To our
national shame - the World Health Organisation repeatedly uses this example of
health inequalities from Scotland:
“In Glasgow alone we can still see
differences in life expectancy as extreme as 54 years in the poorest
communities and 82 years in the most affluent, a near 30 year difference”.
Giving
parts of Glasgow – lower life
expectancy for men than the national average in Yemen, India, or North Korea. While other parts of Glasgow – have among the highest life expectancy
across the whole of the UK and
the world. Thus, depending, literally, on which side of the railway tracks you
are born will predict how long a life you will live. But, we know - it is not
about luck. And it is not a Glasgow effect
either. A substantial body of international evidence shows that poor
health is a direct consequence of wider social and economic inequalities.
Inequalities in income. Inequalities in health. Thatcher’s real lasting legacy…
We - in SHA
Scotland - believe that inequality remains the greatest challenge we face.
Health
inequalities need to be at the top of our policy agenda – not a matter for NHS
Scotland alone.
Inequalities
in health can be defined as:
(i) Inequalities
in access and uptake of health services – for example GPs
working in the most deprived communities – also described as
working in the “Deep End” – have less time and capacity than GPs working in
other areas.
(ii) Inequalities in health behaviours -
which themselves are more socially
determined rather than merely lifestyle choices; and despite
our successful ban of smoking in public places – smoking still plays a big part
in health inequalities
(iii) Inequalities
in health and disease outcomes – the big killers and almost any
disease you care to investigate.
These
challenges almost seem too great, too intractable. But to quote George Orwell “Economic injustice will stop the moment we
want it to stop and no sooner, and if we genuinely want it to stop the method
adopted hardly matters”.
So, the
first and most important requirement therefore is to find and harness this will.
There are
four arguments that make the case for tackling health inequalities, which we
believe would carry opinion.
1. Inequalities are unfair – with poor health the
consequence of the unjust distribution of social determinants such as income,
jobs and education
2. Health inequalities affect
everyone across the socioeconomic gradient – this is described as the “spill over” effects
associated with factors such as alcohol, drugs, violence. Just because you are
at the top – does not make you immune.
3. Health inequalities are avoidable – they are created – they can
be tackled - policy options such as tax policy, regulation of business and
labour, and welfare benefits are the key. And in this regard - we welcome the
proposed Labour Party Commission to review devolution of income tax powers.
4. The means to reduce inequalities
are available and affordable and save in the long run. Preventative spending can
work.
These means
would provide outcomes which would benefit all in health, social and economic
terms. But in addition to macro-economic solutions we also believe 3 broad
policy areas are worthy of our attention:
Firstly -
we
need to re-engage with community development work – move
away from silo individual behaviour lifestyle change
interventions that were damned in the recent Audit Scotland report
as having limited success and cost no small fortune. Community Development can
build on the recent enthusiasm for “asset based approaches” – but will need the
targeted financial commitment.
Good examples of Community Development work which aims to develop
local solutions for local issues – include fresh food cooperatives, credit
unions, local energy saving initiatives, environmental enhancing schemes, and
community support workers.
Secondly -
we do need the
democratisation of NHS and reform of local
organisational structures – grasping the Christie Commission
recommendation for local government and health agencies to work together. But
more radically - the creation of common public service authorities should be in
our sites: bringing public health and primary care together within new local
public service authorities.
Finally -
we need to resolve the
thorny issue of targeted vs universal services. It needn’t be either or.
Focusing solely on the most disadvantaged - a purely targeted approach - will
not reduce inequalities sufficiently. To reduce the gradient of inequalities
actions must be universal. But – and here is the caveat – with a scale and
intensity that is proportionate to the level of disadvantage. Proportionate
universalism if you like.
There is no
doubt we will have to make tough decisions – but a government that genuinely
cares about improving the health of the population and reducing health
inequalities ought therefore to incorporate health inequality impact in its
policy setting processes.
The SNP’s
Ministerial Taskforce on Health Inequalities is inadequate and sidelines the
issue.
SNP policy
does not have tackling health inequalities at its heart. Even the Coalition
government in England have
a more explicit health inequalities outcome target.
We call on
the Labour Party Scottish Policy Forum:
to grasp the thistle of health inequalities – which so
burdens us in Scotland.
to ensure that measures to address health inequality are a
major element of Scottish Labour’s next policy programme
and to recognise that this is not a matter for NHS Scotland
alone and requires a comprehensive policy response across all government
departments.
