Partnership Summit 30th July 2010

Jim McManusJoint Director of Public Health

Children and Young People: HealthInequalities – Reference Slides

Section 1: Background and Introduction

National Audit Office 2010

Unequal distribution of determinants underlies health inequalities

• Inequalities in ‘general socioeconomic & environmental conditions’

• unequal access to good education, secure employment, income etc

• Inequalities in living & working conditions from childhood to old age

inequalities in

• Inequalities in community resources

• Inequalities in lifestyle factors like cigarette smoking, diet & physical activity

National Audit OfficeReview of Health Inequalities 2010

• Not on course to meet target for spearheads nationally

• Gap between spearheads and national targets

• Persisting health inequalities despite the Quality and Outcomes Framework and despite the introduction of spearheads.

• Quality of primary care crucial• Spearheads suggested to be of limited

effectiveness

Challenges

• Be clear about problems• National Support Teams and implementing

recommendations• Reconfiguration• Be clear about what actually works and what

doesn’t• Be clear whose role it is• Focus on priorities• Primary Care is key to short term• Focused on outcomes

Section 2: Births, Stillbirths and Infant Mortality

Total Births

Stillbirthsincluding major congenital anomalies

Stillbirthsadjusted to exclude major congenital anomalies

Stillbirth Main Groups

Infant Deaths

Section 3: Early and Avoidable Death

Life expectancy and disability free life expectancy at birth, persons by neighbourhood income level, England, 1999-2003

45

50

55

60

65

70

75

80

85

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

Neighbourhood Income DeprivationSource: ONS (Population Percentiles)

Age

Life expectancy

DFLE

Pension age increase2026-46Poly. (DFLE)

Years of Life Lost (Under 20 yrs)ONS 2005-2008, Latest source

Male AAACM by IMD Quintile in Birmingham 1995 - 2008

Three year rolling average

0.00

200.00

400.00

600.00

800.00

1000.00

1200.00

1400.00

1995

/ 19

97

1996

/ 19

98

1997

/ 19

99

1998

/ 20

00

1999

/ 20

01

2000

/ 20

02

2001

/ 20

03

2002

/ 20

04

2003

/ 20

05

2004

/ 20

06

2005

/ 20

07

2006

/ 20

08

Years

DS

R

Affluent Less Affluent Average Less Deprived Deprived

Data source : ONS de ath registra tionsPHIT ca lcula tion

Life Expectancy by Ward

Life Expectancy Gap Males

Breakdown of the life expectancy gap with England, by cause - males

7%

13%

15%

4%

5%

12%

13%

31%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

00CN Birmingham England Spearhead Group

All circulatory diseases, 30%

All cancers, 22%

Respiratory diseases, 16%

Digestive, 11%

External causes, 7% Infectious and parasitic diseases, 2%

Other, 10%

Deaths under 28 days, 3%

Life Expectancy Gap by AgeGroup Males

Breakdown of the life expectancy gap with England, by age group - males

20%

10%

0%

4%

25%

20%

3%0%2%

15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

00CN Birmingham England Spearhead Group

<1, 4%

80+, 10%

70-79, 24%

60-69, 26%

50-59, 17%

40-49, 10%

30-39, 5%20-29, 2%

10-19, 1%

01-09, 1%

Life Expectancy Gap Females

Breakdown of the life expectancy gap with England, by cause - females

18%

5%

22%

14%

5%

9%

12%

14%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

00CN Birmingham England Spearhead Group

All circulatory diseases,

All cancers, 22%

Respiratory diseases, 20%

Digestive, 10%

External causes, 3% Infectious and parasitic diseases, 2%

Other, 12%

Deaths under 28 days, 4%

Life Expectancy Gap by AgeGroup Females

Breakdown of the life expectancy gap with England, by age group - females

11%

8%

21%

25%

9%

5%1%0%4%

17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

00CN Birmingham England Spearhead Group

<1, 5%

80+, 17%

70-79, 29%

60-69, 22%

50-59, 14%

40-49, 7%

30-39, 3%

20-29, 1%

10-19, 1%

01-09, 1%

Section 4: Burden of Health Inequalities

DH Health Profile 2010www.healthprofiles.info

Significantly better than England average

Significantly worse than England average

DH Health Profile 2010www.healthprofiles.info

Significantly better than England average

Significantly worse than England average

A & E Attendances

A and E Social Gradient

Statistically significant, above the Birmingham average

Statistically significant, consistent with the Birmingham average (normal distribution)

Statistically significant, below the Birmingham average

Hospital Admissions for Accidents

Accident Social Gradient

Self Harm

Female Male

Deprivation and Service UseCAMHS Tier 3

Social Gradient for Accessing CAMHS Tier 3 services by CWI Decile 2008BCH

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

1.60%

1 2 3 4 5 6 7 8 9 10

Child Wellbeing Index Decile (Where 1 is Most Deprived)

Add Trendline

Statistically significant, above the Birmingham average

Statistically significant, consistent with the Birmingham average (normal distribution)

Statistically significant, below the Birmingham average

Income Deprivation Affecting Children

Statistically significant, above the Birmingham average

Statistically significant, consistent with the Birmingham average (normal distribution)

Statistically significant, below the Birmingham average

Positive Contribution:Youth Offending by Ward

Obesity

Core City Results Childhood Obesity 2006/07 to 2008/09

Core City Reception Year 6

Dateline 2006/07 2007/08 2008/09 2006/07 2007/08 2008/09

Birmingham 11.3% 10.6% 10.8% 21.5% 22.1% 21.6%

Bristol 10.3% 9.7% 10.4% 19.5% 15.2% 17.9%

Leeds 8.4% 9.2% 10.3% 19.3% 17.8% 20.9%

Liverpool 12.1% 10.6% 10.4% 20.8% 18.0% 22.6%

Manchester 11.5% 11.5% 12.4% 21.9% 22.8% 22.6%

Newcastle upon Tyne

10.9% 10.9% 12.3% 20.8% 21.3% 21.9%

Nottingham 12.8% 12.5% 10.0% 22.0% 20.1% 22.6%

Sheffield 8.1% 6.9% 9.4% 17.4% 14.8% 18.7%

Children Obese Year 0 by PCT

Source PHIT 2010

Children Obese Year 6 by PCT

Source PHIT 2010

Birmingham by Cadbury Neighbourhood Classifications

• Understanding these as drivers and intervening variables

• Transit or Escalator– move to less deprived areas

• Isolate – move to equally or more deprived areas

Section 5: Preventive Health Measures

Data on dental public health is in the previous section

Immunisation 1st Birthday

1st Birthday Childhood Immunisations 2008 – 2009 by Birmingham PCT

DTaP/IPV/Hib MMR PCV

% % %

ENGLAND 92 91 91

WEST MIDS 94 94 94

NHS BEN 90 89 90

HOB PCT 93 93 93

NHS SOUTH 91 91 91

Immunisation 2nd Birthday

2nd Birthday Childhood Immunisations 2008 – 2009 by Birmingham PCT

DTaP/IPV/Hib MMR MenC Hib/Menc PCV

% % % % %

ENGLAND 94 85 92 85 81

WEST MIDS 96 88 95 90 86

NHS BEN 92 88 91 85 83

HOB PCT 96 94 94 90 89

NHS SOUTH 95 85 93 87 82

Immunisation 5th Birthday

5th Birthday Childhood Immunisations 2008 – 2009 by Birmingham PCT

Diphtheria /Tetanus /

PolioHib

Diphtheria /Tetanus /

Polio

MMRPCV

Primary Primary Booster First DoseFirst & Second

Dose

% % % % %

ENGLAND 93 91 80 89 78

WEST MIDS 96 94 87 91 82

NHS BEN 95 94 82 92 78

HOB PCT 95 94 90 95 89

NHS SOUTH 95 94 79 91 76

Smoking/Tobacco 1

• 25% citywide prevalence of smoking allages– Much higher in more deprived areas i.e., 45% in

Kingstanding, over 30% in Longbridge…

• Nearly 50% smokers are under 35 years old– Inequality: Routine and manual smoking rates are the

highest, tend to have more children under 5 than the better off

• New Tobacco Control Strategy for Birmingham aims to denormalise smoking in the city

Smoking/Tobacco 2

• In 2009, 6% of pupils smoked regularly (at least once a week) • The prevalence of regular smoking among 11 to 15 year olds

has halved since its peak in the mid 1990s – 13% in 1996 –suggesting a sustained decline to levels well below the government’s 1998 target of reducing the prevalence of regular smoking among 11 to 15 year olds to 9% by 2010

• Girls are more likely to smoke regularly than boys (7% and 5% respectively)

• The prevalence of smoking increases with age, from less than 0.5% of 11 year olds to 15% of 15 year olds.

• White pupils are more likely to smoke than pupils of Black or Mixed ethnicity, and smoking is also more likely among pupils inreceipt of free school meals, an indicator of low family income

• Regular smoking is also associated with drinking alcohol, drug use, truancy and exclusion from school

Smoking/Tobacco 3

A recent research project in Birmingham on the Use of Tobacco by Under 18year olds[1] has highlighted the following issues for youth smoking which weneed to act on;• we need to understand more about how many young people smoke, and what

services they think they need and would access • Given the access many young people have to cigarettes through family and

friends, at home and at school, through retailers and from illegal sources, strategies need to be developed at the community level which involve families, social networks and key stakeholders rather than just individual smokers

• addressing community norms including attitudes towards youth smoking and purchasing or providing cigarettes for under 18s

• continued action to increase the enforcement of the age of sale law through retailer education, encouragement of requests for IDs and targeted test purchasing and fines. There is some evidence from this study that this is taken more seriously by retailers for alcohol sales

[1] The Use of Tobacco by Under 18 year olds. Amos A, Robinson, J 2009

Smoking/Tobacco 4 :Suggested Actions

• action to address proxy sales (may require legislation on purchasing on behalf of under-18s), though experience in other countries suggests that this may be difficult to enforce

• continued action to reduce cigarette and tobacco black market activities

• action in schools including smoking prevention programmes and review of policies on smoking in school grounds and premises. This may require extra resources and training

• more local research to (i) increase understanding about youth access and sources (including 16 and 17 year olds) and (ii) assess youth prevention programme and cessation service needs

Section 6: What Can be Done?

• Short Term

• Medium Term

• Long Term

Marmot’s Conceptual Framework

A Matrix

Short Medium Long

Give every child the best start in life

Natal care

Smoking

Imms

Health visiting

Health visiting

Schooling

Emotional health

Play

Integrated education

Educational outcomes

maximise capabilties and have control

Fair employment and good work

An alternative

NHS Local Authority

Other

Healthy standard of living

Access to primary care

Target least healthy for intervention

Decent Homes (social sector)

Physical environment

Decent homes (private sector)

Physical environment

Culture of healthy living

Healthy and sustainable places

Encourage physical activity

Licensing

Parks and Spaces

Core Strategy

Planning

Transport Strategy

Strengthen ill health prevention

Identify, target and screen in primary care

Behavioural pathways and self-management

Change culture

Priorities for Scrutiny

• Having a clear overview of the problems and solutions

• Asking the awkward questions• “Will this really make Birmingham

healthier and reduce inequalities?”• Scrutinising delivery and progress• Understand short, medium and long term• Understand key role of Primary Care• Ensure system is capable, appropriately

funded and is DELIVERING

Matrix for our persistent issues

NHS Local Authority

Other

Infant Mortality

•Maternity specification

•Health Visiting

•Pick up & Pass

•Housing

•Income Maximisation

•Private Landlord

•Childrens Centres

•Community culture change

Child Obesity

•Nutrition planning with parents pre-school

•GP screening and nutrition classes

•Parenting Skills

•School PH Nursing

•School Day Nutrition-Action Balance

•Obesogenic environment

•Physical Activity/Play

•Health Trainers

Mental Health

•CAMHS check for all professionals

•Pick up and pass

•Tier 1 in schools

•Emotional health curriculum

A Matrix..continued

NHS LA Other

Infectious Diseases

Self Harm

Smoking initiation

Child Poverty

Conclusions

• Persistent Social Inequalities

• Persistent Health Inequalities

• Needs Clear “Matrix” Child Public Health Strategy

• Focus on key outcomes