>>Gerry McCartney 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]