Key Facts

Health inequalities are differences in health outcomes that are systematic, socially produced, and avoidable. They reflect broader societal inequalities and represent a major challenge for the NHS and public health system.

Key Frameworks

• Dahlgren-Whitehead model: layers of influence from individual to societal
• Marmot Review (2010): six policy objectives to reduce health inequalities
• Acheson Report (1998): first comprehensive UK government review of health inequalities
• Black Report (1980): identified social class gradient in health; controversial suppression by government

Dimensions of Health Inequality

• Socioeconomic: income, education, employment, housing
• Geographic: north-south divide, urban-rural differences, coastal towns
• Ethnic: higher rates of diabetes, CVD in South Asian populations; higher maternal mortality in Black women
• Gender: men have shorter life expectancy; women have more years of disability
• Age: older adults face multiple disadvantages
• Disability: people with learning disabilities die 15-20 years earlier
• Inclusion health: homeless, Travellers, prisoners face extreme health disadvantage

Statistics

• Life expectancy gap (most vs least deprived): 9.4 years (men), 7.4 years (women)
• Healthy life expectancy: men in most deprived areas reach disability at 52 years vs 71 years in least deprived
• Infant mortality rate: 70% higher in most deprived vs least deprived
• Smoking prevalence: 25% in most deprived quintile vs 8% in least deprived

Impact on Clinical Presentation

• Later presentation of disease in deprived communities
• Higher prevalence of multimorbidity (2+ chronic conditions) at younger ages
• Multiple risk factor clustering (smoking + obesity + alcohol + poor diet)
• Higher rates of mental health conditions coexisting with physical disease
• Poorer access to and experience of healthcare services

Examples of Health Inequalities

• Cardiovascular disease: mortality rate 60% higher in most deprived quintile
• Cancer: lung cancer incidence 3× higher in most deprived; later stage at diagnosis
• Diabetes: T2DM prevalence 2× higher in most deprived areas
• Mental health: depression and anxiety rates 2× higher in lowest income group
• COVID-19: mortality rate 2× higher in most deprived areas; 2-4× higher in some ethnic minority groups
• Maternal health: maternal mortality 5× higher in Black women vs White women in UK

Measuring Health Inequalities

• Index of Multiple Deprivation (IMD): composite measure of area deprivation (income, employment, education, health, crime, barriers to housing, living environment)
• Slope index of inequality: measures absolute gap in health between most and least deprived
• Relative index of inequality: measures relative gap
• PHE Fingertips tool: interactive data on health outcomes by area and deprivation
• JSNA (Joint Strategic Needs Assessment): local population health assessment

Equity Audit

• Examines whether services are distributed proportionate to need
• Steps: identify population, define equity, collect data, analyse, develop recommendations
• Examples: screening uptake by deprivation quintile, vaccination coverage in minority groups

Marmot Review Policy Objectives (2010)

1. Give every child the best start in life
2. Enable all children, young people, and adults to maximise their capabilities
3. Create fair employment and good work for all
4. Ensure a healthy standard of living for all
5. Create and develop healthy and sustainable places and communities
6. Strengthen the role and impact of ill health prevention

NHS Approaches

• Core20PLUS5: target most deprived 20% + inclusion health groups for: maternity, severe mental illness, chronic respiratory disease, early cancer diagnosis, hypertension case-finding
• Anchor institutions: NHS as a major employer can address local economic and social determinants
• Population health management: using data to identify and target at-risk populations
• Social prescribing: linking patients with community resources
• Personalised care: shared decision-making, health coaching, supported self-management

GP Practice Actions

• Practice-level equity audit of chronic disease management
• Targeted outreach for screening and vaccination
• Enhanced access for deprived populations
• Training in health literacy and culturally sensitive care
• Advocacy for patients and communities
• Participation in local health inequality programmes

• Without action, health inequalities are widening in the UK (Marmot Review 10 Years On, 2020)
• Life expectancy improvements have stalled since 2010, with declines in most deprived areas
• COVID-19 exacerbated existing health inequalities
• Integrated care systems (ICS) offer opportunity for place-based population health approaches
• Evidence shows early years investment is the most effective long-term strategy
• Cost of health inequalities estimated at £31-33 billion/year to the NHS and £60 billion to the wider economy

Core20PLUS5 Clinical Areas

Index of Multiple Deprivation Domains