Cost of health inequality to the NHS in Wales

Rajendra Kadel*, James Allen, Oliver Darlington, Rebecca Masters, Brendan Collins, Joanna M. Charles, Miqdad Asaria, Mariana Dyakova, Mark Bellis, Richard Cookson

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background: Forty years from the seminal work of Welsh GP Julian Tudor Hart on the Inverse Care Law, inequalities in health and healthcare remain deeply embedded in Wales. There is a wider gap (over 17 years) in healthy life expectancy between people living in the most and least deprived neighborhoods in Wales. This health inequality is reflected in additional healthcare use. In this study we estimate the cost of inequality associated with this additional healthcare use to the publicly funded National Health Service (NHS) in Wales. Methods: We retrieved administrative data on all NHS inpatient admissions, outpatient and accident and emergency attendances in Wales between April 2018 and March 2019 from Digital Health and Care Wales (DHCW). Hospital service use data were translated to costs using Healthcare Resource Group (HRG) and health service specific unit cost data and linked with area level mid-year population and deprivation indices in order to calculate the healthcare costs associated with socioeconomics deprivation. Results: Inequality in healthcare use between people from more and less deprived neighborhoods was associated with an additional cost of £322 million per year to the NHS in Wales, accounting for 8.7% of total NHS hospital expenditure in the country. Emergency inpatient admissions made up by far the largest component of this additional cost contributing £247.4 million, 77% of the total. There are also substantial costs of inequality for A&E attendances and outpatient visits, though not maternity services. Elective admissions overall have a negative cost of inequality, since among men aged 50–75 and women aged 60–70, elective utilization is actually negatively associated with deprivation. Conclusion: There are wide inequalities in health and healthcare use between people living in more deprived neighborhoods and those living in less deprived neighborhoods in Wales. Tackling health inequality through a combination of health promotion and early intervention policies targeted toward deprived communities could yield substantial improvement in health and wellbeing, as well as savings for the Welsh NHS through reduced use of emergency hospital care.

Original languageEnglish
Article number959283
Number of pages10
JournalFrontiers in public health
Publication statusPublished - 16 Sept 2022

Bibliographical note

Funding Information:
RC is supported by the Wellcome Trust (Grant No. 205427/Z/16/Z).

Funding Information:
We are thankful to the WHESRi Joint Scientific and Advisory Group, the WHO CC Senior Leadership Team and the Public Health Wales Population Health Strategic Group for their helpful comments.

Publisher Copyright:
Copyright © 2022 Kadel, Allen, Darlington, Masters, Collins, Charles, Asaria, Dyakova, Bellis and Cookson.


  • cost
  • health service use
  • inequality
  • NHS
  • Wales

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