Inequalities in East Lothian Philip Conaglen Consultant in Public Health Medicine

Ageing population, living longer with complex needs People Ageing population, living longer with complex needs Increasing multi-morbidity High levels of mental health problems Increasing burden of non-communicable diseases Persistent health inequalities Increased expectations of health services Why change is needed SG Outcomes Framework for Primary Care Workforce Recruitment and retention challenges System Increased financial pressures on the health and social care system Advances in technology

We are more informed and empowered when using primary care Our primary care services better contribute to improving population health Our experience of primary care is enhanced Our primary care workforce is expanded, more integrated and better co-ordinated with community and secondary care Our primary care infrastructure – physical and digital – is improved Primary care better addresses health inequalities Scottish Government, 2018 Primary Care National Outcomes

Inequalities Unfair and avoidable differences in people’s health and wellbeing across social groups and between different population groups NHS Health Scotland Health inequalities are unfair because they do not occur randomly or by chance, but are socially determined by circumstances largely beyond an individual’s control. These circumstances disadvantage people and limit their chance to live a longer, healthier life. Health inequalities are avoidable because they are rooted in political and social decisions. There was a substantial narrowing of health inequalities in the UK and USA between the 1920s and 1970s, the period in which welfare states were constructed and income inequalities declined.

NHS Health Scotland Mitigating the impact of inequality on health Take action to reduce the impact of social inequalities on outcomes for individuals Preventing inequality Undoing inequality NHS Health Scotland

Population density = 154 people per km2 Births = 971 (10.6 per 1,000) Population = 104,840 (54,617 female) Population density = 154 people per km2 Births = 971 (10.6 per 1,000) Deaths = 1,141 (10.9 per 1,000) Cause of death Male Female Cancers 192 167 Circulatory system 151 145 Respiratory 54 76 Nervous system & senses 53 67 All other causes 107 129 Population density – compared with Glasgow = 3,555; Edinburgh = 1,949; Orkney = 22 Rates are standardised Causes of death listed in table: top 4 = 79% of all deaths Cancers Circulatory system – mostly IHD and CVD Respiratory – mostly pneumonia and COPD Nervous system & senses – mostly Alzheimer’s (73%)

Population projections

2016 population by deprivation SIMD 2016

Female life expectancy Geography Male life expectancy Female life expectancy East Lothian (2015) 78.5 82.1 Scotland 77.1 81.1 East Lothian most deprived 15% (2009-2013) 74.7 78.8 East Lothian least deprived 85% (2009-2013) 78.6 81.9 http://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/life-expectancy/life-expectancy-in-scottish-areas

East Lothian all-cause, age & sex standardised East Lothian all-cause, age & sex standardised* under 75 year old mortality rates 2009-2013 Deaths per 100,000 The European Standard Population (ESP) is an artificial population structure used in the weighting of mortality or incidence data to produce standardised rates * European Standard Population NHS Lothian Analytical Services

Health and social inequalities Department of Public Health and Health Policy for NHS Lothian Board 07 September 2016 Premature death, illness, poor health or wellbeing This is the pattern. For almost all indicators. Ultimately these inequalities in health outcomes caused by, social and economic inequalities in society. (paraphrased Marmot, 2010) What causes inequalities ? Causes of health and inequalities (and interventions) range from individual to broader determinants. Inequalities as they appear in health care are often a function of social factors. Ultimately (caused by and) sensitive to political and social decisions – influence income, education, employment etc. Welfare state spending higher – inequalities improve. (Inherited) wealth and power structures are significant determinants of inequalities. If social justice argument is not compelling enough, good evidence that more unequal societies are worse for everyone (Wilkinson & Peckett). Less deprivation Those less well-off experience more ill-health, from a younger age and die younger

www.equalitytrust.org.uk Wilkinson & Pickett, The Spirit Level Neither health nor social problems are related to national income per head Index of: Life expectancy Math & Literacy Infant mortality Homicides Imprisonment Teenage births Trust Obesity Mental illness – incl. drug & alcohol addiction Social mobility Index of health and social problems

Health and social problems are worse in more unequal countries Index of: Life expectancy Math & Literacy Infant mortality Homicides Imprisonment Teenage births Trust Obesity Mental illness – incl. drug & alcohol addiction Social mobility Index of health and social problems www.equalitytrust.org.uk Wilkinson & Pickett, The Spirit Level

Patients in most deprived areas more psychological problems more long-term illness more multimorbidity more chronic health problems more problems to discuss (esp. psychosocial) encounter length was generally shorter access to care generally took longer satisfaction with access was significantly lower when dealing with psycho-social problems GP stress = higher; patient enablement = lower The availability of good medical care tends to vary inversely with the need for the population served e.g. Mercer & Watt 2007 Annals of Fam Med

Research tells us what does not work to reduce inequalities Information based campaigns and written materials Campaigns reliant on ‘opt in’ Approaches with price or other barriers Programmes that raise costs

What works to reduce inequalities Fiscal policies Support for low and lower incomes Reducing price barriers (access) Structural changes in the environment Legislative and regulatory controls Services proportionate to need/ improving accessibility of services Intensive support Starting young

Further reading Materials around inequalities from NHS Health Scotland A straightforward overview of why more equal societies are better for everyone: Wilson & Pickett, The Spirit Level, 2009