Who still dies young in a rich city? Revisiting the case of Oxford

There are substantial inequalities in mortality and life expectancy in England, strongly linked to levels of deprivation. Mortality rates among those who are homeless are particularly high. Using the city of Oxford (UK) as a case study, we investigate ward-level premature standardised mortality ratios for several three-year and five-year periods between 2002 and 2016, and explore the extent to which the mortality of people who become homeless contributed to any rise or fall in geographical inequalities during this period. Age–sex standardised mortality ratios (SMRs) for people aged under 65 years old, with and without deaths among the homeless population, were calculated using Office for National Statistics Death Registration data for England and Wales 2002−2016. Individuals who were homeless or vulnerably housed were identified using records supplied by a local Oxford homeless charity. We found that in an increasingly wealthy, and healthy, city there were persistent ward-level inequalities in mortality, which the city-wide decrease in premature mortality over the period masked. Premature deaths among homeless people in Oxford became an increasingly important contributor to the overall geographical inequalities in health in this city. In the ward with the highest SMR, deaths among the homeless population accounted for 73% of all premature deaths of residents over the whole period; in 2014–2016 this proportion rose to 88%. Homelessness among men (the vast majority of the known homeless population) in this gentrifying English city rose to become the key explanation of geographical mortality patterns in deaths before age 65 across the entire city, particularly after 2011. Oxford reflects a broader pattern now found in many places across England of increasing homeless deaths, widening geographical inequalities in life expectancy, and sharp increases in all-age SMRs. The answer to the question, “Who dies young in a rich, and in fact an even richer, place?” is – increasingly – the homeless.