Intended for healthcare professionals

Education And Debate

As the health divide widens in Sweden and Britain, what's happening to access to care?

BMJ 1997; 315 doi: (Published 18 October 1997) Cite this as: BMJ 1997;315:1006
  1. Margaret Whitehead, visiting fellowa (,
  2. Maria Evandrou, visiting fellowb,
  3. Bengt Haglund, associate professorc,
  4. Finn Diderichsen, professora
  1. a Department of Public Health Sciences, Karolinska Institute, S-172 83 Sundbyberg, Sweden
  2. b King's Fund Policy Institute, London W1M OAN
  3. c Centre for Epidemiology, National Board of Health and Welfare, Stockholm, Sweden
  1. Correspondence to: Professor M Whitehead The Old School, Ash Magna, Whitchurch, Shropshire SY13 4DR
  • Accepted 5 August 1997


In both Sweden and Britain, social inequalities in health have been widening over the past 20 years. In Sweden, improvement in life expectancy weighted for health has been greater for men and women in non-manual than in manual occupations.1 Swedish industrial workers experienced increasing mortality in the 1970s and early 1980s, at a time when death rates among professional and managerial workers were decreasing sharply.2

Likewise in Britain, large and widening differentials in mortality have been reported between the most and the least deprived areas in Scotland and northern England.3 4 At a national level, the gap between the death rates of different social classes has also widened over the 1980s and up to 1993.5 6 Mortality is now three times higher in unskilled manual workers than among professionals.6 Large differentials in morbidity have also been found.7 8

The role of equitable health services

Lack of access to essential health care is likely to make only a minor contribution to the overall difference in mortality.9 Nevertheless, health services have an important role, not least in coping with and ameliorating the damage to health caused by inequalities in society. At times of growing inequalities in health, it is more important than ever to ensure equitable access to health care for those hardest hit.10 11

In this respect, both Sweden and Britain have prided themselves on their national health services, based on equal access for equal need. Swedish evidence from the 1970s and 1980s supported the claim of an equitable service. After health status was controlled for, no socioeconomic differences were found in the proportion who had visited a doctor12 13; whereas studies from the 1960s (before user fees were reduced in a major health policy reform) had found higher use of the health service among high income …

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