SES Health inequalities “Downstream causes” –Specific exposures (e.g. damp housing, hazardous work or neighbourhood settings) –Behaviours (e.g. smoking, diet, exercise, alcohol) –Personal strengths or vulnerabilities (e.g. coping styles, resilience, ability to plan for the future). “Upstream causes” –Pathways that put members of different SES groups at lower or higher risk of such exposures and vulnerabilities (e.g. the education, taxation, and health care systems, the labour and housing markets, planning regulations, crime and policing etc).

Education, Employment, Income

Measures of SES and deprivation Socioeconomic status (SES) –Education –Occupation –Household income Poverty and deprivation –Area-based measurements

Occupation Social Class IProfessional occupations IIManagerial and intermediate occupations IIISkilled occupations NM: non-manual M: manual IVPartly skilled occupations V Unskilled occupations Examples of occupations Doctor, accountant Teacher, manager Secretary, sales rep Bus driver, electrician Security guard, assembly worker Office cleaner, labourer

Smoking prevalence UK men 1948 to 1999 by social class Source: Lawlor et al. 2003, Am J Public Health 2003;93:266-70

Routine and manual work Lower earnings Less stable earnings Poorer working conditions Greater risk of – recurrent and long-term – unemployment Decline in traditional manufacturing jobs Growth in part-time service sector jobs

Unemployed/Unfit to work Welfare reforms will take nearly £19bn out of economy –£4.3bn from incapacity benefits –£3.6bn from changes to tax credits –£3.4bn from 1% up-rating of most working-age benefits Poorest areas hit hardest Approx £620 per working age adult per year in Glasgow Beatty and Fothergill, 2013

Image: The Independent Online

Unclaimed benefits? Process marginalises individuals who depend upon highly stigmatised social support Difficulty engaging with complex and stressful system of applications, assessment and appeals for often vulnerable, marginalised patients (e.g. people with physical and mental health problems, addictions and learning difficulties) There are contracts with money advice services in all areas of GGC so that direct NHS referrals can be made See Royal College of Psychiatrists Resources, 2015

Poverty – a definition “Individuals, families, and groups in the population can be said to be in poverty when they lack resources to obtain the types of diet, participate in the activities, and have the living conditions and amenities which are customary, or at least widely encouraged or approved, in the societies in which they belong.” Prof P Townsend “Poverty in the UK” (1979)

Poverty – another definition… “I think that poverty is a form of violence. When you live in a world where some people are very poor and other people are very rich, it’s only possible to sustain that situation if the rich are cutting themselves off from seeing and feeling what it is like for the other half. And that cutting off, that deficit of empathy, would be one of my definitions of both violence and poverty.” Alastair MacIntosh Poverty Truth Commissioner

Deprivation Area-based measures –Take information from individuals and households and aggregate them at area level. 1.SIMD – Scottish Index of Multiple Deprivation 2.ScotPHO – Scottish Public Health Observatory

SIMD – Scottish Index of Multiple Deprivation Developed in response to 2003 report “Measuring Deprivation in Scotland : Developing a Long-Term Strategy” Combines 38 indicators across 7 domains: –current income (28%) –employment (28%) –health (14%) –education (14%) –geographic access (9%) –crime (5%) –housing (2%) 6505 datazones (populations of between 500 and 1000 residents)

ScotPHO – Public Health Observatory 59 indicators across 10 domains: –Life expectancy & mortality –Behaviours –Ill health and injury –Mental Health –Social care & housing –Education –Economy –Crime –Environment –Women & Children’s Health 38 comparator areas (most based on CHPs) cf. 32 local authorities/councils

G77 5 – Broom; Newton Mearns ‘Better’ ‘Worse’

G40 4 – Dalmarnock ‘Better’ ‘Worse’

Health determinants are multiple, complex, and interlinked “People do not just live in poverty, they may also be a lone parent, may have a long term disability that affects the work they can do, or live with discrimination that impacts on their mental health. Gender, and masculinity in particular, contributes to problems of violence, to the reluctance of men to seek help for problems and may make men more likely to resort to alcohol and drugs than to seek help for a mental health problem.” Equally Well: Report of the Ministerial Task Force on Health Inequalities, 2008

What is the role of primary care in addressing health inequalities? In the consultation? Within the practice? Working with other practices/services? At the policy level?

NHS Health Scotland, 2015 NHS Health Scotland (2016). Health inequalities: What are they? How do we reduce them?

NHS Health Scotland, 2015 NHS Health Scotland (2016). Health inequalities: What are they? How do we reduce them?

RCGP policy, 2015

Inequalities in health in Scotland: what are they and what can we do about them? Key messages: –Changes over time (infectious disease then; chronic disease now) –Different axes of variation (SES, gender, ethnicity, geography) –Specific exposures, behaviours, strengths and vulnerabilities –“downstream” vs. “upstream” causes –Earlier and later life risks can be cumulative (lifecourse approach) –Social gradient in most diseases, but not all –Education, Employment and Income are key entry points –Most health determinants lie outside the NHS –Policy matters…