Cardiac MCN April 2007 Tackling Health Inequalities: Keep Well Programme.
Professor David Gordon Tackling Inequalities in Health: the UK experience 22 nd November 2005.
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Transcript of Professor David Gordon Tackling Inequalities in Health: the UK experience 22 nd November 2005.
Professor David Gordon
Tackling Inequalities in Health:the UK experience
22nd November 2005
2
1. The problem
2. The solutions?
- What can be done
- What can the health service do
Tackling Health Inequalities
3
4 WHO Ranking of Health Systems
5
Frank Dobson, 1997(Secretary of state for health 1997-1999
“Inequality in health is the worst inequality of all. There is no more serious inequality than knowing that you’ll die sooner because you’re badly off”
6 Age at death by age group, 1990-1995
Source: The State of the World Population 1998
7
Cause of death for children under five
Bars show estimated confidence interval
Only the good die young? – what kills children
8
“The world's biggest killer and the greatest cause of ill health and suffering across the globe is listed almost at the end of the International Classification of Diseases. It is given code Z59.5 -- extreme poverty.World Health Organisation (1995)
Seven out of 10 childhood deaths in developing countries can be attributed to just five main causes - or a combination of them: pneumonia, diarrhoea, measles, malaria and malnutrition. Around the world, three out of four children seen by health services are suffering from at least one of these conditions.World Health Organisation (1996; 1998).
9Severe Deprivation of Basic Human Need
•A third of the Worlds children live in squalid housing condition with more than five people to a room or living on a mud floor
•Over half a billion children have no toilet facilities whatsoever - not even a hole in the ground.
•Over 400 million children are using unsafe open water sources, rivers or ponds or they have to walk 15 minutes or more there and back to water, that’s a thirty minute round trip, that’s so far they cannot carry enough for their needs. Therefore, they cut down on water use and tend to get infections.
•About 1 in 5 children (aged between 3 and 18) lack access to radios, televisions, computers, telephones or newspapers at home. They have no information about the outside world apart from what they can see in their community.
•16% of the world’s children under the age of 5 are very severely malnourished and almost half of these live in South Asia.
•275 million children have not been immunised against any disease whatsoever, or they have had a recent illness causing diarrhoea, which is one of the major killers and received no medical advice or treatment. As far as we can determine, about 13% of the world’s children have never come into contact with medical services.
•140 million children aged between 7 – 18, that’s about one in nine, are severely educationally deprived - they have never stepped inside a school building
10 Expectation of years of life, at birth
30
40
50
60
70
80
9018
40s
1850
s
1860
s*
1870
s
1880
s
1890
s
1900
s
1910
s
1920
s
1930
s
1940
s*
1950
s
1960
s
1970
s
1980
s
1990
s
Men
Women
11
% Deaths among recorded baptisms
Under 5 years Under 21 years
British Dukes(Hollingsworth, 1965
20
27
Bedfordshire peasants(fairly prosperous)(Tranter, 1966)
24
31
Lincolnshire peasants(Chambers, 1972)
39
60
Mortality of Infants and Young People, 1739-79
12
District Gentry and professional
Farmers and tradesman
Labourers and artisans
Rural
Rutland 52 41 38
Urban
Bath 55 37 25
Leeds 44 27 19
Bethnal Green
45 26 16
Manchester 38 20 17
Liverpool 35 22 15
Longevity of families, by class and area of residence, 1834-41
13
Accidents
Cancers
DigestiveRespiratory
Genitourinary
Circulatory
14 SMRs - From the 1920s to the 1990s, men 20-64
Year SMR by Social Class
I II III IV V Ratio V:I
1921-23 82 94 95 101 125 1.5
1930-32 90 94 97 102 111 1.2
1942 88 93 99 103 115 1.3
1949-1953 86 92 101 104 118 1.4
1959-1963 76 81 100 103 143 1.9
1970-1972 77 81 103 114 137 1.8
1981-1983 66 76 100 116 165 2.5
1991-1993 66 72 113* 116 189 2.9
15
Source: DoH 2003
16
17 The highest and lowest premature mortality constituencies of Britain
(1991-95)
18
60
70
80
90
100
110
120
130
140
150
160
1950-53
1959-63
1969-73
1981-85
1986-89
1990-92
1993-95
1996-98
1999-2000
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Ninth
Tenth
Figure #. Standardised mortality ratios for deaths under 65 in Britain by tenths of population by area, 1950-53 to 1999-2000
19 Low Income in Britain 1961-2003
20
21
22
Shettleston, Glasgow
23
24
Critical Periods of the Life Course
• Foetal development• Birth• Nutrition, growth and health in adulthood• Educational Career• Leaving parental home• Entering labour market• Establishing social and sexual relationships• Job loss or insecurity• Parenthood• Episodes of illness• Labour market exit• Chronic sickness• Loss of full independence Source: Shaw et al., The Widening Gap, 1999, p. 106.
25
Source: Pantazis and Gordon 1997
% with long standing illness by history of poverty
2527
40
47
52
0
10
20
30
40
50
60
never rarely occasionally often most of the time
history of poverty
%Socio-economic disadvantage has a cumulative effect across the life course
26
The solutions?
- What can be done
- What can the health service do
Tackling Health Inequalities
First prerequisite - political recognition of the
problem and coordinated action across
government departments, and;
Second prerequisite - commitment to act on
specific measurable health inequalities targets
27
•You need a plan and clear, measurable objectives.
•You need belief … Action needs to start with the belief that you can do
something about it.
•You need a cross-governmental plan to address health inequalities –
including the finance ministry.
•Although this work is not about health services alone, the health sector has
an important leadership role to play.
•‘Joined up government’ is very important, particularly at the local level,
where planning and funding mechanisms need to be brought into the picture.
www.who.int/social_determinants/advocacy/wha_csdh/en/
Tackling Health Inequalities: lessons from the UK
28
Aims and targets
“The government’s strategy on health inequalities aims to narrow the gap in health outcomes across geographical areas, socio-economic groups, age groups and different black and minority ethnic groups, as well as between men and women and between the majority of the population and vulnerable groups with special needs”
(HM Treasury and Department of Health, 2002)
29 Canadian Government Statements on Social Determinants of Health
All policies which have a direct bearing on health need to be coordinated. The list is long and includes, among others, income security, employment, education, housing, business, agriculture, transportation, justice and technology.
-- Achieving Health For All: A Framework for Health Promotion, J. Epp. Ottawa: Health and Welfare Canada, 1986.
30
Canadian Government Statements on Social Determinants of Health
In the case of poverty, unemployment, stress, and violence, the influence on health is direct, negative and often shocking for a country as wealthy and as highly regarded as Canada.
-- The Statistical Report on the Health of Canadians. Ottawa: Health Canada, 1998.
31
1. By 2010 to reduce the inequalities in health outcomes by 10 per cent as measured by infant mortality and life expectancy at birth.
2. 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;
3. starting with local authorities, by 2010 to reduce by at least 10 per cent the gap between the fifth of areas with the lowest life expectancy at birth and the population as a whole.
UK health inequalities targets set in 2002
32
In the European Union;
“most countries with quantitative targets have
set them in terms of reducing gaps between the
poorest and the more affluent, but Scotland and
Wales appear to be unique in terms of
emphasising the importance of improving the
position of the poorest groups per se.”
In Wales & Scotland the targets do not focus explicitly on
‘closing the gap’ but emphasise relatively faster
improvements for the most deprived groups.
Source: Judge et al (2005)
Approaches to Health Inequality Target Setting
33
Child Poverty in the UK
The UK Government is committed to tackling the problem of child poverty. In March 1999, the Prime Minister Tony Blair set out a commitment to end child poverty forever:
“And I will set out our historic aim that ours is the first generation to end child poverty forever, and it will take a generation. It is a 20-year mission but I believe it can be done.
34
UNICEF Child Poverty League of Rich CountriesPercent of children living below 50% of median national income
Source: UNICEF (2005)
35
The Cost of Ending Child Poverty: the amount needed to raise the incomes of all poor families with children above the poverty threshold
36 Likely health impact of socio-economic interventions
Source: Mitchell et al 2000
37
Very little of the mortality gap by social class can be
explained by known ‘risk’ factors
38
1. The solutions?
- What can the health service do
Tackling Health Inequalities
Ending the Inverse Care law - equitable, accessible
and inclusive health care and health resource
allocation
39
The term 'inverse care law' was coined by Tudor Hart
(1971) to describe the general observation that "the
availability of good medical care tends to vary inversely
with the need of the population served."
A primary aim of health inequalities audits and impact
assessments should be to identify the best method or
methods of allocation in order to distribute resources on
the basis of health needs and thereby alleviate the
problems caused by the ‘inverse care law’.
The Inverse Care Law
40The Inverse Care Law
Average number of GPs per 100,000 by area deprivation, 2002 & 2004
Source: SRGHI 2005
41
Health resources should be allocated on the basis of the amount of health need multiplied by the cost of meeting that need. Many (most) health resource allocations in the UK have been based mainly upon the population size weighted by the age and sex distribution of people who have recently died under the age of 75 (eg standardised mortality rate under 75). However, there are a number of problems with the current methodology: 1.The health service mainly provides services for people who are alive, not dead. In particular, it provides the bulk of its services for the ‘sick’ rather than the ‘healthy’. 2.The health service provides a considerable number of services for people with health conditions that only very rarely result in death eg tooth decay, back pain, food poisoning, arthritis, etc. 3.The geographical distribution of health need and death are not the same. 4.A large number of people require health services in any given year but only a relatively small number will die under the age of 75 (approximately 15,000 people per year in Wales).
Health Resource Allocation
42· Most effective medical interventions do not reduce disease incidence risk but may improve prognosis and quality of life through primary, secondary and tertiary prevention. · In order to reduce health inequalities it is essential that all segments of society share equally in these advances on the basis of clinical needs and not be influenced by spurious socio-demographic factors· Health care provision must be commensurate with clinical need and unbiased by socio-economic status. A mismatch between need and provision is inequitable. · Evidence of clinical effectiveness is essential in interpreting patterns of service provision by socio-economic status as overprovision may be as harmful as under-provision. · Inequity can function at various different domains such as age, socioeconomic status, geography, ethnicity and gender. These domains may act independently or additively. · Inequity can occur at primary, secondary and tertiary care levels within the NHS.
Ending inequity in health care
43
“it is important that strategies developed to reduce
inequalities are not assumed to be having a positive
impact simply because the aim is ‘progressive’ and so
rigorous evaluation of promising interventions are
important.”
Source: Arblaster, et al (1995). Review of the research on the effectiveness of health service interventions to reduce variations in health
44
1. Patient variations in health care seeking behaviour
2. Doctor-patient interactions at a primary care level
3. Variations in primary care referral patterns
4. Variations in levels of investigation
5. Deciding on treatment options
6. Patient preferences
Identifying the sources of inequity in health care
45
Health equity audit cycle
46 Ten Tips For Better Health – Liam Donaldson, 1999
1. Don't smoke. If you can, stop. If you can't, cut down.
2. Follow a balanced diet with plenty of fruit and vegetables.
3. Keep physically active.
4. Manage stress by, for example, talking things through and making
time to relax.
5. If you drink alcohol, do so in moderation.
6. Cover up in the sun, and protect children from sunburn.
7. Practice safer sex.
8. Take up cancer screening opportunities.
9. Be safe on the roads: follow the Highway Code.
10. Learn the First Aid ABC : airways, breathing, circulation.
47Alternative Ten Tips for Health
1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.
2. Don't live in a deprived area, if you do move.
3. Be able to afford to own a car
4. Don't work in a stressful, low paid manual job.
5. Don't live in damp, low quality housing or be homeless
6. Be able to afford to go on an annual holiday.
7. Don’t be a lone parent.
8. Claim all benefits to which you are entitled
9. Don't live next to a busy major road or near a polluting factory.
10. Use education to improve your socio-economic position