I am going to take you through initially just a quick revision on
how we measure Health Inequalities in Scotland. I know there are a lot of people who are fairly
new to this today, and then I will spend most of the time talking through what we already
know about what works to reduce health inequalities and importantly what doesn’t work.
In case anyone needs reminded, health inequalities matters. Martin Luther King said that of all inequalities,
injustice in health is the most shocking and inhumane. And who can disagree with that? Obviously
the loss of life in Glasgow and across Scotland due to health inequalities is massive and
it is preventable. So therefore it demands our attention.
Fortunately in Scotland we have an excellent Annual Report produced by the Scottish Government
which monitors our health inequality trends. We monitor a whole variety of outcomes from
premature mortality, mental wellbeing, first heart attacks, heart disease mortality amongst
adults, cancer incidents, alcohol first admissions, alcohol deaths, mortality among young adults,
low birth weight and healthy birth weight as well.
So we monitor all these outcomes in Scotland every year and so we have a really good picture,
a very rounded picture of what is happening with our health inequalities. I am going to
pick just one of these trends to illustrate some of the measures we use to say whether
health inequalities are getting worse or better. Sorry self-assessed health as well, and [inaudible] long-term conditions. [laughter] I had originally said that all of these would come up at once, but I failed in my PowerPoint skills today. Ok, so, I am going to pick one of them which is mortality
rate for those aged under 75 years. A really good measure of health, because we
know that the best countries across the World the life expectancy is well above 75 years,
and so this is very attainable. So it is good news on average. From 1997 to 2015 you can
see that mortality rates have gone down for this group over time. Pretty steadily until the
last year of data in 2015. So that is good news, but that masks the inequalities across Scotland. So if we take the most affluent group, that’s that blue line (there), you can see that the
most affluent group enjoy a mortality rate that is roughly half the average. That is
the most affluent 10th of the population, a markedly different mortality rate than the
average for the whole of Scotland. What I am going to do is add in each 10th of the
population now. You can see each 10th of the population has a slightly higher mortality
rate, until you get to the most deprived groups there. Look how much higher the mortality
rate is over time. Mortality rates are coming down in all those
groups by and large, they are quite bumpy because it is smaller sized populations, but
the general trend is downwards. That inequality, the gap or the ratio across those groups is larger.
I want to talk a wee bit about how we measure that, so you can understand what it says in
this annual report on health inequalities. So if we present the data in a slightly different
way, this is just taking the 2015 data, and ranking from the most deprived to the least
deprived on the left, you can see that very stark gradient of higher mortality in the
most deprived groups is there. What we do is we draw a best fit line. So a linear straight
line through those points. It doesn’t exactly match each of those, it is a best fit. That
is the sort of gradient across the population and that is important because it doesn’t
just look at the worst and best, it takes into account all the groups across the whole
of society. That’s also important because even if you are in the middle, so if you are
sort of in the 5th decile, the 5th group in that line, you can see that your mortality rates
are higher than the most affluent groups. So health inequality affects everybody in
society, not just the people at the extremes. Now, what we do to measure the absolute gap,
what is called the slope index of inequality, we draw a line across from the top and bottom
of that red line. You can see it is not equivalent to the highest mark, it is not equivalent
to the lowest mark, it is looking at that best fit line. Then we measure the distance
between those two lines and that is the slope index of inequality. That is the absolute
inequality, the gap across the population after taking into account the slight variation
across deciles. That is quite important and that is one of
the headline measures we use in Scotland and I just wanted you to understand that but very
few people understand what the absolute inequality is, and it is even more tricky to understand
the relative inequality but I am going to give it a go.
So just remember what that red line means – so that is the gap. The relative inequality,
the RII, is the ratio of how many times worse things are, which is approximated by taking
that absolute inequality, that red line and dividing it by the average, so we take an
average line across there, we measure how high up that is, we compare the size of those
lines and then we take a ratio of them. That is the RII, that is 1.33 times. So the red
line is 1.33 times greater in size than the black line, that is the RIA. Hopefully we
all understand those figures now. Yes? Lots of nods.
But this is important because in Scotland, that is all the data there, but we summarise it
in two lines, so we summarise it as the RII and SII and you can see they are going in
different directions. You will be thinking what is going on, why are they going in different
directions, I don’t get this. Sol it is because the average is also coming down over
this time period so we need to understand that they measure different things. So by and large
absolute inequalities, the SII is getting better in Scotland, but the relative inequalities,
the RII is getting worse and that is because the average is improving over time, so what
we are dividing the absolute by over time is changing. Hope you are all still with me here.
So largely the absolute inequality, the SII has been declining mostly because of the decline
in heart disease and alcohol related mortality over time, but as I say because the average is also
improving so the relative inequalities have gone up.
Notice that in 2015, in particular, mortality rates and inequalities of mortality has gone up a wee
bit. There is a lot of work going on to look at that. National Records for Scotland just
published earlier this week that life expectancy for the first time in many decades has stalled
in Scotland, and there is a lot of worry about what the causes of that might be. And we will
be publishing some more detail on that in March. So just to go back to that and try to understand
it a wee bit more. This is roughly, I am just simplifying this graph into two lines, so
poor and rich, this is the current situation. So absolute inequalities are going down but
relative inequalities are going up. The ideal is of course that absolute inequalities
go down and relative inequalities go down, and to achieve that, what we need is a much
faster improvement in the health of the poorest groups compared to the rich. That will get
us a decline in both absolute and relative inequalities. That is what we are aiming for.
What I am hopefully going to spend the next few slides talking about is what is causing
inequalities in general, what do we know about that and then importantly what do we know
works to do about it. What causes health inequalities? Four theories
have been proposed, there they are there. Artefact, Selection, Behaviours and Culture,
and Structural and Political Economy. I will take you through the evidence for these very quickly.
First is Artefact. That is basically it is not real it is something wrong with the statistics.
This is not the case, we are very confident that it is not an artefactual relationship.
It is not untrue; it is not based on a problem with our statistics. That is because no matter
what indicator of social status or socioeconomic position you use, you see that same pattern
in different places and different time. It is very difficult to sustain that this is an artefactual
relationship. However that is not to say we can’t measure the lived experience of deprivation
better. So one of the big limitation of things like the Scottish Index of Multiple Deprivation
is that it is an area based phenomenon, it does not work well in all areas of Scotland,
we know that, and it does not really capture what it is really like for the people within the
most deprived areas so we need to get better at measuring that, and so it is not to dismiss
artefact entirely but it certainly does not explain away health inequalities.
Second theory is Selection theory. I call this the zombie hypothesis because no matter
how much evidence accumulates against it you still see it quoted, particularly in the economics
literature. In essence it’s a reverse causation argument, so that poor health causes a social slide, rather than vice-versa, but it is totally undermined by longitudinal studies where you measure social
status when you are healthy, and then see who gets healthy and who gets sick. There’s lots
and lots of longitude studies that now show that selection theory really doesn’t explain
very much of health inequalities at all. The third theory, Behavioural and Cultural,
well this is a really important theory, but it is partial. The advocates of it in a strong sense would suggest
that the prevalence of behaviour such as smoking, alcohol and diet; cultures or skills,
such as parenting, are the root cause of health inequalities. In softer terms, people would say that
this is part of the causal pathway. What we know is that unhealthy behaviours are more prevalent
in the lower socioeconomic groups, however the same behaviours generate higher mortality
amongst the working class. So if you compare smokers who are working class compared to
smoker who are professionals, it is the smokers in the working class that will get higher
lung cancer rates for example. It knows why particular social groups adopt unhealthy behaviours,
the context. The patterning of health behaviours is explained by socioeconomic circumstances,
and, really importantly, and this is based on a really big study in France, the Gazelle Study,
where unhealthy behaviours have equalised across social groups; mortality and inequalities
have not. So it is not all about health behaviours. Another argument against this has been the
root causes, the fundamental causes theory that Bruce Link and Jo Phelan have talked
about over the years. That means over time, the different causes of death that have become
important, the different causal pathways, have changed, and if it was simply about behaviours,
then as behaviours have changed you would see those inequalities come and go. So for
example if you went back to Glasgow in 1850 it would be about access to clean water that
would be the important driving factor of health and inequalities. It would not be about whether
you smoked or not. But then it was about malnutrition; then over time environmental toxins such
as asbestos and exposures in the shipyards and things became more important. Smoking
then became important after World War II. Then alcohol and drugs more recently, and as
each of these causes of death have been tackled effectively by public health and policy action,
health inequalities have been maintained. Even in the future as we manage to tackle
alcohol and drugs, other future mechanisms such as obesity that we talked about this
morning, will become more important in driving health inequalities. All of that means tackling
socioeconomic inequalities in society is the most important thing in tackling health inequalities.
So what this theory argues is that differences in income resources and power between groups
cause health inequalities. We know that because health inequalities rise and fall with income
inequalities and I will show you a couple of graphs on that in a second. We now that
the health of communities has improved when they have been given more resources by chance and
there are references for that. We also know those with most resources in any society are
always the healthiest regardless of their behaviours. Even when you have genetic factors
such as with Cystic Fibrosis, the people that die earlier from Cystic Fibrosis are still the more deprived
groups, so it is the context in which people live that is the most important thing.
This isn’t unknown in our most deprived communities. There was a study done by Mhairi Mackenzie and colleagues at Glasgow Uni and University of the West of Scotland, which asked
people in post-industrial towns in Ayrshire what they thought about health and equalities
and some of the quotes that they came up with are really really staggering. First one:
“That’s the cause of it, his ill health, aye the lack of work. See if I had been working,
I’d never have had any bother, because you were that used to working and it kept
you fit, so if you’re no working what are you doing, your system is shutting doon and
that’s what’s wrang with all these men roond here, the systems are shutting doon.”
So people instinctively link unemployment and de-industrialisation with health outcomes.
Another quote “Everybody kind of looked out for one another.
If someone was short of money like the neighbours next door, there was still a long running joke of
the floating fiver (£5 note), because this fiver, you dinnae ken who it belonged to,
it just went between the two hooses. There was mair a sense of community, that’s no the
same kind of feeling noo. Shut doors and all that.” And of course, that is what we would maybe codify as social capital nowadays, but that existed and people
knew that that’s what existed within working class communities in the past, and what has
been eroded since the deindustrialisation came on. One more quote.
“Brian was only what, two year unemployed, when his wife left him. All those unemployed miners
was drink and gamble. They had nae work, nothing else to do in the mornings. Got
up go to the pub, come back hame. Go to the pub. It ruined my brother’s life. His wife left,
James’ wife left and a lot of guys in this area. All the women were seeing was drunk
men coming in, an awfy lot of men went off the rails.”
Again, linking health behaviours and cultures very strongly with what was going on it the jobs
market, what was going on with the mines in that area. So this is common knowledge
in our communities, this isn’t new, this evidence is out there colloquially, but also
in the academic literature. Just to show that health inequalities tracks
income inequalities, this is a measure of health inequalities across Great Britain. You can
see they went down from the 1920’s to the 1970’s, before rising, and there’s the trend
in income inequalities, we don’t have earlier trends. That is for Great Britain.
Very similar thing for the USA, that is from 1960 to 2000, the mortality gap has increased
over that time and there is the income inequality trends. So income inequality is a big driver
of health inequalities in society. So on the causes of health inequalities we
know structural explanations fit best. Behavioural and cultural theories are relevant, but they
are insufficient and they need to be contextualised. Blaming poor people for their behaviour, skills
or cultures is really quite damaging and stigmatising. Selection theory does not explain much and
therefore health inequalities are largely determined by the political decisions and
political priorities we have in any society. But really importantly as those last trend
graphs showed, health inequalities are not inevitable and have been more in the past
and in different places and other populations. So, rather than leaving us in doom and gloom,
I wanted to spend the last few slides just talking through what we know works to reduce health
inequalities. A lot of this is pulled from a report done by NHS Health Scotland called the
Health Inequalities Policy Review, which is available on our website.
So, just to start the least likely actions to reduce health inequalities we know are information
based campaigns, so when we are inviting people to opt in to healthier behaviours, less effective
at reducing health inequalities. Written materials, campaigns reliant on people taking the initiative
to opt in and campaigns and messages designed for the whole population. Whole school health
education approaches. Not that effective at reducing health inequalities. Anything that
involves a significant price or other barrier to access. We also know that housing and regeneration
programmes that raise costs and cost gentrification are ineffective.
However to balance this up I have two slides on effective actions, you will be glad to hear.
So structural changes on the environment, things like area wide traffic calming, separation
of pedestrians and vehicles, child resistant containers to stop poisoning and installation
of smoke alarms and wiring them in. Installing affordable heating in damp cold houses, all
those structural changes to people’s environment, really effective at reducing health inequalities.
Legislation and regulation really effective, so drink driving limits, lower speed limits,
seat belt legislation really effective. More recently the ban on smoking in public places and then
obviously minimum unit pricing again will be a very effective way of reducing health
inequalities, and then vitamin supplementation of foods. Again it doesn’t rely on people
opting into things and taking vitamin tablets it’s just part of what people do it is just
part of the diet. Fiscal policies, so making unhealthy products
more expensive is effective, and then of course income support, so boosting peoples income particularly in
the lower income groups equalising income distribution across society, really really
important, and more recently we have some evidence around welfare rights advice in primary care, a really effective way of maximising what people actually get in terms of what they
are due in social security. The flip side of putting price barriers in
place for unhealthy things is reducing price barriers in healthy things so free prescriptions,
free school meals, free fruit and milk, free access to smoking cessation, free eye tests.
All of these things reduce barriers and reduce health inequalities. Improving the accessibility of services, we know that the more barriers you put in place whether it’s the infamous primary
care receptionist or the need to phone up 15 times to get an appointment for something.
The more barriers we have, the more inequalities will result, because we know that the middle classes can navigate that more easily than everybody else. Prioritising disadvantaged groups so people
who are multiply deprived, rough sleepers, unemployed, homeless. Then obviously offering
intense support for those that have the greatest need. We know starting young is really important
as well. If we wait ’til inequalities are ingrained within peoples’ lives, it is much more difficult to turn that round. So to summarise, health inequalities are largely
due to politics and policies, behaviours are important but only part of that story. Clearly
addressing poverty inequality in the social determinants of health is essential if we
are to reduce health inequalities, and the evidence suggests that the most effective
actions in that regard involve legislation, regulation and taxation.
Thank you very much. [applause]