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Health inequalities

    Summary

    Health outcomes for people in Merton are generally better than those in London and largely in line with or above the rest of England. The graph below shows healthy life expectancy at birth in Merton compared with other similar or neighbouring boroughs in South West London, London and England.

    In Merton, overall life expectancy at birth is longer than the England average, but there is a difference between the most and least deprived areas within the borough of about 7.9 years for men and about 5.2 years for women. Between 2009-11 and 2011-13 this gap has remained almost the same for men1 .but has increased by about one year for women.  The increase in the gap for women is because for female life expectancy has increased at a faster rate in the most affluent areas compared to the most deprived areas of the borough.

    Premature mortality (deaths under 75 years) is very strongly associated with deprivation, with all wards in East Merton being more deprived and having higher rates of premature mortality than their West Merton counterparts.  A third of total deaths occur ‘prematurely’ in Merton as a whole, in those under the age of 75. However there are inequalities between the east and the west, with premature deaths making up 38.3% of all deaths in East Merton compared to 27.6% in the West of the borough.2

    In general, East Merton is younger, poorer, ethnically more diverse and with relatively lower levels of education outcomes and training qualifications than West Merton.

    High-level recommendations to tackle health inequalities

    • With limited resources, a much more targeted approach will be required to address the differences in health and social outcomes and to develop services that respond to our increasing ethnic diversity.  
    • Placing a priority on the early years offers opportunities for the largest gains in life expectancy.   
    • Priority on prevention will reduce future need for health and social care services. Risk factors such as smoking, obesity and risky drinking behaviour underlie increasing levels of long-term conditions, such as heart disease and cancer, especially in the more deprived groups. Efforts need to be spread proportionally by need across all social groups.
    • Partnerships with the voluntary, community and business sectors will accomplish a broader outreach by embedding health as part of all frontline work.   
    • An improved understanding of the social determinants of health and of the role local government plays in creating health will lead to more effective use of local government levers, including early childhood development, education and training, and licensing and planning.
    • Improvements in early detection and management of long-term conditions provide opportunities for the quickest gains in life expectancy.  Along with improved access to services, this will improve residents’ quality of life and reduce the need for more expensive acute services.  
    • Improvements to ensure more robust data is captured on the population accessing services and better use of this data, through health equity audits, for example, would support understanding service need and design.

    Introduction

    It has been estimated that if all inequalities in access to health care were eliminated, inequalities in health would remain given the more important influences on health (discussed in Social determinants) that would still remain if nothing were done to mitigate their negative impacts. As shown in that section, inequities in health are related to social and economic policies that lead generally to better health for those with higher incomes and better education.  

    The Marmot Review, a major report entitled ‘Fair Society, Healthy Lives' (2010), sets out the health inequalities challenges for England, priorities for action and evidence about how these could be translated into practice at national and local levels. Marmot’s key messages are that reducing health inequalities is not just about health services but is a matter of fairness across society. There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action needs to focus on reducing this gradient in health.

    Health inequalities result from social inequalities, and action on health inequalities requires action across all the social determinants for health – education, housing, environment and employment, as well as health and social care services. However, focusing solely on the most disadvantaged will not reduce health inequalities sufficiently – support and help to live a healthier life must be open to everyone, but the scale and intensity of that help need to be in proportion to the level of disadvantage.

    Action to reduce health inequalities will benefit society in many ways, including increasing economic productivity and reducing health care costs.

    Health inequalities are measured by differences in life expectancy.  Life expectancy is a well- recognised measure of comparative health between countries, boroughs and sub-groups within the population. It is an estimate of how long a child born today might expect to live if current age and gender specific death rates applied throughout their life.  The links between deprivation and health inequalities are strong, with the most deprived areas broadly correlating to the areas with lowest life expectancy.

    Merton picture

    Life expectancy - headlines

    Health outcomes for people in Merton are generally better than those in London and largely in line with or above the rest of England. We are interested both in life expectancy (an estimate of how many years a person might be expected to live, assuming that age-specific mortality levels remain constant) as an overarching health outcome, but also in healthy life expectancy (an estimate of how many years a person might live in a ‘healthy’ state).

    Life expectancy at birth in Merton for males ranks as 13th highest out of 32 boroughs in London and 16th highest for females.3 Trends show that there has been a steady increase in life expectancy in both males and females since 2000. Life expectancy for males is slightly higher in Merton (80.3) compared to London (80) and England (79.4). Females in Merton have the same life expectancy as London (84.1), and higher than England (83.1).3

    Healthy life expectancy - headlines

    The graph below shows healthy life expectancy at birth in Merton compared with other boroughs in South West London, London and England.

    Healthy life expectancy at birth by gender and comparators, 2011-13

    Inequalities in life expectancy within Merton

    In Merton, overall life expectancy at birth is longer than the England average; however, there are stark differences between different groups and areas within the borough, for example by gender and by deprivation.

    For the period 2011-13 average life expectancy for Merton men overall was 80.3 years (range:76.5 in Ravensbury to 84.6 in Wimbledon Village). In women, life expectancy overall was 84.1 years (range: 80.5 years in Ravensbury to 90 years in Hillside).3,4

    Male and Female life expectancy at birth in Merton by Ward 2008-12.

    life expectancy at birth by ward in Merton 2008-12

    Absolute gap: There is a difference between the most and least deprived areas within the borough of about 8 years (7.9) for men and about 5 years (5.2) for women. Between 2007-09 and 2011-13 this gap has remained the same for men, but has increased by about 1 year for women. The increase in the gap for women is because for women life expectancy has increased at a faster rate in the most affluent areas compared with the most deprived areas of the borough.1 See the discussion below about Slope Index of Inequality for more detail.

    Average gap: as a whole West Merton has an average life expectancy for men around 3.3 years longer than for men in East Merton.  For women, the difference is 2.5 years as demonstrated in the Figure below.

    Difference between East and West Merton for average life expectancy, by gender, 2008-12

    life_expectancy_at_birth_by_gender_and_ward_2008-12

    Over time average life expectancy has increased for both men and women in Merton, but the gap between West and East Merton has remained relatively constant. However, the gap between East and West Merton for women has declined slightly and increased for men in recent years.

    Persistence in the difference between East and West Merton for average life expectancy, by gender, from 1999-03 to 2008-12.

    Inequality in male life expectancy in East & West Merton1993-03 to 2008-12

    Inequality in female life expectancy in East & West Merton 1999-2003 to 2008-12

    Slope Index of Inequality

    Health inequalities are differences in the health status of groups and individuals that are both avoidable and unjust. Health inequalities arise from social inequalities resulting in the unequal distribution of factors influencing health (housing, environment, social background, income, employment and education). The Slope Index of Inequality (SII) is a measure of health inequalities in life expectancy at birth within a local area. Two measures are required to construct the indicator –

    • Socioeconomic deprivation – The Index of Multiple Deprivation (IMD) scores ranked into deciles. Deciles are ten equal groups constructed by ranking and aggregating IMD scores assigned to Lower Super Output Areas (LSOAs).
    • Life expectancy at birth – estimated from mortality data and population estimates.

    This measure gives a description of the extent of inequality within a local authority and measures the gap in years in life expectancy between the least and most deprived tenths of the population (not based on wards). Areas with wide variations in deprivation tend to have a steeper slope, and areas with a relatively uniform population (either affluent or deprived) tend to have a flatter slope, meaning the more equal the life expectancy.

    Those in more deprived groups live the shortest lives for both males and females. See below.

    life_expectancy_gap_for_men

    life_expectancy_gap_for_women

    The slope index of inequality in life expectancy at birth in Merton for males ranks as 25th lowest out of 32 boroughs in London and 20th lowest for females. Trends show that there has been a steady increase in the slope index of inequality in life expectancy in both males and females since 2002.3

    Male Slope Index of inequality in life expectancy at birth in London boroughs, 2011-13

    Female Slope index of inequality in life expectancy at birth in London boroughs, 2011-13

    Life expectancy and mortality by disease

    In Merton circulatory disease is the biggest cause of the gap in life expectancy, for both men and women, followed by cancer and then by respiratory disease. This is shown in the figure below, which gives a breakdown of the life expectancy gap between the most and least deprived quintiles attributable to broad cause of death.

    Life expectancy gap by cause of deathand gender in Merton.

    life_expectancy_gap_by_cause_of_death

    Over the past 10 years there has been a consistent difference of two to three years between life expectancy for women and for men (women living longer than men); male and female life expectancy in Merton is significantly higher than in London. Life expectancy has increased by two and a half years for men and just over two years for women (from 2004-06 to 2010-12). Estimates suggest life expectancy will continue to increase.

    Using ‘All-Age All-Cause’ mortality, a measure of the rate at which people are dying, allows us to estimate ‘excess’ deaths between East and West Merton.  On its own however the information is limited and needs to be looked at together with other mortality rates, such as the rate at which people die from specific conditions such as heart disease and the ages people die (both of which help us understand the causes of death that could be avoided i.e. avoidable mortality) and the rates at which people die in different areas (which can help us understand inequalities in health).

    In Merton, All-Age All-Cause mortality rates have been progressively improving, consistent with the growth in life expectancy experienced across England as a whole. Current rates for 2008-12 place Merton among the healthier areas in England, with standard mortality ratios of 90.2 below national (100) and regional levels (94.6).5

    Excess mortality in East Merton

    Within Merton there is a marked difference in mortality rates, with the more deprived electoral wards having a much higher mortality ratio compared with the less deprived wards. After controlling for age (SMR*) the wards of Merton were found to have all-cause mortality rates that range from 64.5 in Hillside to around 123.8 in Ravensbury compared with England.  Most of the wards in East Merton had the highest mortality ratios compared to the West of the borough based on the ward data for 2008-12.5

    Difference of standardised mortality rates from all causes, all ages in east & west Merton, 2008-12

    An SMR is a comparison of the number of observed deaths in a population with the number of expected deaths if the age specific deaths rates were the same as a standard population.  Standard mortality rates from all causes in East Merton are similar to England. In comparison West Merton has a below than average mortality rate.

    Premature Mortality

    Premature mortality (deaths under 75 years) is very strongly associated with deprivation, with all wards in East Merton being more deprived and having higher rates of premature mortality than their West Merton counterparts. When the standardised mortalities for each ward are plotted against their IMD scores, a very strong correlation is evidenced – the R2=0.76 means that 76% of the variation in ward mortality rates is ‘explained’ by variations in deprivation.  This is a very strong correlation between premature mortality and deprivation.

    standardised mortality ratio for deaths from all causes under 75 and IMD 2010 scores by wards in Merton, 2008-12

    Between January 2010 and December 2014, 1 in 3 deaths in Merton were premature (occurring in individuals under 75 years of age).2

    The higher the deprivation of an area, the higher the proportion of deaths that is premature. As illustrated by Figure 3.10, the proportion of premature deaths more than doubled when we compare Quintile 5 (least deprived) to Quintile 1 (most deprived). For all deaths of individuals who lived within LSOAs in Quintile 1, 58.5% were premature. In contrast, the proportion is 25% of deaths in those living within LSOAs in Quintile 5.

    Proportion of premature deaths (under 75 years) by IMD 2010 Quintiles in Merton, 2010-2014

    More premature deaths occur in the East of the borough compared to the West between January 2010 and December 2014. Of all deaths in East Merton, nearly 2 in 5 deaths were premature. In comparison, in West Merton, the figure is just over 1 in 4 deaths were premature See the figure on the proportion of premature deaths in east and west Merton.

    Proportion of premature deaths (under 75's) by east & west Merton, 2010-2014

    Causes of Premature Deaths

    Between Jan 2010 to Dec 2014, the major causes of premature deaths in Merton were Cancer (35%), Circulatory diseases (30%), and external causes (8%), as summarised in the figure on the  main causes of premature deaths. External causes include deaths from accidents, poisoning, assaults, etc. Please note that the causes that each make up less than 3% were grouped together under “Others”. This category includes congenital, musculoskeletal, skin, genitourinary and infectious conditions.

    Main causes of premature deaths in under 75 years in Merton, 2010-2014

    There are significant differences in the major causes of premature deaths depending on where an individual lived and how deprived the area is. The most notable difference between the main causes of death in the least deprived areas (cancer) and most deprived areas (circulatory diseases). Analysis suggest that premature deaths in people who live in the most deprived areas are nearly twice more likely to be caused by circulatory diseases compared to those who live in the least deprived areas. On the other hand, premature deaths in people who live in the lease deprived areas are four times more likely to be caused by cancer than those who live in the most deprived areas.2

    For individuals who lived in the most deprived area (Quintile 1), 1 in 2 (50%) premature deaths was due to circulatory conditions (including heart diseases). Only 1 in 10 premature deaths was caused by cancer. In contrast, for individuals who lived in the least deprived area (Quintile 5), 2 in 5 (42%) premature deaths were caused by cancer and 28% were caused by circulatory diseases See figure below.

    Main causes of premature deaths in under 75s by IMD 2010 quintiles in Merton, 2010-2014

    Note: Merton has below average levels of deprivation. Only 2 Lower Super Output Areas in Merton falls within Quintile 1 (most deprived), so the numbers used for this analysis are still quite small despite aggregating the data over 5 years

    There are differences between the East and West of the borough in terms of the main causes of mortality. 2 in 5 (40%) premature deaths in the West of the borough were caused by Cancer, and nearly 1 in 3 (29%) by circulatory diseases. In the East of the borough, 1 in 3 (33%) premature deaths were caused by cancer and 1 in 3 (31%) were caused by Circulatory diseases .

    Main causes of premature deaths in under 75s by east & west Merton 2010-2014

    The figure below summarises the main causes of premature deaths by ward in East and West Merton.

    Main causes of premature deaths in under 75s by ward in Merton, 2010-2014

    Index of Multiple Deprivation (IMD)

    The Index of Multiple Deprivation (IMD) sets out the relative position of local areas in terms of deprivation.  It does not measure absolute deprivation but deprivation in relation to other areas, capturing a particular point in time.  The following discussion focuses on the seven domains that make up the IMD, while specific inequalities in health outcomes will be discussed in the sections that follow dedicated to stages across the life course.  The seven underlying domains are:

    • income deprivation
    • health deprivation and disability
    • employment deprivation
    • education, skills and training deprivation
    • barriers to housing and services deprivation
    • living environment deprivation
    • crime deprivation.

    Evidence has shown that deprivation/income, education, and employment are the largest influences on health.  The discussion that follows therefore focuses on these domains, while recognising that the housing, living environment and crime domains also show a similar pattern of difference between East and West Merton.

    The map below of the deprivation domain across Merton illustrates the relatively higher level of deprivation in the east of Merton with pockets in the west in Raynes Park and Wimbledon Park.  The Merton divide affects all ages – the two maps that follow show that deprivation affecting older people and children mirror the overall differences between East and West Merton.

    Difference between East and West Merton for deprivation.

    Difference between East and West Merton for deprivation 2010

    Our most deprived wards according to the Indices of Deprivation Affecting Children are Ravensbury, Cricket Green, Lavender Fields, Figge's Marsh Longthornton and Pollards Hill. These wards are also home to the majority of children and children and families supported by Childrens Social Care Services. Merton has 39 areas which are amongst the 30% most deprived areas across England for children (39 Super Output Areas)

    According to the model of social determinants of health, early childhood development, education and training are the precursors for individuals being able to find employment or work that enables people to provide for themselves and their families.  The indicators that make up this measure are split into subdomains: one relates to education deprivation for children and young people in the area and the other to lack of skills and qualifications among the working age adult population.

    The map below clearly shows that residents in the west of the borough have higher levels of education outcomes and training qualifications.

    Difference between East and West Merton for education, skills and training, IMD 2010.

    IMD 2010: Education, Skills and Training Deprivation

    Difference between East and West Merton for education, skills and training, IMD 2010

    The knock-on effect between good education results and training that prepares individuals for life can be seen in the map below, which again shows employment deprivation highest in the east of the borough.

    Difference between East and West Merton for employment, IMD 2010.

    IMD 2010: Employment Deprivation

    Difference between East and West Merton for employment, IMD 2010

    Key commissioning implications for services to help reduce health inequalities

    There are clear inequalities in terms of life expectancy for both gender and levels of deprivation between East and West Merton.  

    The Marmot review of health inequalities in England (2010) sets out six policy objectives to tackle inequalities in health:

    • Give every child a healthy start.
    • Enable all children, young people and adults to maximise their 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.

    Delivering these objectives requires national, regional and local action across government, the NHS, the voluntary and community sectors and the private sector, and effective local delivery focused on health equity across all policies. It also, most importantly, requires participation and empowerment of individuals and local communities.

    Specific recommendations will be set out in the sections that follow. High-level recommendations include:

    • With limited resources a much more targeted approach will be required to address the differences in health and social outcomes and to develop services that respond to our increasing ethnic diversity.  
    • Placing a priority on the early years offers opportunities for the largest gains in life expectancy.  
    • Priority on prevention will reduce future need for health and social care services. Risk factors such as smoking, obesity and risky drinking behaviour underlie increasing levels of long-term conditions, such as heart disease and cancer, especially in the more deprived groups. Efforts need to be spread proportionally by need across all social groups.
    • Partnerships with the voluntary, community and business sectors will enable a broader outreach by embedding health as part of all frontline work.  
    • An improved understanding of the social determinants of health and of the role local government plays in creating health will lead to more effective use of local government levers, including early childhood development, education and training, and licensing and planning.
    • Improvements in early detection and management of long-term conditions provide opportunities for the quickest gains in life expectancy. Along with improved access to services, this will improve residents’ quality of life and reduce the need for more expensive acute services.  
    • Improvements to ensure more robust data is captured on the population accessing services and better use of this data, through health equity audits, for example, would support understanding service need and design.

    1.^ a b. Slope Index of Inequality, Public Health Outcomes Framework (PHOF), May 2015

    2.^ a b c Primary Care Mortality Data (PCMD), Health & Social Care Information Centre (HSCIC), January 2010-December 2014.

    3.^ a b c d Public Health Outcomes Framework (PHOF), May 2015

    4.^ a Life expectancy by ward, 2008-12, Local Health

    5.^ a b All age all cause mortality, 2008-12, Local Health

    This page was last updated on Friday 28 April 2017

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