1. Ethnicity Executive Summary

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					Indications of Public Health in the English Regions



4: Ethnicity and Health
Executive Summary
Acknowledgements

This report was prepared by Justine Fitzpatrick and Bobbie Jacobson from the London
Health Observatory (LHO), and by Peter Aspinall from the Centre for Health Services
Studies, University of Kent and LHO, on behalf of the APHO.

We would like to thank:

• All members of the steering group for their valuable contributions including:
        Arun Bhoopal (Department of Health)
        Michelle Bradley (East Midlands Public Health Observatory)
        Sunita Gould (Department of Health)
        Dave Jenner (East Midlands Public Health Observatory)
        John Hamm (North West London Strategic Health Authority)
        Giovanna Maria Polato (Healthcare Commission)
        Veena Raleigh (Healthcare Commission)
        Steve Salzano (East Midlands Public Health Observatory)

• East Midlands Public Health Observatory for completing the demographic work and
  analysis of the National Statistics Socio-economic classification.

• The Healthcare Commission for analysing the Hospital Episode Statistics and the
  Patient Satisfaction Survey

• James Nazroo (University College London), Sarah Corlett (Lambeth PCT), David
  Pevalin (University of Essex), Rob Lewis (Greater London Authority) and Mark Bellis
  (North West Public Health Observatory) for peer review comments.



Next reports in the series

Future reports will address topics covered by the White Paper Choosing Health:
making healthy choices easier. They will include:

• Sexual health
• Child health
• Mental health



About the APHO

Please turn to the inside back cover of this Executive Summary.
                                                                              Association of Public Health Observatories




Indications of Public Health in the English Regions

4: Ethnicity and Health

Executive Summary


Introduction

The drive for race equality, the Race Relations (Amendment) Act 2000, gives public
authorities a new statutory duty to promote race equality. To demonstrate compliance with
these duties, ethnicity monitoring data needs to be collected and analysed across the
workforce and service delivery areas. This is a summary of the main report that provides a
comprehensive regional analysis of inequalities in health and health care between ethnic
groups in England, and also examines workforce data by ethnic group. It is the fourth in
the series ‘Indications of public health in the English Regions’ produced by the Association
of Public Health Observatories (APHO). The report follows the structure of previous reports
and looks at indicators of:

     1   The determinants of health (or causes of ill health)

     2   Health status

     3   Public health interventions

     4   Effectiveness of partnership

     5   Patient experience and workforce

The main report is available from the LHO website at www.lho.org.uk and the APHO
website at www.apho.org.uk. The data for each indicator is also available from the LHO
website at www.lho.org.uk.


Ethnic minority populations across the regions

For the purposes of this report the term ethnic minority groups encompasses all groups
except the White British group. Data are presented for Government Office Regions.

The size of the ethnic minority populations varies substantially across regions from 4 to 5%
in the South West and the North East, to 40% in London. London has the largest number of
people in all ethnic minority groups, except Pakistani where the largest population is in
Yorkshire & the Humber and the West Midlands. These variations in the size of the
population can influence the ability to analyse and interpret ethnic inequalities in health.




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Indications of Public Health in the English Regions   Executive Summary




                           Within all regions the population of ethnic minority groups is on average younger than the
                           White British population, although there are a couple of exceptions namely the White Irish
                           and the White Other groups.


                           Ethnicity monitoring

                           In spite of the mainstreaming of ethnicity monitoring, there are still only a limited number
                           of routine, ethnicity-coded health-related datasets that are amenable to analysis. In
                           particular, there are few or no data from primary care or birth and death registration. For
                           those where ethnicity is recorded the main conclusions about data quality are (Table 3.1):

                           •    The incompleteness of ethnic coding varies substantially across datasets, from
                                2% (medical and dental workforce data) to 36% (Hospital episode statistics), and
                                between regions.

                           •    There is no relationship between the density of the ethnic minority group population
                                within each region and completeness of ethnic coding. This suggests that
                                organisational factors are thus mainly responsible for the variability.

                           •    The fact that different classifications of ethnic minority populations are still being
                                used presents barriers to analysis that are now unacceptable.


                           Inequalities between ethnic groups

                           These findings reinforce what we already know about ethnic inequalities in health and
                           provide a comprehensive regional analysis of these indicators. The main findings are:

                           •    People from most ethnic minority groups are generally more deprived in terms of
                                socio-economic status, and poverty as indicated by eligibility for free school meals.
                                The Pakistani and Bangladeshi groups have the lowest proportion of the population in
                                ‘managerial and professional occupations’ (Figure 5.1). The highest proportions of
                                children eligible for free school meals are among the Travellers of Irish Heritage,
                                Gypsy/Roma, Bangladeshi and Black African groups (Figure 5.2).

                           •    The health experience of different ethnic groups is not uniform e.g. the percentage of
                                the population that report their health as ‘not good’ is highest among the Pakistani
                                and Bangladeshi populations (Figure 6.2). People born in these countries, but living in
                                England and Wales, have the highest mortality rates from circulatory disease.
                                However, those born in Ireland and Scotland have the highest mortality rates from all
                                causes of death combined and from cancer (Figure 6.1).

                           •    A higher than average proportion of admissions due to coronary heart disease is
                                found in the Pakistani, Bangladeshi, Indian and Mixed White & Asian ethnic groups,
                                reflecting the higher prevalence of CHD in these groups (Figure 7.2). However,
                                analysis of revascularisation procedures generally shows provision in proportion to
                                need (Figure 7.3).

                           •    A higher than average proportion of admissions due to diabetes is found in the Asian




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     groups, Black Caribbean and Black Other group in most regions, reflecting the higher
     prevalence of diabetes in these groups (Figure 7.4).

•    The Indian and Pakistani groups have a higher than average proportion of hospital
     episodes for cataract surgery, reflecting reports of a higher prevalence of cataracts in
     these groups (Figure 7.5). This is consistent with their higher prevalence of diabetes, a
     known risk factor for cataracts.

•    Among ethnic minority groups, Black Africans comprise the largest proportion of
     those seen for HIV care in all regions (Figure 8.2). Along with the Other ethnic group,
     Black Africans also have the highest rates of tuberculosis (Figure 8.5).

Some of the main findings are less well-known and require further explanation:

•    Educational attainment is highest among the Chinese group, yet in every ethnic group
     except the Chinese, those who are eligible for free school meals have a lower
     educational attainment than those who are not. The difference in education
     attainment between those who are eligible for free school meals and those who are
     not is most marked amongst the White groups (Figure 5.3).

•    Asian, Black and Mixed minority populations have lower rates of setting a smoking
     quit date for both males and females (Figure 7.1). Females are more likely to set a quit
     date than males in every ethnic group. Monitoring of smoking cessation by ethnic
     group is important but hampered by a lack of local reliable data on smoking
     prevalence.

•    The highest treatment rates for drug misuse are in the Mixed group and lowest in the
     Asian group (Figure 8.1).

•    The worst patient experience was found in the Asian group across all regions
     (Figure 9.1).

•    The medical workforce is overrepresented with people from minority ethnic groups
     when compared to the general population in all regions (Figure 9.3). However, White
     staff are more likely to be employed at the Consultant grade and staff from ethnic
     minority groups at the lower Associate Specialist and Staff Grade levels (Figure 9.4).


Regional inequalities by ethnic group

There is a north-south divide on some health determinant indicators such as social class,
with northern regions having a higher proportion in the lower social classes among most
ethnic groups (Figure 5.1). The north-south pattern in educational attainment is less clear
(Figure 5.3). Among health indicators, the north-south pattern in ‘not good’ health is very
clear e.g. higher rates of ‘not good’ health in the northern regions among most ethnic
groups (Figure 6.2).

The regional pattern on partnership indicators such as treatment of drug misuse, HIV and
tuberculosis is very mixed (Figure 8.1, Figure 8.3, Figure 8.6). However, some of the regional




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patterns will be due to regional variation in the recording of ethnic group. London has by
far the highest rates of HIV (measured by those seen for care) and tuberculosis amongst
the White group, but the reverse pattern is found in Black Africans. London’s HIV care rate
among Black Africans is significantly lower than other regions, although London accounts
for 58% of all Black African HIV patients seen for care. Tuberculosis diagnoses rates are
also lower than average among this group in London.

Among all ethnic groups combined, the North West has the highest drug treatment rate
followed by Yorkshire and the Humber, and the South East and East of England the lowest.
However, with the exception of the White group, this north-south pattern was not
apparent in individual ethnic groups.

Further regional points of interest include:

•    All ethnic groups generally have a poor patient experience in London, the main
     exception being the Mixed group, and a better experience in the Midlands and the
     North (Figure 9.1).

•    The NHS non-medical workforce from minority ethnic groups is significantly over
     represented compared with the minority ethnic population in East of England, London,
     South East, and South West. The opposite is found in all other regions (Figure 9.2).

The role of socio-economic status and deprivation in explaining patterns of health by
ethnic group and region is not entirely clear. For example the Pakistani and Bangladeshi
groups have the highest proportions reporting that their health is ‘not good’ as well as the
lowest proportions in the ‘managerial and professional’ occupations who are known to
report higher rates of ‘not good‘ health than other social groups. However, it is unlikely
that this accounts for all of the variation or that socio-economic status correctly captures
all of the forms of disadvantage that may be experienced by ethnic minority groups. Other
factors are likely to be playing a part e.g. environmental factors in influencing poor health
outcomes for ethnic minority groups.




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About the APHO

The Association of Public Health Observatories was established in 2000 and
has as a main focus facilitating collaborative working between the Public
Health Observatories (PHO) in the UK and Ireland. APHO was set up with the
following aims:

• To be a learning network for members and participants
• To be a single point of contact for external partners
• To be an advocate for users of public health information
• To coordinate work across public health observatories.


Joint work is facilitated by:

• Each PHO taking the lead in a defined area to avoid duplication at regional
  and national levels.
• Acting as a major public health resource, raising the public health profile
  at regional and national levels.
• Developing collaboration through links at regional, national and
  international levels.

Further information about APHO, the PHOs and their work can be obtained
from www.apho.org.uk.