Associate feature: Direction of travel – tackling health inequalities
Glasgow trainline life expectancy map - Image credit: NHS Health Scotland
It is said that a picture paints a thousand words, and perhaps some of the starkest graphics relating to Scotland’s health are those that show a railway line running through Glasgow comparing the life expectancies of some of the richer and poorer areas of Scotland’s largest city.
Around Jordanhill, in the west, the average life expectancy for men in 2015 was 78.0 years, while for women it was 83.8.
Travel across town to the east end, though, and near Bridgton it was just 63.7 for men and 72.1 for women, a difference in life expectancy of over 14 years for men and nearly 12 for women.
A similar picture is seen travelling just two stops along the Edinburgh tram line. And it is not only in Scotland’s major cities that this picture could be painted.
Pick any two areas of relative wealth and poverty in Scotland and similar differences would be shown.
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Nor is it just life expectancy that is affected by inequality. In the most affluent areas of Scotland men enjoy, on average, 23.8 more years of good health and women experience 22.6 more years of good health compared to the most deprived areas.
Alcohol-related mortality rates in Scotland’s most deprived areas are nearly eight times those in the least deprived areas.
Thirty-four per cent of adults in the most deprived areas smoke, compared to nine per cent in the least deprived areas.
Many struggle to maintain a healthy diet, contributing to their higher incidence of conditions such as obesity, heart disease, type 2 diabetes and certain cancers.
And adults in the most deprived areas are twice as likely to have common mental health problems as those in the least deprived areas, and are at highest risk of suicide.
Why do we see all of this in our poorest areas? Because poverty and inequality damage health and make it more difficult to live a healthy life.
Although Scotland’s health is improving, it is not improving at an equal rate for all and inequality in health persists on a large scale.
These continued health inequalities are what NHS Health Scotland has set out to tackle over the last five years and continues to direct its attention to, with the key focus on the ‘causes of the causes’ rather than simply the individual issues.
Concerns about health inequality have been around for a long time, but the issue gained particular momentum in Scotland around 2010 by people such as then chief medical officer Harry Burns and then public health minister Michael Matheson.
“Here was this additional challenge – folk whose health is poorest and whose health needs to improve fastest isn’t improving.
“This both has an impact on the average, but particularly it leaves a substantial part of our population living much shorter lives and living a much bigger part of their life in poor health,” NHS Health Scotland chief executive Gerry McLaughlin tells Holyrood.
That led to a change in focus from tackling key health issues to delving into the root cause of those issues: inequality.
This informed NHS Health Scotland’s strategy for 2012 to 2017, ‘A Fairer Healthier Scotland’.
McLaughlin says: “If you then read any of the evidence around what is it that really impacts our health, and that creates good health and wellbeing, of course it goes way beyond healthcare.
“It goes right to the circumstances into which we’re born, to how we grow up, the families we grow up in, our education, our employment opportunities, ultimately, most importantly, the level of income we’ve got, the resources we have behind us, and the extent to which we feel able to control and influence our own environments, and I guess that really is about power.”
Progress has been made in a number of health areas, such as smoking, with, for example, fewer young people taking up smoking and a ban on smoking in pubs leading to fewer opportunities to smoke.
We’ve also seen a reduction in children and young people being taken to hospital with asthma attacks due to less exposure to second-hand smoke.
There is a growing acceptance that structural and policy changes like we saw in smoking, can have a bigger impact on equitable health improvement than interventions that focus solely on behaviour.
That’s why we see a move towards minimum unit pricing on alcohol, which NHS Health Scotland contributed evidence towards, and a focus on things like NHS Health Scotland’s Healthy Living Awards, which encourage food outlets to provide healthy options.
NHS Health Scotland wants to avoid an approach that just says ‘do more of this, do less of that’ and that apportions blame for health problems, instead recognising the underlying circumstances that contribute to them.
Their work with planners and local government on the Place Standard Tool, which has been adopted by 70 per cent of councils and downloaded by around 11,000 people, represents this focus.
Recognising the impact that the physical, social and economic environment has on health and wellbeing, the tool supports communities and decision makers to share power and design spaces and places, together.
There is a growing public awareness that this approach, that issues such as housing, transport and particularly income have an effect on health.
McLaughlin says: “What we’ve seen, I think, is that public acceptance of it not being a good state of affairs to have such unequal outcomes has moved much more into the centre of the political narrative.
“I think that particularly around the 2014 referendum, this seemed to come very much to the fore. I think that’s really important, because we know that if we spend all of our time talking about lifestyle and health behaviours, we won’t crack this.”
He continues: “I guess the next part of the challenge is to build up a sufficiently accessible body of public evidence that says that we might need to make some different choices.
“I’m not sure we’ve won that battle yet. I think certainly the political rhetoric has definitely changed and is more sympathetic, but it does sometimes mean making quite tough choices.”
At the end of the five years, a decision was made to continue the focus into their work over the next five years, resulting in the launch of ‘A Fairer Healthier Scotland’ for 2017 to 2022.
The reason for continuing to focus on inequality to improve health was twofold.
“One, because…Scotland’s health record has not improved yet, so if the evidence has remained the same, why would we change that?” explains McLaughlin.
The second was that the Scottish Government has announced plans for a new public health body, to be launched in 2019, which will mean that NHS Health Scotland will no longer exist in its present form.
“We felt it would be one of the opportunities we would have to create a legacy for that new body, to be able to say, ‘so here’s what we’ve set out for the next five years, a blueprint for the future of equitable public health improvement in Scotland’.
“The hope is that efforts on health improvement to date will be continued.”
The five strategic priorities in the framework are: fairer and healthier policy; children, young people and families; a fair and inclusive economy; healthy and sustainable places; and transforming public services, to address the causes of health inequalities and make the right to health a reality for people in Scotland.
McLaughlin says: “There’s a real direction of travel…continuing with less concentration on individual health topics.
“These things are still important, but setting them in that broader context of addressing inequality is crucial.
“That’s why we want the evidence on the need to address inequality to influence action on health, and we hope that this will be central to the new public health body.”
The new public health body will also bring public health closer to local government.
“I call it reconnecting public health with local government,” says McLaughlin.
“And that’s absolutely crucial within the broader endeavour of transforming public services, because if it’s all of those other public services – transport, planning, housing, education – if it’s all of those things that contribute to improving people’s health and wellbeing, then it is important to bring the evidence, and the action, into that sphere.”
Collaboration is at the heart of the model, from midwives and health visitors linking families with income and welfare advice services, to the NHS inputting on the Scottish Government plans for using its new welfare powers, to working with third sector partners to ensure the evidence includes the voice of lived experience.
“Integration, and collaboration, I think, is at the heart of all of this work,” says McLaughlin.
“There’s no one group responsible for Scotland’s public health. There’s a whole series of services – public, private and in the third sector – and individuals – needed to make Scotland healthier, and fairer.
“So us in the public health community reaching out to local government, reaching out to the third sector, who are critical partners, who in many cases are much closer to local communities, is an essential part of growing our collective understanding of the experience of living in communities that are really challenged.
"I believe that if we keep that principle of collaboration at the heart of what we do to influence the change we need, a fairer, healthier Scotland will come.”
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