The reasons for the wide difference in mortality rates across English local authorities is a continuing source of controversy. The Black Report, published in 1980, began a lively debate as to the reasons for these inequalities in mortality rates (DHSS, 1980). The causes of inequalities in health and mortality are not yet clear, but one thing is certain. These causes are complex and there is no simple or quick way to equalise mortality rates across England.
Part of the answer is for some individuals to change their habits and eg eat more healthily and take part in regular physical activity. That in itself, though, would not solve the problem. The behaviour of individuals is influenced by the community they live in, their friends, family and colleagues. Regional factors like the availability of stable employment and affordable housing also influence health. At the national level policies on tobacco control, air quality and food standards affect the health of individuals.
Public Health England (PHE) appears to see the situation differently. The new organisation has launched a website, called Longer Lives, aimed at supporting local authorities in their work to reduce mortality rates (Public Health England, 2013). The website states that “every community faces its own challenges. PHE has been created to help communities decide on steps they can take to improve their collective health. The Longer Lives Project gives them the tools to help do this.”
The causes of ill health
The information on the website concentrates on mortality from the four most common causes of mortality in England. These are heart disease and stroke, lung disease, liver disease and cancer. A user can type in a postcode and will find the mortality rate for each of these conditions for the local authority in which that postcode is situated. The same page also names the local authorities with the highest and lowest mortality rates for each illness.
Next to each condition is a list of the common causes of that condition. For example cancer is attributed to smoking, alcohol and a poor diet. This is curious since many cancers which result in premature mortality are not caused by any of these risk factors. Heart disease and stroke are listed as being the result of high blood pressure, smoking and a poor diet.
These lists of causes are so simplistic as to be of little value to policy makers. The causes of these illnesses are seen by PHE as the consequence of inadequate behaviour by individuals. Much of the research into health inequalities has found that the social and economic environment in which an individual lives can increase or decrease the risk of developing one of these fatal conditions. That environment can have a damaging influence on individual choices of behaviour.
Most of the interventions PHE is suggesting to reduce mortality are to change the behaviour of individuals. For example, to reduce high blood pressure local authorities are encouraged to give “Advice to reduce intake of salt and processed food, which is high in salt and is linked with high blood pressure”. Would it not be more efficient and effective for food manufacturers to reduce the amount of salt they add to processed food?
Ironically, the suggested interventions could increase inequalities. A study by Simon Capewell and Hilary Graham found “there is evidence that cardiovascular disease prevention strategies for screening and treating high-risk individuals may represent a relatively ineffective approach that typically widens social inequalities. In contrast, policy interventions to limit risk-factor exposure across populations appear cheaper and more effective; they could also contribute to levelling health across socioeconomic groups” (Capewell and Graham, 2010).
Seeing the bigger picture
The mortality rates PHE presents on the website relate to the years 2009-11. At the level of a local authority mortality rates can change from year to year, sometimes widely. On the website local authorities are ranked in a league table from Wokingham with the lowest under 75 mortality rate in 2009-11 to Manchester, with the highest rate. The range of values is from 200 deaths per 100,000 population in Wokingham to 455 in Manchester. However if we consider death rates during 2008-10, using data from the NHS Information Centre website, the picture is slightly different . Manchester still has the highest death rate, with a figure of 469, but the lowest is the London Borough of Kensington and Chelsea, with a figure of 196. A difference of one year gives an indication of a trend which deserves further exploration. Regrettably it is no longer possible to access easily data on trends in mortality rates. Until relatively recently the NHS Information Centre website listed mortality rates from 1991 onwards for every local authority. Most of this historic information has gone from the Information Centre website and it is only possible to see figures for the most recent three years for which information is available.
Between 2008-10 and 2009-11 mortality rates in Westminster and in Kensington and Chelsea increased, whereas in most of the rest of the country they declined. The table below is an extract from data provided by the NHS Information Centre and Public Health England (NHS Information Portal,2013). Between 2008-10 and 2009-11 the death rates in Brent and Newham showed substantial improvement, with a 13% reduction in Brent and a 17% reduction in Newham. The death rate in Salford went down by 8% and that in Liverpool by 7%. If we had available a set of trend data we could see if this is a blip or part of a long term change. PHE should make available trend data so policymakers are forming strategies based on a wider perspective than a snapshot.
Premature mortality among a selection of local authorities
Under 75 directly standardised mortality rate| Premature mortality among a selection of local authorities | |||
|---|---|---|---|
| Under 75 directly standardised mortality rate | |||
| Local Authority | 2008-10 | 2009-11 | % change |
| Wokingham | 205 | 200 | -2.1% |
| Kensington and Chelsea | 196 | 213 | 8.5% |
| Richmond upon Thames | 208 | 202 | -2.7% |
| Rutland | 224 | 209 | -6.8% |
| Westminster | 232 | 248 | 6.8% |
| Brent | 290 | 252 | -13.1% |
| Newham | 370 | 316 | -14.7% |
| .. | .. | .. | .. |
| Salford | 416 | 382 | -8.1% |
| Liverpool | 418 | 389 | -7.0% |
| Blackpool | 441 | 432 | -2.0% |
| Manchester | 469 | 455 | -3.1% |
The questions raised in this note are also discussed in a comment available at https://sochealth.co.uk/2013/06/19/longer-lives-monitoring-premature-mortality/
References
Capewell, S and Graham, H 2010 Will Cardiovascular Disease Prevention Widen Health Inequalities? PLoS Medicine August 2010 Vol 7 Num 8
DHSS 1980 Inequalities in Health (The Black Report)
Public Health England, 2013 Longer lives