Social Policy Research
August 1997
Changing mortality ratios in
local areas of Britain 1950s1990s
Britain became a signatory to the World Health Organization’s Targets for
Health in 1985. The primary target commitment was to reduce inequalities in
health, measured by mortality differences, by 25% by the year 2000,
including reducing geographical variations. The most detailed study to date of
mortality trends by area in Britain, by Daniel Dorling at Bristol University,
shows that inequalities in health have been rising since 1985, making it
extremely unlikely that this international commitment will be met. The
research found that:
Although absolute mortality rates for all groups in society have fallen
steadily since the 1950s, the gap between people living in different areas has
widened, particularly since the 1980s.
People under 65 living in the worst tenth of areas were almost twice as likely
to die in 1990-92 than people living in the tenth of areas with the lowest
mortality rates. This is the highest inequality ever recorded and compares to
a difference of one-and-a-half times as likely 20 years ago.
Those living in the worst tenth of areas in terms of mortality in the early
1990s are in those areas where indicators of poverty are also the greatest.
More people in Britain live in areas of high relative mortality now than have
at any time since the early 1950s - 1 in 12 now live in areas where more than
15% of deaths are above expected levels, after standardising for age
differences.
Men aged between 15 and 44 are the group who have experienced the least
improvement in their life chances in recent years, but there is wide area
variation to these changes over time.
Nationally there were 77,000 excess deaths in the 1990-92 period,
representing about 4% of all mortality.
126
Variation between areas
Increasing health inequalities
Where a child is born in Britain today is more
important than ever in determining that child’s life
chances, particularly his or her chances of survival.
Such a finding is the opposite to common
preconceptions of relatively even life chances across the
country. This inequality has arisen partly because
absolute mortality rates have fallen steadily over the
years, but mainly because those improvements have
not been distributed evenly amongst the population as
a whole. For instance, an infant girl in Leeds is now
more than twice as likely to die in the first year of life
as is an infant girl growing up in a town in Dorset.
Proportionately, eight times as many boys aged
between 1 and 4 years died in Manchester as compared
to rural Gloucestershire between 1990 and 1992. There
has been a 50% increase in the absolute death rate of
boys aged between 5 and 14 in Salford since 1981,
similarly with adult male mortality in Hammersmith.
These are not the most extreme discrepancies but they
are places in which the long-term trend is worsening.
We are becoming less equal in death.
Using comparable 1951 local authority
boundaries, the three areas with the highest
mortality rates in the 1990s (Oldham, Salford and
Greenock) had mortality ratios only a fifth higher
than the national average in the early 1950s. Their
rates are now rising towards being a third higher than
the national rate. Almost a thousand deaths a year
would be avoided, were the mortality rates not
excessive in just these three places. ‘Excess deaths’
are calculated as deaths above the average rate, not
deaths above the lowest rate, which would have
produced far higher numbers of ‘avoidable’
mortalities and a much more dramatic summary.
Nationally there were 77,000 excess deaths in the
1990-1992 period, representing about 4% of all
mortality. Because mortality statistics require census
statistics, this is the latest date for which reliable local
estimates can be made for small areas.
Nationally, mortality rates are higher in the north
and in urban areas. In recent years, a person living in
Glasgow was 66% more likely to die in any given year
than someone living in the districts of rural Dorset
and 31% more likely than a resident of Bristol. At
the end of the 1960s the excess chance of dying in
Glasgow, relative to these two places, was much
lower, at 42% and 21% respectively. Crude death
rates have fallen for most people in places like
Glasgow, but not as quickly as they have in cities
further south or in rural areas (where they were also
lower to begin with). There has been a divergence in
mortality along geographical as well as social lines.
To produce a fair measure of geographical
inequality in mortality all parts of Britain need to be
included. This is done by dividing the population into
ten groups of equal size (deciles), the worst group
living in the places with the worst mortality records
for people under the age of 65 and the best group
living in the places that contain the tenth of the
population with the best mortality records at any one
time. Historical records do not provide enough detail
to look at variations in mortality over the age of 65
(although this is of great contemporary interest).
Table 1 shows the age and sex standardised
mortality ratio of the under-65 population of Britain
living in each decile group of areas in 1950-53 and
1990-92. At the start of the 1950s people in the
worst decile areas were 31% more likely to die than
average. By the early 1990s that differential had
grown to 42%, the largest divergence ever recorded,
resulting from steady growth in the level of
geographical inequality in mortality since 1981
(when rates of inequality were marginally better than
in the early 1960s). At the other extreme, people
living in the areas with least deaths were 18% less
likely to die than average in 1950-53. By 1990-92
this differential had grown to 24% less likelihood of
death in that period. Where you live is more
important in assessing your chances of dying in
Table 1: Relationship between health inequalities and poverty
Health decile
Standardised mortality ratio
residents in
households
with no car
Current Poverty indicators
children in
adults under
households
65 with a longwith no work
term illness
1950-53
1990-92
Worst
2
3
4
5
6
7
8
9
Best
131
118
112
107
103
99
93
89
86
82
142
121
111
105
99
94
91
86
80
76
40.8%
31.4%
30.8%
26.2%
23.1%
22.3%
19.7%
17.0%
13.0%
10.9%
33.2%
24.2%
21.0%
19.9%
15.2%
15.7%
14.1%
11.6%
9.6%
7.9%
9.7%
8.4%
8.0%
8.3%
6.9%
6.4%
6.0%
5.6%
4.9%
4.5%
Britain
100
100
23.6%
17.4%
6.9%
Table 2 Areas with the ten highest and
lowest excess deaths for males in 1950-53
Table 3 Areas with the ten highest and
lowest excess deaths for males in 1990-92
Area
Area
15-45
Scotland north and east
Edinburgh
443
Scotland west and south
Glasgow
Lanark County
1715
255
15-45
Scotland north and east
Dundee
Edinburgh
Scotland west and south
Glasgow Ci
Lanark County
North East
Northumberland urban
Durham urban
Durham rural
Lancs/Yorks rural
Lancashire rural
Yorkshire West Riding rural
1191
1960
2428
336
South West
Devon rural
Wiltshire rural
South rural
Kent rural
Berkshire rural
Essex rural
Norfolk rural
South urban
Southampton urban
Kent urban
Surrey urban
Middlesex
Hertfordshire urban
Essex urban
North East
Newcastle
Durham Urban
Yorkshire urban
Yorkshire West Riding urban
Bradford
Sheffield
-148
-876
1722
388
300
710
1125
West Midlands
Birmingham
Wales
Glamorganshire urban
9296
431
366
532
Yorkshire urban
Leeds
Lancashire urban
Lancashire urban
Salford
Manchester
Liverpool
45-64
850
3781
1945
5163
4532
1559
2398
-273
1192
-213
496
2687
1282
3921
3005
-172
3122
-170
South West
Gloucestershire rural
-960
2728
South rural
Southampton rural
Kent rural
Berkshire rural
Essex rural
-919
-915
-913
-927
-247
-809
-152
-265
-228
-473
-1029
-172
-666
West Midlands
Staffordshire urban
Birmingham
Warwickshire urban
10047
1179
1913
-785
-210
Lancs/Cheshire urban
Lancashire urban
Salford
Manchester
Liverpool
45-64
-747
-1065
-1656
-2642
-3827
-945
-2036
The highest and lowest three figures are shown in dark coloured blocks.
South urban
Southampton urban
Kent urban
Surrey urban
Middlesex
Hertfordshire urban
Essex urban
London
Lambeth
Southwark
Hammersmith
Kensington
St. Pancras
Islington
-194
-245
-248
-441
-300
-351
-968
-1306
-2231
-1062
-1199
735
308
706
456
297
499
The highest and lowest three figures are shown in dark coloured blocks.
the early 1990s that it has been at any time since
World War II. The table also shows that those living
in the worst health decile areas in the early 1990s are in
those areas where indicators of poverty are the greatest.
Mortality by age and sex
The rise in geographical variations in mortality is
different for different groups of the population
subdivided by age and sex. There is little geographical
variation in the level of mortality amongst very elderly
people for the simple reason that mortality is so
common amongst this group. The study considered
each sex and six age groups of the population
separately. The main findings are as follows.
Infant mortality (under 1)
Nationally, infant mortality has seen the most
dramatic falls since the start of the period under
study here, but regionally divides are growing
between different parts of the country. Although in
most parts of Britain rates are still falling steadily, the
exceptions warrant further investigation (see maps 1
and 2). For instance, male infant mortality rates have
risen steadily in the northern boroughs of Blackburn,
Halifax and Preston, where the death rates of boys
aged under one year are now roughly twice the
national average. In 1981 these areas had rates
which were only just above the national average. It
should be noted, however, that in all these places
infant mortality rates are still at half the levels they
stood at in the 1950s, despite having risen so quickly
during the 1980s. There is less variation amongst
infant girls’ mortality, where rates only rose steadily
recently in Paisley borough.
Table 4 Areas with the ten highest and
lowest excess deaths for females in 1950-53
Table 5 Areas with the ten highest and
Area
15-45
Area
15-45
Scotland west and south
Stirling County
Glasgow
Paisley
Lanark County
4365
458
815
Scotland north and east
Dundee
Edinburgh
105
246
1186
408
431
1158
North East
Newcastle
Durham urban
Yorkshire urban
Yorkshire West Riding urban
Bradford
Lancashire urban
Lancashire urban
Manchester
Liverpool
West Midlands
Staffordshire urban
Stoke-on-Trent
Wales
Glamorganshire urban
South rural
Southampton rural
Kent rural
Buckinghamshire rural
Norfolk rural
South urban
Bournemouth
Southampton urban
Kent urban
Surrey urban
Middlesex
Hertfordshire urban
Essex urban
London
Croydon
Lewisham
45-64
6057
-158
1014
805
718
1283
1344
3339
2494
1368
339
1045
683
-131
-133
1273
-322
-330
-350
-268
-147
-275
-541
-891
-205
-471
-1243
-1971
-3247
-542
-1516
-129
-318
The highest and lowest three figures are shown in dark coloured blocks.
lowest excess deaths for females in 1990-92
Scotland west and south
Glasgow
Lanark County
Ayr County
419
109
North East
Durham urban
Middlesbrough
133
Lancs/Cheshire urban
Lancashire urban
Manchester
Liverpool
Cheshire urban
114
140
-70
West Midlands
Stoke-on-Trent
Birmingham
109
Wales
Glamorganshire urban
-68
South West
Wiltshire rural
-63
South urban
Southampton urban
Kent urban
Surrey urban
Middlesex
Buckinghamshire urban
Hertfordshire urban
Essex urban
London
Lambeth
Southwark
6001
1066
792
1460
773
Lancs/Yorks rural
Yorkshire West Riding rural
South rural
Southampton rural
Kent rural
Buckinghamshire rural
Essex rural
Norfolk rural
45-64
-74
2122
1272
1798
735
1115
-625
-577
-465
-439
-519
-546
-139
-153
-112
-79
-121
-228
-1200
-1100
-600
-641
177
128
The highest and lowest three figures are shown in dark coloured blocks.
Early childhood mortality (aged 1 to 4)
Mortality is very rare in this age range, but
where geographical variations do occur they
can be dramatic and certainly warrant further
study. Rates of male early childhood
mortality in the old boroughs of Dewsbury,
Bethnal Green, Manchester and St. Helens,
have as much as doubled since 1981, so as to
be now approaching the rate reported in these
areas in the 1950s. Absolute, but smaller, rises
were also recorded for young girls, again in
Manchester, but also in Birkenhead, rural Isle
of Wight and Newport.
Adolescent mortality (aged 5 to 14)
Amongst this age group, mortality rates are
also very low, although similar places appear
when those areas leading the trend towards
geographical divergence in mortality rates are
listed. An adolescent child’s chances of dying
rose during the 1980s in absolute terms in
Salford, rural Camarthenshire, St. Helens,
Nottingham and Bethnal Green, but in all
cases rates were still lower than recorded in
the 1950s. For adolescent girls, absolute
mortality rates rose in Barrow-in-Furness in
the most recent period.
Younger adult mortality (aged 15 to 44)
Mortality rates are much more important
amongst adults in terms of the actual numbers
of people who die each year. Those areas with
the highest and lowest number of ‘excess
deaths’ are shown in Tables 2 to 5. Amongst
younger adult men, mortality rates fell sharply
in Britain from 1950 to 1981, but have
remained practically static since then, with
0.11% of this population dying per year.
However, this proportion is very, and
increasingly, unevenly distributed across the
country. In Hammersmith, Port-Glasgow and
Southwark a man this age is more than twice as
likely to die than average and in too many areas to
list here, adult male mortality rates are high and
rising. For women, variations are also high, with
absolute mortality rates rising in several parts of the
country, including in many Scottish counties.
Older adult mortality (aged 45 to 64)
The great majority of premature deaths in Britain
occur to people in this age range and here there has
been a continuation of the improvement in rates
which began in earnest in the 1970s. Despite this,
geographical variations have increased again
amongst this group. For men and women in the
early 1960s, 6.9% and 5.4% of deaths in this age
group would have been avoided if no area had overaverage mortality. By the early 1990s these
proportions had risen to 9.6% and 8.9%
respectively. More deaths could be attributed to
geographical variations in mortality rates. Where
people live has become more reliable as a predictor
of whether they are likely to die before the age of
retirement. However, only Shoreditch records a
steady absolute increase in mortality, where the
mortality rate for men has risen since 1981 and is
now almost twice the national average.
Conclusions
By using the same age and sex groups and same
geographical areas as were used in 1951, this analysis
shows that a large degree of inequality persists.
This study did not set out to speculate on the
causes of the maintenance and selective widening of
these divisions in society, save to say that many of
the trends which have been shown here have
occurred too quickly, or involve too many deaths, to
be ascribed simply to changing socio-economic
structures, or changing causes of death, or simply
the reflection of past health variations. Explaining
the patterns of life chances will be far more difficult
than describing them.
About the study
The improvements in mortality rates for different age
and sex groups are compared across a constant set of
areas. The areas used are those for which
standardised mortality ratios were published in the
Registrar General’s Decennial Review of 1951.
Published by the
Joseph Rowntree Foundation
The Homestead, 40 Water End
York YO3 6LP
Tel: 01904 629241 Fax: 01904 620072
ISSN 0958-3084
Calculations are also made on the basis of
contemporary administrative geography and for
more recent dates (up to 1995), although records
with detailed geographical location were only
available up to 1992. Whereas figures on changes in
mortality by social group are available for most of
this century using a consistent set of definitions, data
on mortality using a consistent set of areas have had
to be constructed separately especially for this study.
Data from the Censuses of Population are
Crown Copyright and are reproduced by permission
of the Controller of Her Majesty’s Stationery Office
and accessed through the ESRC/JISC purchase. Data
on mortality were kindly provided by the Office for
National Statistics. The research on which these
findings are based was also funded by the Economic
and Social Research Council Health Variations
Programme.
Further information
A short report from this project, Death in Britain: How
local mortality rates have changed: 1950s to 1990s ,
by Daniel Dorling, is published by the Joseph Rowntree
Foundation. (Price £11.95 plus £1.50 p&p, ISBN 1
85935 031 3).
The technical report, Changing life chances in
Britain, 1950s to 1990s , is available from the
Department of Geography, University of Bristol,
University Road, Bristol BS8 1SS (Price £11.95).
Related Findings
The following Findings look at related issues:
55
The geography of poverty and wealth
1981-1991 (Sep 94)
56 Poorer neighbourhoods in Oxford and
Oldham (Sep 94)
87 Mapping British society (Nov 95)
123 Local variations in costs (Jul 97)
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