Socioeconomic inequalities in healthWhat are they, what causes them and what can we do about them?

Dr Sonya Scott, Consultant in Public Health Medicine

Of all inequalities, injustice in health is the most shocking and inhumane

Martin Luther King

Question 1: What are health inequalities?

Health inequalities can be defined as the:

1 Graham H. The challenge of health inequalities, In: Graham H. Understanding health inequalities. Maidenhead: Open University Press, 2009.

systematic differences in the health of people occupying

unequal positions in society

Key Point:Health inequalities are not just about the gap between the least and most deprived.

The importance of the gradientNearly all of us are affected

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Women - 2001Men - 2001

Carstairs deciles Scotland (1=least deprived)

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Question 2:What causes health inequalities?

Four explanations considered: 1.Artefact (i.e. doesn’t really exist just flawed

measurement)2.Social Slide (i.e. poor health results precedes

lower socioeconomic status)3.Behaviours and culture (i.e. poor people

behave badly)4.Materialist

4. Materialist explanation• Whilst unhealthy behaviours are more prevalent in lower

socio-economic groups, the patterning of health behaviours is explained by socio-economic circumstances

• Differences in income, resources and power between groups cause health inequalities

• Those with most resources and power are always the healthiest, regardless of their behaviours1

• The health of communities has improved when they have been given more resources by chance2

1 Commission on Social Determinants of Health. 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization. 2Costello EJ, Compton SN, Keeler G, Angoid A. Relationships between poverty and psychopathology. JAMA 2003; 290: 2023-9. 3 Barr HL, Britton J, Smyth AR, Fogarty AW. Association between socioeconomic status, sex, and age at death from cystic fibrosis in England and Wales (1959 to 2008): cross sectional study. BMJ 2011; 343: d4662.

FundamentalUnequal distribution of resource and power.

Intermediate•Education•Labour and housing markets•Taxation•Legislation•Health and social care systems

Immediate - e.g.•Damp housing•Hazardous work•Adverse life events•Personal strengths and vulnerabilities•Behaviours (e. g. smoking, diet, exercise)

Question 3:What can we do about them?

Key Point :

They aren’t inevitable.

Health inequalities are not inevitableInequality in mortality between best and worst 10% of local authorities in Great Britain (sources: Thomas 2010 and Luxembourg Income Study)

Key Point :Action which improves health doesn’t necessarily reduce inequalities.

Whilst health is improving on average…

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Males Ayrshire & Arran Females Ayrshire & Arran Males Scotland Females Scotland

Source: http://www.gro-scotland.gov.uk/statistics/theme/life-expectancy/scottish-areas/archive/index.html

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Health inequalities are not improving(source: NHS Health Scotland)

Reduced Inequalities

Efficient services

Better Health

Key Point :Action on immediate causes alone is unlikely to achieve sustainable reduction in inequalities.

The Problem of Substitution (source: McCartney G. 2013)

FundamentalUnequal distribution of resource and power.

Intermediate•Education•Labour and housing markets•Taxation•Legislation•Health and social care systems

Immediate - e.g.•Damp housing•Hazardous work•Adverse life events•Personal strengths and vulnerabilities•Behaviours (e. g. smoking, diet,

exercise)

Prevent & Undo as well as Mitigate

Key Point :Action needs to be wider than that of health and social care services.

FundamentalUnequal distribution of resource and power.

Intermediate•Education•Labour and housing markets•Taxation•Legislation•Health and social care systems

Immediate - e.g.•Damp housing•Hazardous work•Adverse life events•Personal strengths and vulnerabilities•Behaviours (e. g. smoking, diet, exercise)

Key Point :Upstream, regulatory and proportionate actions are most likely to reduce inequalities.

3 Axes of Action

Progressive taxation/Basic Income Guarantee

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Requires individual action Regulatory

Financial Inclusion /Participatory Budgeting

Alcohol/ fast food outlet licensing

Health related behaviour change

Lifestyle D

rift

Third Axes for Action

Targeted Universal

Proportionate Universalism

Key Point :There are a number of actions which can be taken at a local level.

Actions as employers

• Participative Management and Co-determination

• Recruitment • Terms and Conditions• Training• Making easy choice health choices

Actions as service providers

• Proportionate universalism• Inequalities impact assessments• Inequalities sensitive practice• Welfare rights/income maximisation • Empower communities – e.g. participatory

budgeting• Community benefit clauses

Actions as a partners

• Inform, advocate, monitor• Living wage• Place standard• Reducing fuel poverty• Inequalities impact assessments• Alcohol licensing• Reducing price barriers

Summary

• Avoid lifestyle drift • Make healthy choices easy choices• Proportionate Universalism not inverse care• Action as employers, service providers and

partners