Unequal Lives: Breaking the Wealth-Health Link Professor Richard - - PowerPoint PPT Presentation

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Unequal Lives: Breaking the Wealth-Health Link Professor Richard Cookson Centre for Health Economics University of York Acknowledgements This inaugural lecture is dedicated to my family with thanks and love, and especially to Maria, Laura and

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Unequal Lives:

Breaking the Wealth-Health Link

Professor Richard Cookson

Centre for Health Economics University of York

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This inaugural lecture is dedicated to my family with thanks and love, and especially to Maria, Laura and Harry; Brian and Susan; Ari and Dora; Sarah, Tim, Lyra and Lani; Ani, Bo, Theo, Alice and Arthur. Special thanks to Miqdad Asaria and Shehzad Ali for their invaluable contributions to the research presented in this lecture and the camaraderie we shared along the way; to Karen Bloor, Tim Doran and Adam Oliver for their comradeship and support in many different academic ventures; to Michael Bacharach, John Bone, John Broome, John Hey, Graham Loomes, Mark Machina, and Sue Mendus for their inspirational teaching and supervision during my undergraduate and postgraduate training; and to Anthony Culyer, Maria Goddard, Miranda Mugford, Alan Maynard, Trevor Sheldon and Alan Williams for their generous mentorship during my postdoctoral career as a health economist. Funding from the following organisations is gratefully acknowledged – NIHR Senior Research Fellowship (SRF-2013-06-015), DH Policy Research Programme Public Health Research Consortium (PHRC), NIHR Health Services and Delivery Research (HSDR) Programme (project 11/2004/39), The University of York and Wellcome Trust Centre for Chronic Diseases and Disorders – as is support from my department, the Centre for Health Economics, University of York, in providing such a great research environment. I would also like to thank: Ruth Helstrip, Linda Baillie, Gill Forder, Kay Fountain and Frances Sharp for administrative support. Susan Griffin, James Koh, Andrew Mirelman and Bryony Dawkins for their contributions to developing “distributional” cost-effectiveness analysis. The rest of my NIHR equity indicators project team: Helen Barratt, Brian Ferguson, Robert Fleetcroft, Maria Goddard, Peter Goldblatt, Mauro Laudicella, Rosalind Raine and Jessica Sheringham. My PhD students: Robert Fleetcroft, Shehzad Ali, Mauro Laudicella, Yeunsook Rho, Ricardo Rodrigues, Laetitia Schmitt, Estela Barbosa and James Koh. My other co-authors: Matthew Adler, Thomas Allen, Mark Ashworth, Enrique Bernal-Delgado, Karen Bloor, Baltica Cabieses, Simon Capewell, Karl Claxton, Brendan Collins, Owen Cotton-Barrett, Anthony Culyer, Bryony Dawkins, Diane Dawson, David McDaid, Paul Dolan, Peter Dorman, Mike Drummond, Mark Dusheiko, Richard Edlin, Manuel Espinoza, Alastair Fischer, Chris Flood, Adam Formby, Chris Gale, Sandra Garcia-Armesto, Hilary Graham, Susan Griffin, Hugh Gravelle, Nils Gutacker, Simon Halliday, Geoff Hardman, Amanda Howe, John Hutton, Kjell-Arne Johansson, Andrew Jones, James Love-Koh, Paolo Li Donni, Peter Littlejohns, Michael Rhodes, Steve Martin, Alan Maynard, Rebecca Mason, Chris McCabe, Andrew Mirelman, Luke Mondor, Giuseppe Moscelli, Erik Nord, Ole Norheim, Adam Oliver, Toby Ord, Carol Propper, Nigel Rice, Matthew Robson, Franco Sassi, Mark Sculpher, Koonal Shah, Luigi Siciliani, Nick Steel, Marc Suhrcke, Matt Sutton, Peter Tugwell, Aki Tsuchiya, Stephen Verguet, Vivian Welch, Walter Wodchis, Andrew Walden, Simon Walker, Helen Weatherly, Piran White and Alan Williams. My equity project advisory group: Allan Baker, Chris Bentley, Sarah Curtis, Tim Doran, Brian Ferguson, Donald Franklin, Chris Gale, Peter Goldblatt, Ann Griffin, Iona Heath, Azim Lakhani, Alan Maynard, Nick Mays, Lara McClure, Mark Petticrew, Jennie Popay, Carol Propper, Wim Troch; and other key project advisers: Mark Dusheiko, Hugh Gravelle, Rita Santos and Peter Smith. Paul Toner, Gill Forder, Ness King, Sarah Dwyer and Rita Neves De Faria for help in piloting our public consultation materials; Adriana Castelli and Katja Grasic for help with the HES data access requests and data provision; John Galloway and Mark Wilson for IT support; Sarah Kennedy for administrative support with advisory group meetings at LSHTM in London; Sue Pargeter for NIHR research management support; and Alistair Keely, Felicity Porritt, Andy Rausse and John Yates for public communications support. For helpful comments and discussions I would like to thank Sara Allin, Yukiko Asada, Ray Avery, Gwyn Bevan, Chris Belshaw, Alan Brennan, Patel Bhavana, Karen Bloor, Paul Brant, Simon Capewell, Kalipso Chalkidou, Brendan Collins, Annmarie Connolly, Anthony Culyer, Anthony Darne, Sharmela Darne, Raiser Deber, Maria Dimova-Cookson, Paul Fryers, Amanda Glassman, Jeremy Grimshaw, Thomas Hennell, Steve Holland, John Holmes, John Hutton, Andrew Jackson, Sasha Keshavarz, Carleigh Krubiner, Audrey Laporte, Ryan Li, Frank Markel, Gustavo Mery, Helen McManus, Una Mcleod, Luke Mondor, Helena Norwell, Martin O’Flaherty, Andrew Parker, Jennifer Petkovic, Erin Pichora, Christian Piller, Veena Raleigh, Dan Roper, Robert Shaw, Trevor Sheldon, Sunita Shier, Nancy Sikich, Nick Steele, Andrew Street, Peter Tugwell, Jeffrey Turnbull, Adam Wagstaff, Vivian Welch, Mike Wimmer, Walter Wodchis, Michael Wolfson and Tony Woods. The views expressed are my own and not those of the individuals and organisations listed above.

Acknowledgements

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Publications and Resources

www.york.ac.uk/che/research/equity

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“Richard” (Rich Family) “Paul” (Poor Family)

Introduction

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10 20 30 40 50 60 70 80

Richest Fifth 2nd Richest Middle Fifth 2nd Poorest Poorest Fifth

Healthy Years of Life

Life expectancy adjusted for health quality, England and Wales 2011

12

Source: Love-Koh, J., Asaria, M., Cookson, R., & Griffin, S. (2015). The Social Distribution of Health: Estimating Quality-Adjusted Life Expectancy in England. Value in Health, 18(5), 655-662.

75 63

Introduction

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12 Healthy Years

Paul Richard

Introduction

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Inequality costs the NHS £20 billion a year 158,000 preventable emergency admissions

3.7

Least Deprived Fifth Most Deprived Fifth

9.0

Unfair Health Emergencies

Emergency hospital admissions considered preventable, per 1,000 people

Introduction

Notes:

1. Admissions for long-term conditions like heart and lung disease, diabetes and dementia 2. Source: Hospital episode statistics; England 2011/12; indirectly age-sex adjusted

158,000 preventable emergency admissions and 38,000 deaths from treatable conditions

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Introduction

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Introduction

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Introduction

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  • 12%
  • 10%
  • 8%
  • 6%
  • 4%
  • 2%

0% 2% 1 2 3 4 5 6 7 8 9 10 Change in net income

Long-run impact of tax and benefit reforms introduced between May 2015 and April 2019 by income decile Working Age

Source: Institute for Fiscal Studies https://www.ifs.org.uk/publications/8210

Distributional analysis for budget day

Why not do distributional analysis:

  • In terms of lifetime health and

wellbeing, not just annual income

  • For all public decisions, not just tax

and benefit reforms?

Introduction

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Understanding Causes

A lifetime perspective on the wealth-health link

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Health Behaviour

1: Family inheritance and childhood development

Family

Wealth Health

Childhood Development

  • Physiological
  • Cognitive
  • Social and Emotional

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Health Behaviour

2: Living conditions

Wealth Health

Living Conditions Chronic stress

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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3: Ill-health impacts on wealth

Wealth Health

Mental and physical ill-health reduce earnings and increase costs of health and social care

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Health Behaviour

The wealth-health link

Family

Wealth Health

Childhood Development

  • Physiological
  • Cognitive
  • Social and Emotional

Living Conditions

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Health Behaviour Family

Wealth Health

Childhood Development

  • Physiological
  • Cognitive
  • Social and Emotional

Living Conditions

Breaking the wealth-health link

State

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Can the NHS reduce health inequality? Yes it can!

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

Inequality in mortality amenable to health care England vs. Ontario, 2004-11

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Clarifying Principles

Why clear thinking about the ethics of reducing health inequality requires a lifetime perspective

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Who are the worse off?

e.g. Should the NHS fund: (1) a new drug for skin cancer or (2) screening for maternal depression?

  • Current health perspective

– Skin cancer: greater severity of illness; more immediate and certain health gains

  • Lifetime health perspective

– Maternal screening: disproportionately benefits poorer mothers and children with low life expectancy at birth – More than half of skin cancer deaths in the UK are in people age 70 or over

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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The lifetime health perspective gets short shrift

  • Not promoted by conventional or social media
  • Not protected by legislation
  • Not quantified by policy analysts

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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500 1000 1500 2000 2500 3000 3500 4000 4500 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110

Number per 100,000 deaths

Age at death, adjusted for health quality

Born Richest Fifth

The lifetime health perspective

Fictitious example, loosely based on data for England in 2010

Average 75

Some of the variation around the average

  • f 75 might be considered “fair”
  • Pure luck
  • Individual choice or responsibility

Some might be considered “unfair”

  • Social responsibility

Often hard to disentangle “fair” and “unfair”, with room for disagreement

  • e.g. smoking, gender

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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500 1000 1500 2000 2500 3000 3500 4000 4500 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110

Number per 100,000 deaths

Age at death, adjusted for health quality

Born Richest Fifth Born Poorest Fifth

This average gap of 12 years of healthy life seems clearly “unfair”

12 year average gap

Paul has to be lucky to have as long and healthy a life as Richard

The lifetime health perspective

Fictitious example, loosely based on data for England in 2010

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Finding Solutions

Equity-informative health economic evaluation

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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  • III. Lose-Lose
  • IV. Lose-Win
  • I. Win-Win
  • II. Win-Lose

Cost-Effectiveness (Total Health Impact) Equity Impact

+

  • +

Health Equity Impact Plane

Cost-effective Improves equity Cost-effective Harms equity Cost-ineffective Improves equity Cost-ineffective Harms equity

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Unequal uptake of bowel cancer screening, UK

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Bowel cancer screening reminders

  • 0.001

0.001 0.002 0.003 0.004 0.005

Incremental per person QALYs

Proportional Standard

Least Deprived Most Deprived Middle

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

Standard approach (“Win-Lose”) vs. Proportional approach focusing on deprived (“Lose-Win”)

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Confronting Trade-Offs

How much do you care about reducing health inequality versus improving total health?

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Expected Lifetime Health of Group 2 (Born Richest Fifth) Expected Lifetime Health of Group 1 (Born Poorest Fifth) Possibility frontier Equality

  • BENTHAM

(maximum total) RAWLS (maximin)

  • Theories of justice…applied to health

MARX (As close to equality as possible) PLATO (maximum ratio)

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Expected Lifetime Health of Group 1 (Born Poorest Fifth) Equality

  • Theories of justice…applied to health

ATKINSON (priority to the worse off)

  • ●

Expected Lifetime Health of Group 2 (Born Richest Fifth)

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Setting Equity Benchmarks

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Monitoring Progress

Equity-informative quality assurance

Understanding Causes Clarifying Principles Finding Solutions Confronting Trade-Offs Monitoring Progress

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Preventable emergency admissions in each neighbourhood, by deprivation

Source: Hospital episode statistics 2015, * indirectly standardised for age and sex

Health care outcome inequality in your area

National Similar areas North Lincolnshire Inequality gradient National Similar areas Ashford Inequality gradient

Least Deprived Most Deprived Least Deprived Most Deprived

North Lincolnshire Ashford

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Paul Richard

12 Year Gap

Conclusion