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The widening gap in health inequality

This week (March 4th), Parliament debated the connection between health inequalities and life expectancy in the UK. In this blog, IFoA Honorary Fellow Madhavi Bajekal provides an overview of the recent report which has caused politicians to look at this issue in more depth: ‘Health Equity in England: The Marmot Review 10 years on'.  Bajekal is acknowledged in the 2020 report for providing input on life expectancy data.

To misquote Jane Austen, it is a truth universally acknowledged, that when life expectancy improves rapidly, it improves fastest for the most advantaged groups (2001-2010); and conversely, when it stalls, the slow-down is most marked for those at the bottom of the social hierarchy (2011-2018).

The recent decade-long slowdown in rates of mortality improvement for all socioeconomic groups in England has been forensically examined by social epidemiologists, actuaries and demographers. They used a range of tools such as: analysis by cause of death; age-period-cohort models; demographic decomposition methods; and adjusting for seasonal excess in winter mortality due to cold weather and ‘flu.[i] [ii] [iii] Irrespective of the metric used, the underlying message is uncontested – mortality improvements slowed from 2011 onwards and socioeconomic inequalities in life expectancy widened.

This slowdown is not unique to England. Many high income countries have had a similar experience. However, it is not the case across the board and some countries, that already had higher life expectancies than England, have continued to see improvements (e.g. Japan and the Nordic counties).[iv] Other high income countries, which have data by socioeconomic categories, have also seen inequalities widening (e.g. the Netherlands and Germany).[v] But two things stand out:

  1. England has fared worse than any other country in Europe; and
  2. older, disadvantaged women have been the hardest hit. The sex differential in mortality trends could in part be attributable to a lag in smoking-related mortality as the take up of smoking among women was later than men. It could also be in part due to cuts in social care funding, with deprived areas losing a greater proportion of government funding than more affluent areas.[vi]

Prof Sir Michael Marmot refocuses the debate, bringing attention back to policy actions that are needed to reverse the downward trajectory in population health and longevity. The report “Health equity in England: the Marmot review 10 years on[vii] shines a light on the impact of large funding cuts over the last decade. It addresses the impact on income insecurity, educational attainment, health and social care services, services for children and young people, housing affordability and in-work poverty levels. Cautious about suggesting a causal link between austerity and the worsening of population health, Prof Marmot makes the case for the plausibility of such a link, given the adverse trends in the key indicators of the social determinants of health over the past decade. He and his colleagues reiterate their call to action on the key recommendations made in the first review– Fairer Society, Healthy Lives (2010):

“There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health”.

Social justice in addressing the drivers of health across the life-course remains at the heart of the report’s policy recommendations. These include policies to: give every child the best start in life; enable children, young people and adults to maximise their capabilities; create fair employment; ensure a standard of living to sustain good health for all; and develop health-enhancing and sustainable communities.  Prof Sir Michael Marmot argues that the “health of the population is not just a matter of how well the health service is funded and functions, important as that is: health is closely linked to the conditions in which people are born, grow, live, work and age and inequities in power, money and resources – the social determinants of health.”  The UK is a world-leader in the analysis of health equity and how to tackle it. Prof Marmot and colleagues make a compelling case for the UK Government to implement policies to reverse the downward trend in health and to close the health gap between those at the bottom and the top of the social hierarchy.

Madhavi Bajekal, PhD, Hon FIA

Senior Research Fellow, Dept for Applied Health Research, UCL

Principal Scientist (Research), Legal and General

[i] Public Health England (20118). A review of recent trends in mortality in England. 2018. Available from:

[ii] Longevity Science Panel (2020). An analysis of mortality trends in developed countries, focusing on the recent slowdown in mortality improvements.

[iii] The Health Foundation (2019). Mortality and life expectancy trends in the UK: stalling progress

[iv] OECD (2019) Trends in life expectancy in EU and other OECD countries: Why are improvements slowing?". OECD Health Working Papers, No. 108, OECD Publishing, Paris.

[vii] Institute of Health Equity and The Health Foundation (2020). Health equity in England:  The Marmot review 10 years on.