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

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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

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Cause of death for children under five

Bars show estimated confidence interval

Only the good die young? – what kills children

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“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

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  % 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

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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

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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

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Source: DoH 2003

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17 The highest and lowest premature mortality constituencies of Britain

(1991-95)

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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

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21

22

Shettleston, Glasgow

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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.

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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

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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

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•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

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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.

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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.

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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

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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

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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.

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UNICEF Child Poverty League of Rich CountriesPercent of children living below 50% of median national income

Source: UNICEF (2005)

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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

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Very little of the mortality gap by social class can be

explained by known ‘risk’ factors

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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

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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

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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

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“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

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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

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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