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4. Increasing health inequalities

4. Health inequalities are increasing

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Differences in income, gender, race and faith, disability, sexual orientation and social class are all associated with inequalities in health. The interactions between and among them are also powerful determinants of health. Socio-economic status, however, is central to inequality.  Life expectancy is a useful indicator for highlighting inequalities in health outcome.  We know, for example that the number of years a newborn child might expect to live varies significantly across the NHS board area by sex and geography.

Figures 4.1 and 4.2 show trends in life expectancy for males and females from 1991-93 to 2004-06 for the six councils which lie wholly within NHS Greater Glasgow and Clyde and for Scotland.

Figure 4.1

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Figure 4.2

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There is no doubt that, overall, people in NHS Greater Glasgow and Clyde are living longer.  However, as Figures 4.1 and 4.2 illustrate, wide variations exist between council areas: East Renfrewshire and East Dunbartonshire residents have a longer life expectancy than Scotland as a whole, but the other council areas in NHS Greater Glasgow and Clyde still lag well behind.

Other examples of life expectancy clearly illustrate this polarity:

  • There is a nine-year gap in male life expectancy between East Dunbartonshire CHP (77.7 years) and North Glasgow CHCP (68.6 years) (16).
  • Female life expectancy is higher than male life expectancy by six years across the NHS Greater Glasgow and Clyde area as a whole, but also varies by around 5.5 years across the CH(C)Ps;
  • The gap in life expectancy between the most affluent and deprived population communities has widened significantly in the last 20 years, particularly among males (17).
  • Estimates of healthy life expectancy - years of life without a limiting long-term illness - show that across the West of Scotland there is a 12 year gap in male healthy life expectancy between Glasgow City Council (46.7 years) and East Renfrewshire (58.5 years). There is an equally pronounced gap for women (18).

Patterns and trends in mortality are measured by standardised mortality ratios (SMRs) which mean that variations in ratios are not explained by differences in the age or sex profile of the population. 

As shown in Figure 4.3, the NHS Greater Glasgow and Clyde area has a mortality rate that is almost a quarter higher than would be expected based on the Scottish rate. Across CH(C)Ps, this variation ranges from 65% above the Scottish rate in East Glasgow to approximately 27% below in East Dunbartonshire.  The three CH(C)Ps with the highest standardised mortality ratios also have the highest concentrations of most deprived data zones in their areas (60% of the population in East Glasgow lives in the 15% most deprived data zones in Scotland, 63% in North Glasgow;  and 49% in the South West Glasgow - see Chapter 2 Figure 2.3).

Figure 4.3

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Recent research has highlighted a rise in death rates in younger age groups, especially among men, between 1981 and 2001 (19).  The main drivers behind this rise are deaths due to chronic liver disease, suicide, assault and drug and alcohol related deaths and the main concentration of these “self-destructive” deaths is in the West of Scotland, particularly in Glasgow City.

At the heart of many of these differences in health outcome are issues of socio-economic deprivation and inequality.  Recent reports provide a snapshot of poverty, nationally and locally:

  • It is estimated that there are 240,000 children in Scotland who are part of households living in poverty (20);
  • In 2001, more than 100,000 children in the West of Scotland were living in households where neither parent was in employment;
  • Recent analysis by NHS Health Scotland (21) show that from 1980 to the latest analysis point, 2000, the West of Scotland (22) had the highest levels of ‘core poverty’ and ‘breadline poverty’ among UK regions (23);
  • Between 1980 and 2000 the proportion of the West of Scotland population estimated to be ‘breadline poor’ rose from 24.5% to 36%.21 (22).

Living on a low income affects different sectors of the population in different ways.  For children, it means that their diet and health suffers, they are more likely to die in an accident, they have higher rates of long-standing illness and have poorer attainment and school attendance records. As adults, they are more likely to have poor health, be unemployed or be homeless. They are also more likely to become involved in offending drug and alcohol use.

Inequalities in health-related behaviours are often associated with socio-economic differences, although gender, age, race and faith can also be important.  The following two examples, breastfeeding and children’s dental health, illustrate inequalities in health behaviours. 

Breast feeding is known to give health benefits to both mother and child.  There have been modest rises in breastfeeding numbers in recent years though only just over a third of children are still being breastfeed at six weeks of life.  There are still large variations in breastfeeding rates across Greater Glasgow and Clyde ranging from 20% in West Dunbartonshire to 47.5% in East Renfrewshire (Figure 4.4).

Figure 4.4

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The dental health of children is slowly improving. However, throughout the NHS Greater Glasgow and Clyde area, between 40% and 70% of children aged five have decayed teeth. Dental caries is the most frequently recorded cause of admission to acute hospitals in the area for children aged 0 to 15. Children from the 15% most deprived parts of the area had 67% more admissions than expected, based on all NHS Greater Glasgow and Clyde area rates. Children from the other areas had 33% less admissions than expected.

Socio-economic inequalities form part of the picture, but there are other forms of inequalities that have a differential and compounding effect on health.  These inequalities affect people throughout their lives. The following examples include the effect of gender, sexual orientation, race and faith and having learning disabilities.  The links between gender and health are becoming more widely recognised. An example of this can be illustrated by looking at mental illness.  Although there do not appear to be sex differences in the overall prevalence of mental and behavioural disorders, there are significant differences in the pattern and symptoms of the disorders.  These differences vary across age groups. In childhood, a higher prevalence of conduct disorders is noted for boys than in girls.  During adolescence, girls have a much higher prevalence of depression and eating disorders and engage more in suicidal thoughts and suicide attempts than boys.  Boys experience more problems with anger, engage in high risk behaviours and commit suicide more frequently than girls.  In adulthood, the prevalence of depression and anxiety is much higher in women, while substance use disorders and antisocial behaviours are higher in men.  In the case of severe mental disorders such as schizophrenia and bipolar depression, men typically have an earlier onset of schizophrenia while women are more likely to exhibit serious forms of bipolar depression.  In older age groups, the incidence rates for Alzheimer’s disease is reported to be the same for women and men, however, women’s longer life expectancy means that there are more women than men living with the condition.

Gender-based violence is recognised as a significant public health problem.  Its physical and mental health consequences are profound.  In addition, childhood physical, emotional and sexual abuse, domestic abuse and sexual violence contribute to physical and mental ill health of children, adolescents and adults, affecting a significant proportion of the population throughout their lives.

Where lesbian, gay, bisexual and transgender people are concerned, there is an added dimension of discrimination which can make the difference between good and bad health.  Problems associated with homophobia in early life such as bullying and low self-esteem can continue into adulthood and have serious long-term negative effects on health.  This has been evidenced in that attempted suicide rates amongst gay men are higher than in the heterosexual population and anxiety, depression, self-harm and attempted suicide have been linked with experiences of prejudice and discrimination. A needs assessment of young lesbian, gay and bisexual people in Glasgow recorded that 80% of them had experienced discrimination. Those surveyed had up to three times as many suicidal thoughts as the general population. 

Differences in health are also experienced by different ethnic groups due to a complex mix of factors including genetic and behavioural. For example, people of Pakistani and Indian origin living in Scotland have an increased incidence of 60% to 70% of having a heart attack – but a large part of the inequity is due to social determinants of health, such as poverty, poor education, lack of employment opportunities as well as poor access to health care. The experience of racism is a significant factor in the health of black and ethnic minority communities, and the consequences are similar to those faced by people abused on the basis of their sexual orientation. There are two major barriers to NHS Greater Glasgow and Clyde improving the health of people in the black and ethnic minority communities. One is the lack of routine capture of data by ethnic grouping for use in the planning or design of services; the other is the low level of staff awareness of how to provide appropriate services to diverse communities. 

An area of particular concern for NHS Greater Glasgow and Clyde is meeting the health needs of asylum seekers. Because asylum populations change frequently, it can be difficult for NHS Greater Glasgow and Clyde to identify and address their health needs. This will continue to be a challenge as the new asylum model is implemented and the turnover of asylum seekers increases. It is difficult to acquire robust health information or immigration status, and good ethnic recording is fundamental to the analysis of unmet need. The health induction process is central to ensuring needs are met.  Since many asylum seekers come from countries where they have experienced rape and torture, or seen rape, torture or death, there is a high incidence of mental health issues. Qualitative research indicates that asylum seekers experience racism regularly, which can have an impact on their mental and physical health.

People with learning disabilities also experience significant health inequalities and there is evidence that they also experience institutional discrimination.  They have a significantly lower life expectancy and higher standardised mortality ratio compared to people without learning disabilities. The most common causes of death also differ for people with learning disabilities compared to the general population and the health needs of people with learning disabilities are often complex with co-morbid physical and mental health issues. Studies have shown that people with learning disabilities experience inequalities due to their greater levels of health needs when compared with the general population, and also experience significant barriers to these needs being met by services (24,25,26).

Research in Glasgow has provided more evidence that adults with learning disabilities have increased needs, that there is a high level of unmet health need, and that health monitoring and health promotion needs are poorly addressed.    For example, an adult with learning disabilities is 10 times more likely to have an episode of psychosis and almost twice as likely to have a common mental disorder, though less likely to have health problems associated with alcohol misuse and smoking (27,28).  Problems with accessing services are illustrated by the finding that only 13.5% of the 400 women with learning disabilities who took part in the health check programme in 2002 in Glasgow had an up-to-date cervical smear, compared with all women in the Greater Glasgow area who had 74% uptake 2001 (29).  These differences in the patterns of mortality and morbidity, and increased health needs, show the need for specific public health measures to reduce the inequalities experienced by people with learning disabilities.

How NHS Greater Glasgow and Clyde and its partners are responding

In recognition of the growing need to address the inequalities issues mentioned, a significant reorganisation has been carried out in NHS Greater Glasgow and Clyde. This was done in response to both national and local initiatives designed to maximise existing resources and to provide a coherent structure for meeting more effectively the health needs of our population. In addition, we have co-ordinated the NHS contribution to improving employability, as part of a wider programme to address the causes and consequences of poverty, carried out in conjunction with community planning partners. As part of this drive to address inequalities, NHS Greater Glasgow and Clyde have also put in place the following:

Corporate Inequalities Team

This team is leading the organisation to maximize its potential for addressing the causes and health consequences of inequality and discrimination.  The work of the team also includes managing the legal requirements in relation to inequalities.

Equality and Diversity Team

This team is within the Organisational Development department and helps the organisation to integrate equality and diversity awareness into the planning and delivery of services. The team also helps departments in all parts of the organisation to develop links with diverse communities (30).

Public Health Resource Unit and Public Health Networks

These help the organisation to build the capacity of the public health work force (31).

Performance Management Systems

NHS Greater Glasgow and Clyde has developed effective performance management systems to support its pursuit of its objectives, including the reduction of health inequalities. Many of the organisation’s targets and key measures specifically concern reducing inequalities and we are working to make these more effective in all parts of the organisation.

Glasgow Centre for Population Health (32)

This research and development centre focuses on reducing health inequalities and improving health and quality of life. The centre has four aims:

  • to build a deeper understanding of Glasgow’s health and its determinants;
  • to evaluate the health impacts of local strategies, and to generate evidence to strengthen the processes of health improvement;
  • to invest in engagement and participation, by providing a focus for independent thinking, analysis and debate about population health and inequalities; and
  • to develop greater capacity to deliver innovation and change.

Along with the above NHS Greater Glasgow and Clyde have introduced other new ways of working and the following are a few of the many new initiatives:

Inequalities Sensitive Practice Initiatives (ISPI)

This Scottish Government funded initiative supports the organisation and its partners in the delivery of integrated services to identify actions that will improve the effectiveness and efficiency of frontline practice.

Community Planning

NHS Greater Glasgow and Clyde has contributed to Community Planning Partnerships across all council areas as well as pathfinder initiatives in Glasgow to develop actions on the social determinants of health along with other partners such as local authorities, local economic development companies, police, housing, voluntary sector, private sector and others.

Homelessness Partnership

The Glasgow Homelessness Partnership recognises the significant health and social consequences of homelessness, and is developing gender sensitive responses that meet the differential needs of men and women and that also take account of the impact of other social inequalities such as race, disability and age.

Infant Feeding Strategy

NHS Greater Glasgow and Clyde is launching an infant feeding strategy that is designed to improve health and reduce inequalities through supporting improved nutrition for all children aged from 0 to 2 years. An area-wide Infant Feeding Co-ordinator has been appointed to provide its partners with the expertise to implement the strategy. The strategy is based on the principles of the Baby Friendly Initiative. All maternity units in NHS Greater Glasgow and Clyde are accredited ‘Baby Friendly’ and CH(C)Ps will be urged both to implement the strategy and attain community accreditation. The University of Paisley is the first university in the world to receive a Baby Friendly Award (33).

Financial Inclusion

CH(C)Ps across NHS Greater Glasgow and Clyde are contributing to reducing poverty through a variety of interventions. An example of such work is in West Dunbartonshire CHP where an evidence- based model of money advice has been established with general practice and the Local Council’s Welfare Rights Unit.

Keep Well

This programme, described in the previous chapter, is another example of how the organisation is designing projects to overcome inequalities in health care access. The first phase operated in North Glasgow CHCP and East Glasgow CHCP areas, and phase two is being introduced in South West Glasgow CHCP, Inverclyde CHP and West Dunbartonshire CHP areas, again targeted at the most deprived communities. The evaluation of the initiative will show whether these more intensive ways of engaging with people in deprived communities is effective.

Unmet need project

The Have a Heart Paisley project offered health checks to all 45 to 60 year old people in Paisley, but there was a lower uptake of the offer in the more deprived communities. A new community development approach to reach those who did not respond in the Ferguslie Park area is currently underway.

Key public health messages and priorities for action

As factors that cause inequalities in health are multiple and complex, a joint partnership approach to reduce health inequalities is essential.  Examples of this approach are:

  • Local and national economic strategies, employment plans, taxation, benefits and education policies must be influenced in order to, attain a more equitable distribution of wealth in our population, to reduce poverty and its effects, and to enhance equality of opportunity. Success in these areas will help reduce the inequalities gap.
  • Because health service provision can, paradoxically, increase health inequalities - since those with most need are least likely to take up services, especially preventative services, offered - specific targeting of health resources is required to reach those with unmet need.
  • A focus on addressing social determinants of health with our community planning partnerships must be maintained to reduce worklessness, improve educational attainment and enhance the local environment.
  • There must be a programme of health impact assessment of all strategies and plans that can influence health and inequalities.

Good trend and profiling information and evidence of effective interventions to address and monitor health inequalities and determinants of health must be made available at national, NHS Greater Glasgow and Clyde and CH(C)P level to inform service planning and allow targeted resource allocation.  Examples of this approach are:

  • The lessons learned from evaluations of new programmes such as Have a Heart Paisley and Keep Well must be incorporated into local practice
  • Capacity must be built in order to facilitate all staff to understand the complexities of inequalities in health and how they may help in reducing these inequalities.

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