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Scottish Health Inequalities in context Dr Laurence Gruer OBE.

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Presentation on theme: "Scottish Health Inequalities in context Dr Laurence Gruer OBE."— Presentation transcript:

1 Scottish Health Inequalities in context Dr Laurence Gruer OBE

2 Why am I here? An overview of health inequalities 14 years experience of developing, managing and evaluating innovative services for the most disadvantaged –Drug injectors, prostitutes, problem drinkers, homeless, people with HIV, people with psychosis

3 Who do I need to thank? Harry Burns Peter Donnelly David Gordon Carole Hart ISD Scotland Andrew Tannahill Graham Watt

4 The menu The changing challenge of health inequalities in Scotland Where can we make the biggest difference? Designing services to work

5 Life expectancy at birth by CHP, 2003-2005 (95% ci)

6 Male life expectancy for 10 lowest and highest postcode sectors (1998-2002)

7 Complex relationships Life circumstances Good health Ill-health Behaviours

8 Scotland’s pattern of affluence/deprivation is changing smaller numbers of most deprived evolving nature of deprivation

9 1981

10 1991

11 2001



14 Health protection and improvement resources now available to vast majority in Scotland Clean water Clean air Good sanitation Safe and nutritious food Warm, weatherproof homes Free education and lifelong learning opportunities Free health care Social services and benefit system Public transport Unlimited information Safer working conditions

15 Health inequalities in Scotland today Underlying factors Pregnancy and parenting Cultural norms Intellectual, emotional and physical limitations Educational attainment Difficulty in understanding, engaging and succeeding in a society that rewards talent, skills, beauty, energy Failure, drug misuse, mental health problems

16 Cardiovascular disease mortality and deprivation in Scotland

17 The role of smoking in health inequality in Scotland

18 The Renfrew and Paisley Study 7049 men and 8353 women living in Renfrew and Paisley Aged 45-64 when recruited in 1972-76 About 80% of that age group Detailed questionnaire and clinical exam All deaths recorded since then

19 Comparing survival rates Each person assigned to a group according to sex (2), smoking status at recruitment (3) and social class (4) 24 mutually exclusive groups Survival curves for 28 years of follow-up

20 Survival of most and least affluent women

21 Survival of most and least affluent men

22 Renfrew and Paisley 28 year survival ranking of never-smokers and smokers Top 8 F I&II65% F IIIN57% F IV&V56% F IIIM53% M I &II53% M IIIN47% F IIIN 42% F I & II41% Bottom 8 M IIIM 38% M IV & V 36% F IV & V 35% F IIIM33% M I & II 24% M IIIN 24% M IIIM 19% M IV & V 18%

23 Interpretation Among both women and men, the least affluent never-smokers have much better survival than smokers in all social classes Health inequalities due to smoking are greater than all other factors in this population Survival rates of non-smoking women in lowest social class among the best Even if the socio-economic circumstances of less affluent smokers improve, their health gain is likely to be minimal if they continue to smoke

24 Implications for policy and practice To improve health overall, help all smokers to stop To reduce health inequalities every effort must be made to enable less affluent people to stop smoking/ never to start

25 Other growing contributors to health inequalities in Scotland Problems in the early years Obesity Alcohol

26 Smoking Age of mother at birth Lone parent Breast-feeding

27 Body mass index and relative risk for type 2 diabetes among American nurses (Colditz et al 1995).

28 Obesity and overweight by SIMD quintile in men, Scottish Health Survey 2003

29 Obesity and overweight by SIMD quintile in women, Scottish Health Survey 2003

30 Reported weekly alcohol consumption by SIMD quintile among men, Scottish Health Survey 2003

31 Reported weekly alcohol consumption by SIMD quintile among women, Scottish Health Survey 2003

32 Death rates due to alcohol in Scotland by deprivation

33 Inequalities of service provision and outcome Cancer Cardiovascular disease Primary care

34 Colorectal cancer incidence, 5 year survival and mortality by SIMD quintile, Scotland: patients diagnosed 1991-95 Source ISD Scotland

35 Adjusted operations rate ratios for CABG by SIMD decile, Scotland 2006-07 Source ISD Scotland

36 Self-assessed health, mortality rates and provision of GPs by SIMD decile, Scotland Source Prof G Watt

37 The challenge How to tackle the major preventable health problems in ways that will not widen existing health inequalities

38 Dearth of evidence on how to do it Better at describing the inequalities than showing how they can be reduced Evidence on effectiveness in general populations, but little about applicability or adaptation to disadvantaged groups Lack of inequalities-related analysis of inerventions

39 Tackling inequalities through health service provision Investing more in primary care in disadvantaged areas Logical but imaginative new service design Maximise the use of effective interventions –Smoking cessation –Statins & antihypertensives –Brief interventions for problem drinking –Weight management –Immunisation –Breast feeding

40 New service design Start small but think big Design the services to fit the patient – Right place, right time, right staff Design for reproduction across the service Design for the long term Evaluate and aim for continuous improvement

41 Keep Well Pilots – Linking Activities & Outcomes Reduced premature CVD mortality in deprived areas Reduced health inequalities Identify population Invite / contact Engage Reach Uptake GP Practice & local service impacts LOCAL SERVICE DELIVERY (GP practices with most deprived population) OUTCOMES ACTIVITIES Identify barriers to service access Re-design services and resource deployment Improved access Assess for disease and risk Provide effective interventions Secondary prevention High risk primary prev CVD risk factor modificat n Maintain, monitor & follow-up Compliance

42 The future Huge potential for preventive/anticipatory care Can we find the models and resources to make the most of it? Do we have the expertise to prove it?

43 Conclusions The dynamics of health inequalities in Scotland are changing Culture, capabilities, hard to change behaviours Parenting and early development are widening future inequalities Health services must adapt and innovate to meet complex needs


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