As part of the launch of Common Weal policy unit, we will be encouraging people to commission papers on a range of topics. Whilst these papers are not Common Weal policy, they are designed to instigate dialogue and act as a foundation for which policy can stem from.
Dr Steve McCabe is a general practitioner and a member of the Scottish council for the British Medical Association, a professional association and registered trade union for doctors in the UK. Dr McCabe’s paper highlights how Scotland’s immensely high levels of inequality exacerbate our chronic ill health, and provides recommendations to improve this ingrained problem.
INEQUALITY AND HEALTH
If there is one thing Scotland excels at compared to any other EU country, it is illness. Almost everyone recognises our epithet – “the sick man of Europe” – and almost no-one disputes it. And within Scotland there are differences with Glasgow/West Central Scotland faring significantly worse than the rest of the country – the so-called Glasgow effect. (1)
Children in particular have suffered since 1979 (2) and the effects of that childhood poverty are then carried into adulthood.
As a family doctor with over twenty years’ experience working in urban and remote rural communities I have seen first-hand the effects of inequality on the health of the Scottish people.
With this discussion paper I would like to examine why inequality matters and what impact it has in terms of reduced life expectancy and increased problems with health issues such as obesity, cancer, substance misuse, mental illness, heart disease and diabetes.
But I also want to highlight some of the recommendations which could change things for the better.
It is relatively easy to define inequality as a difference in size, degree, circumstances, etc. Health is more difficult to define. The 1948 WHO definition of health describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (3) However, this definition leads to most of us being less than healthy most of the time and as such it has been criticised and calls have been made to reform it. (4)
An attempt to define the link between inequality and health was published in the Lancet in 1971. With this paper Julian Tudor Hart described his ‘inverse care law’ as: “the availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources”. (5) He also suggested that those least in need of healthcare services access them more effectively than those who need the services most.
Produced in 1980, the Black Report was a milestone in recognising the link between income inequality and ill-health. (6) The report identified large differences in levels of morbidity and premature mortality between higher and lower socio-economic classes. It also demonstrated that the gap between rich and poor – income inequality – had widened substantially between 1950 and 1980.
Ten years later a review of the issues raised by Black, published in the British Medical Journal, found that the gap in morbidity and mortality levels between socioeconomic groups was actually widening. (7)
In 2010 the Marmot Review detailed the clear implications of income inequality for health and demonstrated that:
1. Reducing health inequalities is “a matter of fairness and social justice”. Many people are dying prematurely as a consequence of inequality that would otherwise have enjoyed longer, healthier lives.
2. The lower someone’s socio-economic status the worse is their health status.
3. Health inequality is due to social inequality and therefore action is needed across “all the social determinants” of health.
4. It is not enough to simply look at the most disadvantaged. We need to look across the social spectrum but this needs to be more focused on the most disadvantaged – what the review terms ‘proportionate universalism’.
5. If health inequalities are tackled it will benefit society in a number of ways – socially and economically.
The Marmot Review made six key recommendations for action which are, in their own words: “give every child the best start in life; enable all children, young people and adults to maximise their capabilities and have control over their lives; create fair employment; ensure healthy standards of living for all; create and develop healthy and sustainable places and communities; and strengthen the role and impact of ill health prevention”. (8)
This will require a concerted effort from all – central and local government, the NHS, the third sector (voluntary and community organisations), and the private sector. But more than anything in needs the empowerment of local communities and individuals themselves.
In 2009 a collaborative project called the Deep End Project was launched with the support of the Scottish Government Health Department, the Royal College of General Practitioners in Scotland, and Glasgow University. It aimed to bring together the 100 general practices serving the 15% most deprived post codes in Scotland. Over the last five years they have produced numerous reports looking at the impact of deprivation on health from a primary care perspective. (9) In March 2013 they released a report asking ‘What can NHS Scotland do to prevent and reduce health inequalities?’ The report states that: “it is time to move beyond advocacy, and small projects […] to make a real difference to inequalities in health. By recognising the causes and consequences of the inverse care law, NHS Scotland can help to prevent poor health and life chances in young families, improve the health and life expectancy of patients with established conditions and prevent the further widening of health inequalities in adults”. (10)
In Scotland we measure life expectancy (LE) and healthy life expectancy (HLE). Healthy life expectancy refers to the number of years someone might expect to live in a reasonably healthy state.
Both LE and HLE are significantly worse in Scotland than the rest of the UK and many other EU countries. On average Scottish men and women live about 2 to 2.5 years less than their English counterparts. Scottish men live 3.6 years less than Swedish men (who have the highest male LE in the EU). For women, between 1998 and now the gap in LE between Scotland and France (which has the highest female LE in the EU) has widened, whilst the gap between Scotland and Romania (which has the lowest female LE in the EU) has reduced – in other words Romania is catching Scotland up.
Scottish life expectancy has increased since 1998 – but this trend is repeated across the EU and Scotland has done less well than most other EU countries. Between 1998 and now the average LE in Scotland has increased by about 4% for men and 2.5% for women.
At present a ‘least deprived’ male in Scotland will live till 81 but their HLE is 12.5 years less at 68.5. A ‘most deprived’ male will only live to 70 and their HLE will be a whopping 20 years less at 50. A least deprived female can expect to live till 84 with a HLE 13 years less at 71 whilst a most deprived female will live till 70.5 with a HLE 18 years less at 52.5. (11) (12)
1. As has been recommended in England we need greater investment in tackling health inequalities.(13) (14)
2. We need to encourage closer working between the Scottish Government’s Health and Social Care Department, NHS Health Scotland and local NHS Boards to address health inequality issues with a readily recognised and understood national strategy. (15)
OBESITY AND INACTIVITY
The highest levels of obesity are seen in those with the highest levels of poverty. Energy-dense foods (refined carbohydrates, sugars, and hydrogenated fats) often provide the lowest-cost option. This high energy density together with increased consumption associated with the palatability of sugars and fats results in higher energy intakes. Poverty leads to lower food expenditure in general, resulting in low fruit and vegetable consumption because of their relative expense, and poorer-quality diets overall. High sugars, high fat, high energy-dense diets are more affordable than healthier diets based on lean meat, fish, and fresh fruit and vegetables.
According to Public Health England: “socio-economic inequalities have increased since the 1960s and this has led to wider inequalities in both child and adult obesity, with rates increasing most among those from poorer backgrounds. This worsening of health inequalities in relation to obesity is more marked for women. In children, socioeconomic inequalities in obesity are stronger in girls than boys”. (16)
Obesity reduces quality of life and increases the risk of chronic ill-health in the form of hypertension, type 2 diabetes, hyperlipidaemia and cardio-vascular disease and premature death. It places an enormous strain on health services and has major future financial implications, with the cost to the NHS in Scotland estimated to reach PS3 billion by 2030. (17)
Between 1995 and 2012 the proportion of adults aged between 16 and 64 in Scotland who were obese rose from 17.2% to 26.1%, a relative increase of 52%. At the same time the percentage of this age group who were either overweight or obese rose from 52.4% to 61.9%. And by 2012 it was estimated that over 30% of Scottish children were at risk of obesity or overweight. (18)
To its credit, the Scottish Government has recognised that obesity has become a critical issue in Scotland. This resulted in the publication of ‘A Route Map Toward Healthy Weight’ in 2010 which laid out 4 key strategies as follows:
1. Energy consumption – controlling exposure to, demand for and consumption of excessive quantities of high calorific foods and drinks.
2. Energy expenditure – increasing opportunities for and uptake of walking, cycling and other physical activity in our daily lives and minimising sedentary behaviour.
3. Early years – establishing life-long habits and skills for positive health behaviour through early life interventions.
4. Working lives – increasing responsibility of organisations for the health and wellbeing of their employees. (19)
The ‘Route Map’ focuses on the obvious traditional attempts to tackle obesity – improving levels of physical activity and reducing the obesity-causing contents of our diet – sugar, refined carbohydrates, hydrogenated fats.
What has not really been addressed by public health or by Government is the role that income inequality might play in obesity. Where the levels of income inequality are highest (e.g. in Mexico and the US) the relationship is most striking (20). But even where there are lower levels of inequality (e.g. Japan) a relationship between income inequality and levels of obesity exists (21). As the Equality Trust puts it – more adults are obese in more unequal rich countries. (22)
1. The Food Standards Agency’s ‘traffic lights’ system of food packaging should be used on all food packaging. This approach is advocated by the Faculty of Public Health who point out that this system is more effective than the system of guideline daily amount (GDA%) favoured by a number of large retailers. They argue that the traffic light system is likely to reduce dietary and health inequalities across socio-economic groups. (23)
2. Sugar has little nutritional value and may be mildly addictive. For these reasons urgent consideration should be given to taxing sugar – just as we already tax alcohol and tobacco. This will help to reduce consumption and break ‘the cycle of obesity’. (24)
Evidence suggests that those living in the most deprived areas have the lowest levels of physical activity and the highest proportion of the population failing to meet current physical activity recommendations. (25)
Although not conclusive, there is evidence to suggest a link between increased physical activity within the school curriculum in children and attainment at school, and there is no negative impact despite reduced class teaching time. (26)
1. The current Scottish Government commitment is for two hours of physical activity per week in primary schools and two periods per week (i.e. less than two hours) in secondary schools. Consider introducing a compulsory three hours per week of physical education into the school curriculum from P1 to S6. This should be linked to the bigger educational agenda of healthy living. This will require increased resources for equipment, facilities and qualified teaching staff. It will also require clear guidance from Scottish Government as to which areas of the curriculum can have time allocation reduced in order to allow time for increased levels of physical education.
2. Increase the availability, accessibility, and affordability of physical activity facilities and programs in deprived communities.
Cancer is a leading cause of death in Scotland and the evidence shows that cancer rates are highest and survival rates lowest in the most deprived socio-economic communities. An extensive report on cancer and inequality has been produced by Cancer Research UK.
Recommendations (from Cancer Research UK):
1. Work should be undertaken to tackle the inequalities in tobacco consumption which is the main factor driving higher rates of cancer in poorer communities.
2. Information and support should be targeted at those with the worst rates of and poorest survival rates from cancer. (27)
DRUG AND ALCOHOL PROBLEMS
Scotland’s alcohol consumption figure of 11.8 litres of pure alcohol per person per annum ranks us fourth in the world alcohol consumption table, behind France, Austria and Estonia. The consequences of excess alcohol consumption are well-recognised and will not be reiterated here but they are a global issue. (28)
Whilst alcohol consumption rises with socio-economic status, the negative impacts of alcohol are highest in the poorest socio-economic groups. (29)
1. A minimum unit price for alcohol should be introduced. The evidence from elsewhere, most notably Canada, shows quite clearly that such a policy reduces alcohol-related hospital admissions and mortality. (30)
2. Continue to ensure current Scottish Government restrictions on the display and promotion of alcohol in supermarkets are adequately enforced.
There are strong links between drug misuse in Scotland and poverty and income inequality. (31)
Again, the impacts of drug misuse at both an individual and a community level are well-recognised. Scotland has tens of thousands of problem drug users and hundreds of drug-related deaths each year. The estimated cost to the Scottish economy is in excess of PS2 billion per annum. (32)
1. Treat drug misuse as a chronic relapsing-remitting health problem, supporting treatment and recovery and supporting affected families too.
2. Introduce compulsory substance misuse education into the school curriculum as part of a wider programme of prevention work. Such universal education in schools does have an impact on levels of misuse. But resorting to fear tactics is ineffective, as are methods which just focus solely on self-esteem or simply provide didactic information without addressing social and cultural aspects. A holistic, non-judgemental approach is needed. (33)
There is a clear linear relationship between increased levels of deprivation and increased levels of smoking and one in two smokers will die prematurely. Smoking accounts for one fifth of all deaths in the UK, largely as a result of three smoking-related diseases: lung cancer, chronic obstructive pulmonary disease and coronary heart disease. (34)
In March 2006, the Scottish Government introduced a smoking ban in enclosed public spaces. The evidence collected since the ban was introduced has shown a reduction in hospital admissions – for asthma in children and for ‘acute coronary syndrome’ (heart attacks) in adults. (35) (36)
Smoking, however, remains the real ‘elephant in the room’. It largely negates any socio-economic health advantages. Research carried out in West Central Scotland has shown, among both women and men, ‘never smokers’ had much better survival rates than smokers in all social positions. Smoking itself was a greater source of health inequality than social position. Or, to put it bluntly, the wealthiest smokers will still die younger than the poorest ‘never smokers’. (37)
At the time of writing the Scottish Government has launched a consultation looking at e-cigarettes and at strengthening existing smoking legislation by: banning smoking in cars in the presence of children under the age 18 (mirroring what is coming into force in England in October 2015); ensuring smoke-free NHS grounds; and establishing smoke-free children and family areas. (38)
1. Support the Scottish Government’s proposals to tighten existing smoking controls.
2. Enhance the availability of existing smoking cessation services in the community.
ANXIETY AND DEPRESSION
There is a direct link between the degree of income inequality and levels of depression. This is particularly so amongst women. In the USA the incidence of depression is twice as high in those states with the widest degree of income inequality compared to the most equal states (39). Similar patterns have been identified in other developed countries. Those with the poorest socio-economic status have the highest incidences of depression and the highest risk of persisting depression. But higher levels of depression are seen across the social strata in those areas with the widest degrees of income inequality. (40)
Much the same is seen in relation to anxiety which is often linked to depression. In 2013 the GINI (Growing Incomes Inequalities) project published a paper which concluded: “people are, on average, more concerned about their position in social hierarchy in unequal contexts…an increase in inequality is associated with an increase in status concerns. Moreover, we find that status seeking increases among all income groups. Both the poor and the rich feel more anxious about their status in unequal societies”. (41)
Mental health problems have a significant impact in Scotland, affecting more than a fifth of the population at any one time, and Scotland has a higher rate of suicide than England and Wales.
The Deep End Project published a report in April 2014 which found that: “mental health problems, and GP consultations involving mental health problems, are more than twice as prevalent in deprived areas as in affluent areas”. (42)
1. A report by Audit Scotland in 2009 made the following recommendation: “the Scottish Government and local partners should ensure that they work together to deliver services […] which are joined up and that appropriate services are provided on the basis of need” (43). This remains a key aim 5 years down the line.
2. The identification of depression and provision of community mental health services needs to be more focused in those areas with the highest levels of socio-economic deprivation.
Coronary heart disease (CHD) remains a leading cause of death in Scotland (44). Despite dramatic declines in the last twenty years, the incidence of CHD in Scotland is higher than anywhere else in the UK and the CHD premature death rate in Scotland is 37% higher for men and 60% higher for women than in England – a consistent finding since modern records began twenty five years ago (45). The incidence is highest in the lowest socio-economic groups and lowest in the highest socio-economic groups – a difference more marked in women – such that the overall mortality from CHD is more than twice as high in the lowest socio-economic group compared to the highest (46). When the under-65s are looked at in isolation the difference is more than fivefold.
1. The Scottish Intercollegiate Guidelines Network (SIGN), which is widely regarded as the ‘gold standard’ in healthcare guidelines development, currently advises that: “all adults aged over 40 with no history of cardio-vascular disease or diabetes and who are not already receiving treatment for hypertension or abnormal cholesterol should have a cardio-vascular risk assessment carried out every five years”.
2. Those individuals identified as being at ‘high risk’ of cardio-vascular disease should receive intervention in the form of lifestyle advice diet, exercise, smoking, etc., statins and, when appropriate, blood pressure control. (47)
However, this advice from SIGN was produced in 2007 and it is currently under review with revised guidelines due in 2015. Such risk assessment is particularly important in areas of high deprivation.
There is evidence to suggest that income inequality and poverty are associated with higher rates of diabetes and poorer access to care (48)
This may have a particular impact among women (49). In Scotland there are over quarter of a million diabetics and this figure is anticipated to rise to 350,000 by 2030. (50)
It is estimated that as many as 620,000 Scots are at risk of developing diabetes.Diabetes costs the NHS in Scotland over PS1 billion per year – 10% of the total NHS budget – and most of that money is spent managing avoidable complications. (51) (52) (53)
In Scotland those living in the lowest socio-economic 20% have a 77% greater risk of developing diabetes than those in the highest 20%. (54)
The leading diabetes charity, Diabetes UK, produced a comprehensive overview of the Scottish diabetes crisis in 2013 which details a number of key recommendations for trying to turn the rising tide of diabetes in Scotland. Perhaps the single biggest issue that needs to be tackled is obesity. (55)
There is substantial evidence that income inequality leads to an increased disease burden on society as a whole – but this is a burden borne most heavily by our most deprived citizens who also suffer from poorer access to the care and preventative strategies that they need.
Evidence shows that ‘primary care’ is an effective way of tackling these health problems.
Primary care provides a first point of contact with healthcare services. In Scotland this is achieved through universal coverage with family doctors (GPs), community nurses and other community-based health professionals.
This model of universal primary health coverage was first realised in the Highlands and Islands of Scotland in 1913 in the form of the Highlands and Islands Medical Service. This Service was established on the basis of evidence collected by the Dewar Committee in 1912. It was subsequently used as a blueprint for the provision of primary care throughout the UK by the NHS from 1948. (56)
And therein lays the solution. Health inequalities in Scotland have been less marked in the past and can be less marked in the future.
Barbara Starfield was an American paediatrician and a strong advocate for the role of primary care in tackling the health issues brought about by inequality. Writing in 2005 she said: “evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care in contrast to specialty care is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups”. (57)
We need to take on the challenges and invest in primary healthcare for the good of all of us – we cannot afford not to.
I am very grateful to Professor Graham Watt, the Norie Miller Professor of General Practice and Primary Care, School of Medicine, Glasgow University, for his valuable feedback on an earlier draft of this article. I would also like to thank Dr Catherine Maclean, former Lecturer in the School of Social and Political Studies at Edinburgh University for proof-reading and advising on redrafts. Any remaining errors or inaccuracies are entirely my own.
DR STEVE McCABE email: email@example.com 16/12/2014