Tackling health inequalities: 2007 Status Report on the Programme for Action provides a review of developments against the data since the publication of the Programme for Action in 2003. It considers progress against the Public Service Agreement (PSA) target, the national headline indicators and against government commitments. The report shows:

• Further slight narrowing of the infant mortality gap, little change in the gap in male
  life expectancy and a widening of the gap in female life expectancy since 2003–05.

• An encouraging picture on the cross-government indicators, with long-term progress in reducing child poverty and narrowing inequalities in housing quality, educational
  attainment and uptake of flu vaccinations. Cancer and circulatory (heart) disease
  mortality, child road accident casualties and teenage conceptions show a narrowing of
  inequalities in absolute terms (but not in relative terms); other areas, for example
  smoking, show a general reduction in prevalence but no narrowing of the gap between social groups

• Most departmental commitments set out in the Programme for Action and due for
  delivery by the end of 2006 have been wholly or substantially achieved.

More than 17,000 people receiving treatment in the UK have died unnecessarily because of the inadequacies of the NHS, it is claimed today. The figure, in Wasting Lives: A statistical analysis of NHS performance in a European context since 1981 published by the Taxpayers’ Alliance, is calculated using data given to the World Health Organisation. It compares the number of people who died prematurely, even though their illness was treatable in the UK to that of Germany, France, the Netherlands and Spain.

Food: an Analysis of the Issues, a report from the Cabinet Office suggests that up to 70,000 lives could be saved every year if people improved their diets.  One in ten premature deaths would be prevented if Britons reduce the amount of salt, sugar and fat they eat, it was claimed. And people are digging an early grave for themselves by not eating enough fruit, vegetables, fibre or oily fish, according to a report by the Cabinet Office.  The risk from cancer and heart disease from poor diet is unrelated to the current rise in obesity.

Caring for Vulnerable Babies: The reorganisation of neonatal services in England (Executive Summary) considers if the reorganisation of neonatal services in England has helped improve care for premature and low birth weight babies with fewer babies travelling long distances for suitable treatment. The National Audit Office in it find that further improvements to the service are being limited by shortages in nursing staff, a lack of cots in the right place at the right level of care and a lack of widespread specialist 24 hour transport. They also provide a comparison with international neonatal services via RAND Europe: The provision of neonatal services and the Survey of Neonatal Units in England by the National Audit Office upon which the report is based.

Every year around 10 per cent, or 60,000, newborn babies require some form of specialized neonatal care. And these numbers are increasing, up 5 per cent between 2005 and 2006, due to an increase in the proportion of women with high risk factors such as high or low maternal age, obesity, ethnic origin, deprivation and assisted conception such as IVF. In 2006-07, some £420 million was spent on running the 180 neonatal units in England, which are organized into 23 managed clinical networks.

A number of improvements since the Department announced the reorganization of neonatal services into networks in 2003 are identified. There has been a reduction in long distance transfers of mothers and babies, with only 3.4 per cent of babies across England admitted to units outside of their network. Overall, 17 networks are meeting the target to treat babies within their network and the consistency, communication and co-ordination of care within and between the networks has improved. The number of cots has also increased from 3,243 to 3,521. Neonatal units have made strides in considering the needs of parents and involving them in their babies care. Parents are mostly very happy with the specialist care and expertise their babies receive.

In 2005, England’s neonatal mortality rate was 3.5 deaths per 1,000 live births, similar to other developed countries. But the report found that this figure masks wide variations across the country. The South West Midlands had the highest mortality rate of 4.8 deaths per 1,000 live births, compared to Surrey and Sussex with 1.8 deaths per live 1,000 births. More work is required to determine the contribution that different socio-economic, ethnic, demographic, cultural and service factors are making to these variations in mortality rates.

The report also highlighted shortages in the numbers of neonatal nurses. On average, each unit had nearly three nursing vacancies for nurses qualified in neonatal care. Only half of units met the British Association of Perinatal Medicine (BAPM) professionally developed standard for high dependency care of one nurse to two babies, and only 24 per cent met the standard for intensive care of one nurse to one baby. The vast majority of level three (intensive care) units, which require a 1:1 ratio of nurses to babies for the whole unit, did not meet the standards for intensive care.

Cots for the right level of care are not always available, resulting in units having to close and babies being cared for in the wrong places on occasions. On average, each unit had to close to new admissions once a week, the most common reasons being a lack of cots or skilled nursing staff. Nearly a third of units had to care for a baby who should have been transferred to a higher level of care and just over half looked after an improving baby who was ready to be transferred but could not because a receiving cot was not available. In 2006-07, nearly a third of neonatal units operated above the BAPM recommended occupancy rate of 70 per cent and three units operated above 100 per cent. High occupancy rates could have consequences for patient safety, for example due to increased risk of infection or inadequate levels of care.

Neonatal transport is an essential element of networked neonatal care, with all bar one providing some form of specialist transport during day time working hours, but only half of networks providing specialist transport services 24 hours a day seven days a week. Few transport services have separate staffing arrangements from the clinical inpatient services meaning that staff have to leave the unit to accompany a baby on a transfer. Three quarters of units experienced delays in moving babies and 44 per cent believed that care was compromised as a result.

The report concludes that the cost of neonatal services as a whole are not fully understood and there is a mismatch between costs and charges. Also charges per day for an intensive care cot varied from £173 to £2,384. The reorganization of care into neonatal networks has improved the co-ordination and consistency of services pointing to increased effectiveness, however there is still capacity and staffing problems and a lack of clear data on outcomes. In addition, the variable financial management information makes it difficult to judge the economy and efficiency of the service.

The NAO recommends that NHS and Foundation Trusts need to improve their financial management information. Commissioners, in conjunction with networks and Strategic Health Authorities, should commission all neonatal care services together and in particular examine the relative cost-effectiveness of the different transport options currently in place. In addition, NHS and Foundation Trusts should develop a targeted action plan to address neonatal staffing shortages.

Excess cancer mortality and incidence by PCT in the North West, 2001-2005   a report from the  North West Cancer Itelligence Service states that over a thousand more people die from cancer every year in the North West – who wouldn’t have died if the region had the same rates death rates as the rest of the country. The great majority of these deaths are caused by lung cancer highlighting the links between cancer, smoking and deprivation.

There are 1334 excess deaths annually in the North West than would be expected if the cancer death rates were the same as the rest of the country. 60% of these are due to lung cancer with the rest being down to deaths from many different types of cancer. Cancer deaths in the North West are 8.5% higher for men and 6.7% higher for women than in England and Wales.

The comparison focuses on excess mortality for the most common cancers between 2001 and 2005. Excess mortality is the additional number of cancer deaths above what would be expected using England and Wales rates.

These reports summarise progress against Department of Health inequality targets for 2010.

Infant mortality report

The inequality gap in the infant mortality rate has reduced but not yet by a sufficient amount to meet the target, based on the trend since the current socio economic classifications were introduced in 2001.

Life Expectancy Report

Inequality gaps in male and female life expectancy at birth have both increased since the baseline. If current trends continue, the target would not be met.

Mortality Report

Cancer mortality

The inequality gap in cancer mortality has declined since the baseline and the minimum requirement for the 2010 target has already been met.

All circulatory diseases mortality

The inequality gap in circulatory disease mortality has declined, and is on track to meet the target.

The NHS has improved dramatically over the last few years, but still cannot guarantee that basic minimum standards are being met for patients throughout England and Wales, according to State of Heatlhcare 2007: Improvements and challenges in services in England and Wales. More than a quarter of NHS hospitals failed to provide adequate emergency services for children and 48% could not provide children with a satisfactory service in outpatient clinics, the Healthcare Commission said in its annual report on the state of the nation’s healthcare.

Key findings are:

The health of the population is improving with significant increases in life expectancy, but there are major disparities around the country, particularly in poorer areas where there are often fewer GPs.

• Men are living over four years longer than they were 20 years ago, while women are living three years longer.
• Men from more deprived areas live for a decade less than those in wealthier areas. Looking at local authority areas, for example, Kensington and Chelsea has the highest life expectancy for both men and women, at 82.2 years and 86.2 years respectively. The lowest life expectancy for men is in Manchester at 72.5 years, and for women in Liverpool at 78.1 years.
• In poorer areas, where people tend to experience worse health, there are 18% fewer GPs than in the least deprived areas (54 per 100,000 people compared to 66).

Patients are positive about hospital services overall but some organisations perform poorly. Beneath the headline figures there are concerns about aspects of care such as dignity and privacy.

• National analysis of the Commission’s survey of 80,000 inpatients at acute hospital trusts shows that 89.2% (149) were ranked “satisfactory” on patient experience, 7.8% (13) were “below average” and 3% (5) were “poor”. Eleven of those in the latter two groups were rated as “below average” or “poor” for the second year running. The survey also shows concern about specific issues such as help with eating - one in five patients who wanted help eating did not get it.
• Almost a third of the complaints about hospitals referred to the Commission for independent review relate to dignity and respect, nutrition and other aspects of basic personal care. They included: patients left in soiled bedding and clothing; no regular baths or showers or oral hygiene; inappropriate or inadequate clothing.

There have been dramatic improvements in waiting times but there are hidden waits for some services, which are not measured and therefore difficult to address.

• Government standards say no patient should wait longer than 26 weeks for a hospital appointment. In 2006/07, 83% of trusts met this, leaving some 350 patients with longer to wait than 26 weeks. This is a vast improvement on figures for 2000 when 264,000 patients waited this long.
• Waiting time targets do not apply fully to some services, making it difficult for problems to be addressed and patients needs to be met. Evidence suggests that a two-year wait for those referred for psychological therapies is not uncommon. People in some areas are still waiting between 12 and 24 months to have hearing aids fitted.

NHS trusts are performing better overall on quality of services, but the performance of primary care trusts (PCTs) has declined, with many not getting to grips with the needs of their communities so as to provide services to match.

• Overall, the quality of NHS services is improving with 46% of trusts rated ‘excellent’ or ‘good’ in 2006/07, compared to 40% in 2005/6. But for PCTS, only 26% were ‘excellent’ or ‘good’ in 2006/7 compared to 33% in 2005/6. Many PCTs went through a reorganisation over the period but this does not provide a complete explanation for the underperformance.
• The Commission says PCTs form the bedrock of healthcare. They control more than three-quarters of the budget, purchasing services from other providers, including hospitals. They are directly responsible for providing services handling more than 80% of NHS contact with patients, including those carried out by GPs and dentists.
• The report says that many PCTs do not fully understand the health needs of their local people, making it difficult for them to buy targeted services. For instance, last year 2.3 million people did not have their BMI index recorded as planned, with GPs not recording the data, which provides vital statistics on levels of obesity. The number of people diagnosed with heart failure is also considerably less (140,000) than expected, indicating that GPs may not be picking up on signs of serious illness. There is also a poor understanding of the sexual health of local populations at a time when sexually transmitted infections are rising rapidly.
• Where there is a known need, PCTs are not always providing the services required. Some 60,000 people with serious long-term conditions did not get the care from community matrons that was originally planned. Forty-one per cent of PCTs failed to purchase sufficient crisis services for people who are seriously mentally ill, resulting in 5,000 fewer people receiving the service than planned. Some 85% of PCTs did not have arrangements for providing education programmes for patients with diabetes in their area. And 2,000 GP practices did not fulfil their PCT’s plans to establish registers for those people at risk of coronary heart disease, designed to help prevent these patients from becoming seriously ill.

There is progress towards a stronger culture of safety and grounds for cautious optimism in reducing healthcare-associated infection. But trust boards need to show stronger leadership.

• On safety more generally, there has been an encouraging increase in reporting of incidents. Reported figures show more than 229,000 known incidents causing low or moderate harm and more than 9,400 incidents causing severe harm or death.
• Only 58% of NHS trusts complied with all the government’s nine core standards on safety, with infection control, decontamination of medical devices and medicines management the biggest areas of concern.
• Infection control is arguably of greatest public concern; latest figures suggest grounds for cautious optimism. Cases of MRSA fell from 7,096 in 2005/2006 to 6,381 in 2006/2007. There are early signs that increases in cases of Clostridium difficile are slowing. Between 2005 and 2006 the number of cases increased 7% to 55,620, compared to a 16% rise from 2004 to 2005.
• By the end of October 2007 the Commission had visited 87 trusts to check their performance in meeting the requirements of the hygiene code. Only one trust needed to be issued with an improvement notice, suggesting that organisations are taking the issue seriously. But there was a need for stronger leadership from trusts’ boards to improve monitoring, isolation facilities, training, and compliance with policies and procedures.

New figures show that more independent healthcare providers meet core standards, mirroring a similar trend among NHS trusts. But there are concerns about compliance among independent providers of mental healthcare.

• The proportion of independent healthcare establishments that met the government’s national minimum standards - including those that were not inspected as they were considered not to be at risk - was 63% in 2006/07 compared to 50% the year before. Five per cent of independent establishments failed five or more of the standards.
• Although NHS trusts must meet a different set of standards, the broad picture is similar. The number of trusts that were “fully met” on government core standards rose from 49% in 2005/06 to 55% in 2006/07. Six per cent of trusts were judged “not met” on core standards overall.
• In the independent sector, non-compliance was greatest on national minimum standards covering: monitoring of quality of treatment (C4); ensuring patients get care from appropriately recruited, trained and qualified staff (C9); and taking account of patients’ views (C6).
• Independent mental health providers, which mostly look after NHS patients, performed worse than others in the sector. Non-compliance was greatest in relation to national minimum standards for: ensuring patients receive care from appropriately recruited, trained and qualified staff (C9); providing treatment in safe and appropriate premises (C17); and ensuring patients are resuscitated appropriately (C27).
  Independent providers of mental health services need to focus on ensuring patients are appropriately and safely restrained. In 2006/7, 17% of establishments failed a standard in this area compared with under 9% in 2005/2006.

The NHS often fails to meet the needs of children and young people and there are concerns about other groups requiring specialist care, such as people with mental health problems and with learning difficulties.

• Paediatric hospital services are generally good at looking after children, but other more general services are not. Some 70% of specialist inpatient services were rated “good” or “excellent” by the Commission, but 28% of emergency and day case services were “weak”. Transition from children to adult services is not managed well in services for people with mental health problems, diabetes and disabilities, and those requiring palliative care services. Vulnerable children such as those with disabilities, those in care and young offenders face particular problems in getting appropriate care. One in 20 NHS trusts are not yet compliant with child protection standards.
• On specialist wards for people with mental health problems and people with learning difficulties, more than half of the inpatients were found to be in mixed-sex accommodation.
  Levels of violence in mental health services remain high, although there are signs of it being dealt with better. The report includes new data from an audit into violence in the sector, which found that almost one in 20 patients reported being assaulted. Forty-six per cent of nurses reported being physically assaulted, and 72% said they had been threatened or made to feel unsafe. On older people’s mental health wards, almost two-thirds of nurses reported physical assault by patients.

There have been dramatic improvements in responding to the big killers - cancer, circulatory and respiratory disease - but five-year survival rates for cancer, and mortality rates for respiratory disease, are worse than in other comparable countries.

• The mortality rate for people under 75 diagnosed with cancer fell by almost 17% between 1996 and 2005, which suggests that some 60,000 fewer people died prematurely.
• Despite this improvement, the UK survival rates do not compare favourably with most of Europe. For instance, the survival rate for lung cancer in Holland and Spain is around double that in England, which stands at 6.5% for men and 7.6% of women.

From the Confidential Enquiry into Maternal and Child Health today is the report Saving Mothers’ Lives Reviewing maternal deaths to make motherhood safer 2003-2005. It finds that obesity is the fastest growing cause of women dying in pregnancy or childbirth in the UK. More than half the 294 women who died during or after pregnancy between 2003 and 2005 were overweight or obese. Experts say the number of deaths - from a total of two million pregnancies - is low - but the trend is very worrying.

They have also published:

Diabetes in Pregnancy: Caring for the baby after birth which sets out the results of a special audit set up to examine in greater depth a number of neonatal care issues including neonatal morbidity, establishment of breast feeding, separation of mothers and babies, and NHS resources. The CEMACH report contains recommendations for policy and practice and should be considered by health service commissioners and managers, and clinical staff of all disciplines, not simply those directly involved in neonatal care.

This report from the think tank Civitas, uses the concept of avoidable mortality to analyse the NHS’ performance on the biggest ‘killers’, cancer and circulatory disease, focusing on the years 1999-2005. Real improvements have been made, and that performance has compared quite favourably with other European countries of comparable development.

Two concerns identified in Just how well are we? A glance at avoidable mortality from cancer and circulatory disease in England & Wales are:

1. The rate of improvement in avoidable cancer mortality has fallen since 1999.
2. Avoidable mortality from circulatory disease remains high.

National Confidential Study of Deaths Following Meticillin Resistant Staphylococcus aureus (MRSA) Infection is a qualitative research study that provides an in-depth description and evaluation of patient and institutional factors leading to the deaths of a small randomly selected sample of patients who died in NHS hospitals in England who had MRSA mentioned on their death certificate (pilot phase) or who died within 30 days of an MRSA positive blood culture specimen being taken (main phase).  Produced by the Health Protection Agency and the subject of the latest Professional Letter for Nurses from the Chief Nursing Officer, PL CNO (2007)7: National confidential study of deaths following meticillin resistant staphylococcus aureus (MRSA) infection.

The Health profile of England 2007 provides a collation of national and regional data to provide a baseline against which people can compare data from their own Local Health Profile (LHP). The 2007 report updates tables showing regional comparisons and national trends for indicators presented in LHP, as well as a wide ranging snapshot of public health and well-being in England and a section on international comparisons.

• A general improvement in health outcome
  The report shows recent improvements in a number of critical areas, e.g.:
  • declining mortality rates in targeted killers (cancers, all circulatory diseases and suicides)
  • increasing life expectancy, now at its highest ever level
  • reducing infant mortality, now at its lowest ever level

Challenges remain to achieve and sustain progress, e.g.:
• rising rates of diabetes

• Similarly for the determinants of health,
  • Improvements in some important areas, e.g.:
  • the number of people who smoke
  • quality of housing stock
  • Areas of concern, e.g.:
  • increasing levels of obesity in adults and children
  • high levels of teenage pregnancy
• Health inequalities are often present
  • The report illustrates various geographical inequalities across the UK
• International comparisons give a wider context presenting national progress in comparison to countries of the European Union (EU), or to the 15 countries that were members of the EU prior to 2004 (EU-15), e.g.:
  • Premature mortality rates from the two biggest killers, circulatory diseases and cancer, are reducing faster in England than the average for the EU
  • Death rates from motor vehicle traffic accidents in the United Kingdom are amongst the lowest in EU
  • The prevalence of obesity in England is the highest in the EU
  • Death rates for chronic liver disease and cirrhosis have risen markedly, particularly since the mid-1990s, and for females, latest data show England has risen above the EU-15 average
  • The percentage of all live births to mothers under age 20 in the United Kingdom remains the highest when compared to other EU-15 countries.

You can see the mass media’s take on this report on 23rd October 2007.