Children and Young People: Health Inequalities – Reference Slides Partnership Summit 30th July 2010
Jim McManus Joint Director of Public Health
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 Office Review 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
Stillbirths including major congenital anomalies
Stillbirths adjusted 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
Age 85 80 75 70 65 60 55
Life expectancy DFLE
50 Pension age increase 2026-46 Poly. (DFLE)
45 0
5
10
15
Source: ONS
20
25
30
35 40 45 50 55 60 65 70 75 Neighbourhood Income Deprivation (Population Percentiles)
80
85
90
95 100
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 1400.00
1200.00
1000.00
DSR
800.00
600.00
400.00
200.00
Years Affluent
Less Affluent
Average
Less Deprived
Deprived
/2 00 8 20 06
/2 00 7 20 05
/2 00 6 20 04
/2 00 5 20 03
/2 00 4 20 02
/2 00 3 20 01
/2 00 2 20 00
/2 00 1 19 99
/2 00 0 19 98
/1 99 9 19 97
/1 99 8 19 96
19 95
/1 99 7
0.00
D a ta source : ON S de a th re gistra tions P H IT ca lcula tion
Life Expectancy by Ward
Life Expectancy Gap Males Breakdown of the life expectancy gap with England, by cause - males
100% 90% 31%
All circulatory diseases, 30%
80% 70% 13%
60%
All cancers, 22%
50%
12% 7%
40%
Respiratory diseases, 16% 5%
30%
4% Digestive, 11%
20%
15%
External causes, 7%
10% 13%
Other, 10% Deaths under 28 days, 3%
0% 00CN Birmingham
England Spearhead Group
Infectious and parasitic diseases, 2%
Life Expectancy Gap by Age Group Males Breakdown of the life expectancy gap with England, by age group - males
100%
<1, 4% 15%
90%
30-39, 5% 2%
80%
3%
0%
40-49, 10%
10% 50-59, 17% 20%
50% 60-69, 26%
40% 25%
30% 20%
70-79, 24% 20%
10% 0%
10-19, 1% 20-29, 2%
0%
70% 60%
01-09, 1%
4%
00CN Birmingham
80+, 10%
England Spearhead Group
Life Expectancy Gap Females Breakdown of the life expectancy gap with England, by cause - females
100% 90%
22% All circulatory diseases,
80% 14%
70% 60%
All cancers, 22% 12%
50%
5% 9%
40%
Respiratory diseases, 20%
5%
30% Digestive, 10%
18%
20%
External causes, 3%
10% 14%
Other, 12% Deaths under 28 days, 4%
0% 00CN Birmingham
England Spearhead Group
Infectious and parasitic diseases, 2%
Life Expectancy Gap by Age Group Females Breakdown of the life expectancy gap with England, by age group - females
100% 17%
90% 4%
80%
0%
01-09, 1%
30-39, 3%
10-19, 1%
40-49, 7%
20-29, 1%
1%
5%
70%
<1, 5%
50-59, 14% 11%
60%
9%
60-69, 22%
50% 40%
25%
30% 20%
70-79, 29%
21%
10%
80+, 17% 8%
0% 00CN Birmingham
England Spearhead Group
Section 4: Burden of Health Inequalities
DH Health Profile 2010 www.healthprofiles.info
Significantly better than England average Significantly worse than England average
DH Health Profile 2010 www.healthprofiles.info
Significantly better than England average Significantly worse than England average
A & E Attendances
A and E Social Gradient
Hospital Admissions for Accidents
Statistically significant, above the Birmingham average Statistically significant, consistent with the Birmingham average (normal distribution) Statistically significant, below the Birmingham average
Accident Social Gradient
Self Harm
Female
Male
Deprivation and Service Use CAMHS Tier 3 Add Trendline
Social Gradient for Accessing CAMHS Tier 3 services by CWI Decile 2008 BCH 1.60%
1.40%
1.20%
1.00%
0.80%
0.60%
0.40%
0.20%
0.00% 1
2
3
4
5
6
Child Wellbeing Index Decile (Where 1 is Most Deprived)
7
8
9
10
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
Statistically significant, above the Birmingham average Statistically significant, consistent with the Birmingham average (normal distribution) Statistically significant, below the Birmingham average
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 â&#x20AC;&#x201C; 2009 by Birmingham PCT Diphtheria /Tetanus / Polio
Hib
Diphtheria /Tetanus / Polio
MMR PCV
Primary
Primary
Booster
First Dose
First & 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 in receipt 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 18 year olds[1] has highlighted the following issues for youth smoking which we need 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
Marmotâ&#x20AC;&#x2122;s Conceptual Framework
A Matrix Short Give every child the best start in life
maximise capabilties and have control Fair employment and good work
Natal care Smoking Imms Health visiting
Medium Health visiting Schooling Emotional health
Long Play Integrated education Educational outcomes
An alternative NHS
Local Authority
Other
Healthy standard Access to primary of living 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 Core Strategy Parks and Spaces 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
Infant Mortality
•Maternity specification •Housing •Income Maximisation •Health Visiting •Private Landlord •Pick up & Pass •Childrens Centres
Child Obesity
•Nutrition planning with parents pre-school •GP screening and nutrition classes •Parenting Skills
•School PH Nursing •School Day NutritionAction Balance •Obesogenic environment •Physical Activity/Play
Mental Health
•CAMHS check for all professionals •Pick up and pass
•Tier 1 in schools •Emotional health curriculum
Other •Community culture change
•Health Trainers
A Matrix..continued NHS Infectious Diseases
Self Harm
Smoking initiation Child Poverty
LA
Other
Conclusions
• Persistent Social Inequalities • Persistent Health Inequalities • Needs Clear “Matrix” Child Public Health Strategy • Focus on key outcomes