What happened to health inequality in England & Wales after 1991?

Someone asked me what has happened to health inequality between social class groups (not areas) between 1991 and the present time. I said I would post something about this, taken from my book "Health Inequality: An Introduction".

To start with, lets have a look at what happened to social class difference in mortality between 1931 an 1991. This is a unique series of data, the likes of which does not exist anywhere else in the world. If you want to know what a Standardized Mortality Ratio is you will need to buy the book :-). You culd look it up i Wikipedia I guess, but my explanation is specially designed for people who don't like algebra formulas (because I don't either). At a very simple level, an SMR of 100 means that group has around the average level of mortality for the whole population of that age and sex. More than 100 is higher mortality (bad) and less than 100 means lower mortality (good).

These figures only refer to England and Wales because of the way in which health statistics and censuses are organised in the United Kingdom.

Table 1: Health  inequality i n  England  and Wales,  1931-1991 : Standardized Mortality Ratios by Registrar-General's Social Class (RGSC) i n men aged 15-64

RGSC	1931	1951	1961	1971	1981 *	1991 *
I: Professional	90	86	76	77	66	66
II: Managerial 1991 Il l routi ne	94	92	81	81	76	72
IIIN: Routine non- manual (1991)						100
Ill : Routine non manual & skilled manual (1931-1981)	97	101	100	104	103
IIIM: Skilled manual						117
IV semi-skilled manual	102	104	103	114	116	116
V  unskilled manual	111	118	143	137	1 66	189

*ages 20-64

Source: (Wilkinson, 1986) ( 1 986: 2, table I . I ); (Drever, Bunting and Harding, 1997): 98, table 8.2)

As you can see, in 1931 mortality in professional men aged 15-64 was 90, i.e.about 10% lower than the average, and for unskilled manual workers it was around 11% higher than the average for all men. By 1971, the SMR for professoinal men was 77, that is, 23% lower than averege and for unskilled manual men it was 37% higher than the average. This dramatic increase in inequality in mortality was what gave rise to the Black Report on health inequality. However, the publication of the Black Report in 1980 did not prevent further sharp increases in the difference in mortality risk between working age men in different social classes up to 1991.

What happened after 1991? Since then more information on health inequality in England and Wales has appeared, but in a rather different form. The numbers that provide the closest we have to a comparison between the series 1931-1991 and 2001 were provided by the Office for National Statistics for England and Wales and are shown in the next Table, which needs to be read in conjunction with the account of the NS-SEC given in the book. Table 2 also gives standardised death rates, not ratios. This is also explained in the book.

Table 2: Trend in inequality in mortality between 1970s and 2001-2 using old and new social class measurements. England and Wales, men age 25-64. Directly age standardized rates per 100,000

	1970-72	1979-83	1991-93	2001-03	2010
RGSC I	500	373	280
RGSC V	897	910	806
Rate Ratio	1.8	2.4	2.9
NS-SeC 1.1				182	128
NS-SeC 7				513	458
Rate Ratio				2.8	2.8

Sources: (White, 2007; Office for National Statistics, 2012)

The second table is obviously very different to the first one. . It has been simplified drastically by only including the most and least advantaged occupational classes at each time point. Like table 1 however, what makes it possible to calculate these figures is having a numerator (numbers who die) taken from official death records, and a denominator taken from Censuses or other official statistics.

What the figures seem to show is that the difference in mortality risk between the most advantaged (RGSC I and NS-SeC 1.1) and the least advantaged (RGSC V and NS-SeC 7) social classes slightly fell and then stabilised to a situation where working age men in the least advantaged social class had around 2.8 times the risk of early death of those in the most advantaged class. We do need to be cautious about these digures of course because both the definition of social class and the sources from which the data have been derived have changed.

Drever, F., Bunting, J. and Harding, D. (1997), Male mortality from major causes of death. In F. Drever and M. Whitehead (eds), Health Inequality, 122-142. London: HMSO.

Office for National Statistics (2012), Intercensal Mortality Rates by NSSEC, 2001-2010. London: Office for National Statistics.

White, C., Glickman, M., Johnson, B. and Corbin, T. (2007), Social inequalities in adult male mortality by the National Statstics Socio-economic classification, England and Wales, 2001-03. Health Statistics Quarterly 36, 6-23.

Wilkinson, R.G. (1986), Income and mortality. In R.G. Wilkinson (ed), Class and health: research and longitudinal data, London: Tavistock.