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Tackling Life Expectancy Gap

Introduction

“Inequalities are a matter of life and death, of health and sickness, of well-being and misery. The fact that in England today people from different socio-economic groups experience avoidable differences in health, wellbeing and length of life, quite simply, unfair and unacceptable”

(see reference 1).

Life expectancy at birth is the number of years of life from birth that can be expected on average in a given population. Life expectancy at birth has increased over recent years in Haringey and nationally. There are significant inequalities nationally and locally in the life expectancy according to socio-economic group and ethnicity; certain sub-groups such as people with mental health problems also have a lower life expectancy than the general population. Reducing the gaps in life expectancy between boroughs of lower life expectancy (previously called Spearhead areas) and the England average has been a focus of national policy (see reference 2). In Haringey we have a stark difference in life expectancy between deprived and affluent wards in Haringey, especially for men.

Achieving “A reduced gap in life expectancy” is Outcome 2 of the Health and Wellbeing Strategy (see reference 3). Key interventions to address this gap are tackling lifestyle factors and ensuring early intervention and prevention of key diseases. This chapter gives an overview of tackling the life expectancy gap in Haringey. It links closely with other more detailed sections including: the population profile for Haringey (particularly life expectancy, premature mortality), sections on life style issues (drug misuse, alcohol, obesity, diet and nutrition, physical activity, smoking) that need to be tackled to reduce the life expectancy gap and sections on certain diseases (cardiovascular diseases, respiratory diseases, cancer, diabetes) that contribute to the life expectancy gap.

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Key issues and gaps

Life expectancy is increasing in Haringey and nationally.
There is significant inequality in male life expectancy in Haringey. There are approximately nine years gap in male life expectancy between Tottenham Green in the east and Fortis Green in the west
Life expectancy is significantly lower in certain “vulnerable” groups.
Key contributors to the life expectancy gap are stroke, heart disease, cancer, alcohol, lung disease and deaths in men over 40.
Haringey has a high number of smokers. Smoking is a major risk factor for cardiovascular disease and cancers and is responsible for half the difference in death rates between socio-economic groups in middle aged men
Addressing the life expectancy gap requires action on a number of fronts:
- Prevention – particularly addressing smoking, obesity, alcohol misuse and physical inactivity
- Early intervention – to diagnose and treat major diseases early i.e. cancer, cardiovascular disease (CVD) and other long term conditions
Approaches include: delivery across the social gradient, target key groups e.g. mental health users, addressing the wider determinants
The council and NHS have key roles working with partners including the voluntary sector and communities

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Who is at risk and why

Life expectancy in men is lower than for women in Haringey, London and England and Wales. Haringey females live 6.3 years longer than Haringey males on average (83.7 years compared to 77.4 years) (Office for National Statistics 2008-10, see JSNA section on population profile) - (see reference 4).
There are big differences in life expectancy in males between the east and west of Haringey: nine years difference between the highest in Fortis Green (81.5) and the lowest in Tottenham Green (72.5) (see reference 5) (see also JSNA section population profile). The gap in life expectancy across Haringey, mirrors the Index of Multiple Deprivation across the borough.
However most risk factors and mortality inequalities show a gradient from worse to better health across socio-economic groups rather than just good health for the affluent and bad health for the poor in society. The Marmot Review (see reference 1) emphasises that policy delivery and resources should reflect this gradient rather than just focus on the worst off.
Certain “vulnerable’” groups in society e.g. people with mental health problems or learning disabilities also have a lower life expectancy than the general population. For example a person with schizophrenia lives on average 10 years less than some one without a mental health problem, mainly due to physical health problems (see reference 6).
Figure 1 shows the proportion of the life expectancy gap that is due to different age groups. National guidance suggests efforts to encourage early intervention in disease and thus reduce the life expectancy gap should focus on the over 40s. This is consistent with the Haringey picture where the majority of the life expectancy gap is in the over 40s: 8% is due to men aged 40-49 years, 30% of the gap is due to men aged 50-59 years, 35% is due to men 60-69 years; in total 73% of the gap in male life expectancy is due to men aged 40-69 years.

Figure 1. Life expectancy gap between Haringey and England. Breakdown by cause of death and by age group, males (2006-8) - “the scarf”:

Figure 1 Tackling Life Expectancy Gap

Figure 2 Life Expectancy Gap

Source: Independent health inequalities intervention toolkit, London Health Observatory (see reference 7)

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The level of need in the population

The life expectancy at birth in Haringey has increased over recent years as it has nationally (see section on population profile). However whilst life expectancy for Haringey males is significantly worse than the England average (77.4 and 78.6 respectively), life expectancy in females in Haringey is significantly higher than in England (83.7 and 82.6 respectively). (Office for National Statistics (2008-10) (see reference 4). See also JSNA section on population profile.
Figure 1 “the scarf” demonstrates that main contributors to the male life expectancy gap between Haringey and England by cause of death. CVD (28%) and cancers (25%) are major contributors to the life expectancy gap. The contribution of other causes is shown: respiratory diseases includes chronic obstructive pulmonary disease (COPD), a long term condition closely related to smoking; alcohol related conditions, such as chronic liver disease and cirrhosis, are important contributors to digestive diseases and external causes including accidental injury and suicides and excess winter deaths have an important seasonal contribution. Diabetes is important both as a risk factor for heart disease and stroke and prevalent in its own right particularly within Black and minority ethnic groups (BME) (including South Asian and Black) and deprived groups. Local information shows under-diagnosis of many of these diseases and their risk factors, high rates of admissions, and other indicators suggesting late diagnosis (e.g. indicators of poor diabetic control, poor cancer survival). As with life expectancy many of these indicators are worse in east Haringey than west and amongst lower socio-economic groups or BME groups.
Reducing inequalities in CVD and cancer mortality in adults (particularly men over 40) will have the greatest impact on reducing inequalities in life expectancy in Haringey.
More information on the distribution of these diseases and how they can be prevented and treated can be found in relevant chapters.
It is well established that a number of modifiable behavioural risk factors are linked to both increased likelihood of CVD and cancers as well as other long term conditions (e.g. diabetes). Figure 2, “the caterpillar” demonstrates the proportion of deaths attributable to each factor.
Smoking, physical inactivity, obesity, poor nutrition and alcohol are important risk factors (see reference 8) for CVD and cancers, demonstrate a social gradient across socio-economic groups and are commoner in certain BME groups and sub-groups such as people with learning disabilities. Addressing inequalities in these factors in the population through preventative programmes will lead to a reduction in the life expectancy gap (see reference 1 and reference 9).
More information on the distribution of these risk factors and how they can be reduced in Haringey can be found in relevant chapters.

Figure 2: Key modifiable behavioural factors contributing to death in Haringey. The “caterpillar”

Figure 3 Tacking Life Expectancy Gap

Source: Public Health Mortality File (Prepared by NHS Islington) (see reference 10).

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Current services in relation to need

“Inequalities in health exist, whether measured in terms of mortality, life expectancy or health status; whether categorised by socioeconomic measures or by ethnic group or gender.” (see reference 11).

Prevention

The behavioural risk factors contributing to the key causes of death are distributed unequally within the population of Haringey by geography, socio-economic or ethnic group (see sections on relevant risk factors). For example, smoking prevalence and childhood obesity both show a pattern by electoral ward similar to life expectancy with more affluent wards having poorer health than deprived wards.
National, regional and local policy documents emphasise the importance of reducing inequalities in these risk factors in order to reduce inequalities in life expectancy. The Health Inequalities National Support Team (see reference 9) recommended making “Health Gain” everyone’s business – this includes providing training in brief interventions (see below, physical activity section) and monitoring referrals for all front line staff from health, local authority and voluntary sector.
There is a range of preventative services in Haringey, (more details are found in the relevant JSNA sections). These include services supporting individual life style change – for example the Stop Smoking Service (Smoke Free Enfield and Haringey (external link)) and the exercise referral scheme (Active for Life). There are also generic services, including the Health Trainer Service that works with clients in the east of Haringey to identify, set goals and support behaviour change across a number of lifestyle issues. Key areas are taken forward in partnership, for example, Tobacco Control – through the Enfield and Haringey Tobacco Control Alliance.

Early intervention and management of key diseases

Again within Haringey there are many examples of inequalities of disease detection, access to services or outcomes for the common diseases (see JSNA sections for those diseases). Examples include: variations in cancer screening rates by GP practice and ward level differences in CVD mortality and diabetes admissions showing a similar pattern to male life expectancy by ward.
The Health inequalities National Support Team (see reference 9) identified evidence based actions that would have an effect on reducing inequalities within a short timescale. This includes early diagnosis and management of disease (early intervention) and effective prevention of further illness (secondary prevention) in people who are already ill e.g. had a heart attack or stroke. A systematic approach to diagnosis and treatment of chronic diseases is required to tackle the socio-economic gradient and reduce inequalities in outcomes.
Within Haringey work is being taken forward on a number of fronts: work is underway to reduce practice variation in diagnosis and referral rates and a number of programmes raise public awareness of signs and symptoms of certain diseases for example through community champions for diabetes and for cancer services. The NHS Health Checks programme (see reference 12) is an important public health programme to prevent cardiovascular disease through systematic assessment of risk factors and support to address behavioural factors or prescribing medication as required. Integrated care services are being developed to improve patient experience and disease management.

Wider determinants of health

Addressing the wider determinants of health such as income and housing will have the greatest impact on life expectancy inequalities in the longer term (see reference 2). These are important issues in Haringey and relate to key work-streams for the council and partners as outlined in the Haringey Health and Wellbeing Strategy (see reference 3) including: the regeneration of Tottenham and the social inclusion policy.

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Service users and carers opinion

Service users and carers views have been sought within some of the key programmes that support tackling the life expectancy gap. Examples are: very active user and carer involvement in stroke care pathway design and the implementation and development of stroke services in Haringey and focus groups and interviews of users in the evaluation of the NHS Health Checks pathway. An Overview and Scrutiny Review of Men’s Health in Haringey involved users in identifying issues and we are now working closely with the Men’s Health Forum.

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Expert opinion and evidence base

Tackling the Life Expectancy Gap: briefing paper for the cross party working group. Haringey Council, 2011 (see reference 13).
Fair Society, Health Lives: The Marmot Review. 2010. (see reference 1)
London Health Inequalities Strategy. Greater London Authority, April 2010 (see reference 14)
Redoubling Efforts to achieve the 2010 National Health Inequalities Life Expectancy Target. Department of Health, March 2010 (see reference 9).
Five Year Strategy 2009/10 -2013/14. Nottingham City (see reference 8).
Health Inequalities in Sutton and Merton. Annual Report of the Director of Public Health, 2005 (see reference 15).
Choosing Health: making healthy choices easier. Department of Health, 2004 (see reference 16).
Tackling Health Inequalities: a programme for action. Department of Health, 2003 (see reference 2).
Cross Cutting Review on Health Inequalities. Department of Health, 2002 (see reference 17).
Independent inquiry into inequalities in health (The Acheson Report). Department of Health, 1998 (see reference 11).

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Projected service use in 3-5 years and 5-10 years

There were no projections available for Haringey life expectancy at the time of publication.

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Unmet needs and service gaps

The individual JSNA sections linked to this overview highlight unmet needs and service gaps, additional information is also available in the Cross Party Working Group Paper on Life Expectancy (see reference 13). These inform the actions to reduce the life expectancy gap in Haringey.

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Recommendations for commissioning

To allocate resources and implement programmes that prevent ill health and detect and manage key diseases early.
To take forward key priorities as outlined in the Haringey Health and Wellbeing Strategy (see reference 3). Haringey Health and Wellbeing Strategy) to deliver Outcome 2, “ A reduced gap in life expectancy”:
- Reduce smoking. For example through tobacco control measures such as extended smoke free policies and by supporting smokers to stop smoking through a specialist service
- Increase physical activity. For example by scaling up brief interventions to encourage people to take up physical activity and by making Haringey more cycle friendly
- Reduce alcohol misuse. For example by a reduction in alcohol related admissions.
- Reduce early death from cardiovascular disease and cancer. For example by increasing uptake of the NHS Health Checks programme and developing community champions to raise public awareness of key diseases.
- Support people with long term conditions to live a healthier life. For example by implementing evidence based care pathways and integrated care systems.
To ensure the following approaches are integral to addressing these priorities:
- Address the social gradient, not just target the worst off
- Address the needs of certain “vulnerable groups” who may be at higher risk of lifestyle factors or diseases contributing to the life expectancy gap or have a lower life expectancy e.g. the frail elderly
- Work with partners to tackle the social determinants of health such as poor housing
Most policies inadvertently widen gaps (see reference 11). Therefore utilise information on local needs, for example from JSNAs, and undertake equity audits and impact assessments to inform service delivery so as to address inequalities.