Intended for healthcare professionals

CCBYNC Open access

Inequalities in premature mortality in Britain: observational study from 1921 to 2007

BMJ 2010; 341 doi: (Published 22 July 2010) Cite this as: BMJ 2010;341:c3639
  1. Bethan Thomas, research fellow1,
  2. Danny Dorling, professor of human geography1,
  3. George Davey Smith, professor of clinical epidemiology2
  1. 1Social and Spatial Inequalities Group, Department of Geography, University of Sheffield, Sheffield S10 2TN
  2. 2Department of Social Medicine, University of Bristol, Bristol BS8 2BN
  1. Correspondence to: B Thomas B.S.Thomas{at}
  • Accepted 18 May 2010


Objective To report on the extent of inequality in premature mortality as measured between geographical areas in Britain.

Design Observational study of routinely collected mortality data and public records. Population subdivided by age, sex, and geographical area (parliamentary constituencies from 1991 to2007, pre-1974 local authorities over a longer time span).

Setting Great Britain.

Participants Entire population aged under 75 from 1990 to 2007, and entire population aged under 65 in the periods 1921-39, 1950-3, 1959-63, 1969-73, and 1981-2007.

Main outcome measure Relative index of inequality (RII) and ratios of inequality in age-sex standardised mortality ratios under ages 75 and 65. The relative index of inequality is the relative rate of mortality for the hypothetically worst-off compared with the hypothetically best-off person in the population, assuming a linear association between socioeconomic position and risk of mortality. The ratio of inequality is the ratio of the standardised mortality ratio of the most deprived 10% to the least deprived 10%.

Results When measured by the relative index of inequality, geographical inequalities in age-sex standardised rates of mortality below age 75 have increased every two years from 1990-1 to 2006-7 without exception. Over this period the relative index of inequality increased from 1.61 (95% confidence interval 1.52 to 1.69) in 1990-1 to 2.14 (2.02 to 2.27) in 2006-7. Simple ratios indicated a brief period around 2001 when a small reduction in inequality was recorded, but this was quickly reversed and inequalities up to the age of 75 have now reached the highest levels reported since at least 1990. Similarly, inequalities in mortality ratios under the age of 65 improved slightly in the early years of this century but the latest figures surpass the most extreme previously reported. Comparison of crudely age-sex standardised rates for those below age 65 from historical records showed that geographical inequalities in mortality are higher in the most recent decade than in any similar time period for which records are available since at least 1921.

Conclusions Inequalities in premature mortality between areas of Britain continued to rise steadily during the first decade of the 21st century. The last time in the long economic record that inequalities were almost as high was in the lead up to the economic crash of 1929 and the economic depression of the 1930s. The economic crash of 2008 might precede even greater inequalities in mortality between areas in Britain.


  • This paper is dedicated to the memory of Jerry Morris, a lifelong advocate of serious efforts to reduce inequalities in health.

  • Contributors: BT planned the study, analysed the data, discussed the results, and wrote the manuscript. DD planned the study, analysed the data, discussed the results, and wrote the manuscript. GDS planned the study, discussed the results, and wrote the manuscript. All authors saw and approved the final version. BT had full access to the individual specific mortality data used in the study, and can take responsibility for the integrity of the data and the accuracy of the data analysis. All authors had access to the processed tables and figures. BT and DD act as guarantors for the paper.

  • Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that all authors had: no financial support for the submitted work from anyone other than their employer; no financial relationships with commercial entities that might have an interest in the submitted work; and no non-financial interests that may be relevant to the submitted work.

  • Ethical approval: Ethical approval was not required.

  • Data sharing: No additional data available.

  • Accepted 18 May 2010

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

View Full Text