Health inequalities in Scotland Prepared for the Auditor General for Scotland and the Accounts Commission
Auditor General for Scotland
The Auditor General for Scotland is the Parliament’s watchdog for helping to ensure propriety and value for money in the spending of public funds.
She is responsible for investigating whether public spending bodies achieve the best possible value for money and adhere to the highest standards of financial management.
She is independent and not subject to the control of any member of the Scottish Government or the Parliament.
The Auditor General is responsible for securing the audit of the Scottish Government and most other public sector bodies except local authorities and fire and police boards.
The following bodies fall within the remit of the Auditor General:
directorates of the Scottish Government
government agencies, eg the Scottish Prison Service, Historic Scotland
further education colleges
NDPBs and others, eg Scottish Enterprise.
The Accounts Commission
The Accounts Commission is a statutory, independent body which, through the audit process, requests local authorities in Scotland to achieve the highest standards of financial stewardship and the economic, efficient and effective use of their resources. The Commission has four main responsibilities:
• securing the external audit, including the audit of Best Value and Community Planning
• following up issues of concern identified through the audit, to ensure satisfactory resolutions
• carrying out national performance studies to improve economy, efficiency and effectiveness in local government
• issuing an annual direction to local authorities which sets out the range of performance information they are required to publish.
The Commission secures the audit of 32 councils and 45 joint boards and committees (including police and fire and rescue services).
Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. It provides services to the Auditor General for Scotland and the Accounts Commission. Together they ensure that the Scottish Government and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds.
There are significant and long-standing health inequalities in Scotland. The public sector can make better use of its resources to address these challenges.
Key facts £170 million 2011/12 allocations to the NHS for schemes related to health inequalities
£11.7 billion Total amount spent by the NHS in 2011/12
40 per cent least deprived* / 15 per cent most deprived Exclusive breastfeeding rate at 6-8 weeks
28 least deprived* / 62 most deprived GP consultations for anxiety per 1,000 patients
11 per cent least deprived* / 40 per cent most deprived Percentage of adults who smoke
214 least deprived* / 1,621 most deprived Alcohol-related hospital admissions per 100,000 population
81.0 years least deprived* / 70.1 years most deprived Average life expectancy of men
84.2 years least deprived* / 76.8 years most deprived Average life expectancy of women
* These comparisons refer to people living in the one-fifth most deprived and one-fifth least deprived areas.
1. Tackling health inequalities is challenging. Health inequalities are influenced by a wide range of factors including access to education, employment and good housing; equitable access to healthcare; individuals’ circumstances and behaviours, such as their diet and how much they drink, smoke or exercise; and income levels.1
2. Given the complex and long-term nature of health inequalities, no single organisation can address health inequalities on its own. Community Planning Partnerships (CPPs) are responsible for bringing all the relevant organisations together locally and for taking the lead in tackling health inequalities.2 Many public sector bodies and professionals contribute to reducing health inequalities; it is not just the responsibility of health services. Councils have a major role through their social care, education, housing, leisure and regeneration services. The voluntary sector also has a role in reducing local health inequalities.
3. There have been long-term increases in average life expectancy in Scotland and considerable improvements in overall health. However, there are still significant differences in life expectancy and health depending on deprivation, age, gender, where people live, and ethnic group. More data is available about the links between deprivation and health inequalities so we are able to provide more comment on deprivation in this report.
4. Reducing health inequalities will help increase life expectancy and improve the health of people in disadvantaged groups. It could also bring considerable economic benefits. For example, if the death rate in the most deprived groups in Scotland improved then the estimated average economic gains would be around £10 billion (at 2002 prices); and if the death rate across the whole population fell to the level in the least deprived areas, the estimated economic benefit for Scotland could exceed £20 billion.3 These are conservative estimates as they relate only to differences in life expectancy and do not include other health inequalities.
5. Tackling the problems most commonly associated with health inequalities would also help to reduce the direct costs to the NHS and wider societal costs. For example, the Scottish Public Health Observatory has estimated that a one per cent reduction in smoking prevalence would save around 540 lives a year; reduce smoking-attributable hospital admissions by around 2,300; and reduce estimated NHS spending on smoking-related illness by between £13 million and £21 million.4
6. In 2007, the Scottish Government established a Ministerial Task Force for Health Inequalities to identify and prioritise practical actions to reduce the most significant and widening health inequalities. The Task Force published its report, Equally Well, in June 2008. This considered the evidence for health inequalities in Scotland and identified a range of priorities where action is most needed to tackle health inequalities, including: children’s early years; tackling poverty and increasing employment; physical environments and transport; and access to health and social care services. The report also included recommendations for the Scottish Government, NHS boards, councils and other public sector bodies. The Task Force published a review of Equally Well in 2010 which examined progress since the publication of Equally Well and made more recommendations for addressing health inequalities. The Task Force reconvened in November 2012.
7. Reducing health inequalities has been a priority for successive governments in Scotland with the introduction of major legislation supporting this aim, such as the ban on smoking in public places and minimum pricing for alcohol. The Scottish Government’s 2012/13 spending review reiterated its commitment to addressing health inequalities, and in 2011/12 it allocated around £170 million to NHS boards to directly address health-related issues associated with inequalities.5
8. Shifting resources from dealing with the consequences of health inequalities to effective early intervention and access to preventative services is essential to tackling health inequalities.6 The Scottish Government’s policies prioritise preventing social problems rather than reacting to them but our previous work has highlighted that shifting resources will be challenging for the public sector, particularly in the current financial climate.789
9. Our audit aimed to assess how well public sector organisations are working together to tackle health inequalities. Given the scale and complexity of the problem, we have not examined in detail the impact of wider policies such as education, employment and housing on reducing health inequalities. Instead we have focused on how bodies work together to identify need, target resources and monitor their collective performance in reducing health inequalities. In this report, we:
• outline the scale of health inequalities and the effects on specific groups of people
• estimate how much the public sector spends on reducing health inequalities, although information on this was limited
• look at the quality of evaluations
• review how well CPPs ensure that there is a coordinated focus on health inequalities
• look at whether access to health services is equitable for all groups within the population, particularly people living in deprived areas.
10. Evidence for this audit is based on an analysis of national and local strategies and evaluations; finance and performance data; interviews with Scottish Government officials, NHS and council staff, academics and other relevant professionals; a review of CPP annual reports; and focus groups with a range of staff. We also visited five Equally Well test sites to review their progress to date. Further details of our methodology are set out in Appendix 1. Appendix 2 lists members of our Project Advisory Group, who gave advice and feedback at key stages of the audit, and Appendix 3 presents a summary of progress against national strategies for improving health and addressing health inequalities.
• Spending on reducing health inequalities (Part 2)
• Local health services for reducing health inequalities (Part 3)
• Effectiveness of approaches to reducing health inequalities (Part 4).
12. In addition to this report, we have also published a range of accompanying documents on our website:
• a detailed analysis of the extent of health inequalities across a range of indicators
• a report on our focus groups with CPP managers, Community Health Partnership (CHP) managers and frontline staff
• a checklist for CPPs to help improve their approach to addressing health inequalities
• a checklist for non-executive and elected members to assess how well health inequalities are being addressed in their local areas.1011
• Overall health has improved over the last 50 years but health inequalities remain a significant and long-standing problem in Scotland. Deprivation is a major factor in health inequalities, with people in more affluent areas living longer and having significantly better health. Health inequalities are highly localised and vary widely within individual NHS board and council areas. Children in deprived areas have significantly worse health than those in more affluent areas.
• The Scottish Government takes account of deprivation, rurality and remoteness, and other local needs in allocating funding to NHS boards and councils. However, it is not clear how NHS boards and councils allocate resources to target local areas with the greatest needs.
• The distribution of primary care services across Scotland does not fully reflect the higher levels of ill health and wider needs found in deprived areas, or the need for more preventative healthcare. Patterns of access to hospital services also vary among different groups within the population, with people from more deprived areas tending to have poorer access and outcomes.
• Reducing health inequalities requires effective partnership working across a range of organisations. However, there may be a lack of shared understanding among local organisations about what is meant by ‘health inequalities’ and greater clarity is needed about organisations’ roles and responsibilities.
• National policies and strategies which aim to improve health and reduce health inequalities have so far shown limited evidence of impact. Changes will only be apparent in the long term but measures of short-term impact are important to demonstrate progress towards policy goals. Many initiatives to reduce health inequalities have lacked a clear focus from the outset on cost effectiveness and outcome measures. This means that assessing value for money is difficult.
• Current performance measures do not provide a clear picture of progress. CPPs’ reports on delivering their Single Outcome Agreements (SOAs) are weak in the quality and range of evidence used to track progress in reducing health inequalities, and differences among SOAs means that a Scotland-wide picture is hard to identify.
The Scottish Government should:
• introduce national indicators to specifically monitor progress in reducing health inequalities and report on progress.
The Scottish Government and NHS boards should:
• review the distribution of primary care services to ensure that needs associated with higher levels of deprivation are adequately resourced
• include measurable outcomes in the GP contract to monitor progress towards tackling health inequalities, and ensure that the Quality and Outcomes Framework is specifically designed to help reduce health inequalities.
The Scottish Government and CPPs should:
• ensure that cost effectiveness is built into evaluations of initiatives for reducing health inequalities from the start
• align and rationalise the various performance measures to provide a clear indication of progress in reducing health inequalities.
• ensure that all partners are clear about their respective roles, responsibilities and resources in tackling health inequalities, and take shared ownership and responsibility for actions aimed at reducing health inequalities
• build robust evaluation, using all available data and including outcome measures and associated costs, into local initiatives aimed at reducing health inequalities
• include in SOAs clear outcome measures for reducing health inequalities which demonstrate impact, and improve the transparency of their performance reporting.
NHS boards should:
• monitor the use of primary care, preventative and early detection services by different groups, particularly those from more deprived areas. If this identifies systemic under-representation of particular groups, NHS boards should take a targeted approach to improve uptake
• monitor the use of hospital services by different groups and use this information to identify whether specific action is needed to help particular groups access services.
NHS boards and councils should:
• identify what they collectively spend on reducing health inequalities locally, and work together to ensure that resources are targeted at those with the greatest need.
The Spirit Level, R Wilkinson and K Pickett, Bloomsbury Press, 2009.
All council areas have a CPP to lead and manage community planning. CPPs are required to engage with communities, report on progress, and publish information on how they have implemented their duties and how outcomes have improved as a result. CPPs are not statutory committees of a council, or public bodies in their own right. They do not directly employ staff or deliver public services.
These estimates are based on a pro-rata comparison with estimates produced for the Marmot Review of health inequalities in England (‘The economic benefits of reducing health inequalities in England and Wales’, S Mazzucco, S Meggiolaro and M Suhrcke, background paper for the Marmot Review, January 2010).
ScotPHO Smoking Ready Reckoner – 2011 Edition, Scottish Public Health Observatory, June 2012.
Scottish Spending Review 2011 and Draft Budget 2012-13, Scottish Government, September 2011.
Report on preventative spending, Scottish Parliament Finance Committee, 2011.
Report of the Commission on the future delivery of public services, 2011.
Review of Community Health Partnerships, Audit Scotland, 2011; Commissioning social care, Audit Scotland, 2012.
CHPs are responsible for coordinating a wide range of primary and community health services in the local areas, including GP services, general dental services, community-related health services and mental health services. We use the term CHP in this report to refer to both health-only structures and Community Health and Care Partnerships (CHCPs) which are integrated health and social care structures. The Scottish Government plans to integrate adult health and social care services, and to replace CHPs with Health and Social Care Partnerships.
Part 1. Health inequalities in Scotland
The health of people in Scotland continues to improve but significant inequalities remain.
• Overall health has improved over the last 50 years but deep-seated inequalities remain. Deprivation is the key determinant of health inequalities although age, gender and ethnicity are also factors. Health inequalities are highly localised and vary widely within individual NHS board and council areas.
• Children in the most deprived areas have significantly worse health compared to children living in the least deprived areas. They are more likely to have a lower birthweight, poorer dental health, higher obesity levels and higher rates of teenage pregnancy. They are also less likely to be breastfed, which is associated with a healthy start in life.
• There is a mixed picture of progress in tackling health inequalities. For some indicators, such as deaths from coronary heart disease, inequalities have decreased but other indicators, such as healthy life expectancy, mental health, smoking, and alcohol and drug misuse, remain significantly worse in the most deprived parts of Scotland.
13. Health inequalities are linked to a range of factors that are complex and interrelated. For example, genetic factors and poor housing can have a major effect on an individual’s health over time, and these are likely to be exacerbated by harmful behaviours such as smoking, alcohol misuse and a lack of exercise. Public services in Scotland can address some of these factors, for example by improving social housing or access to sports facilities. Broader UK and global factors, such as the current economic downturn, also play a part.
14. Health and life expectancy generally worsen as deprivation levels increase. For example, the incidence of low birthweight and lung diseases are both higher in deprived areas, with the latter linked to higher rates of smoking in more disadvantaged groups. But other conditions such as high blood pressure and high cholesterol are not so directly associated with deprivation although they are risk factors for major illnesses that are strongly linked to deprivation, such as cardiovascular disease.12 Binge drinking is more common among men living in the most deprived areas, but levels of weekly alcohol consumption vary across the whole population and are not linked to deprivation. There are also gender differences in terms of inequalities; for example, women living in more deprived areas are more likely to be obese, but this pattern is less evident among men.
People in deprived areas have lower life expectancy
15. Overall life expectancy has increased in Scotland in recent years but continues to be closely associated with deprivation (Exhibit 1). Between 1999-2000 and 2009-10, the average life expectancy of men living in the least deprived areas remained around 11 years higher than in the most deprived areas but the corresponding difference for women increased from around 6.5 years to around 7.5 years. Life expectancy can vary widely within individual NHS board and council areas. For example, between 2006 and 2010, the average life expectancy among males in the most deprived areas of Renfrewshire was around 66 years which was nine years less than in the rest of Renfrewshire.13
16. Women tend to live longer than men but have more years living in poorer health. In 2009-10, average healthy life expectancy for women was around 2.5 years higher than for men, although this difference has fallen in recent years.14 Between 1999-2000 and 2007-08, healthy life expectancy increased by around three years for men (from 65.1 to 68.0) and over two years for women (from 68.2 to 70.5).15 The average healthy life expectancy of people living in the least deprived areas in 2009-10 was around 18 years higher than people living in the most deprived areas.16
17. People living in rural areas live on average two to three years longer than people in urban areas and can expect to live in good health for an average of six years longer. This may be partly due to rural areas generally having lower levels of deprivation than urban areas.17
18. Although average life expectancy and healthy life expectancy in Scotland have increased, average life expectancy is lower than in other parts of the UK (Exhibit 2). Average healthy life expectancy is lower than the UK averages for both men and women.18 Both life expectancy and healthy life expectancy are lower in Scotland than in many Western European countries.
Deprivation is most concentrated in the west of Scotland
19. All NHS boards and councils in Scotland have areas of deprivation but the west of Scotland, especially Glasgow and its surrounding areas, has high levels of deprivation and consequently accounts for a significant proportion of health inequalities in Scotland.19 Deprivation and life expectancy vary widely between CHPs in different parts of Scotland, and between CHPs within NHS board areas (Exhibit 3).20
Health inequalities vary widely within local areas
20. There are wide variations in both deprivation and health inequalities in smaller geographical areas within individual NHS board or council areas. To assess variation within one council area, we compared deprivation and an indicator of health inequalities (rate of hospital admission for drug misuse) across the 21 electoral wards within the Glasgow City Council area (Exhibit 4). To further examine the variation within an individual electoral ward, we also compared deprivation and health inequalities within one ward – Glasgow Shettleston (Exhibit 5). Our analysis shows that both deprivation and health inequalities can vary widely among small local areas.
Children in deprived areas have poorer health
21. Children’s early years are a major determinant of their future health.21 Children living in the most deprived areas of Scotland experience significantly worse health outcomes than children living in the least deprived areas (Exhibit 6).
There is a mixed picture of progress in tackling health inequalities
22. Scotland faces major challenges in tackling a range of deep-rooted health problems, and the inequalities associated with them. We reviewed a range of health indicators to look in detail at the extent of health inequalities related to them and progress made in reducing them (Exhibit 7). These indicators are all linked to deprivation and some are linked to other factors such as gender and ethnicity. Health inequalities have decreased for some indicators, but they have either remained the same or worsened for others.
23. Since 2008, the Scottish Government has published an annual report setting out progress against a range of long-term indicators of health inequalities.22 The most recent report, published in 2012, shows that the gap in health inequalities has not narrowed for these indicators apart from indicators for low birthweight and alcohol-related deaths. These measures give an indication of progress but the Scottish Government has not set out timescales or numerical targets to measure progress against these long-term indicators.
Inequalities in health in Scotland: what are they and what can we do about them?, S Macintyre, MRC Social and Public Health Sciences Unit, 2007.
Life Expectancy in Scottish Council Areas split by Deprivation, 2005-2010, National Records of Scotland, October 2011.
Healthy life expectancy is the number of years people can expect to live in good health.
Healthy life expectancy data from 2009/10 is not comparable with earlier years owing to a major change in methodology.
This comparison refers to people living in the one-fifth most deprived and one-fifth least deprived areas.
Scottish Public Health Observatory, 2011.
Health Expectancies at birth and at age 65 in the United Kingdom, 2008-2010, Office for National Statistics, August 2012.
Deprivation tends to be concentrated in small local areas and it can be difficult to see the pattern of local deprivation by looking at just the NHS board or council level. In this report, we have used CHP areas where possible to provide a more detailed analysis of the effect of deprivation.
We have presented data for CHPs as we present data in Part 2 of this report to compare local deprivation level and indicative funding allocations by CHP.
Early Years Framework, Scottish Government, 2008. The Scottish Government defined early years as pre-birth to eight years old.
Long-Term Monitoring of Health Inequalities, Scottish Government, October 2012.