Health Inequalities- PH Research Unit

Jacqueline ClayRoss MaconachiePublic Health Research UnitWest Sussex County Counciljacqueline.clay@westsussex.gov.uk

Reducing health inequalities is a matter of fairness and social justice

Action is needed to tackle the social gradient in health –Proportionate universalism

Action on health inequalities requires action across all the social determinants of health

Reducing health - cost of inaction Beyond economic growth to well-being

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Marmot Review (2010) - Key themes

Marmot Update and Review Clear inequalities evident in children’s development, difficult to know if this is

worse because DfE keep changing the measures. – Improvement in early years provision, parenting support, reduction of child poverty – Stable measures of development to help track progress.

Nearly a quarter of households do not have enough money to live on and this has been increasing. More than half of those in poverty are in work. – Government to identify policy lead for ensuring sufficient incomes, with plan of action. – Employers to take responsibility for ensuring that work pays sufficiently.

Inequalities worse for men than women– More focus on men’s health needed

North/south divide– More investment in the north, focus on affordability in the south.

Unemployment higher than pre recession levels and five fold increase in JSA claimants on for longer than 12 months. – Action to support all members of society into good work.

Significant regional variation – Learn from variation - poorly performing local authorities to learn from local authorities

with similar deprivation levels who are doing better.– Local authorities to utilise evidence based practices, see evidence briefings IHE

authored for PHE.

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Determinants of Health

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Attributing Contribution- Kings Fund briefingA number of studies have attempted to estimate how the broader determinants of health impact on our health.

Main findings of research papers:

Inequalities in Service Access and Take Up

Source : London School of Economics and Political Science

Points of potential inequality

  Diagnosis RateCCG CCG Overall Highest Practice Lowest PracticeCoastal CCG 42% 100% 16%

Practice Name Locality

Care Home Adjusted Rank by CCG

ADUR MEDICAL GROUP Adur 1

TANGMERE MEDICAL CENTRE Chichester 2

HENFIELD MEDICAL CENTRE Chanctonbury 3

ARUN MEDICAL CENTRE Arun 4

VICTORIA ROAD PRACTICE Worthing 5

AVISFORD MEDICAL GROUP Regis 14

WESTCOURT SURGERY Arun 45

OLD SHOREHAM ROAD PRACTICE Adur 48

MILL STREAM MEDICAL CENTRE Chanctonbury 52

CROFT SURGERY Regis 53

LANGLEY HOUSE SURGERY Chichester 55

SELDEN MEDICAL CENTRE Worthing 56

Identification by services / e.g. dementia diagnosis rates

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Mental illness is 'as bad for life expectancy as smoking', experts warn

Nut eaters may have

a longer life

expectancy

Life expectancy gap between men and women

narrows to less than four years as Dorset is

revealed as the place to grow old.

Life expectancy a powerful measure of inequality

Life expectancy – inequalities of specific groups

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• Life expectancy is lower for men than women.

• Life expectancy is lower in lower income groups.

• Life expectancy is lower in some BME groups and certain vulnerable groups e.g. people with mental health problems, people with learning disabilities.

Measuring the social gradient

Index of Deprivation

Income (22.5%)

Employment(22.5%)

Health deprivation & disability (13.5%)Education, skills & training (13.5%)Barriers to housing & services (9.3%)Living environment (9.3%)

Crime (9.3%)

38 separate indicators • appropriate,robust and nationally available• direct measures, • able to be updated, • major features not just affecting very small

numbers

Arundel

Haywards Heath

Burgess Hill

Chichester

Selsey

Horsham

Crawley

Fernhurst

Petworth

Midhurst

Pulborough

Billingshurst

Shoreham

Worthing

LittlehamptonBognor

East Grinstead

Deprivation Rank(national ranking)

Most deprived 10%

Least deprived 10%

The social gradient – how are we measuring?

Deprivation Domain Bottom 10%

10% to 20%

Bottom 20% Total

IMD Overall 4 15 19

Income 2 12 14

Employment 6 12 18

Health and Disability 11 22 33

Education 12 22 34

Barriers to Housing and Servs 34 37 71

Crime 4 7 11

Living Environment 14 37 51

 Total LSOAs in Coastal CCG     301

Index of Multiple Deprivation

• Many LSOAs in Coastal CCG are in the bottom 10% and 20% nationally

Small area life expectancy – West Sussex

Despite Life expectancy having risen across the board in West Sussex, the gradient has increased.

This change statistically significant for men and all persons combined but not for women

Least deprived areasMost deprived areas

Life

exp

ecta

ncy

2001-03

2010-12

……People move, not all deprived people live in deprived areas, possible increased residualisation, also the knowledge of, access to, take-up and outcomes of services (progressive universalism)

Ward level life expectancy – West Sussex (2007-2012)

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Highest

LE (2007-

12) 95% CI Lowest LE (2007-12) 95% CI

Burgess Hill Dunstall 89.3 (84.3 - 94.4) Southgate 78.0 (76.9 - 79.1)

East Grinstead Imberhorne 87.5 (85.1 - 89.8) Central 76.7 (75.6 - 77.9)

Findon 87.4 (85.1 - 89.7) Heene 75.2 (73.9 - 76.5)

Pound Hill South and Worth 86.6 (84.4 - 88.9) Marine 74.5 (73 - 75.9)

Harting 86.6 (84.1 - 89.1) River 74.2 (72.8 - 75.6)

-% of students achieving 5+ GCSEs at C and above incl Maths and English (by IMD decile) – West Sussex 2008 and 2013 Source: EPAS

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Most deprived to least deprived areas

% of Pupils/Learner Places (by home postcode) by Ofsted Judgement on Quality of Teaching

Latest inspection data as of 31/03/2014. Relates to all schools.

Geographic Pattern of Long Term Health Conditions /Disability aligned to Deprivation

Standardised Rate (Per 100 Population)

Residents with a health condition or disability limiting day-to-day activities (a little or a lot)

Mental Health Admission Rate (per 100,000 population aged 17 years+)

Pooled Year Data 2010-2012

Mental Health Diagnosis – excluding organic mental

Not just single conditions, many people have multi-morbidities – Study of Scottish Patients

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• The prevalence of multi-morbidity increased (substantially) with age.

• For people living in the most deprived areas the onset of multi-morbidity occurred 10-15 years earlier than people living in the least deprived areas.

• Mental health was not only associated with physical illness but the presence of a mental health disorder increased as the number of physical morbidities increased.

Source: Epidemiology of multi-morbidity and implications for health care, research, and medical education: A cross-sectional study (Lancet 2012).

Behavioural risks – exposure in childhood Targeting groups and areas of higher smoking rates – including manual workers, young women, households of new born babies

Chichester

Areas with High Rates (30% or higher) of New Borns in Households with a Smoker (2012/13 Data) Source: West Sussex Public Health Research Unit

Broadfield

Bewbush

Bersted

Littlehampton Boundstone

Not just about direct SHS, children learn behaviours from their parents /families, - much more likely to becomes smokers themselves

Map shows areas of county where 1 in 3 new born babies lives in a household with a smoker.

SmokingBroadfield, Rural Horsham, West Sussex

23.8%

19.2%20.8%

41.5%

11.3%

7.5%

11.5%

22.0%

14.2%

10.3%

13.9%

24.6%

0%

10%

20%

30%

40%

50%

60%

% Smoking at theTime of BOOKING

% Smoking at theTime of DELIVERY

% Smoking at theTime of the 12-16

WEEK CHECK

% stating SMOKERIN THE

HOUSEHOLD

Broadfield Rural Horsham West Sussex

Four quarters of information have been included, Q3 and Q4 from 2010/11, and Q1 and Q2 2011/12

Co-occurrence of risk factors

• Study by Kings Fund analysed risk factors (smoking, harmful drinking, poor diet and low physical activity rate) Data from the 2003 and 2008 Health Survey for England.

• The percentage of adults engaged in three or all four of the behaviours had declined.

• However the rate of decline was less amongst the most deprived areas and amongst people with the lower level of education; and that this would act to increase inequalities in health outcomes. factors

Source: Buck, D. and Frosni, F (2012) Clustering of Unhealthy Behaviours Over Time: Implications for Policy and Practice

The Cost of Emergency Admissions

Data taken from SUS database 2012/13 (newer data not available)

Costs measured in PBR cost charged to CCGs

Deprivation measured as WSx deciles (tenths of our local population)

Social Gradient in Spend WSx CCGs spent £154m on emergency admissions in

2012/13 (£98m of this was Coastal)

Most De-

prived

Least Deprived

£0

£50

£100

£150

£200

£250

£300

f(x) = − 12.0528154711046 x + 258.537611173451R² = 0.82532965485458

Age standardised cost per head of popu-lation (2012/13)

Social Gradient in Spend Pattern similar in Coastal, gradient steeper Total costs would be £20m less per year if each decile had the

same age standardised cost per head as the least deprived (or £40m more if average as per most deprived!)

Most Deprived Least Deprived£0

£50

£100

£150

£200

£250

£300

f(x) = − 13.0111370841504 x + 271.329133401006R² = 0.766883504209054

Age standardised cost per head of population by deprivation decile

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Age standardised cost of emergency admissions per head by practice – CCG value £187

Practice Locality Av Cost

SELDEN MEDICAL CENTRE Cissbury £257

THE PHOENIX SURGERY Cissbury £158

BILLINGSHURST SURGERY Chanctonbury £178

THE GLEBE SURGERY Chanctonbury £131

FITZALAN MEDICAL GROUP Arun £218

THE COPPICE PRACTICE Arun £164

BOGNOR HEALTH CENTRE Regis £236

ARUNDEL SURGERY Regis £147

NEW POND ROW PRACTICE Adur £243

THE LYONS PRACTICE Adur £166

CATHEDRAL MEDICAL GROUP Chichester £217PULBORORUGH MEDICAL GROUP Chichester £157

Age standardised cost of emergency admissions per head by practice – CCG value £187

• Highest and lowest

Age standardised cost per registered patient of specific primary diagnoses

Most Deprived Least Deprived£0.00

£1.00

£2.00

£3.00

£4.00

£5.00

£6.00

£7.00

UNSPECIFIED ACUTE LOWER RESPIRATORY INFECTIONACUTE RENAL FAILUREOTHER CHRONIC OBSTRUCTIVE PULMONARY DISEASEPAIN IN THROAT AND CHESTDIARRHOEA AND GAS-TROENTERITIS OF PRESUMED INFECTIOUS ORIGIN

• There were 20 different primary diagnoses for which Coastal spent over £1m in 2012/13 – all had a correlation with deprivation, for example:-

Age standardised cost per registered patient of specific primary diagnoses

• Adding in Fracture of Femur to the previous graph• Total cost of Fracture of Femur – £5.5m (CWS, 2012/13)

Most Deprived Least Deprived£0.00

£2.00

£4.00

£6.00

£8.00

£10.00

£12.00

£14.00

£16.00

£18.00

UNSPECIFIED ACUTE LOWER RESPIRATORY INFECTIONACUTE RENAL FAILUREOTHER CHRONIC OBSTRUCTIVE PULMONARY DISEASEPAIN IN THROAT AND CHESTDIARRHOEA AND GAS-TROENTERITIS OF PRESUMED INFECTIOUS ORIGINFRACTURE OF FEMUR

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Wide range of resources to support work on inequalities

Marmot Reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewKings Fundhttp://www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health#messagesNICEhttp://www.nice.org.uk/advice/lgb4