Elsevier

Public Health

Volume 123, Issue 1, January 2009, Pages e50-e56
Public Health

e-Supplement
Improving male life expectancy in Birmingham

https://doi.org/10.1016/j.puhe.2008.10.029Get rights and content

Summary

On average, a man in Birmingham can expect to live 2 years less than men in the rest of England. Taken together, diseases of the circulatory system are responsible for the majority of deaths. This paper lays out the challenge faced and the interventions used to close that gap, with a particular focus on a large-scale cardiovascular disease screening programme. Data from general practitioners' registers were used to target men over 40 years of age to be invited to special screening clinics to assess cardiovascular risk. The results obtained from almost 10,000 men are now being used to improve disease registers and to provide preventative treatments.

Introduction

On average, a man in Birmingham can expect to live 2 years less than men in the rest of England. A widening of this gap between 1997 and 2004 (Fig. 1) was identified as a failure to meet a floor target and a major concern by both the local authority and the National Health Service (NHS) in the city. A ‘floor target action plan’1 (FTAP) to reduce this gap was submitted to the Government Office of the West Midlands in March 2006.

‘Floor target’ is a generic term to describe government targets that set a minimum standard of service for disadvantaged groups or areas, or a narrowing of the gap between them and the rest of the country. The government floor target for life expectancy, agreed in 2000, is to reduce the gap between the fifth of local authority areas with the worst deprivation and the average for England by 10% by 2010. In 1997, the baseline date, the gap between Birmingham and the English average was 1.7 years. By 2004, that gap had grown to 2.3 years, so the trajectory was in exactly the wrong direction. The FTAP acknowledged that the original target would not be met, but pledged to reduce the gap by 10% from 2.3 years. A target for closing the gap between the most deprived wards in Birmingham and the city average was also included.

This paper lays out the challenge faced and the interventions that were attempted to close the gap. There is a particular focus on one of the interventions, a large-scale cardiovascular disease screening programme that preceded the UK Government's announcement of vascular screening for all people over 40 years of age.

The Public Health Information Team (PHIT) in Birmingham carried out an analysis of the causes of death for all men in Birmingham (Fig. 2), and then a similar analysis for the potential years of life lost for men in the most deprived areas who died before 75 years of age (Fig. 3). The causes of male deaths vary considerably at different ages. Infant mortality plays a part, with some deaths occurring before 1 year of age. For young men, vehicle accidents and suicide need to be reduced, and for men in their 40s, liver disease is a significant killer. Cancers, especially lung cancer, are the second biggest killer, and cerebrovascular disease is also significant for men in their 50s and 60s. Ischaemic heart disease is the biggest killer of all. Taken together, diseases of the circulatory system are responsible for the majority of deaths.

The graph in Fig. 3 was influential in a decision to target men over 40 years of age, a younger age than had previously been targeted for prevention measures.

The FTAP also found a very strong correlation between life expectancy and income (Fig. 4); men living in the most deprived areas of Birmingham die younger. They do not die from different causes – heart disease is still the biggest killer – but they do die earlier. Black and minority-ethnic populations make up a significant proportion of the population in the worst affected areas.

General practitioners (GPs) are required to maintain disease registers of patients, including a coronary heart disease (CHD) register, as part of the Quality Outcomes Framework.a The PHIT in Birmingham mapped the prevalence of heart disease across the city using data from CHD registers. The resulting map (Fig. 5) showed that the highest incidence of known disease occurs outside the inner city areas and outside those areas with the highest deprivation or larger ethnic-minority populations. A similar map showing the standard mortality rate from CHD across the city suggests a very different picture. The incidence of CHD deaths is much higher in high deprivation areas and, to some extent, in those areas with large ethnic-minority populations. Two conclusions which may be drawn from this are: (1) being on a disease register reduces the chance of death; and (2) GPs in the most deprived areas are not detecting men at risk in the same way as GPs in more affluent areas.

As a result, the FTAP committed the primary care trusts (PCTs) in Birmingham to systematically seek out men at risk in 12 of the most deprived wards in the city.

Section snippets

Primary prevention and secondary prevention

Primary prevention usually means intervention on ‘lifestyle factors’, especially smoking cessation, diet, obesity, physical activity and alcohol consumption in patients without existing CVD. Secondary prevention includes more intensive lifestyle intervention and the appropriate use of antihypertensives, lipid-lowering drugs, glucose-lowering drugs and other cardiovascular protective drugs in patients with known CVD. The widespread use of cheaper statins has blurred this distinction in

Has the programme worked?

A full evaluation of the whole programme is underway and will be published in October 2008.12 The programme was assembled in haste because of available funding; with more time, some of the operational aspects could certainly have been improved. Over 15,000 men from the most deprived areas of Birmingham have been affected by at least one of the initiatives in this programme, most of them will have benefited and some will enjoy longer lives as a result.

It is easy to criticize this screening in

Discussion

‘The NHS is becoming more personal and responsive to individual needs; becoming as good at prevention and keeping people healthy as it is providing care and cures.’ Health Secretary Alan Johnson 200815

Although often clinically innovative, the NHS has been notoriously resistant to organizational change. Almost three decades of uninterrupted policy change and attempts at organizational restructuring have produced small results given the sustained efforts that have been made.16, 17

The risks of

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