Operationalising health inequalities across multiple policy levels in the UK: place, gaps and the missing social gradient

Background Health inequalities are widely studied but how governments operationalise (define and measure) the phenomenon is less well-understood. Existing research focuses mainly on health-led responses and national bodies. We examined how ‘health inequalities’ are operationalised across diverse policies at devolved national, regional and local levels in the UK. Methods We conducted a qualitative study combining policy document analysis and semistructured interviews in the Scottish Government, Greater Manchester Combined Authority and Sheffield City Council. We coded documents (primarily 2017–2023) for how health inequalities were specified (eg, axis, level/scale, measure, outcome), compiled a synthesis of health-inequality frameworks to sensitise analysis and undertook three rounds of interviews with policy professionals (2019–2023). Results Across documents and interviews, health inequalities were primarily operationalised spatially. Socio-demographic operationalisations (eg, focused on ethnicity, disability, gender, homelessness) were evident where specific services or policy concerns identified a relevant inequality but were rarely quantified. Across all settings, health inequalities were framed predominantly as ‘gaps’; none of the texts analysed described a social gradient. Interview accounts suggested the gradient was viewed as conceptually difficult to communicate and politically challenging to pursue, given limited resources and pressures for demonstrable progress. Conclusion Across the settings studied, ‘health inequalities’ are chiefly rendered as place-based health gaps, rather than a social gradient. This framing shapes the focus of policy attention and potential action. Researchers and policymakers should work collaboratively to ensure operational definitions and accountability mechanisms support addressing the systemic and structural factors that underpin health inequalities.