Published: 15/04/2004, Volume II4, No. 5801 Page 21
Social deprivation alone does not explain different mortality rates between the haves and have nots, says Roger Taylor
Shortly after coming to power, the government instituted the Acheson inquiry into health inequalities and in 1999 set out a policy framework to tackle health inequalities in Our Healthier Nation. A review of policy by the Joseph Rowntree Foundation published in March last year concluded that policies were now in place to address most of the issues raised by Acheson.
Mortality rates and incidence of many illnesses is higher among less affluent communities. The first chart shows the age-standardised mortality rates per 100,000 for men and women of different social groups. In the five years to 1992, manual workers were about 60 per cent more likely to die from coronary heart disease than non-manual workers. And while the overall rate has been coming down over the last 25 years, the gap between manual and non-manual workers has risen. According to figures from the Heart Foundation in1972, manual workers were just 20 per cent more likely to die from CHD than nonmanual workers.
Policies to even out health inequalities are primarily focused on public health initiatives to tackle the underlying causes of ill-health such as smoking cessation efforts, SureStart for children and the 'five-a-day' campaign to improve diet. Policies aimed at standardising the quality of care across the NHS, such as the national service framework for coronary heart disease, also play an important role.
The difference in outcomes for different social groups can also be seen in in-hospital mortality rates following admission for a heart attack. In 2002-03 we can identify 72,245 valid records of emergency admissions to acute hospital trusts for patients suffering a heart attack as their primary diagnosis. This excludes patients who were dead on arrival in hospital.
For all social groups, 15-16 per cent of these patients died while in hospital. After adjusting for age and sex, there is a significantly higher in-hospital mortality rate among patients from more deprived areas (see table 2). These figures use the quintile of the ward of residence of the patient as the measure of deprivation (based on the index of multiple deprivation). The differences may reflect the inverse care law or they may reflect generally higher illhealth among less affluent communities, reducing their chance of survival.
The difference between social groups for in-hospital mortality rates is much lower than between the population at large. About 40 per cent of people suffering heart attacks die before reaching hospital and the rate of heart attacks is higher among less affluent communities.
However, if the patient survives long enough to reach hospital, the chances of survival are greatly evened up between social groups, although disparities still exist.
The differences in in-hospital mortality rate between hospitals remains greater than can be explained by social deprivation. The third chart shows in-hospital mortality ratios for English acute trusts adjusted for age, sex and deprivation. Excluding four outlying results, the mortality ratios vary by 2.5 times from lowest to highest.
Roger Taylor is research director with information analysts Dr Foster. www. drfoster. co. uk
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