Introduction
In 2007, a Ministerial Task Force on Health Inequalities led by the Minister for Public Health was established to identify and prioritise practical actions to reduce the most significant and widening health inequalities in Scotland. The Task Force recognised the need to monitor progress in tackling health inequalities in the longer term as well as managing short- and medium-term progress.
A short life technical advisory group was set up in early 2008 to advise the Task Force on long-term monitoring of health inequalities (see Annex 1 for membership of this group). The remit of this group was to explore how best to measure health inequalities and which high level national indicators should be monitored over time. The group's advice was as follows:
Recommended headline indicators of inequalities in health outcomes
- Healthy Life Expectancy (at birth)
- Premature Mortality - from all causes, aged under 75 years
- Mental Wellbeing - adults aged 16 years and over
- Low birthweight
Recommended indicators of inequalities in morbidity and mortality from specific causes for specific age groups
- Coronary Heart Disease (first ever hospital admission for heart attack aged under 75 years; deaths aged 45-74 years)
- Cancer (incidence rate aged under 75 years; deaths aged 45-74 years)
- Alcohol (first ever hospital admission aged under 75 years; deaths aged 45-74 years)
- All-cause mortality aged 15-44 years (to capture large inequalities in mortality observed in this age group)
Details of the definitions and sources for these indicators are provided below. Note that the time periods for which data are available for these indicators vary.
Some of these indicators (healthy life expectancy, mental wellbeing, alcohol related hospital admissions and premature mortality from coronary heart disease in deprived areas) are also included in the National Performance Framework. Further information about these national indicators is available on the Scotland Performs website:
http://www.scotland.gov.uk/About/scotPerforms
The Task Force considered that the expert group's proposals would give a much better basis for Government reporting on long-term success in reducing health inequalities and therefore included in their report ("Equally Well"; published in June 2008), the following recommendations on long-term monitoring of health inequalities:
70. The Government should adopt the recommended new headline indicators and measures for reporting on long-term progress in reducing health inequalities in Scotland and driving action on the underlying causes of the most important inequalities.
71. The Government should publish in summer 2008 detailed proposals for the new high level indicators and measures of health inequalities, along with current levels and trends for each measure.
This is the first report on long-term monitoring of health inequalities, produced by the Scottish Government in response to these recommendations. Its aim is to present the detailed definitions for each of the proposed indicators of inequalities in health outcomes (as agreed by the Task Force), and to present current trends to set a baseline for long-term monitoring at Scotland level.
Equally Well also included the recommendation that information about medium-term outcomes be published:
72. The Government should arrange for a clear analysis of the medium-term outcome indicators critical to achieving reductions in the key health inequalities outcomes. This analysis should reflect the National Performance Framework and the new relationship between the Scottish Government and local authorities as embodied in the Single Outcome Agreement process, It should be published by autumn 2008, in order to guide community planning partnerships and their constituent organisations in their own planning and performance reporting.
The Health Inequalities Task Force will be reconvened in 2010 to assess progress in implementing the recommendations set out in Equally Well. This will be too soon to assess progress on the indicators included in this report, but information published to meet recommendation 72 on medium-term outcomes should assist in managing progress in the meantime.
Detailed Definitions for the recommended indicators of inequalities in health outcomes
Source: Scot PHO (using raw deaths data from the General Register Office for Scotland; Scottish Household Survey data on self-assessed health for adults aged 16+ years [data for 2003/04 not available]; Census 2001 data for self-assessed health for those aged <16 years).
Definition: Healthy life expectancy ( HLE) is defined as the number of years people can expect to live in good health. The discrepancy between healthy and total life expectancy ( LE), therefore, indicates the length of time people can expect to spend in poor health. HLE is calculated through a combination of life expectancy and survey data on people's own assessments of their health. The method used to calculated the Life Expectancy estimates is based on Chiang (II) methodology; the HLE calculation is based on the Sullivan method. The uncertainty around estimates of HLE are larger than those around life expectancy because relatively small samples are involved in the age and sex specific breakdowns of survey data required to calculate HLE (for example: In the calculations to produce these estimates of HLE, there were 900 age/sex/decile breakdowns for self-assessed health data from the Scottish Household Survey; 53% of which had fewer than 100 respondents and 13% of which had fewer than 50 respondents).
- Premature Mortality (from all causes, aged under 75 years)
Source: General Register Office for Scotland.
Definition: European age-standardised rates of deaths from any cause amongst those aged under 75 years.
- Mental Wellbeing (adults aged 16 years and over)
Source: WEMWBS; Initial results available from the Well? Survey 2006; Future source will be the Scottish Health Survey (annually for 2008-2011).
Definition: Warwick-Edinburgh Mental Wellbeing Scale. This has been developed as a tool for measuring positive mental wellbeing at a population level. The scale comprises fourteen separate statements describing feelings related to mental wellbeing; respondents are asked to indicate how often they have felt such feelings over the last two weeks. Results are presented as average WEMWBS score for the population concerned.
Source: NHS Information Services Division ( ISD) ; SMR02 maternity dataset.
Definition: The figures are presented as a percentage of all live, full term, singleton births (not including home births or births in non- NHS hospitals). Figures are for financial year ( i.e. '2005' is for '2004/05'). Low birth birthweight is defined as < 2,500g - the standard World Health Organisation definition. Figures for the most recent year are provisional.
- Coronary Heart Disease - first ever hospital admission for heart attack aged under 75 years
Source: NHS Information Services Division ( ISD) ; SMR1/01 records (all inpatient and daycase discharges) - all records were extracted from the SMR01 linked database as at 24th July 2007.
Definition: European age-standardised rates of first ever hospital admission for acute myocardial infarction (heart attack) amongst those aged under 75 years. The following World Health Organisation International Classification of Disease coding was used: ICD10 'I21-I22'; ICD9 '410'.
- Coronary Heart Disease - deaths aged 45-74 years
Source: NHS Information Services Division ( ISD); using deaths data from General Register Office for Scotland.
Definition: European age-standardised rates death from coronary heart disease amongst those aged 45-74 years. The following World Health Organisation International Classification of Disease coding was used: ICD10 'I20-I25'; ICD9 '410-414'.
- Cancer - incidence rate aged under 75 years
Source: NHS Information Services Division ( ISD); Scottish Cancer Registry.
Definition: European age-standardised rates of new cases of cancer amongst those aged under 75 years. Cancer defined as all malignant neoplasms excluding non-melanoma skin cancer. The following World Health Organisation International Classification of Disease coding was used: ICD10 'C00-C96' excluding 'C44' (the Scottish Cancer Registry does not use code 'C97').
- Cancer - deaths aged 45-74 years
Source: NHS Information Services Division ( ISD); Scottish Cancer Registry.
Definition: European age-standardised rates of deaths from cancer amongst those aged under 45-74 years. Cancer defined as all malignant neoplasms excluding non-melanoma skin cancer. The following World Health Organisation International Classification of Disease coding was used: ICD10 (2000 onwards) 'C00-C97' excluding 'C44'.
- Alcohol - first ever hospital admission aged under 75 years
Source: NHS Information Services Division ( ISD).
Definition: European age-standardised rates of first ever hospital admission for alcohol related conditions amongst those aged under 75 years. These rates include hospitals discharges where alcohol-related problems are recorded as either primary or secondary reasons for admission to hospital and will cover first ever admission since 1981 (a patient may have had admissions prior to 1981 which would not be recorded in this database). Caution is necessary when interpreting these figures. The recording of alcohol misuse may vary from hospital to hospital. Where alcohol misuse is suspected but unconfirmed it may not be recorded by the hospital. The following World Health Organisation International Classification of Disease coding was used: ICD10 F10, R780, Y90, Y91, Z637, Z811, Z864, Z714, Z502, T506, Y573, T510, T519, X45, X65, Y15, O354, Q860, P043, Z721, Z133, G621, G721, K860, I426, K70, K292, G312 & E52; ICD9 291, 303, V11, 3050, 3575, 4255, 5353, 5710, 5711, 5712, 5713, 6555, 7607, 7903, 9773, 9800, E8600, E8609, E9473, E9773, E9800.
- Alcohol - deaths aged 45-74 years
Source: General Register Office for Scotland.
Definition: European age-standardised rates of death from alcohol related conditions amongst those aged 45-74 years. The definition of alcohol related deaths includes deaths where there was any mention of alcohol related conditions on the death certificate, rather than just as the main cause of death. The following World Health Organisation International Classification of Disease coding was used: ICD10 F10, G31.2, G62.1, I42.6, K29.2, K70, K73, K74.0, K74.1, K74.2, K74.6, K86.0, X45, X65, Y15; ICD9 291, 303, 305.0, 425.5, 571.0, 571.1, 571.2, 571.3, 571.4, 571.5, 571.8, 571.9, E860.
- All-cause mortality aged 15-44 years
Source: General Register Office for Scotland.
Definition: European age-standardised rates of deaths from any cause amongst those aged 15-44 years. Specific breakdowns for deaths from assault, drug related deaths and suicide are also provided, as the major causes of death for which there are large inequalities amongst young people. There may be some double counting in these breakdowns. The following World Health Organisation International Classification of Disease coding was used: Assault ICD10 'X85-Y09', 'Y87.1' ICD9 'E960-969'; Drug related ICD10 'F11-16', 'F19', 'X40-44', 'X60-64', 'X85', 'Y10-Y14'; Suicide (intentional self harm + undetermined intent) ICD10 'X60-84', 'Y87.0' ICD9 'E950-959', 'E980-989'.
Recommended measurement approaches to monitoring health inequalities
The expert group recognised that different types of measure give insight into different aspects of inequalities. The recommended approach therefore uses a combination of measures, with the aim of giving a fuller understanding of the inequalities concerned.
- Relative Index of Inequality ( RII): How steep is the inequalities gradient? This measure describes the gradient of health observed across the deprivation scale, relative to the mean health of the whole population.
- Absolute gap: How big is the gap? This measure describes the absolute difference between the extremes of deprivation - the rate in the most deprived minus the rate in the least deprived group.
- Scale: How big is the problem? This measure describes the underlying scale of the problem, puts it into context and presents past trends at Scotland level.
Detailed descriptions of these measures are provided in Annex 3.
In the absence of individual level data on socio-economic circumstance, which the group identified as the ideal but acknowledged is not yet possible, an area based index based on income and employment has been used to define "deprivation". Details about the reasons for this and the way that this index was calculated are provided in Annex 3.
The expert group also advised that these indicators and measures were recommended for long-term monitoring of health inequalities due to deprivation at Scotland level. Monitoring of health inequalities due to other factors (such as age, gender, ethnicity for example) would require different indicators and measures. Similarly, the group advised that these recommended indicators and measures would not necessarily be the most appropriate for long-term monitoring of health inequalities at a local level.