Equality and Reducing Inequalities Strategy 2019

Sandwell and West Birmingham Clinical Commissioning Group

A strategy for Equality and Reducing Health Inequalities across Sandwell and West Birmingham

2019

Contents

1. Executive summary a. Principles b. Equality objectives

2. Legislative and policy requirements a. Equality Act 2010 b. Health and Social Care Act c. NHS Five Year Forward View d. CCG Leadership and Governance

3. Determinants of good health a. What determines good health b. Principles underpinning strategy

4. Measuring good health a. Life expectancy b. Healthy life expectancy c. Years of life lost

5. Risk factors across a life course a. Life course approach

6. Strategic plan for inclusion and reducing inequalities

7. Population overview - geographical a. West Birmingham b. Sandwell

1) Executive Summary

Sandwell and West Birmingham CCG is a membership organisation involving 85 GP practices and serving around 570,124 patients across Sandwell and Western Birmingham.

People across Sandwell and West Birmingham are living more of their lives in ill health. Alarmingly, for our local populations, their opportunities are diminished from the moment of birth due to a complex interaction of factors that will influence the lifestyle behaviours and choices they make throughout their lives. Some groups in our population will be disproportionately affected by these factors because of characteristics that they share. These inequalities are avoidable and unjust.

As a clinical commissioning group we, along with other public sector bodies have a duty to reduce avoidable inequalities in health. This requires action across a range of dimensions and determinants that are beyond the sole remit of the CCG. Therefore in developing our strategy it is important that we are clear about the guiding principles underpinning the delivery of our strategy and implementation of our Equality Objectives:

Principles The CCG strategy for equality and reducing health inequalities will be underpinned by the following principles.

• We will collaborate with other agencies and sectors that are working to improve the health and wellbeing of populations across Sandwell and West Birmingham. • Take a life course approach to ensure that resources and capacity are invested in addressing inequalities where need is greatest; Therefore, maximising opportunities to improve population and individual health and wellbeing. • Change our relationship with individuals and communities from passive recipients of health services to active agents of positive change.

Equality Objectives 2019

Equality Objectives

Objective 1: We will EMBED equality and reducing inequality approaches into our CCG commissioning processes. We will develop robust plans for PREVENTION and SELF CARE, targeting Objective 2 groups where need is greatest.

We will EMPOWER our communities to take ownership of their health Objective 3 and become more resilient.

We will DEVELOP the skills of our workforce and the service providers we Objective 4 commission.

2) Legislative and Policy Requirements

This strategy sets out the CCGs strategic plans to demonstrate due regard in delivering its legal equality and health inequality duties in its role as a commissioner of health services. It sets out how the CCG will achieve this in the context of the current policy directives, economic climate and population imperatives.

The Equality Act 2010 prohibits unlawful discrimination, harassment and victimisation in the provision of services on the grounds of protected characteristics. These protected characteristics include age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.

Section 149 of the Equality Act 2010 (Public Sector Equality Duty) places specific duties on public bodies to demonstrate due regard to the Equality Act by:

• Developing an equality strategy and equality objectives • To do this in consultation with communities • To publish one or more equality objectives • To demonstrate progress annually in achieving its objectives.

The Health and Social Care Act 2012, also requires CCG’s to demonstrate due regard, in the exercise of their functions to the need to:

• Reduce inequalities between patients with respect to their ability to access health services and, • Reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services. • To ensure that services are provided in an integrated way where this may reduce inequalities.

NHS 5 Year Forward View The NHS Five Year Forward view sets out how our health services need to change to reduce the health and wellbeing gap and to prevent further widening of health inequalities. The 5 year forward view argues for a new relationship between health services, patients and communities. It articulates that the transformation required in the NHS is dependent to a great extent upon building community capacity which encompasses engagement with communities, empowering individuals, personalised approaches and investment in new models and partnerships.

CCG Governance of Equality and Health Inequalities The CCG has developed robust governance arrangements for effective strategic oversight and delivery of the equality and health inequalities agenda. The Quality and Safety Committee will have oversight of the delivery and implementation of the strategy with the Governing Body retaining delegated responsibility for ensuring compliance against the Public Sector Equality Duty of the Equality Act 2010.

3) Determinants of Good Health

What determines good health? Health is determined by a complex interaction between an individual’s characteristics, lifestyle and the physical, social and economic environment, Figure 1. A person’s chance of enjoying good health and a longer, healthy life are determined by the social and economic conditions in which they are born, grow, work, live and age. The experiences and opportunities that a person has across their whole life will impact their health and wellbeing.

Most experts agree that wider determinants of health have a greater impact on population health than healthcare services alone. For example;

Housing: Poor housing conditions have a significant detrimental impact on the health of adults and children. Poor housing increases risk of cardiovascular disease, respiratory disease, depression and anxiety as well as lack of sleep, restricted physical activity and poor educational attainment in children.

Employment: Has both a direct and indirect effect on health through other factors including income, the environment and housing. Socio-economic classification is based on type of employment and is strongly linked to health inequalities. People in higher socio economic groups fare better on many health indicators compared to people in routine and manual occupations. Poor work conditions can expose workers to stress and other hazards.

Multiple Deprivations: socio-economic factors are often linked together and can combine to re-inforce disadvantage in communities and across generations. This multiple deprivation is often concentrated in specific geographical areas, particularly in inner city areas.

Figure 1: Wider Determinants of Health

However, not everyone has the same (equitable) chances or opportunities in life. Health inequalities are the differences in health status between different population groups, these are unfair and avoidable.

Tackling health inequalities is therefore central to improving access to health services, ensuring better health outcomes, improving the quality of services and peoples experiences of them.

As a clinical commissioning group we, along with other public sector bodies, have a duty to reduce avoidable inequalities in health. As the evidence demonstrates this requires action across a range of dimensions and determinants that are beyond the sole remit of the CCG. Therefore, the CCG strategy for inclusion and reducing health inequalities will be underpinned by the following principles:

Principles … The CCG will:

• Collaborate with other agencies that are working to improve the health and wellbeing of populations across Sandwell and West Birmingham. • Take a life course approach to ensure that resources and capacity are invested in addressing inequalities where need is greatest, therefore maximising opportunities to improve population and individual health and wellbeing. • Change our relationship with individuals and communities from passive recipients of health services to active agents of positive change.

4) Measuring Good Health

Sandwell and West Birmingham CCG are responsible for the health of populations across its footprint. The CCG boundaries span two local authorities and include the population of Sandwell and a large proportion of the populations across the Ladywood and Perry Barr districts of Western Birmingham.

To improve the health of this population and help people stay well it is important to understand the current picture of health, which can be measured in a variety of ways:

Life Expectancy (LE) The first approach may be to think about how long people live or their life expectancy. The evidence for Sandwell and West Birmingham demonstrates that life expectancy for both men and women is much lower than the average for England. The populations living in the Ladywood district in Birmingham have one of the lowest life expectancies across Birmingham, with men dying 2 ½ years earlier and women 1 ½ years earlier than people in the neighbouring district. The difference is much greater when compared to life expectancy across England:

Population Men (Years) Women (Years) Life Expectancy Life Expectancy England 79.5 83.1 Birmingham 77.2 81.9 • Ladywood District 74.8 80.5 • Perry Barr District 77.4 82.8 Sandwell 77 81.4 Sandwell and West Birmingham CCG 77.1 81.6

However this measure doesn’t tell us about the quality of people’s lives, just that they live longer or shorter lives. More helpful measures are to consider how long people expect to live in good health (healthy life expectancy) and how many years of people’s lives are lost due to dying earlier than they should (years of life lost). As a CCG our aim is to increase people’s healthy life expectancy and reduce the numbers of years of life lost to conditions that can be treated.

Healthy Life Expectancy (HLE) This is a measure of the average number of years a person would expect to live in good health. As the data below indicates, populations across Sandwell and Birmingham have much lower healthy life expectancy than the rest of England with stark differences between men and women.

Population Men (Years) Women (Years) Life Expectancy Healthy Life Life Healthy Life Expectancy Expectancy Expectancy England 79.5 63.4 83.1 64.1 Birmingham 77.2 58.4 81.9 59.4 • Ladywood District 74.8 80.5 • Perry Barr District 77.4 82.8 Sandwell 77 57.1 81.4 59.7 Sandwell and West 77.1 57.3 81.6 56.7 Birmingham CCG

What the information tells us is that: 7

• Women across the CCG can expect to live longer than men, but about 1/3 or 24.9 years of their lives will be in ill health • Men across the CCG can expect to live shorter lives than women but ¼ or 19.8 years of their lives will be in ill health

Years of Life lost (YLL) Another way to measure health is the number of years of life lost due to people dying before the age of 75. This information helps to identify the major health conditions that contribute to people dying earlier than would be expected.

Birmingham Years of Life Lost Local data indicates that in Birmingham: • Infant Mortality is the biggest single contributor to excess YLL (43.4%) with Ladywood district having an extremely worrying rate of 9.5 per 1000 live births compared to the Birmingham average of 7.5 and national average of 3.9. This accounts for 46.8% of YLL within the Ladywood district. • Ladywood loses more years of life than Birmingham for infant mortality, lung cancer; and pneumonia. However, it loses less years of life for alcoholic liver diseases, and COPD (chronic respiratory diseases) • Perry Barr loses more years of life than Birmingham for pneumonia, infant mortality and alcoholic liver diseases’, however; it loses less years of life for coronary heart disease and lung cancer.

Other major causes of excess years of life lost in Birmingham between 2013-151 are identified as: • Coronary Heart Disease • Alcoholic Liver Disease • COPD • Heart Disease • Lung Cancer

Sandwell Years of Life Lost Across Sandwell, the major causes of early death for people under 75 years of age are: • Cardiovascular Disease • Liver and respiratory diseases • Cancer. • Coronary Heart Disease. • Alcoholic Liver Disease.

To have any impact on improving the health and wellbeing of our local populations, the CCG will need to consider how it can promote factors that determine good health and lessen those that lead to people living more of their lives in poor health and dying earlier than they should. The next chapter will consider the causes of early death that can be prevented.

1 Birmingham JSNA 2017/18 strategic overview 8

5) Risk Factors across a Life Course

There are common risk factors for many of the leading causes and determinants of an early death which can be prevented. These risk factors affect people and groups differently across the course of their life and include:

• Lifestyle behaviours – such as smoking, alcohol misuse, living a sedentary lifestyle or eating an unhealthy diet • Life Stressors – such as low income, poor quality work, poor housing and neighbouring conditions, childhood experiences, poor education , lack of community connectedness and isolation • Inequalities in health caused by barriers to access and use of preventative healthcare and social care services

People will experience different risk factors across their life which will contribute either positively or negatively to their healthy life expectancy. The life course approach helps to identify the inequalities that will impact an individual’s (and population’s) life expectancy.

Life course Approach: The table below provides a brief insight into some of the factors that impact life expectancy across the life course and highlights the differences between groups afforded protection by the Equality Act, or that are vulnerable due to characteristics or circumstances they have in common.

Life Course Approach

The below table seeks to demonstrate how protected and vulnerable groups are impacted during different stages of their lives. For Example, in the perinatal stage, the health of mother and baby are affected by the mothers ability to access maternity care (pre-natal and ante-natal services) and make healthy lifestyle choices (stop smoking, reduce stress). However, we know from Local Evidence that a large percentage of full term babies are born with a low birth weight and many are stillborn. Within our local population there are many groups that have low levels of educational attainment and may not understand why it is important to access early maternity care. In addition many women choose to have their first baby at a young age which is linked to low birthweight; whilst cultural and family barriers may prevent other women from accessing services early in their pregnancy. Over ½ of all babies that die as infants do so because of factors that impacted the baby during the perinatal stage (whilst they were in the womb).

Life Stage Local Evidence Contributory factors that Evidence across protected and vulnerable impact life expectancy at groups. each life stage i Sandwell 2016: Access to maternity care and early Racial / Socio-economic differences have been linked to poor 4% full term babies have detection rates, educational attainment and poor health literacy (understanding low birth weight Termination rates, of risky health behaviours & how / when to access services). (2nd highest in region). Maternal lifestyle behaviours i.e. • smoking in pregnancy Racial / ethnic differences linked to language competency and • psychological stress ability to communicate effectively.

PERINATAL: Age related differences - maternal age of first pregnancy is linked to low birthweight. Leading cause of stillbirth is short Ethnic / cultural differences linked to FGM (female genital gestation (babies not mutilation), Maternal Mental health and exposure to domestic going to full term) and abuse. low birthweight:

Life Stage Local Evidence Contributory factors that Evidence across protected and vulnerable impact life expectancy at groups. each life stage i CCG footprint : Maternal risky lifestyle behaviours, for Racial / ethnic differences are evident in low birthweight babies. Infant mortality rate of example : 7.5 deaths per 1,000 live • unhealthy diet Socio-economic disadvantage linked to lower rates of breast INFANT 0-1: births. • feeding, smoking in pregnancy and poor housing conditions smoking which impact infant health (chronic respiratory disease), and Over 50% infant deaths • not breastfeeding Ladywood district sudden infant death. attributed to (Birmingham) conditions originating Infant mortality rate of Socio-economic disadvantage linked to neonatal mortality in the perinatal period. 9.5 per 1000 – associated with congenital anomaly. Congenital anomalies 2 ½ times the England account for ¼ of average deaths.

CCG footprint: Adherence to treatment, child Socio-economic disparities linked to higher risk of un-intentional Childhood vaccination supplements, birthweight – linked to suffocation and drowning. rates are below targets negative maternal behaviours expected. Racial and socio-economic status linked to higher risk of certain cancers from poor folate / iron uptake before and during pregnancy and in unintentional pregnancies. CHILD 1-4:

Leading cause of death – injuries and poisoning and cancers, congenital anomalies.

Life Stage Local Evidence Contributory factors that Evidence across protected and vulnerable impact life expectancy at groups. each life stage i Birmingham: Negative maternal behaviours resulting Socio-economic disadvantage impacts Parental lifestyle 32.9% children live in in : behaviours - Smoking, alcohol and drug misuse. poverty with 58% of • Short gestation, children entitled to free • low birth weight and Racial / ethnic differences linked to child physical inactivity and school meals. 28% of year • Infections during pregnancy. obesity 6 children classed as obese. Adverse childhood experiences linked Mental health and resilience impacted by socio economic disadvantage and parental lifestyle – Being a witness or victim of CHILD 5 – 14 to: Sandwell: domestic abuse, neglect, poverty across all groups. Leading cause of death • parental unemployment Estimated prevalence of – cancers, injuries and • low income, mental health disorders is external causes. • Depleted resilience from 10.7% amongst 5-16 yr exposure to social isolation, olds mental ill health, domestic abuse, substance abuse. • Being a victim or witnessing violence. Nationally: Hazardous environments, Risky lifestyle behaviours are often initiated during adolescence; ½ secondary school Housing density, increasing during teenage years and into adulthood. children have Housing conditions, experienced homophobic Traffic and illegal driving, Age and socio-economic disadvantage in young people (esp. bullying. males) who are more likely to commit suicide. Suicide risk factors 50% LG & B young people Parental factors such as: include individual and parental behaviours, such as: have self-harmed. • mental ill health , • dropping out of school unemployment & low income, • parental early death Sandwell: • exposure to stressful life events • parental mental illness 37.7% lone parent • unemployment families. Adolescent mental health. • low income, low education skills Young People : 15-19 22% population have no • divorce

Life Stage Local Evidence Contributory factors that Evidence across protected and vulnerable impact life expectancy at groups. each life stage i qualification (2 ½ times Leading cause of death more than England Refugee, asylum seeker, looked after children and LGBT young – suicide, self-harm average) people are at increased risk of poor mental health and and road crashes. wellbeing.

Nationally : Employment status / work quality, shift Children and young adults: Those that experience 18% of all homelessness work patterns. childhood abuse and have exposure to neglect and adverse child related to foreign hood experiences in adulthood . That experience Individual and nationals. Perceived acculturation (sense of parental alcohol / drug misuse. belonging /integration with society ) LGBT groups have higher Lower socio-economic groups have 10x greater risk of suicide. levels of binge drinking, Mental health / self-harm rates / experience of hate crime exposure to adverse childhood Sex: Men are at higher risk of suicide. Lower cancer screening YOUNG ADULTS 20-34 and bullying. experiences rates and late presentation amongst women who have experienced sexual abuse, have a learning disability, are from Leading cause of death: Lifestyle behaviours, BME groups, younger women and Lesbian/Bi-sexual women Suicide and intentional • tobacco use, alcohol self-harm, road consumption, early sexual Migrants who are less integrated at greater suicide risk. accident and cancers. experiences, Use of preventative services: • Uptake of HPV vaccinations and screening rates.

Life Stage Local Evidence Contributory factors that Evidence across protected and vulnerable impact life expectancy at groups. each life stage i Nationally: Diet and lifestyle behaviours including Ethnic / racial and socio-economic differences linked to uptake The Average age of the smoking which accounts for 90% of lung of screening services and low perceived risk as well as higher death of a homeless cancer deaths. incidence of developing type 2 diabetes. person is 47 years old (Crisis) Access to care and uptake of Disability linked to low rates of screening uptake amongst people preventative services. with a learning or physical disability 30% of gay and bisexual men have never had a Childhood IQ, obesity, mental health Socio-economic disadvantage linked to smoking tobacco and HIV test (Stonewall 2012) and psychological / physiological alcohol consumption. responses to adverse circumstances, ADULTS 35-64 Sandwell : Ethnicity, gender, geography and socio-economic factors linked Leading cause of death 3 in every 1000 deaths Social isolation and loneliness. to inequalities in CVD and chronic liver disease mortality and – diseases and related are Smoking related , morbidity causes including cancer, heart disease, 9.2% over 17s recorded heart attacks, chronic as having diabetes liver disease. Men also suicide and intentional CCG: self-harm. Bowel, Cervical, Breast,

Diabetic retinopathy, Latent TBI screening rates below England average or target rates.

Life Stage Local Evidence Contributory factors that Evidence across protected and vulnerable impact life expectancy at groups. each life stage i Sandwell: Lower Socio-economic status and ethnic / racial differences 18.4 per 100,000 people Unhealthy Diet and lifestyle behaviours linked to cancer deaths especially in terms of frequency of under 75 die from in adulthood, screening and perceived risk by some BME communities. Risky alcoholic liver disease. Lifestyle behaviours such as smoking in Bangladeshi, Caribbean Disease awareness, and Chinese populations increase risk. Birmingham: 60% people aged over 65 Housing conditions, Age related quality of care, choice and treatment options by have their activities health professional’s impact mortality rates. limited by a long term Community connections health problem. Fuel poverty in older, low income households linked to increase Cultural competence of health in respiratory diseases and excess winter morbidity. professionals. ADULTS 65-74 Isolation is a risk factor for older people.

Leading cause of death – cancers, heart disease, vascular disease, respiratory diseases.

6) Our Strategic plan for equality and reducing inequalities

The profile of Sandwell and West Birmingham demonstrates that for all populations, the opportunities across a person’s life course are diminished from birth, due to a complex interaction of factors that influence the lifestyle behaviours and choices they make throughout their lives.

Different groups however, within the population are disproportionately affected by these factors throughout the course of their lives which give rise to inequalities in their health status. These groups have many characteristics in common such as their ethnicity, age, disability, sexual orientation, gender, religion or belief and socio-economic background for example. In addition, some groups are particularly vulnerable due to circumstances that place them at greater risk, such as homeless groups, carers, victims of trafficking and sexual exploitation and asylum seekers. The Equality Act requires us to pay due regard to these groups within our population. in its approach to delivering its equality and health inequality duties, the CCG will need to consider the factors that protect and create health and wellbeing in all of its local communities, as well as the reasons that prevent some groups from having equitable access to those factors.

With this in mind the CCG’s strategic equality and reducing inequality objectives will be to:

Objective 1 • EMBED equality and reducing inequality approaches into the CCG commissioning process o Embed the requirement to undertake equality analysis / impact assessment within the CCG commissioning and decision making process. o Embed the requirement for population equality and health inequalities intelligence, information and data to inform commissioning decisions at each stage of the commissioning process. o Engage and involve local interests and stakeholders from protected and vulnerable groups in the commissioning of services and pathways that will have an impact upon them. o Ensure staff and service providers understand their equality and health inequality duties and responsibilities.

Objective 2 • Develop robust plans for prevention and personalised care, targeting groups where need is greatest. o We will address the barriers that prevent people from having equitable access to health and wellbeing programmes and initiatives across our footprint. This includes barriers related to language, literacy and digital exclusions. o We will ensure that health checks, screening and immunisation programmes target groups at greatest risk. o Reduce variation in health outcomes for people with long term conditions across pathways through primary and secondary care o We will personalise care around people with long term conditions (or chaotic lifestyles), giving them choice and control in managing their conditions and maintaining self-care.

Objective 3 • EMPOWER our communities to take ownership of their health and become more resilient. o We will ensure that people and communities are empowered to stay well and have the necessary skills and opportunities to make healthier lifestyle choices. o We will utilise the breadth of community assets across the footprint, to ensure vulnerable and at-risk groups in the population have access to information and services to maintain and/or improve their health and wellbeing. o We will engage and involve at-risk and vulnerable groups to co-design services and pathways around their needs.

Objective 4 • Develop the skills of our workforce and service providers o Ensure our workforce and service providers have the skills, knowledge and confidence to instigate positive behaviour change within targeted patient groups and local communities. o Ensure consistency in the health education and prevention messages patients receive regardless of which agency or organisation they are engaging with. o Ensure health care professionals make every contact count.

7) Population Overview

Sandwell and West Birmingham CCG is a membership organisation involving 85 GP practices and serving around 570,124 patients across Sandwell and West Birmingham.

Local populations are made up of individuals, communities and groups. They are not homogenous or constant and plenty of evidence exists to suggest that some groups experience of, and access to services vary more than others. Equally, some group’s experience worse health outcomes than others. These variations are avoidable and unjust.

To understand our populations, commission effective services, and address health inequalities across the life course of our populations; it is important to appreciate the disparities that currently exist within population groups across the CCG footprint. It is also important to appreciate how these differences impact people’s ability to positively influence their health and wellbeing status.

West Birmingham The CCG is responsible for the health of populations across Western Birmingham. This includes people registered with GP practices across the Wards of Ladywood and Perry Barr. Much of the available data and information is drawn from a range of sources that are either at a Birmingham city wide, district or ward level and not always co-terminus with the CCG boundaries.

Birmingham has a total of 208 GP practices (2016/17); from April 2018 this is be split between Birmingham and Solihull CCG and Sandwell and West Birmingham CCG. Birmingham has a younger and super diverse population with higher than average levels of deprivation compared to the rest of England.

• Total population of Birmingham is 1,117,008 people (2016). 40% of the population are aged between 0 to 25 years, 13% of the population are over 65. • 56.4% of Birmingham’s population live in the most deprived 20% of areas in England (IMD2015). • Life expectancy in Birmingham is lower than the national average. For males life expectancy at birth is 77.2 years (England 79.5) and females 81.9 years (England 83.1). • During 2013 to 2015 Birmingham’s under 75 death rate was 28% higher than the rate for England. • Infant mortality is an area of concern: the rate was 7.5 per 1,000 live births during 2013 to 2015; this compares to 3.9 nationally. Ladywood District has the highest rate of infant mortality at 9.5 per 1000 live births. • The 2011 census showed that 60% of Perry Barr and 72.7 % Ladywood districts populations are made up of BME groups (42% Birmingham) and that 65% of school age children had a first language other than English. • 32.9% of Birmingham’s children were living in poverty during 2014. This compared to a national average of 20.1%. Ladywood district (42.5%) had the highest percentage in Birmingham during 2014 (Department of Works and Pensions published Aug 2017). • Unemployment levels were 6.1% in Birmingham. (BCC/ONS/NOMIS – Dec 2017). • The Department for Education school census 2016 showed that 45% of pupils of school age had a first language other than English. • 67% of Birmingham residents said they felt safe going out in the dark whilst 90% felt safe in the day. 86% of Birmingham residents are either fairly or very satisfied with living in the local area (Birmingham Residents Survey Oct 2015 to Dec 2015).

Sandwell Sandwell has a total of 54 GP practices and is split into 24 wards. Sandwell has high levels of deprivation across most of its wards.

• Total population of Sandwell is 316,720 (June 14 estimate). The borough has experienced an 11.3% (32,100 people) increase in its population between 2001-2014, higher than England and other Black Country boroughs. • Sandwell has high numbers of young children under 10 and adults aged 25-34 than national average. • 19,300 children live in poverty across Sandwell. • 65.8% of the population is White British compared to 34.2 % from other ethnic groups. The greatest increase has been in the ‘white other’ category which increased by 78% between the years 2001 - 2011. • Life expectancy is 77 years for men and 81.4 years for women, lower than the England average. • People in Sandwell, on average experience illness and disability at a younger age than in other parts of England. They therefore spend more of their lives experiencing illness and disability. Healthy life expectancy is 59.7 years for men and 58.6 years for women. • A woman in Sandwell can expect on average to spend nearly 23 years with a long term illness or disability. For men in Sandwell this is nearly 18 years. • Life expectancy is 7.8 years lower for men and 6.2 years lower for women in the most deprived areas of Sandwell than in the least deprived.

i UCL Institute of Health Equity (2015) Social inequalities in the Leading Causes of Early Death, A life course approach.