“The Health Inequalities Targets What do they mean for London?” Justine Fitzpatrick David Hofman Dr Bobbie Jacobson Leading on Health Intelligence for London

PPF = The NHS Priorities and Planning Framework The PPF Inequalities targets Deliver a 1% point reduction per year in the proportion of women continuing to smoke throughout pregnancy, focussing especially on smokers from disadvantaged groups Achieve agreed local teenage conception targets while reducing the gap in rates between the worst fifth of wards and the average by at least a quarter in line with national targets. Contribute to a national reduction in death rates from CHD of at least 25% in people under 75 by 2005 compared to , targeting the 20% of areas with the highest rates of CHD. Contribute to a national reduction in cancer death rates of at least 12% in people under 75 by 2005 compared to , targeting the 20% of areas with the highest rates of cancer. Achieve the target of 70% uptake in influenza immunisation in people aged 65 years and over, targeting population in the 20% of areas with the lowest life expectancy. Increase breast-feeding initiation rates by 2% points per annum, focusing especially on women from disadvantaged groups.

Objectives To provide baseline figures for five of the six health inequalities targets listed in the PPF, by PCT and by electoral ward, for London only. To determine the wards and local authorities/PCTs that are among the worst 20% of areas in relation to each target. To indicate the changes by local authority/PCT and ward that are required to achieve the target reductions in inequalities in the timescales set out. To agree a London method of defining, monitoring and presenting progress against targets.

Data problems Lack of reliable information on smoking and breast-feeding in pregnancy at PCT or ward level No ward level data for flu immunisations and little trend information at PCT level Teen Conceptions – not enough trend data at borough level as definition has changed

Areas in the ‘worst 20%’ for each target/indicator

Number of wards in worst 20% for CHD by borough Barking& Dagenham 5 Barnet 1 Bexley 1 Brent 1 Camden 3 Croydon 2 Ealing 4 Enfield 2 Greenwich 4 Hackney 7 Hammersmith & Fulham 1 Haringey 2 Havering 2 Hillingdon 3 Hounslow 2 Islington 7 Lambeth 3 Lewisham 2 Newham 16 Southwark 7 Sutton 1 Tower Hamlets 10 Waltham Forest 3 Wandsworth 3 Westminster 2 TOTAL94

% wards in worst 20% for CHD by borough

Number of wards in worst 20% for cancers by borough Barking& Dagenham 6 Camden 2 Croydon 3 Enfield 1 Greenwich 3 Hackney 4 Havering 5 Hillingdon 1 Hounslow 4 Islington 5 Kingston 1 Lewisham 4 Merton 1 Newham 6 Southwark 5 Sutton 1 Tower Hamlets 6 Waltham Forest 1 Wandsworth 3 Westminster 2 TOTAL62

% wards in worst 20% for cancers by borough

Number of wards in worst 20% for teenage conceptions Barking & Dagenham 8 Bexley 2 Brent 5 Bromley 2 Camden 1 Croydon 7 Ealing 1 Enfield 2 Greenwich 3 Hackney 9 Hammersmith & Fulham 6 Haringey 10 Havering 1 Hillingdon 2 Hounslow 3 Islington 4 Kensington & Chelsea 2 Kingston 1 Lambeth 11 Lewisham 6 Merton 2 Newham 5 Southwark 13 Sutton 2 Tower Hamlets 2 Waltham Forest 3 Wandsworth 5 Westminster 6 TOTAL124

% wards in worst 20% for teen conceptions by borough

Projecting to 2010 Borough level – Assess trends over time and extrapolate to 2010 (assuming no change in current trends) Ward level – “What if” scenarios at ward level to estimate effect at borough level

CHD borough level trends No reliable trend was found for Bexley, Greenwich, Havering, Hounslow, Islington, Merton, Newham, Southwark and Tower Hamlets. K&C, Ealing, Sutton, Richmond and Harrow had the highest projected annual % reduction. All with a significant trend are expected to reach target reduction if current trends continue. Couldn’t recalculate inequality between boroughs as couldn’t extrapolate rates for those boroughs with no reliable trend.

Cancers: borough level trends No significant trend was found for Barnet, Bexley, Brent, Camden, Ealing, Hillingdon, Islington, Kingston, Lambeth, Lewisham, Merton, Newham, Redbridge, Richmond, Sutton, Waltham Forest. K&C, H&F and Westminster had the highest projected annual % reduction. Not all with a reliable trend are expected to reach target reduction if current trends continue – Enfield, Haringey, Harrow, Wandsworth. Couldn’t recalculate inequality between boroughs as couldn’t extrapolate rates for those boroughs with no significant trend.

Ward level analysis – CHD and Cancers Scenario 1 - Reduce the SMR of each ‘worst 20%’ ward by 10%. Recalculate borough SMRs and calculate effect on inequality between boroughs. Scenario 2 - Reduce the SMR of each ‘worst 20%’ ward to the same level as the overall SMR of the ‘next worse 20%’ wards. Recalculate borough SMRs and calculate effect on inequality between boroughs.

Ward level analysis - CHD

Ward level analysis – All Cancers

Ward level analysis – teen conceptions The teenage conception rate for the worst fifth of wards combined was equal to 93 per 1000 girls in The overall teenage conception rate for London for was This is an absolute gap of 43. If the conception rate in the worst 20% of wards is reduced by 10% to 84, the gap will have reduced to 34, a reduction of 21%.

Emerging Fundings Areas in the “worst 20%” for all Targets Cluster in the inner city Parts of “Outer North & East London” fall into an inner city picture (e.g. Haringey, Waltham Forest, Barking & Dagenham) Wider spread of areas for “worst 20%” for teen conceptions (includes Croydon, Barking & Dagenham, Brent) Pattern of inequalities for cancers probably clouded by gender differences If targets are reached as defined, there will be little reduction in inequalities, with the exception of teen conceptions

Next Steps Review of methods used for projecting borough level rates Re-analyse cancers by gender Vary assumptions in Scenario 1 and 2 To agree definition of the ‘worst 20%’ of areas and method of monitoring progress against targets Encourage better data collection on smoking in pregnancy and breast-feeding Discussion paper in light of Wanless comments on targets