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An introduction to health inequalities
Many different factors have an important influence on health.

The factors which have been found to have the most significant influence – for better or worse – are widely known as the determinants of health. While health and social services make a contribution to health, most of the key determinants of health lie outside the direct influence of health and social care, for example, education, employment, housing, and environment. The diagram below presents the determinants of health in terms of layers of influence, starting with the individual and moving to wider society.

Source: Dahlgren G and Whitehead M (1991) Policies and strategies to promote social equity in health. Stockholm, Institute for Futures Studies

What is meant by 'health inequalities'?

Broadly speaking, there are three types of inequality in health:

• inequality in access to health care (for example, refugees in London often have difficulty in obtaining primary health care)

• inequalities in health/health outcomes (for example, there are six years’ difference in average life expectancy at birth between the boroughs in London)

• inequalities in the determinants of health (for example, in education, employment or housing)

Different groups and categories of people have very different experiences of the determinants of health. These different experiences can have an effect on health. Some of the groups and categories involved are well known – in particular, gender, class, ethnic group, age and geographical area. Others might be less obvious – such as disability, single parenthood, quality of school, age of housing stock, type of road user.

Inequalities can become entrenched when these categories overlap (for example, in a combination of ethnic group, age, area). In these circumstances, there can be a ‘snowballing’ effect where it is unclear exactly how the determinants are related to each other – but it is clear that the combined negative impact is strong. Some factors, like age, are dynamic; people do not necessarily stay in poverty – they can move in and out of it.

One of the Commission's aims is to raise awareness of the determinants of health and their effects on the health of Londoners. Our Health in London reports are useful publications that identify important inequalities in health and the determinants of health in London, tracking trends in these inequalities. The World Health Organisation has also produced a document on the social determinants of health, 'The Solid Facts', which can be found on the WHO Europe website.