Health Inequalities

The Cities Health Inequalities Project

Aim: Accelerating action to tackle health inequalities in English devolved urban regions

Health inequalities between England’s deprived and more affluent populations are stark, and in some cases widening. Devolution provides opportunities for Combined Authority areas to approach and tackle the challenge of health inequalities in new and unique ways. Health inequalities between England’s deprived and more affluent populations are stark, and in some cases widening. Devolution provides opportunities for Combined Authority areas to approach and tackle the challenge of health inequalities in new and unique ways.

In February 2019, a partnership of the Greater London Authority, Greater Manchester Combined Authority and West Midlands Combined Authority was awarded grant funding from The Health Foundation to establish a project to accelerate efforts to tackle health inequalities in city regions. 

The Health Foundation, have since developed an Evidence Hub: What drives health inequalities?

As a key partner within the public health system, ADPH London were invited to  design, structure, mobilise and drive action to deliver the project aims and objectives.

What are health inequalities?

“People with higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health.” Sir Michael Marmot, ‘Fair Society, Health Lives’, 2010

Inequalities in health arise because of inequalities in society – in the conditions in which people are born, grow, live, work, and age. The magnitude of health inequalities is a good marker of progress towards creating a fairer society.

Health inequalities are manifested in the differences that people experience in health and wellbeing determined by the social and environmental factors that shape their lives, such as: the quality of housing, accessibility of streets, quality and access to education, nutrition, cleanliness of the air, employment, income, amongst many others. These conditions influence the stress we are under, how in control we feel about our lives, the options and opportunities we have to make changes, the likelihood that we will adopt health harming activities, our ability to manage our health and be resilient and how we engage with individuals and services.

Collectively, these are known as the Wider Determinants of Health, which the evidence shows are key to addressing the widening gap in health inequalities. These differences in people’s circumstances are not set in stone, therefore the health inequalities caused by these differences are also not set in stone: health inequalities are both unfair and preventable. 

Why is this important?

Health inequalities are a challenge across the country and particularly stark in cities and urban areas. The ethical and economic impact of health inequalities are huge; doing nothing cannot be an option.

According to the 2010 Fair Society, Healthy Lives report (The Marmot Report), the human cost of health inequalities is enormous, with 2.5 million years of life potentially lost to health inequalities by those dying prematurely each year in England.

The 2020 publication of the Marmot Review 10 Year On report shines a spotlight on the increasing gap over in health inequalities over the previous decade, highlighting the stalling improvements in life expectancy and healthy life expectancy for the most deprived communities in England.

In nearly every aspect of the wider determinants of health, quality of life is worsening for the most deprived populations of England. Average life expectancy for those living in the most deprived areas of England are 9.5 years less for men and 7.7 years less for women than those living in the least deprived areas.

Figure 1 Life Expectancy by area deprivation in England (Source: Health Equity in England: The Marmot Review 10 Years On, 2020)

Opportunities to escape poverty through work and income are also stalling. Nearly half of workers living in poverty are in full-time employment. Families in the most deprived communities spend over 35% of their income on housing costs, while healthy eating guidelines would require households in the most deprived decile to spend 75% of their income on healthy food alone.

Figure 2 Proportion of income spent on housing for income deciles (Source: Health Equity in England: The Marmot Review 10 Years On, 2020)

Covid19 Pandemic

The Covid19 pandemic has amplified the disparities that exist in health in a most tragic manner. The appalling toll that the epidemic has caused in England has shone a spotlight on what public health experts have known for some time: that the social disparities that permeate our most populous regions exposure our most deprived communities to health risks to an extent not felt in other communities, including within the BAME communities.

As a result of this tragic spotlight, interest in health inequalities at political and strategic levels have been re-energised, creating momentum in the fight to redress the balance in health and wellbeing.

The project – Addressing health inequalities through devolution

Addressing health inequalities and their determinants is a challenge for all; going beyond the health and care system. Cities share features that can enable them to take brave and bold action on health inequalities; devolution agreements provide the power and responsibilities to enable that action.

As evidence on the wider determinants of health continues to grow, the question becomes one of translating and applying this growing body of evidence into creating change in real world settings, particularly within the context of changes to powers and structures in city/metro regions.

The Cities Health Inequalities Project aims to accelerate this action by providing the means to reflect, share and learn more widely across cities and urban areas on how to approach the population health challenges consistent across other cities and metro regions.

To achieve this, the project aims to:

  • Improve understanding of regional priorities, contexts, challenges and approaches to tackling health inequalities. Identifying the levers of change, power and influence at our disposal
  • Engage all cities/Combined Authorities in seeking leading practice and sharing knowledge
  • Create a mandate for action by identifying policy that works; shaping how health inequalities are framed and utilising the opportunities of devolution
  • Facilitate conversations, developing ideas, building relationships, collating evidence and link partners
  • Create consensus on action by realising evidence in driving improvements, showcasing action taken to successfully address health inequalities
  • Champion improvements to accelerate activity in tackling health inequalities through developing guidance, toolkits, networking, expertise and support

For more information on this project, please contact