Tackling Health Inequalities in England

Congrès national des Observatoires régionaux de la santé 2008 - Les inégalités de santé Marseille, 16-17 octobre 2008 Tackling Health Inequalities in England Dr Bobbie Jacobson, Director London Health Observatory, Vice chair APHO Professor John Wilkinson, Director, North East Public Health Observatory. Thank you for inviting us to join your congress. We feel honoured to take part in this vital debate. We hope that our limited French will make it possible to follow our arguments and want to thank Bernard Ledesert for his help in making sure our translation makes sense. Public health observatories in England have learnt a great deal from the experience of health observatories in France. I am aware that John came to your previous conference in Clermont-Ferrand three years ago. We think it s time to try our best in French although we suspect that many of you will speak better english than we do French! 1

What this presentation will cover Introduction to the health system England and the UK/Ireland Association of Public Health Observatories (APHO) National priorities/policies for tackling health inequalities Tools for tackling health inequalities some English examples Conclusions and Issues raised In this presentation. John and I are going to cover the following areas. We will give a brief introduction to the UK and Ireland Association of public health observatories. We will say a little bit about the national priorities and policies of tackling health inequalities. We will then give some examples of tools that have been developed by the observatory network. We will then conclude and open for discussion. 2

Observatory Network and Lead Areas NE lead areas: Mental health Prison health Europe & International LHO lead areas: Health inequalities Ethnicity Smoking NICE There are a total of 12 observatories in the Association of public health observatories of UK and Ireland. These comprise of nine observatories covering the regions of England won in Scotland, one in Wales, and one Observatory covering both North and South Ireland. It is worth commenting on the Irish Observatory as this is one of many organisations which cover both North and South of Ireland and of course the North and the South of Ireland are in fact, different countries. The Observatories cover populations of between 2.5 and 9 million people. The population of England, is just over 50 million population of Scotland is 5 million population of Wales 2 million population of Ireland in the North is 1 million and in the South is formally?. This gives you some idea of the overall scale of population covered by the observatories. Connecting the observatories together, we have established the Association of public health observatories. The Association of public health observatories is essentially a learning network for the observatories. We have a small office, which is based in York of three people. Each Observatory has a number of lead areas. For example the North East Observatory has three lead areas. These are mental health, prison health Europe and international. Similarly, London, has three areas health inequalities, ethnicity and tobacco. In addition, each Observatory has a link to a key organisation. Thus, for example, London is linked to NICE- the National Institute of Health and Clinical Excellence. This is the body, which is responsible for assessing the evidence of both clinical and public health interventions. It then issues guidance to the national health service about the appropriateness or otherwise of such interventions. 3

The Observatory Network What do we do? We work in partnership to turn data into health intelligence to support decision-making on health and health care nationally and in our regions We monitor, forecast and assess the impacts of health policy in our regions We are a network of regional hubs connected nationally for signposting health intelligence and developing innovative methods for sharing that knowledge. We work with APHO, researchers and the Department of Health to produce national e-tools, reports and advice to support local action We help build analytic /public health capacity in our regional workforces In this slide. I have set out the roles of the Observatory network. Partnership working is very important for the observatories. Partnership working both between our observatories, and also with local organisations is a vital element of our work. These include the local national health service, local authorities, voluntary groups and others. Our role is to turn raw data, often collected for other purposes into health intelligence which supports policy makers. We monitor, forecast and assess the impact of health policy in our regions. Although we are funded by the Department of Health, mainly we are also encouraged to be independent and to make independent commentary on local health policy. Clearly this needs to be undertaken with a degree of sensitivity. We also act as the hub for intelligence across each of our regions. This involves signposting evidence and health intelligence and developing innovative methods sharing that knowledge across many bodies. We also work both with colleagues in other observatories as well as University departments and the Department of Health to produce resources, tools and and advice to support local action. We also have a key role in building local intelligence capacity in each of our countries and regions. 4

The English Health and Health Care System NATIONAL Government Departments NHS Government Office Regional Bodies REGIONAL Public Health Director/Team Public Health Observatory Commissioning arrangements Third Sector LOCAL NHS Trusts Director of Public Health Primary Care Trusts Local Authorities Police Education Communities In this next slide we have tried to demonstrate the way in which the English health care system works. Since devolution, the health care systems of the four countries, which comprise the United Kingdom have diverged as for example in England. There is a model of health care delivery, which is based on a purchaser provider split. This is not the case in the other parts of the United Kingdom, with the exception North of Ireland, as for example in England. The money for health care and health improvement. It is shared between the primary care trusts of which there are hundred 50 these primary care trusts are responsible for assessing the health needs of the population and commissioning of purchasing health care for their respective population. They are also responsible for providing primary care in their areas. The policy control of health rests with the Department of Health in London (for England). There are nine government office regions in England. These are representatives of central government in the region s. They are not democratically elected. In London there is an added dimension of a directly elected mayor who has a duty to produce a health inequalities strategy. As well as the 9 government office regions -which is where the regional director of public health is based- there are also 10 strategic health authorities. These are responsible for the running and monitoring of the national health service. 5

Which inequalities? Spectrum of inequality GENDER GEOGRAPHY SEXUALITY DISABILITY SOCIO-ECONOMIC AGE GROUP DISABILITY AGE ETHNICITY Social-economic environment e.g. jobs, housing, education, transport Lifestyles/health behaviour e.g. diets, smoking, social networks Access to effective health/social care e.g. services that result in health benefits Health outcomes e.g. increase/reduce mortality, morbidity, ill health, disability 7 Of course when we talk about inequalities. There is a vast range of inequalities that we could consider as this conference will be well aware. There are differences in most populations by gender, geography sexualities socioeconomic group disability, age and ethnicity. These of course all interact with the environment, with lifestyles and access to effective health and social care to produce a level of health outcome, which often varies considerably. 6

English Health Inequalities Policy 1997 Current Labour Government elected 1998 Independent inquiry into inequalities in health (Acheson Report) 2001: First cross government target set to reduce Inequalities in Life expectancy at birth 1999 Saving lives: our healthier nation 2002 Government s cross cutting review on tackling health inequalities 2003 Tackling health inequalities: a programme for action 2003 Securing our future health: taking a long-term view 2004 Securing good health for the whole population 2005 Choosing health: making healthy choices easier 2006 Our Health, Our care, Our say 2006 Promoting prosperous communities 2006 NHS Operating Framework identifies health inequalities as one of 6 priorities 2007 Commissioning Framework for Health and Wellbeing 2007 Joint Health and social care Performance framework 2008 Tackling Health in Equalities :Progress and Next Steps There have been many policy initiatives on health inequalities in recent years. The most important in recent history was when the Labour government commissioned Sir Douglas Black in the 1980s to produce his now famous Black report, which was one of the first reports to describe the scale and nature of the inequalities in England. His report was published after the Labour government was defeated by the Conservatives. During its period in government the use of the word inequalities was not permitted under the conservatives who preferred instead, to refer to variations in health. This prevented any progress on inequalities for many years. The slide shows that since the election of the current Labour government there has been a sustained commitment to address inequalities. The slide highlights the importance of the recent independent enquiry into health inequalities, chaired by Sir Donald Acheson and commissioned by the health minister. This report was the foundation for much of the Labour government s policies in the late 1990s and beyond. Of the many initiatives that have followed, probably the most influential has been the agreement of a national, quantifiable target to reduce health inequalities that for which all government departments are accountable. 7

Current national health inequalities targets Starting with children under one year, by 2010 to reduce by at least 10% the gap in infant mortality between routine and manual groups and the population as a whole. Starting with local authorities, by 2010 to reduce by at least 10% the gap between the fifth of areas with the lowest life expectancy at birth (spearhead PCTs) and the population as a whole. The new targets for reducing health inequalities were announced by the secretary of state in February 2001. These are shown on the slide. The first one relates to children under one year and the target is to reduce by at least 10%. The gap in infant mortality between routine and manual groups and the population as a whole by the year 2010. The second target is, starting with local authorities by 2010 to reduced by at least 10% the gap between the fifth of areas with the lowest life expectancy at birth, and the population as a whole. There are 70 local authorities in the fith of areas defined as having the lowest life expectancy and highest deprivation. They are called the Spearhead authorities. The targets are as follows:... Routine and manual groups are derived from the National Stats Socio-economic classification our national classification of social groups. Routine and manual are the most deprived groups those in routine and manual occupations such as labourers, cleaners etc Allocated to infants on the basis of the fathers occupation. Measured by the relative gap. Second target spearhead areas 8

APHO tools to support tackling Inequalities National Library for Public Health Community Health Profiles Health Inequalities Intervention tool Local Basket of Inequalities Indicators GP Practice Profiles We are now going to talk about three examples of tools to support inequalities. I am now going to hand over to my colleague John Wilkinson to talk about the national library for public health. The National library for public house is based in the North East public health Observatory. We will then say something about the health profiles which have been published for every local authority in England. Over 350, and I will then say something about the health inequalities intervention tool, which is all also been developed by the London health Observatory. For surely, there will not be time to mention of of tools which have been developed, such as the local basket indicators and GP practice profiles which we have been developing in the London health Observatory 9

The National Library for Public Health 10

Overview What is the National Library for Public Health (NLPH)? The Public Health Language National Knowledge Weeks & Annual Evidence Updates Future knowledge weeks & updates The National library for public health is of the 28 th specialist libraries have the national library for health. It is an electronic resource, which aims to support those working in public health and local authorities on an agenda to improve health. The library aims to present in a very and accessible formats. The main evidence of policy documents relating to any one particular policy area. It does not aim to replicate the work of Cochrane library as you know. It was set out to produce systematic reviews, although systematic reviews are of course contained within the library. So far the national library has assembled a material in nine key areas. And if you look on our website. You will see 11

National Library for Public Health Single source for evidence for public health workforce Evidence-based resources from around the world, UK policy and guidance, news & events, etc. On the slide, you can see a clip from the homepage of the national library. It covers such areas as mental-health sexual health and health inequalities. It is aimed to be a single source of evidence will public health workforce and is an evidence base resource from material around the world. UK policy. It also includes information on local events and news. The public health library was only launched in April of this year but already has been a very big success. Each topic in the library porvides a link to the relevant lead PHO. In the case of health inequalities it would be the LHO, and for mental health it would be NEPHO. 12

Community Health Profiles APHO produces an annual health profile for each local authority area in England The profiles are viewed via an interactive web tool Commissioned by the English Department of Health 32 indicators on: health determinants, young people and adult lifestyles, disease and health outcomes (31 indicators), inequalities and trends The PHOs work together to produce a set of 32 comparable indicators of health and disease annually. This work is funded by the national Information and Intelligence strategy for England. All profiles can be selected and accessed via an interactive website. We have brought a few hard copies to show you what they look like. All indicators are benchmarked by a system of carefully defined traffic lights to demonstrate the range of comparative performance. They are widely used by the local NHS, local authorities and seen as an authoratative source of information by the media. 13

Health Profiles: Tower Hamlets This is an example of one local health profile for Tower Hamlets, London whose population is very deprived, with a predominantly Bangladeshi community. The small areas or wards within the local authority are divided into quintiles/fifths of deprivation as measured by a standard England composite score that is used across government., It is known as The Index of Multiple Deprivation. The two maps illustrate how the pattern of relative inequality is different depending on the comparators used. The left hand map compares Tower Hamlets small areas with England and the right hand map compares the same areas and the local authority as a whole. 14

APHO Health Inequalities intervention tool Planning tool to help local partnerships with local delivery planning to reduce inequalities in life expectancy Commissioned by the Department of Health and produced by LHO and partner observatories The starting point for the APHO inequalities tool is the national target for reducing relative inequalities in life expectancy at birth. Every local Primary Care Trust (PCT) has to demonstrate how much it intends reducing this gap as part of its annual planning process. This is part of the English performance management process. APHO has developed an easy to use tool which helps local NHS and partners to understand the size and causes of their inequality gap and to plan evidence-based investments to reduce. 15

What does the tool do? It Quantifies the current life expectancy gap at birth within local authority areas, and between spearhead local authorities and England It Quantifies the diseases contributing to the life expectancy gap It Models the effect of four high impact interventions on closing the life expectancy gap This is the first tool of its kind that attempts not only to calculate causes of the life expectancy gap, but also to model the impact of four key primary care based interventions based on their evidence of cost-effectiveness. 16

Understanding the gap Variations in the top four diseases which make up the within authority gap across the country Key diseases making up the gap in males in two London authorities (Most Deprived Quintile compared to Least Deprived Quintile): Bromley (non-spearhead) % Gap Lewisham (spearhead) % Gap CHD (coronary heart disease) 19 CHD 8 Lung cancer 11 Stroke 9 COPD (chronic obstructive 8 Other CVD 9 pulmonary disease) Other CVD (cardiovascular 7 Other cancers 8 disease) TOTAL 45% 34% This slide provides a comparison of the most deprived and least deprived quintiles/fifths in two local authorities It shows the top four diseases making up the life expectancy gap in each area. It provides an example of how the tool can help local partnerships to distinguish which diseases are the most important to tackle to reduce the gap. Bromley is a predominantly white, more affluent area and Lewisham is a more deprived community with a significant African-Caribbean population. Lewisham is one of the 70 Spearhead authorities in the bottom quintile/fifth of communities in England. Stroke in Lewisham not surprisingly, is a more important cause of the inequality gap than in Bromley. This analysis is designed to help local authorities to prioritise their preventive strategies. 17

Applying evidence- based measures to show impact on the gap Interventions included: Increasing smoking quitters Improving blood pressure control in people without diagnosed cardiovascular disease (CVD) Improving blood cholesterol control in people without diagnosed CVD Reducing infant mortality Modelling of two scenarios: Applying the interventions across the authority as a whole Focusing the interventions in the MDQ(Most Deprived Quintile) The tool gives the user a lot of choice both in which level of geographical inequality to choose for comparison, as well as which interventions to select and what level of intervention.. 18

Applying the interventions in the Most Deprived Quintile (MDQ) Chart shows the reduction in the within area life expectancy gap in males in Lewisham if the following interventions are applied 3.00% % reduction in life expectancy gap 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% 2000 smoking quitters Smoking quitters + 2000 hypertensives treated 1 intervention Combination of interventions Smoking quitters + 2000 hypertensives treated + with statin This slide gives an example from one local authority of the potential impact of the modelled interventions in the tool. In this example we assume that the user has chosen to reduce inequalities in life expectancy between the most deprived quintile in their local area and the local authority as a whole. It shows that the impact of increasing the number of smoking quitters on its own is small, but if the other interventions are also added- the impact on reducing the life expectancy gap is bigger. It also illustrates that local interventions have a small effect overall. This reinforces our understanding of remaining central importance of government s central role in tackling the determinants of health. 19

North East Case Study An example of improvement As in most parts of the developed world, coronary heart disease is a major health problem in the north east of England. Over the past few years there has been considerable action taken in the region to reduce this burden. There has been major action in terms of primary prevention (such as efforts to reduce smoking, secondary prevention (the prescrbing of statins to at risk patients) and tertiary prevention such as a move to introduce emergency revascularisations for acute myocardial infarctions. 20

Mortality from Coronary Heart Disease in the North East of England by Quintiles of Deprivation, Direct age-standardised rates (DSRs), 2003-2007 200 Mortality Direct age-standardised Rates per 100th 180 160 140 120 100 80 60 40 20 03/04 CHD Death Rate 05/06 CHD Death Rate 0 1st Q. 2nd Q. 3rd Q. 4th Q. 5th Q. Index of Multiple Deprivation 2007 quintiles (1: least deprived; 5: most deprived) Source: Revascularisation surgery in the North East of England, Occasional Paper, NEPHO, October 2008 21

Revascularisations in the North East of England by Quintiles of Deprivation, Direct age-standardised rates (DSRs), 2003-2007 Revascularisation Direct age-standardised Rates per 100th 200 180 160 140 120 100 80 60 40 20 0 03/04 Revascularisation Rate 05/06 Revascularisation Rate 06/07 Revascularisation Rate 1st Q. 2nd Q. 3rd Q. 4th Q. 5th Q. Index of Multiple Deprivation 2007 quintiles (1: least deprived; 5: most deprived) Source: Revascularisation surgery in the North East of England, Occasional Paper, NEPHO, October 2008 22

Conclusions and discussion The commitment of our governments has made tackling inequalities mandatory for local agencies The need to provide local measures and evidence of action has made it possible for the PHOs to combine their skills to produce some widely valued tools The nationally defined health inequalities targets are helpful but difficult to measure and monitor at small area levels and force us to plan in the short term only The evidence base to support modelling is limited to the health care sector The limitations on routine data restrict the current extension of the tool to other interventions There is commitment from this government to set a new long term target after 2010 but uncertainty about the future direction in the this policy area if there is a change of government 23

Further information? www.apho.org.uk www.nepho.org.uk www.lho.org.uk www.library.nhs.uk/publichealth 24