A new era of inequality: profound changes to mortality in England, Scotland, and 10 major British cities.

Deeply concerning changes to UK health trends have been noted since the early 2010s, including a widening of mortality inequalities. Given the importance of urban areas to national health outcomes, we sought to address gaps in the evidence by examining trends in intra-city mortality inequalities across Britain, including assessing the impact of the peak COVID-19 pandemic period. Age-standardized mortality rates were calculated (for England, Scotland, and 10 major UK cities) by age (all ages, 0-64 years), sex, year (1981-2020), and country-specific and city-specific area-based quintiles of socio-economic deprivation. Trends in absolute and relative inequalities in mortality by country and city were analysed by means of the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII), respectively. Profound changes to mortality trends and inequalities were observed across both nations and all cities in the decade up to 2020, including increases in death rates among the 20% most deprived populations of almost every city. For deaths at all ages, this was particularly evident in Leeds, Liverpool, Edinburgh, Dundee, and Glasgow. For 0-64 years, Scottish cities stood out. With few exceptions, both absolute and relative inequalities increased in the same time period. COVID-19 further increased death rates and inequalities. The analyses provide a hugely concerning picture of worsening mortality and widening inequalities across England and Scotland. When viewed in the context of the evidence for the impact of UK government austerity policies on population health, they represent a wake-up call for both current and future UK governments.