Health Inequalities - PH Research Unit

1. Health Inequalities - PH Research Unit Jacqueline Clay Ross Maconachie Public Health Research Unit West Sussex County Council jacqueline.clay@westsussex.gov.uk

2. Marmot Review (2010) - Key themes • 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

3. 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.

4. Determinants of Health

5. Attributing Contribution- Kings Fund briefing A number of studies have attempted to estimate how the broader determinants of health impact on our health. Main findings of research papers:

6. Inequalities in Service Access and Take Up Points of potential inequality Source : London School of Economics and Political Science

7. Identification by services / e.g. dementia diagnosis rates

8. Life expectancy a powerful measure of inequality Life expectancy gap between men and women narrows to less than four years as Dorset is revealed as the place to grow old. Mental illness is 'as bad for life expectancy as smoking', experts warn Nut eaters may have a longer life expectancy

9. Life expectancy – inequalities of specific groups • 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.

10. 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%) Measuring the social gradient Index of Deprivation • 38 separate indicators • appropriate,robust and nationally available • direct measures, • able to be updated, • major features not just affecting very small numbers

11. The social gradient – how are we measuring?

12. Index of Multiple Deprivation • Many LSOAs in Coastal CCG are in the bottom 10% and 20% nationally

14. 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 2010-12 2001-03 Life expectancy ……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) Most deprived areas Least deprived areas

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

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

17. % 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.

18. Geographic Pattern of Long Term Health Conditions /Disability aligned to Deprivation Residents with a health condition or disability limiting day-to-day activities (a little or a lot) Standardised Rate (Per 100 Population)

19. Mental Health Admission Rate (per 100,000 population aged 17 years+) Pooled Year Data 2010-2012 Mental Health Diagnosis – excluding organic mental

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

21. Behavioural risks – exposure in childhood Targeting groups and areas of higher smoking rates – including manual workers, young women, households of new born babies Map shows areas of county where 1 in 3 new born babies lives in a household with a smoker. Not just about direct SHS, children learn behaviours from their parents /families, - much more likely to becomes smokers themselves

22. Smoking Broadfield, Rural Horsham, West Sussex Four quarters of information have been included, Q3 and Q4 from 2010/11, and Q1 and Q2 2011/12

23. 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

24. 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 WSxdeciles (tenths of our local population)

25. Social Gradient in Spend • WSx CCGs spent £154m on emergency admissions in 2012/13 (£98m of this was Coastal)

26. 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!)

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

28. Age standardised cost of emergency admissions per head by practice – CCG value £187 • Highest and lowest

29. Age standardised cost per registered patient of specific primary diagnoses • There were 20 different primary diagnoses for which Coastal spent over £1m in 2012/13 – all had a correlation with deprivation, for example:-

30. 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)

31. Wide range of resources to support work on inequalities Marmot Review http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review Kings Fund http://www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health#messages NICE http://www.nice.org.uk/advice/lgb4