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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


Health_Inequalities_Reference_Slides_CYPP_Summit_30_July_2010