Allowing so many people to die or become ill earlier than their neighbours because of a simple accident of birth underpins our national ignominy in this policy field. We know both what causes and what will solve health inequality. As a society we comment and frown about how terrible unequal health outcomes are, but we don’t devise, and then put in place, the bold polices that we know could go some way towards tackling the biggest policy failure of our times.
In case anyone needs reminding of the scale of the problem this chilling example says it all: “A boy born in Lenzie, East Dunbartonshire, can expect to live until he is 82. yet for a boy born only 8 miles away in Calton in the East End of Glasgow life expectancy may be as low as 54 years, a difference of 28 years or almost half as long again as his whole life.” (SPHC, 2015). And it's not only life expectancy - in the most deprived areas, males spend 22.7 years ‘not in good health’, compared to 11.9 years in the least deprived areas.
The practical actions in this report cut across almost all government portfolios - this is not an issue that can simply be tucked away in the NHS. Health inequalities have been too often written off as a problem of individual behaviour.This is not to say that this does not contribute poor health, but behaviours are impacts, not causes, of wider inequality.
Employment and income are fundamentally associated in attaining either good or bad health outcomes. Work in Scotland is characterised by underemployment and insecurity, zero-hours as well as low pay. Action on the real Scottish Living Wage and reversing the shift from wages to profit are essential if we are to tackle inequality. Equally important, is the quality of work and improving health and safety in the workplace. However, wages alone are not enough. For families in particular, the social security system has an important role to play, as the savage cuts in tax credits will highlight.
Community Planning Partnerships must have an understanding that health inequalities are about social inequality rather than purely a concern of the NHS.The Christie Commission and the Equally Well test sites highlighted this in 2008. Key messages included the strengthening of democratic accountability, joined up public sector leadership, working with communities and giving public service staff the autonomy to develop approaches in accordance with local circumstances, rather than top down structural change. A key recommendation in the report is the establishment of community hubs that will physically bring together public services in real communities, together with the voluntary sector.
Other public services need to play a key role in reducing inequality. The report covers the need for affordable and accessible public transport; sport and recreation facilities; housing; schools and further education. Crucially, there must be an unrelenting focus on early years by supporting parents and through universal high quality early years provision. Stimulating learning in very young children and preparing them for primary school is essential to help break the cycle of health inequality.
While tackling health inequality is a cross cutting issue there is still a role for the NHS. However, resources and priorities are not always focused on health inequality. As the Deep End GP’s told the Commission; “NHS Scotland should be seen at its best in areas of greatest need, or inequalities in health will widen”. We have a raft of targets and measures of NHS activity, but little that addresses health inequality. The report recommends measures to put inequality in the centre of NHS Scotland activity.
Health inequality has to be put in the centre of all policy development. It needs a cross cutting minister and every legislative proposal and plan should have a health inequality impact assessment.
Health inequalities are a manifestation of socioeconomic inequalities, they also reflect political inequalities. How we organise society creates inequalities.Therefore, how we organise society in the future can eliminate them.To do so means tackling injustice, unfairness and inequality.This report is an appeal to the Scottish Labour Party and other policy makers to take this challenge head on. This report proposes a transformative agenda for Scotland – where we shift from health inequalities to health equity.
(The Commission on Health Inequalities was established by Neil Findlay MSP. It was chaired by Dr David Conway from SHA Scotland. It took evidence from a wide range of organisations and held evidence sessions in communities. Contributing authors were Dave Watson and Tommy Kane)