Reducing health inequalities is a priority for the Scottish Government. Healthcare services can contribute through prevention of poor health for those most at risk and by promoting equality of access to and outcomes from service provision. This page outlines the main legislation and policies for promoting equality and for reducing health inequalities.
"NHSScotland is committed to understanding the needs of different communities, eliminating discrimination, reducing inequality, protecting human rights and building good relations by breaking down barriers that may be preventing people from accessing the care and services that they need."
(NHSScotland Quality Healthcare Strategy, 2010)
Everyone in Scotland can describe themselves in terms of their age, disability status, ethnicity, gender/sex, religion/belief, sexual orientation, and transgender identity. Understanding the characteristics of an individual can help to improve individual care and support at the point of service delivery and recording information about personal characteristics can help to plan services that are accessible and beneficial to all.
The public sector duties on equalities included in the Equality Act (2010) (external link) place a requirement on all public bodies to consider the impact of policies and services on the needs of individuals with the ‘protected characteristics’ of age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief and sexual orientation. There is also a legislative requirement that human rights are considered by public bodies and this has some crossover with equality legislation (NHS Health Scotland, 2011).
There is some evidence to suggest how a person’s equality characteristics can be associated with their health and care. For example:
- People from minority ethnic groups generally have lower mortality than the general population in Scotland. There is a higher prevalence of heart disease and diabetes among those in the South Asian population (Gordon et al, 2010).
- People with learning disabilities have been found to have untreated medical conditions that would normally have been identified and resolved for other members of the community, these can be minor conditions but also include serious concerns such as breast lumps or diabetes (Gordon et al, 2010).
- We have a good understanding of how a person’s gender is associated with certain health conditions. For example, in terms of mental health and wellbeing, in 2007, 74 per cent of suicide deaths were men, yet women are more likely than men to be admitted to hospital for self-harm and women account for 70 per cent of GP consultations in which a diagnosis of ‘anxiety and other related conditions’ is recorded (Gordon et al, 2010).
- Studies in Scotland demonstrated that the inverse care law (where resource distribution favours the affluent) was entrenched within general practice and exacerbated by quality measures rather than reversed (e.g. Guthrie, 2006).
- In 2010, the Scottish Better Together patient survey programme found that patients who were most likely to report poorer experience of Scottish hospitals were those with poorer self-reported health status, a disability, or those requiring translation, interpretation or communication support.
Reducing health inequalities
Health inequalities are the ‘systematic differences in the health of people occupying unequal positions in society’ (Graham, 2009). They are most commonly associated with socio-economic inequalities but can also result from discrimination. Health inequalities in Scotland are wide and increasing (particularly relative outcomes). The causes of death increasingly responsible for mortality inequalities are suicide, alcohol and drug-related violence, all with clear social causes.
Welfare reforms are anticipated to exacerbate health inequalities. The impact of welfare reforms are presented in a report detailing the impact on life course groups (Health Scotland, 2013) and in evidence reviews (external link).
The Scottish Public Health Network has published guidance for NHS Boards on mitigating for the impacts of welfare reform (PDF:644KB) (external link).
An Audit Scotland report, Health inequalities in Scotland (external link), says that while overall health has improved in the past 50 years, deep-seated inequalities remain. Deprivation is the key determinant, although age, gender and ethnicity are also factors. The report assesses how well public sector bodies are working together to target resources at health inequalities and monitor their collective performance, and reviews health services and initiatives aimed at reducing health inequalities. The report says it is not clear how much money NHS boards and councils spend in this area, or what it is spent on.
Equally Well (external link) together with Achieving our Potential (external link) and the Early Years Framework (external link) provide the current strategies for the public sector to tackle the root causes of health inequalities in Scotland.
In addition, the Christie Commission Report (external link) is a key driver for policy and budget allocation, since it emphasises the need to address the causes of inequalities and the need for preventative spend.
There is evidence that interventions which utilise taxation, legislation, regulation and changes in the broader distribution of income and power in society are likely to be the most effective means of reducing health inequalities; whilst those which rely on individual agency are less likely to be effective. Agency refers to resources and freedoms available to individuals to act (Macintyre 2007, Equally Well 2008).
Many interventions are rightly aimed at improving whole population health but can inadvertently widen health inequalities amongst marginalised groups, as this segment of the population experience different barriers to engagement with services. Where planning and practice systematically consider equality and inequality from the start, service provision decisions including diagnosis, treatment and onward referral whether to secondary healthcare, preventative services, social care or community based support can identify and rectify the barriers faced by some people more than others.
For example, low literacy, fear, poverty, social isolation, language and communication differences have all been identified in research as presenting barriers to taking up and benefiting from service provision. The Marmot Review of Health Inequalities in England (external link) proposed actions that the NHS could take to plan differently for services to be provided in proportion to need. Actions to contribute directly to reducing the impact of adverse social circumstances on health are unlikely to come within the day to day functions of most frontline nursing staff. However, opportunities for referrals to local services for social support such as financial or social inclusion and for joint working or advocacy to act on the causal factors might present through membership or awareness of local partnerships (Craig, 2011).
A list of external sources used for the information on this page (where not directly linked to).
Craig P (2011) Focus on Inequalities – a framework for action. Glasgow Centre for Population Health.
Equality and Human Rights Commission (2011). The essential guide to the public sector equality duty.
Gordon DS, Graham L, Robinson M, Taulbut M. (2010) Dimensions of Diversity: Population Differences and Health Improvement Opportunities. Glasgow: NHS Health Scotland.
Graham H. (2009) The challenge of health inequalities, In: Graham H. Understanding health inequalities. Maidenhead: Open University Press.
Macintyre S. (2007) Inequalities in health in Scotland: what are they and what can we do about them? Glasgow: MRC Social and Public Health Sciences Unit.
G McLean G, Sutton M. Guthrie B (2006) Deprivation and quality of primary care services: evidence for persistence of the inverse care law from the UK Quality and Outcomes Framework. Epidemiol Community Health 2006; 60:917-922
NHS Health Scotland (2011) Health Inequalities Impact Assessment Guidance Appendix 5: Equality and human rights legislative requirements.
Scottish Government (2011) Scottish Inpatient Patient Experience Survey 2011 Volume 1: National Results.