Concern argued that too often the organisation of health services directly discriminates against people on the grounds of age, resulting in health inequalities. These include: Mental health services, which are often focused on 'adults of working age' and may exclude older people; breast and bowel cancer screening programmes are still not extended upwards to the maximum ages at which people can achieve health gains. HI 59.  Back

25   HI 106 - Margaret Whitehead Back

26   HI 101 - The EPIC-Norfolk (European Prospective Investigation into Cancer in Norfolk) is a prospective population study of 25,000 men and women aged 40-79 years resident in East Anglia first surveyed in 1993-97 and followed up to the present for changes in health Back

27   Q 155 Back

28   Q 156 Back

29   Q 156 Back

30   Gruer L, Hart CL, Gordon DS, Watt GCM. Effect of tobacco smoking on survival of men and women by social position: a 28 year cohort study. BMJ 2009;338:b480 doi:10.1136/bmj.b480. Available online at:  Back

31   Q 177 Back

32   Scott-Samuel A. What the Renfrew / Paisley data really tell us about tackling health inequalities: the need to refocus upstream. BMJ 2009 (Rapid response) Available online at:  Back

33   INCOME, RELATIVE INCOME, AND SELF-REPORTED HEALTH IN BRITAIN 1979-2000 HEALTH ECONOMICS, Hugh Gravelle and Matt Sutton, Health Econ. 18: 125-145 (2009) Back

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