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Target D:
To reduce health inequalities by increasing the rate of improvement for under 75 Coronary Heart Disease mortality and under 75 cancer mortality (1995-2003) for the most deprived communities by 15% by 2008 12
SUMMARY EVALUATION
A4.120 Average annual percentage reductions of under 75 cancer and CHD mortality rates in the 20% most deprived areas between 2003 and 2005 were higher than the respective targets of 2.1% and 6.1%. Therefore Target D has been surpassed.
A4.121 Improvements in the rate of reduction were highest in the 5% most deprived areas, suggesting that improved health services and efforts to reduce practices that lead to these diseases are impacting upon the most severely deprived communities as well as those relatively less deprived, and the country as a whole.
INTERPRETATION OF TARGET D
A4.122 Target D has been interpreted by the Scottish Executive in terms of average annual percentage improvements. This average is the geometric mean - rather than the arithmetic mean - of the yearly percentage improvements. That is, it is the percentage improvement which, when applied 'n' times, produces the total percentage improvement observed over 'n' years 13.
A4.123 Under 75 coronary heart disease mortality decreased by 35.4% between 1995 and 2003. This equates to an average annual percentage improvement of 5.3% 14. An increase of 15% in this rate of reduction would require an average annual percentage improvement of 6.1%.
A4.124 Under 75 cancer mortality decreased by 13.7% between 1995 and 2003. This equates to an average annual percentage improvement of 1.8%. An increase of 15% in this rate of reduction would require an average annual percentage improvement of 2.1%.
A4.125 Finally, note that the Target has been interpreted by the Scottish Executive as requiring an average annual percentage improvement of 6.1% / 2.1% for the entire period 2003-2008, rather than a yearly percentage improvement which increases to reach 6.1% / 2.1% by 2008.
A4.126 The 'most deprived communities' have been interpreted as the 20% most deprived areas according to the Carstairs Index. See Objective 5 analysis 'Measuring deprivation' for more information on the Carstairs Index.
WORK PROGRAMME AND POLICY CONTEXT
A4.127 Target D requires improvements in deprived areas with regard to two specific types of illness. As such it comes under the umbrella of Objective 5, the aim to "increase the rate of improvement of the health status of people living in the most deprived communities". As discussed in the analysis of Objective 5 the driver behind this objective is the Scottish Executive's aim to reduce health inequalities in Scotland.
A4.128 The specific delivery plan for Target D - the Prevention 2010 pilots, now known as Keep well15 - is part of a wider programme of health initiatives across Scotland, and particularly in deprived areas. The pilots will offer enhanced primary care services in deprived areas, focusing on cardiovascular disease and its main risk factors.
A4.129 It should be noted that progress made with regard to Target D between 2003 and 2005 cannot be attributed to Prevention 2010/ Keep well, which only began in 2006.
EVIDENCE
A4.130 Figure A4.22 shows cancer and coronary heart disease ( CHD) mortality rates in the 20% most deprived areas. It shows that mortality rates for both illnesses have decreased between 2003 and 2005. Figure A4.23 shows the average annual percentage improvement between 2003 and 2005, alongside the figure for 1995-2003, and reveals that the rate of improvement for both kinds of mortality is higher in the second period, as required by the target.
A4.131 Between 2003 and 2005 the under 75 coronary heart disease ( CHD) mortality rate fell by 12.7% from 112.0 to 97.8 (Figure A4.22). This equates to an average annual percentage improvement of 6.6%, higher than the target figure of 6.1%.
A4.132 Between 2003 and 2005 the under 75 cancer mortality rate fell by 7.4% from 186.4 to 172.6 (Figure A4.22). This equates to an average annual percentage improvement of 3.8%, higher than the target figure of 2.1% (Figure A4.23).
Figure A4.22: Under 75 cancer and coronary heart disease mortality rates in the 20% most deprived areas: 2003-2005
Notes: Rate per 100,000 population; age-standardised to the European population. Deprivation measured using the Carstairs index. <75 mortality rates are used for the Closing the Opportunity Gap Target D rather than all age mortality rates.
Source: General Register Office for Scotland ( GROS); Analytical Services Division of the Scottish Executive Health Dept ( ASD Health).
Figure A4.23: Under 75 cancer and coronary heart disease mortality rates in the 20% most deprived areas: annual improvement 2003-2005
Notes: Rate per 100,000 population; age-standardised to the European population. Deprivation measured using the Carstairs index. <75 mortality rates are used for the Closing the Opportunity Gap Target D rather than all age mortality rates. Sources: GROS; ASD Health.
Impact on Equalities groups
A4.133 Figures A4.24 and A4.25 disaggregate 2005 cancer and CHD mortality rates in the 20% most deprived areas by gender and age, and reveal which groups of individuals (aged 74 or under) are most at risk of cancer and CHD mortality, respectively. Mortality rates for both illnesses are relatively low for the under 45 age group. In contrast, people over 65 are more than five times more likely than average, in each case, to suffer mortality as a result of CHD or cancer. Additionally, men are more likely to die from each of the illnesses than women, particularly CHD, mortality rates for which are three times higher amongst males than females.
Figure A4.24: Under 75 cancer mortality rates in the 20% most deprived areas, by gender and age: 2005
Notes: Rate per 100,000 population; age-standardised to the European population. Deprivation measured using the Carstairs index. <75 mortality rates are used for the Closing the Opportunity Gap Target D rather than all age mortality rates.
Sources: GROS; ASD Health.
Figure A4.25: Under 75 coronary heart disease mortality rates in the 20% most deprived areas, by gender and age: 2005
Notes: Rate per 100,000 population; age-standardised to the European population. Deprivation measured using the Carstairs index. <75 mortality rates are used for the Closing the Opportunity Gap Target D rather than all age mortality rates.
Sources: GROS; ASD Health.
A4.134 Figure A4.26 and Figure A4.27 show improvement between 2003 and 2005 in cancer and CHD mortality rates, respectively, broken down by age, gender and level of deprivation.
A4.135 Figure A4.26 shows that the percentage reduction in cancer mortality rates was highest in the 5% most deprived areas. This provides some evidence that efforts to reduce cancer mortality are impacting upon the most severely deprived communities as well as the rest of Scotland. Figure A4.26 shows that cancer rates among the under 45 age group are increasing overall in the 20% most deprived areas. However, because cancer rates are relatively low amongst people aged under 45, this change represents an increase of only 1.4 deaths per 100,000 population between 2003 and 2005, which is an increase of around 14 deaths per year in the 20% most deprived areas 16.
A4.136 The 5% most deprived areas have seen the highest annual percentage improvement in CHD mortality rates, both overall and for each individual group considered. Annual reductions among women and the 45 to 64 age group were nearly 20% between 2003 and 2005.
Figure A4.26: Under 75 cancer mortality rate in the 20% most deprived areas: annual improvement 2003-2005
Notes: Rate per 100,000 population; age-standardised to the European population. Deprivation measured using the Carstairs index. <75 mortality rates are used for the Closing the Opportunity Gap Target D rather than all age mortality rates.
Sources: GROS; ASD Health.
Figure A4.27: Under 75 coronary heart disease mortality rate in the 20% most deprived areas: annual improvement 2003-2005
Notes: Rate per 100,000 population; age-standardised to the European population. Deprivation measured using the Carstairs index. <75 mortality rates are used for the Closing the Opportunity Gap Target D rather than all age mortality rates.
Sources: GROS; ASD Health.
A4.137 The data available on cancer and CHD mortality rates cannot be disaggregated by ethnicity, faith, sexuality or disability status. In the absence of qualitative information on how individuals of different ethnicity, faith, sexuality or disability status are progressing against the Target, the research team spoke to members of the Scottish Executive monitoring this Target about its impact upon different equalities groups. They believed that the major equality issue for this target was the difference in outcomes for different socio-economic groups, this being the rationale for focusing on deprived areas and requiring an increased rate of improvement (thus motivating a 'catching up' of the most deprived areas with the rest of Scotland, in terms of health status).
A4.138 It is acknowledged in the Equalities Impact Assessment for Target D that the risk of heart disease and cancer increases with age, and that men are more likely to develop CHD than women, and it is intended that Prevention 2010/ Keep well will be targeted at those most at risk of developing preventable conditions. However, it was also stressed that an important aspect of the Prevention 2010/ Keep well pilots is ensuring that services are extended to all 'hard-to-reach' groups. As part of this effort, a number of measures have been taken which will increase the impact of work on equalities groups, for example, producing information leaflets in different languages. However, the focus is on helping individuals who are hard to reach "for whatever reason" access primary care services, rather than on tailoring delivery to the specific equalities groups identified by the Scottish Executive.
DATA ISSUES
A4.139 As discussed above, some of the figures in this section show average annual percentage improvements. It is important to be aware that similar percentage changes in groups of very different size will not represent similar absolute changes. For example, the rate cancer deaths is much lower among people aged under 45 than among people aged 65-74. Therefore, a fall of 1% in the 2005 cancer rate amongst people aged 65-74 in the 20% most deprived areas would represent 113 fewer people experiencing cancer. Whereas a fall of 1% in the 2005 cancer rate among people aged under 45 in the 20% most deprived areas would represent only 1 less person experiencing cancer. However, percentage changes do allow us to compare changes occurring in groups of different sizes, and they have been presented here in line with the Scottish Executive's interpretation of the Target in terms of percentage change (see 'Target Interpretation' above).
A4.140 As discussed in the analysis of Objective 5, most of the health indicators available for Scotland cannot be disaggregated by ethnicity, disability status, faith or sexuality. This is the case for the cancer and CHD mortality rates analysed in this chapter. These data are provided by the General Register Office for Scotland ( GROS), which registers deaths and records causes of death. The GROS does not currently provide data on ethnicity, disability status, faith or sexuality to the Scottish Executive, and in the case of the latter two in particular, it is difficult to see how the GROS could ascertain this information.
A4.141 Although the Carstairs Index is currently used to identify the 20% most deprived areas for which cancer and CHD rates are measured for Target D, the local authority areas chosen for Prevention 2010/ Keep well pilots - the delivery plan for Target D - were those with the highest numbers of people living in the 15% most deprived data-zones as identified using the Scottish Index of Multiple Deprivation ( SIMD). This disparity reflects the fact that the Scottish Executive currently employs two different measures of deprivation for different purposes. See the analysis of Objective 5 for more information on the differences between the Carstairs Index and the SIMD.
A4.142 See the analysis of Objective 5 for full description of the data sources for Cancer and CHD rates.
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