The case for making health inequalities a top priority

To our national shame the World Health Organisation repeatedly uses this example of health inequalities from Scotland:

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:

1. 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.
2. 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
3. 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 sights: 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:

1. to grasp the thistle of health inequalities – which so burdens us in Scotland.
2. to ensure that measures to address health inequality are a major element of Scottish Labour’s next policy programme
3. and to recognise that this is not a matter for NHS Scotland alone and requires a comprehensive policy response across all government departments.