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06 CHAPTER SIX TACKLING HEALTH INEQUALITIES

The challenge of health inequalities in Scotland

01 In Chapter 3 we saw that, while Scotland's health is improving, it is improving more slowly than any other Western European country and as a result Scotland is losing ground. It is likely that most of the improvement in life expectancy in Scotland is being enjoyed by people living in more affluent areas and those living in poorer areas are being left behind. For example, as we show below, the gap in life expectancy between the most affluent and deprived areas in Scotland seems to have been widening in recent years.

02 For many Scots this relatively low life expectancy is associated with serious health problems which limit their capacity to lead effective lives. Again there is a gap between rich and poor with, for example, 21% of women in deprived areas reporting a limiting long-standing illness compared to 8% of women in affluent areas.

03 In this chapter we set out proposals which will address the issue of health inequalities by carefully targeting those individuals who, largely because of their deprived circumstances, have been missing out on what modern health care has to offer.

04 Inequalities in health among socio-economic groups are a problem facing all developed countries (van Doorslaer et al., 1997), but are a particular issue in the UK. Scotland has particularly high levels of health inequality, despite having lower levels of income inequality than England as a whole (Gravelle and Sutton, 2003). It is the poor-health consequences of poverty that set Scotland apart.

05 The level of health inequality in Scotland shows up across a wide range of indicators of health-related behaviour, health and mortality. For example, in 2002, 37% of mothers in the most deprived fifth of Scotland's postcode sectors smoked during pregnancy, compared with 14% in the most affluent fifth. The all-cause mortality rate per 100,000 women aged under 75 in deprived areas in 2001 was 452, compared with 245 in affluent areas (Scottish Executive Health Department, 2003).

06 In 2002, life expectancy at birth for men living in deprived areas was 69.5 years, compared with 78.4 years in affluent areas. The life expectancy for women was 77.3 years, and 82.3 years in the affluent areas. These gaps in life expectancy between rich and poor are widening (Figure 6.1), and the gap between best and worst areas of Scotland is now substantial.

Figure 6.1 Change in Male Life Expectancy, 1991-2001 Best and Worst Constituencies

(Source: GRO(S), NHS Health Scotland) Best and worst constituencies

07 A traditional view was that health care can have only a relatively limited impact on population health compared with lifestyle factors and the social environment (McKeown, 1976). More recent thinking holds that better health care - and in particular strong primary and community health systems - can have a significant effect on health (Bunker, 1995; Macinko, Starfield and Shi, 2003; Shi, Starfield, Politzer and Regan, 2002). The effects may be strongest for deprived groups (Shi and Starfield, 2001), suggesting that redesign of health services in the community could play an important role in reducing health inequalities.

08 A range of sources suggest that deprived groups in Scotland often suffer under the inverse care law, which states that most health care is provided to those who need it least. Deprived groups may also receive inappropriate services characterised by relatively high rates of emergency care and low rates of scheduled care. A recent review of the structure of general practice found that practices serving deprived areas had poorer structural and organisational conditions than other practices. They tended to be smaller and were more likely to be staffed by less experienced GPs. They were also less likely to participate in voluntary schemes that promote quality care and open access to additional resources, such as Personal Medical Service pilots and training and accreditation by the Royal College (Mackay and Sutton, 2003).

Tackling inequalities in health

09 The NHS invests heavily in a variety of activities aimed at improving health. Behaviour change campaigns that focus on smoking, diet and exercise are highly visible and usually have some effect. The fact is, however, that the individuals best able to respond to invitations to change their lifestyles tend to be more affluent and, as MacIntyre (2003) has pointed out, such programmes may actually widen health inequalities if not adequately thought through and targeted.

10 The health service has had an explicit presence in tackling adverse life circumstances in recent years through involvement in community planning processes and engagement with a wide range of agencies providing social, educational, employment and housing support to deprived communities. But again, MacIntyre has warned that many of the projects emerging from multi-agency working have not been properly evaluated and may fail to have the desired effect in narrowing health inequalities.

11 Social and environmental change will eventually lead to significant reductions in health inequalities. In the process, great strides will be made in persuading individuals to adopt healthy lifestyles. But it may take many years for such benefits to become apparent.

12 We know that healthcare interventions available to the population are effective, and we also have strong evidence that people living in deprived areas have less access to those interventions. The quickest way to make an impact on health inequalities is therefore to enhance access to care for the most deprived sectors of the population.

13 It is proposed that NHS Scotland should tackle health inequalities by focusing its resource more closely on the early detection and management of problems in deprived communities.

14 Early intervention can contribute to better outcomes for many serious illnesses, but patients in deprived areas may be less willing to seek advice for their condition early, meaning they present to clinicians with more advanced disease which is harder to cure.

15 A study carried out in the West of Scotland (Stirling et al., 2001) found the average GP consultation length was around 1-2 minutes longer for patients from an affluent background than for patients from deprived areas. Analysis of Scottish hospital admission records shows that patients from the most deprived areas are more likely than patients from the most affluent to present for medical care with several significant conditions. Patients from deprived areas therefore face a 'double whammy' of having more health problems and less time available to have them addressed.

16 We suggest, therefore, that the most appropriate place for the NHS to begin to narrow the gap between rich and poor is through the systematic adoption of the principles of anticipatory care and preventive medicine. Resources should be selectively targeted to deprived areas to ensure that patients have enhanced opportunities to be seen and have their problems dealt with at an early stage.

Enhancing primary care

17NHS Scotland should embark on a programme of enhancing primary care capacity to allow it to meet the needs of the most deprived members of our society. It should do this by expanding the numbers of professionals available to see patients, ensuring they have adequate time to discuss their problems and obtain treatment.

18NHS Scotland also needs to invest in services to identify patients at risk, actively recruit them into intervention programmes and follow them up to ensure the process is effective. The essential platform for an early-detection and prevention programme is a system that provides good community-based data. Scotland has the basis of such a system as we move towards the full implementation of the Community Health Index into NHS computer systems.

19 We should pursue the creation of an Electronic Health Record ( EHR) for everyone living in Scotland as a matter of urgency. Using the EHR will improve our ability to identify all those individuals who need to have blood pressure, cholesterol, body mass index and other prognostic factors for chronic ill health more closely monitored.

20 The suggested approach offers opportunities for positive health promotion initiatives. An individual with an elevated blood pressure, for instance, might be offered smoking cessation advice or advice on alcohol consumption. With sufficient resource invested in primary care, the patient could be directed into smoking cessation programmes or other appropriate health promoting programmes. At present, opportunities to offer patients services such as this are highly dependent on local conditions.

21 Much of our thinking on current models of health centre on the need to strengthen the capacity of individuals to take control of their own wellbeing. The problem that exists among people living in deprived communities is that their self-esteem and confidence may have been eroded through years of unemployment, poor education opportunities, poverty and bad housing. It should be possible through the development of Community Health Partnerships ( CHPs) to expand health and local authority services in a way that offers a holistic approach to individuals who need to build confidence and the ability to control their own lives.

22 It is unlikely that a primary care system focused on prevention of ill health can be adequately staffed by the creation of more GP principals. It may be that salaried GPs could be recruited in deprived areas, but it is much more likely that appropriate capacity will be developed through extending the role of nurses, allied health professionals and other staff.

23 Inevitably, this approach sees additional resource being targeted at general practices in deprived areas. GPs whose practice contains predominantly affluent patients may still have individuals in their practice living in poverty. They may feel that their patients are being discriminated against. The resource should be made available across a Community Health Partnership to be targeted at individuals who need it. The management of such resource should be left to the CHP to determine.

24 We need to recognise that patients in deprived areas have been under-served by existing systems. The approach set out here is aimed at redressing the inequity that has existed since the NHS was first set up.

Recommendations

At policy level

25 The Scottish Executive should commit to targeting new investment to allow people from deprived communities to have enhanced access to a range of health interventions. In the first instance, this might be through targeting new resources to tackle the problem of unmet need within GP practices with high numbers of patients from deprived areas.

At national level in the NHS

26 Protocols which outline the action to be taken to tackle problems such as undiagnosed or untreated high cholesterol and other risk factors for heart disease should be developed as a matter of urgency. Many evidence-based and widely-accepted protocols already exist. Action should be taken with CHPs to agree a standard protocol-driven approach for GPs across Scotland.

27 Protocols for the identification of individuals at risk of having cancer should be developed. Local health economies should consider ways in which investigation of patients with cancer can be taken forward in the light of existing waiting time guarantees which will come into operation at the end of 2005.

28 The Managed Public Health Network should consider what other conditions within deprived communities need to be identified as being suitable for a preventive approach. They might include chronic obstructive lung disease, osteoporosis, alcohol-related problems and significant mental illness. Directors of Public Health should commission work to develop protocols to allow case finding, early detection and appropriate treatment.

29 Health promotion managers should consider appropriate interventions for individuals to encourage smoking cessation and control of substance abuse. Programmes for obesity management should be developed.

NHS Boards and Community Health Partnerships

30NHS Boards should ensure that appropriate administrative and management support is available to assist GPs to identify patients from deprived areas and those identified as having significant health problems.

31NHS Boards and CHPs should develop information systems to allow monitoring of individuals and collection of health-needs data, treatment offered and follow-up data to allow evaluation of health improvement impacts.

32NHS Boards and CHPs should organise appropriate financial support for individual practitioners to allow systems to function effectively and to permit an eventual calculation of the cost effectiveness of the programme.

33NHS Boards and CHPs should develop workforce plans to ensure an appropriate skill mix of professionals is available to support GPs in the delivery of this targeted programme of care.

Underpinning the process with better information

34 The creation of an Electronic Health Record linked to an effective decision-support system is essential in identifying appropriate individuals and recommending the right course of treatment. The programme can, however, be piloted in selected areas without a completely electronic information system.

References

Bunker J (1995) Medicine matters after all: measuring the benefits of medical care, a healthy lifestyle, and a just social environment. Nuffield Trust Series 15.

Gravelle H, Sutton M (2003) Income-related inequalities in self-assessed health in Britain: 1979-1995. Journal of Epidemiology and Community Health 57:125-129.

Macinko J, Starfield B, Shi L. (2003) The contributions of primary care systems to health outcomes within Organization for Economic Cooperation and Development ( OECD) countries, 1970-1998. Health Services Research. 38: 831-865.

MacIntyre S (2003) Evidence based policy making. BMJ, 326: 5-6

Mackay D, Sutton M (2003) The Partiality of Primary Care Intelligence and Structure. Platform Project Technical Report. University of Glasgow, 2003. http://www.gla.ac.uk/projects/platform/Partiality.pdf

McKeown T (1976) The role of Medicine: dream, mirage or nemesis? London: Nuffield Principal Hospital Trust.

Scottish Executive Health Department (2003) Inequalities in Health: Report of the Measuring Inequalities in Health Working Group. Edinburgh: SEHD. http://www.scotland.gov.uk/library5/health/hirnov03.pdf

Seshamani M (2004) The Impact of Ageing on Health Care Expenditures: impending crisis or misguided concern? London: Office of Health Economics.

Shi L, Starfield B, Politzer R, Regan J (2002) Primary care, self-rated health, and reductions in social disparities in health. Health Services Research 37: 529-550.

Shi L, Starfield B. (2001) The effect of primary care physician supply and income inequality on mortality among blacks and whites in US metropolitan areas. American Journal of Public Health 91: 1246-1250.

Stirling AM, Wilson P, McConnachie A (2001) Deprivation, psychological distress, and consultation length in general practice. British Journal of General Practice 51: 467, 456-460.

Van Doorslaer E et al. (1997) Income-related inequalities in health: some international comparisons. Journal of Health Economics 16: 93-112.

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