Narrowing the Health Inequalities Gap: What went right and what went wrong

Assets for Health and Wellbeing across the Life Course26th September 2011

Tom Hennell Senior Public Health Analyst

Department of Health North WestThomas.hennell@dh.gsi.gov.uk

0776 803 04630161 625 7452

National objectives on reducing health inequalities

• In 2004, as part of the Public Service Agreement of the Department of Health, targets were agreed for locality improvement in public health to narrow the gap between populations with the worst health and the England average; compared to a baseline of 1995-1997

• Defined a fifth of England local authorities as ‘spearhead’ areas: 70 in all, with a total population of 14.3 million

• Selected on the basis of mortality 1995-1997 (all cause. Circulatory and Cancer) and multiple deprivation 2001.

• From 2007, the national inequalities targets were translated into tailored local target mortality improvements for each Local Strategic Partnership and PCT; disseminated through the mechanisms of ‘Local Area Agreements’ and ‘Vital Signs’.

The ‘Spearhead’ Areas

70 Spearhead Local Authorities

None in Southern England outside Inner London

Concentrated in metropolitan cities and the North

Tend to have a differentially younger population

Five specific objectives; by 2009-2011

• To reduce Health inequalities by 10%, as measured by life expectancy at birth in spearhead areas

– Separate objectives for males and females– Measured as reducing gaps relative to England three-year averages– Supplemented in 2007 with local target trajectories for absolute improvements in

all-age all-cause mortality for males and females

• To narrow the gap in mortality from circulatory diseases by at least 40%– Measured as the absolute gap between spearhead circulatory mortality under 75

and the England average

• To narrow the gap in mortality from cancer by at least 6%– Measured as the absolute gap between spearhead cancer mortality under 75

and the England average

• To narrow the gap in infant mortality by at least 10%– Measured as the relative gap between infant mortality in ‘routine and manual’

socio-economic groups and the England average

Life Expectancy Gaps for Spearhead populations in England1995-97 to 2008-10 (provisional)

-3.0%

-2.5%

-2.0%

-1.5%

-1.0%

-0.5%

0.0%

95-97 96-98 97-99 98-00 99-01 00-02 01-03 02-04 03-05 04-06 05-07 06-08 07-09 08-10

three years pooled data

Pe

rce

nta

ge

dif

fere

nc

e f

rom

En

gla

nd

av

era

ge

spearhead female

spearhead male

female target

male target

All age Standardised Mortality Ratios for Spearhead areas; annual rates 1995 to 2010; England = 100.

110

111

112

113

114

115

116

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Month by month mortality; North West SpearheadsCounts and Standardised Mortality Ratios

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

jan

febm

arapr

may

jun ju

laug se

poct

nov dec jan

febm

arapr

may

jun ju

laug se

poct

nov dec jan

febm

arapr

may

jun ju

laug se

poct

nov dec jan

febm

arapr

may

jun

2008 2009 2010 2011

mo

nth

ly p

rov

isio

na

l d

ea

ths

co

un

ts

(co

lum

ns

)

110

112

114

116

118

120

122

124

126

Sta

nd

ard

ise

d M

ort

ali

ty R

ati

o (

lin

es

):

En

gla

nd

= 1

00

75 plus

under 75

smr all

Linear (smrall)

'Spearhead' deaths as a % of England total: 2006 to July 2011month by month counts and 12 months smoothed - ONS provisional death registrations

26.0%

26.5%

27.0%

27.5%

28.0%

28.5%

29.0%

29.5%

30.0%

Dec

-06

Feb-

07A

pr-0

7Ju

n-07

Aug

-07

Oct

-07

Dec

-07

Feb-

08A

pr-0

8Ju

n-08

Aug

-08

Oct

-08

Dec

-08

Feb-

09A

pr-0

9Ju

n-09

Aug

-09

Oct

-09

Dec

-09

Feb-

10A

pr-1

0Ju

n-10

Aug

-10

Oct

-10

Dec

-10

Feb-

11A

pr-1

1Ju

n-11

% o

f E

ng

lan

d d

ea

ths

month by month

12 month smoothed

population proportion

Good news and Bad news• Bad news:

– With only a year to go, spearhead life expectancy gaps are still wider than they were in the baseline year, marginally for males, substantially for females

• Good news– Since 2008, life expectancy and mortality in spearheads has been improving

faster than the national average; a rate of improvement confirmed as being maintained or increasing in the most recent published provisional data (July 2011).

– Whatever interventions spearhead areas have been applying to reduce inequalities in public health over the last four years; they should keep them up, because they’re working. This appears to apply especially for interventions to reduce excess winter deaths.

• Bad news– Even the most recent rate of improvement, if maintained, won’t narrow life

expectancy gaps enough to meet the targets until 2010-12 (male) and 2012-14 (female); one to three years late.

Circulatory <75 standardised mortality: Spearhead Gapschange in absolute gap between annual mortality rates for spearhead areas and the England

average

-60%

-50%

-40%

-30%

-20%

-10%

0%

10%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

ann

ual

cir

cula

tory

mo

rtal

ity

gap

co

mp

ared

to

th

at f

or

the

bas

elin

e ye

ars

1995

-97

persons

male

female

target reduction

Cancer <75 standardised mortality: Spearhead Gapschange in absolute gap between annual mortality rates for spearhead areas and the England average

-30%

-25%

-20%

-15%

-10%

-5%

0%

5%

10%

15%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

an

nu

al c

irc

ula

tory

mo

rta

lity

ga

p c

om

pa

red

to

th

at

for

the

ba

se

line

ye

ars

19

95

-97

persons

male

female

target reduction

Infant Mortality: Spearhead gapschange in relative gap between three year speahead mortality rates and the England average

-20%

-10%

0%

10%

20%

30%

40%

95-97 96-98 97-99 98-00 99-01 00-02 01-03 02-04 03-05 04-06 05-07 06-08 07-09 08-10

three years pooled

pe

rce

nta

ge

dif

fere

nc

e f

rom

th

e E

ng

lan

d

av

era

ge

, co

mp

are

d t

o t

ha

t in

19

95

-97 infant mortality gap

target reduction

Good news and Bad news

• Good news:– The two cause-specific objective targets for 2010 were achieved

in spearheads in areas in 2009

• Bad news:– Improvement in the female cancer mortality gap is badly lagging

that for the male cancer mortality gap

– Relative infant mortality gaps remain greater than was the case in 1995-97, in spite of having improved in the past seven years.

– Why are we lagging behind the overall target, when we are running ahead of the cause specific targets, and when the specific causes represented, in 1995-1997, constituted nearly 70% of the <75 gap?

Components of the <75 gap by broad category of deathstandardised mortality gaps for spearhead areas compared to each year's England <75 mortality

0%

5%

10%

15%

20%

25%

30%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

ca

us

e o

f d

ea

th g

ap

s r

ela

tiv

e t

o E

ng

lan

d a

ve

rag

e <

75

mo

rta

lity

in

ye

ar

other

digestive

cancer

circulatory

Components of the male <75 gap by detailed cause of deathcause specific standardised mortality gap as percentage of total England <75 mortality

-1% 0% 1% 2% 3% 4% 5% 6% 7% 8%

infant mortality

coronary heart disease

stroke

other circulatory

lung cancer

mouth cancer

colorectal cancer

prostate cancer

other cancer

copd

other chest diseases

diabetes

digestive (incl. cirrhosis)

self harm

violence

accidental overdose

other accidents

other causes

1995

2010

Components of the female <75 gap by detailed cause of deathcause specific standardised mortality gap as percentage of total England <75 mortality

-1% 0% 1% 2% 3% 4% 5% 6% 7% 8%

infant mortality

coronary heart disease

stroke

other circulatory

lung cancer

mouth cancer

colorectal cancer

breast cancer

other cancer

copd

other chest diseases

diabetes

digestive (incl. cirrhosis)

self harm

violence

accidental overdose

other accidents

other causes

1995

2010

Detailed breakdown analysed• Comparing 1995 with 2010, both male and female <75 mortality rates show:

– a substantial narrowing due to improved survival in coronary heart disease.– a widening gap due to ‘other causes’ (to which the major identified contributor is early dementia), and ‘other cancers’ (to which the

major identified contributors are digestive cancers and leukaemia).– a widening gap due to digestive causes (to which the major contributor is cirrhosis of the liver).

• Infant Mortality gaps in 2008-10 remain greater than at the baseline 1995-97, although considerably reduced from their peak in 2001-03. Progress shows strong geographic variation, with persistent gaps in areas with high indicators of maternal isolation, and in areas with high proportions of mothers in particular ethnic groups British Pakistani, British Black Caribbean)

• Male mortality rates otherwise show a narrowing of mortality gaps in proportion to the overall reduction of <75 mortality.

• Female <75 mortality rates otherwise show a widening gap due to lung cancer and chronic chest diseases.

• Both increased <75 mortality rates due to digestive causes, and increased mortality due to digestive cancers, can be substantially attributed to alcohol-related harm.

• Increased <75 mortality rates due to early dementia are known substantially to be an artefact of the change in coding rules on the introduction of ICV10 in 2001. However, a minority component of the change is also likely to be alcohol-related.

• If it were not for alcohol-related deaths, the objective to narrow overall spearhead life expectancy gaps would almost certainly have been achieved for males; and would be well on the way to being achieved for females.

‘Spearhead’ and ‘Non-spearhead’ Government Office Regions

(for a cross-referencing with Health Survey for England)

• ‘Spearhead regions’ – North West and North East– Around 70% of population in spearhead districts

• ‘Non-spearhead regions’ – East, South East, South West– No population in spearhead districts

Non-spearhead and Spearhead regions - 1995 to 2010Standardised Mortality from Digestive Causes; under 75Binge drinking 1998 & 2008: Health Survey for England

0

5

10

15

20

25

30

35

40

Male non spearhead regions Male spearhead regions Female non spearhead regions Female spearhead regions

sta

nd

ard

ise

d <

75

mo

rta

lilt

y f

rom

dig

es

tiv

e c

au

se

s p

er

10

0,0

00 Male Binge Drinking aged 16-74, 1998 and 2008

More than 8 units in one day: Health Survey for England

0%

5%

10%

15%

20%

25%

30%

35%

40%

male non spearhead regions male spearhead regions

Female Binge Drinking aged 16-74, 1998 and 2008More than 6 units in one day: Health Survey for England

0%

5%

10%

15%

20%

25%

30%

35%

female non spearhead regions female spearhead regions

The conundrum of alcohol-related harm

• Between 1995 and 2008, the major components of the increased gap between spearhead and non spearhead mortality, appear to have been alcohol-related. Alcohol-related gaps appear, however, to have narrowed slightly since.

• But – from population surveys between 1998 and 2008, spearhead and non-spearhead populations have experienced very similar rates of increase in average alcohol consumption and in binge drinking (on revised quantifications of wine consumption). Surveys of drinking tend to show similar (and dramatic) consumption increases in all income groups except the very poorest.

• Ongoing clinical studies appear to find that the experience of alcohol harm in the two ‘worst’ deprivation quintiles has been radically different from that in the three ‘better’ deprivation quintiles; there has been relatively less increase in alcohol-related mortality over the past 15 years in more affluent populations, in spite of their experiencing a big increase in hazardous drinking.There has been substantial increase in mortality in the two most deprived quintiles.

• The major components of the mortality increases are in alcoholic liver disease in early middle age (45-64); and also in digestive cancers and alcohol-related dementia in late middle age (60-74):

– Killing yourself from alcoholic liver disease in middle age is hard; it takes a lot of drink over a prolonged period, long after the experience of drinking becomes overwhelmingly unpleasant, for the drinker and for anyone who knows them.

– Recovery from alcoholic liver disease can be easy and quick; stop drinking dangerously, and if you survive the following months, your risk of liver mortality will drop towards the population average in less than two years.

– So what is stopping people from stopping; and why has success in stopping become relatively more difficult in more deprived populations in recent years?

‘getting ill less’ versus ‘getting ill better’

• The ‘spearhead’ programme to reduce health inequalities in England is now, belatedly, showing clear evidence of achieving its objectives. There are indications of widespread success in:

– Reducing locality excess winter death rates,– Reducing mortality gaps in male and female coronary heart disease,– Reducing mortality gaps in other male smoking-related conditions – cancers, chest diseases.

• The context for these achievements, since 2007, is that of open and shared commitments by Local Strategic Partnerships to adopt locality-wide and cross-sectoral actions aimed at reducing incidence, through tackling differential exposure to avoidable health risks.

• This is the conventional Prevention agenda for ‘getting ill less’.

• There has been less success in responding to increased health inequalities in alcohol-related harm; relatively insignificant in the baseline period, but now in many localities, the major component of their mortality gap.

• We find that areas with increased alcohol-related mortality do tend to also to have experienced increased patterns of harmful drinking; nevertheless alcohol-related mortality in other areas with equally increased exposure to harmful drinking has increased much less, if at all. This suggests:

– That differential alcohol-related local mortality is not so much about differential incidence, as about differential recovery,

– That to tackle inequalities in alcohol-related mortality, localities need to tackle differential access to recovery assets

• This corresponds to the Asset agenda for ‘getting ill better’

Getting Ill better: the Asset approach

• Differential access to assets is most patent in statistics for alcohol-related mortality; but we can also find and quantify it within health survey data in respect of:

– Differential access to disease management for diabetes,– Differential access to disease management for hypertension,– Differential access to recovery from musculo-skeletal conditions.

• Differential access to personal, social and reciprocal assets is significantly associated with:– The under-construction of illness; persons with poor access to assets for wellbeing tend to be recognised as

ill later, to access services less appropriately, to have higher levels of unmet health needs and to die sooner,

– The under-construction of recovery; persons with poor access to assets for wellbeing – once recognised as ill – tend to stay ill longer, to recover less completely, and to consume higher levels of health resources

• Clinical Approach to ‘Getting Ill’– Become ill when you are diagnosed as having a pathological condition by a doctor or health professional,– When the doctor or specialist has finished with you, your are ‘discharged’, long-term illnesses do not have a

limited duration, so long as the underlying pathological condition (e.g. diabetes, cancer) persists,– Clinician seeks to discharge patient, so far as possible, the way they were,– ‘Recovery’ is only recognised in relation to addicts and alcoholics.

• Asset Approach to ‘Getting Ill’– Become ill when you are recognised, and can recognise yourself, as ill within your social context; you are

then ‘constructed as ill’ allowing you access to illness resources and assets,– Recover from illness when you are able to function within your social environment of choice;

long term illnesses can have a duration; indicated as experiencing condition as non-limiting,– Full recovery is associated with control; having access to a state in which the condition will not recur, – Recovery is normal and real; and is a contagious condition (as is non-recovery)

increased reduced RISKS

AS

SE

TS

redu

cded

incr

ease

dBody mass overweightAdult social drinking at hazardous levelsTeenagers making their own way to schoolTeenagers cycling and walkingTeenage recreation away from homeLight adult recreational participationAdults attempting to quit smokingHigh adult time commitment to home lifeGoing out at night

Body mass obese or underweightAdult drinking at harmful levelsAny under-age alcohol consumptionCigarette smoke, active and passiveSedentary lifestyleNot joining local organisations & groupsLow recreational participationSub-standard housing or neighbourhoodWorklessness in adults of working ageLiving alone

Adults abstaining from alcoholTeenagers taken to school by parentsTeenage use of parents’ car transportTeenage recreation at homeAdult mistrust of teenagers ‘hanging around’Parents’ mistrust of non-household adultsHigh adult time commitment to workStaying in at night

Body mass normal weightAdult social drinking at moderate levelsTeenagers abstaining from alcoholNon-smoking – adults & teenagersHigh recreational participationJoining local groups (esp. sports & religious)Social contact and trust with neighboursAdult satisfaction with work/life balanceContinuing participation in educationSatisfaction with long-term relationships

Assets and Risks