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Impact on health inequalities of rising prosperity in England 1998-2007, and implications for performance incentives: longitudinal ecological study

BMJ 2012; 345 doi: (Published 04 December 2012) Cite this as: BMJ 2012;345:e7831
  1. Ben Barr, National Institute of Health research fellow,
  2. David Taylor-Robinson, MRC population health scientist,
  3. Margaret Whitehead, W H Duncan professor of public health
  1. 1Department of Public Health and Policy, Institute of Psychology, Health and Society, University of Liverpool, Liverpool L69 3GB, UK
  1. Correspondence to: B Barr benbarr{at}
  • Accepted 30 October 2012


Objective To investigate whether the uneven rise in prosperity between 1999 and 2008 accounted for differential increases in life expectancy in English local authorities.

Design Longitudinal ecological study.

Setting 324 local authorities in England, classified by their baseline level of deprivation.

Main outcome measures Multivariable regression was used to investigate the association between trends in prosperity between 1998 and 2007 and trends in life expectancy. Trends in health inequalities were assessed by comparing the experience of Spearhead local authorities (the 70 most deprived in 1998) with the average for all English local authorities.

Results Those local authorities that experienced the greatest improvement in prosperity experienced greater increases in life expectancy. With each 1% absolute decline in unemployment, life expectancy increased by 2.2 (95% confidence interval 0.5 to 3.8) months in men and by 1.7 (0.4 to 3.1) months in women. With each £1000 increase in average household income in a local authority, life expectancy increased by 1.4 (0.3 to 2.5) months in men and by 1.1 (0.2 to 1.9) months in women. The more deprived a local authority was in 1998, the lower the rate at which life expectancy improved.

Conclusion Decreases in unemployment and increases in average income in an area explained, to a large extent, why some local authorities “performed” better than others. Health inequalities between Spearhead and all local authorities widened during the period of rising prosperity, but they would have widened to an even greater extent had unemployment not fallen at a faster rate in more deprived areas. With worsening economic trends over the next 10 years, this research suggests that increases in life expectancy are likely to be smaller and health inequalities may widen at a faster rate than in the previous decade. Allocating resources to local authorities on the basis of their “performance” at increasing life expectancy is likely to reward more affluent areas rather than disadvantaged areas with greater needs, exacerbating the problem.


  • Contributors: BB was responsible for the concept and design of the study. MW and DT-R developed the performance incentives analysis. BB did the analysis with support from DT-R. All authors contributed to the interpretation of the data, drafting the article, and final approval of the version to be published. BB is the guarantor.

  • Funding: BB is supported by an NIHR doctoral research fellowship (DRF-2009-02-12). DT-R is supported by an MRC population health scientist fellowship (G0802448). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

  • 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.

  • Ethical approval: Not needed.

  • Data sharing: Statistical code and dataset available from corresponding author at benbarr{at}

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