North and South: addressing the English health divide

The North South divide in England has been a popular trope from the mid-19th century novels of Charles Dickens (Hard Times, 1854) and Elizabeth Gaskell (North and South, 1855) through to TV and radio documentaries of 2014.1,2 These often focus on culture and the economy, but it is also well known that there are large and longstanding geographical inequalities in health in England.3 Between 2009 and 2011 people in Manchester were more than twice as likely to die early (455 deaths per 100 000) as people living in Wokingham (200 deaths per 100 000).3 This sort of finding is not new; for the past four decades, the North of England (commonly defined as the North East, North West and Yorkshire and Humber regions) has persistently had higher all-cause mortality rates than the South of England, and the gap has widened over time.4 This dates back to at least the early 19th century when, for example, Chadwick5 found that life expectancy for all social classes was higher in Bath than in Liverpool. \udThe extent of the current spatial health divide in England is extreme by contemporary comparative standards. England has some of the largest regional inequalities in health in Europe (Fig. 1). The scale of the divide is such that the life expectancy gap for women between the poorest English regions—the North East (NE) and North West (NW)—and the richest—London and the South East—was similar to the gap between the former West Germany and post-communist East Germany in the mid-1990s (Fig. 2). What the history of German reunification shows is that these regional differences can be addressed. After reunification in 1990, life expectancy for women in East Germany caught up with that of women in West Germany in little more than a decade, whereas the gap between the North of England and London has persisted for women. East German women now have a higher life expectancy than NE English women. The German spatial life expectancy gap for men is now smaller than the English one