Before the COVID-19 pandemic, England was a deeply unequal country. Individual circumstances, such as where you lived, caused markedly different outcomes in key aspects of people’s lives, including their health and wealth. People living in the north of England died earlier, had worse health and faced fewer economic prospects.
Then the pandemic arrived.
COVID-19 affected everyone, but did not do so equally. In this context of deep-rooted pre-pandemic regional inequalities, and the imbalanced geographical impacts of austerity, some regional variations in COVID-19 and its impacts might have been expected.
However, the disproportionate extent to which the north of England suffered during the pandemic was beyond what many had feared. In our book Northern Exposure, free to download via Open Access, we demonstrate the size and scale of the regional inequalities that emerged during the pandemic and the pressing need for an approach to ‘levelling up’ which truly addresses these stark and persistent geographical disparities.
Mortality from COVID-19 in the north was 17 per cent higher compared to the country as a whole. However, this need not have been the case. If ‘levelling up’ had occurred pre-pandemic, and deprivation (area-level socioeconomic disadvantage) and health in the north were at similar levels to the rest of England, then 51 per cent of this increased northern COVID-19 mortality could, and should, have been prevented. This equates to around 2,500 northern deaths that could have been avoided.
Deprived areas in the north experienced greater COVID-19 mortality than equally deprived areas in the rest of the country – a demonstration of ‘deprivation amplification’. In other words, the effects of deprivation on health are amplified (or made worse) when an area is in the North. With a properly funded ‘levelling up’ strategy, these inequalities could have been avoided.
As well as the increased likelihood of death, other impacts associated with the COVID-19 pandemic included declines in mental health, increased hospital disruption and problems with long COVID. We might understand these additional health impacts as ‘parallel pandemics’, problems running alongside COVID-19 illness and mortality which require public health attention. Outcomes in these three domains worsened across the country, yet the nature of these parallel pandemics in the north was worse.
Mental health had declined by approximately five per cent for both the north and the rest of the country. However, not all groups in society felt this decline equally. In particular, women and people from minority ethnic backgrounds experienced greater declines and people in these groups in the north fared worse.
Together, these ‘parallel pandemics’ have concerning implications for the long-term recovery of the north from the COVID-19 pandemic and highlight the immediate need for a strategy that supports policies to improve health care access and investment in NHS services in the north. It is important that any such strategy also seeks to target the wider determinants of health – factors outside the formal health and care systems.
In addition to the severe health impacts, the COVID-19 pandemic also took a toll on economic outcomes. Productivity in the north was disproportionately impacted and those living in the north experienced an additional six weeks in the harshest levels of lockdown, a rise in levels of unemployment and a drop in wages during the pandemic.
We also estimate that the disproportionate health effects of the pandemic on the north could cost the UK economy over £9 billion per year unless urgent action is taken to rectify these inequalities. This leak in the economy could be plugged through political and economic policies that increase the devolution of political power to local communities and place health needs at the heart of all policy making.
Stepping back to consider the broader context of geographical inequalities in England, there are some explanations for the unequal effects of the pandemic.
The inequalities in COVID-19 outcomes have arisen from a geographically unequal distribution of pre-existing risk factors, including inequalities in health and deprivation. These underpin the five pathways to inequalities in COVID-19 morbidity and mortality: exposure, transmission, vulnerability, susceptibility and treatment.
At a time when regional inequalities in England are some of the worst in Europe, the need for an extensive and long-term national health inequalities strategy is essential. Now, emerging from the COVID-19 pandemic and entering further challenging times, we need policies that support the building of a stronger, healthier and more equal country.
The government’s ‘levelling up’ strategy should be at the forefront in seeking to reduce these widening inequalities. However, to date there still remain large differences in ‘levelling up’ funding allocations, with grants to the north considerably lower. If these pressing issues are not addressed with policies that focus on the social determinants of health (the conditions in which people are born, grow, live and work), as well as increasing NHS provision in the poorest areas, we can expect these inequalities to continue to grow.
Clare Bambra is Professor of Public Health at the Population Health Sciences Institute, Newcastle University.
Luke Munford is Senior Lecturer in Health Economics at the University of Manchester.
Sam Khavandi is a research associate in Health Economics at the University of Manchester.
Natalie Bennett is a research associate in the Population Health Sciences Institute at Newcastle University.
Twitter handles: @ProfBambra @dukester24 @DrNCBennett
Northern Exposure by Clare Bambra, Luke Munford, Sam Khavandi and Natalie Bennett is available on the Policy Press website. Pre-order here for £35.00. This book will also be published Open Access.
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