Reducing Inequalities in Primary

Care – Where are we?

Dr Bobbie JacobsonDirector

www.lho.org.uk

What will this presentation cover?

• What basics do we need?

• What are we trying to achieve?

• Which inequalities are we looking at?

•What action can we take?

Primary Care – what basics do we need?

• Spearhead PCT?• >30% ethnic minority population• Under-served by GPs• Under-served by non-medical primary care

staff• >10,000 residents not registered with a GP• High numbers of avoidable admissions

Primary Care – what basics do we need?

Primary Care Quality – Admission rates for Asthma and Diabetes

What are we trying to achieve? The life expectancy inequalities target

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 (England).

The areas covered by the target are known as the Spearhead Group.

The baseline is 1995-97.

The spearhead group of Local Authorities

• Those In the worst 20% for 3 or more of the following indicators:– Male life expectancy– Female life expectancy– Cancer mortality in under 75s– Cardiovascular disease mortality in under 75s– Multiple deprivation score

• Covers 70 Local Authorities in England

The spearhead group (London)

Which inequalites? Tower Hamlets Health Profile

Tower Hamlets Health Profile

GP practice profiles – Tower Hamlets

Diabetes

Practice PCT London Statistic

value value value

Diabetes prevalence (all ages) (QOF) 7.4 4.2 3.6 %Diabetes ratio of QOF to estimated prevalence 147.6 85.0 77.2 RatioBMI recorded in last 15 months (DM2) 97.8 94.1 94.5 %HbA1c 10 or less in last 15 months (% of register) 82.6 83.1 83.0 %HbA1c 7.5 or less in last 15 months (% register) 50.9 52.7 55.4 %BP 145/85 or less in last 15 months (% register) 96.9 74.3 72.0 %Chol 5 mmol/l or less last 15 mths (% of register) 79.5 76.4 71.1 %Peripheral pulses recorded in last 15 mths (DM9) 98.6 89.6 89.9 %Neuropathy tested in last 15 months (DM10) 98.6 89.1 89.5 %Micro-albuminuria tested in last 15 mths (DM13) 88.7 40.4 83.0 %Flu vaccine uptake (DM18) 89.3 88.8 88.8 %Retinal screening in last 15 months (DM21) 75.0 72.5 84.1 %eGFR or serum creatinine in last 15 mths (DM22) 95.9 95.6 94.8 %Exception rate for diabetes indicators 2.3 7.3 7.2 %

-5 -3 -2 -1 0 1 2 3 5Worse London Mean Better

Exception rate for COPD indicators

What action can we take? The Health Inequalities intervention

tool• Planning tool to help PCTs and LAs with

local delivery planning and commissioning to reduce inequalities in life expectancy

• Commissioned by Department of Health and produced by LHO and YHPHO for APHO

What does the tool do?• Quantifies the current life expectancy gap

at birth within local authority areas, and between spearhead local authorities and England

• Quantifies the diseases contributing to the life expectancy gap

• Models the effect of four high impact interventions on closing the life expectancy gap

Why use the tool?• There are inequalities in life expectancy within all local areas – spearhead and non-spearhead

• Examples of life expectancy gap between Most Deprived Quintile and Local Authority as a whole in London:– Bromley (non-spearhead) – 4 year difference, 5% gap

(males)– Lewisham (spearhead) – 3 year difference, 4.5% gap

(males)

Understanding the gap• Variations in the top four diseases which make up the within

LA gap across the country

• Key diseases making up the gap in males in two London LA’s (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 pulmonary disease)

8 Other CVD 9

Other CVD (cardiovascular disease)

7 Other cancers 8

TOTAL 45% 34%

If females in the most deprived quintile had the same mortality rate from stroke as females in the least deprived quintile, they would live 0.4 years longer

Applying evidence- based measures to show impact on the gap

• Interventions included:• Increasing smoking quitters• Improving blood pressure control in people without

diagnosed CVD• Improving blood cholesterol control in people without

diagnosed CVD• Reducing infant mortality

• Modelling of two scenarios:• Applying the interventions across the LA as a whole• Focusing the interventions in the MDQ(Most Deprived

Quintile)

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

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

2000 smoking quitters Smoking quitters + 2000hypertensives treated

Smoking quitters + 2000hypertensives treated + with

statin

1 intervention Combination of interventions

% r

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in li

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Some Questions• Clarity about which inequalities to address?

• Do local partners agree with me?

• What influence can my service/programme realistically have?

• Is there enough evidence to justify the directions taken?

• How can change be measured?

Want to know more?

www.lho.org.uk

• Local health profiles: www.healthprofiles.info

• Health inequalities intervention tool: http://www.lho.org.uk/HEALTH_INEQUALITIES/Health_Inequalities_Tool.aspx