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Chapter Six: Health
Social Focus on Deprived Areas
Health
There are clear links between ill health or mortality and deprivation. The analyses in this chapter make use of some of the indicators identified by the Health Working Group for monitoring progress in tackling health inequalities, and also the indicators included in the health domain of the Scottish Index of Multiple Deprivation ( SIMD) 2004 as well as other established indicators. The analyses included in this chapter are not broken down by sex, although general trends between sexes are reported using information from the Inequalities in Health Report of the Measuring Inequalities in Health Working Group.
The analyses show the distribution of health indicators across SIMD 2004 deciles; previous analysis of health inequality has been based on the Carstairs index. The transition from the use of the Carstairs index (based on larger postcode sector areas) to the SIMD (based on smaller more homogeneous areas) results in a wider inequality gap for most health indicators - because SIMD is a better discriminator.
The Scottish Executive's Closing the Opportunity Gap programme is focusing on reducing the inequalities in premature death caused by coronary heart disease and cancer.
Key points
- Life expectancy in the 10% most deprived areas is 70 years, compared with 81 years in the 10% least deprived areas, and 76 years in Scotland.
- Some 30 per cent of people in the 10% most deprived areas have a limiting long term illness, compared to 12 per cent in the 10% least deprived areas - since 1991 there have been considerable relative increases across all age groups and areas.
- Mortality rates for those aged under 75 in the 10% most deprived areas are 845 per 100,000 of the population compared to 265 per 100,000 in the 10% least deprived areas. This means that the mortality rates for those aged under 75 in the 10% most deprived areas are three times as high as those in the 10% least deprived areas.
- An estimated 43 per cent of people in the 15% most deprived areas smoke, compared to 28 per cent across Scotland as a whole. The Scottish Household Survey shows that since 1999 there has been a reduction in smoking across all areas of Scotland.
- In the 10% most deprived areas, there were 460 admissions to hospital for drug abuse conditions per 100,000 population (on average per year) between 1999 and 2001, compared with 20 per 100,000 in the 10% least deprived areas.
- Emergency admission rates for young people aged 16 to 24, people aged 25 to pensionable age, and pensioners are all considerably higher in the 10% most deprived areas compared to the rest of Scotland.
- Some 11 per cent of all delayed discharges from hospital were patients from the 10% most deprived areas, and seven per cent of all delayed discharges were patients from the 10% least deprived areas.
- An estimated 17 per cent of people living in the 15% most deprived areas visit a GP 10 or more times in the last year compared with 10 per cent of people in the rest of Scotland.
- In 2003, 19 per cent of those in the 15% most deprived areas required help or care, compared with nine per cent in the rest of Scotland.
Deprivation within health board areas
There are 15 Health Boards in Scotland ranging in population from 19,245 in Orkney to 868,087 in Greater Glasgow. Greater Glasgow Health Board area has by far the greatest concentrations of multiple deprivation with over one third of the data zones in the Greater Glasgow Health Board area in the 10% most deprived areas nationally (all things being equal, it would be expected that 10 per cent of Greater Glasgow's data zones should be in the 10% most deprived areas) (See Table 6.1). Orkney, Shetland and Western Isles do not contain any data zones in the most deprived decile, but this does not mean that there are no deprived people or households living in these areas because the SIMD is designed to identify concentrations of deprivation not individual deprivation.
The SIMD 2004 includes current income and employment deprivation domains which can be used as a proxy for individual deprivation. These proxies show that Greater Glasgow again has the highest levels of individual deprivation, with around one in five people in Greater Glasgow considered deprived.
Table 6.1: Deprivation within Health Board Areas
Numbers, percentages | Health Board Population, 2001 census | Percentage of data zones in most deprived decile of SIMD 2004 | Percentage of working age population on key employment benefits, 2002 | Percentage of adults and children households receiving key income benefits and credits, 2002 |
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Argyll & Clyde | 420,132 | 11.7 | 15.7 | 15.9 |
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Ayrshire & Arran | 368,149 | 7.7 | 15.9 | 16.9 |
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Borders | 106,764 | 0.8 | 8.9 | 9.8 |
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Dumfries & Galloway | 147,765 | 1.6 | 11.8 | 12.5 |
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Fife | 347,685 | 2.7 | 13.1 | 13.1 |
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Forth Valley | 280,130 | 4.3 | 13.6 | 13.2 |
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Grampian | 526,473 | 1.3 | 8.0 | 9.2 |
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Greater Glasgow | 868,087 | 33.5 | 19.6 | 22.5 |
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Highland | 208,914 | 2.4 | 11.1 | 12.2 |
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Lanarkshire | 551,591 | 9.3 | 17.1 | 16.9 |
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Lothian | 778,367 | 4.6 | 10.4 | 12.0 |
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Orkney | 19,245 | 0.0 | 8.2 | 8.0 |
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Shetland | 21,988 | 0.0 | 6.6 | 6.8 |
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Tayside | 390,219 | 7.2 | 12.4 | 13.9 |
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Western Isles | 26,502 | 0.0 | 12.9 | 15.2 |
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Scotland | 5,062,011 | 10.0 | 13.8 | 15.0 |
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Source: Scottish Neighbourhood Statistics
Life expectancy at birth
Life expectancy is recognised as one of the key indicators which shows the impact of health inequality. In its simplest terms, life expectancy is calculated by applying the death rates for each five year age group to the population at birth until the whole population has died. Although not shown in Chart 6.2, female life expectancy is greater than male life expectancy across all area types.
There is a clear association between deprived areas and life expectancy at birth. In the whole of Scotland, for men and women combined, the life expectancy at birth is 76 years, compared to 70 years in the 10% most deprived areas and 81 years in the 10% least deprived areas.
Chart 6.2: Life expectancy at birth, 2000-2002Age
Source: ISD Scotland
Limiting long-term illness and general health
In Scotland as a whole in 2001, census data show that 20 per cent of people had a limiting long-term illness ( LLTI) and 10% of people said that their general health was not good. The Census form asks people to note any 'long-term illness, health problem or disability that limits your daily activities and the work you can do; include problems which are due to old age'. LLTI covers many different types of illness or impairment type including heart, blood pressure or circulation problems; chest or breathing problems; problems or disabilities related to legs or feet, neck or back; and mental health problems. In the 10% most deprived areas, however, 30 per cent of people had a limiting long-term illness, compared with some 12 per cent in the 10% least deprived areas. Looking at people whose self assessed general health is declared as 'not good' in the 2001 census, 18 per cent of people living in the 10% most deprived areas rated their health as 'not good', compared to five per cent in the 10% least deprived areas (Chart 6.3).
Pensioners (females 60 years and over, males 65 years and over) in all areas across Scotland are much more likely than other age groups to have an LLTI, while children and young people are the least likely. Working age people and pensioners living in the 10% most deprived areas are much more likely to have an LLTI than those in the 10% least deprived areas. In 2001, more than four times as many working age people in the 10% most deprived areas (33 per cent) had an LLTI than those in the 10% least deprived areas (eight per cent), while 65 per cent of pensioners in the 10% most deprived areas, and 40 per cent in the 10% least deprived areas had an LLTI (Chart 6.4).
The proportion of the population with a limiting long-term illness in all areas has increased by around 50 per cent between 1991 and 2001 (Chart 6.5). The absolute increase has been greatest among those of pensionable age, where the proportion of the age group having an LLTI has increased from 47 per cent in 1991 to 65 per cent in the 10% most deprived areas and, from 31 per cent to 40 per cent in the 10% least deprived areas. However, the relative increases, albeit from a lower base, have been greatest in children and young people. The proportion of children with an LLTI increasing by between 80 and 120 per cent across all areas. The proportion of young people with an LLTI has increased by between 60 and 100 per cent across all areas.
Chart 6.3: Limiting Long-Term Illness and General Health, 2001
Percentage
Source: General Register Office for Scotland (2001 census)
Chart 6.4: Limiting Long-Term Illness by lifestage, 2001Percentage
Source: General Register Office for Scotland (2001 census)
Chart 6.5: Limiting Long-Term Illness, 1991 and 2001Percentage
Source: General Register Office for Scotland (1991 and 2001 census)
Premature mortality
The life expectancy in the 10% least deprived areas is higher than in the 10% most deprived areas and deaths in the under-75 age group account for 55 per cent of all deaths in the 10% most deprived areas, compared to 34 per cent of all deaths in the 10% least deprived areas. The average annual number of deaths for those aged between 20 and 49 account for 10 per cent of all deaths in the 10% most deprived areas, compared to four per cent of all deaths in the 10% least deprived areas (Chart 6.6).
Chart 6.6: Deaths per five year age group as a percentage of all deaths, 2000-2002Percentage
Source: ISD Scotland
Inequalities in Health shows that over recent years, there have been significant improvements in mortality rates for those aged under 75 across the whole of Scotland. The reasons for the significant improvements are due to improvements in treatment and also to the healthier lifestyles, in particular the long term decline in smoking rates. However, the improvements have been greater in the least deprived areas and this has resulted in increased inequality between the most and least deprived areas for both men and women. Mortality rates for those aged under 75 in the 10% most deprived areas are 845 per 100,000 of the population compared to 265 per 100,000 in the 10% least deprived areas (Chart 6.7). This means that the mortality rates for those aged under 75 in the 10% most deprived areas are three times as high as those in the 10% least deprived areas.
Although not shown here, male premature mortality rates are consistently higher than female rates across all areas.
Chart 6.7: Premature mortality (under 75 years), by cause, 2001Rate per 100,000 population
Source: ISD Scotland
The two main causes of premature mortality across Scotland are cancer (153 per 100,000 population) and coronary heart disease (85 per 100,000 population). In the 10% most deprived areas these two main causes account for 59 per cent of all premature deaths, and this compares to 47 per cent in the 10% least deprived areas. Other significant causes of premature mortality in the most deprived areas are Chronic Liver Disease and Cirrhosis and Suicides/Self Inflicted Injury.
Smoking
Smoking is a significant cause of premature death and ill health in Scotland, claiming 13,000 lives each year, around one in four deaths overall. According to the Scottish Household Survey ( SHS) over a quarter (28 per cent) of people in Scotland were smokers in 2003 (Chart 6.8). In the 15% most deprived areas, however, considerably more of the survey respondents (43 per cent) said that they smoked. Within the 15% most deprived areas, working age people are much more likely to smoke. Almost half of the working age population in the most deprived 15% of areas smoked, compared with 30 per cent of pensioners and 40 per cent of young people (Chart 6.8). The SHS also shows that there has been a reduction in the percentage of respondents that smoke across all areas of Scotland since 1999.
Chart 6.8: Percentage of SHS respondents who smoke, 2003Percentage
Source: Scottish Household Survey
Smoking during pregnancy
Smoking during pregnancy has been linked to a range of potential health issues for children in later life. Inequalities in Health show that in recent years there has been a reduction in the proportion of mothers smoking during pregnancy in deprived areas. However, there is still a clear association between deprived areas and the proportion of mothers smoking during pregnancy. Just under one in four of all mothers in Scotland smoke during pregnancy and this proportion increases substantially in the 10% most deprived areas to 42 per cent.
Chart 6.9: Percentage of women smoking during pregnancy*, 2003Percentage
Source: ISD Scotland
*Percentage smoking at their first antenatal booking, usually within the first 3 months of pregnancy
Low birth weight
There has been little change in the proportions of low birth weight babies over recent years. There is a clear association between deprived areas and low birth weight. Low birth weight affects about one in every 40 babies in Scotland compared to about one in 26 babies born in the 10% most deprived areas. Low birth weight babies may face health problems at birth and in later life. It is not clear why some babies are born with low weight, but a mother's medical conditions and lifestyle are factors.
Chart 6.10: Low birth weight babies*, 2002Number of live births
Source: ISD Scotland
*Low weight live singleton births (under 2500g)
Breastfeeding
In Scotland, some 36 per cent of all babies are breast feeding in the six to eight weeks following the birth. This compares with some 20 per cent of babies living in the 10% most deprived areas. The average breastfeeding rate in Scotland recorded at the six to eight week review has risen by 1.3 percentage points between 1999 and 2004 (35.9 per cent in 2004 compared with 34.6 per cent in 1999).
Teenage pregnancies aged 13 to 15
Teenage pregnancy can have a detrimental effect on choices and opportunities available to young mothers. Over recent years the rate of teenage pregnancies in girls aged 13 to 15 has been relatively static. In Scotland, between 2001 and 2003, one in 135 teenage girls aged 13 to 15 conceive, this raises to one in 77 girls living in the 15% most deprived areas.
Drugs misuse and alcohol related admissions
There are clear associations between the rates of hospital admissions for drug abuse and alcohol related conditions and deprived areas, with markedly higher rates in the 10% most deprived areas. Between 1999 and 2002, there were 173,310 alcohol and drug related admissions for Scotland, of which 40,207 (23.3 per cent) were in the 10% most deprived areas.
Alcohol related admissions include all admissions to acute and psychiatric hospitals in Scotland with a main or secondary diagnosis of alcohol related conditions. It is possible, therefore, that an episode could be an alcohol related injury, e.g. main diagnosis of a broken leg and have an alcohol related secondary diagnosis. There were some 1,940 alcohol related admissions per 100,000 population on average per year between 1999 and 2002 in the 10% most deprived areas, compared to 207 admissions per 100,000 in the 10% least deprived areas.
For drug misuse, there were some 460 admissions per 100,000 population in the 10% most deprived areas on average per year between 1999 and 2002, compared with 20 admissions per 100,000 in the 10% least deprived areas.
It is important to note that these statistics relate to individual occurrences, not people, and it is possible that the same person can be admitted more than once. On average a person admitted for drugs misuse and alcohol related conditions will be admitted between 1.5 and two times in the four year period. The majority of patients will only have one admission, but some may have over ten.
Chart 6.11: Drugs misuse and alcohol related hospital admissions*, 1999-2002Rate
Source: ISD Scotland
*Annual admission rate to acute and psychiatric hospitals in Scotland with a main or secondary diagnosis of drugs/alcohol misuse
Emergency admissions
There is an association between emergency admission rates and area deprivation. Emergency admission rates for young people aged 16 to 24, people aged 25 to pensionable age, and pensioners are considerably higher in the 10% most deprived areas compared to the rest of Scotland.
Chart 6.12: Emergency Admission Rates by age, 2000-2002Rate
Source: ISD Scotland
Note: Pensionable age defined as 60+ for women and 65+ for men
Delayed discharge
As at April 2005, there were 1,430 patients ready for discharge from hospital in Scotland but, for some reason, were unable to be discharged. Not all patients could be assigned to a data zone, but for those that could there appears to be an association between area deprivation and delayed discharge - some 11 per cent of all delayed discharges were patients from the 10% most deprived areas, and seven per cent of all delayed discharges were patients from the 10% least deprived areas (Table 6.13).
Table 6.13: NHS Patients ready for discharge, 2005
Numbers, percentages | Total 1 | Percentage |
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Decile 1 - Most deprived | 164 | 11 |
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Decile 2 | 176 | 12 |
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Decile 3 | 177 | 12 |
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Decile 4 | 162 | 11 |
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Decile 5 | 137 | 10 |
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Decile 6 | 135 | 9 |
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Decile 7 | 120 | 8 |
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Decile 8 | 131 | 9 |
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Decile 9 | 91 | 6 |
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Decile 10 - Least deprived | 102 | 7 |
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Scotland | 1,430 | |
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No match 2 | 22 | 2 |
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No fixed abode/Postcode not known | 13 | 1 |
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Source: ISD Scotland
Notes:
1. Total number of patients ready for discharge, in all specialties, reported as at April 2005 census.
2. The cases which did not match to a deprivation decile involved 10 postcodes. From the April 2005 census principal reason codes 24DX, 24EX and 42X (awaiting place or bed availability where no appropriate facilities exist) have been taken out of the census numbers and reported on separately in Appendix 5 of the Patients ready for discharge publication. The 16 cases that are affected by this change have been excluded in this analysis. From the April 2005 census principal reason code 33 (change in patients health circumstances) has been taken out of the census numbers and reported on separately in Appendix 5 of the Patients ready for discharge publication. The 4 cases that are affected by this change have been excluded in this analysis.
Reasons for admissions to hospital
In 2003, there were 1,192,198 diagnosed admissions to hospital as emergencies, non-emergencies, inpatient and day cases. Of these diagnoses, 13 per cent were among people living in the 10% most deprived areas, while seven per cent were among people from the 10% least deprived areas. This equates to admission rates of 297 and 166 per 1,000 people in the 10% most and 10% least deprived areas, respectively (236 per 1,000 in Scotland as a whole).
Chart 6.14: Hospital admissions: number of diagnoses made, 2003Rate per 1,000 population
Source: ISD Scotland
A selected sub-set of the ten most common groups of diagnoses are shown in Table 6.15 as a rate per 1,000 population in each SIMD decile. The most common diagnoses made on patients admitted to hospital in 2003 were for diseases of the digestive system.
People from the 10% most deprived areas had considerably higher rates of diagnoses than those from the 10% least deprived areas for injury or poisoning and other external causes (32 per 1,000 population in the 10% most deprived areas and 14 per 1,000 in the 10% least deprived areas), diseases of the digestive system (42 per 1,000 population in the 10% most deprived areas and 20 per 1,000 in the 10% least deprived areas); diseases of the respiratory system (26 per 1,000 population in the 10% most deprived areas and nine per 1,000 in the 10% least deprived areas) and symptoms, signs & abnormal clinical & laboratory findings (43 per 1,000 population in the 10% most deprived areas and 17 per 1,000 in the 10% least deprived areas). The distribution is also similar for heart disease diagnoses, for which the 10% most deprived areas has a rate of 21 per 1,000 population compared with 12 per 1,000 in the 10% least deprived areas.
Table 6.15: Ten most common diagnoses: hospital inpatient and daycase discharges, 2003Numbers: rate per 1,000 decile populationDiagnosis group | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | Scotland |
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Disease of the digestive system | 42 | 39 | 36 | 34 | 32 | 31 | 29 | 26 | 24 | 20 | 31 |
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Malignant neoplasms | 28 | 31 | 31 | 30 | 31 | 30 | 29 | 26 | 27 | 28 | 29 |
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Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified | 43 | 37 | 35 | 31 | 29 | 26 | 23 | 22 | 20 | 17 | 28 |
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Injury, poisoning and certain other consequences of external causes | 32 | 27 | 26 | 23 | 21 | 20 | 19 | 17 | 14 | 14 | 21 |
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Heart disease | 21 | 22 | 21 | 20 | 19 | 18 | 17 | 15 | 14 | 12 | 18 |
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Diseases of the respiratory system | 26 | 23 | 21 | 18 | 17 | 16 | 14 | 13 | 11 | 9 | 17 |
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Factors influencing health status and contact with health services | 11 | 13 | 13 | 13 | 12 | 12 | 12 | 11 | 10 | 9 | 12 |
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Diseases of the musculoskeletal system and connective tissue | 12 | 13 | 12 | 13 | 13 | 12 | 12 | 11 | 10 | 9 | 12 |
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Diseases of urinary system | 10 | 9 | 8 | 8 | 8 | 7 | 7 | 6 | 6 | 5 | 7 |
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Other diseases of the circulatory system | 7 | 7 | 7 | 6 | 7 | 6 | 6 | 5 | 5 | 5 | 6 |
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Source: ISD Scotland
Note: Numbers refer to acute (non psychiatric, non obstetric) inpatient and daycase discharges.
GP visits
People living in the 15% most deprived areas are much more likely to visit a GP repeatedly (Chart 6.16). In 2001, 17 per cent of people in the 15% most deprived areas had visited a GP more than ten times in the previous year, compared with ten per cent of people living in the rest of Scotland. The number of people visiting their GP more than ten times was consistently higher in the most deprived 15% of areas in each of the Scottish Household Surveys between 1999 and 2001. Those from the rest of Scotland were more likely to visit their GP five times or less.
Chart 6.16: Number of occasions in which a GP was seen in the last year, 2001Percentage
Source: Scottish Household Survey
Note: This question was removed from the SHS in 2002.
Anxiety, depression or psychosis drugs prescribing
In 2002, the estimated percentage of patients being prescribed drugs for anxiety, depression or psychosis varies by level of deprivation, with slightly higher rates in the most deprived areas. In the most deprived 15% of areas, an estimated 9.5 per cent of the population were prescribed these drugs over 2002, compared to the rate for Scotland of 7.5 per cent.
Care
The Scottish Household Survey ( SHS) asks whether people need regular help or care because they are sick, disabled or elderly. It cannot be assumed that all people saying they needed regular help or care are actually receiving it. Between 1999 and 2003, there was little change in the number of SHS respondents aged over 16 that require help or care. Around twice as many people from the 15% most deprived areas said that they or a member of their household required help or care than those in the rest of Scotland over all of the years. In 2003, 19 per cent of those in the 15% most deprived areas required help or care, compared with nine per cent in the rest of Scotland (Chart 6.17). This may reflect the higher number of people in the most deprived areas with a limiting long-term illness.
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