Scottish Health Inequalities in context

Dr Laurence Gruer OBE

Why am I here?• An overview of health inequalities• 14 years experience of developing, managing

and evaluating innovative services for the most disadvantaged– Drug injectors, prostitutes, problem

drinkers, homeless, people with HIV, people with psychosis

Who do I need to thank?• Harry Burns• Peter Donnelly• David Gordon• Carole Hart• ISD Scotland• Andrew Tannahill• Graham Watt

The menu• The changing challenge of health inequalities

in Scotland• Where can we make the biggest difference?• Designing services to work

Life expectancy at birth by CHP, 2003-2005 (95% ci)

64 66 68 70 72 74 76 78 80 82 84

Age

North Glasgow *East Glasgow *

South West Glasgow *West Glasgow *

West Dunbartonshire Inverclyde *

South East Glasgow *Western IslesRenfrewshire

North Lanarkshire Dundee City

Clackmannanshire East Ayrshire

North Ayrshire Kirkcaldy & Levenmouth

West LothianSouth Lanarkshire

FalkirkSouth East Highland

Aberdeen City South Ayrshire

Argyll & Bute North Highland

MidlothianEdinburgh South

Mid HighlandShetland

Dunfermline & West Fife Edinburgh North

Moray ^Dumfries & Galloway

AngusScottish Borders *

East Lothian Glenrothes & North East Fife

Orkney Stirling

Perth & Kinross Aberdeenshire

East Renfrewshire *East Dunbartonshire

Males

Female

Scotland

Male life expectancy for 10 lowest and highest postcode sectors (1998-2002)

1988-92 1998-2002

Scotland

Complex relationships

Life circumstances

Good health

Ill-health

Behaviours

Scotland’s pattern of affluence/deprivation is changing

smaller numbers of most deprivedevolving nature of deprivation

1981

1991

2001

Health protection and improvement resources now available to vast

majority in Scotland

• Clean water• Clean air• Good sanitation• Safe and nutritious food• Warm, weatherproof

homes• Free education and

lifelong learning opportunities

• Free health care

• Social services and benefit system

• Public transport• Unlimited information• Safer working conditions

Health inequalities in Scotland today

• Underlying factors• Pregnancy and parenting• Cultural norms • Intellectual, emotional and physical limitations• Educational attainment• Difficulty in understanding, engaging and

succeeding in a society that rewards talent, skills, beauty, energy

• Failure, drug misuse, mental health problems

Cardiovascular disease mortality and deprivation in Scotland

The role of smoking in health inequality in

Scotland

The Renfrew and Paisley Study

• 7049 men and 8353 women living in Renfrew and Paisley

• Aged 45-64 when recruited in 1972-76

• About 80% of that age group• Detailed questionnaire and clinical

exam • All deaths recorded since then

Comparing survival rates

• Each person assigned to a group according to sex (2), smoking status at recruitment (3) and social class (4)

• 24 mutually exclusive groups

• Survival curves for 28 years of follow-up

Survival of most and least affluent women

0.0

00

.25

0.5

00

.75

1.0

0S

urv

iva

l

0 10 20 30Years after screening

SC I&II never SC IV&V never

SC I&II current SC IV&V current

0.0

00

.25

0.5

00

.75

1.0

0S

urv

iva

l

0 10 20 30Years after screening

SC I&II never SC IV&V never

SC I&II current SC IV&V current

Survival of most and least affluent men

Renfrew and Paisley 28 year survival ranking of never-smokers and

smokers• Top 8• F I&II 65%• F IIIN 57%• F IV&V 56%• F IIIM 53%• M I &II 53%• M IIIN 47%• F IIIN 42%• F I & II 41%

• Bottom 8• M IIIM 38%• M IV & V 36%• F IV & V 35%• F IIIM 33%• M I & II 24%• M IIIN 24%• M IIIM 19%• M IV & V 18%

Interpretation• Among both women and men, the least

affluent never-smokers have much better survival than smokers in all social classes

• Health inequalities due to smoking are greater than all other factors in this population

• Survival rates of non-smoking women in lowest social class among the best

• Even if the socio-economic circumstances of less affluent smokers improve, their health gain is likely to be minimal if they continue to smoke

Implications for policy and practice

• To improve health overall, help all smokers to stop

• To reduce health inequalities every effort must be made to enable less affluent people to stop smoking/ never to start

Other growing contributors to health

inequalities in Scotland

• Problems in the early years• Obesity• Alcohol

Smoking

Age of mother at birth

Lone parent

Breast-feeding

Body mass index and relative risk for type 2 diabetes among American nurses (Colditz

et al 1995).

Obesity and overweight by SIMD quintile in men, Scottish Health

Survey 2003

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5

SIMD Quintile

% o

f s

am

ple

Obese

Overweight

Normal

Obesity and overweight by SIMD quintile in women, Scottish Health

Survey 2003

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5

SIMD Quintile

% o

f s

am

ple

Obese

Overweight

Normal

Reported weekly alcohol consumption by SIMD quintile among men, Scottish Health

Survey 2003

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5

SIMD Quintile

% o

f s

am

ple

> 50 Units

> 21 Units

< 21 Units

Reported weekly alcohol consumption by SIMD quintile among women, Scottish

Health Survey 2003

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5

SIMD quintile

% o

f s

am

ple

> 35 Units

> 14 Units

< 14 Units

Death rates due to alcohol in Scotland by deprivation

Inequalities of service provision and outcome

• Cancer• Cardiovascular disease • Primary care

Colorectal cancer incidence, 5 year survival and mortality by SIMD quintile, Scotland: patients diagnosed 1991-95

Source ISD Scotland

0.0

10.0

20.0

30.0

40.0

50.0

60.0

1 2 3 4 5

SIMD quintile

Ra

te

Incidence (EASR)

Mortality (EASR)

Survival % at 5 years

Adjusted operations rate ratios for CABG by SIMD decile, Scotland 2006-07

Source ISD Scotland

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

1 2 3 4 5 6 7 8 9 10

Affluent SIMD Decile Deprived

Op

era

tio

ns

ra

te r

ati

o

Males

Females

Self-assessed health, mortality rates and provision of GPs by SIMD decile, Scotland

Source Prof G Watt

0

50

100

150

200

250

300

350

400

450

1 2 3 4 5 6 7 8 9 10

SIMD decile

Ra

te

Self health

SMR

WTE GPs

The challenge• How to tackle the major preventable health

problems in ways that will not widen existing health inequalities

Dearth of evidence on how to do it

• Better at describing the inequalities than showing how they can be reduced

• Evidence on effectiveness in general populations, but little about applicability or adaptation to disadvantaged groups

• Lack of inequalities-related analysis of inerventions

Tackling inequalities through health service provision

• Investing more in primary care in disadvantaged areas• Logical but imaginative new service design• Maximise the use of effective interventions

– Smoking cessation– Statins & antihypertensives– Brief interventions for problem drinking – Weight management– Immunisation– Breast feeding

New service design• Start small but think big• Design the services to fit the patient

– Right place, right time, right staff• Design for reproduction across the service• Design for the long term• Evaluate and aim for continuous improvement

Keep Well Pilots – Linking Activities & Outcomes

Reduced premature CVD mortality in deprived areas

Reduced health inequalities

Identify population

Invite / contact

Engage

Reach Uptake

GP Practice & local service impacts

LOCAL SERVICE DELIVERY (GP practices with most deprived population)

OUTCOMESACTIVITIES

Identify barriers to service access

Re-design services and

resource deployment

Improved access

Assess fordisease and risk

Provide effective interventions

• Secondary prevention• High risk primary prev

CVD risk factor modificatn

Maintain, monitor & follow-up

Compliance

The future• Huge potential for preventive/anticipatory care• Can we find the models and resources to make

the most of it?• Do we have the expertise to prove it?

Conclusions• The dynamics of health inequalities in Scotland

are changing• Culture, capabilities, hard to change

behaviours• Parenting and early development are widening

future inequalities• Health services must adapt and innovate to

meet complex needs