1. Socioeconomic inequalities in health What are they, what causes them and what can we do about them? Dr Sonya Scott, Consultant in Public Health Medicine

2. Of all inequalities, injustice in health is the most shocking and inhumane Martin Luther King

3. Question 1: What are health inequalities?

4. Health inequalities can be defined as the: 1 Graham H. The challenge of health inequalities, In: Graham H. Understanding health inequalities. Maidenhead: Open University Press, 2009. systematicdifferences in the health of people occupyingunequal positions in society

5. Key Point: Health inequalities are not just about the gap between the least and most deprived.

6. The importance of the gradient Nearly all of us are affected

7. Question 2: What causes health inequalities?

8. Four explanations considered: 1.Artefact (i.e. doesn’t really exist just flawed measurement) 2.Social Slide (i.e. poor health results precedes lower socioeconomic status) 3.Behaviours and culture (i.e. poor people behave badly) 4.Materialist

9. 4. Materialist explanation Whilst unhealthy behaviours are more prevalent in lower socio-economic groups, the patterning of health behaviours is explained by socio-economic circumstances Differences in income, resources and power between groups cause health inequalities Those with most resources and power are always the healthiest, regardless of their behaviours 1 The health of communities has improved when they have been given more resources by chance 2 1 Commission on Social Determinants of Health. 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization. 2 Costello EJ, Compton SN, Keeler G, Angoid A. Relationships between poverty and psychopathology. JAMA 2003; 290: 2023-9. 3 Barr HL, Britton J, Smyth AR, Fogarty AW. Association between socioeconomic status, sex, and age at death from cystic fibrosis in England and Wales (1959 to 2008): cross sectional study. BMJ 2011; 343: d4662.

10. Fundamental Unequal distribution of resource and power. Intermediate Education Labour and housing markets Taxation Legislation Health and social care systems Immediate - e.g. Damp housing Hazardous work Adverse life events Personal strengths and vulnerabilities Behaviours (e. g. smoking, diet, exercise)

11. Question 3: What can we do about them?

12. Key Point : They aren’t inevitable.

13. Health inequalities are not inevitable Inequality in mortality between best and worst 10 % of local authorities in Great Britain (sources: Thomas 2010 and Luxembourg Income Study)

14. Key Point : Action which improves health doesn’t necessarily reduce inequalities.

15. Whilst health is improving on average…

16. Health inequalities are not improving (source: NHS Health Scotland)

17. Reduced Inequalities Efficient services Better Health

18. Key Point : Action on immediate causes alone is unlikely to achieve sustainable reduction in inequalities.

19. The Problem of Substitution (source: McCartney G. 2013)

20. Fundamental Unequal distribution of resource and power. Intermediate Education Labour and housing markets Taxation Legislation Health and social care systems Immediate - e.g. Damp housing Hazardous work Adverse life events Personal strengths and vulnerabilities Behaviours (e. g. smoking, diet, exercise) Prevent & Undo as well as Mitigate

21. Key Point : Action needs to be wider than that of health and social care services.

22. Fundamental Unequal distribution of resource and power. Intermediate Education Labour and housing markets Taxation Legislation Health and social care systems Immediate - e.g. Damp housing Hazardous work Adverse life events Personal strengths and vulnerabilities Behaviours (e. g. smoking, diet, exercise)

23. Key Point : Upstream, regulatory and proportionate actions are most likely to reduce inequalities.

24. 3 Axes of Action Progressive taxation/Basic Income Guarantee Down stream Upstream Requires individual action Regulatory Financial Inclusion /Participatory Budgeting Alcohol/ fast food outlet licensing Health related behaviour change Lifestyle Drift

25. Third Axes for Action TargetedUniversal

26. Proportionate Universalism

27. Key Point : There are a number of actions which can be taken at a local level.

28. Actions as employers Participative Management and Co- determination Recruitment Terms and Conditions Training Making easy choice health choices

29. Actions as service providers Proportionate universalism Inequalities impact assessments Inequalities sensitive practice Welfare rights/income maximisation Empower communities – e.g. participatory budgeting Community benefit clauses

30. Actions as a partners Inform, advocate, monitor Living wage Place standard Reducing fuel poverty Inequalities impact assessments Alcohol licensing Reducing price barriers

31. Summary Avoid lifestyle drift Make healthy choices easy choices Proportionate Universalism not inverse care Action as employers, service providers and partners