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 by a person’s health, but their experience in accessing care and the quality of that care. Health inequalities arise from the conditions that people experience in their lives. Some drivers are environmental and tend to change slowly, so can impact over long periods and multiple generations. Policy-making may also disadvantage some groups in society over long periods of time. Inequalities can be mapped across interacting domains including geographies, socio-economic background, protected characteristics or being in a vulnerable group. There is an extensive research literature on health inequalities; a prominent report examining this in England was published in 2010,2 and updated in 2020.3 A key message is that there is a social gradient of health: “the higher a person’s social position the better their health is likely to be”.4 This, and other data from a variety of sources,5,6 demonstrate that there is a range of persistent health inequalities across the life course, some of which are widening. Examples include stalled improvements in life expectancy, longer periods of life spent in poor health and a growing gap in health outcomes between affluent and deprived areas. The COVID-19 pandemic has focused attention on the extent to which socio-economic status and other demographic characteristics are associated with poor health outcomes and differing provision of care across the UK population, including ethnicity.7,8 As inequalities are well-characterised, the focus is on what interventions are effective and how they can be used. Resources about effective interventions are available from organisations including the National Institute for Health and Care Excellence (NICE)9 and Public Health England,10,11,12 and are implemented by key actors, including public health bodies within local government and by healthcare settings. Critiques of government approaches to narrowing health inequalities have focused on a lack of the value placed on taking a long-term, whole systems approach; creating connected and cross-cutting policy, and learning from previous approaches to health inequalities. There are also criticisms about whether the NHS has given sufficient focus to reducing inequalities.13 The extent to which social determinants of inequality are addressed in current policy-making is a key message coming from the public health community. The COVID-19 pandemic has brought the drivers behind health inequality into sharp focus.14,15,16

Challenges and opportunities

Key challenges and opportunities include:

  • Strengthening the evidence base on which health inequalities are measured and ensuring that ethnic minority communities, and vulnerable and marginalised groups are better represented in research and in policy-making.
  • Designing approaches to predict inequalities in health outcomes and to model/simulate the likely impacts of policy changes on the inequalities in those outcomes.
  • Developing cross-cutting policies that will effect positive change and that take a long-term view, reflecting that success is predicated on leadership by government,17 and action from a range of organisations outside the health and care system.
  • Realising and strengthening the ambitions that relate to narrowing health inequalities as set out in the NHS Long Term Plan,18 and the NHS’s response to COVID-19, relating to approaches at both the national and local level.
  • Maximising the economic and employing role of the NHS, which can impact the structural drivers of inequalities. Its role as an employer as a route out of poverty (and poorer health) has been raised as an area for positive change.

Key unknowns

  • The extent to which COVID-19 will worsen pre-existing social gradients in health and, if so, for how long.
  • UK economic outlook impacts on investments in interventions to address public health inequalities.

Key questions for Parliament

  • Whether there is sufficient focus on health inequalities in government strategy and policy and the extent to which resources are available to meet the ambitions set out in the NHS Long Term Plan.
  • Scrutinising the extent to which public health is valued by government as part of a thriving society, how narrowing health inequalities are recognised across government and across the public sector, and how this is reflected in policy decisions.
  • How effective the current approaches are in reducing inequality gaps and the consistency with which interventions are implemented.
  • How the COVID-19 pandemic has affected health inequalities, and the long-term implications and consequences for health inequalities policy-making going forward.
  • How NHS reforms and imminent public health system reforms will impact on the ability of the health and care system, and wider public services, to tackle health inequalities.
  • The extent to which policy-making can be formulated and tailored using involvement from a range of inputs from numerous sectors (central and devolved government, NHS, private, third sector, communities, and individuals).

Likelihood and impact

There is extensive research evidence that health inequalities have impacted society for years; the long-term impact of the COVID-19 pandemic has renewed focus and attention on this issue.

Research for Parliament 2021

Experts have helped us identify 30 areas of change to help the UK Parliament prepare for the future.


  1. NHS England. Definition of Health Inequalities
  2. Institute of Health Equity (2010). Fair Society, Healthy Lives (The Marmot Review)
  3. Institute of Health Equity (2020). Health Equity in England: The Marmot Review 10 Years On
  4. House of Commons Library (23 November 2016). Debate Pack, Number CDP 2016/0225.  Reducing health inequality
  5. Office for National Statistics. Health Inequalities
  6. The King’s Fund (18 February 2020). What are health inequalities?
  7. Office for National Statistics (last revised 7 May 2020). Coronavirus-related deaths by ethnic group, England and Wales methodology
  8. The King’s Fund (February 2021). The health of people from ethnic minority groups in England
  9. National Institute for Health and Care Excellence (4 March 2016). NICE Guideline [NG44], Community engagement: improving health and wellbeing and reducing health inequalities.
  10. Public Health England (2018). Health Inequalities: reducing ethnic inequalities
  11. Public Health England (2018). Local action on health inequalities
  12. Public Health England (2019). Health inequalities: place-based approaches to reduce inequalities
  13. The King’s Fund (2018). Health inequalities: the NHS plan needs to take more responsibility
  14. Public Health England (October 2020). An opportunity to address inequalities: learning from the first months of the COVD-19 pandemic
  15. Office for National Statistics. Coronavirus and the social impacts on Great Britain
  16. Public Health England. Wider Impacts of COVID-19 on Health
  17. The Health Foundation (September 2019). Creating Healthy Lives.
  18. NHS (January 2019). NHS Long Term Plan

Photo by National Cancer Institute on Unsplash

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