Posts Tagged ‘Health inequality’

Reform added to inequality in life expectancy

By Mike Broad - 5th May 2015 10:57 am

There are rising inequalities in life expectancy, research suggests, with the gap between the top and bottom 1% of life expectancies in local authority districts of England and Wales increasing by around 0.9 of a year for men and 1.1 years for women.

Moreover, the research shows that the inequalities (gaps) between the top and bottom 1% of life expectancies of English and Welsh local authority districts are expected to continue to rise steadily, from 6.1 years in 2012 to 8.3 years in 2030 in men, and from 5.6 years to 8.3 years in women.

The inequalities are set against rising national life expectancy. By 2030, life expectancy in England and Wales is expected to reach 85.7 years for men and 87.6 years for women - closing the gap between male and female life expectancy from 6.0 years in 1981 to just 1.9 years by 2030.

The Lancet study suggests that between 1981 and 2012, national life expectancy in England and Wales increased by 8.2 years in men (to 79.5 years) and 6.0 years in women (to 83.3 years).

“Our national forecasts of life expectancy in 2030 are higher than official figures from the Office for National Statistics, by 2.4 years for men and 1.0 years for women, meaning that pensions will have larger pay-outs than planned, and health and social services will have to serve an even older population than currently planned,” says senior author Professor Majid Ezzati from Imperial College London, UK.

”The discrepancies found between our estimates and earlier figures are likely to be because previous estimates have extrapolated from past trends in death rates, an approach that may underestimate gains in life expectancy.”

Ezzati and colleagues used mortality and population data from the Office for National Statistics for 375 of the 376 local authority districts in England and Wales between 1981 and 2012. Data on the age at death and district of residence were used in advanced statistical methods which analysed current mortality patterns, and then forecast life expectancy to 2030 for each of the districts.

Key findings include:

- In 2012, life expectancy was lowest in urban northern England (Blackpool in north west England had the lowest male life expectancy for men at 75.2 years, with Manchester and Liverpool next lowest, and Middlesbrough and Manchester had the lowest life expectancy for women at 80.2 years, followed by Blaenau Gwent in southern Wales).

The highest life expectancies in 2012 were in southern England and some of London’s most affluent districts (the small district of the City of London had the highest life expectancy for both men and women, at 83.4 and 87.3 years, respectively; for men, the next highest life expectancies were found in South Cambridgeshire and East Dorset, and, for women, East Dorset and the London borough of Kensington and Chelsea had the next highest life expectancies).

- Within London, male and female life expectancies varied by 5 to 6 years, with the lowest life expectancies in Tower Hamlets or Barking and Dagenham, and the highest in the City of London or Kensington and Chelsea.

- The largest difference in life expectancy between English and Welsh local authority districts in 2012 (8 years for men and 7 years for women) was equivalent to the gap between the average life expectancy in the UK and countries like Sri Lanka, Vietnam, and Nicaragua.

According to Professor Ezzati, “The present UK coalition Government has cut public spending on a range of social determinants of health under the rhetoric of austerity. Such policies will, at best, cause the rising inequality trends to continue, and could well worsen them because their adverse effects are particularly large on children and working-age people, and on more disadvantaged social groups and communities, with signs of a rise in poverty already emerging.”

“Moreover, National Health Service reforms, which devolve health and social care responsibilities to local governments, coupled with tight budgets and a large role for the private sector in commissioning and provision of health services, will weaken health systems and worsen inequalities in health care access and quality.”

Read more.

Higher spending reduces health inequalities

By Mike Broad - 28th May 2014 12:56 pm

A policy of higher NHS spending in deprived areas compared with affluent areas is associated with a reduction in absolute health inequalities from causes amenable to healthcare in England, suggests a study.

In 1999, the government introduced a new ‘health inequalities’ objective for the allocation of NHS resources in England, which resulted in greater NHS spending in deprived areas with the worst health outcomes. But it is not known whether this policy was successful in contributing to a reduction in health inequalities.

So researchers based at the universities of Liverpool and Durham analysed trends in NHS spending per head of population between 2001 and 2011 in the 20% most deprived and the 20% most affluent local authorities in England.

They then looked at trends in mortality from causes amenable to health care within these local authorities over the same period.

Amenable mortality is defined as mortality from causes for which there is evidence of preventability given timely, appropriate access to high quality care.

Between 2001 and 2011, NHS spending in the most deprived areas increased by 81% (from £1074 per head to £1938 per head) compared with 70% in the most affluent areas (from £881 per head to £1502 per head).

This increase in NHS resources to deprived areas was associated with a reduction in the gap between deprived and affluent areas of 35 male deaths per 100,000 and 16 female deaths per 100,000 from causes amenable to healthcare.

The authors, writing on, calculate that each additional £10m of resources allocated to deprived areas was associated with a reduction in 4 male deaths per 100,000 and 1.8 female deaths per 100,000 from causes amenable to healthcare.

In contrast, there was no significant association between absolute increases in NHS resources and absolute improvements in either male or female deaths amenable to healthcare in the more affluent areas.

Although the researchers cannot rule out the possibility that these associations are due to some other unmeasured (confounding) factors, they say that investment of NHS resources in more deprived areas “was associated with a greater improvement in outcomes than investment in more affluent areas.”

They conclude: “Our study suggests that any change in resource allocation policy that reduces the proportion of funding allocated to deprived areas may reverse this trend and widen geographical inequalities in mortality from these causes.”

These results are encouraging and provide evidence for continuing to target NHS resources at deprived areas, say Azeem Majeed and Michael Soljak from Imperial College London in an accompanying editorial.

However, they warn this may be more difficult in the current political and financial climate “as the coalition government has sharply curtailed the growth in NHS spending that England previously experienced.”

They point out that NHS spending “is only one component of an effective strategy to reduce health inequalities” and say other key areas such as housing, education, and employment, and the wider determinants of health inequalities, “also need to be dealt with by national and local government and by other public sector organisations.”

Read the study.

Local autonomy key to improving health outcomes

By Elliot Bidgood, research fellow at Civitas - 29th October 2013 12:48 pm

Engagement and accountability can be challenges in the NHS. This year, Mid Staffordshire and other hospital care scandals have brought both these issues and the general question of standards into particular focus.

In a new report for the think-tank Civitas, I have set out how the Swedish healthcare system may offer some sound lessons as we go about tackling these problems. The history and core ideals of their system are similar, in that they have a universal public system, developed in the post-war era and financed from general taxation. However, there are crucial differences in performance and structure, mostly relating to decentralisation and local autonomy.

Health outcomes in Sweden are better in terms of life expectancy, infant mortality and potential years of life lost (PYLL). According to a Lancet study this year, Sweden has the fewest preventable child deaths among 15 European nations, while Britain has the most. Sweden also performs better on mortality amenable to healthcare, the best available measure of deaths preventable by healthcare intervention. Sweden’s system is also rated highly in both international rankings and national surveys.

One compelling explanation for some of these differences is the placement of both day-to-day provision and broad taxation powers in the hands of county councils, which handle healthcare services, and municipal councils, which handle public health and social care. Over 70% of funding comes from local taxation. It is felt that this makes services flexible and more accountable to local electorates, strengthening engagement and creating pressure to ensure standards.

It may also explain their high turnouts in local elections, which allow Swedes to shape health services more than our general elections do, and the willingness of Swedes to pay more in tax and fund Sweden’s higher per-head health spending, since the value for money link is clearer.

Also comparable is the fact that Sweden has seen internal market and patient choice reforms, intended to improve efficiency and standards. However, these are more entrenched in Sweden, and have accelerated since 2006. Despite issues and a need for more evidence, Swedish patients have appreciated choice and it appears that in some areas, reform has improved accessibility, responsiveness, productivity and satisfaction.

Also crucial is the role that decentralisation has played in allowing localities to shape the reforms, innovate and learn best practice from each other.

A continual concern about decentralisation of course relates to the fear of “postcode lotteries”, hence why the Swedish state still provides extensive oversight and guidelines, as well as a quarter of all health funding, ensuring critical balance.

But we must also remember that centralism in the NHS has never truly stamped out variance and that democratic local control means that service differences are not a haphazard ‘lottery’, as they are shaped by local service users.

Future Forum boss joins NHS Commissioning Board

Pulse - 2nd September 2012 11:50 am

Former RCGP chair Professor Steve Field has been appointed deputy national medical director at the NHS Commissioning Board.

The appointment will mean Professor Field will have responsibility for reducing health inequalities in the NHS.

Professor Field is currently chairing a review of the NHS Constitution as part of his work on the government’s NHS Future Forum, which conducted the listening exercise on the Health and Social Care Bill last year.

Read more in Pulse.

Health inequalities: time to park the Health Bill

By Katherine Teale - 23rd January 2012 11:37 pm

Unless you’ve been hiding under the duvet for the last 18 months, you must be aware of the furore over the Health Bill, which has received a new battering this week from the Health Select Committee.

As a GP friend pointed out during a commissioning meeting, we work in an inner-city area where most residents take home less than the UK median wage (£23,000), and so, under the proposed system,  probably won’t be buying health insurance or ‘top ups‘, or whatever this will be called when the GP commissioners run out of money and decide that they can’t afford to fund procedure X or Y on the NHS. And that therefore if you require an X- or Y-plasty you will have to find alternative funding or just put up with it.

So poverty (or, at least, being unable to afford health insurance) and illness is going to be a bad combination - but if you’re a healthy doctor in the top 5% wage bracket and able to ‘work’ the health system, do you care?

Some do. NHSCA chair Dr Clive Peedell ran six back-to-back marathons this month to draw attention to the dismantling of universal healthcare - that’s what I call putting ‘skin in the game’.

Others, though, are less sympathetic, and take the view that the poor have only themselves to blame. Apparently they should have bothered to get themselves a good education when they were younger, and then they wouldn’t be in this mess. This was my second interesting discussion this week, and came on the back of complaints about our graduated car park charges, whereby a consultant on £90K has to pay about £15 a month more than a support worker on £18K.

“We don’t have to pay more for a pint of milk at Tesco just because we earn more.”  The Tesco argument is one which I’ve heard before, so this is not an isolated view.

I’m no saint when it comes to compassion - I don’t even  buy the Big Issue every week - but where do I start? For one thing, the comparison doesn’t work because, of course, poor people probably do pay less for a pint of milk at Tesco -  they simply avoid the organic or decent locally farmed stuff. Hospital car park charges are quite substantial (I pay over £30 monthly) and a significant burden for low paid workers taking home less than £1,000. Even means tested, it’s still a helluva lot more, proportionately, for them than for us.

My concern with this is that it’s a small step from saying it’s OK to price our poorly paid colleagues out of the car park, to saying that poor people don’t  deserve the same healthcare, because  they obviously didn’t try hard enough at school.

How appropriate that in the bicentenary of Dickens’ birth, we should be hearing about the undeserving poor. Doctors have traditionally stood up for the poor and the sick. As well as getting angry about the theft of our pension funds, we should all be striving to preserve the NHS as a good, universal service for all - even for those who didn’t manage 10 GCSE’s. Please sent an email to your Royal College president asking them to support dropping the Health and Social Care Bill.

Doctors should be ‘community leaders’ as well

by Mike Broad - 18th October 2011 8:50 am

Doctors have a key role to play in reducing health inequalities, says a new report.

Social determinants and health inequalities pose a significant challenge to governments around the world and the BMA’s report highlights how doctors can use their expertise to act as community leaders to tackle this issue.

Dr Vivienne Nathanson, director of professional activities at the BMA and author of Social determinants – what doctors can do, explains that the social determinants of health are factors that impact on health and wellbeing for which there is little control, for example, where we are born, grow up, live, work and our gender and age.

While these factors are not usually directly responsible for ill-health they have been described as ‘the causes of the causes of disease’. For example, while smoking may lead to heart disease and lung cancer, it is the social factors that largely determine whether an individual is more or less likely to smoke, and if they start to smoke whether they are likely to quit successfully.

The report emphasises that while not every doctor has the opportunity to change the life course of individual patients they can make a difference in others ways to reduce health inequalities on a local, regional, national and international level.

Dr Nathanson highlights examples of work doctors and their teams are already involved in, these include the Bromley-by-Centre in East London where GPs refer patients to professionals from welfare, employment, housing and debt advice services so that the underlying causes of their health problems can be addressed.

Other examples include doctors working with homeless people in Glasgow and clinicians at the Royal United Hospital in Bath developing training programmes to help staff improve the care they provide to profoundly deaf patients.

Dr Nathanson said: “We have some very good examples in the report but we will be seeking more so that we can develop a resource to help doctors exchange ideas and best practice in this area.”

She added: “Having Sir Michael Marmot, the global expert on health inequalities and author of Fair Society, Healthy Lives as our recent president provided the BMA with an ideal opportunity to develop our work on social determinants and health inequalities.

“We are committed to continuing with this project and will press the four UK governments to assess the health impact of all policies and interventions with a special emphasis on the social determinants of health. We will also urge the General Medical Council and the medical royal colleges to include an understanding of social determinants in examinations syllabi for future doctors.”

Read the full report.

Trying to close the gap in times of austerity

By Dr Vivienne Nathanson, BMA director of professional activities - 22nd February 2011 4:39 pm

At a conference on health inequalities held at the BMA recently, a member of the audience asked if it is possible to reduce the health inequalities gap during times of financial constraint.

Sir Michael Marmot, the global expert on health inequalities and BMA president, gave an inspiring keynote speech. He talked about the social gradient in health and well being from the poorest to the richest and explained that while the overall health of the nation had improved in the last decade, the gap between the haves and the have-nots has widened.

One speaker made the point that if you stand on top of leafy Primrose Hill in London and look down towards the more urban Somers Town, an area near Kings Cross, the decrease in life expectancy is about nine years.

Despite the gradient, it is still the poorest in society who are most likely to suffer from complex illnesses related to obesity, mental illness, alcohol misuse and tobacco addiction and these significantly contribute to health inequalities. The tragedy is that so many of these illnesses are avoidable.

At the end of the conference the question about funding came up - with the NHS looking to make around £20 billion in efficiency savings and go through massive structural change - are innovative projects dealing with health inequalities going to be priority?

Sir Michael Marmot answered that “doing nothing costs money”. If doctors can work in partnership with other healthcare professionals and help reduce teen pregnancies, provide guidance about parenting skills and promote healthy eating and exercise in children and adults it will be NHS and society who will reap the benefits in future years.

These initiatives will help people live longer healthier lives and will save the healthcare billions of pounds.

A greater threat perhaps than funding are the implications of the Health and Social Care Bill and the proposals in the white paper on public health.

While it is positive that health inequalities are central in the white paper, there is a real risk that the current decimation of PCTs could mean that the expertise and skills of dedicated staff who know how to run projects to tackle health inequalities will be lost.

The government’s proposals of enforced competition between healthcare providers where price is a key factor will also be barrier to reducing health inequalities. It is unlikely that the private sector will want a slice of this particular pie as the services aimed at the vulnerable and poor will not be cheap or profitable.

The news wasn’t all bleak however. Sir Michael Marmot made the point that the UK has the most equitable health service among the richest countries in the world. This is something we should be really proud of and do everything we can to protect - without it, it is likely that the gap in health inequalities will widen even further.

Age, sex and wealth affect referral to secondary care

BBC Health - 1st December 2010 11:08 am

Age, sex and wealth all affect how likely your GP is to refer you for a specialist appointment, a study has concluded.

A UK team analysed data for 130,000 patients, reporting their findings in the BMJ.

Older people were less likely to be referred for three common symptoms, with sex and deprivation also influential.

A charity said the study should raise alarm bells across the NHS.

Michelle Mitchell, Charity Director at Age UK, said: “A doctor’s decision to refer patients must be based solely on the patient’s clinical need, not their age. Age discrimination in health provision will be unlawful from 2012 and it can’t come a moment too soon for older people in need of medical care.”

The study from the King’s Fund and University College London covered decisions on patients with postmenopausal bleeding, hip pain and heartburn from 326 UK practices across a six-year period.

Read a blog on the issue.

Read more at BBC Health.

Labour Party savaged over health inequalities

The Lancet - 16th November 2010 11:02 am

The Lancet remembers well the genuine excitement we felt at the commitment that the Labour government made in 1997 to attack health inequalities in Britain.

The dismal record of the Conservatives before them left a deep scar on the NHS. The creation of Donald Acheson’s Independent Inquiry into Inequalities in Health was a new opportunity to recalibrate the health service to meet the needs of the most deprived communities in the UK. Our sense of hope was, it turned out, misplaced - Labour presided over 13 years of failure.

Inequalities in health widened despite huge investment in the NHS. The reasons for this failure have now been exposed in an astonishingly candid report, published by the House of Commons Public Accounts Committee. This committee examines how taxpayers’ money is spent. It is chaired by a Labour Member of Parliament, Margaret Hodge. She has produced a tale of decrepitude at every level of the health system.

Labour was elected in 1997 with a promise and mandate to tackle inequalities in health. Yet it took nine years (to 2006) before ministers and their civil servant officials made inequalities an NHS priority.

“What on earth went wrong?” asked Hodge. She was questioning the Department of Health’s Permanent Secretary, Richard Douglas, together with Ruth Hussey (a regional director of public health) and Mark Davies (the Department’s Director of Health Inequalities).

Douglas was evasive. Hodge dismissed his “claptrap” as “despairing”. Eventually, he admitted that his Department’s interpretation of ministers’ election commitments was merely “aspirational” (ie, it did not have to be taken seriously).

The picture of government he painted was far from flattering. Figures showing the worsening situation for health equality would be sent to the Department and forwarded to ministers. But civil servants - including, it seems, the Chief Medical Officer - did little to address the growing problem. The best officials could do collectively was send out “toolkits” of guidance to PCTs and cross their fingers that they might trigger a response.

But the Department had no mechanism to monitor or evaluate the implementation of what limited guidance it did provide. It was a “fair criticism” to say that “we were slow off the mark”, conceded Douglas. Members of the Public Accounts Committee were clearly shocked by this admission.

The government and civil service were not wholly to blame. Where was the medical profession? Doctors are supposed to feel an acute responsibility to deliver the best health service to the whole population. It is on this basis that they ask the public and government to support generous pay increases and terms and conditions of service. These attitudes and behaviours are what we commonly mean by professionalism. It seems that doctors failed completely to live up to the rhetoric of their commitment to professional values.

Members of Hodge’s committee tried to find out why doctors had been so reluctant to address inequalities themselves.

There are some simple and proven interventions that, if implemented evenly across the population, would go a long way to reduce inequalities in health - notably, smoking cessation and the treatment of high blood pressure and raised cholesterol. But doctors did not respond to the clear public and political call to take action on inequalities (and nor did the media). Instead, they sought to massively increase their salaries in a new general practitioner (GP) contract in 2005, one that itself was empty of commitment to reduce inequalities.

People died because of this professional failure. The negotiators of that GP contract, together with the Department of Health, share a responsibility for those deaths.

During the course of this systemic failure, the Department of Health employed over 2300 people. Mr Douglas earns £170,000. Yet this great number of civil servants and their highly paid Permanent Secretary failed to deliver on a public promise, democratically endorsed. A bureaucracy’s first priority is usually to protect itself. Only secondarily will it try to deliver on the pledges of its political leaders.

To call this period in the Department’s history shameful does not even begin to do justice to the way it let down the millions of people to whom it owed a duty to serve.

Despite the bland reassurances made to the Public Accounts Committee, there is not one shred of evidence that the Department has learned the lessons of this agonising debacle.

This article first appeared as an editorial in The Lancet.

Government failed to tackle health inequalities

By Mike Broad - 15th November 2010 11:53 am

The Department of Health has failed to tackle health inequalities in England, a parliamentary report claims.

A cross-party group of MPs that examines public spending criticised the DoH for being too slow to develop an evidence base of cost-effective interventions to reduce inequalities, and for failing to adequately to address GP shortages in areas of highest need - missing an opportunity with the GP contract.

Furthermore, the House of Commons Committee of Public Accounts urges the new government to ensure GP consortia are made more accountable for measures to cut inequality.

The committee looked into why the health department has failed to reach the target set by the government in 2007 of reducing the gap in life expectancy by 10% between councils with high deprivation and the population as a whole by 2010.

Although life expectancy in the whole population has risen, the gap between the national average and the deprived areas has widened by 7% for men and 14% for women since 1995-7. Life expectancy in the whole population is now 77.9 years for men and 82 years for women, whereas in the 70 deprived councils it is now 75.8 years for men and 80.4 years for women.

Only 12 of them are on track to shrink the gap in life expectancy of men and women.

The report also reveals that two thirds of PCTs in areas with the highest deprivation still do not receive the money due to them under the DoH’s funding formula.

Margaret Hodge, the committee’s chairwoman, said: “A central challenge for all governments is to reduce health inequalities between the affluent and the disadvantaged. The problem is complex, but the fact that the gap continues to widen is of great concern, especially against a background of a general improvement in public health over the last decade.”

The report concludes that addressing health inequalities requires sustained and targeted action.

“The Department’s experience to date shows that greater focus and persistence will be needed to drive the right interventions. We expect the Department to provide strong leadership and to continue to monitor the outcomes of those suffering health inequalities. As there is an inevitable time lag between public health interventions and observable outcomes, the Department should monitor the implementation of those activities which, in the short term, would be strong indicators of progress,” it says.

Read the report’s recommendations.

Read a blog on the issue.