Intended for healthcare professionals


The north-south health divide

BMJ 2011; 342 doi: (Published 15 February 2011) Cite this as: BMJ 2011;342:d584
  1. Margaret Whitehead, WH Duncan professor of public health1,
  2. Tim Doran, clinical research fellow2
  1. 1Department of Public Health and Policy, University of Liverpool, Liverpool L69 3GB, UK
  2. 2School of Health Sciences, University of Manchester, Manchester, UK
  1. mmw{at}

The NHS must do more than pick up the pieces

The north-south divide is one of England’s most powerful and enduring myths: one country geographically, politically, and culturally separated into beautiful south and grim north. On one side rolling fields, dazzling sunshine, conspicuous wealth, conservatism, and flat beer; on the other coal, cloud, desolation, socialism, and froth.

In the linked observational study (doi:10.1136/bmj.d508), Hacking and colleagues show that not only is the divide in premature mortality real, but that it has persisted and continued to widen over four decades and under five governments.1 Since 1965, the toll of excess deaths has surpassed 1.5 million—the north is being decimated at the rate of a major city every decade.

Many explanations have been offered for this northern catastrophe. Hacking and colleagues discuss the contributions of genetics, lifestyle, and migration and find them modest. Explanations related to the differing social composition of the population in the north compared with the south also fall short, because southerners enjoy better health across the entire social spectrum.2 Any damage inflicted by climate and geology is likely to be indirect: the cotton industry developed where the weather was damp, the coal industry where there were seams to exploit. These and other industries provided enough income to engender dependency, but too little to generate affluence. When the industries declined, entire communities withered with them.

The evidence suggests that the underlying causes of the divide are social and economic, so bridging it will require social and economic solutions. In 1997, the incoming New Labour government broke with its predecessor in acknowledging the existence of health inequalities and mounted a cross departmental campaign against them. The health divide continued to grow, however, and for people under 75 it is now at its widest for 40 years.1 Having reached this nadir in the relatively favourable economic and political climate of the 2000s, future prospects look grim.

Analysis of the impact of the current recession shows that deprived communities in the northern city regions have borne the brunt. Unemployment has increased most in manufacturing areas, where it was already high, exacerbated by the disproportionate effects of the recession on housing led regeneration efforts in the north.3 Government spending cuts will also hit hardest in the north, which will sustain greater proportional job losses in the public and private sectors and has a greater reliance on welfare benefits and public services that are being cut.4 This increasingly intractable problem can only be solved by renewed regional development policies, which have repeatedly been stressed in the past but are insufficiently implemented.

Given its limited influence on the underlying causes, can the NHS do more than pick up the pieces? The Royal College of Physicians envisages an important role for clinicians as advocates, educators, and partners of public health specialists and local authorities.5 These responsibilities will fall predominantly on general practitioners, both as providers of primary care and as commissioners. As providers, GPs have made substantial advances over the period of Hacking and colleagues’ study. Inner city practices are no longer “the source of public danger” that some of them were in the 1950s,6 and management of chronic conditions has improved markedly over the past decade.7 The efforts of practices in response to quality improvement initiatives, particularly in deprived areas, have yielded more equitable care in terms of secondary prevention.8 This has yet to be reflected, however, in outcomes.

It is also not clear whether the recent emphasis on secondary prevention through the Quality and Outcomes Framework (QOF) has distracted attention from primary prevention. In their new commissioning role,9 GPs will be hampered by the loss of the ability to plan for whole populations in defined geographical areas as a result of the switch from primary care trusts to consortiums based on registered patients.10 Effective collaboration with public health services and local authorities will be crucial, at a time when local authorities are under immense financial pressure. It will be imperative for GP consortiums to take on public health expertise to incorporate a population perspective into their commissioning processes. This applies to commissioning of services across the board, but especially in relation to tackling the social determinants of health and the health divide.10

The activities of local consortiums will be constrained by the demands and allocations of the NHS Commissioning Board, which will have to balance its duty to tackle inequalities with those to improve quality and promote patient choice. A practical challenge for the board will be the distribution of GPs, which had become less equitable, year on year, since the early 1990s, and especially since the abolition of entry controls in 2002.11 More fundamentally, the board will have to ensure the equitable allocation of NHS resources, taking account of the increased needs associated with deprivation around the country. This applies both to the formula for the allocation of commissioning funds to GP consortiums and to the transfer of ring fenced public health budgets to local authorities.12

Last, but not least, the board or the Department of Health must take a national overview of the cumulative effects of resource allocation to, and commissioning decisions made by, GP consortiums on equitable access to NHS services for different sections of the population living in different parts of the country. Otherwise, the result could be chaos and an even wider health divide.


Cite this as: BMJ 2011;342:d584


  • Research, doi:10.1136/bmj.d508
  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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