Tackle inequality not just disease

A new study by NHS Health Scotland has examined 30 years of health trends in Scotland and found large differences in preventable causes of death across social groups. In simple terms the gap between rich and poor is leading to thousands of unnecessary deaths in Scotland.

Increasing inequality in morbidity and mortality from the poorest and to the wealthiest, is described as 'a gross injustice'. The report positively highlights periods of decreasing inequality in the UK and elsewhere, showing that this trend is not inevitable and further action can make a difference.

International research (Phelan and Link) indicates that approaches which focus on reducing immediately visible causes (such as tobacco and alcohol) and targeting professional support to those living in deprived areas, will ultimately fail to eliminate health inequalities. This research hypothesises that socioeconomic inequality is a fundamental cause of health inequality.

The report describes trends in absolute and relative inequalities for 47 to 50 causes of death for men and women across Carstairs deprivation deciles between 1983 and 1999 and men aged 20‐64 years across occupational social classes between 1976 and 1999 to determine whether new socioeconomic inequalities in mortality emerged for certain causes of death whilst declining for others in Scotland during this time. In addition, they tested Phelan and Link’s theory by comparing socioeconomic gradients for avoidable and non‐avoidable mortality and assessing whether inequalities in mortality increase with increasing preventability of cause of death.

They found that absolute and relative socioeconomic gradients for specific causes of mortality decreased whilst others emerged. There was a clear socioeconomic gradient for avoidable causes of mortality, but not for non‐avoidable causes of death. Where causes of death became more preventable, it is clear that relative inequalities in mortality increased.

The results have important policy implications for any efforts to reduce health inequalities in Scotland. Evidence that all‐cause socioeconomic inequalities in mortality persist despite reductions for some specific causes, and that inequalities are greater with increasing preventability, suggests that focussing on reducing individual risk and increasing individual assets will ultimately be fruitless in reducing inequalities and may even increase them. Elimination and prevention of inequalities in all‐cause mortality will only be achieved if the underlying differences in income, wealth and power across society are reduced.

This report is further and detailed evidence to support the view, advanced by SHA and others, that behavioural change programmes have limited impact. Seriously tackling health inequalities requires a comprehensive and cross cutting policy response that is not limited to the NHS.