Health Inequalities “preventing early death” · Health Inequalities Unit ... • Secondary...

Health Inequalities“preventing early death”

Chris Lovitt

Health Inequalities Unit

14h June 2007

Overview

Life expectancy

Early death

What we can do about it

What are we doing

Conclusion

Health Inequalities PSA Target:

By 2010 to reduce inequalities in health inequalities by 10% by 2010 as measured by infant mortality and life expectancy at birth.

This target is underpinned by two more detailedobjectives:

starting with children under one year, by 2010 to reduce by at least 10 per cent the gap in 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 in life expectancy between the fifth of areas with the “worst health and deprivation indicators”and the population as a whole

Life Expectancy at birth- Male

Inequality Gap*, in years

70

71

72

73

74

75

76

77

78

79

80

1993/4/5 1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9 2009/10/11

Age in years

Target:

10%minimum reduction in relative gap, from1995-97 baseline

baseline Progress target

2.57%

Male life expectancy at birthEngland 1993-2005 and target and projection for the year ‘2010’

3 year average

2.61%

2.32%

England

SpearheadGroup

Source: ONS data, analysed by DH analysts

TargetProjection of life expectancy for EnglandProjection of life expectancy for Spearhead GroupTarget Reduction

0

Actual Data

* The relative gap between life expectancy at birth in England and in the Spearhead Group. As a proportion of life expectancy for England.

77

78

79

80

81

82

83

1993/4/5 1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9 2009/10/11

Age in years

Target:

10%minimum reduction in relative gap, from1995-97 baseline

1.77%

Female life expectancy at birthEngland 1993-2005 and target and projection for the year ‘2010’

3 year average

1.91%

1.59%

England

SpearheadGroup

Projection of life expectancy for EnglandProjection of life expectancy for Spearhead GroupTarget Reduction

0

Inequality Gap*, in years

baseline Progress target

TargetActual Data

* The relative gap between life expectancy at birth in England and in the Spearhead Group. As a proportion of life expectancy for England.

Source: ONS data, analysed by DH analysts

Life Expectancy at birth- Female

So did this matter locally?Results of high level review

Lack of engagement with target

Unaware of local “gap”

Little knowledge of interventions thatwould deliver by 2010

Focus of local work on wider determinants

Discounting of target

?Saving a few years at the end of life?

Is there another way of looking at the target?Is there another way of looking at the target?

a more compelling story?a more compelling story?

13,700 13,700

early deaths in early deaths in

Spearhead areasSpearhead areas

D iffe re n c e in % d is tr ib u t io n o f m o r ta li ty b e tw e e n S p e a r h e a d G ro u p a n d E n g la n d in q u in a r y a g e b a n d s , 2 0 0 3 -0 5

-6 .0 %

-5 .0 %

-4 .0 %

-3 .0 %

-2 .0 %

-1 .0 %

0 .0 %

1 .0 %

2 .0 %

< 1

01-04

05-09

10-14

15 - 19

20 - 24

25 - 29

30 - 34

35 - 39

40 - 44

45 - 49

50 - 54

55 - 59

60 - 64

65 - 69

70 - 74

75 - 79

80 - 84

85+

F e m a le d if fe re n c e

M a le d if fe re n c e

There were approximately 13,700 additional deaths for 30 to 59 year olds in Spearhead groups, across the 3 years 2003-2005, compared to the national average for England

The focus needs to be on reducing adult early deaths

Action on the overall PSA target to reduce infant mortality will also help deliver the reduction in life expectancy gap target

Too many people in Spearhead areas are dying early

Know

Your

Gap

1) Know your gap- EnglandWhat is causing the gap for males?

The Gap – for males

35% All circulatory diseases, 70% of which are Coronary Heart Disease (CHD)

18% All cancers, 61% of which are lung cancer

15% Respiratory diseases, 53% of which are chronic obstructive airways disease

10% Digestive, 50% of which are chronic liver disease and cirrhosis5% External causes of injury and poisoning, 60% of which are suicide and undetermined death2% Infectious & parasitic diseases10% Other5% Deaths under 28 days

Contribution to Life Expectancy Gap in MalesBreakdown by disease, 2003

*locally determinedUniversalist:• Smoking reduction in clinics – as at

present• Secondary prevention of CVD:75%

coverage of 35-74yrs• Primary prevention of CVD in hyptensives

under 75 yrs:20% coverage antihypertensivestatin therapy

The Interventions The Impact – for malesTargeted:• Smoking cessation clinics: double

capacity in Spearhead areas for 2 years

• Secondary prevention of CVD: additional 15% coverage of effective therapies in Spearhead areas 35-74 yrs

• Primary prevention of CVD in hypertensives under 75yrs:

40% coverage antihypertensives

statin therapy

• Primary prevention of CVD in hypertensives 75yrs +:


statin therapy

• Other*, including:Early detection of cancerRespiratory diseasesAlcohol related diseasesInfant mortality

1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%

Further modelling of O

ther actions will

need to contribute the remaining 2.1%

11%
















statin therapy



statin therapy


1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%


ther actions will


11%
















statin therapy



statin therapy


1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%


ther actions will


11%

Universalist:• Smoking reduction in clinics – as at









statin therapy



statin therapy


1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%


ther actions will


11%










statin therapy



statin therapy


1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%


ther actions will


11%

8.9%


ther actions will


11%

And what can you do about it?
















statin therapy



statin therapy


1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%


ther actions will


11%
















statin therapy



statin therapy


1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%


ther actions will


11%
















statin therapy



statin therapy


1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%


ther actions will


11%










statin therapy



statin therapy


1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%


ther actions will


11%










statin therapy



statin therapy


1.0%

2.3%

1.0%

0.7%

1.2%

0.7%

2.1%

0.2%

1.4%0.2%0.2%

8.9%


ther actions will


11%

8.9%


ther actions will


11%

And for females ?

The Gap – for females





Contribution to Life Expectancy Gap in FemalesBreakdown by disease, 2003





The Interventions The Impact – for femalesTargeted:• Smoking cessation clinics: double





statin therapy



statin therapy


*locally determined

1.0%

1.4%

0.9%

0.5%

3.2%

1.6%

5.6%

0.4%1.0%0.2%0.2%

10.4%


ther actions will


16%

The Gap – for females





Contribution to Life Expectancy Gap in FemalesBreakdown by disease, 2003










statin therapy



statin therapy


*locally determined

1.0%

1.4%

0.9%

0.5%

3.2%

1.6%

5.6%

0.4%1.0%0.2%0.2%

10.4%


ther actions will


16%Universalist:• Smoking reduction in clinics – as at









statin therapy



statin therapy


*locally determined

1.0%

1.4%

0.9%

0.5%

3.2%

1.6%

5.6%

0.4%1.0%0.2%0.2%

10.4%


ther actions will


16%

10.4%


ther actions will


16%

So what can we do about this?

Understand cause of local gap

Model interventions

Plan & IMPLEMENT interventions

Know your local gap: Health Inequalities Intervention Tool (1)

Local Planning: Health Inequalities Intervention Tool (2)

Local Planning: Model what to do about it (3)

Summary

• Smoking, CVD prevention & cancer key

• Health services central to delivery

• Life expectancy 2010 is about preventing early death

•Achieve Balance

2010 2010 TargetTarget

Wider SocialWider SocialDeterminantsDeterminants

HealthHealthInequalitiesInequalities

Achieving BalanceAchieving Balance

Web addresses

Health Inequalities Intervention Toolwww.lho.org.uk/HEALTH_INEQUALITIES/Health_Inequalities_Tool.aspx

Commissioning framework for health &Well being

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_072604

Programme Budgetingnww.nchod.nhs.uk/

Health Equity Auditwww.dh.gov.uk/healthineqaulities

Health Poverty Indexwww.hpi.org.uk/

Contact:

Chris Lovitt

Health Inequalities Unit

[email protected]

020 7972 5109

National Planning and Alignment of Incentives Joint Local Planning

DH has aligned incentives for the NHS and LocalGovernment:

New line on All Age All Cause Mortality as proxy for life expectancy is now mandatory for Spearheads as part of the LAA and LDP processes

Same Local trajectories agreed in LAA and LDP, based on nationally provided indicative figures

LDP Refresh: strengthened inequalities elements of existing Blood Pressure, Cholesterol, Practice Based Registers and, in some Spearhead Areas, smoking cessation

Local Planning: Know your SpendingProgramme Budgeting – CVD Correlation

CVD Mortality

CVD Spend

Local Planning: Health Equity Audit

Review progress & assess impact

• Ensure effective monitoring systems are in place using indicators etc

Use data onHealth Inequalities

to support decisions at all levels:make appropriate comparisons by area,ethnicity, socio-economic group, gender,

age etc

Secure changes in investment

& service delivery

• Ensure changes in contracts & commissioning are reaching

areas & groups with highest need

• assess impact on inequalities

• Develop service delivery to match need

• Move resources to match need

5

6Agree partners and issues

• Relate issues to service planning & commissioning, take opportunities where changes are planned

• Identify factors driving low life expectancy• Take on views of front line staff and users

• Scope for joining up services with local government

1 • Choose issue(s) with highest impact eg cancer, CHD, primary care, over 50s, infant health

Agree priorities for actionIdentify highest impact interventions for effective local action, for example:• Diet & physical activity• Promoting healthy life styles

in over 50’s• Ensure choice,

responsiveness & equity forall

4

• Smoking prevalence • Screening• ‘flu vaccinations• accidents• Statins & antihypertensives

• Review progress

Agree high impact local action to narrow the gap

• Quality & quantity of primarycare in disadvantaged areas

• Commission new services, change oramend existing contracts• Develop LIFT projects where

health need is highest• holistic services through

partnerships

3

• Address inequalities through NSF implementation

•Use data to compare service provision with need, access, use & outcome • measures including proxies for

disadvantage, social class, ward in the bottom

quintile,BME, gender or other population group

• Focus on the third of population with

poorest health outcomes

2Equity profile: identify the gap

• Identify local areas or groups wheremore action is required

• Assess the impact of action, has change been made and is it fast enough?

Commissioning Framework for Health & Well Being

Launched March 2007; three month consultationKey development in system reform agendaFocus on promoting health and well-being, including prevention of ill-healthStronger focus on commissioning for outcomesto reduce inequalitiesEmphasises importance of strong partnershipsRecognises potential role of third sector

Duty of strategic needs assessment

Joint Strategic Needs Assessment

Key building block of the commissioning processWill be a duty of the local authority and the PCT (DPH, DASS, DCS)

LAA and local targets based on the SNAMust be focussed on outcomesMust be focussed on the future

3-5 years: improvements in outcomes/reductions in health inequalities5-15 years: for major infrastructure planning(transport, housing, healthcare facilities)1 year: contractual changes at frontline / PBC level

National Planning and Alignment of Incentives Joint Local Planning

DH has aligned incentives for the NHS and LocalGovernment:

New line on All Age All Cause Mortality as proxy for life expectancy is now mandatory for Spearheads as part of the LAA and LDP processes

Same Local trajectories agreed in LAA and LDP, based on nationally provided indicative figures

LDP Refresh: strengthened inequalities elements of existing Blood Pressure, Cholesterol, Practice Based Registers and, in some Spearhead Areas, smoking cessation

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