Health inequalities

Inequalities in health exist, whether measured in terms of mortality, life expectancy or health status; whether categorised by socioeconomic measures or by ethnic group or gender. Recent efforts to compare the level and nature of health inequalities in international terms indicate that Britain is generally around the middle of comparable western countries, depending on the socioeconomic and inequality indicators used. Although in general disadvantage is associated with worse health, the patterns of inequalities vary by place, gender, age, year of birth and other factors, and differ according to which measure of health is used.

Death rates have been falling over the last century, from a crude death rate of 18 per thousand people in 1896 to 11 per thousand in 1996. Over the last 25 years, there have been falls in death rates from a number of important causes of death, for example lung cancer (for men only), coronary heart disease and stroke. Life expectancy has risen over the last century, but not all life is lived in good health. Healthy life expectancy - the measure of average length of life free from ill health and disability - has not been rising; the added years of life have been years with a chronic illness or disability, also the proportion of people reporting a limiting long standing illness has risen from 15 per cent to 22 per cent since 1975 and the proportion reporting illness in the two weeks previous to interview has nearly doubled from 9 per cent to 16 per cent. There is a slight increase in the proportion of people consulting the NHS.

A number of different measures can be used to indicate socioeconomic position. These include occupation, amount and type of education, access to or ownership of various assets, and indices based on residential area characteristics. There has been much debate as to what each indicator actually measures, and how choice of indicator influences the pattern of inequalities observed. For example, measures based on occupation may reflect different facets of life for men compared to women, and for people of working age compared to older people or children.

Mortality - Over the last twenty years, death rates have fallen among both men and women and across all social groups. However, the difference in rates between those at the top and bottom of the social scale has widened. For example, in the early 1970s, the mortality rate among men of working age was almost twice as high for those in class V (unskilled) as for those in class I (professional). By the early 1990s, it was almost three times higher. This increasing differential is because, although rates fell overall, they fell more among the high social classes than the low social classes. Between the early 1970s and the early 1990s, rates fell by about 40 per cent for classes I and II, about 30 per cent for classes IIIN, IIIM and IV, but by only 10 per cent for class V. So not only did the differential between the top and the bottom increase, the increase happened across the whole spectrum of social classes.

Both class I and class V cover only a small proportion of the population at the extremes of the social scale. Combining class I with class II and class IV with class V allows comparisons of larger sections of the population. Among both men and women aged 35 to 64, overall death rates fell for each group between 1976-81 and 1986-92 (table 3). At the same time, the gap between classes I and II and classes IV and V increased. In the late 1970s, death rates were 53 per cent higher among men in classes IV and V compared with those in classes I and II. In the late 1980s, they were 68 per cent higher. Among women, the differential increased from 50 per cent to 55 per cent.

These growing differences across the social spectrum were apparent for many of the major causes of death, including coronary heart disease, stroke, lung cancer and suicides among men, and respiratory disease and lung cancer among women.

Death rates can be summarised into average life expectancy at birth. For men in classes I and II combined, life expectancy increased by 2 years between the late 1970s and the late 1980s. For those in classes IV and V combined, the increase was smaller, 1.4 years. The difference between those at the top and bottom of the social class scale in the late 1980s was 5 years, 75 years compared with 70 years. For women, the differential was smaller, 80 years compared with 77 years. Improvements in life expectancy have been greater over the period from the late 1970s to the late 1980s for women in classes I and II than for those in classes IV and V, two years compared to one year31.

A good measure of inequality among older people is life expectancy at age 65. Again, in the late 1980s, this was considerably higher among those in higher social classes, and the differential increased over the period from the late 1970s to the late 1980s, particularly for women.

Years of life lost

Premature mortality, that is death before age 65, is higher among people who are unskilled. A study in the number of deaths in men aged 20 to 64 years was carried out If all men in this age group had the same death rates as those in classes I and II, it is estimated that there would have been over 17,000 fewer deaths each year from 1991 to 1993. Deaths from accidents and suicide occur at relatively young ages and each contribute nearly as much to overall years of working life lost as coronary heart disease. Death rates from all three causes are higher among those in the lower social classes, and markedly so among those in class V.

These major differences in death rates and life expectancy between social classes do not just apply to those people already well into adulthood. Infant mortality rates are also lower among babies born to those of higher social classes. In 1994-96, nearly 5 out of every thousand babies born to parents in class I and II died in their first year. For those babies born in to families in classes IV and V, the infant mortality rate was over 7 per thousand babies. As with mortality at other ages, infant mortality rates in each class have been decreasing over the last twenty years. However, there is no evidence that the class differential in infant mortality has decreased over this period.

Morbidity

Although death rates have fallen and life expectancy increased, there is little evidence that the population is experiencing less morbidity or disability than 10 or 20 years ago. There has been a slight increase in self-reported long standing illness and limiting long standing illness, and socioeconomic differences are substantial. For example, in 1996 among the 45 to 64 age group, 17 per cent of professional men reported a limiting long standing illness compared to 48 per cent of unskilled men. Among women, 25 per cent of professional women and 45 per cent of unskilled women reported such a condition. These patterns were similar among younger adults, older men and among children.

In adulthood, being overweight is a measure of possible ill health, with obesity a risk factor for many chronic diseases. There is a marked social class gradient in obesity which is greater among women than among men. In 1996, 25 per cent of women in class V were classified as obese compared to 14 per cent of women in class I. For men, there was no clear difference in the proportions reported as obese except that men in class I had lower rates of obesity, 11 per cent, compared to about 18 per cent in other groups. Overall, rates of obesity are rising. For men, 13 per cent were classified as obese in 1993 compared to 16 per cent in 1996. For women, the rise was from 16 per cent to 18 per cent.

Another indicator of poor health is raised blood pressure. There is a clear social class differential among women, with those in higher classes being less likely than those in the manual classes to have hypertension. In 1996, 17 per cent of women in class I and 24 per cent in class V had hypertension. There was no such difference for men where the comparable proportions were 20 per cent and 21 per cent respectively.

Among men, major accidents are more common in the manual classes for those aged under 55. Between 55 and 64, the non-manual classes have higher major accident rates. For women, there are no differences in accident rates until after the age of 75 when those women in the non-manual group have higher rates of major accidents.

Mental health also varies markedly by social class. In 1993/4, all neurotic disorders, such as anxiety, depression and phobias, were more common among women in class IV and V than those in classes I and II - 24 per cent and 15 per cent respectively. This difference was not seen among men. However, there were striking gradients for alcohol and drug dependence among men, but not women. For example, 10 per cent of men in classes IV and V were dependent on alcohol compared to 5 per cent in classes I and II.

Over the last twenty years, household disposable income per head of population has grown both in actual and in real terms. Between 1961 and 1994, average household disposable income (in real terms) rose by 72 per cent. However, this was not experienced to the same extent across the whole of the income distribution.

The median real household disposable income, before housing costs, rose over the period 1961 to 1994 from �6 per week, to �4 per week. The top decile point more than doubled, from �3 per week to �3 per week. The bottom decile point rose by 62 per cent from � per week to �9 per week.

The proportion of people whose income is below average has been at about 60 per cent for the last 35 years (figure 6). However, the proportion of people below half of the average income (the European Union definition of poverty) has grown over this period from 10 per cent in 1961 to 20 per cent in 1991. It has decreased since then and was at 17 per cent in 1995.

Since the early 1970s, the proportion of children aged 3 or 4 who attend school has trebled from 20 per cent to nearly 60 per cent40. The proportion who attend school (as opposed to playgroups) varies from 84 per cent in the North East to 43 per cent in the South West. Educational attainment - as measured by the proportion of children gaining 5 or more GCSEs at grades A star to C - has risen from less than 25 per cent in 1975/76 to about 45 per cent in 1995/96. This measure of attainment varies not only by gender, but also by geographical area and by measures of deprivation. As well as looking at the future workforce and their qualifications, it is useful to look at the educational attainment of those presently of working age. In 1997, 16 per cent of men and 21 per cent of women of working age had no qualifications. There were also large differences between ethnic groups.