Are local public expenditure reductions associated with increases in inequality in emergency hospitalisation? Time-series analysis of English local authorities from 2010 to 2017.

BACKGROUND: Reductions in local government funding implemented in 2010 due to austerity policies have been associated with worsening socioeconomic inequalities in mortality. Less is known about the relationship of these reductions with healthcare inequalities; therefore, we investigated whether areas with greater reductions in local government funding had greater increases in socioeconomic inequalities in emergency admissions. METHODS: We examined inequalities between English local authority districts (LADs) using a fixed-effects linear regression to estimate the association between LAD expenditure reductions, their level of deprivation using the Index of Multiple Deprivation (IMD) and average rates of (all and avoidable) emergency admissions for the years 2010-2017. We also examined changes in inequalities in emergency admissions using the Absolute Gradient Index (AGI), which is the modelled gap between the most and least deprived neighbourhoods in an area. RESULTS: LADs within the most deprived IMD quintile had larger pounds per capita expenditure reductions, higher rates of all and avoidable emergency admissions, and greater between-neighbourhood inequalities in admissions. However, expenditure reductions were only associated with increasing average rates of all and avoidable emergency admissions and inequalities between neighbourhoods in local authorities in England's three least deprived IMD quintiles. For a LAD in the least deprived IMD quintile, a yearly reduction of £100 per capita in total expenditure was associated with a yearly increase of 47 (95% CI 22 to 73) avoidable admissions, 142 (95% CI 70 to 213) all-cause emergency admissions and a yearly increase in inequalities between neighbourhoods of 48 (95% CI 14 to 81) avoidable and 140 (95% CI 60 to 220) all-cause emergency admissions. In 2017, a LAD average population was ~170 000. CONCLUSION: Austerity policies implemented in 2010 impacted less deprived local authorities, where emergency admissions and inequalities between neighbourhoods increased, while in the most deprived areas, emergency admissions were unchanged, remaining high and persistent.

A core outcome set for trials evaluating self-management interventions in people with severe mental illness and coexisting type 2 diabetes.

BACKGROUND: People with severe mental illness (SMI), such as schizophrenia, have higher rates of type 2 diabetes and worse outcomes, compared to those without SMI and it is not known whether diabetes self-management interventions are effective for people who have both conditions. Research in this area has been impeded by a lack of consensus on which outcomes to prioritise in people with co-existing SMI and diabetes. AIMS: To develop a core outcome set (COS) for use in effectiveness trials of diabetes self-management interventions in adults with both type 2 diabetes and SMI. METHODS: The COS was developed in three stages: (i) identification of outcomes from systematic literature review of intervention studies, followed by multi-stakeholder and service user workshops; (ii) rating of outcomes in a two-round online Delphi survey; (iii) agreement of final 'core' outcomes through a stakeholder consensus workshop. RESULTS: Seven outcomes were selected: glucose control, blood pressure, body composition (body weight, BMI, body fat), health-related quality of life, diabetes self-management, diabetes-related distress and medication adherence. CONCLUSIONS: This COS is recommended for future trials of effectiveness of diabetes self-management interventions for people with SMI and type 2 diabetes. Its use will ensure trials capture important outcomes and reduce heterogeneity so findings can be readily synthesised to inform practice and policy.

Decomposition of Quality-Adjusted Life Expectancy Inequalities by Mortality and Health-Related Quality of Life Dimensions.

BACKGROUND: Quality-adjusted life expectancy (QALE) combines mortality risk and multidimensional health-related quality of life (HRQoL) information to measure healthy life expectancy in terms of quality-adjusted life years (QALYs). This paper estimates the relative importance of individual quality of life dimensions in explaining inequalities in QALE. METHODS: We combined EQ-5D-5L data from the Health Survey for England for 2017 and 2018 (N = 14,412) with full population mortality data from the Office for National Statistics to calculate QALE by age, sex and deprivation quintile. The effect of HRQoL dimensions on the socioeconomic gradient in QALE was decomposed using an iterative imputation approach, in which inequalities associated with socioeconomic status in each domain were removed by imputing the response distribution of the richest quintile for all participants. Sampling uncertainty in the HRQoL data was evaluated using bootstrapping. RESULTS: People in the least deprived fifth of neighbourhoods in England can expect to live 7.0 years longer and experience 11.1 more QALYs than those in the most deprived fifth. Inequalities in HRQoL accounted for 28.0% and 45.7% of QALE inequalities for males and females, respectively. Pain/discomfort, anxiety/depression and mobility were the most influential HRQoL domains. DISCUSSION: Our results identify the extent of inequalities associated with socioeconomic status in lifetime health and the relative importance of inequalities by mortality and HRQoL. The contributions of the individual dimensions of HRQoL towards lifetime inequalities vary substantially by sex. Our findings can help to identify the types of interventions most likely to alleviate health inequalities, which may be different for males and females.

Sodium channel-inhibiting drugs and cancer-specific survival: a population-based study of electronic primary care data.

OBJECTIVES: Antiepileptic and antiarrhythmic drugs inhibit voltage-gated sodium (Na+) channels (VGSCs), and preclinical studies show that these medications reduce tumour growth, invasion and metastasis. We investigated the association between VGSC inhibitor use and survival in patients with breast, bowel and prostate cancer. DESIGN: Retrospective cohort study. SETTING: Individual electronic primary healthcare records extracted from the Clinical Practice Research Datalink. PARTICIPANTS: Records for 132 996 patients with a diagnosis of breast, bowel or prostate cancer. OUTCOME MEASURES: Adjusted Cox proportional hazards regression was used to analyse cancer-specific survival associated with exposure to VGSC inhibitors. Exposure to non-VGSC-inhibiting antiepileptic medication and other non-VGSC blockers were also considered. Drug exposure was treated as a time-varying covariate to account for immortal time bias. RESULTS: During 1 002 225 person-years of follow-up, there were 42 037 cancer-specific deaths. 53 724 (40.4%) patients with cancer had at least one prescription for a VGSC inhibitor of interest. Increased risk of cancer-specific mortality was associated with exposure to this group of drugs (HR 1.59, 95% CI 1.56 to 1.63, p<0.001). This applied to VGSC-inhibiting tricyclic antidepressants (HR 1.61, 95% CI 1.50 to 1.65, p<0.001), local anaesthetics (HR 1.49, 95% CI 1.43 to 1.55, p<0.001) and anticonvulsants (HR 1.40, 95% CI 1.34 to 1.48, p<0.001) and persisted in sensitivity analyses. In contrast, exposure to VGSC-inhibiting class 1c and 1d antiarrhythmics was associated with significantly improved cancer-specific survival (HR 0.75, 95% CI 0.64 to 0.88, p<0.001 and HR 0.54, 95% CI 0.33 to 0.88, p=0.01, respectively). CONCLUSIONS: Association between VGSC inhibitor use and mortality in patients with cancer varies according to indication. Exposure to VGSC-inhibiting antiarrhythmics, but not anticonvulsants, supports findings from preclinical data, with improved survival. However, additional confounding factors may underlie these associations, highlighting the need for further study.

Periodontal disease in people with a history of psychosis: Results from the UK biobank population-based study.

OBJECTIVES: To test the hypotheses that: (1) Prevalence of periodontal disease would be higher in people with a history of psychosis when compared to the general population and (2) Demographic, life-style related factors and co-morbid medical conditions would predict periodontal disease in people experiencing psychosis. METHODS: The authors performed cross-sectional analysis of baseline data from the UK Biobank study (2007-2010), identifying cases with psychosis using clinical diagnosis, antipsychotic medication, and self-report. Demographic (age, gender, ethnicity, socioeconomic status), lifestyle-related(BMI, blood pressure, smoking and alcohol intake, physical activity) and physical co-morbidities (cancer, cardiovascular, respiratory, inflammatory disease and metabolic conditions) were included as potential risk factors for periodontal disease among people with a history of psychosis using logistic regression analyses. The analysis sample included 502,505 participants. RESULTS: Risk of periodontal disease was higher in people with psychosis, regardless of how cases were identified. Patients with a clinical diagnosis had the highest proportion of periodontal disease compared to the general population (21.3% vs. 14.8%, prevalence ratio 1.40, 95% CI: 1.26-1.56). Older and female cases were more likely to experience periodontal disease. Lifestyle factors (smoking) and comorbidities (cardiovascular, cancer or respiratory disease) were associated with periodontal disease among people with a history of psychosis. CONCLUSIONS: The findings suggest that periodontal disease is more common in people with a history of psychosis, compared to the general population. Prevention and early diagnosis of periodontal disease should be a priority for oral health promotion programmes, which should also address modifiable risk factors like smoking which also contribute to co-morbid systemic disease.

Impact of prevention in primary care on costs in primary and secondary care for people with serious mental illness.

A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare.

Quality-Adjusted Life Expectancy Norms for the English Population.

OBJECTIVES: The National Institute for Health and Care Excellence in England has implemented severity-of-disease modifiers that give greater weight to health benefits accruing to patients who experience a larger shortfall in quality-adjusted life-years (QALYs) under current standard of care than healthy individuals. This requires an estimate of quality-adjusted life expectancy (QALE) of the general population based on age and sex. Previous QALE population norms are based on nearly 30-year-old assessments of health-related quality of life in the general population. This study provides updated QALE estimates for the English population based on age and sex. METHODS: 5-level version of EQ-5D data for 14 412 participants from the Health Survey for England (waves 2017 and 2018) were pooled, and health-related quality of life population norms were calculated. These norms were combined with official life tables from the Office for National Statistics for 2017 to 2019 using the Sullivan method to derive QALE estimates based on age and sex. Values were discounted using 0%, 1.5%, and 3.5% discount rates. RESULTS: QALE at birth is 68.24 QALYs for men and 68.21 QALYs for women. These values are significantly lower than previously published QALE population norms based on the older 3-level version of EQ-5D data. CONCLUSION: This study provides new QALE population norms for England that serve to establish absolute and relative QALY shortfalls for the purpose of health technology assessments.

Do general practitioners working in or alongside the emergency department improve clinical outcomes or experience? A mixed-methods study.

OBJECTIVES: To examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce. DESIGN: Mixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory's four main constructs of coherence, cognitive participation, collective action and reflexive monitoring. SETTING AND PARTICIPANTS: Data were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available. RESULTS: There was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient 'streaming' processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring). CONCLUSIONS: We found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience. TRIAL REGISTRATION NUMBER: ISCRTN5178022.

Socioeconomic inequalities in HRQoL in England: an age-sex stratified analysis.

BACKGROUND: Socioeconomic status is a key predictor of lifetime health: poorer people can expect to live shorter lives with lower average health-related quality-of-life (HRQoL) than richer people. In this study, we aimed to improve understanding of the socioeconomic gradient in HRQoL by exploring how inequalities in different dimensions of HRQoL differ by age. METHODS: Data were derived from the Health Survey for England for 2017 and 2018 (14,412 participants). HRQoL was measured using the EQ-5D-5L instrument. We estimated mean EQ-5D utility scores and reported problems on five HRQoL dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) for ages 16 to 90+ and stratified by neighbourhood deprivation quintiles. Relative and absolute measures of inequality were assessed. RESULTS: Mean EQ-5D utility scores declined with age and followed a socioeconomic gradient, with the lowest scores in the most deprived areas. Gaps between the most and least deprived quintiles emerged around the age of 35, reached their greatest extent at age 60 to 64 (relative HRQoL of most deprived compared to least deprived quintile: females = 0.77 (95% CI: 0.68-0.85); males = 0.78 (95% CI: 0.69-0.87)) before closing again in older age groups. Gaps were apparent for all five EQ-5D dimensions but were greatest for mobility and self-care. CONCLUSION: There are stark socioeconomic inequalities in all dimensions of HRQoL in England. These inequalities start to develop from early adulthood and increase with age but reduce again around retirement age.

Polypharmacy in Children and Young People With Life-limiting Conditions From 2000 to 2015: A Repeated Cross-sectional Study in England.

CONTEXT: Polypharmacy is often appropriate for children with life-limiting conditions but is associated with an increase in hospitalizations and inappropriate prescribing, and can affect the quality of life of children and their families as they manage complex medication schedules. Despite this, little is known about polypharmacy in this population. OBJECTIVE: To describe the prevalence and patterns of polypharmacy in children with a life-limiting condition in a nationally representative cohort in England. METHODS: Observational study of children (age 0-19 years) with a life-limiting condition in a national database from 2000 to 2015. Common definitions of polypharmacy were used to determine polypharmacy prevalence in each year based on unique medications and regular medications. Hierarchical regression analyses were used to explore factors associated with polypharmacy. RESULTS: Data on 15,829 individuals were included. Each year 27%-39% of children were prescribed ≥5 unique medications and 8%-12% were prescribed ≥10. Children with a respiratory (OR 7.6, 95%CI 6.4-9.0), neurological (OR 2.8, 95%CI 2.4-3.2), or metabolic (OR 2.2, 95%CI 1.7-2.8) condition were more likely than those with a congenital condition to experience polypharmacy. Increasing age, being diagnosed with a LLC under one year of age, having >1 life-limiting or chronic condition or living in areas of higher deprivation were also associated with higher prevalence of polypharmacy. CONCLUSION: Children with life-limiting conditions have a high prevalence of polypharmacy and some children are at greater risk than others. More research is needed to understand and address the factors that lead to problematic polypharmacy in this population.

Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: A cohort study.

BACKGROUND: Atrial fibrillation (AF) is an important risk factor for ischaemic stroke, and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development of stroke. However, studies have reported the frequent underuse of OACs in AF patients. The objective of this study is to describe nonvalvular atrial fibrillation (NVAF) incidence in England and assess the clinical and socioeconomic factors associated with the underprescribing of OACs. METHODS AND FINDINGS: We conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD) database to identify patients with NVAF aged ≥18 years and registered in English general practices between 2009 and 2019. Annual incidence rate of NVAF by age, deprivation quintile, and region was estimated. OAC prescribing status was explored for patients at risk for stroke and classified into the following: OAC, aspirin only, or no treatment. We used a multivariable multinomial logistic regression model to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) of the factors associated with OAC or aspirin-only prescribing compared to no treatment in patients with NVAF who are recommended to take OAC. The multivariable regression was adjusted for age, sex, comorbidities, socioeconomic status, baseline treatment, frailty, bleeding risk factors, and takes into account clustering by general practice. Between 2009 and 2019, 12,517,191 patients met the criteria for being at risk of developing NVAF. After a median follow-up of 4.6 years, 192,265 patients had an incident NVAF contributing a total of 647,876 person-years (PYR) of follow-up. The overall age-adjusted incidence of NVAF per 10,000 PYR increased from 20.8 (95% CI: 20.4; 21.1) in 2009 to 25.5 (25.1; 25.9) in 2019. Higher incidence rates were observed for older ages and males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose from 59.8% (95% CI: 59.0; 60.6) in 2009 to 83.2% (95% CI: 83.0; 83.4) in 2019. Several conditions were associated with lower risk of OAC prescribing: dementia [RRR 0.52 (0.47; 0.59)], liver disease 0.58 (0.50; 0.67), malignancy 0.74 (0.72; 0.77), and history of falls 0.82 (0.78; 0.85). Compared to white ethnicity, patients from black and other ethnic minorities were less likely to receive OAC; 0.78 (0.65; 0.94) and 0.76 (0.64; 0.91), respectively. Patients living in the most deprived areas were less likely to receive OAC 0.85 (0.79; 0.91) than patients living in the least deprived areas. Practices located in the East of England were associated with higher risk of prescribing aspirin only over no treatment than practices in London (RRR 1.22; 95% CI 1.02 to 1.45). The main limitation of this study is that these findings depends on accurate recording of conditions by health professionals and the inevitable residual confounding due to lack of data on certain factors that could be associated with under-prescribing of OACs. CONCLUSIONS: The incidence of NVAF increased between 2009 and 2015, before plateauing. Underprescribing of OACs in NVAF is associated with a range of comorbidities, ethnicity, and socioeconomic factors, demonstrating the need for initiatives to reduce inequalities in the care for AF patients.

Does the presence of general practitioners in emergency departments affect quality and safety in English NHS hospitals? A retrospective observational study.

OBJECTIVES: Emergency departments (EDs) in NHS hospitals in England have faced considerable increases in demand over recent years. Most hospitals have developed general practitioner services in emergency departments (GPEDs) to treat non-emergency patients, aiming to relieve pressure on other staff and to improve ED efficiency and patient experience. We measured the impact of GPED services on patient flows, health outcomes and ED workload. DESIGN: Retrospective observational study. Differences in GPED service availability across EDs and time of day were used to identify the causal effect of GPED, as patients attending the ED at the same hour of the day are quasi-randomly assigned to treatment or control groups based on their local ED's service availability. PARTICIPANTS: Attendances to 40 EDs in English NHS hospitals from April 2018 to March 2019, 4 441 349 observations. PRIMARY AND SECONDARY OUTCOMES MEASURED: Outcomes measured were volume of attendances, 'non-urgent' attendances, waiting times over 4 hours, patients leaving without being treated, unplanned reattendances within 7 days, inpatient admissions and 30-day mortality. RESULTS: We found a small, statistically significant reduction in unplanned reattendances within 7 days (OR 0.968, 95% CI 0.948 to 0.989), equivalent to 302 fewer reattendances per year for the average ED. The clinical impact of this was judged to be negligible. There was no detectable impact on any other outcome measure. CONCLUSIONS: We found no adverse effects on patient outcomes; neither did we find any evidence of the hypothesised benefits of placing GPs in emergency settings beyond a marginal reduction in reattendances that was not considered clinically significant.

Excess years of life lost to COVID-19 and other causes of death by sex, neighbourhood deprivation, and region in England and Wales during 2020: A registry-based study.

BACKGROUND: Deaths in the first year of the Coronavirus Disease 2019 (COVID-19) pandemic in England and Wales were unevenly distributed socioeconomically and geographically. However, the full scale of inequalities may have been underestimated to date, as most measures of excess mortality do not adequately account for varying age profiles of deaths between social groups. We measured years of life lost (YLL) attributable to the pandemic, directly or indirectly, comparing mortality across geographic and socioeconomic groups. METHODS AND FINDINGS: We used national mortality registers in England and Wales, from 27 December 2014 until 25 December 2020, covering 3,265,937 deaths. YLLs (main outcome) were calculated using 2019 single year sex-specific life tables for England and Wales. Interrupted time-series analyses, with panel time-series models, were used to estimate expected YLL by sex, geographical region, and deprivation quintile between 7 March 2020 and 25 December 2020 by cause: direct deaths (COVID-19 and other respiratory diseases), cardiovascular disease and diabetes, cancer, and other indirect deaths (all other causes). Excess YLL during the pandemic period were calculated by subtracting observed from expected values. Additional analyses focused on excess deaths for region and deprivation strata, by age-group. Between 7 March 2020 and 25 December 2020, there were an estimated 763,550 (95% CI: 696,826 to 830,273) excess YLL in England and Wales, equivalent to a 15% (95% CI: 14 to 16) increase in YLL compared to the equivalent time period in 2019. There was a strong deprivation gradient in all-cause excess YLL, with rates per 100,000 population ranging from 916 (95% CI: 820 to 1,012) for the least deprived quintile to 1,645 (95% CI: 1,472 to 1,819) for the most deprived. The differences in excess YLL between deprivation quintiles were greatest in younger age groups; for all-cause deaths, a mean of 9.1 years per death (95% CI: 8.2 to 10.0) were lost in the least deprived quintile, compared to 10.8 (95% CI: 10.0 to 11.6) in the most deprived; for COVID-19 and other respiratory deaths, a mean of 8.9 years per death (95% CI: 8.7 to 9.1) were lost in the least deprived quintile, compared to 11.2 (95% CI: 11.0 to 11.5) in the most deprived. For all-cause mortality, estimated deaths in the most deprived compared to the most affluent areas were much higher in younger age groups, but similar for those aged 85 or over. There was marked variability in both all-cause and direct excess YLL by region, with the highest rates in the North West. Limitations include the quasi-experimental nature of the research design and the requirement for accurate and timely recording. CONCLUSIONS: In this study, we observed strong socioeconomic and geographical health inequalities in YLL, during the first calendar year of the COVID-19 pandemic. These were in line with long-standing existing inequalities in England and Wales, with the most deprived areas reporting the largest numbers in potential YLL.

Healthcare resource use and costs for people with type 2 diabetes mellitus with and without severe mental illness in England: longitudinal matched-cohort study using the Clinical Practice Research Datalink.

BACKGROUND: Approximately 60 000 people in England have coexisting type 2 diabetes mellitus (T2DM) and severe mental illness (SMI). They are more likely to have poorer health outcomes and require more complex care pathways compared with those with T2DM alone. Despite increasing prevalence, little is known about the healthcare resource use and costs for people with both conditions. AIMS: To assess the impact of SMI on healthcare resource use and service costs for adults with T2DM, and explore the predictors of healthcare costs and lifetime costs for people with both conditions. METHOD: This was a matched-cohort study using data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics for 1620 people with comorbid SMI and T2DM and 4763 people with T2DM alone. Generalised linear models and the Bang and Tsiatis method were used to explore cost predictors and mean lifetime costs respectively. RESULTS: There were higher average annual costs for people with T2DM and SMI (£1930 higher) than people with T2DM alone, driven primarily by mental health and non-mental health-related hospital admissions. Key predictors of higher total costs were older age, comorbid hypertension, use of antidepressants, use of first-generation antipsychotics, and increased duration of living with both conditions. Expected lifetime costs were approximately £35 000 per person with both SMI and T2DM. Extrapolating nationally, this would generate total annual costs to the National Health Service of around £250 m per year. CONCLUSIONS: Our estimates of resource use and costs for people with both T2DM and SMI will aid policymakers and commissioners in service planning and resource allocation.

Reducing inequality in avoidable emergency admissions: Case studies of local health care systems in England using a realist approach.

OBJECTIVE: People in disadvantaged areas are more likely to have an avoidable emergency hospital admission. Socio-economic inequality in avoidable emergency hospital admissions is monitored in England. Our aim was to inform local health care purchasing and planning by identifying recent health care system changes (or other factors), as reported by local health system leaders, that might explain narrowing or widening trends. METHODS: Case studies were undertaken in one pilot and at five geographically distinct local health care systems (Clinical Commissioning Groups, CCGs), identified as having consistently increasing or decreasing inequality. Local settings were explored through discussions with CCG officials and stakeholders to identify potential local determinants. Data were analysed using a realist evaluation approach to generate context-mechanism-outcome (CMO) configurations. RESULTS: Of the five geographically distinct CCGs, two had narrowing inequality, two widening, and one narrowing inequality, which widened during the project. None of the CCGs had designed a large-scale package of service changes with the explicit aim of reducing socio-economic inequality in avoidable emergency admissions, and local decision makers were unfamiliar with their own trends. Potential primary and community care determinants included: workforce, case finding and exclusion, proactive care co-ordination for patients with complex needs, and access and quality. Potential commissioning determinants included: data use and incentives, and targeting of services. Other potential determinants included changes in care home services, national A&E targets, and wider issues - such as public services financial constraints, residential gentrification, and health care expectations. CONCLUSIONS: We did not find any bespoke initiatives that explained the inequality trends. The trends were more likely due to an interplay of multiple health care and wider system factors. Local decision makers need greater awareness, understanding and support to interpret, use and act upon inequality indicators. They are unlikely to find simple, cheap interventions to reduce inequalities in avoidable emergency admissions. Rather, long-term multifaceted interventions are required that embed inequality considerations into mainstream decision making.

Health inequality in Britain before 1750.

BACKGROUND: This study examines the claim that social inequality in health in European populations was absent prior to 1750. This claim is primarily based on comparisons of life expectancy at birth in England between general and ducal (elite aristocrat) social classes from the 1550s to the 1870s. METHODS: We examined historic childhood mortality trends among the English ducal class and the general population, based on previously published data. We compared mid-childhood to adolescent mortality (age 5-14) and early-childhood mortality (age 0-4) between the ducal class and the general population from the 17th to 19th centuries. RESULTS: Prior to 1750, ducal early-childhood mortality was higher than the general population. However, mid-childhood to adolescent mortality was lower among the ducal class than the general population in all observed periods for boys, and almost all periods for girls. Among the ducal class, but not the general population, there was a sharp decline in early-childhood mortality around the 1750s which may partly explain the divergent trends in overall life expectancy at birth. CONCLUSION: Health inequality between the ducal class and general population was present in England from the 16th to mid-18th centuries, with disadvantages in mortality for ducal children in infancy and early childhood, but survival advantages in mid-childhood and adolescence. These opposing effects are obscured in life expectancy at birth data. Relatively high early-childhood mortality among ducal families before 1750 likely resulted from short birth intervals and harmful infant feeding practices during this time.

Estimating the equity impacts of the smoking ban in England on cotinine levels: a regression discontinuity design.

OBJECTIVE: To estimate the equity impacts of the 2007 smoking ban in England, for both smokers and non-smokers. DESIGN: Doubly robust regression discontinuity analysis of salivary cotinine levels. Conditional average treatment effects were used to estimate differential impacts of the ban by socioeconomic deprivation (based on the Index of Multiple Deprivation). Distributional impacts were further assessed using conditional quantile treatment effects and inequality treatment effects. SETTING: In 2007, England introduced a ban on smoking in public places. This had little impact on tobacco consumption by smokers but was associated with decreases in environmental tobacco smoke exposure for non-smokers. However, the impact of the ban on socioeconomic inequalities in exposure is unclear. PARTICIPANTS: 766 smokers and 2952 non-smokers responding to the Health Survey for England in 2007. OUTCOME MEASURE: Levels of salivary cotinine. RESULTS: Before the ban, socioeconomic deprivation was associated with higher cotinine levels for non-smokers but not for smokers. The ban caused a significant reduction in average cotinine levels for non-smokers (p=0.043) but had no effect for smokers (p=0.817). Reductions for non-smokers were greater for more deprived groups with higher levels of exposure, and there was a significant reduction in socioeconomic-related inequality in cotinine. Across the whole population (both smokers and non-smokers), there was no significant increase in the concentration of cotinine levels among the socioeconomically deprived. CONCLUSION: The 2007 ban on smoking in public places had little impact on smokers, but was, as intended, associated with reductions in both (1) average levels of environmental tobacco smoke exposure and (2) deprivation-related inequality in exposure among non-smokers.

Excess deaths from COVID-19 and other causes by region, neighbourhood deprivation level and place of death during the first 30 weeks of the pandemic in England and Wales: A retrospective registry study.

BACKGROUND: Excess deaths during the COVID-19 pandemic compared with those expected from historical trends have been unequally distributed, both geographically and socioeconomically. Not all excess deaths have been directly related to COVID-19 infection. We investigated geographical and socioeconomic patterns in excess deaths for major groups of underlying causes during the pandemic. METHODS: Weekly mortality data from 27/12/2014 to 2/10/2020 for England and Wales were obtained from the Office of National Statistics. Negative binomial regressions were used to model death counts based on pre-pandemic trends for deaths caused directly by COVID-19 (and other respiratory causes) and those caused indirectly by it (cardiovascular disease or diabetes, cancers, and all other indirect causes) over the first 30 weeks of the pandemic (7/3/2020-2/10/2020). FINDINGS: There were 62,321 (95% CI: 58,849 to 65,793) excess deaths in England and Wales in the first 30 weeks of the pandemic. Of these, 46,221 (95% CI: 45,439 to 47,003) were attributable to respiratory causes, including COVID-19, and 16,100 (95% CI: 13,410 to 18,790) to other causes. Rates of all-cause excess mortality ranged from 78 per 100,000 in the South West of England and in Wales to 130 per 100,000 in the West Midlands; and from 93 per 100,000 in the most affluent fifth of areas to 124 per 100,000 in the most deprived. The most deprived areas had the highest rates of death attributable to COVID-19 and other indirect deaths, but there was no socioeconomic gradient for excess deaths from cardiovascular disease/diabetes and cancer. INTERPRETATION: During the first 30 weeks of the COVID-19 pandemic there was significant geographic and socioeconomic variation in excess deaths for respiratory causes, but not for cardiovascular disease, diabetes and cancer. Pandemic recovery plans, including vaccination programmes, should take account of individual characteristics including health, socioeconomic status and place of residence. FUNDING: None.

Equity-informative methods of health services research.

PURPOSE: We review quantitative methods for analysing the equity impacts of health care and public health interventions: who benefits most and who bears the largest burdens (opportunity costs)? Mainstream health services research focuses on effectiveness and efficiency but decision makers also need information about equity. DESIGN/METHODOLOGY/APPROACH: We review equity-informative methods of quantitative data analysis in three core areas of health services research: effectiveness analysis, cost-effectiveness analysis and performance measurement. An appendix includes further readings and resources. FINDINGS: Researchers seeking to analyse health equity impacts now have a practical and flexible set of methods at their disposal which builds on the standard health services research toolkit. Some of the more advanced methods require specialised skills, but basic equity-informative methods can be used by any health services researcher with appropriate skills in the three core areas. ORIGINALITY/VALUE: We hope that this review will raise awareness of equity-informative methods of health services research and facilitate their entry into the mainstream so that health policymakers are routinely presented with information about who gains and who loses from their decisions.

Living with diabetes alongside a severe mental illness: A qualitative exploration with people with severe mental illness, family members and healthcare staff.

AIMS: Diabetes is two to three times more prevalent in people with severe mental illness, yet little is known about the challenges of managing both conditions from the perspectives of people living with the co-morbidity, their family members or healthcare staff. Our aim was to understand these challenges and to explore the circumstances that influence access to and receipt of diabetes care for people with severe mental illness. METHODS: Framework analysis of qualitative semi-structured interviews with people with severe mental illness and diabetes, family members, and staff from UK primary care, mental health and diabetes services, selected using a maximum variation sampling strategy between April and December 2018. RESULTS: In all, 39 adults with severe mental illness and diabetes (3 with type 1 diabetes and 36 with type 2 diabetes), nine family members and 30 healthcare staff participated. Five themes were identified: (a) Severe mental illness governs everyday life including diabetes management; (b) mood influences capacity and motivation for diabetes self-management; (c) cumulative burden of managing multiple physical conditions; (d) interacting conditions and overlapping symptoms and (e) support for everyday challenges. People living with the co-morbidity and their family members emphasised the importance of receiving support for the everyday challenges that impact diabetes management, and identified barriers to accessing this from healthcare providers. CONCLUSIONS: More intensive support for diabetes management is needed when people's severe mental illness (including symptoms of depression) or physical health deteriorates. Interventions that help people, including healthcare staff, distinguish between symptoms of diabetes and severe mental illness are also needed.