Transcript Introduction

Tackling Health
Inequalities
Dr Rashmi Shukla
Director of Public Health
Eastern Leicester Primary Care Trust
Why worry about health
inequalities?
• Health inequalities persist despite
prosperity and reductions in
mortality in Britain, for e.g.
– Socially disadvantaged and affluent
sections of society
– Men and women
– People from different ethnic groups
• Many of the gaps are large and wider
than 20 years ago
Determinants of Health
National Targets
Infant Mortality (deaths in the first year of life)
Starting with children under one year, by 2010 to
reduce by at least 10 per cent the gap* in mortality
between manual groups and the population as a
whole
Expectation of Life
Starting with Health Authorities, by 2010 to reduce
by at least 10% the gap* between the quintile of
areas with the lowest life expectancy at birth and
the population as a whole.
Determinants of health
Use of Indices of Multiple
Deprivation 2000
• Six domains of deprivation to give a
composite value
– Income, Employment, Health, Education,
Housing, Access to services
• Overall Index
• Child Poverty Index
• Ranking plus worst 10% and 20% at
electoral ward level (over 5,000 in
England)
Overall index
Deprivation
• Education
– About 1/3rd of the people in Leicester,
Leicestershire & Rutland live in wards in
worst 20% nationally.
– 76% of city residents in worst 20% for
education. A majority of city residents
live in wards in the worst 20% for all
domains bar access.
• Level of deprivation correlates
significantly with mortality and
teenage conceptions
Other dimensions of
Health Inequalities
• Previous data focussed on
geographical analyses of health
inequalities using the Indices of
Multiple Deprivation.
• Other ways of illustrating health
inequalities
– age, ethnicity, disability and/or
gender.
Excluded groups
• Homeless, Prisoners and Asylum
seekers
– Often hidden from official statistics
– Homeless mortality 3 times that of
the domiciled
– Up to 90% of prisoners have a
diagnosable mental disorder
– Asylum seekers have poorer health
and significant health needs
Equality
The NHS Plan states:
“The NHS will shape its services
around the needs and preferences of
individual patients, their families and
their carers. The NHS of the 21st
century must be responsive to the
needs of the different groups and
individuals within society and
challenge discrimination on the
grounds of age, gender, ethnicity,
religion, disability and sexuality……”
Ethnicity
• Some ethnic groups have a higher burden
of poor health:
– 30% higher rates of heart disease in South
Asians
– Diabetes is 4 x more common in South Asians
and up to 3 x more common in AfricanCaribbeans
– Self-reported cigarette smoking rates are
highest among Bangladeshi men (44%), Irish
men (39%) and Black Caribbean men (35%),
compared to 27% of men in the general
population.
• Perceptions of discrimination can have a
considerable impact on health
Ethnicity (2)
Admission rates for acute heart attacks in patients
aged over 40 years
50
40
Men:
30
Women:
S. Asian - 12/1,000
White - 6/1,000
S. Asian - 6/1,000
White - 3/1,000
20
10
SOUTH ASIAN
WHITE
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
00-04
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
0
00-04
Annual rate per 1,000 population*
60
Ethnicity (3)
Revascularisation rates by gender: 1998 -2001
Gender PTCA
Age
Standardised
Rate per
100,000
Male
CABG
Adjusted
Rate Ratio
Age
Standardised
Rate per
100,000
639
797
3.5
Female
228
Adjusted
Rate Ratio
3.9
166
Ethnicity (4)
• Being older, male and of South Asian
origin are all risk factors for higher
rates of CHD.
• Revascularisation rates for CHD
appear to show that women may
have unequal access.
• No difference in waiting times by
ethnic group for revascularisation
procedures
Disability
• In Leicester, Leicestershire &
Rutland:
– 1000 people who use sign language
– 64,000 people with hearing aids
– 5,809 registered with the Society for the
blind
– 20% will have a mental illness at some
stage in their life
– 3,552 people on the learning disabilities
register
South
eicestershire
Melton,
Rutland,
Harborough
Leicester City
West
Hinckley and
Bosworth
Eastern
Leicester
Charnwood
and North
West Leics
Disability (2): LD rates
LEARNING DISABILITY RATES IN LEICESTERSHIRE
per 10,000 registered population
60
50
40
30
20
10
0
Disability (3): Incontinence
• Around 50,000 (5%) people affected
– More common in older people and those
with learning disability living in care
homes than in private households.
– Similar levels between men and women
however, relatively fewer women access
primary and secondary services.
• Considerable variation in the provision in
community continence clinics for adults
across Leicestershire.
Age
• Standard one of the National Service
Framework for Older People is
‘Rooting Out Discrimination’
– Initial audits of all written age related
policies suggest there are very few
policies that have references to age.
– Key issue of age discrimination should
be linked closely into the wider agenda
of equality and clinical governance.
Age(2):Health of Older People
• Older people living in care homes tend to
be in a poorer state of health compared to
those living in private households:
– Higher prevalence of longstanding
illness
– Poorer state of psychosocial well-being
– Half as likely to be eating fruit and red
meat 6 or more times a week
– Less likely to have had dental checkups
and half as likely to have own teeth
– Significantly more likely to be on 4 or
more prescribed drugs.
Source: Health Survey for England
Age(3): Cataract Surgery
Age Group
(years)
50-64
65-69
70-74
75-79
80-84
85+
All ages
Age
Specific
April 1998 to
March 1999
23.4
71.6
121.0
191.5
257.0
258.9
74.2
Intervention rates
April 2000 to
March 2001
27.1
106.7
165.8
255.1
322.4
309.6
95.6
% change in rate
15.8%
49.0%
37.0%
27.9%
25.4%
19.6%
28.8%
Age(4): Alzheimer’s disease
• Commonest of all dementias
– increases with age
• NICE guidance in January 2001
– anti-cholinesterase therapy for mild to
moderate disease.
– estimated to be around 3900 people in
Leicestershire with mild to moderate
Alzheimer’s disease.
– however, latest figures show that less
than 300 (7.7% of expected) on
treatment!
Concluding Remarks
• Primary Care Trusts will be the key
NHS organisations for health
improvement and reducing
inequalities
– It will be for each PCT to undertake a
comprehensive review of health
inequalities at a local level
– It is anticipated that the first major
public health report to PCT boards by
the Directors of Public Health should
have a strong focus on reducing health
inequalities
National Drivers
• Neighbourhood Renewal, Local
Strategic Partnerships and
Public Service Agreement
– Regeneration programmes
– Social capital
– Role of the NHS as an employer
Summary
• Examples of health needs and health
inequalities can be identified.
• These can include inequalities in
relation to:
–
–
–
–
Socio-economic factors
Minority ethnic groups
People with disability
Older people