Health inequalities in Scotland: now and in the future.

Carol Tannahill

Director

Glasgow Centre for Population Health

What I’m going to coverhat I’m going to cover• A bit about patterns and trends

• A bit about explanations

• A bit about implications

• What I’m not going to coverWhat I’m not going to cover• All types of health inequality

What we’re up against:What we’re up against:history, geography and history, geography and

the life coursethe life course

Mortality by social class 1911-1981Mortality by social class 1911-1981 (Men, 15-64 yrs, E&W) (Marmot, 1986; OPCS, 1978)

Year I II III IV V

1911 88 94 96 93 142

1921 82 94 95 101 125

1931 90 94 97 102 111

1951 86 92 101 104 118

1961 76 81 100 103 143

1971 77 81 104 114 137

1981 66 76 103 116 166

(Mackenbach, 2005)

(Mackenbach, 2005)

Lifecourse effects

Age adjusted relative rates of CVD mortality by father’s social class and smoking

Smoking

Father’s social class Other Current cigarette

Non Manual 1 2.20 (1.66 – 2.93)

Manual 1.80 (1.40 – 2.31) 3.11 (2.45 – 3.95)

Davey Smith and Hart, AJPH 2002

20th century trends in life expectancy in Scotland and 16 other Western European countries

Males

30

40

50

60

70

80

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Year of birth

Life expectancy in years

Scotland

Trends in life expectancy - malesTrends in life expectancy - males

All cause death rates, Men 0-64, 2001 (Leyland et al, 2007)

Glasgow City

Inverclyde

West Dunbartonshire

Dundee City

RenfrewshireEilean Siar

North Ayrshire North Lanarkshire

All cause death rates, Men 0-64, 2001

30%

Death rate per 100,000 men age 15-29

0

20

40

60

80

100

120

140

160

1981 1991 2001

Year

De

ath

Ra

te p

er

10

0,0

00

Aberdeen Dundee Edinburgh Glasgow

The Scottish Health Survey (2003)The Scottish Health Survey (2003)

The pattern of health inequalities The pattern of health inequalities

is not always predictableis not always predictable

Self-reported cigarette smoking Self-reported cigarette smoking by SIMD quintile and sexby SIMD quintile and sex

05

101520253035404550

1st 2nd 3rd 4th 5th

SIMD Quintile

Cu

rren

t sm

oke

r (%

)

MaleFemale

Accident rates per 100 children Accident rates per 100 children by SIMD quintile and ageby SIMD quintile and age

1st 2nd 3rd 4th 5th

0-5

yrs 13 17 11 14 20

6-10

yrs 15 14 22 17 22

11-15

yrs 29 16 25 19 34

All 19 16 20 17 25

Alcohol consumption by SIMD Alcohol consumption by SIMD quintile and sexquintile and sex

05

101520253035404550

1st 2nd 3rd 4th 5th

Men >21units

Women >14 units

Alcohol consumption by SIMD Alcohol consumption by SIMD quintile and sexquintile and sex

05

101520253035404550

1st 2nd 3rd 4th 5th

Men >21units

Women >14 units

Men 8 or more

Women 6 or more

A whistle-stop tour of A whistle-stop tour of some explanationssome explanations

1. Global factors are at play

• Yeah but no but yeah but no but …

• Or, more scientifically, “necessary but not sufficient”

• Scotland does behave differently (ref Walsh and Taulbut in preparation)

Life expectancy - RuhrEstimates of male life expectancy at birth: Ruhr area compared to Scotland, West of

Scotland and GGC, 1982-2005 (3-year averages)Source: GRO(S) mortality & population data (Scotland); NRW lögd mortality & population data (Ruhr)

64.0

66.0

68.0

70.0

72.0

74.0

76.0

78.0

1982-1984

1983-1985

1984-1986

1985-1987

1986-1988

1987-1989

1988-1990

1989-1991

1990-1992

1991-1993

1992-1994

1993-1995

1994-1996

1995-1997

1996-1998

1997-1999

1998-2000

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

Lif

e ex

pec

tan

cy a

t b

irth

Scotland WoS GGC

Estimates of male life expectancy at birth: Ruhr area compared to Scotland, West of Scotland and GGC, 1982-2005 (3-year averages)

Source: GRO(S) mortality & population data (Scotland); NRW lögd mortality & population data (Ruhr)

64.0

66.0

68.0

70.0

72.0

74.0

76.0

78.0

1982-1984

1983-1985

1984-1986

1985-1987

1986-1988

1987-1989

1988-1990

1989-1991

1990-1992

1991-1993

1992-1994

1993-1995

1994-1996

1995-1997

1996-1998

1997-1999

1998-2000

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

Lif

e ex

pec

tan

cy a

t b

irth

Scotland WoS GGC Ruhr area

Life expectancy - RuhrEstimates of female life expectancy at birth: Ruhr area compared to Scotland, West of

Scotland and GGC, 1982-2005 (3-year averages)Source: GRO(S) mortality & population data (Scotland); NRW lögd mortality & population data (Ruhr)

71.0

72.0

73.0

74.0

75.0

76.0

77.0

78.0

79.0

80.0

81.0

82.0

1982-1984

1983-1985

1984-1986

1985-1987

1986-1988

1987-1989

1988-1990

1989-1991

1990-1992

1991-1993

1992-1994

1993-1995

1994-1996

1995-1997

1996-1998

1997-1999

1998-2000

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

Lif

e ex

pec

tan

cy a

t b

irth

Scotland WoS GGC

Estimates of female life expectancy at birth: Ruhr area compared to Scotland, West of Scotland and GGC, 1982-2005 (3-year averages)

Source: GRO(S) mortality & population data (Scotland); NRW lögd mortality & population data (Ruhr)

71.0

72.0

73.0

74.0

75.0

76.0

77.0

78.0

79.0

80.0

81.0

82.0

1982-1984

1983-1985

1984-1986

1985-1987

1986-1988

1987-1989

1988-1990

1989-1991

1990-1992

1991-1993

1992-1994

1993-1995

1994-1996

1995-1997

1996-1998

1997-1999

1998-2000

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

Lif

e ex

pec

tan

cy a

t b

irth

Scotland WoS GGC Ruhr area

Life expectancy – N. MoraviaEstimates of male life expectancy at birth, Northern Moravia compared to Scotland, West of Scotland

and Greater Glasgow & Clyde, 1982-2005 (3-year averages)Source: Calculated from GRO(S) and Institute of Health Information & Statistics (CZ) data

65.0

66.0

67.0

68.0

69.0

70.0

71.0

72.0

73.0

74.0

75.0

1982-1984

1983-1985

1984-1986

1985-1987

1986-1988

1987-1989

1988-1990

1989-1991

1990-1992

1991-1993

1992-1994

1993-1995

1994-1996

1995-1997

1996-1998

1997-1999

1998-2000

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

Lif

e ex

pec

tan

cy a

t b

irth

Scotland WoS GGC

Estimates of male life expectancy at birth, Northern Moravia compared to Scotland, West of Scotland and Greater Glasgow & Clyde, 1982-2005 (3-year averages)

Source: Calculated from GRO(S) and Institute of Health Information & Statistics (CZ) data

65.0

66.0

67.0

68.0

69.0

70.0

71.0

72.0

73.0

74.0

75.0

1982-1984

1983-1985

1984-1986

1985-1987

1986-1988

1987-1989

1988-1990

1989-1991

1990-1992

1991-1993

1992-1994

1993-1995

1994-1996

1995-1997

1996-1998

1997-1999

1998-2000

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

Lif

e ex

pec

tan

cy a

t b

irth

Scotland WoS GGC Northern Moravia

Life expectancy – N. MoraviaEstimates of female life expectancy at birth, Northern Moravia compared to Scotland, West of

Scotland and Greater Glasgow & Clyde, 1982-2005 (3-year averages)Source: Calculated from GRO(S) and Institute of Health Information & Statistics (CZ) data

72.0

73.0

74.0

75.0

76.0

77.0

78.0

79.0

80.0

1982-1984

1983-1985

1984-1986

1985-1987

1986-1988

1987-1989

1988-1990

1989-1991

1990-1992

1991-1993

1992-1994

1993-1995

1994-1996

1995-1997

1996-1998

1997-1999

1998-2000

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

Lif

e ex

pec

tan

cy a

t b

irth

Scotland WoS GGC

Estimates of female life expectancy at birth, Northern Moravia compared to Scotland, West of Scotland and Greater Glasgow & Clyde, 1982-2005 (3-year averages)

Source: Calculated from GRO(S) and Institute of Health Information & Statistics (CZ) data

72.0

73.0

74.0

75.0

76.0

77.0

78.0

79.0

80.0

1982-1984

1983-1985

1984-1986

1985-1987

1986-1988

1987-1989

1988-1990

1989-1991

1990-1992

1991-1993

1992-1994

1993-1995

1994-1996

1995-1997

1996-1998

1997-1999

1998-2000

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

Lif

e ex

pec

tan

cy a

t b

irth

Scotland WoS GGC Northern Moravia

2. It’s about socio-economic status

• Yes – If Glasgow had the SES of the rest of Scotland, much of its health excess would disappear

• But – it would still have poorer mental health among women, higher levels of alcohol consumption, more long standing illness..

• And – it’s already no different in terms of eg obesity

(Gray, 2007)

3. Better services can sort it

• Remember remember the 7th of November (our last meeting)?

• Attention to how services are delivered can really make a difference

• We heard about partnerships, inequalities sensitive practice, NHS using its wider influence

• But we are against the inverse care law – especially for some of the more effective interventions

CHD PREVALENCE IN PRACTICE POPULATIONSUNDER 70 IN NHS GREATER GLASGOW

CHD EMAs Angina No of Population

deaths practices

1 Most deprived 9.1 46.2 6.7 24 82,5022 10.7 40.8 6.4 26 81.9273 8.3 34.6 5.9 20 82,1634 8.0 34.0 5.6 20 90,4075 8.7 27.5 5.0 27 79,6806 6.2 22.2 4.5 20 82,7957 6.7 21.7 4.2 21 84,4568 4.9 18.6 3.7 21 84,9229 2.9 15.3 3.0 13 89,00710 Most affluent 2.7 14.8 2.8 17 81,941

10:1 Ratio 3.3 3.1 2.4

TRENDS IN STATIN PRESCRIBING IN PRACTICE POPULATIONSIN NHS GREATER GLASGOW BETWEEN 2001/2 AND 2004/5

Dispensed daily doses (millions)

2001/2 2004/5 Increased

10 Most deprived 1.08 5.74 5.319 1.10 5.93 5.398 0.96 5.39 5.617 0.92 4.86 5.286 0.90 4.74 5.275 0.87 5.30 6.094 0.98 5.05 5.153 1.00 4.70 4.702 0.86 3.55 4.131 Most affluent 1.04 4.63 4.45

10:1 Ratio 1.04 1.24

4. It all matters

• Yes

• Although some things seem to matter more than others (income, education, employment)

• And there may be some important underpinning factors (resilience, ‘control’, adaptability, etc)

-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

Newton Mearns – G77 5

-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

Dalmarnock – G40 4

And finally..And finally.. a bit about implications a bit about implications

Implications

• Globally things are getting worse and Scotland is behind the pack. What can we do?

• Influence out as well as in.• Set realistic aspirations.• Ensure our policies are inequalities proofed.• Act on the causes behind the causes.• Invest in resilience, adaptability, coping and

control.• Create environments conducive to health.• Systematically deliver services in a way that

reduces inequity.

“The omnipresence and persistence of health inequalities should warn against

unrealistic expectations of a substantial reduction within a short

period of time and by using conventional approaches. ”

Mackenbach, JP (2005). ‘Health Inequalities: Europe in Profile’