Health Inequality: Closing the life expectancy gap over time? September 2014 Camden & Islington Public Health Ester Romeri (Public Health Information Analyst) Alex Cronberg (Senior Public Health Information Analyst)

Purpose of this slide set Reducing the level of health inequality is a priority for both Camden and Islington Councils and Clinical Commissioning Groups. This slide set is intended to inform Camden and Islington public health teams and CCGs about causes of death contributing to changes in the life expectancy gap over time. Specifically, this slide set shows how the gap in life expectancy between the most and least deprived areas have changed over time in Camden and Islington, and analyses the causes of death contributing to these changes.

Summary The life expectancy gap between people living in the most and least deprived areas has increased for women in Camden, whereas there has been no consistent change for men in the borough. For men and women in Islington the life expectancy gap has narrowed. The widening gap for women in Camden is largely due to more deprived women falling behind in terms of CHD/MI and stroke deaths. Specifically, the death rate for CHD/MI has fallen notably in the least deprived quintiles, while it has remained fairly unchanged in the more deprived ones. For stroke there has been a much more substantial drop in the death rate for women living in the single least deprived quintile than for other women. The narrowing gap for men and women in Islington is due to fewer deprivation attributable deaths for CHD/MI and COPD for men and CHD/MI, lung cancer and stroke for women. There has been no clear trend driving these changes. Some of it is explained by falling death rates in more deprived areas, but for stroke there has been an increase in deaths in the least deprived quintile. Despite the narrowing life expectancy gap overall, the mortality gap has widened for heart failure for men and women in Islington. This is due to a falling death rate in least deprived quintile while there has been no consistent change for the other quintiles. This pattern is seen for both men and women.

Methods The analysis presented in this slide set quantifies the inequality gap in mortality by measuring the proportion of deaths that can be attributed to deprivation. The main measure that has been applied is population attributable risk. This measure calculates the age standardised death rate for each deprivation quintile and uses the rate for the least deprived quintile as reference rate. It then calculates the number and proportion of deaths in the other quintiles in excess of the reference rate. Note that this means a negative value may be produced if the least deprived quintile does not have the lowest death rate. The causes of death covered in this analysis include stroke, coronary heart disease (CHD)/myocardial infarction (MI), chronic liver disease (CLD), chronic obstructive pulmonary disease (COPD), heart failure, and lung cancer. These causes are common causes of death that tend to be related to deprivation. Data on cause of death are based on ONS mortality files for 2006 to 2012. The data have been grouped into five-year periods to ensure the numbers are large enough for robust analysis. Data on deprivation are based on the Index of Multiple Deprivation (2010), with small areas (Lower Super Output Areas) in Camden and Islington grouped into five equal groups (quintiles) within each borough based on their deprivation score. It should be noted that deprivation quintiles are not comparable across Camden and Islington. Other inequality measures have also been applied, with results available in the summary tables in the Appendix. These measures show consistent results with the population attributable risk. Analysis on health inequalities for both prevalence and deaths for long term conditions has also been conducted for both boroughs and is available on request. That analysis was presented at the Health Inequality Network Conference at Kings College in May 2014. Our overall method was to measure the relationship between deprivation and the prevalence and deaths from 14 long term conditions. Deprivation is based on the Index of Multiple Deprivation, each lower super output area is assigned to a deprivation score and then this is then grouped into quintiles. We implemented the health inequality measures as proposed in the document produced by SCOTPHO. In Camden and Islington we have a unique dataset which collects data for the registered population, this includes prevalence of long term conditions by age and deprivation quintile. This was used to calculate the directly standardised rates.

Deprivation level CAMDEN ISLINGTON These maps show small areas* grouped into deprivation quintiles within each borough (based on the Index of Multiple Deprivation (IMD) 2010). Note that since the overall level of deprivation is different in the two boroughs, the deprivation quintiles are not comparable. In Camden there is a clear geographical pattern with respect to deprivation. In Islington there is no such clear cut pattern. Instead, the most and least deprived people live side-by-side within small areas. The lack of a distinctive geographical pattern in Islington means the full extent of inequalities in the borough is probably not captured by the Index of Multiple Deprivation. This is evident from analysis done by the ONS using occupational groups. This shows that Islington has the largest health inequality gap in England for both men and women when based on occupational groups and self-reported good health. For comparison, Camden ranks third and seventh for men and women respectively (Source: ONS 2013). * Lower Super Output Areas (LSOA). Each LSOA has a population of about 1,500 people. CAMDEN ISLINGTON According to analysis produced by ONS, looking at the health gap in “Not Good” health rate by local authority and gender, by NS-SEC occupational groups. Islington has the largest health inequality gap compared to other local authorities in England (ranked 346 out of 346 authorities), closely followed by Camden (ranked 344 for men, 340 for women). Reducing health inequalities is a high priority in both boroughs, working with local NHS to achieve this. The strategic plan for Camden known as the “Camden Plan” includes developing new solutions with partners to reduce inequality. In Islington, the Fairness Commission was set up to address inequalities in the borough. The health and wellbeing boards in both boroughs are responsible for overseeing efforts to tackle inequalities locally. Camden and Islington show very different geographical pictures for deprivation, using the indices of multiple deprivation, there is a clear geographical divide for Camden, with the less deprived areas in the North of the borough. Whereas in Islington, deprived areas are more spread out with least deprived LSOAs interspersed with more deprived LSOAs. National quintiles show us that Islington is a very deprived borough, with quintile 3-5, whereas Camden has a bigger range Q1-5.

Background: Overall deaths Trend in deaths per 100,000 population, Camden and Islington, 1996-98 to 2010-12 The overall death rate in both Islington and Camden has been falling since 1996-98. In recent years both boroughs have seen mortality rates falling slightly faster than the England average. The main causes of death (cardiovascular disease, cancer, and respiratory disease), have all fallen over time for both men and women (data not shown). Source: Office for National Statistics (ONS)

Overview of life expectancy gap While the overall death rates have decreased in Camden and Islington, it has fallen at different rates for people living in more and less deprived areas within each borough. This is reflected in the slope index of inequality (SII) in life expectancy, which estimates the difference in life expectancy (in years) between the groups who are best and worst off. For women in Camden, there has been a sharp increase in the inequality gap in life expectancy. For men in Camden, there has been no consistent change. In contrast, for men and women in Islington, the inequality gap in life expectancy has narrowed in recent years.

Main causes of death Total number of deaths by sex, 2008-12 Islington Camden Of the causes of death analysed in this slide set, CHD/MI make up the largest number for both men and women in both boroughs. Lung cancer, COPD, and stroke are the next most common causes of death. Stroke contributes to more deaths among women than men, whereas the opposite is true for COPD. ‘All other causes of death’ include all cancers other than lung cancer. Because there is no clear association with deprivation for many of these causes, they are not included in the analysis presented here.

CAMDEN

Deprivation attributable deaths in Camden: Women The mortality gap between more and less deprived women has widened for CHD/MI and stroke between 2006-10 and 2008-12 in Camden. CHD/MI in particular accounts for a large number of deaths for women, meaning the impact on the overall life expectancy gap is substantial. The widening gap for stroke and CHD/MI is mostly due to more deprived women falling behind: the death rate for CHD/MI has fallen notably in the least deprived quintiles, while it has remained fairly unchanged in the more deprived ones. For stroke there has been a much more substantial drop in the death rate for women living in the single least deprived quintile than for other women (data not shown). The mortality gaps for heart failure and to a lesser extent lung cancer and COPD have also narrowed. Chronic Liver Disease (CLD) has the widest mortality gap due to deprivation (77% attributable risk), followed by COPD. However, the number of deaths is comparatively small. There has been little change over time in the mortality gap for CLD but it has narrowed slightly for COPD.

Trend in mortality gap for women - Camden For women in Camden, chronic liver disease (CLD) has the highest proportion of deprivation attributable deaths, followed by COPD. This pattern has remained unchanged between 2006-10 and 2008-12. Over this period, the mortality gap between more and less deprived women has widened notably for CHD/MI and stroke. It has narrowed slightly for COPD, lung cancer and heart failure over the same period.

Trend in mortality gap for women - Camden The proportion of deprivation attributable deaths increased for CHD/MI from 26% to 38% between 2006-10 and 2008-12. The equivalent increase for stroke was 13% to 38%. The proportion of deprivation attributable deaths has fallen notably for heart failure (from 45% to 17%) and to a lesser extent lung cancer (from 38% to 20%) and COPD (from 65% to 51%). The large number of deaths from CHD/MI and stroke means the widening gap from these causes outweighs the narrowing effect from heart failure, lung cancer, and COPD on the life expectancy gap overall.

Deprivation attributable deaths in Camden: Men There has been no consistent change in the life expectancy gap over time for men in Camden. The mortality gap for CHD/MI widened slightly while it narrowed notably for heart failure. There has been no notable change for the other causes of death.

Trend in mortality gap for men - Camden For men in Camden, chronic liver disease (CLD), lung cancer, and COPD have the highest proportion of deprivation attributable deaths. This pattern has remained unchanged between 2006-10 and 2008-12. Over this period, the mortality gap between more and less deprived men has narrowed for heart failure.

Trend in mortality gap for men - Camden The proportion of deprivation attributable deaths has increased for CHD/MI from 40% to 48% between 2006-10 and 2008-12. The proportion of deprivation attributable deaths has fallen notably for heart failure (from 38% to 2%). There have been no other consistent changes.

ISLINGTON

Deprivation attributable deaths in Islington: Women The life expectancy gap for women in Islington has narrowed over time. The causes of death driving this trend include CHD/MI, lung cancer, and stroke, accounting for a large number of deaths. The narrowing gap for these causes is consequently reflected in a narrowing life expectancy gap overall. The factors contributing to the narrowing gap have not been consistent for the different causes (data not shown). For CHD/MI, the death rate has fallen most notably for women living in the middle deprivation quintile. For stroke, the death rate has decreased in the more deprived quintiles, but also increased slightly in the least deprived one. The mortality gap for heart failure has widened substantially for women in Islington. This is due to a falling death rate in least deprived quintile (data not shown). There has been no consistent change for the other deprivation quintiles. However, the overall number of heart failure deaths is small, and the contribution to overall life expectancy is limited.

Trend in mortality gap for women - Islington Heart failure, lung cancer, and chronic liver disease (CLD) have the widest mortality gap for women in Islington. CHD/MI and stroke have negative values for deprivation attributable deaths. This is because women in the least deprived quintile have comparatively high death rates to other deprivation quintiles (data not shown). There has been a sharp increase in the mortality gap for heart failure over time. There has been a narrowing gap for CHD/MI, lung cancer, and stoke.

Trend in mortality gap for women - Islington The proportion of deprivation attributable deaths for heart failure has increased notably for women in Islington, from 10% to 63%. The proportion of deprivation attributable deaths has fallen for stroke (from -30% to - 69%), lung cancer (from 54% to 37%) and CHD/MI (-5% to -15%).

Deprivation attributable deaths in Islington: Men The life expectancy gap has narrowed over time for men in Islington. This is due to a smaller mortality gap for CHD/MI and COPD. The factors contributing to the narrowing gap have not been consistent for the different causes (data not shown). For COPD, the death rate has fallen in more deprived areas, but also increased slightly in the least deprived ones. For CHD/MI, the death rate has fallen for all quintiles but most notably for the most deprived ones. In contrast, the mortality gap for heart failure has widened substantially. This is due to a falling death rate in least deprived quintile (data not shown). There has been no consistent change for the other deprivation quintiles. However, the overall number of heart failure is small, and the contribution to the overall life expectancy is limited. The mortality gap for CLD, which has the highest proportion of deprivation attributable deaths for men in Islington, has also increased slightly.

Trend in mortality gap for men - Islington Chronic liver disease (CLD) has the widest mortality gap for men in Islington. COPD and stroke have negative values for deprivation attributable deaths. This is because men in the least deprived quintile have comparatively high death rates to other deprivation quintiles (data not shown). There has been a sharp increase in the mortality gap for heart failure over time. The gap has narrowed for COPD and CHD/MI.

Trend in mortality gap for men - Islington The proportion of deprivation attributable deaths from heart failure increased from -26% to 28%. However, the number of deaths from heart failure is comparatively small. The gap for CLD has also increased, from 49% to 60%. The proportion of deprivation attributable deaths has fallen for COPD (from 12% to -7%) and CHD/MI (from 30% to 18%).

Appendix: health inequality measures for women, Camden Source: ONS mortality files, analysis by Camden & Islington PH

Appendix: health inequality measures for men, Camden Source: ONS mortality files, analysis by Camden & Islington PH

Appendix: health inequality measures for women - Islington Source: ONS mortality files, analysis by Camden & Islington PH

Appendix: health inequality measures for men - Islington Source: ONS mortality files, analysis by Camden & Islington PH

Further information This slide set has been created by Camden and Islington’s Public Health Knowledge and Intelligence team. For further information please contact Ester Romeri or Alex Cronberg. Email: publichealth.intelligence@islington.gov.uk Tel: 020 7527 1248 We would also very much welcome your comments on these profiles and how they could better suit your individual or practice requirements, so please contact us with your ideas. © Camden and Islington Public Health Knowledge & Intelligence