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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