The public health team was asked to provide a report on indicators which mark the associations between economic wellbeing and health. Health is determined by a range of factors including the social, economic and physical environment and individual characteristics and behaviours. As many health indicators rely on national data collection and are not available quarterly, they cannot be used regularly to aid the Executive Board in closely monitoring the impacts on health. Therefore, this annual report summarises a range of relevant indicators, which we propose to publish annually to augment the existing health indicators included in the quarterly report.
This set of indicators was developed by the UCL Institute of Health Equity (IHE) under four broad headings. The first three are markers of social determinants of health while the last category highlights health indicators which may be relatively responsive to changes in the economy:
Employment – Unemployment is associated with a higher risk of poor physical and mental health and an increase in unhealthy behaviours, including smoking, harmful drinking and inactivity.
Economic security – There is an inverse relationship between income and health. Low income is associated with poorer mental health for all age groups, particularly women. Children born into poverty have higher rates of physical and mental ill health and developmental and social problems both immediately during childhood and throughout their life-course.
Housing – Type and condition of housing is closely related to income. Conditions such as homelessness, overcrowding and difficulties with affording to heat a property may constitute a risk to health.
Health and wellbeing – A number of negative health outcomes are particularly related to economic factors, including depression, suicide, infectious disease and low birth weight.
2 Indicator set
E1, E2, E3a and E3b measure the rates and duration of unemployment. Richmond is lower than London and England averages for all these indicators. Whilst the trends indicate a reduction in unemployment over the last three years, the proportion of the population claiming JSA for over 6 months is still higher than 5 years ago.
E4 (new Employment Support Allowance claimants) gives an indicator of the number of new people of working age claiming illness-related benefits, which is expected to be associated with the incidence of illness. Whilst the rate of new claims in Richmond is lower than in London and England overall, it has approximately doubled since 2010.
Quality of work is an important determinant of health and rising part-time employment may indicate ‘under-employment’, with those who can only find part-time employment being unable to sustain a healthy standard of living. However, this may be less applicable in the Richmond context, as many people also choose to work part-time due to family commitments and the adequate income of a spouse. The ratio of full-time to part-time work (E6) indicates that the number of people working full-time is about four times the number of those working part-time. This is higher in Richmond than England and London, and has increased over the last 5 years.
Not being in education, employment or training has a significant negative effect on employment opportunities later in life. The proportion of 16-18 year-olds not in education, employment or training (NEET; E7) was developed when youth unemployment was at its peak, although a law passed in 2013 requiring all 16-17 year olds to participate in some form of education, training or employment affects the validity of this indicator with regards to time trends. It is surprising that the estimated proportion in Richmond is slightly higher than the London average. However, the proportion of 16-18 year-olds in Richmond whose activity is unknown is over 50% above the England average, so the estimate may be inaccurate.
4 Economic security
ES1, ES2 and ES7 indicate the number of people that are eligible for benefits by having a low income. Richmond is lower than the London and England averages for these indicators.
The number of individual insolvencies (ES6) gives an indication of levels of over-indebtedness. The Richmond rate is lower than London and England averages, and has been decreasing over the last 5 years. ES5a and ES5b provide measures of the extreme end of over-indebtedness where landlord and mortgage repossession claims and orders are issued. Richmond rates are lower than London and England.
Changes in housing benefit claims (ES9) provide an indication of the level of ‘population churn’. Housing benefit claims within a ward can fall because the area has become increasingly unaffordable to those on Local Housing Allowance. This has implications for health as security of tenure and social cohesion can impact on psychological wellbeing and health. The number of claims dropped sharply in 2014, the causes of which may merit further investigation.
Overcrowding (H1) is associated with higher rates of respiratory disease, tuberculosis, meningitis and gastric conditions and impacts negatively on children’s education, family relationships and physical and mental wellbeing. The proportion of overcrowded households for Richmond was lower than London and England in 2011. However, we have been unable to replicate the indicator to provide a more recent figure.
H2, H3 and H4 give an indication of incidence and prevalence of homelessness, which is associated with poorer health outcomes, including premature death and higher rates of physical and mental health. Moreover, the homeless population are at the extreme end of deprivation and experience the health problems and stresses related to poverty and over-indebtedness mentioned above. Rates of homelessness acceptances and use of temporary accommodation are lower in Richmond than the London average, but higher than the England average. However, the rates remain higher than in previous years.
H6 is an indicator of fuel poverty. Those living in cold, damp homes have higher rates of cardiovascular disease, respiratory disease and mental ill health. There are indirect negative impacts, for example on children’s educational attainment, and fuel poverty is a contributor to excess winter deaths. The proportion of Richmond households in fuel poverty is slightly lower than the London average and below the England average.
6 Health and wellbeing
The rate of emergency hospital admissions to hospital for self-harm (HW1) is used as a proxy for suicide, since suicide numbers on a local level are very small. The rate in Richmond appears relatively stable, higher than the London average, but below the England average. The percentage of adults with depression (HW2) is a marker for the impacts of rising unemployment on mental health, which is more immediate than on physical health. The proportion in Richmond is slightly lower than the London and below the England average.
The proportion of babies born with a low birth weight (HW4) in Richmond remains around 6%, which is slightly lower than the London and England averages. Poverty is a risk factor for premature birth and low birth weight, particularly for children of young single mothers.
Tuberculosis incidence (HW5) is one infectious disease which has been shown to worsen following periods of economic crisis. Stress levels can affect immunity and poorer living conditions increase the chances of contracting the disease. Whilst the TB rate in Richmond is well below the London rate of 41.4 per 100,000, the neighbouring borough of Hounslow has the third highest rate in London (74.4 per 100,000).
This initial paper presents a set of health indicators that might be relevant in monitoring the impacts of the economic context on health. However, for many of these indicators, the relationship to health is complex and many health effects of social and economic stresses can be delayed or long-lasting. The first three categories of indicators listed here focus on the most deprived part of the population, which has the highest rates of physical and mental ill health and mortality. Economic stresses and job insecurity associated with recession can affect all social groups, however, and only HW1 and HW2 of the indicator set provide an indication of the impact on the population as a whole.
Future work is required to investigate these indicators in more depth. Additional indicators which require sourcing further data locally were proposed by the IHE: job availability (E5), council tax arrears (ES3), housing rent arrears (ES4), new school registrations (ES8), Local Housing Allowance allocations by small area (ES10), tenancy rescue services (H5), domestic abuse (HW3), GLA well-being score (HW6).
 UCL Institute of Health Equity, The impact of the economic downturn and policy changes on health inequalities in London – Development of an indicator set:
 With changes to the welfare system, this indicator may have to be revised.
 More in-depth analysis has been undertaken in the recent homelessness health needs assessment (Richmond Council, Homelessness in Richmond upon Thames Health Needs Assessment.
 The Richmond suicide and self-harm prevention strategy is currently under development.
Wider analysis of trends in the local economy is available in the London Borough of Richmond upon Thames Quarterly Economic Indicators Report
Published: September 2014
For review: September 2015
Public Health Topic Lead: Steven Bow, Public Health Epidemiologist