1. Tackling Health Inequalities Dr Rashmi Shukla Director of Public Health Eastern Leicester Primary Care Trust

2. 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

3. Determinants of Health

5. 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.

6. 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)

7. Overall index

8. Deprivation Education – –About 1/3 rd 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

9. Other dimensions of Health Inequalities Previous data focussed on geographical analyses of health inequalities using the Indices of Multiple Deprivation.Previous data focussed on geographical analyses of health inequalities using the Indices of Multiple Deprivation. Other ways of illustrating health inequalitiesOther ways of illustrating health inequalities –age, ethnicity, disability and/or gender.

10. 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

11. 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 21 st 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……”

12. 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 African- Caribbeans – –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

13. Ethnicity (2) 0 10 20 30 40 50 60 00-0410-1420-2430-3440-4450-5460-6470-7480-8400-0410-1420-2430-3440-4450-5460-6470-7480-84 Annual rate per 1,000 population * SOUTH ASIAN WHITE Men: S. Asian - 12/1,000 White - 6/1,000 Women: S. Asian - 6/1,000 White - 3/1,000 Admission rates for acute heart attacks in patients aged over 40 years

14. Ethnicity (3) Revascularisation rates by gender: 1998 -2001

15. 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

16. 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

17. Disability (2): LD rates

18. 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.

19. 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.

20. 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

21. Age(3): Cataract Surgery

22. 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!

23. 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 – health inequalities –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

24. National Drivers Neighbourhood Renewal, Local Strategic Partnerships and Public Service Agreement – –Regeneration programmes – –Social capital – –Role of the NHS as an employer

25. 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