Guidance

Health disparities and health inequalities: applying All Our Health

Published 11 October 2022

Applies to England

Please note that the Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities on 1 October 2021.

Introduction

This guide is part of All Our Health, a resource that helps health and care professionals and the wider workforce prevent ill health and promote wellbeing as part of their everyday practice. All Our Health content on inclusion health, community-centred practice and improving the wider determinants of health may be of particular interest in connection with this topic. 

Health inequalities are defined as avoidable differences in health outcomes between groups or populations – such as differences in how long we live, or the age at which we get preventable diseases or health conditions. Similarly, health disparities are described by Healthy People 2020 as:

a particular type of health difference that is closely linked with social, economic and/or environmental disadvantage.

Health disparities are said to adversely affect groups of people who have systematically experienced greater obstacles to health. Depending on the workforce, sector or organisation, different language is sometimes used to describe the same problem. The terms ‘health disparities’ and ‘health inequalities’ are sometimes used interchangeably.

The causes of health inequalities or disparities are complex, but are generally associated with variation in a range of factors that positively or negatively influence our ability to be healthy. This includes individual health-related behaviour, such as:

  • smoking and diet
  • access to services
  • social deprivation
  • access to work
  • education levels
  • social networks
  • how much control we feel we have over our lives

In recent times, progress has been made in improving key determinants of health for many people including:

  • driving down rates of smoking
  • introducing measures to address obesity
  • improving the quality of health and care services
  • increases in educational attainment
  • measures to improve housing quality

However, the benefits of this have not been felt equally across the population, resulting in some groups or people living in some areas continuing to spend more of their lives in poor health and dying sooner than others.

This All Our Health: health disparities and health inequalities resource highlights that everyone can contribute to addressing health disparities and health inequalities in the course of their everyday work or role. It has been created to help a wide range of organisations and professionals, including health and care professionals, practitioners, commissioners, senior leaders, managers, and voluntary and community sector workers to:

  • gain a broad understanding of what is meant by ‘health disparities’ and ‘health inequalities’
  • understand the causes of health disparities and health inequalities
  • implement the evidence-based actions and interventions that can be incorporated into everyday practice to address health disparities and health inequalities
  • consider who else they may need to work with to address health disparities and health inequalities

What health inequalities and health disparities are, and who is more likely to experience them

In England, there is a 19-year gap in healthy life expectancy (whether we experience health conditions or diseases that impact how long we live in good health) between the most and least affluent areas of the country, with people in the most deprived neighbourhoods, certain ethnic minority and inclusion health groups getting multiple long-term health conditions 10 to 15 years earlier than the least deprived communities, spending more years in ill health and dying sooner.[footnote 1]

The most recent data on how long we live overall (life expectancy for local areas of the UK: between 2001 to 2003 and 2018 to 2020) includes some data from the coronavirus (COVID-19) period. It indicates that life expectancy for men has fallen for England as a whole, but there is significant variation across the regions for both men and women. For example, for men, life expectancy at birth has fallen in all regions other than the south-east and south-west, and, for females, there have been reductions in all regions other than the south-east, south-west and London.

Health inequalities

These differences in health outcomes are known as health inequalities – unfair and avoidable differences in health across the population, and between different groups within society. Health inequalities arise because of the conditions in which we are born, grow, live, work and age. These conditions influence our opportunities for good health, and how we think, feel and act, and this shapes our mental health, physical health and wellbeing.[footnote 2]

Figure 1: domains of health inequality (adapted from Health inequalities: place-based approaches to health inequalities)

Figure 1 above shows the broad range of individual characteristics and societal factors that have been identified as contributing to health inequalities. These are:

  • socio-economic status and deprivation – for example, unemployment, low income, living in a deprived area, and factors associated with this such as poor housing and educational attainment
  • vulnerable or inclusion health groups – for example, vulnerable migrants, Gypsy, Roma, Irish Traveller and Boater communities, people experiencing homelessness, offenders or former offenders, and sex workers
  • protected characteristics under the Equality Act 2010 – the 9 protected characteristics are: age, sex, race, sexual orientation, marriage or civil partnership, pregnancy and maternity, gender reassignment, religion or belief, and disability
  • geography – the characteristics of the place where we live, such as population composition, built and natural environment, levels of social connectedness, and features of specific geographies such as urban, rural and coastal

These factors (or domains) are complex and interact with each other to benefit or disadvantage people or groups, leading to differences in health outcomes. Individuals fall into more than one category and, subsequently, may experience multiple drivers of poor health at the same time.

Relevant terms

Figure 2: equality, equity and removal of structural barriers

Figure 2 above illustrates the characteristics of people or places associated with differences in health outcomes.

Some other key terms in health inequalities and health disparities are:

Equality

We want everyone to have equally good health. However, the term ‘equality’ is sometimes used to describe equal treatment or access for everyone regardless of need or outcome.

Equity

We want fair outcomes for everyone. What is important is addressing avoidable or remediable differences in health between groups of people.

Figure 2 above demonstrates that, to achieve health equity, some groups may need more or different support or resources in order to achieve the same outcomes.

Ideally, the barriers to good health would be removed for everyone, so adjustments wouldn’t be required – however, this is not always possible.

Access

Ensuring everyone can access services equitably (that is according to need) is a key priority for the NHS.

To achieve this, consideration needs to be given to access to information, services and support. Central to this is enabling people to access the right service at the right time for them, reducing variation in the avoidable use of urgent support such as accident and emergency services through better access to preventative care.

Public Sector Equality Duty

The Public Sector Equality Duty set out in the Equality Act 2010 applies to all public bodies and all those that carry out public functions.

The protected characteristics covered by the duty are:

  • age
  • disability
  • gender reassignment
  • marriage and civil partnership
  • pregnancy and maternity
  • race
  • religion or belief
  • sex
  • sexual orientation

Public bodies are required to have due regard to the need to:

  • eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010
  • advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it
  • foster good relations between persons who share a relevant protected characteristic and persons who do not share it

Inclusion health

Inclusion health is a ‘catch-all’ term used to describe people who:

  • are socially excluded
  • typically experience multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma)
  • experience stigma and discrimination
  • are not consistently accounted for in electronic records (such as healthcare databases)

These experiences frequently lead to barriers in access to healthcare and extremely poor health outcomes.

Deprivation

Deprivation describes a wide range of living conditions that impact on the lives of individuals and communities.  People may be considered to be living in poverty if they lack the financial resources to meet their needs, whereas people can be regarded as deprived if they lack any kind of resources, not just income.

The Index of Multiple Deprivation is the official measure of relative deprivation in England that measures 7 domains of deprivation when combined and appropriately weighted. These are:

  • income
  • employment
  • skills training
  • crime
  • barriers to housing and service
  • living environment
  • health deprivation
  • disability

Geography

Health disparities and health inequalities are not spread equally across England. There are local variations in the concentration of pre-existing health conditions and chronic disease in certain geographies between different areas. Alongside and contributing to driving these are variations in protective factors, such as:

  • living in a strong community
  • access to green space
  • the impact of living in specific geographies, such as coastal communities

Health disparities and COVID-19

The COVID-19 pandemic has shone a spotlight on health disparities and health inequalities. Disparities or differences in both the risk of getting COVID-19 and of having poorer outcomes have been seen by:

  • age
  • ethnicity
  • sex
  • geography
  • deprivation
  • occupation
  • inclusion health groups

The reasons for these disparities are complex with influencing factors including the impact of existing social and economic inequalities, pre-existing disease and other societal factors. 

Alongside the direct impact of COVID-19, some groups have also been more likely to experience greater impact from measures to control the pandemic.

Why take action on health disparities and inequalities

Health disparities and health inequalities impact on the physical and mental wellbeing, and the life chances of the individuals and groups most affected. Alongside the individual human costs, disparities and inequalities impact on society as a whole.

Prior to COVID-19, health inequalities were estimated to cost the NHS an extra £4.8 billion a year, society around £31 billion in lost productivity, and between £20 and £32 billion a year in lost tax revenue and benefit payments.[footnote 3] Health is therefore a major determinant of economic performance and prosperity.

Consequently, taking action on health inequalities:

  • improves the quality of lives of individuals
  • reduces cost to the NHS and social care system of treating and caring for people with preventable conditions
  • benefits the wider economy

Causes of health inequalities

A wide range of factors influence our ability to be healthy. These factors overlap with one another and are often outside the control of individuals themselves.

Figure 3: system map of the causes of health inequalities (adapted from the Labonte model)[footnote 2]

Figure 3 above demonstrates the complex interplay between the determinants of health (for example, income and housing), psychosocial factors (for example, isolation and social support), health behaviours (for example, smoking and drinking) and physiological impacts (for example, high blood pressure, anxiety and depression) of wider social determinants of health with psychosocial factors, individual health behaviours and the resulting physiological impacts (for example, high blood pressure, anxiety and depression).

Wider determinants of health

The wider determinants of health include factors such as:

  • income
  • education
  • housing
  • built and natural environment (including air pollution)
  • access to services
  • power
  • discrimination

These determinants or influences are not spread equally throughout the population, resulting in some groups experiencing multiple disadvantages throughout their lives, and circumstances compounding to create an un-level playing field.

Health behaviours

The ability of individuals to lead healthy lives is influenced both by the wider determinants of health, and by individual factors (health behaviours) associated with people’s opportunities and experiences.

The main behavioural risk factors for poor healthsmoking, poor diet or excess weight, physical inactivity and high alcohol consumption – follow the same pattern of uneven distribution as the wider determinants of health, indicating that there is a relationship between an individual’s likelihood of smoking, eating healthily, physical inactivity, and their social and environmental circumstances.

Linked to health behaviours, the concept of ‘health literacy’ refers to people having the appropriate skills, knowledge, understanding and confidence to access, understand, evaluate, use and navigate health and social care information and services. Improving health literacy by supporting patients to engage in shared decision-making can help to reduce health inequalities by empowering and enabling people to navigate individual and societal barriers to improving their health and managing health problems.

The National Institute for Health and Care Excellence (NICE) guideline on shared decision-making describes how to make it part of everyday care in all healthcare settings.

Psychosocial factors

Different exposure to social, economic and environmental stressors and adversities, also known as psychosocial factors, work alongside factors related to our ability to cope such as:

They affect our state of mind from an early age and throughout life, directly affecting resilience, health conditions and health behaviours. Psychosocial factors can help to mitigate or protect against the impact of the social determinants of health.

Core principles

Because the causes of health disparities and health inequalities are complex, overlapping and not equally distributed, it follows that, in order to address them, our actions need to focus on improving the health of those with the poorest health outcomes first, and fastest. Actions should be evidence based, outcomes orientated, systematically applied, scaled up appropriately and appropriately resourced[footnote 4] to ensure that the gap between populations is narrowed.

This means that everyone and every organisation has a role to play. Building on the findings of Fair Society, Healthy Lives (The Marmot Review), a further report by the Institute of Health Equity focussing on health inequalities in Greater Manchester sets out a framework for addressing the social determinants of health, identifying the range of sectors and organisations that can contribute to this.

Population intervention triangle

Place-based approaches to reducing health inequalities provides tools and resources to support sectors and organisations to work together to take whole-system at-scale action on health inequalities.

It uses the population intervention triangle (see Figure 4, below) to describe how local authorities and policy-makers (civic) can work alongside the NHS and other organisations (services), and with communities (community-centred interventions) to address health inequalities at a scale that makes a difference, and best meets local needs and circumstances. Actions can be targeted to specific population groups, for example:

Interventions should be applied proportionately to need – for example, through a proportionate universalism approach.

Figure 4: population intervention triangle[footnote 2]

Further guidance on community-centred public health (a core component of the population intervention triangle) identifies 11 elements of an integrated whole-system approach, incorporating a range of actions from neighbourhood work through to strategic leadership. Additional learning on community-centred approaches can also be found in Community-centred practice: applying All Our Health..

The following sections set out information to inform the actions that different organisations or sectors can take to play a part in addressing health disparities and health inequalities.

You may wish to focus on the sections relevant to your organisation or role, or to review the whole content to gain wider understanding of the role of different sectors and workforces in addition to your own.

NHS

The 2019 NHS Long Term Plan set out that action to drive down health inequalities is central to everything that the NHS does.

In addition, the Health and Care Bill 2021 to 2022 promotes integration and partnership-working to improve health and tackle health inequalities. This action takes place through integrated care systems (ICSs) and integrated care partnerships, place-based partnerships and through working with people and communities, bringing together health, social care, public health and others to develop strategy and plans to address the needs of the local system.

The NHS operational and planning guidance also builds on previous guidance to prevent ill health and tackle inequalities, particularly in light of the COVID-19 pandemic and its disproportionate impact on certain population groups who were already facing disadvantage and discrimination.

Building on this and contributing to the government’s mission to level up health, NHS England and Improvement (now NHS England) launched the Core20PLUS5 approach to support focused action on improving health inequalities, both at a national and system level. This approach is focused on action in the following areas:

  • Core20: the most deprived 20% of the national population as identified by the national Index of Multiple Deprivation
  • Plus: ICS-determined population groups experiencing poorer than average health access, experience and/or outcomes – this area should be informed by ICS population health data
  • 5: 5 clinical areas of focus. These are:
    • continuity of carer for maternity
    • annual health checks for those living with severe mental illness
    • chronic respiratory disease management, with a focus on COVID-19, flu and pneumonia vaccination uptake
    • early cancer diagnosis
    • hypertension case-finding

Driving this action forward is the NHS England Healthcare Inequalities Improvement Programme, which has the vision of delivering exceptional quality healthcare for all, ensuring equitable access, excellent experience and optimal outcomes. For more information on the work of this programme, please access the Equality and Health Inequalities Network NHS future forum space.[footnote 5]

Local government

The Local Government Association highlights the contribution of different determinants of health on health outcomes, setting out the important role of local authorities in prevention including through their specific public health duties and action on the wider determinants of health.

Local authorities duties, functions and interests cover a broad range of activity, from improving health through:

Local authorities can use their leadership role at place to work alongside partners – for example, through health and wellbeing boards, ICS partnerships and local economic partnerships to enable whole-system action on health inequalities. More information and resources can be found on the LGA website and in the government’s health equity collection.

Voluntary, community and social enterprise (VCSE) organisations

The role of VCSE in addressing health inequalities is wide ranging. For example, the Health Foundation, the Institute of Health Equity and New Philanthropy Capital and the All Party Parliamentary Committee on Arts and Wellbeing identify the contribution that civil society can make to improving health and addressing health inequalities, including through:

  • service delivery
  • raising awareness
  • influencing
  • research

Organisations in these sectors are often trusted by and have good reach into many of the most marginalised communities.

ICS implementation guidance on partnerships with the voluntary, community and social enterprise sector provides further insight on how VCSE partnership should be embedded in how the ICS operates, indicating that VCSE is a key strategic partner with an important contribution to make in shaping, improving and delivering services, and developing and implementing plans to tackle the wider determinants of health. 

View more information on VCSE’s role in health inequalities from the VCSE Health and Wellbeing Alliance.

Businesses

Good-quality work is a key contributor to what makes us healthy. Inclusive and sustainable economies: leaving no-one behind identifies the mutually dependent role of the economy and health.

This includes the potential for businesses to act as anchor institutions,working alongside public and voluntary sector organisations to utilise their spending power and scale social value.

In addition, community businesses can make an important contribution to improving health.

Wider public sector

All public sector organisations have a role to play in addressing health disparities and health inequalities. For many services, the communities they serve are often those that have the poorest health outcomes.

Emergency services such as the police, fire and rescue and ambulance services already recognise their wider role in prevention and contributing to addressing health inequalities. The Royal Society for Public Health’s Emergency Services Hub provides further information and resources to support this role.

The wider public sector can work together to address specific determinants and direct causes of health inequalities – for example, to reduce violence or in respect of the impact of the built and natural environment on health.

Taking action

This section sets out some key considerations against priority areas for action identified by national and regional public health teams. It includes prompts for everyone to consider, as well as specific suggestions for different professional and occupation groups.

Everyone

Ensure you are aware of your organisation or sector’s approach or potential role in addressing health disparities and health inequalities.

You can also keep yourself informed and up to date on the latest information and guidance by joining relevant NHS England Networks or Knowledge Hubs[footnote 5] such as:

In addition, you can review the information above for your organisation or sector, the 6 priority actions for health inequalities below and the suggestions for your occupational group, and consider what you could do in the scope of your role.

Six priority actions

1. Have a clear vision and strategy with measurable goals, co-ordinating action at all levels (for example, across organisations or professional boundaries) with a clear focus on priority groups

Ask yourself:

  • what is your vision? What are you trying to achieve?
  • what would success look like for you or your organisation?
  • do you have a clear strategy and plan for achieving your vision?
  • do you have the right resources, and a timeline and plan?
  • who else could be involved?
  • is there a system, organisational or professional plan or guidance?
  • do you know your priority groups?
  • have you identified SMART (specific, measurable, achievable, relevant and time-bound) goals and measurable targets?
  • are your plans joined up across organisations or with other teams?

2. Put in place effective system leadership and accountability for action on health inequalities

Ask yourself:

  • who leads on action on health inequalities and health disparities?
  • what’s your leadership role (whatever your level) – for example in your team, profession, organisation, multi-agency group, sector or network? 
  • what do you do to support others to take a leadership role?
  • what does your organisation expect of you or others in respect of action on health inequalities? How are people held to account? 
  • are you driving changes using quality, service improvement and redesign methodology including Appreciative Inquiry?
  • are you involving and co-producing change with those who are experiencing healthcare inequalities through engaging communities in design, implementation and evaluation?

3. Use data and evidence systematically to identify root causes, effective solutions and assess progress

Ask yourself:

  • what information do you have to identify the problem you’re trying to address?
  • what’s the scale of the problem and the root causes?
  • how do you know that your planned action is likely to be effective?
  • how will you know when you’ve achieved your goal or outcomes?
  • how can you contribute to data collection – are you systematically recording health inequalities and equality data in your routine practice?

4. Ensure you or others have the knowledge, skills and capability to embed action on health inequalities as a core part of all roles

Ask yourself:

  • do you, your team or organisation have the knowledge, skills or training to take the required action?
  • how could you acquire these?
  • who else could help?
  • what’s included in job descriptions?
  • have you considered health literacy and shared decision-making? Do clients have the appropriate skills, knowledge, understanding and confidence to access, understand, evaluate, use and navigate health and social care information and services?

5. Use systematic assessment tools

Ask yourself:

6. Undertake comprehensive engagement and involvement including magnifying community voice

Ask yourself:

Frontline health and care professionals

Frontline health and care workers have millions of contacts with people at risk of poorer health outcomes every day. As a frontline worker, you can address health inequalities by:

  • supporting individuals through their clinical or social care practice
  • influencing the design of services
  • supporting people to adopt healthier behaviour
  • advocating for wider changes

Your work can also contribute to addressing the social conditions of people’s lives such as poverty, disability, damp or overcrowded housing, or a poor diet, making a difference to the communities in which they work.[footnote 6]

My role in tackling health inequalities: a framework for allied health professionals details how allied health professionals can raise awareness, take action and optimise advocacy through 6 lenses:

  • self
  • patients
  • clinical team, pathway and service groups
  • communities and networks
  • systems
  • nurturing the future

While the framework was developed for and with allied health professionals, many other frontline professionals may find the approach relevant to their area of work.

In addition to reviewing the allied health professional framework, you can:

Team leaders or managers

Team leaders and managers have an important role in actively seeking out and enabling teams to embed evidence-based action targeted at those with the poorest health outcomes.

As a team leader or manager, you can:

Commissioners

Commissioners play an important role in addressing health inequalities as resourcing decisions and service models can have an impact on health outcomes.

In particular, you can:

VCSE sector

The VCSE sector plays an important role in enabling people to improve their health and in addressing determinants of health.

As a VCSE worker, you can:

Senior, strategic or system leaders (including local councillors)

Leaders make an important contribution to prioritising and embedding whole-system action to address health disparities and health inequalities.

As a leader, you can use your role to:

Understanding need – why take action on health disparities and health inequalities

Facts and figures

Data tools and resources can help you to understand more about the causes and impact of health disparities and health inequalities at a national level and in your local area.

A guide to using national and local data to address health inequalities provides an overview of data sources for health inequalities, and their uses. This is updated periodically and can be used alongside local joint strategic needs assessments and other data sources to develop plans to address health inequalities.

The following tools may also be of use:

Measuring impact

There are a range of reasons why it makes sense to measure your and your organisation’s impact, and demonstrate the value of your contribution. This could be about sharing what has worked well in order to benefit your colleagues and local people, contribute to growing the evidence base for health inequalities, help in prioritising future resource allocation or for individual professional development.

The following resources can help with evaluating individual, organisational or programme impact:

Further reading, resources and information about good or emerging practice

Further information on health inequalities in specific population groups can be found in other All Our Health resources.

Collaborative working platforms[footnote 5]

Professional resources and tools

Practice examples

Examples of practice in addressing health inequalities can be found in the UKHSA library, as well as examples on how to use HEAT.

More information on practice in addressing health inequalities can also be found on the Health Inequalities, Healthy Communities and Inclusive and Sustainable Economies Knowledge Hubs.

  1. Barnett K and others. ‘Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.’ Lancet 2012: volume 380, issue 9,836, pages 36–43. 

  2. Public Health England. ‘Place-based approaches for reducing health inequalities: main report.’ July 2019.  2 3

  3. Public Health England. ‘Inclusion and sustainable economies: leaving no one behind (executive summary).’ March 2021. 

  4. Public Health England. ‘Reducing health inequalities: system, scale and sustainability.’ August 2017. 

  5. This forum is open to all but requires users to register or request membership.  2 3 4 5

  6. Social Care Institute for Excellence. ‘Tackling inequalities in social care.’