1. Inequalities in East Lothian
Philip Conaglen
Consultant in Public Health Medicine

2. 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

3. 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

6. 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.

7. 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

8. Population density = 154 people per km2 Births = 971 (10.6 per 1,000)
Population = 104, (54,617 female)
Population density = 154 people per km2
Births = (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%)

9. Population projections

10. 2016 population by deprivation
SIMD 2016

12. 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% ( )
74.7
78.8
East Lothian least deprived 85% ( )
78.6
81.9

13. East Lothian all-cause, age & sex standardised
East Lothian all-cause, age & sex standardised* under 75 year old mortality rates
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

14. 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

15.
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

16. 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
Wilkinson & Pickett, The Spirit Level

17. 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

18. 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

19. 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

20. 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