Health inequalities in the UK are getting worse: people in the least deprived areas of the UK enjoy an average of 18.5 more years of healthy life than those in the most deprived areas. The evidence suggests that these inequalities are caused more by ‘social determinants’ of health, such as poverty, poor-quality housing, low-paid or unstable jobs, and pollution, than by unequal healthcare provision or different lifestyle choices. Meanwhile, poor health makes people poorer, as well as undermining productivity and economic growth.

A lack of government action to tackle these underlying ‘social determinants’ can be partly blamed on lack of public pressure. This in turn stems from limited levels of public awareness and understanding of the impacts of social factors on people’s health outcomes. In the absence of specific case studies, most people put more emphasis on individual responsibility (’healthy lifestyle choices’) and on the quality and availability of NHS services than on social factors when thinking about what makes people ill.

We wanted to find out whether people recognise the impact of social factors on health outcomes when they are presented with specific case studies, and how they compare the impact of those factors to individual choices and healthcare services, as well as who they think should be responsible for addressing the issues, and whether the government should be doing (and spending) more to tackle health inequalities. We also looked at how attitudes vary based on people’s background and beliefs.

People’s assessment of their own physical and mental health

Unsurprisingly, older respondents report worse physical health than younger respondents; however, younger people report much worse mental health than older people. Some groups score themselves as having poor physical and mental health, such as people who are out of work, people with disabilities and people on lower incomes. Looking at voter groups, people who voted Conservative in 2019 report slightly better physical health, and much better mental health, than those who voted for Labour. Those who voted Leave in 2016 report similar levels of physical health to those who voted Remain, but much better mental health.

Note: data on physical and mental health has not been age-standardised, so comparisons between groups that have different age structures should be treated with caution.

People’s assessment of what factors are undermining their health and their family’s health

It is not unexpected that inadequate healthcare services come out on top of the list of factors negatively affecting health (with 62% saying that it affects their or their families’ health at least occasionally). However there is a reasonably even spread across all six factors (albeit less for the environment), suggesting that people recognise the importance of social determinants without being primed on them. A majority of people (52%) admit that their own lifestyle choices affect their health, but perhaps even more strikingly, one in two people say that their jobs negatively impact their or their families’ health, and the same proportion think that their economic situation is leading to ill health.

2019 Conservative voters are slightly less likely than the average respondent to recognise the impact of all six factors on their and their families’ health: bad luck (6 percentage points lower), poor lifestyle choices (7 pp), inadequate healthcare services (4 pp), work (11 pp), economic situation (11 pp) and environment (7 pp), suggesting that they and their families are either in better health (as suggested by the answers to the previous question) or that they are less minded to think about the causes of their ill health.

Person A: LONG COVID

Person A, aged 45, lives in a city with their partner, in a bustling neighbourhood. They have been with their partner for 10 years and own a two-bedroom house together. This person had been a bus driver for 15 years and were a key worker during the Covid-19 pandemic. As a result, they have developed long covid and are unable to work for the foreseeable future. They previously enjoyed gardening, which allowed them to reconnect with nature. Person A also loves to spend quality time with their young nephews and nieces who live nearby. Nowadays, Person A has low energy levels and finds it more difficult to spend time with their nephews or tend to their garden.

Thinking of the health of person A, which factors do you think had the most impact on the person’s situation? Please rank each factor from 1 to 6, where 1 is the factor that you think had the most impact, and 6 the least.

Although the most popular answer overall was bad luck, this scenario attracted the highest proportion of people citing the impact of work on health. We should recognise that the Covid-19 pandemic was an unusual period during which the impact of social determinants on health outcomes were more obvious; this might also provide some useful lessons in how to talk about social determinants in ways that resonate most with people. We do not see major differences of opinion across political or demographic divides for this scenario, although Labour voters are more likely than Conservative voters to focus on the impact of work (as opposed to bad luck) on this person’s health, as are younger people and people who are neither working nor retired.

Person B: ANXIETY

Person B, aged 17, lives in an urban area with their parents and two younger siblings. Their flat is small and overcrowded, and in a noisy area, which makes it challenging for them to find a quiet space to study or get a good night's sleep. Person B enjoys reading and drawing in their spare time, and is excited to do an arts degree when they leave school. However, Person B is struggling at school, falling behind on assignments and studying for exams, because of their difficulty in sleeping and in finding somewhere quiet at home to work. They have recently been diagnosed with generalised anxiety disorder, which has made keeping up with school more difficult.

Thinking of the health of person B, which factors do you think had the most impact on the person’s situation? Please rank each factor from 1 to 6, where 1 is the factor that you think had the most impact, and 6 the least.

A strikingly high proportion of respondents recognise the impact of poverty on this person’s health, and this varies little by politics (with 63% of 2019 Conservative voters and 68% of 2019 Labour voters ranking poverty among the top two factors). There is also consensus on this point across demographic groups - ages, income levels, regions and so on - other than smaller majorities among Londoners (55%), men (55%) and people from ethnic minorities (56%).

Person C: LUNG CANCER

Person C, aged 63, resides in a charming rural village with their spouse. They have been happily married for over 30 years and have a close-knit community of friends. They used to be a primary school teacher, and now, being close to retirement, work part-time at a local library. They’ve always been a keen swimmer, often taking advantage of a lake nearby. Person C has recently been diagnosed with lung cancer, even though they have never been a regular smoker. Despite the long waiting period for treatment, they remain hopeful and engage in hobbies like reading, knitting, and helping their neighbours with small tasks.

Thinking of the health of person C, which factors do you think had the most impact on the person’s situation? Please rank each factor from 1 to 6, where 1 is the factor that you think had the most impact, and 6 the least.

As expected, few people blame this person’s lung cancer on their lifestyle, since the scenario specified that they had not been a regular smoker. Instead, most choose bad luck as the main contributing factor, followed by inadequate healthcare services. There is very little variation in views across political and demographic divides.

Person D: TYPE 2 DIABETES

Person D is 40 and lives near a city with their partner and children. They are severely overweight and have type 2 diabetes. Person D grew up in severe poverty. They started working after they completed their GCSEs. Person D works multiple low-paid jobs to make ends meet, as does their partner. They often have limited amounts of time to cook. They shop the basic range at the local supermarket, because they are unable to afford anything more expensive. In their spare time Person D will watch TV, catch up with friends and family, and spend time with their children. The meals they eat are often not nutritious.

Thinking of the health of person D, which factors do you think had the most impact on the person’s situation? Please rank each factor from 1 to 6, where 1 is the factor that you think had the most impact, and 6 the least.

This scenario is the outlier. Almost one in two people (47%) cite poor lifestyle choices as the most important contributing factor, with poverty some way behind this at 29% (although when we look at the top two most important factors chosen, almost as many recognise the role played by the poverty as those citing lifestyle choices, at 60% compared to 68%). This perhaps reflects the resonance of media narratives about food and diet being within people’s control, regardless of affordability, and the challenge of cutting through with arguments about the links between poverty, diet and health (even though a recent survey found that one in five Britons are eating more processed foods because they are cheaper). But views on this issue do differ; for example, lower proportions of people aged 18-34 (58%), from ethnic minorities (58%), in London (58%), or in bad physical health (58%) put lifestyle choices in the top two factors, compared to higher proportions of 2019 Conservative voters (80%), 2019 Conservative switchers (86%), people aged 65+ (75%), people in the West Midlands (75%), people in good mental or physical health (73/72%), people who said their own health was rarely or never affected by their lifestyle choices (73%), and people who disagreed with raising taxes (76%) and redistributing income (79%). By contrast, we see less variation in the proportion of people who put poverty in the top two factors, which is above 50% among all groups, and in most groups is between 55% and 70%.

Person E: ASTHMA

Person E, aged 32, lives in a deprived urban neighbourhood in a small apartment with one other flatmate. They have always loved films and have been working at their local cinema for the last five years. In their spare time, they love keeping up with all kinds of sports, including football and cricket. They also play football in a local five-a-side team with some neighbours and colleagues on weekends. Lately they have been finding it harder to play football because of their severe asthma that is triggered by high levels of air pollution in their local area.

Thinking of the health of person E, which factors do you think had the most impact on the person’s situation? Please rank each factor from 1 to 6, where 1 is the factor that you think had the most impact, and 6 the least.

Responses to this scenario are again fairly consistent across political and demographic divides, with very large majorities of people recognising the impact of the person’s environment on their health. However, few people (among any respondent group) recognise the underlying impact of poverty, with this option scoring the same as bad luck and inadequate healthcare services, reinforcing the low level of public awareness of the links between deprivation and poor air quality.

Comparisons between views on these five scenarios should be made with caution, since responses will inevitably have been influenced by the precise wording of the question, despite our best efforts to present the scenarios as neutrally as possible. With this caveat in mind, however, the graph below shows how views on the causes of ill health varied across the five scenarios presented.

Thinking of the health of [person X], which factors do you think had the most impact on the person’s situation? Please rank each factor from 1 to 6, where 1 is the factor that you think had the most impact, and 6 the least.

People recognise that social determinants go hand in hand with individual lifestyle choices in impacting on people’s health. Overall, individual responsibility (i.e. poor lifestyle choices) ranks fairly low (with an average of 24% of respondents choosing this as a ‘top two’ factor across all five scenarios), higher only than employers (19%) but below inadequate healthcare services (also quite low at 27%), and bad luck (32%). Poverty and environment are at the top of the table (both with an average of 34% of respondents choosing these as ‘top two’ factors across all five scenarios, although these averages are inflated by very high scores for anxiety and asthma).

Views do vary by political preferences and demographic factors such as age, income and health. However, in general (and with the exception of diabetes), there is a high degree of consensus across respondent groups, and this polling does not uncover consistent patterns between groups and across scenarios (such as people with lower incomes or poorer health being more likely to focus on social determinants, for example).

We also asked, for each of the five people, whether respondents thought that their current health was mostly due to factors within or outside their control.

With the exception of person D (diabetes), large majorities think that the health conditions described are mostly caused by factors outside the person’s control. There are also striking degrees of consensus across political lines, other than for person D (where 48% of 2019 Conservative voters see this as down to individual responsibility, compared to 32% of 2019 Labour voters and 37% of all respondents). However, some patterns of differences between groups can be identified, as detailed in the box below.

Looking at the percentage of respondents who ranked each group as ‘responsible’ (1 or 2), the most popular choice is ‘national or local government tackling societal issues’ (54%), suggesting that when people are presented with examples of how social determinants affect health outcomes, most recognise the importance of focusing on tackling those determinants. However, the data also suggests that more than one in three respondents think that individuals should bear primary responsibility for looking after their own health, regardless of the context, which is the most popular answer when looking purely at the top rankings. Looking at ranks one and two together, the differences between the top three options (social, NHS and individuals, on 52%, 50% and 50%) are unlikely to be statistically significant. However, it is interesting that people consider business to have by far the least responsibility for tackling health inequalities, even though 50% of people say that their work is negatively affecting their health.

It is striking that a majority of respondents are in favour of increasing spending on health inequalities, even if it means paying more in tax to fund it.

The question did not make clear what “spending on health inequalities” means, and each respondent will have had a different understanding of this that may have influenced their answers. Many respondents might have assumed that this would involve an increase in the NHS budget, even though spending on other areas such as social security or housing would arguably be more likely to directly impact health inequalities.

Our overall findings for this question correspond with British Social Attitudes data on public support for increased spending (and our summary of the latest BSA findings), which finds that 55% of Britons now think that the government should increase taxes and spend more on health, education and social benefits (up from 31% in 2010, and compared to 36% who think taxes should stay the same and 8% who think they should be reduced).

However, the answers to this question in our survey contrast strikingly to the answers to some standard questions that we asked in the same survey, which are borrowed from previous British Social Attitudes and British Election Study surveys to give a sense of respondents’ general views about the economy (and to provide another way of analysing people’s views on the other questions in this survey). The 55% who support increasing spending on health inequalities (and raising taxes to fund it) is much higher than the 29% who support raising taxes to spend more on health and social services in the question below. This may be because of the stronger wording of the question below (’government should raise taxes a lot and spend much more on health and social services’), or because the public are more supportive of spending on the NHS in particular than on health and social services, or because people assume that spending on health inequalities would be a small fraction of government spending and so would not lead to a noticeable increase in taxes.

These are broadly consistent with answers to the same question asked by the British Social Attitudes survey in 2021/22 (figure 24), although the proportion choosing health inequalities as a priority is a few percentage points higher in our case, probably simply because our survey has been focused on this issue. The variation could also be explained by changing attitudes over time, or by the fact that other surveys asked the same question at a different point during the survey.

Nonetheless, the low priority accorded to health inequalities seems at odds with the broad recognition of the importance of social determinants in the previous question. This may reflect the fact that concern about health inequalities is ‘crowded out’ by the more visible issues (and concerns) around the availability of NHS services, alongside the difficulty of finding a way to talk about social determinants that really resonates with a broad cross-section of people.

We asked a ‘free text’ question asking people to explain their views about whether the government should spend more on health inequalities. Here are some quotes from people with a range of voting histories and intentions.

A healthy population is a productive population.

2019 Conservative voter, current voting intention not stated

Everybody deserves to live a long healthy life, no matter how rich or poor they are.

2019 Conservative voter, currently intending to vote Conservative

The more equal the opportunities afforded to all, the less at risk our health will be, and the less we will need to spend on maintaining an adequate level of healthcare for all.

2019 Conservative voter, currently intending to vote Lib Dem

If spending on this isn't increased it will lead to more strain on the NHS, as people generally will become ill more often.

2019 Conservative voter, currently intending to vote Labour

In the long term it will pay for itself and reduce costs.

2019 Conservative voter, currently intending to vote Reform

Because health inequalities increase costs across the system and cause bigger costs in future.

2019 SNP voter, currently intending to vote Green

Everyone benefits from a healthy population - productivity increases and less money is spent by the NHS treating preventable illnesses.

2019 Labour voter, currently intending to vote Labour

It is a major problem not just for individuals but also the wider economy, so it's important for government to act.

2019 Lib Dem voter, currently intending to vote Lib Dem

The questions were designed in consultation with a range of organisations working on health inequalities, and with input from polling experts. Thank you to the many experts who commented on both the survey design and the interpretation of the results.

Fieldwork was carried out by Opinium between 7 and 9 September 2023, with a nationally representative sample of 2,038 adults across the UK, weighted to nationally representative criteria and various political criteria. The order of options presented in each question was randomised.

Download the data tables (XLS)

Existing attitudinal research shows that attitudes to health inequalities tend to be framed more in terms of individual responsibility and healthcare services than the social determinants of health.

Statistics

Some relevant statistics (with background information) from the Fairness Index

Arguments

Cause and effect analysis for health inequalities from the Fairness Index

Policy reports

A selection of recent reports by other organisations about health inequalities

Attitudinal and framing research

A selection of recent research by other organisations about health inequalities