Turning the tide on place-based health inequalities

The threads of power and place run through everything we are exploring in UK 2040 Options. Understanding how power and place interact, and how they impact people and communities, is critical to understanding how we might make the UK a fairer place to live. This is part of a series of guest essays that explores these themes.

England is a deeply unequal country. Health, wealth, and opportunities to thrive differ greatly depending on where we live and work.

The relationship between health and place can be considered in terms of the interplay between who lives in a place, what the place is like and the wider public policy context. Often, individual circumstances interact with the place where people live to exacerbate or reinforce inequalities in health outcomes.

In this piece, I highlight the worrying statistics that show the level of health inequality in England and why policymakers must consider a hyperlocal approach. I also outline the policy options that local and central government have available to help tackle place-based health inequalities.

The UK has wide place-based health inequalities: and they are growing

The UK ranks among the highest in terms of regional economic inequalities among OECD countries. The north of England bears the brunt of these inequalities, with lower economic productivity as well as lower life expectancy than the south of England. Nationally, coastal communities grapple with a higher burden of ill-health and substance misuse.

Our analysis of the most recent data shows that on average, males living in the most deprived areas of England are expected to live 9.7 fewer years than males in the least deprived areas. Females living in the most deprived areas can expect to live 8 fewer years than females in the least deprived areas.

These gaps are even bigger when we consider healthy life expectancy, an estimate of lifetime spent in very good or good health. Males living in the most deprived areas have a healthy life expectancy that is 18.2 years lower than males living in the least deprived areas. Females living in the most deprived areas have a healthy life expectancy that is 18.8 years lower than females living in the least deprived areas.

Worryingly, there is a downward trend in life expectancy for those living in the most deprived areas meaning that the gaps between the most deprived and least deprived areas have been growing over time.

“Despair” is not uniformly spread throughout England

In 2015, a phenomenon coined ‘deaths of despair’ emerged in the US, highlighting an increase in deaths caused by drug and alcohol misuse as well as suicide. The underlying cause of these deaths in the US is long-term economic disadvantage: low levels of education, income inequality and poverty, as well as a breakdown of community and social structures, including insecure and low-paid jobs, income inequality, housing evictions and workplace automation.

In a study that my team at the University of Manchester recently conducted, we used the latest available data from England to see whether there was a similar trend. It showed us that between 2019-21, 46,200 lives were lost to deaths of despair (equivalent to 42 each day) with an average rate for England of 34 lives lost per 100,000 people.

But below this average hid significant regional disparities, mapping on to what we know about place-based inequality. The North East had the highest burden, averaging 55 deaths of despair per 100,000 people, but in stark contrast, London’s rate was very low, with around 25 per 100,000. Despair therefore seems to not be uniformly spread throughout England: of the 20 local authorities with the highest rates of deaths of despair, 16 were in the north – but none of the 20 areas with the lowest rates were. These are stark and unacceptable differences.

To understand what might be driving these gaps, we identified a number of area-level factors that were associated with the elevated risk of deaths of despair. These included high unemployment rates, higher proportions of White British ethnicity, solitary living, higher rates of economic inactivity, employment in elementary occupations, and whether the community was urban (compared to rural). This also emphasised that deaths of despair are not inevitable – but rather a tragic consequence of inequitable resource distribution.

Deprivation interacts with place, amplifying its impact

While deprivation and the lack of resources available to people and places are key drivers of health inequalities, there is evidence that region-level deprivation interacts with and amplifies the effect of small area deprivation. We can see deeper health inequalities at a hyperlocal level: this is a phenomenon that we have called ‘deprivation amplification’.

We see this throughout England. Persistent inequalities, evolving over recent decades, have led to the creation of ‘left-behind’ communities. While the use of the phrase left-behind has generated some controversy, it reflects that a set of neighbourhoods and communities have higher levels of need and have largely been forgotten by national policy. There are 225 left-behind neighbourhoods, which are mostly found in post-industrial areas in the north of England and the Midlands.

Again, this has an impact on health outcomes: in left-behind neighbourhoods, men live 3.7 years fewer than average and women 3 years fewer. Both men and women in these neighbourhoods can expect to live 7.5 fewer years in good health than their counterparts in the rest of England, and there is a higher prevalence of 15 of the most common health conditions, even when compared to other deprived areas. This has an economic impact: individuals are twice as likely to claim incapacity benefits due to mental health-related conditions when compared to England as a whole.

This deprivation amplification was particularly acute during the Covid-19 pandemic. Across England, the most deprived areas had the highest rates of Covid-19. But when deprived areas in the north were compared to areas that were equally deprived in other parts of England, we found that northern areas had significantly higher rates of mortality. We found that deprivation alone could not explain these very stark differences. And again, people living in left-behind neighbourhoods in the early stages of the pandemic were 46% more likely to die from Covid-19 than from those in the rest of England.

Options for a more equal England

Interpreting the complex interrelationships between health and place relies heavily on the availability of high-quality data and the definition ‘place’. However, the way that we currently measure the health of a place is based on geographic definitions that are not always meaningful when it comes to supporting decision-making about how to improve health.

For example, Liverpool has the fifth-lowest life expectancy for males if we consider local authority averages. Yet of the 62 middle super output areas (MSOAs) that make up Liverpool, 10 of them have above the national average male life expectancy. Conversely, not all MSOAs within the local authorities that have the best health outcomes experience the best health. For example, based on census data, 12% of areas within Richmond on Thames (the local authority with the highest life expectancy) reported below average levels of very good or good health.

Therefore, if we base funding decisions solely on local authority averages, we mask really important variation that tells us about the health of communities and where services might be needed.
We need to tackle the hyperlocal differences in health outcomes, as well as the between regions and between local authority differences. But the way policymakers currently think about place-based health inequalities is insufficient, as decisions are based on their understanding on averages of disparate areas. And the way that most people conceptualise ‘place’ is very often different to how geographical boundaries are drawn. For example, most people have no idea which MSOA they live in: instead, we tend to define where we live through key landmarks.

We can see this insufficient consideration of place play out in the previous UK Government’s Levelling Up agenda. Our research has previously raised concerns around whether funding is allocated equitably. Around £125 million was allocated to England in the first round of the Community Renewal Fund (one of the first flagship ‘levelling up’ funding pots). However, when a ‘fair share’ funding allocation was created (based on the UK Government’s own formula) and compared to the actual allocation of funding, large place-based inequalities emerged. The North East received £13.4 million less than expected based on its resilience score. At the other end of the scale, the South East received £3 million more from than expected. Overall, analysis showed no significant correlation between need and actual Community Renewal Fund allocations.

The implication of our work is therefore clear: preventive policies must be geographically tailored. There is no one-size-fits-all solution to fixing regional inequalities, and knowing where the hotspots of poor health really are will mean that policymakers can target funding in a much more nuanced way.

We have set out a series of policy options below. Devolving greater decision-making powers and funding to local and regional governments offers one avenue for delivering bespoke solutions. Greater powers are needed for Metro Mayors to direct financial, health, and community resources towards the areas hit hardest by unfair health inequalities. This is underway in Greater Manchester and the West Midlands, with their ‘trailblazer deal’, but this new data highlights the urgent need to accelerate the devolution of place-based powers.

However, the national policy context – prioritising equitable access to economic opportunities, the labour market, and housing – remains paramount in reducing health inequalities by tackling the social determinants of health. This has been shown to be successful in the past in the UK at reducing inequalities in life expectancy, infant mortality and mortality at age 65. Tackling these socio-economic factors requires interdepartmental collaboration, cross-party working and a long-term commitment to levelling up. The responsibility falls across Government to ensure health is embedded in all decisions aimed at reducing inequalities.

Options

What Westminster can do

• A national strategy developed to reduce health inequalities through targeting multiple neighbourhood, community and healthcare factors. However, this needs to be allocated based on need, so that more deprived and left-behind communities receive their fair share.
• The impact on health, and health inequalities, should be taken into account when making all government decisions, regardless of which government department is making the policy.
• An increase in NHS funding in more deprived local areas (including left behind neighbourhoods) to reduce healthcare inequalities.
• Long-term ring-fenced funding put in place for targeted health inequalities programmes, and focussed at the hyper-local neighbourhood level.

What mayoral/combined authorities and local authorities can do

• Local governments should have increased freedom over their spending to ensure it is used in the best way to tackle health inequalities. In particular, following on from the Health Foundation work, local authorities should utilise hyperlocal data to identify the areas with the highest burdens of disease and use this to target services within their jurisdiction.
• Consistent and long-term financial support should be ring-fenced for communities to engage in neighbourhood-based health initiatives. For example, a Community Wealth Fund, which, if implemented, could offer a means of improving social infrastructure and empowering communities by placing neighbourhoods at the heart of decision-making.
• Programmes developed to increase community engagement to better understand and identify the issues and barriers faced by individuals, and thereby improve the quality of local services.
• Set up community consultation processes in left-behind neighbourhoods to identify the issues facing local communities.

What local government and communities can do

• Fund health initiatives that increase the level of control local people have over their life circumstances, such as the community piggy bank.
• Put community engagement which builds social cohesion, networks and infrastructure at the heart of health delivery.
• Help communities to take ownership of community assets facilitated by sufficient help and support from national and local government.
• Support and incentivise residents to make the most of community assets and maintain their participation through schemes such as lower transport costs.
• Existing services should be redesigned to respond to specific challenges within an area.

If we get this right, there is much to be gained. Not only will it improve the lives of millions of people living throughout England, it will also bring significant savings to the taxpayer. If the health outcomes in local authorities that contain left behind neighbourhoods were brought up to the same level as in the rest of the country, an extra £29.8 billion every year could be put into the country’s economy.

Fixing health inequalities must be a moral urgency for this new UK Government.

Dr Luke Munford is a Senior Lecturer in Health Economics at the University of Manchester and deputy theme lead for Economic Sustainability within the NIHR Applied Research Collaboration in Greater Manchester (ARC GM). He is a quantitative researcher who uses existing data to understand the causes and consequences of health inequalities, with a strong emphasis on place, including focussing on the interactions between people and place. He is also academic co-director of Health Equity North. Health Equity North is a virtual institute focused on place-based solutions to public health problems and health inequalities, bringing together world-leading academic expertise from leading universities and hospitals across the North of England.