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2
Healt
h inequalit
ies
stra
tegy r
evie
w Social Inequalities in health
Source: Norwegian Ministry of health Care Services, 2007
3
Healt
h inequalit
ies
stra
tegy r
evie
w Pre-birth Young adultsSchool ageEarly years
Health
Personal development
Educational attainment
Infant healthEarly
development
Achievement at end
primary
Developing positive
behaviours
Staying engaged at
16-18
Opportunities to access university
Where you are born, who your parents are and your earliest life opportunities impact on all your life course
0
25
50
75
100
22 42 62 82 102 122
Age months
High social class
Low social class
High test scores
4
Healt
h inequalit
ies
stra
tegy r
evie
w
In 2006 the most affluent 10% are earning relatively much more per week than in 1961 –
the poorest 10% relatively the sameSource: FES, IFS analyses
0
200
400
600
800
1000
1961
1966
1971
1976
1981
1986
1991
1996
2001
£ eq
uiv
alen
t in
com
e
Relative household income
medianincome
poorest10%
richest10%
The income gap between the richest and the poorest is growing not shrinking
5
Healt
h inequalit
ies
stra
tegy r
evie
w
Living in poverty affects every part of peoples’ lives
For example, children living in poverty are less likely to do well at school
And women who grew up in poverty are less likely to earn at / above the average wage as adults
1958 cohort1970 cohort
00.050.1
0.150.2
0.250.3
0.350.4
0.45
CSE/other O-levels A-levels Higher other
Degree orabove
Highest level of qualification
Co
mp
arat
ive
ho
url
y ea
rnin
gs
wit
h t
ho
se w
ith
no
qu
alif
icat
ion
s
0
10
20
30
40
50
60
0-10 11-20 21-30 31 andover
Pupils eligible for free school meals (percentages)
Pu
pil
s w
ith
5 G
CS
E g
rad
es
A*
to C
(p
erc
en
tag
es
)
6
Healt
h inequalit
ies
stra
tegy r
evie
wPoor health is both a cause and a
consequence of poverty
26 30 34 38 42 44 48 540.93
0.94
0.95
0.96
0.97
0.98
0.99
1.00
Age in years
Pro
po
rtio
n a
liv
e
Cumulative death rates 26 to 54 years by father’s social class men and women born in March 1946
Kuh et al, 2003
KeySocial Class I Social Class V
More people born in to Social Class V die in early middle age than those with fathers in Social Class I
7
Healt
h inequalit
ies
stra
tegy r
evie
wIn 2008 there is 40 years difference in apparent health year between Rutland and Manchester
"Apparent health year" Male & Fem ale
2,050 to 2,0702,040 to 2,0502,030 to 2,0402,020 to 2,0302,010 to 2,0202,000 to 2,0101,990 to 2,0001,980 to 1,9901,970 to 1,9801,960 to 1,9701,940 to 1,960
Manchester has an
apparent health year of
1984
Rutland has an apparent health year
of 2023
8
Healt
h inequalit
ies
stra
tegy r
evie
wPeoples lifestyles & related risks are the causes of a
growing burden of disease
0 2 4 6 8 10 12 14
Iron deficiency
Unsafe sex
Illicit drugs
Physical inactivity
Fruit & Veg intake
Overweight
Cholesterol
Alcohol
High blood pressure
Tobacco
Behavioural factors
explain the majority of years lost
Major burden of disease – leading 10 selected risk factors in developed countries
(% cause of disease burdens measured in Disease Adjusted Life Ye
0 2 4 6 8 10 12 14
Iron deficiency
Unsafe sex
Illicit drugs
Physical inactivity
Fruit & Veg intake
Overweight
Cholesterol
Alcohol
High blood pressure
Tobacco
Major burden of disease – leading 10 selected risk factors in developed countries
(% cause of disease burdens measured in Disease Adjusted Life Years)
9
Healt
h inequalit
ies
stra
tegy r
evie
wSome groups live lives that are riskier
to their health
0 10 20 30 40
I
II
IIIn
IIIm
IV
V
Percentage of men Percentage of women0 10 20 30 40
I
II
IIIn
IIIm
IV
V
For males, 30% of people have two of three behaviours in social class V compared to <10% in social class I
For females, 20% of people have two of three behaviours in social class V compared to <5% in social class I
So
cia
l cla
ss
= Three behaviours = Two or more behavioursKey
So
cia
l cla
ss
People in social class V are three to four times more likely to have two of three lifestyle risks (smoking, harmful levels of alcohol consumption and poor diet) compared to those in social class I
= Three behaviours = Two or more behavioursKey
10
Healt
h inequalit
ies
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w
Problems are interrelated
Substance misuse
NEET
Teenage pregnancy
Truancy & BehaviourYouth crime
3 in 5 excluded young people report having
offended
Young people with emotional &behavioural difficulties are
4 times more likely to use illicit drugs
NEETs are disproportionately
likely to misuse drugs & alcohol
71%of young women who are NEET for
6 months & between16-18 are parents by 21
Persistent truants are nearly 10 times more likely to be
NEET at16 and 4 times more
likely to be NEET at 18
11
Healt
h inequalit
ies
stra
tegy r
evie
wFrom mid life onwards smoking has a greater impact on life expectancy than socioeconomic
status does
20 year survival by smoking status and classMALE
30%
40%
50%
60%
70%
80%
90%
never smoked current smoker never smoked current smoker
SC I & II SC IV & V
% s
urv
ival
50%
15%
63%
Smoking status has a bigger influence on 20 year survival
compared to social class
12
Healt
h inequalit
ies
stra
tegy r
evie
w
In deprived areas, patients do not get the best quality of care
y = -0.0009x + 0.9771
R2 = 0.1555
84.0%
86.0%
88.0%
90.0%
92.0%
94.0%
96.0%
98.0%
100.0%
0.00 10.00 20.00 30.00 40.00 50.00 60.00
IMD
% a
chie
vem
ent
QOF Total Points / available %
QOF: % points available
y = -0.0011x + 0.8636
R2 = 0.1058
0.6
0.65
0.7
0.75
0.8
0.85
0.9
0.95
0.00 10.00 20.00 30.00 40.00 50.00 60.00
IMD
% s
atis
fied
- av
erag
e ac
ross
5 d
omai
ns fr
om p
atie
nt s
urve
y
% satisfied - average across 5 domains from patient survey
% satisfied - average across 5 domains from patient survey:
y = 0.0059x + 0.0744
R2 = 0.1799
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.00 10.00 20.00 30.00 40.00 50.00 60.00
IMD
Pro
porti
on o
f Sin
gle
Han
ded
Pra
ctic
es (S
HP
s)
Proportion of Single Handed Practices (SHPs)
Proportion of single handed practices:
• Scoring on the QOF (a measure of the quality of primary care) is higher in more affluent PCTs
• There are proportionally more single handed practices in deprived PCTs
• Patient satisfaction is higher in affluent PCTs
13
Healt
h inequalit
ies
stra
tegy r
evie
wTargeted interventions do work - Sheffield achieved
a 7% greater reduction in CVD death rates in its most deprived communities (23% v 16%)
Sheffield Initiative to Reduce CHD (CIRC)
Identify GP practices with high CHD mortality Targeted support with specialist nurses to assist them in developing at risk registers
and promoting statin prescribing Differential increase in statin prescribing in less privileged areas
Circulatory disease mortality, Sheffield, 1997 - 2008
0
20
40
60
80
100
120
140
160
180
2006200520042003200220012000199919981997
14
Healt
h inequalit
ies
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tegy r
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w
Meet…
Mark MaggieAntonio VictoriaAnatoly Margareta
Charles HelenMario RebeccaSergej Tatjana
15
Healt
h inequalit
ies
stra
tegy r
evie
wChildren’s health has been affected by a several external
global factors
Children are travelling Children are travelling more and exposed to more and exposed to diseases ((skin cancer)diseases ((skin cancer)
Fast food popular with Fast food popular with children – growing children – growing consumption and rising consumption and rising rate of obesity rate of obesity
TV is major source of TV is major source of
entertainmententertainment
Huge medical Huge medical advances in life advances in life saving treatments-saving treatments-more lives savedmore lives saved
Technology has Technology has transformed transformed communicationcommunication
Genetic Genetic disorders – disorders – diagnosed and diagnosed and treated bettertreated better
(foetal (foetal transfusion)transfusion)
Sex, Drugs, Alcohol no longer have the stigma that they once did when people grew up with strongly involved grandparents of the war / Victorian era.
16
Healt
h inequalit
ies
stra
tegy r
evie
wWe say we know we need to eat more fruit &
vegetables – more so than others
Q What do you think ‘eating a healthy diet’ involves?
Germany
UK
Italy
Netherlands
EU 25
Spain
Sweden
France
Ireland
77%
70%
61%
59%
59%
58%
49%
44%
35%
17
Healt
h inequalit
ies
stra
tegy r
evie
w….For childhood obesity, we reckon its up to the
state
76
48
2212
3140
30
69
0
20
40
60
80
Parents Food and drinkmanufacturers
The individual The state
Who is at fault for obesity
Who is responsible for addressing it?
Source: Henley Centre (2005)Note: HCHLV is soon to release up to datedata. Early cuts of which show broadly similar trends
18
Healt
h inequalit
ies
stra
tegy r
evie
w How do we achieve more equal life
chancesWhose responsibility is it?
Baby
Born to affluent parents – will live 10-15 years longer than friends below
Baby
One of many low income teenage conceptions. Will live 10-15 years less than their friends above.
Aged 10
Enjoying a good life, lots of opportunity, good education, etc
Aged 10
Growing up in a disadvantaged environment, as are many kids in Europe
Aged 20
Enter at university with good marks. Plays sport and eats a healthy diet
Aged 20
Left school with
no qualifications, casual labourer, drinks, smokes and takes drugs
Aged 45
Fit and healthy with a good job
Aged 45
Weighs 18 stone/114 kg, has high cholesterol, early stage type 2 diabetic
Charles, Rebecca, Sergej, Helen
Mark, Maggie, Anatoly, Victoria
Aged 60
Died from massive stroke
Aged 60
Retired early to spend time with grand-children and travel
Adapted from: D. Harrison (2007)
19
Healt
h inequalit
ies
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w
As public service leaders we can change people’s life chances and help shape the communities in which we live
The challenges are to…..
• Raise community aspirations for change
• Identify the positive assets and build upon them
• Create and share common cultures across public services
• Work through commissioning and place shaping
• Build upon JSNA
• Lead together
• Identify and share our strengths