Al Storey presentation to LNNM homeless 2015

1. The public health consequences
of reducing health access
Al Story

2. If austerity had been a clinical trial…
it would have been stopped
David Stuckler and Sanjay Basu

3. We will stop the top-down
reorganisations of the NHS that have
got in the way of patient care
The Coalition: our programme for
government’, 19 May 2010

4. Safe in our hands

5. The Inverse Care Law
• The availability of
good medical care
tends to vary
inversely with the
need for the
population
served.
Julian Tudor Hart. The Lancet: Saturday
27 February 1971

6. The Inverse Care Law
• This inverse care
law operates more
completely where
medical care is
most exposed to
market forces.
Julian Tudor Hart. The Lancet: Saturday
27 February 1971

7. Health spend % GDP
6.0
8.0
10.0
12.0
14.0
16.0
18.0
1997199819992000200120022003200420052006200720082009201020112012
UnitedStates
France
Germany
Canada
Japan
Italy
UnitedKingdom
Positive growth Flat
Total healthcare expenditure as a share of GDP compared with other G7 countries, 1997-2012 (ONS April 2014)

8. The public health impact of austerity
NHS must save £20 billion by 2015 (the Nicholson challenge)
Unprecedentedcuts
disability
unemployment
housing benefits
social care budgets
funding for third
sector support
Economicdecline
unemployment
job insecurity
fuel poverty
homelessness
health?

9. Local authority budget cut 2010-11 to 2014-15 versus premature mortality.
David Taylor-Robinson et al. BMJ 2013;347:bmj.f4208
the largest spending cuts have occurred in the
areas with the highest premature mortality

10. Housed
Bed & breakfast
Sofa surfing
Hostel
Pavement

11. M Shaw, D Dorling, N Brimblecombe. Life chances in Britain by housing wealth and for the
homeless and vulnerably housed Environment and Planning A 1999, volume 31, pages 2239-2248
Cumulative population (millions) in ascending housing wealth order
Lifeexpectancy?Averageageofdeath
Rough sleeper (42)
Hostel (64)
B&B (67)

12. Temporarily staying
with friends or
family
Staying in a hostel
or bed and
breakfast
Squatting
Emergency Hostels
Rough sleeping
Duration
Severity
Severity x Duration = Health impact
Health
impact

13. Temporarily staying
with friends or
family
Staying in a hostel
or bed and
breakfast
Squatting
Emergency Hostels
Rough sleeping
Duration
Severity
Severity x Duration2 = Health impact
Health
impact

14. IMD
6
IMD
5
IMD
4
IMD
3
IMD
2
IMD
1
Impact
IMD
6

15. Extreme risks of chronic disease
0
5
10
15
20
25
IMD 1 IMD 2 IMD 3 IMD 4 IMD 5 IMD 6
RelativeRisk
Age adjusted relative risk of asthma
IMD 1
IMD 2
IMD 3
IMD 4
IMD 5
IMD 6
0
5
10
15
20
25
IMD 1 IMD 2 IMD 3 IMD 4 IMD 5 IMD 6
Relativerisk
Age adjusted relative risk of heart
disease
IMD 1
IMD 2
IMD 3
IMD 4
IMD 5
IMD 6
0
5
10
15
20
25
IMD 1 IMD 2 IMD 3 IMD 4 IMD 5 IMD 6
Relativerisk
Age adjusted relative risk of stroke
IMD 1
IMD 2
IMD 3
IMD 4
IMD 5
IMD 6
0
5
10
15
20
25
IMD 1 IMD 2 IMD 3 IMD 4 IMD 5 IMD 6
Relativerisk
Age adjusted relative risk of epilepsy
IMD 1
IMD 2
IMD 3
IMD 4
IMD 5
IMD 6
Story A. Slopes and cliffs in health inequalities: comparative morbidity of housed and homeless people. The Lancet 382, S93, 29 Nov 2013

16. Multiple morbidity
Age adjusted relative risk (95% CI)
Story A. Slopes and cliffs in health inequalities: comparative morbidity of housed and homeless people.
The Lancet 382, S93, 29 Nov 2013

17. Access barriers
• Organisational/structural
• Staff reluctance and competence
• Staff values and attitudes
• Patient vulnerability
• Patient/condition complexity
• Practical challenges in engaging and continuity
of care for people with chaotic lives

18. Consequences of reduced access
• late diagnosis
• increased morbidity and mortality
• increased use of A&E
• hospital admission and longer hospital stay

19. Homeless Link Health Audit
85%
41%
31%
27%
90%
35%
26%
64%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Registered with
a GP
A&E at least
once
Admittedto
hospital at least
once
Somewhere
suitable to go
upon leaving
hospital
2010* 2014#
* 727 clients with a range of housing and other support needs were interviewed by outreach
teams in day centres, emergency and second stage accommodation.
# 2,590 responses from homeless people using services in 19 areas across England between the
start of 2012 and March 2014.

20. % TB cases with one or more
social/behavioural risk factors
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
North
Central
North East North West South East South West London
Total
2011 2012 2013 2014
Source: London TB Register; Includes Homeless, Drugs, Alcohol, Mental Health

21. Health service access
78
14
3 1 3
75
14
5
2 3
69
17
7
2
5
59
21
9
4 6
0
10
20
30
40
50
60
70
80
90
No Once Twice 3 times >3 times
BIRMINGHAM Hosp Add
LONDON Hosp Add
BIRMINGHAM A&E
LONDON A&E

22. Primary and acute care health spend
per person year
£? £?

23. Health care usage past year - homeless
• PRIMARY CARE - 530 individuals surveyed
– 874 GP appointments = £39,330 (£45 per GP consultation*)
– 1.6 appts per person year = £74
• ACUTE CARE - 934 individuals surveyed
– 625 A&E events = £70,625 (£113 per event*)
– 0.67 events per person year = £76
– 382 hospital admissions = £679,578 (£1,779 per episode*)
– 0.41 events per person year = £729
* http://neweconomymanchester.com/stories/832-unit_cost_database

24. Health care usage past year – gen pop
• A&E general population 0.38 ppy
– £43 ppy
• Hosp admission general population 0.28 ppy
– £498 ppy
• GP appointments general population 6 ppy
– £270 ppy

25. Primary and acute care health spend
per person year
£879 £811
I want
proportional
universalism

26. Proportionate Universalism
• More disadvantaged groups require
a greater share of the overall budget
to maintain or improve health
compared to more affluent groups
Fair Society, Healthy Lives. The Marmot Review. Strategic review of health inequalities in England post-2010

27. Proportionate Universalism
• twice as likely to have a longstanding
chronic physical health problem
• twice as likely to have a diagnosed
mental health problem
• 15 times more likely to be multi-
morbid
• etc………………………….

28. Proportionate Universalism
• twice as likely to have a longstanding
chronic physical health problem
• twice as likely to have a diagnosed
mental health problem
• 15 times more likely to be multi-
morbid

29. So what?
• Previous estimates – 4 x general population*[1]
– 5 x rate of A&E usage
– 3.2 x rate of admission
– 1.5 x care costs per inpatient episode
• Flawed – based on those accessing services
• Impression
– already spending a fortune
– fulfilled our commitment to ‘fairness’
*8 x inpatient costs
[1] Healthcare for Single Homeless People Office of the Chief Analyst Department of Health March 2010
http://www.qni.org.uk/docs/healthcare%20for%20single%20homeless%20people%20NHS.pdf

30. Health costs distribution ppy
£74 £76
£729
£270
£43
£498
£0
£100
£200
£300
£400
£500
£600
£700
£800
GP A&E Hospital inpatient
Homeless General population

31. Conclusion
• Austerity is a political choice which harms the
most vulnerable
• Marginal improvements in access but…
• Extreme inequalities persist
• Lag time/legacy effect?
• Complex to measure
• Did we get it wrong about costs of care!