COVID-19 has brought the drivers behind health inequality into sharp focus. But are there resources available to meet research and policy needs?
Overview of change
Health inequalities are defined by the NHS as unfair and avoidable differences in both physical and mental health across the population.1 Inequality is reflected not only in a person’s health, but their experience in accessing care and the quality of that care. Health inequalities arise from a range of complex and interacting factors including geographies, socio-economic background, protected characteristics or being in a vulnerable group. Examples include differences in life expectancy,2 higher avoidable mortality, or increased prevalence of conditions with poorer outcomes between particular groups. Evidence demonstrates that there is a range of persistent health inequalities across numerous health conditions throughout the life course, some of which are developing at an earlier age, with the inequality gap widening.3,4,5,6 There is also evidence that unhealthy behaviours can cluster, leading to further risk of poor health.7,8 Differences in access to and experience of care are also part of health inequalities, for example in the experience of people from ethnic minority groups.9
One in four people will experience a mental health condition in their lifetime, with anxiety disorders and depression the most common conditions. Mental ill health is linked to many forms of inequalities,10,11 with consequences for prospects of recovery and being able to participate fully and flourish in society. People affected are more likely to live in less safe neighbourhoods, have less access to healthy foods and fewer opportunities to be involved in healthy activities. Mental health inequalities are closely linked to increased risk of having a preventable physical health condition or are themselves caused by other physical conditions. Rising prevalence of non-communicable diseases and conditions (such as type 2 diabetes, cardiovascular disease, some cancers, and neurodegenerative conditions) are a particular concern, as is the increasing prevalence of people developing multiple long-term conditions, across both physical and mental health.12 Together, this creates an economic and health burden of disease that outweighs the impact of infectious diseases. This is a complex area for both research and policy, with multiple interacting factors driving inequalities. Public Health England has published action plans and outlined interventions that can be used to improve outcomes.13,14,15 The extent to which national and local policies are driving positive change equitably across mental and physical health domains is an area of concern. The COVID-19 pandemic has cast renewed focus on the persistent social gradient for both mental and physical health, with inequality reported in terms of health outcomes and access to preventive measures and social conditions to minimise the risk of infection. The impacts of the pandemic are being captured in a range of research studies and surveys.16,17,18
Challenges and opportunities
- Strengthening the evidence base so that trends over time are captured at multiple levels and across health conditions in both physical and mental health. The previous focus on preventable non-communicable disease has been reflected in national policy, notably on approaches to tackle obesity, but it is not clear whether all conditions have been given equal attention. The COVID-19 pandemic also demonstrates how inequalities are reflected in the health outcomes from infectious diseases.
- Understanding, and intervening where appropriate, in the generation of clusters of unhealthy behaviours, and subsequent multiple long-term conditions in the population, which are strongly linked to inequalities in health outcomes.
- Understanding the impact of life events throughout the life course and characterising pathways to health inequality (with a focus on intergenerational inequality and childhood).
- Identifying how factors driving inequalities interact at both the wider environmental and the individual level, and what interventions are most effective for mental and physical health.
- Identifying and addressing barriers that people experience regarding the equality of access to services.
- The role and focus of investment and research into preventive public health approaches, including those that address the wider determinants of health, for both communicable and non-communicable disease.
- COVID-19 has stimulated focus on the social determinants of non-communicable disease more broadly.
- Recognition of the value of developing and implementing a whole-of-government approach to tackle inequity, as endorsed by the World Health Organization.
The COVID-19 pandemic has focused attention on the wider social determinants driving inequalities across physical and mental health. But how any learnings from the experience of the pandemic might be applied to policy-making across all areas of public health is unclear. It is uncertain how public health in England will evolve following the abolition of Public Health England.
Key questions for Parliament
- Whether existing policy approaches to narrow health inequalities are having a meaningful impact, and the extent to which a whole-of-government approach is being applied.
- Understanding what effective interventions are and where, when, and how to target and implement them.
- Scrutinising if there is adequate focus on a long-term view from government and examining if there is meaningful evaluation of the impact of policies.
- Matching and forecasting health and social care provision for an ageing population within which some groups will live for longer periods in poor health or experience reduced life expectancy.
- The short to medium-term impact of COVID-19 on the health and social care system to meet the health needs of the population across other disease areas where inequalities persist.
- How the health and care system can be more proactive in responding to the challenges that COVID-19 will bring, for example in improving integration focused on tackling inequalities. The NHS could also have a more proactive economic role as an employer in poorer communities.
Likelihood and impact
High impact/likelihood, with impacts being felt now.
- NHS England. Definition of Health Inequalities
- Office for National Statistics (27 March 2020). Health state life expectancies by national deprivation deciles, England 2016-2018
- Public Health England (11 September 2018). Chapter 5: inequalities in health, Health profile for England 2018
- Office for National Statistics. Health Inequalities
- The King’s Fund, 18 February (2020). What are health inequalities?
- Institute of Health Equity (2020). Health Equity in England: The Marmot Review 10 Years On
- The King’s Fund (February 2012). Clustering of unhealthy behaviours over time: implications for policy and practice
- The King’s Fund (February 2018). Tackling multiple unhealthy risk factors: emerging lessons from practice
- The King’s Fund (February 2021). The health of people from ethnic minority groups in England
- Centre for Mental Health. Mental health inequalities: factsheet
- The Health Foundation (November 2020). Inequalities in health care for people with depression and/or anxiety
- Guy’s and St Thomas’s Charity (July 2018). Multiple long-term conditions: from one to many, Impact on Urban Health
- Public Health England (August 2018). Health matters: reducing health inequalities in mental illness
- Public Health England (July 2019). Health inequalities: place-based approaches to reduce inequalities
- Public Health England (August 2017). Reducing health inequalities: system, scale and sustainability
- Office for National Statistics. Coronavirus and the social impacts on Great Britain
- Public Health England. Wider Impacts of COVID-19 on Health
- University College London. COVID-19 Social Study
GDP and income inequality both influence population health. How might the COVID-19 outbreak widen economic inequalities in the long-term?
The impacts of COVID-19 on mental health remain unclear. Initial research suggests disproportional impact on children, young people and those with pre-existing mental health conditions.