The north–south divide in English mortality, 1981–2024: a longitudinal population study

BACKGROUND: The north-south mortality divide in England, UK, has persisted for several decades. Previous longitudinal analyses up to 2016 have highlighted a widening mortality gap among those aged 25-44 years since the mid-1990s. We aimed to update mortality trends in England and evaluate how trends differed by age and sex up to 2024. METHODS: We did a segmented longitudinal population study of the north-south mortality divide in England (1981-2024). Using registered deaths and mid-year population estimates by 5-year age group and sex, we calculated standardised mortality rates and estimated adjusted north-south rate ratios using within-year Poisson models. We used segmented Poisson regression to compare mortality trends between 2010-19 and 2020-24. FINDINGS: Despite overall declines in mortality, interrupted by the COVID-19 pandemic, the north-south mortality divide persisted during 1981-2024, widening among both female and male individuals aged 25-49 years. During 2010-19, northern excess mortality among those aged 25-49 years increased per year for female individuals (incidence rate ratio 1·018 [95% CI 1·013-1·022]) and male individuals (1·012 [1·009-1·016]). During 2020-24, these trends continued: Poisson models suggested a slowing among female individuals aged 25-49 years (0·987 [0·975-0·999]) and further widening among male individuals younger than 75 years (1·004 [1·000-1·007]), but neither change was robust to allowance for overdispersion, and the gap did not narrow in any age or sex group. By 2024, northern excess mortality reached 25·9% (95% CI 24·7-27·1) for those younger than 75 years, and 42·4% (38·5-46·3) for those aged 25-49 years. INTERPRETATION: Over the past four decades, England's regional mortality inequalities have widened among working‑age adults, with more rapid increases among female individuals than male individuals up to 2020 (before the COVID-19 pandemic). Pre-pandemic trends continued through 2020-24, with no narrowing of the north-south gap in any age or sex group by 2024. Reducing the north-south health divide will require sustained large-scale action across central government and regional authorities. FUNDING: National Institute for Health and Care Research, British Heart Foundation, and The Pandemic Institute.