Impact on health inequalities of rising prosperity in England 1998-2007, and implications for performance incentives: longitudinal ecological study

Abstract

Objective: To investigate whether the uneven rise in prosperity between 1999 and 2008 accounted for differential increases in life expectancy in English local authorities.

Design: Longitudinal ecological study.

Setting: 324 local authorities in England, classified by their baseline level of deprivation. M: ain outcome measures Multivariable regression was used to investigate the association between trends in prosperity between 1998 and 2007 and trends in life expectancy. Trends in health inequalities were assessed by comparing the experience of Spearhead local authorities (the 70 most deprived in 1998) with the average for all English local authorities.

Results: Those local authorities that experienced the greatest improvement in prosperity experienced greater increases in life expectancy. With each 1% absolute decline in unemployment, life expectancy increased by 2.2 (95% confidence interval 0.5 to 3.8) months in men and by 1.7 (0.4 to 3.1) months in women. With each £1000 increase in average household income in a local authority, life expectancy increased by 1.4 (0.3 to 2.5) months in men and by 1.1 (0.2 to 1.9) months in women. The more deprived a local authority was in 1998, the lower the rate at which life expectancy improved.

Conclusion: Decreases in unemployment and increases in average income in an area explained, to a large extent, why some local authorities "performed" better than others. Health inequalities between Spearhead and all local authorities widened during the period of rising prosperity, but they would have widened to an even greater extent had unemployment not fallen at a faster rate in more deprived areas. With worsening economic trends over the next 10 years, this research suggests that increases in life expectancy are likely to be smaller and health inequalities may widen at a faster rate than in the previous decade. Allocating resources to local authorities on the basis of their "performance" at increasing life expectancy is likely to reward more affluent areas rather than disadvantaged areas with greater needs, exacerbating the problem.

Fig 1 Unadjusted association between increase in life expectancy (1999-2008) and decrease in unemployment rate (top four graphs) or increase in average household income (gross disposable household income (GDHI); bottom four graphs) (1998-2007) for all local authorities and Spearhead local authorities (dashed line shows fitted values). For household income, as GDHI is available only for county councils and contiguous groups of unitary local authorities, graphs show mean increase in GDHI and life expectancy of all local authorities and Spearhead local authorities in these groups

Fig 2 Model estimates of effect on increase in life expectancy if between 1998 and 2007 unemployment rate and average household income “levelled up” in Spearhead local authorities to average level for all local authorities in 2007