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Sheffield Equality Group21 October 2010

Health Inequalities in Sheffield

Jeremy Wight

Director of Public Health

Health inequalities in Sheffield

• Inequalities present and past

• Causes of health inequality

• What can and are we doing about it?

• Last thoughts

Slope Index Chart for Life Expectancy by Deprivation Decile

Sheffield PCT, Males, 2004-2008Slope Index = xxx 95% Confidence Interval = ( xx, yy)

65.0

70.0

75.0

80.0

85.0

90.0

95.0

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Percentage of population, ranked by IMD2007 score from most deprived to least deprived

Lif

e E

xpec

tan

cy a

t B

irth

(ye

ars)

SOURCE: IMD2007, PH Mortality, PH Births, PHR NHS Sheffield, Public Health Analysis team, V 0.2, 9th October 2009

Health inequalities in 1892

Fairer Sheffield, Healthy LivesDistrict All age mortality / 1000 Infant mortality

Sheffield West 24.15 198.0

Sheffield North 27.65 270.3

Sheffield South 22.24 222.2

Sheffield Park 22.33 201.2

Brightside 20.20 206.1

Attercliffe 21.17 266.6

Nether Hallam 08.90 198.9

Upper Hallam 14.60 100.0

Eccleshall 17.80 158.1

All Sheffield 20.75 205.3

Health inequalities in 1987

What do we mean by health inequality?

• Analysis by:– Geography– Income– Class– ‘Community of interest’

• Analysis of:– Mortality / life expectancy– Other measures of health and wellbeing

What are the causes of health inequality?

• Causes of death

• Causes of disease

• Causes of the causes

• Residential sorting?

Causes of death (m)

MaleAttributable LE gap (yrs)

Proportion of gap

Coronary Heart Disease 0.5 19.8%

Lung Cancer 0.2 9.3%

Chronic Obstructive Airways Disease 0.2 8.9%

Other Cardiovascular Diseases 0.2 6.2%

Other Accidents 0.1 5.0%

Chronic Cirrhosis of the Liver 0.1 5.0%

Suicide & Undetermined Injury 0.1 4.5%

Pneumonia 0.1 3.9%

Other Digestive Diseases 0.1 3.9%

Stroke 0.1 3.6%

Deaths Under 1 Year of Age * 0.1 5.3%

All other 0.6 24.6%

Causes of death (f)

Female Attributable LE gap (yrs)Proportion

of gap

Lung Cancer 0.3 14.8%

Chronic Obstructive Airways Disease 0.2 14.2%

Coronary Heart Disease 0.2 14.1%

Stroke 0.1 8.4%

Other Respiratory Diseases 0.1 5.8%

Other Cardiovascular Diseases 0.1 5.7%

Pneumonia 0.1 5.0%

Chronic Cirrhosis of the Liver 0.1 4.5%

Ill-Defined Conditions 0.1 4.4%

Diseases of the Nervous System 0.1 3.1%

Deaths Under 1 Year of Age * 0.0 0.8%

All other 0.3 19.2%

Causes of disease

• Smoking

• Physical inactivity

• Poor diet

• Alcohol

• Drugs

Causes of the causes

• Cheap and illicit tobacco (smuggling)

• Absolute and relative poverty

• Unemployment and underemployment

• Poor housing

• Low educational achievement

• Low aspiration

Inequality in wellbeing

• Nic Marks – New Economics Foundation

Diminishing marginal returnsof well-being to income

Life satisfaction and Household income in the UK

5.00

5.50

6.00

6.50

7.00

7.50

8.00

£0 £20,000

£40,000

£60,000

£80,000

£100,000

£120,000

£140,000

Household total net income

Lif

e S

ati

sfa

cti

on

(0

-10

)

Diminishing marginal returnsof well-being to income

Life Satisfaction and Income Quintiles

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

8.5

Low Income Low-MediumIncome

MediumIncome

High-MediumIncome

High Income

Lif

e S

ati

sfa

cti

on

(0

-10

)

Average Social Connections

What are we doing about it?

• What has worked in the past – CIRC

• Fairer Sheffield, Healthy Lives

<75 Circulatory Mortality Rates% decrease in rate relative to 1997-1999

-60%

-50%

-40%

-30%

-20%

-10%

0%

2004-2006

2003-2005

2002-2004

2001-2003

2000-2002

1999-2001

1998-2000

Most Deprived ED Quintile Sheffield

Public Health Analysis Team, Sheffield PCT

Male Life Expectancy Gap

Male Life Expectancy - Gap between Most Deprived Neighbourhood Quintile and Sheffield

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Lif

e E

xp

ec

tan

cy

Ga

p (

Years

)

Actual gap Exponential projection Linear projection 2010 Target Gap

Actual gap 3.4 3.4 3.1 2.9 2.8 3.0 3.2 3.2

Exponential projection 3.0 2.9 2.9 2.9 2.8 2.8 2.7 2.7 2.7 2.6

Linear projection 2.9 2.9 2.9 2.8 2.8 2.7 2.7 2.7 2.6 2.6

2010 Target Gap 3.4 3.4 3.4 3.3 3.3 3.3 3.2 3.2 3.2 3.1 3.1 3.1

1997-2001

1998-2002

1999-2003

2000-2004

2001-2005

2002-2006

2003-2007

2004-2008

2005-2009

2006-2010

2007-2011

2008-2012

2009-2013

2010-2014

2011-2015

2012-2016

2013-2017

2014-2018

Source: Public Health Analysis Team, Sheffield PCT ( 5 year rates)

Female Life Expectancy Gap

Female Life Expectancy Gap between Most Deprived Neighbourhood Quintile and Sheffield

-0.5

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Lif

e E

xp

ec

tan

cy

Ga

p (

Yea

rs)

Actual gap Exponential projection Linear projection Target Gap

Actual gap 2.9 2.4 2.3 2.2 2.0 1.8 1.8 1.8

Exponential projection 1.5 1.3 1.2 1.0 0.9 0.7 0.6 0.4 0.3 0.1

Linear projection 1.5 1.3 1.1 1.0 0.8 0.7 0.5 0.3 0.1 0.0

Target Gap 2.9 2.9 2.9 2.8 2.8 2.8 2.8 2.7 2.7 2.7 2.6 2.6

1997-2001

1998-2002

1999-2003

2000-2004

2001-2005

2002-2006

2003-2007

2004-2008

2005-2009

2006-2010

2007-2011

2008-2012

2009-2013

2010-2014

2011-2015

2012-2016

2013-2017

2014-2018

Source: Public Health Analysis Team, Sheffield PCT( 5 year rates)

Fairer Sheffield, Healthy Lives

Health Inequalities Action Plan2010-2013

Fairer Sheffield, Healthy Lives

Fairer Sheffield Healthy Lives

• Based on Marmot report• 6 areas for action:

– Give every child the best start in life– Enable all to maximise capabilities and have control

over their lives– Create fair employment and good work for all– Ensure a healthy standard of living for all– Create and develop healthy and sustainable places

and communities– Strengthen the role and impact of ill health prevention

What would a really radical approach look like?

• Shuffling and re-distributing the population• Equalising incomes• De-normalising tobacco smoking in all parts of

society• De-criminalising currently illegal drugs• Random allocation of school places across the

City

Conclusions• Health inequalities are deeply ingrained in the

unequal nature of society• As public health leadership moves from the NHS

to local authorities, it is vital that links with General Practice are not lost

• Efforts to reduce inequalities must focus on improving the health of disadvantaged communities

• There have been huge improvements in the health of disadvantaged communities, even if health inequalities have not reduced as much as we would wish.

Closing the health gapin Sheffield

Danny Dorling

7pm Thursday 21st October 2010Domino Hall, Sheffield Cathedral

Health inequalities have exercised people in Sheffield for many years.This extract below is from ‘Sheffield Targets’ thanks to Geoff Green for sending me a copy of the 1987 pamphlet, in which it said:

Here is the map then. No average is now below age 65, but the gap is now much larger in terms of life expectancy

08/04/23 © The University of Sheffield

Average life expectancy varies by 20 years at the extreme (for women). For men the gap has more than doubled to 16 years.But these are all figures from below the economic crash and before the spending cuts and their effects on inequality

National Government policy had been here – more reviews and yet more reviews but income inequalities rising slowly (6.1:1 to 7.2:1 between quintile groups 1997-2008 in the UK)

Then came the spending review

October 20th 2010 – we were told how savings would be made:One of the first announcements was that new tenants of council and other social housing will now have to pay at least 80 percent of market prices in rent. In one stroke millions of low paid families are to be excluded from living in hundreds of towns, cities and villages where they no longer earn enough to “deserve” to be.

Housing benefit will not be paid for people under the age of 35 who live alone—this previously applied only to those under 25.There would be a 10 percent cut in council tax benefit for those who can not afford to live in certain areas.Are the few remaining people living on modest incomes near affluent suburbs or in economically successful towns and villages to be cleansed away?

It could be the greatest threatThe best-off fifth of society will lose just 1 percent of their entitlements to public services and spending, the lowest losses of any group.A million people currently on employment and support allowance due to ill health will each loose £2,000 a year if they cannot find a job.With the state pension age rising rapidly to 66 years. Only those with private provision can now retire at the normal age. Public sector pensioners will have £1.8 billion removed from them by 2014-15. Pension credits will be frozen for three years.

No family on benefits is to receive more than the income of an average family in work, no matter what the circumstances of their children. If you are poor—or are made poor when you lose your job or have a pay cut forced on you—and have three or more children, you may need to leave your town for a new life in a cheaper area, away from where the remaining well paid work is. People with worse health will have to move to poorer areas.

The health service is being cut

Provision for the NHS did not include the extra costs of the 1946 baby boomers retiring, or the cost of new privatisations being introduced there (which were not even in the Tory manifesto – but are now taking place).Provision for education would not maintain current rates of spending per child once the new privatised “free” school costs are added in. University places will be slashed. This will change who lives where and hence health inequalities.

As school budgets will also be cut, in practise parents may try even harder to live away from more average areas – if they can – raising health inequalities higher again.The educational maintenance allowance for less well-off children will be phased out, another significant cut to children’s finances which, when combined with all the chancellor’s other measures, means that child poverty will rise—despite what he suggested in this speech

Redistribution to better-off

More affluent savers who lost money they invested in Equitable Life and the Presbyterian Mutual Society will soon receive £1.7 billion from tax payers—mostly from tax payers poorer than them. Thus money is being redistributed towards the affluent.There will be more property for the affluent to buy with these windfalls in affluent areas, in villages and in market towns, as the poor vacate their homes for cheaper places to live – increasing inequality.

Local government will be allowed to borrow more in richer areas, against expected business rates, instead of Westminster borrowing, so that the places where business makes a lot of money can be spruced up. Local government in poorer areas cannot make such newly permitted borrowing. Although there are a few token schemes outside the South East, most capital spending is now concentrated there as a result of the cuts.

This is a common response• On 21 October, Teresa

Perchard, director of policy at the Citizens Advise Bureau, warned that housing benefit changes would “create a group of nomads…maybe not where the jobs are.”

• On the same BBC radio programme, Alan Johnston said that Osborne’s speech was “unfair, unwise and untruthful in some of the statistics” and that the chancellor was “asking children to make a bigger contribution than the banks”.

• The former Conservative chancellor, and current secretary of state for justice, Ken Clark (69), had warned of a double-dip recession if cuts were savage.

• Many younger people will now go abroad to find work or a university place. Many of them will never return. Poorer families will struggle the most, but fewer will be visible through the windows of ministerial cars

Think back to 1985 & WHO1

• In 1985 Margaret Thatcher signed the WHO target to reduce inequality by 25% by 2000.

• It increase by much more than 25%. She had not thought it would.

• The gap was measured between areas for all age groups and for infants by social class

• She believed in “trickle down”, in a private sector lead recovery that would bring prosperity to all, with the worst-off benefitting the most as the well-off already lived the longest. She thought she was fair

• More people died young as a result.

Conclusion – keep askingWhy are 16 or 20 countries better?

The latest UN report lists those European countries currently having a higher life expectancy than the UK as: Iceland (almost 82 years), Switzerland, Italy, France (81 years), Sweden, Spain, Norway, Austria (to almost 80 years), the Netherlands, Germany, Ireland, Malta, Cyprus, Finland, Belgium and Luxembourg. People also live for longer than in Britain in Australia, Canada and New Zealand (and especially Japan), but not in the United States (where comparable life expectancy is only 79.1 years)

People do live slightly shorter lives now in Greece, Portugal (more economically unequal than the UK), Denmark (where smoking is still very common) and in Slovenia (78.2 years). All these figures are from Table H of the most recent UNDP human development report (2009) and purport to be for around the year 2007.Life expectancy is up in the UK, but Increased economic inequality in the UK would be expected to move our rank position below one of these four countries next, to slip from 20th place to 21st or 22nd out of 25.

Of the richest 25 nations in the worldthe UK is the 4th most unequal by incomeinequality (90:10 ratio UNDP figures).

Is premature death a price worthpaying in the eyes of some policy makers? – just “inevitable”….

An email – received today“Oh Danny you are far far to nice and reasonable a person to really understand just how

callous and murderous this lot really are. They are the aristocracy and they really do not 'give a ****' about the poor or even the middle class.”

“The best way to explain the effects of the changes to housing benefit is to quote the Tory ministers own words i.e. which ministers say will force an exodus from London and other areas with high property prices ? "it's the Highland clearances", one said”

“Their plan is a 'Highland Clearance' of London, the South East, Bath, York, Bristol, Edinburgh, etc. This is not an accidental change it is a deliberate planned strategy.”

… “about 50,000 households will be affected, with hundreds of thousands more hit by the cap on housing benefit (which ministers say will force an exodus from London and other areas with high property prices ? "it's the Highland clearances", one [Daily Telegraph quoted but not named Tory minster] said).‘”

Cheers!

Source of ministerial quote: Ben Brogan, 2010, “Conservative party conference 2010: Let battle commence”, Daily Telegraph, 6th October: http://www.telegraph.co.uk/comment/columnists/benedict-brogan/8047179/Conservative-party-conference-2010-Let-battle-commence.html

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