Public Expenditure on Health and Personal Social Services 2009 - Health Committee Contents


8.  PSA AND DSO PERFORMANCE

8.1.23  There are four remaining targets from previous spending reviews (CSR 1998, SR 2002, and SR 2004), with six underlying indicators, which have either not been subsumed into CSR 2007 or not been already met. Performance against all these targets has been reported as subject to "slippage", not only in the Departmental Report 2009 (pp. 262-3), but also the previous year's Departmental Report and the 2008 Autumn Performance Report. Can the Department state in respect of each of these four targets what is being done to address this continued "slippage"? The relative gap in life expectancy at birth between England as a whole and the fifth of local authorities with the lowest life expectancy (SR 2002 target 11) has widened significantly in the period 2005-07, compared to the baseline data for the period 1997-99 (particularly among women, where the gap has widened by 12%). Why has there been such a dramatic widening in the life expectancy gap in this case? Can the Department supply runs of historical data for CSR 1998 targets 3 and 4, so the Committee can assess long-term trends in progress towards these targets? (Q114)

Answer

Health inequalities targets—relationship between spearhead areas and bottom quintile for life expectancy

  1.  The first ever national health inequalities targets were introduced in 2001. One was to narrow the gap in life expectancy at birth between the bottom quintile (the fifth of local authorities with lowest life expectancy) and the England average (SR2002 target 11). As part of the Spending Review in 2004, a target was introduced to narrow the gap in life expectancy between the fifth of areas with the "worst health and deprivation indicators" (the spearhead group) and the England average. New inequalities elements were added to the cancer and cardiovascular disease mortality targets enabling all these to be based on the spearhead group rather than separate quintiles.

  2.  There is considerable overlap between the bottom quintile areas and the spearhead group. At present, of the 71 local authorities in the bottom quintiles, for males 60 are in the spearhead group, and for females, 57 are. In terms of population, 88% of males, and 87% of females in the bottom quintile are in the spearhead group. The bottom quintile changes each year. Adopting the spearhead group allows the Department to improve delivery for both targets through focused support in these fixed areas.

Action to meet the inequalities targets

  3.  NHS expenditure is at record levels and deprivation is reflected in NHS financial allocations. As deprivation is a feature of areas in the spearhead group and in the bottom quintile, allocations on this basis support the SR2004 and SR2002 life expectancy targets. Health Inequalities: Progress and Next Steps (2008) announced £34 million additional spending for health inequalities programmes in 2008-09, including £19 million to support local communities in disadvantaged areas working to improve life expectancy and reduce infant mortality quickly in support of the national target.

  4.  Health inequalities has been retained as a key priority for the NHS in the Operating Framework 2009-10. All age all cause mortality, as a proxy for life expectancy, is an indicator in both the NHS Operating Framework "Vital Signs" and the local authority Local Area Agreement National Indicator Set aligning incentives for the NHS and local government.

  5.  The Department has identified the interventions that will impact most on life expectancy and infant mortality within the target timescale. The Department's focus is to provide local areas with the targeted support and tools they need to systematically tackle inequalities with sufficient scale in order to meet the national target. The key interventions for both the SR2004 spearhead life expectancy, and the SR2002 lowest quintile life expectancy targets would be the same.

  6.  A range of National Support Teams (NSTs) with an inequalities focus, are providing tailored, intensive assistance to disadvantaged areas. The NSTs with a particular role in supporting the inequalities targets are: the Health Inequalities NST, Infant Mortality NST, Tobacco Control NST, Teenage Pregnancy NST and Alcohol NST. The Health Inequalities NST has been expanded enabling it to offer to visit all spearheads by summer 2009 and the Infant Mortality NST is focusing on the 43 local authority areas with highest infant mortality rates in routine and manual groups.

  7.  The Health Inequalities Intervention Tools jointly developed by the Association of Public Health Observatories and the Department of Health, are designed to help PCTs and local authorities, including spearheads and all areas in the bottom quintile for life expectancy, to plan and commission services in order to narrow life expectancy gaps.

  8.  The Implementation Plan for Reducing Health Inequalities in Infant Mortality (2007) underpins the work of the Infant Mortality NST. It identifies the specific interventions needed to meet the target and promotes effective action, including through good practice.

Widening gap in life expectancy

  9.  Life expectancy is at record levels including in the spearhead group as a whole and in the fifth of local authority areas with the lowest life expectancy as a whole. However, improvements have been greater on average in more advantaged areas, meaning the life expectancy gaps have not narrowed.

  10.  The reasons for the widening life expectancy gap are complex and not fully understood. The Department has partitioned the life expectancy gap between the spearhead group and the average by age and disease to help understand the drivers. This analysis was sent to the Health Select Committee in a memorandum entitled A DH note on widening life expectancy gap between England and the Spearhead Group on 18 March 2008 as part of the inquiry into health inequalities. The Department would not expect to see different results if the age and disease partitioning was revised with 2005-07 data or if the lowest quintile life expectancy areas were compared with England. This therefore remains our best knowledge of what is driving the life expectancy gap.

CSR 1998 accident targets

  11.  Data showing the age groups and types of accidents responsible for the slippage against CSR 1998 targets 3 and 4 are provided in tables 114a to 114d.

  12.  Latest data for 2005-07 (three-year average) for CSR 1998 target 4 (reduction in the death rate from accidents) is the same as at the baseline (1995-97), having increased slightly above the baseline rate in the intervening years.

  13.  Despite the slippage, the latest data show a continuing reduction in accident death rates in age bands under 15 and 15 to 24 years. Serious accidental injury rates among children are also continuing to decrease.

  14.  Based on data to 2005-07, the 65 and over group continues to account for the main part of the increase in the death rate from accidents. Falls account for the main part of the increase in the death rate from accidents in those over 65.

  15.  Latest data for the financial year 2006-07 for CSR 1998 target 3 (reduction in the rate of hospital admission for serious accidental injury) show an increase of 3.1% from the baseline (1995-96). As before, the 65 and over group accounts for the main part of the increase in the admission rate. Falls account for nearly three-quarters of admissions for serious accidental injury in the 65 and over group, and are a key factor in the increase in the admission rate.

  16.  Trend data for CSR 1998 targets 3 and 4 are provided in table 114e.

  17.  The recently published prevention package will raise the local focus on older people's prevention services, for example through improved implementation and quality of services such as falls where challenges still exist.

  18.  The National Institute for Health and Clinical Excellence issued, in 2004, clinical guidelines on the assessment and prevention of falls in older people; it has also issued clinical guidelines on the assessment of fracture risk; and published final guidance on the use of drugs to prevent osteoporotic fractures in postmenopausal women both as primary and secondary prevention.

Table 114a

DEATH RATES FROM ACCIDENTS (PER 100,000 POPULATION) (1) (3)—PROGRESS BY SELECTED AGE GROUPS


Age group
1995-97
2002-04
2003-05
2004-06
2005-07
% change
1995-97 to
2005-07 
(2)

Under 15
4.1
2.9
2.7
2.6
2.4
-40%
15 to 24
17.8
15.2
14.7
14.3
14.0
-22%
25 to 64
13.0
12.9
12.8
12.8
12.8
-1%
65 and over
50.1
57.6
59.7
59.7
59.3
+18%

Source:
Rates calculated by Health Improvement Analytical Team, Department of Health, based on death registrations and population estimates from the Office for National Statistics (ONS).
  
Footnotes:
1.  Death rates are directly age-standardised to allow for change in the age structure of the population (using the European Standard Population as defined by the World Health Organisation). Rates are for all persons, England. Figures are the average of rates for 3 consecutive calendar years.
2.  A percentage change less than 0 is a reduction, greater than 0 is an increase.
3.  1995-97 data coded used ICD9 (codes E800-E928 exc. E870-E879 used for accidents); 2002-04 to 2005-07 data coded using ICD10 (codes V01-X59 used for accidents).
4.  Data quality: Death registrations data are National Statistics. The coding system for recording cause of death was changed in 2001 (from ICD9 to ICD10), so there may be small discontinuities in the comparison between the data for 1995-97 and later periods (although any effect is not statistically significant for the comparisons presented). The rates are based on the most up to date series of population estimates published by ONS, but population estimates may be revised from time to time.


Table 114b

DEATH RATES FROM ACCIDENTS AMONG AGES 65 AND OVER (PER 100,000 POPULATION) (1) (3)—CONTRIBUTION OF SELECTED ACCIDENT CATEGORIES


Accident category
1995-97
2002-04
2003-05
2004-06
2005-07
Change
1995-97 to
2005-07 
(2)

Land transport
7.8 
6.6 
6.4 
6.0 
5.9 
-1.9
Falls
14.1 
20.0 
21.4 
22.5 
22.7 
+8.5
Drowning and submersion
0.4 
0.4 
0.4 
0.4 
0.4 
0.0
Smoke, fire and flames
2.3 
1.6 
1.4 
1.4 
1.3 
-1.0
Poisoning
1.1 
0.8 
0.8 
0.9 
0.9 
-0.2
Other and unspecified incidents
24.3 
28.2 
29.3 
28.7 
28.2 
+3.9

Source:
Rates calculated by Health Improvement Analytical Team, Department of Health, based on death registrations and population estimates from the Office for National Statistics (ONS).
  
Footnotes:
1.  Death rates are directly age-standardised to allow for change in the age structure of the population (using the European Standard Population as defined by the World Health Organisation). Rates are for all persons, England. Figures are the average of rates for 3 consecutive calendar years.
2.  Deaths per 100,000. A change less than 0 is a reduction, greater than 0 is an increase. The changes in each accident category sum to the change in the all accidents rate for ages 65 and over.
3.  1995-97 data coded used ICD9 (codes E800-E928 exc. E870-E879 used for accidents); 2002-04 to 2005-07 data coded using ICD10 (codes V01-X59 used for accidents).
4.  Data quality: Death registrations data are National Statistics. The coding system for recording cause of death was changed in 2001 (from ICD9 to ICD10), so there may be small discontinuities in the comparison between the data for 1995-97 and later periods (although any effect is not statistically significant for the comparisons presented). The rates are based on the most up to date series of population estimates published by ONS, but population estimates may be revised from time to time.


Table 114c

ADMISSION RATES FOR SERIOUS ACCIDENTAL INJURY (PER 100,000 POPULATION) (1) (3)—PROGRESS BY SELECTED AGE GROUPS


Age group
1995-96 (4)
2003-04
2004-05
2005-06
2006-07
% change
1995-96 to
2006-07 
(2)

Under 5
131.7 
90.2 
88.3 
84.3 
85.2 
-35%
5 to 14
120.8 
77.7 
76.9 
71.9 
65.2 
-46%
15 to 64
221.2 
226.0 
225.3 
227.4 
220.9 
0%
65 and over
1,280.2 
1,460.4 
1,487.8 
1,511.9 
1,471.4 
+15%

Source:
Rates calculated by Health Improvement Analytical Team, Department of Health and National Centre for Health Outcomes Development, based on hospital admissions from Hospital Episode Statistics, The Information Centre for health and social care and population estimates from the Office for National Statistics (ONS).
  
Footnotes:
1.  Admission rates are directly age-standardised rates for all persons, England. Figures are for single financial years.
2.  A percentage change less than 0 is a reduction, greater than 0 is an increase.
3.  ICD10 codes V01-X59, Y40-Y84 used for all accidents.
4.  Figures for 1995-96 are estimates based on trend for subsequent years (due to data quality problems for some areas in 1995-96).
5.  Data quality: Hospital Episode Statistics are compiled from data sent by over 300 NHS Trusts and Primary Care Trusts. The Information Centre for health and social care liaises closely with these organisations to encourage submission of complete and valid data and seeks to minimise inaccuracies and the effect of missing and invalid data. Whilst this brings about improvement over time, some shortcomings remain. Serious injury admission figures are adjusted to include estimates of how many injury admission records without a valid cause code relate to unintentional injury. The rates are based on the most up to date series of population estimates published by ONS, but population estimates may be revised from time to time.


Table 114d

ADMISSION RATES FOR SERIOUS ACCIDENTAL INJURY AMONG AGES 65 AND OVER (PER 100,000 POPULATION) (1)—CONTRIBUTION OF SELECTED ACCIDENT CATEGORIES


Accident category
1996-97 (3)
2003-04
2004-05
2005-06
2006-07
Change
1996-97 to
2006-07 
(2)

Land transport
52.7 
48.4 
49.9 
49.0 
45.8 
-6.9
Falls
942.1 
1,058.4 
1,082.4 
1,098.6 
1,063.4 
+121.3
Drowning and submersion
0.1 
0.2 
0.3 
0.1 
0.2 
+0.1
Smoke, fire and flames
4.3 
2.3 
2.6 
2.7 
1.6 
-2.7
Poisoning
9.7 
9.6 
9.2 
10.8 
9.5 
-0.2
Other and unspecified incidents
323.8 
358.7 
360.9 
369.4 
368.5 
+44.7

Source:
Rates calculated by Health Improvement Analytical Team, based on hospital admissions from Hospital Episode Statistics, The Information Centre for health and social care and population estimates from the Office for National Statistics (ONS).
  
Footnotes:
1.  Admission rates are directly age-standardised rates for all persons, England. Figures are for single financial years.
2.  Admissions per 100,000. A change less than 0 is a reduction, greater than 0 is an increase.
3.  Comparison is with 1996-97 rather than 1995-96 due to data quality problems for some areas in 1995-96.
4.  Data quality: Hospital Episode Statistics are compiled from data sent by over 300 NHS Trusts and Primary Care Trusts. The Information Centre for health and social care liaises closely with these organisations to encourage submission of complete and valid data and seeks to minimise inaccuracies and the effect of missing and invalid data. Whilst this brings about improvement over time, some shortcomings remain. Serious injury admission figures are adjusted to include estimates of how many injury admission records without a valid cause code relate to unintentional injury. The rates are based on the most up to date series of population estimates published by ONS, but population estimates may be revised from time to time.


Table 114e

DEATH RATES FROM ACCIDENTS, ALL AGES, ENGLAND (PER 100,000 POPULATION) AND ADMISSION RATES FOR SERIOUS ACCIDENTAL INJURY (PER 100,000 POPULATION), ALL AGES, ENGLAND—TIME SERIES


Time period
(2)
Accidental injury death rate (1) (4), all ages, England (deaths per
100,000 population)
Time period
(3)
Hospital admission rate(1) (5) for
serious accidental injury, all
ages, England (admissions per
100,000 population)

1988-1990
18.9
  
  
1989-1991
18.7
  
  
1990-1992
18.0
  
  
1991-1993(7)
16.9
  
  
1992-1994
16.2
  
  
1993-1995
15.7
  
  
1994-1996
15.5
1995-96(6)
315.9
1995-1997
15.8
1996-97
319.3
1996-1998
15.9
1997-98
314.3
1997-1999
16.0
1998-99
319.1
1998-2000
15.9
1999-2000
324.9
1999-2001
15.9
2000-01
313.4
2000-2002
15.9
2001-02
312.7
2001-2003
15.9
2002-03
327.9
2002-2004
15.9
2003-04
330.1
2003-2005
16.0
2004-05
332.5
2004-2006
15.9
2005-06
335.5
2005-2007
15.8
2006-07
325.8

Source:
Rates calculated by Health Improvement Analytical Team, Department of Health and National Centre for Health Outcomes Development, based on hospital admissions from Hospital Episode Statistics, The Information Centre for health and social care, and death registrations and population estimates from the Office for National Statistics (ONS).
  
Footnotes:
1.  Rates are directly age-standardised to allow for change in the age structure of the population (using the European Standard Population as defined by the World Health Organisation).
2.  Rolling three calendar year period. Death rates are the average of rates for 3 consecutive calendar years.
3.  Single financial year period. Admission rates for serious accidental injury prior to 1995-96 are not directly comparable with data shown in this table.
4.  Cause of death is identified using the following ICD codes: for 1999 and 2001 onwards, ICD10 V01-X59; for 1995-1998 and 2000, ICD9 E800-E928 excluding E870-E879.
5.  Hospital admissions for accidental injury are identified using ICD10 codes V01-X59, Y40-Y84.
6.  Figures for 1995-96 are estimates based on trend for subsequent years (due to data quality problems for some areas in 1995-96).
7.  There may be discontinuities between data based on 1993 onwards and earlier data due to changes in the process of coding cause of death.
8.  Data quality:
    i.  Death registrations data are National Statistics. The coding system for recording cause of death was changed in 2001 from ICD9 to ICD10 (with 1999 deaths being coded using both ICD9 and ICD10 for comparison), so there may be small discontinuities between data based on 1988-1998 and 2000 and data based on 1999 and 2001 onwards (although any effect is known not to be statistically significant for data from 1993). There may also be discontinuities between data based on 1993 onwards and earlier data due to changes in the process of coding cause of death.
    ii.  Hospital Episode Statistics are compiled from data sent by over 300 NHS Trusts and PCTs. The Information Centre for health and social care liaises closely with these organisations to encourage submission of complete and valid data and seeks to minimise inaccuracies and the effect of missing and invalid data. Whilst this brings about improvement over time, some shortcomings remain. Serious injury admission figures are adjusted to include estimates of how many injury admission records without a valid cause code relate to unintentional injury. The rates are based on the most up to date series of population estimates published by ONS, but population estimates may be revised from time to time.





 
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