Righting a wrong

Health inequalities are an intolerable menace that have plagued our country for too long, wasting potential and stealing lives prematurely.

A report published by Audit Scotland late last year on the extent of health inequalities in Scotland noted that men in the most deprived areas die 11 years earlier than those in the most affluent. For women, the gap is 7.5 years. While it also found that people living in Scotland’s more deprived areas have higher rates of heart disease, obesity, diabetes, drug and alcohol misuse, and mental health problems.

And behind each of these statistics is a person.

“I think what is often forgotten is that behind those statistics are thousands upon thousands of unjust, unnecessary, premature deaths, which are people we all know. It is people in our communities. Family members. It is people who die before their time,” laments Dr Gerry McCartney, public health consultant, NHS Health Scotland.

This injustice should fill us all with a sense of horror. But in some areas, it is accepted as an inevitability, he says, before stressing:

“But it is not inevitable.”

There is no denying the severity of the issue we face. As McCartney points out, you would have to travel to parts of the former USSR to find areas of wider inequality than Scotland. However, he adds that inequalities have successfully been narrowed in the past, and could be again. For example, between the 1920s and 1970s – a period which saw the introduction of the NHS and the welfare state - health inequalities in the UK “radically reduced”, he says. This pattern was also observed in the US at this time as inequalities in wealth, income and power declined.

However: “For the last 30 or 40 years we haven’t done that. We’ve done the opposite,” McCartney says.

“We’ve allowed the wealth in the country to be used for the good of a very small proportion of the population.”

McCartney is persuaded the evidence shows that health inequalities are driven by inequalities in income, power and wealth, and believes focused policy across government departments could narrow that gap once more.

“But I think we are unlikely to narrow health inequalities until it becomes a policy focus, the policy focus for Scotland,” he says.

With a plethora of such statistics and evidence before it, earlier this year the Health and Sport Committee announced that it was to hold a major inquiry into health inequalities in Scotland. To inform this work, it organised a scoping event in the Parliament in February, and also held some preliminary evidence sessions where they heard from key figures such as Scotland’s Chief Medical Officer, Sir Harry Burns and the soon-departing Chief Executive of NHSScotland, Derek Feeley, as well as other public health experts.

If they hadn’t been already, the sessions convinced the committee that this is a complex issue with no single, or simple, solution.

“There is no single view about this. There are all sorts of impacts and disadvantages built into society that places people in that position and depending on who you speak to, you will get different views about where the responsibility lies here,” says convener, Duncan McNeil MSP.

However, governments, past and present, must accept some of that responsibility, he observes.

“Successive governments have made decisions that have inadvertently widened the gap. And my personal view is that in terms of the whole debate about universality and others, you capture a moment in time. But unless you are actually doing something to reduce the gap, you just hold the gap.

“So you’ve had interventions like health messaging and public health messages and campaigns that you and I will listen to but not necessarily the people we need to get to. So as a consequence of that the gap doesn’t narrow at all.”

The scoping exercise was intended to shape the committee’s view and prepare the way for a longer inquiry on health inequalities. However, McNeil admits: “I think the challenge has been too much for us.”

The more the committee heard, the more it realised this is an issue far wider than health alone, and so McNeil says they have decided against holding a major inquiry, and will instead focus on a number of short issue inquiries on related topics such as child poverty, access to health services, early years, and e-Health.

He explains: “After all of that difficult process, we are not going to run a major long-running inquiry into health inequalities because we’ve done this in the Parliament before where we have a big long inquiry with no significant outcomes. But what we are going to do is, we are going to be looking at inequalities as we do our work in general. And we will continue to engage with communities and people where those elements are present and continue to challenge that as a committee.”

McNeil insists that this is not a “cop-out” by the committee, or an acknowledgement that this is too difficult an issue to tackle. Instead, he calls it “a bit of a turning point where we are challenging the Parliament to take this more seriously in all of the subject committees,” while adding that they will also continue to scrutinise the Government’s progress. A report on its preliminary work will be published after the summer recess, and he says they also intend to hold a parliamentary debate to present their findings and challenge other subject committees to take a closer look at this issue also.

“Health strategies and priorities can be set to affect this. But we are saying that health alone can’t fix this and there is a wider responsibility. And that is our challenge to the other subject committees and to governments past and future that we can do a lot about this. We can improve people’s lives and make a difference. But we’ve got to be serious about it right across the board.”

For its part, Public Health Minister Michael Matheson insists the Scottish Government remains committed to reducing the health gap between Scotland’s richest and poorest, which he says is why it reconvened the Ministerial Taskforce on Health Inequalities and continues to press the UK Government for fairer welfare reform and to ensure that safeguards are in place for those who need them.

He explains: “The Equally Well framework sets out the Scottish Government’s strategy for reducing health inequalities, and this has already shifted the emphasis of our approach from dealing with the consequences of health inequalities to tackling the underlying causes such as poverty, employment, support for families and improving physical and social environments.”

It has also made “fundamental” shifts to focus on preventative spending, he says, and adds that the Early Years Framework, Getting it Right for Every Child approach, and Modern Apprenticeships are also making a real difference to future health and life chances.

He continues: “In all areas of our work, this Government is undertaking a range of activities to address the underlying causes behind health inequalities, such as preventing fuel poverty, protecting household incomes and preserving universal entitlements, which include free personal care for the elderly, abolition of tuition fees and increasing the provision of free nursery education.”

Among the issues it has been looking at, Matheson says the taskforce, which is expected to report in the autumn, has been examining the work of ‘Good Places Better Health’, the role of the public sector reform agenda – particularly the community planning partnerships, and the Equally Well test sites.

“The success of the test sites demonstrated the importance of working with the community and the need to test ideas and partnerships,” says Matheson.

“It was always the intention that the Equally Well test sites would be embedded into mainstream services and we are currently working with the community planning partnerships on how they will deliver these services.”

The Government has also asked the community planning partnerships to increase their focus on tackling health inequalities, he says.

“We issued guidance at the end of 2012 that identified six priority areas: economic recovery and growth, employment, early years, safer and stronger communities and reducing offending, health inequalities and physical activity, and outcomes for older people.

“However, it is only with full control of the levers of the economy, employment and welfare that we can make a real difference to the inequalities in our society.”

With this in mind, Matheson says the Scottish Government continues to have “serious concerns” about the negative impact of the Westminster Government’s welfare reform programme on individuals.

“The concerns are based on real examples, one of which is an admission from the Department for Work and Pensions that 15,000 children in Scotland will be pushed into relative income poverty by 2016, as a result of the changes.

“We have made clear our concerns on the negative impact on those who will lose out in the face of the UK Government’s welfare reform programme. We are working with partners in local government, health and the third sector to mitigate the worst impacts of the reforms on people and organisations in Scotland. Work is also being taken forward by the Scottish Public Health Observatory to establish a means of monitoring the effects on public health of welfare reform and austerity. This shows that Scotland needs control of its own welfare benefits system,” he says, adding his belief that it is only in an independent Scotland that we can “truly devise policies for the benefit of Scotland’s people.”

However, while he supports the taskforce’s ambition of preventing future inequality, Dr Graham Watt, Professor of General Practice, University of Glasgow and a member of the Deep End GPs steering group, argues that there is also a need for a greater focus on reducing inequalities that have already arisen.

The Deep End group consists of experienced general practitioners from the 100 practices serving the most socio-economically deprived populations in Scotland and so they are all too aware of the scale of the challenge faced. While Deep End GPs are not alone in dealing with the consequences of inequality, Watt points out that just one sixth of patients account for half of the in more deprived areas. And yet he says this demand is not met by resource, and many Deep End practices lack the time, links to other services, and NHS support and leadership roles needed to maximise what NHS Scotland could do to prevent and reduce inequalities in health.

To avoid widening inequalities further, he argues that the NHS must be at its best where it is needed most.

“The whole point about the Deep End is that resources are not provided pro-rata. So the health service at its Deep End is poorly equipped to reduce the effects of inequality. That means that people die earlier, get admitted to hospital as emergencies sooner than they need to be – these are large effects.

“And the whole point of the Deep End is that if the NHS were at its best where it is needed most, we could be complementing the strategies to prevent inequalities with strong policies to reduce the inequality that exists.”

A sense of “moral injustice” should drive Government and Parliament to act to address health inequalities, McCartney argues. However, this is also a debate in which all of us should participate. At present, much of political discourse has been dominated by speculation about Scotland’s constitutional future. However, McCartney agrees that this also presents a window of opportunity for a parallel debate with the public about the kind of country we want to be.

“I think, although the political debate should be cognisant of the health inequalities that we’ve got but, you’re right, there is a particular opportunity for people to put forward what kind of Scotland they want. And that stands for both sides.

“Those who advocate independence have a duty to outline what kind of Scotland might be possible with independence. But those who are advocating staying within the Union, or for further devolution, have also got a duty to say, ‘Well, OK, if we are staying in the Union, or if we are having further powers in the Scottish Parliament, what would we use them to do? What is our vision for that new arrangement and how would that deliver reduced inequality in Scotland in the future?’ “So [it is] less about where the powers lie and more about what the powers are going to be used for.” McCartney supports the Health Committee’s decision to focus on shorter inquiries, rather than on major pieces of work, and hopes it will inspire further debate and galvanise action.

“I think that is entirely appropriate. And what’s more, I think the Parliament and the country as a whole has to decide what sort of country they want to be.

“Some people might argue that health inequalities are a price worth paying for having a dynamic economy or focusing on economic growth as a prime mover in Scotland. I think that as a public health doctor, my prime concern is for the health of the population and I can’t stand back when I’m seeing people die prematurely, I can’t see them die unnecessarily and I can’t not fight the injustice that that represents.

“So I will do everything I can to inform the public debate on health inequalities and, ultimately, it is about what values as a country we adopt and what priorities we place on health inequalities.”