Nick Hopkinson: Health inequality in the new decade—we need a new strategy

The poorer you are the shorter your life and the shorter your disability free life expectancy. [1] Our common objective in medicine is to improve human health and wellbeing, so a key challenge is the fact that a third of premature deaths in the UK can be attributed to socio-economic inequality; around 900,000 premature deaths over 15 years, or one every 10 minutes. [2] The simplest way to reduce the health impacts of inequality is, of course, to reduce inequality. Unfortunately, in the current political climate, the most effective means to achieve this, such as redistributive fiscal policies, a non-punitive welfare system, or restoring SureStart are unlikely to be used. While continued advocacy for social justice remains a professional obligation, the immediate question is how to mitigate this situation.

The general answer I think must be to focus intensely on the actual mechanisms linking deprivation to adverse health outcomes and prioritise tackling them where they are amenable to intervention. The obvious example is smoking, which is responsible for half the difference in life expectancy between rich and poor. [3] The Government’s recent green paper, Advancing our Health: Prevention in the 2020’s, calls for England to be smoke free by 2030, defined as smoking rates below 5% in all population groups.  However, achieving this will require pressure for the swift implementation of an ambitious policy agenda, including a polluter pays levy on the industry to fund tobacco control measures, raising the age of sale from 18 to 21, requiring retail licensing, and comprehensive targeted media campaigns, covering groups including smoking in pregnancy and smoking in people with mental health problems. 

Simultaneously, we need to improve performance in day to day clinical practice. The Royal College of Physicians report “Hiding in Plain Sight: treating tobacco dependence in the NHS” sets out the woeful delivery of evidence-based smoking cessation therapy across the NHS and across specialities. [4]  Although a systematic approach to smoking cessation by NHS trusts would lead to substantial in-year savings—around £80million saved for an investment of £20 million—current targets for implementation within the NHS Long Term Plan are too slow and it is still widely considered to be a low status “prevention” rather than a “treatment” intervention. 

Beyond smoking, other mechanisms that link deprivation to poor health outcomes also require attention. Some need more systematic clinician advocacy—how many of our patients with lung disease live in cold damp homes with visible mould? Can patients access transport to get to pulmonary rehabilitation? How can we ensure those with the most disorganised lives access vaccinations? All specialities need to think about the barriers to care that deprivation produces for their patient populations. 

The concept of value in healthcare is increasingly accepted as a way to prioritise finite healthcare resources, but the failure to deliver the highest value interventions systematically is itself a driver of health inequality. [5,6] Tackling the mechanisms of health inequality must be brought to the forefront of clinical guidelines and clinical practice. This way we can prioritise the most effective interventions and have the greatest impact on the most vulnerable, to prevent and ameliorate ill health. 

In the absence of political will to reduce inequality, action to promote smoking cessation may be the most effective tool to reduce the health harms that inequality causes. 

Nicholas S Hopkinson, Reader in Respiratory Medicine, National Heart and Lung Institute, Imperial College, London, medical director of the British Lung Foundation and Chair of ASH.

Twitter: @COPDdoc

Competing interests: None


  1. Marmot M. Fair Society Healthy Lives – strategic review of health inequalities in England post-2010, 2010.
  2. Lewer D, Jayatunga W, Aldridge RW, et al. Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study. The Lancet Public Health doi: 10.1016/S2468-2667(19)30219-1
  3. Jha P, Peto R, Zatonski W, et al. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. The Lancet 2006;368(9533):367-70. doi:
  4. Royal College of Physicians. Hiding in plain sight: Treating tobacco dependency in the NHS, 2018.
  5. Zoumot Z, Jordan S, Hopkinson NS. Emphysema: time to say farewell to therapeutic nihilism. Thorax 2014;69(11):973-5. doi: 10.1136/thoraxjnl-2014-205667 [published Online First: 2014/07/06]
  6. Steiner MC, Lowe D, Beckford K, et al. Socioeconomic deprivation and the outcome of pulmonary rehabilitation in England and Wales. Thorax 2017;72(6):530-37. doi: 10.1136/thoraxjnl-2016-209376