Key facts on the major killers and causes of poor health
Merton has a young age profile with the highest proportion of its residents around the late 20s to early 40s age range and with an ethnically diverse population, which is similar to the population structure of Inner London boroughs.
Overall for premature deaths – i.e. deaths in people aged under 75 years of age – many of which are considered preventable, in the period 2009-11 Merton had 1,204 premature deaths, which equates to 236 premature deaths per 100,000 population adjusted for various factors, including the age of the population. Out of 150 local authorities this ranked Merton at 29th (1 = best, Wokingham; worst was Manchester) putting Merton overall in the ‘best outcomes’ category.1
In terms of under 75 mortality rates from all causes, in 2010 Merton had a directly standardised rate of 220.77 per 100,000 population, compared with 272.77 for England and 271.87 for London. This equates to 1,157 deaths in Merton from all causes. Compared with other boroughs in South West London, Merton had a mortality rate lower than Croydon and Kingston upon Thames, but higher than Richmond upon Thames, Sutton and Wandsworth. In terms of trend since 2006, compared with London and England, Merton’s mortality rates have been consistently lower than both and decreased in 2010 more than the rates in London or England (see graph below).
Mortality rates in Merton from 2006-10 from all causes, compared with London and England.
Source: Health & Social Care Information Centre website 13.11.2013
Breaking down the mortality by causes of death, the top three causes of death in those under 75 years of age were (in order of frequency, from most to least common) cancers, circulatory disease and accidents and injuries – which accounted for 70% of all deaths in Merton.
In terms of under 75 mortality rates from cancers, in 2010 Merton had a directly standardised rate of 78.58 per 100,000 population, compared with 108.05 for England and 102.85 for London. Compared with other boroughs in South West London, Merton had a mortality rate lower than Croydon, Kingston upon Thames, Richmond upon Thames, Sutton and Wandsworth. In terms of trend since 2006, compared with London and England, Merton’s mortality rates have been consistently lower than, and decreased in 2010 more than, the rates in London or England.
Under 75 mortality rates in Merton from 2006-10 from cancers, compared with London and England.
In terms of under 75 mortality rates from circulatory disease, in 2010 Merton had a directly standardised rate of 72.13 per 100,000 population, compared with 64.67 for England and 68.16 for London – higher than both London and England. Compared with other boroughs in South West London, Merton had a mortality rate higher than all the boroughs barring Wandsworth (121.00). In terms of trend since 2006, compared with London and England, Merton’s mortality rates have been variable starting in 2006 lower than both England and London, then sharply increasing in 2007 until it equalled the England rate in 2008 and then steadily rose until in 2010 it was higher than both London and England.
There are clear inequalities across Merton in terms of mortality and ill health, especially when comparing East Merton with West Merton. These inequalities can be seen in the differences in circulatory disease, including coronary heart disease (CHD) and stroke, and diabetes and for chronic obstructive pulmonary disease (COPD) across the different communities in Merton. Higher levels of these conditions are associated with areas of deprivation and are linked to higher levels of the major risk factors: smoking, hypertension and obesity.
Mortality rates in Merton from 2006-10 from circulatory disease, compared with London and England.
Looking at rates of death in a population (rather than life expectancy), if East Merton had the same rate of deaths as West Merton, there would be around
113 fewer deaths each year in East Merton – an 18% reduction on the 640 deaths each year among East Merton residents.
Mortality rates in West and East Merton. Graph compares the estimated standardised mortality ratio (SMR)* for East and West Merton, derived from ward level 2006-10 SMRs. Expected deaths are the sum of ward expected deaths. ‘Excess’ deaths in East Merton are derived from calculating expected deaths using West Merton SMR.
*SMR = Standardised mortality ratio. This is a ratio of the observed number of deaths in an area to the number expected if the area had the same age-specific rate as England.
When the 113 excess deaths are analysed further by cause of death and by whether these were under 75 years (described as premature deaths as many of these are considered as preventable) or 75 years of age and over, 41 excess deaths in East Merton occurred due to circulatory disease, 24 due to cancer and 48 due to other causes, in each year [between 2006 and 2010]. A significant element of the ‘other causes’ will be respiratory disease. As can be seen from the graph below, a significant proportion of these excess deaths were premature deaths in the under 75’s (81 in total) and many of these would have been preventable.
Excess deaths [between 2006 and 2010] in Merton by cause.
The wards in Merton with a mortality rate higher than the England average are also those that are the most deprived and are some of the more ethnically diverse. There are potential issues in terms of the most in need accessing appropriate services at the right time to improve outcomes.
When East and West Merton are compared against the England average for the number of admissions in the population aged under 75 years (see graph below) for all causes, accidental falls, cancer, circulatory diseases and respiratory diseases, for each of these categories East Merton had more admissions than West Merton. All the metrics are however below the England average and the desired direction for improvement is to reduce the number of admissions.
Standardised hospital admissions ratios* in under 75 years [2006-10] in East and West Merton. This graph shows that both East and West Merton are achieving lower rates of hospital admissions than the average in England but there are much higher rates in East Merton compared with West Merton.
SAR = Standardised admission ratio. This is a ratio of the observed number of admissions in an area to the number expected if the area had the same age-specific rate as England.
There are also differences in incidence and mortality for all cancers, not only geographically but also between genders. This is reflected in differences in the prevalence of some of the main risk factors, such as smoking and obesity. Uptake of screening (the opportunity for early diagnosis) is above regional but below national uptake for breast and cervical cancer. For bowel screening, it is very low.
In terms of smoking there are clear differences in rates within the borough with much higher levels seen in more deprived communities. The levels of obesity and lack of physical activity are linked to deprivation in Merton and show an increasing trend that is of concern for future health.
Overall Merton is a healthy place to live, however there are a number of causes for concern:
Circulatory disease: Under 75s death rate from circulatory disease (including stroke) is higher than for England and although the overall trend is downward there was a slight upturn in the last period and it is still the second biggest cause of premature death. The rate of stroke for under 75s increased for both men and women in the last period, although the overall trend is also downwards (2008-10).
Diabetes: Diabetes recorded in primary care is 5.3% for Merton CCG overall, but ranges from 2% to nearly 10% by practice. Comparing modelled with recorded prevalence of diabetes suggests a proportion remains undiagnosed, which is something that requires a more in-depth look.
Cancer: Death rates from cancer in people aged under 75 have reduced, particularly for females. However, it is still the main cause of premature death and inequalities remain with a higher rate of deaths in the eastern wards.
Respiratory diseases: Deaths from respiratory diseases have declined, but there are wide variations in hospital admissions by area. This needs to be studied in more depth.
Mental health: Levels of depression are higher than for England, and although proxy measures for mental health outcomes are good, recovery rates following the use of psychological therapies are lower than for England and London. Levels of depression need to be monitored in light of the potential impact of the recession on mental health and wellbeing.
Key facts on services
The Public Health England CCG Spend and Outcome Factsheets and Tool (SPOT) (see chart below) for NHS Merton CCG in 2011-12 shows:
Lower spend and better outcome areas were: cancer, mental health and genito-urinary medicine.
Higher spend and better outcome areas were: respiratory, neurological, dental, gastro-intestinal system, trauma and injuries, maternal and neonatal.
Lower spend and worse outcome areas were: endocrinal, nutritional and metabolic (of which diabetes is a part), healthy individuals and vision.
Higher spend and worse outcome areas were: circulatory and musculoskeletal.
Lower spend and average
outcome areas were: social care needs, learning disabilities and hearing.
Higher spend and average outcomes areas were: skin, adverse effects and poisoning, and blood disorders.
Spend and outcomes in NHS Merton CCG 2011-12, relative to other CCGs in England.
Interpreting the chart:
Spend: By population, Population: Unified Weighted
Each [diamond] dot represents a programme budget category. The three largest spending programmes nationally (mental health, circulatory diseases and cancer) are represented by larger dots [diamonds].
The outcome measures on the chart have been chosen because they are reasonably representative of the programme as a whole. This means that for some programmes no outcome data is available.
The source data for the outcome measures shown on the chart can be found in the Spend and Outcome Tool.
A programme lying outside the solid +/- 2 z scores box may indicate the need to investigate further. If the programme lies to the left or right of the box, the spend may need reviewing, and if it lies outside the top or bottom of the box, the outcome may need reviewing. Programmes outside the box at the corners may need a review of both spend and outcome.
Programmes lying outside the dotted/thin +/- 1 z score box may also warrant further exploration.
A z score essentially measures the distance of a value from the mean (average) in units of standard deviations. A positive z score indicates that the value is above the mean, whereas a negative z score indicates that the value is below the mean. A z score below -2 or above +2 may indicate the need to investigate further.
Key commissioning recommendations
There are clear inequalities in terms of coronary heart disease (CHD), stroke, diabetes, respiratory disease (COPD) and cancer across the borough and between genders. The linking factors are smoking and obesity. Identifying people at risk of these conditions through screening or surveillance would enable prevention and early intervention to reduce future reliance on health and social care services.
- Current screening coverage for cervical and breast cancers is above regional but below national levels. Bowel screening uptake and coverage are very low. Improvement in the uptake and coverage of all screening services is needed for early identification, to prevent cancers becoming untreatable and improve outcomes. This improvement needs to be targeted at the more deprived areas in Merton and disadvantaged groups in the community where uptake of screening programmes is generally lower.
- Commissioners need to use social marketing approaches to understand why the uptake of screening services is below national rates and how future uptake could be improved and to improve the systems to identify patients and non-attendees for screening services. Groups that need particular focus are: people with learning disabilities, ethnic minorities, younger women and socially deprived groups.
- Early identification of those at high risk of circulatory diseases (including stroke) and diabetes could improve outcomes for patients and create less reliance on services. The introduction of the NHS Health Check programme should support this and needs to be targeted at populations who are likely to be at increased risk, such as those in areas of deprivation.
- Interventions available to support individuals to reduce risk factors need to be in place. A coordinated programme of personalised advice and support services has been introduced to support people to make healthy lifestyle choices to achieve a healthy weight, become more physically active, and reduce risky drinking behaviour, to reduce risks of future ill health. This programme also includes the Stop Smoking Service. However, the success of this programme will depend on primary care and other services (pharmacies, social care, voluntary sector) taking an active role in identifying those at risk and referring them into the service. Commissioners need to monitor and evaluate the success of this programme.
- There are variations in the prevalence of diseases identified through primary care practices across Merton and these need to be understood better. Where such variations exist, Merton CCG should work with practices to reduce these variations to ensure that patients are identified early and receive timely and appropriate treatment and support for their condition.
- As part of their new responsibility for health improvement, wider local authority input through existing contracts with services such as leisure and housing, and through planning responsibilities, will help to support people to achieve healthy lifestyles and will be of significance in reducing the risk of disease in a wider range of population groups, targeting people who are potentially at risk of poor health but who may not necessarily access existing health services on a regular basis.
- A whole systems approach focusing the model of care is needed to deliver ‘integrated’ services. This approach should include access to support for primary prevention (to focus on improving lifestyles and improving uptake of early intervention and prevention services), and for secondary prevention in primary care (community and secondary health care services); these services should work in close partnership with social services.
- There is a real opportunity afforded by the development of CCGs and the partnership in the Health and Wellbeing Boards in taking this work forward.
1.^Public Health England, Longer Lives.