Tag Archives: health inequalities

Digesting diet and health: the challenges of eating well

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Diet-related health problems are rarely out of the news. That’s because so many illnesses and diseases are the result of poor diet. There’s no shortage of suggestions for improving our diet, and for educating all of us on the benefits of eating well.

Policymakers are also concerned about this issue. Since the start of the COVID-19 pandemic, the NHS has been under greater pressure than ever, and government has been keen to address diet-related health problems.  

Examples of this include the most recent legislation to add calorie labelling to  restaurants and takeaways, which has been controversial. The new rules for England make it a legal requirement for large businesses with more than 250 employees, including cafes, restaurants and takeaways, to display calorie information of non-prepacked food and soft drinks.  The Scottish Government is consulting on similar proposals.

Sugar and salt taxes

Another example of regulations directed towards diet-related health problems would be taxes on sugar and salt in foods. There have been suggestions to either tax all foods based on their salt content, or specific foods which are classed as “high” in salt.

A sugar tax – the Soft Drinks Industry Levy – was introduced in April 2018 by the UK Government. It was later reported that consumers had bought 10% less sugar through soft drinks, which will also have lowered risks of obesity, type 2 diabetes and high blood pressure.

A report from the Institute of Fiscal Studies in 2021, looked at the impacts a tax on added sugar and salt could have on purchases of food both at home and out of the home in the UK. The report found that a salt tax could potentially see a decrease in risks of coronary heart disease and strokes.

In addition, the study suggested a salt tax could reduce the number of NHS treatments for obesity-related conditions, resulting in  lower NHS costs. The report also indicated an increase in overall economic output due to a healthier workforce.

However, there may also be less welcome consequences. A ‘snack tax’ has been estimated to potentially add as much as £3.4billion a year to families’ shopping bills. Introducing such a tax during the current cost of living crisis would add greatly to the financial stresses being experienced by households across the country.

Counting the calories

Displaying the number of calories in meals on menus has long been proposed as a way to tackle obesity and health issues, as so many people are unaware of just what is in the food they order. Public opinion is extremely divided on this subject, with some being in favour of this extra measure to help them when eating out if they wish to make healthier choices.

However, adding calorie information to menus may have undesirable effects. 1.25 million people in the United Kingdom have an eating disorder, and the COVID-19 pandemic is likely to have increased this number as more people struggle with mental illness and increased stress.

Beat, a UK-based eating disorder charity, has highlighted  that calorie labelling exacerbates eating disorders of all kinds. In addition, pushing a “diet culture” could send the wrong messages about eating rather than embracing a more positive approach towards food.

A further  study by the British Medical Journal reported only a small decrease in calories purchased when trialling calorie labelling in three chain restaurants in the United States. The researchers also found that after one year, that reduction diminished.

Meeting in the middle?

Another suggestion that has been discussed is tackling health-related inequalities, and understanding why certain groups are more vulnerable to these issues than others. For example, the House of Commons library has reported that in England people living in the most deprived areas were 9% more likely to be overweight or obese than those in the least deprived areas. The briefing also reported that  children in the most deprived areas of England were twice as likely to be obese.. More education focusing on not only what is healthy food, but how to be healthy with fewer resources could help reduce such inequalities.

Final thoughts

From tooth decay and high blood pressure to cancer, eating disorders and mental ill health, there are significant health and wellbeing impacts resulting from unhealthy eating habits. These issues also have serious consequences for healthcare services.

As we’ve seen, legislation has already been introduced to tackle diet-related health problems. But it’s likely that government will have to consider further measures to ensure that the food that we eat is both good for individuals and for wider society.

Further reading: more on food and nutrition from The Knowledge Exchange blog

Health inequalities and ethnic minority communities: breaking down the barriers

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Almost from the start of the coronavirus (COVID-19) pandemic, its unequal impact on ethnic minorities has been clear. But the health inequalities experienced by Black, Asian and Minority Ethnic (BAME) communities predate the pandemic. As the Local Government Association has observed:

“…the truth is these inequalities were already having an impact on the health and wellbeing of ethnic minority communities before COVID-19 hit – it is just that the pandemic has shone a light on them like nothing before.”

Recently, the Centre for Ageing Better hosted a webinar titled “Ethnic health inequalities in later life,” based on the report of the same name, published in November 2021.

The report mainly looked at the period from 1993 to 2017, although the webinar was able to offer more recent information regarding the COVID-19 pandemic, which of course greatly affected health inequalities.

Widening inequalities

Dr. Sarah Stopforth, one of the researchers for this study, explained that  ethnic inequalities have been found to widen more after the age of 30, and by the age of 40 have established themselves. One of the study’s main findings was that poor health for White British women in their 80s was the equivalent to the poor health of African and Caribbean women in their 70s, and the equivalent to Pakistani and Bangladeshi women in their 50s.

While there were similar results for men from these same ethnic groups, it is clear that women across all ethnicities have poorer health than their male counterparts. Why is this happening?

The reasons are complex, but Sara suggested that  health inequalities are usually tied to the socio-economic inequalities present in our society. However, she also said that this tends to ignore the underlying causes of these health outcomes.

The role of the NHS

Dr. Habib Naqvi from NHS England talked about the role of the NHS in tackling health inequalities. He asserted that our healthcare system should be well equipped to respond to these inequalities, given the UK’s long history of migration by people from Afro-Caribbean communities. So why has it not been able to?

A lot of this, he explained, was due to the fragmentation of the NHS. The many areas of the sector are not working co-operatively to reach a collective and consistent goal, which then affects the ability to tackle issues such as inequalities in the sector.

In addition, Dr Naqvi pointed to mortality rates for ethnic minority groups – living longer does not always mean living in a healthy way. One of the features of “long Covid,” is its tendency to exacerbate long-standing health complications or to weaken COVID-19 patients’ health even after the illness. Again, ethnic minority communities have been disproportionately affected by this condition.

Another impact of  the COVID-19 pandemic has been a heightened feeling of isolation and fear for many ethnic minority groups, something highlighted in a report from the University of Manchester. Many were unable to communicate with healthcare staff due to language barriers or health conditions affecting their communication skills, and were often having to be admitted alone due to Covid restrictions. The inability of patients from ethnic minority backgrounds  speak for themselves raises concerns about their healthcare. Research has found evidence that ethnic minority patients – especially women – are not having their illnesses taken seriously.  

Vaccine hesitancy

Linked to this is the controversial issue of vaccine hesitancy, which has become a particular concern among ethnic minority groups. One of the reasons that many members of ethnic minorities may feel hesitant or scared to take the vaccination is because of the lack of communication and information, linked with their previous healthcare experiences.

It was suggested during the webinar that even throughout the pandemic, the healthcare sector has not effectively protected ethnic minorities, despite these health inequalities long being known.  Health professionals have attempted to reach out to communities and help them with any fears regarding COVID-19 or the vaccination process, but this can be difficult with social distancing restrictions. As a result, people within BAME communities may have to rely on family and friends to get information regarding vaccination, which may not calm their fears.

Data, care and trust

One of the key points driven home by Dr. Naqvi was the need for better data in order to better understand health inequalities among ethnic minority communities. Birth to end-of-life care was also mentioned, including tackling racial bias that can be found even in antenatal care. Finally, the concept of earning trust was highlighted. Dr. Naqvi said that the NHS must work to earn trust from BAME communities, particularly among the elderly, given the long-standing disparities in treatment and discrimination many have faced over the years.

Final thoughts

The webinar offered useful insights into how deeply healthcare inequalities lie. Our previous blog post on the future of public health offered a reminder that access to efficient, well-supported and high quality healthcare is vital for everyone. This webinar underlined that message, but highlighted its special significance for those experiencing longstanding health inequalities.

Photo by Hush Naidoo Jade Photography on Unsplash

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The future of public health: lessons from the pandemic

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The Coronavirus pandemic (COVID-19) has impacted all sectors of our society, but none more-so than public health services.

Last month, The Health Foundation hosted a webinar discussing the lessons from the pandemic and the future role of public health. The webinar drew on the findings from The Kings Fund report “Directors of public health and the COVID-19 pandemic”.  It considered the issues facing public health as a result of COVID-19, and proposed steps to rebuild the healthcare sector and begin tackling the problems left as we slowly move out of the pandemic.

Lack of resources

One of the main themes of the webinar was raised by Shilpa Ross of The Kings Fund, who explained that a lack of resources and shortages in public health existed long before the COVID-19 pandemic. The impact of longer term reductions to the public health grant meant that health services were not ready for the pandemic, nor for how long it has lasted. This has had a knock-on effect elsewhere in the NHS. A Care Quality Commission report noted that in July 2021, almost 300,000 people were waiting more than 52 weeks to begin hospital treatment.

On top of this, public health has faced staff shortages. Because so many healthcare services are “fishing in the same pond for recruits,” Shilpa explained that it has been especially hard to fill vacancies. In addition, many healthcare workers have experienced short and long-term effects of the virus, and the additional workloads have left many stressed and burnt out. The disruption to education could further delay the training and employment of potential new healthcare workers.

While the NHS has in some cases set up drop-in sessions for support and made efforts to provide even basic support, such as bottled water to aid hydration, these cannot fill the hole created by healthcare staff shortages.

Widening inequalities

Professor Kevin Fenton of Public Health England argued that “inequalities have defined the pandemic,” and would be the legacy of the last year and a half. A 2020 report by the Institute of Health Equity, commissioned by The Health Foundation, found that in England members of Black, Asian and minority ethnic groups (BAME) were more likely to be affected by COVID-19. The report attributed this partly to people in these groups living in more deprived areas, working in occupations with a higher exposure risk to the virus (such as healthcare or customer service roles), and in some cases living with multiple generations in their home (complicating self-isolation). The authors contended that while inequalities in social and economic conditions were present before the pandemic, they contributed to the unequal death toll resulting from COVID-19.

These inequalities have widened, partly due to the shortage of resources and staff. It has only grown more difficult to address the ever increasing numbers of people needing treatment, both urgent and non-urgent. As a result, the most vulnerable in society have fallen by the wayside.

Changing how public health works

The webinar also discussed how public health can move forward as the country slowly returns to a new form of normal. In addition to the restructuring of Public Health England, a new tax – the Health and Social Care Levy – will put an additional £12 billion into health and social care over the next three years. However, money alone is not enough – the webinar participants agreed that the infrastructures and inner workings of public health must evolve as we move towards a more efficient system of working.

Professor Fenton stressed the importance of engaging with local communities, and that the response towards the pandemic going forward must be grounded in their experiences, and what they need from both the public health system and also local authorities. He noted that while there may be pressure to go back to the way things operated before the pandemic, we must move forward: by understanding what worked and what didn’t, progress and better services can be achieved. Shilpa Ross added that a more targeted and tailored approach to health inequalities has provided more significant results in terms of vaccination and testing rates. This has in turn raised levels of trust within communities that public health teams may not have engaged with before the pandemic. All of this, however, takes up precious time.

Professor Jim McManus, Director of Public Health for Hertfordshire County Council, highlighted the importance of prevention not only for COVID-19 moving forward but other health conditions.  He stated that they must be tackled at a place where they can stop others continuing to be affected, in addition to treating those who are currently being affected.  Robin Tuddenham, Accountable Officer for NHS Calderdale Clinical Commissioning Group, agreed, and stressed that problems like homelessness and poverty should not be seen as separate from health but rather as important factors in the prevention of ill health.

Concluding thoughts

Highlighting the underlying issues and difficulties affecting public health before the pandemic is one step towards addressing them.

The webinar demonstrated that the pandemic has shifted how public health is perceived and valued. It has reminded all of us how important access to efficient, well-supported and high quality healthcare really is. Those working in decision-making roles in the healthcare sector are clearly looking towards the next steps for public health and how to give people the highest quality and most efficient care possible. With this in mind, the pandemic may have created a stepping stone towards a better healthcare system.

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Keeping our finger on the pulse: recent additions to our collection across health

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The health and care landscape has been changed in unprecedented ways over the past year. The coronavirus pandemic has not only highlighted strains within the system and required a response to a public health emergency unlike anything else that has been seen for decades, it has also provided an opportunity to push innovation in areas like digital infrastructure and partnership working, and encouraged decision makers to look at public health as an essential part of policy making in all areas.

The Knowledge Exchange database is full of reports, articles and documents which offer insight into these themes, published by organisations from across the heath and social care landscape. In this blog post, we’re highlighting some recent additions to our collection and some of the big themes being discussed within the sector.

Covid-19, “building back better” and a “health in all policies” approach

In March 2021 think tank IPPR published their report State of health and care: the NHS Long Term Plan after Covid-19. The recommendations form a £12 billion blueprint to ‘build back better’ in health and care and the report calls for an adaptation of the NHS Long Term Plan published in 2019 focusing on cancer, mental health, cardiovascular disease and multimorbidity. The authors believe the Long Term Plan needs to change to ‘build back better’ health and care post-pandemic, in relation to: ensuring a sustainable workforce; resourcing the NHS to deliver transformation; empowering integration; upgrading the digital NHS; funding and reforming social care; and levelling up the nation’s health.

Another report, from the Local Government Association (LGA), published in September 2020, provides specific guidance to local authority councillors on ways to improve the approach to population health and use of public health resources in dealing with the pandemic, highlighting the Health in All Policies (HiAP) approach to addressing health inequalities and improving wellbeing. There are a number of other resources which look at public health approaches to tackling other areas of policy such as youth violence and urban regeneration.

Build back fairer: the Covid-19 Marmot Review: the pandemic, socioeconomic and health inequalities in England, published by the Health Foundation and the Institute of Health Equity examines inequalities in coronavirus mortality, looks at the effects that the pandemic, and the societal response, have had on social and economic inequalities, the effects on mental and physical health, and the likely effects on health inequalities in the future. The report assesses the inequalities in the risk of COVID-19 and mortality and explores the impact of containment on inequalities in the social determinants of health, in terms of: early life; education; children and young people; employment and working conditions; a healthy standard of living; healthy and sustainable places and communities; and healthy behaviours.

Mental health

Mental health services have been under significant pressure in the UK for a number of years now, with children’s services (CAMHS) particularly stretched as the number of specialist practitioners is limited. The coronavirus pandemic has, according to many specialists, exacerbated existing pressures and placed even more demand on services. In April 2021 the All-Party Parliamentary Group on a Fit and Healthy Childhood published a report: The COVID generation: a mental health pandemic in the making – the impact on the mental health of children and young people during and after the COVID-19 pandemic  which explores a range of themes in relation to the impact of the pandemic on the mental health of children and young people. The report presents evidence from a range of sources on the potential implications of the pandemic on young people’s mental health and discusses the impact of school closures on children’s future health and well-being.

The Children’s Commissioner for England recently published a report  which looks at the progress made in improving children’s mental health services in England, and  the impact of the pandemic on the mental health of children. The report also examines the provision and accessibility of children’s mental health services in 2019/20, finding that access is still not adequate and not improving as quickly as expected.          

The other pandemic: the impact of Covid-19 on Britain’s mental health  explores how the mental health of people in the UK has been affected by the pandemic, drawing on a survey of over 4000 people. It describes the different experiences of groups across society and the highlights the disproportionate mental health impact on people who are exposed to higher levels of social deprivation, as well as on women, younger people and those who live alone.

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Structural reform

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, such as taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

One of the main focuses of the health and social care white paper published in February 2021 is around developing an integrated health and social care system and taking a ‘population health’ preventative approach to healthcare, while a report from the NHS confederation recommends a reformation of the framework for elective care and increased healthcare funding.

Digital transformation

Even before the pandemic, The King’s Fund was publishing widely on digital transformation. But their recent report Understanding factors that enabled digital service change in general practice during the Covid-19 pandemic  looks specifically at the impact of the pandemic on accelerating the transformation of the delivery of some services by GPs to focus more on digital delivery and whether this change can (or should) be sustained once the pandemic is over. It explores the challenges around trust, staff and patient digital literacy and the evaluation of digital tools in practice. Parliamentary Office of Science and Technology (POST) published their own review of AI and healthcare , providing an overview of AI in the healthcare system and its potential impacts on the cost and quality of healthcare, and on the workforce.

Final thoughts

The landscape of health and care is changing. The Covid-19 pandemic has placed unprecedented demands on a system which was already facing significant challenges. While in some instances this has led to innovation and accelerated the pace of change, it has also exposed some of the significant weaknesses of the system.

This blog highlights some of the big topics the sector is currently grappling with, but there is more available for TKE members on our database. Members can also sign up to receive our health Topic Update, which will provide fortnightly email updates of items recently added to the collection in health, easily allowing you to stay up to date.

If your organisation is not a member of the Knowledge Exchange and you would like more information, please contact us.

If you liked this article you may also be interested in reading:

A nudge in the right direction? Using behavioural insights in health

Virtual reality: a game changer for mental health treatment?

Devolving health and social care in England: an opportunity to transform how we approach health and care?

Cross-border handshakes: what’s next for digital contact tracing?

“Same storm, different boats”: addressing covid-19 inequalities and the ‘long term challenge’

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The coronavirus pandemic has impacted upon almost every aspect of life.  However, this impact has not been felt by everyone equally. Some groups of people have been particularly badly affected – both by the virus itself and by the negative social and economic consequences of social distancing measures.  The phrase ‘same storm, different boats’ has been used widely to emphasise this.

The pandemic has exposed and deepened many of the deep-rooted inequalities in our society, including gender, ethnicity and income.  It has also shone a light on more recent inequalities too, such as the growth of precarious employment among sections of the population.

As we move out of lockdown, the long term consequences of the pandemic will continue to be felt unevenly across different sections of society, with those on the lowest incomes being most vulnerable.

As thoughts turn to recovery, there is a growing sense that now is the time to consider how we can create a more equitable society that benefits those most in need.

 

The long-term challenge

During a recent Poverty Alliance webinar, ‘Build Back Better: Poverty, Health and Covid-19: emerging lessons from Scotland’, Dr Gerry McCartney, Head of the Public Health Observatory at Public Health Scotland noted that the coronavirus pandemic was causing three concurrent public health crises:

  • the direct impact of the virus (through ill health and/or death);
  • the indirect impacts on health and social care services (e.g. reduced hospital admissions/referrals, delayed diagnoses); and
  • the long term unintended consequences of physical distancing measures

Dr McCartney’s recent research sets out the different groups at particular risk from covid-19 and outlines a number of ways in which the unintended consequences of physical distancing measures may negatively impact upon health via a complex set of pathways – including reduced physical activity, fear, anxiety, stress, boredom and loneliness, economic stresses related to reduced income and unemployment, the impact of the loss of education, as well as the risk of abuse and exploitation of children not in school, substance abuse, and domestic abuse and violence.

Dr McCartney has also been involved in a project that sought to quantify the direct impact of the pandemic in terms of years of life lost.  The results showed that, over 10 years, the impact of inequality on life expectancy is actually at least six times greater than the direct impact of the pandemic itself.

Dr McCartney referred to this as the “long-term challenge” and argues that in order to address these inequalities, it is crucial that society aims to ‘build back better’ following the pandemic.

Build Back Better

But what does this mean?  Put simply, Build back better argues that pandemic offers an unprecedented opportunity to refocus society on the principles of equity and sustainability.

A recent paper by the Wellbeing Economy Alliance (WEAll) sets out 10 key principles for ‘building back better’, covering a range of environmental, social and governance issues:

It highlights international examples of each of these principles in action, for example, speeding up the adoption of the doughnut economics framework in Amsterdam in response to the pandemic, and through the wellbeing principles implemented by the Wellbeing Economy Governments (WEGo) group, consisting of Iceland, New Zealand and Scotland (and recently joined Wales).

Indeed, in Scotland, the independent Advisory Group on Economic Recovery, established by the Scottish Government, have recently published their findings on how to support Scotland’s economy to recover from the pandemic.  It states that “establishing a robust, wellbeing economy matters more than ever”.

Unequal employment impact

One of the guiding principles set out by the Advisory Group on Economic Recovery is to “tackle inequality by mitigating the risks of unemployment, especially among groups hit hard by the crisis”.

Indeed, unemployment following the pandemic is unlikely to affect everyone equally – women, young people, BAME individuals and the low-paid are predicted to suffer the brunt.

In a subsequent Poverty Alliance webinar, ‘Addressing unemployment after Covid-19’, Tony Wilson from the Institute for Employment Studies (IES) highlights the scale of the problem.  He states that unemployment is rising faster than at any point in our lifetimes (barring a blip in 1947), and is likely to increase by 3 million as a result of the pandemic.

Again, the impact of this will be uneven.  Anna Ritchie Allan, director of Close the Gap, discusses the impact upon women in particular.  As well as being more likely to work in a sector that has been shut down, women are also more likely to have lost their job, had their hours cut, or been furloughed. As women are also usually the primary carers of their children, they have disproportionately affected by the closure of schools and home learning.

A recent report by Close the Gap highlights how the impending post-covid downturn is different than previous recessions, as the restrictions imposed to tackle the virus have impacted most heavily upon sectors that employ large numbers of female (e.g. hospitality, retail, care), as well as services that enable women’s participation in the labour market (e.g. nurseries, schools, and social care). Young and Black and minority ethnic (BME) women have been particularly affected.

For example, Kathleen Henehan, Research and Policy Analyst at the Resolution Foundation, considers how young people’s employment prospects have been affected by the pandemic. She notes that young people leaving education are likely to be worst affected.  However, again, inequalities exist – with those with lower levels of qualifications being particularly affected, and women and BME individuals within those groups affected most of all.

According to Anna Allan, policy to address unemployment as a result of the pandemic needs to be both gender-sensitive and intersectional – taking account of the fact that women are not one homogenous group, and ensuring that any job creation is not just providing more ‘jobs for the boys’.  For example, recent research by the Women’s Budget Group shows that investing in care would create 7 times as many jobs as the same investment in construction: 6.3 as many for women and 10% more for men.

Building forwards

In a third webinar, ‘Disability, rights and covid-19: learning for the future’, Dr Sally Witcher, CEO of Inclusion Scotland, suggests that as well as exposing and deepening existing inequalities, the coronavirus pandemic has created the scope for new inequalities to be created – ‘faultlines’ created by the differing impacts of the virus.

Dr Witcher questions the term ‘build back better’ – she asks whether indeed we should want to build back, when the old normal didn’t work for a large proportion of people, particularly those with disabilities. Dr Witcher also questions ‘who’ is doing the building, and whether the people designing this new future will have the knowledge and lived experience of what really needs to change.

Dr Witcher suggests that for any attempt to ‘build back better’ to be meaningful, it needs to reach out to the people that don’t currently have a voice – the people who have been most heavily affected by the virus.  Not only do these groups need to be involved, but they need to be leading the discussion about what a post-covid future looks like.

A post-covid future

Whilst the coronavirus pandemic has had a massive, devastating impact on people and economies around the world, it has created an opportunity to reflect on what is important to us as individuals and as a society.

There is strong public demand for change. According to a new YouGov poll, only 6% of the public want to return to the same type of economy as before the coronavirus pandemic.

Building back better recognises that addressing the causes of the deep-rooted and long-standing inequalities in our society is critical to a successful post-covid recovery.

There is also a need to protect and enhance public services, address issues of low-pay and insecure work, and prioritise wellbeing and the environment through a ‘green recovery’.

As Tressa Burke, of the Glasgow Disability Alliance, states:

“History will recount how we all responded to the coronavirus outbreak.  We need to ensure that the story told demonstrates our commitment, as a society, to protecting everyone from harm, particularly those most at risk of the worst impacts of covid.”

For further discussion of the wellbeing economy, you may be interested in our blog post ‘How well is your economy? Moving beyond GDP as an indicator of success‘

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Supporting perinatal mental health: from peer-support to specialist services

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There is a societal expectation that pregnancy and the arrival of a new baby are happy and exciting times.  However, it may come as a surprise to learn that up to 1 in 5 women develop a mental illness during pregnancy or within the first year after having a baby (also known as the ‘perinatal period’).

Up to 1 in 10 women may develop postnatal depression, however, there are actually a number of other mental illnesses that can affect women during pregnancy or following birth.  These include:

  • Antenatal depression
  • Perinatal anxiety
  • Perinatal obsessive compulsive disorder
  • Post-traumatic stress disorder (PTSD)
  • Post-partum psychosis

These illnesses can range from mild to severe.  Left untreated, perinatal mental illnesses can have a devastating effect on mental and physical health.  In fact, suicide is the leading cause of death for mothers during the first year after pregnancy.

The wider impact on children and families

Perinatal mental illnesses can also impact upon children, partners and significant others.  Research shows links to depression in partners, higher rates of divorces, lower levels of emotional and cognitive development and higher levels of behavioural problems and psychological disorders among children.

As well as the high human cost, there are also a number of economic costs associated with failing to address perinatal mental health needs. Research commissioned by the Maternal Mental Health Alliance found that perinatal depression, anxiety and psychosis carry a total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK.

In comparison, it would cost only an extra £280 million a year to bring the whole pathway of perinatal mental health care up to the level and standards recommended in national guidance.

Access to specialist services is a ‘postcode lottery’

The good news is that most mothers who experience mental ill health can and do make a full recovery.

At present, mild to moderate cases of mental ill health in pregnancy and following birth are treated by the GP through anti-depressants, talking therapies and/or support from a community mental health team.  For more complex or serious illnesses, GPs can make a referral to specialist perinatal mental health services for expert advice and support.  This may involve staying in a specialist psychiatric Mother and Baby Unit (MBU) – where mothers and their baby can be admitted together.

However, despite the high prevalence of, and risks associated with, perinatal mental illness, access to specialist perinatal mental health services across the UK is a postcode lottery.

Maps by the Maternal Mental Health Alliance show that women in around half of the UK have no access to specialist perinatal mental health services.  There are currently no MBUs in Wales or Northern Ireland, meaning mothers with more serious or complex mental illnesses often face either being admitted to a MBU far from home, or being admitted to a general psychiatric ward without their babies, in order to receive treatment.

For those with mild to moderate mental illness, waiting times for NHS talking treatments can be many months.  Lack of awareness means that many cases of mild to moderate mental ill health go undiagnosed and untreated.  There is an urgent need for both greater awareness of mental illness and better access to mental health services across the country.

The role of peer-support

In recognition of and response to the need for better access to mental health support for pregnant and new mothers, a number of local ‘grassroots’ peer-support projects have been established by dedicated volunteers and campaigners.

One such project is Blank Canvas.  Blank Canvas is a creative journaling workshop in Lanarkshire, aimed at women during pregnancy or in the first two years since birth, who are experiencing mental health difficulties.

The project was set up earlier this year by midwife Elaine Connell, together with some of her midwife colleagues, who shared her dedication to improving mental health support for women in the perinatal period.

Elaine was keen to start her own peer support group following her own personal and professional experiences of perinatal mental ill health, and was inspired by the success of other projects focusing on art and creativity, such as Maternal Journal.

As Elaine explains:

“It is free… …to access, and each attendee is given their own art kit to keep. We have a different theme each week and have guest speakers coming to do sessions also. During the group they can explore new art materials and create reflections in their journal, whilst chatting over some tea and cake. Each session they will take home a prompt card which can inspire their journalling during the week until the group meets next.”

Blank Canvas is free to access and works on a self-referral basis, with advertising mainly through Facebook.  A local shop and community space (Swaddle in Hamilton) donated a venue space, and all other costs (including materials) have been raised by volunteers committed to the project, through fundraisers such as coffee mornings and participation in the Kiltwalk.

Elaine has conducted an evaluation of the first 10-week block and feedback from participants has been extremely positive.  Word about the project has spread and the next block of Blank Canvas – which started on the 18th September – is fully subscribed (with a waiting list).  As Elaine notes, this is fantastic for the project, but highlights the high level of demand that exists for mental health support among new mothers.

The long term plan is to run 6-week blocks frequently throughout the year, moving to separate antenatal and postnatal sessions in 2020.  Elaine also hopes to start up a creative journaling group aimed at fathers too – noting that father’s mental health is often overlooked.

One of the key things Elaine has learned from the creation of Blank Canvas is that there is a lack of support available for people who want to establish their own peer-support groups:

“What has been clear when forming the group, is that there is very little support to establish peer support. There are lots of people who want to help others but who won’t because they don’t know where to begin, or how to access funding, or lack of training opportunities.”

Grassroots peer-support groups are an important source of support for mothers in the perinatal period, particularly in cases of mild to moderate mental ill health, where NHS capacity is strained.

Attending peer-support groups such as Blank Canvas may also have a preventative effect for mums who attend during pregnancy. Statistically, women who experience antenatal anxiety are more likely to develop postnatal depression, and so early intervention could help to reduce that risk.

Urgent need for better access to specialist services

While these projects have been successful, they are aimed predominantly at women experiencing mild to moderate mental ill health.

For those experiencing more complex or serious mental ill health, there remains an urgent need for better access to specialist treatment and support.  The Maternal Mental Health Alliance ‘Everyone’s Business’ campaign calls for all women throughout the UK who experience perinatal mental ill health to receive the care that they and their families need.  Specifically, it demands that:

  • perinatal mental health care should be clearly set at a national level and complied with
  • specialist perinatal mental health teams meeting national quality standards should be available for women in every area of the UK
  • training in perinatal mental health care should be delivered to all professionals involved in the care of women during pregnancy and the first year after birth

Promising signs of progress

There have been some promising signs of progress.  NHS England recently announced their plans to rollout specialist perinatal community services across the whole of England, including the opening of four new Mother and Baby Units.

And in Scotland, the Scottish Government recently announced the rollout of an initial £1 million for perinatal mental health services, as part of a wider £50 million investment in mental health services.  This initial investment will support a range of areas, including supporting the third sector to provide counselling, befriending and peer support for women and their families.  It will also help provide more consistent access to psychological assessment and treatment, by increasing staffing levels and training at Mother and Baby Units, for women with the most serious illnesses.

The Scottish Government also established a Perinatal and Infant Mental Health Programme Board earlier this year.  The PIMH Programme Board aims to help implement the commitments to improving perinatal and infant mental health set out in the 2018/19 Programme for Government and Better Mental Health in Scotland.

Clare Thomson, Everyone’s Business Co-ordinator for Scotland, says “It’s fantastic to see the evidence-based approach to developing community perinatal mental health services and look forward to hearing about the first steps – particularly in the North of Scotland“.

Perinatal mental health is Everyone’s Business

However, there is still much to do, including ensuring that this funding translates into services on the ground.  Wales and Northern Ireland are still without MBUs and there is a pressing need to raise awareness of and address mental illness among fathers.

The cost to the public sector of perinatal mental health problems is 5 times the cost of improving services.  It clearly makes sense to invest in improving this care – not only from an economic perspective, but to help improve the lives of women, their children and families across the country. And while more funding is essential to achieve this, raising awareness of the importance of perinatal mental health really is ‘everyone’s business’.

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Good enough is not enough: International Making Place Conference

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International Making Place Conference, Glasgow. Image: Jason Kimmings

There is now a growing body of evidence to indicate that our physical environment – the places where we live, work and socialise – affects our health and wellbeing and contributes to creating or reducing inequalities. But even without the research, it’s plain to see how a neighbourhood with lots of facilities for pedestrians and cyclists, a choice of shops and good public transport connections could benefit health in ways that one with an excess of pubs, fast food shops and car traffic would not.

The importance of place-based approaches to improving health and reducing inequalities was the theme of an international conference held in Glasgow last week.

The venue for the conference – Glasgow’s Old Fruitmarket building – is a shining example of how a great place can be repurposed and reinvented. Originally a wholesale fruit market, the building has been reborn as a unique setting for cultural and business events, but has retained many of its original features, including a lofty vaulted roof and a cast iron balcony.

David Crichton, Chair NHS Scotland
Image: Jason Kimmings

Facing up to the challenge of place

In his introduction, David Crichton, Chair of NHS Scotland, pointed to the sobering statistics that throw the importance of place into sharp focus. He noted that while the health of Scotland’s population was generally improving, people living in 10% of the country’s poorest areas are four times more likely to die prematurely than those in more prosperous places. The city of Glasgow knows all too well about these stark health inequities. A person living in the deprived area of Calton has an average life expectancy of 54 years, while someone growing up in affluent Lenzie, just 12km away can expect to live to 82.

Glasgow Lord Provost Eva Bolander
Image: Jason Kimmings

Glasgow’s Lord Provost, Eva Bolander, acknowledged the challenges facing the city, but also noted that Glasgow is at the vanguard of place making. The city council’s Avenues Project aims to transform 17 key streets, prioritising space for cyclists and pedestrians, introducing sustainable green infrastructure and improving public transport connections. Glasgow is also investing £20m in its Community Hubs programme to bring multiple support services together in areas experiencing high levels of poverty.

Aileen Campbell, the Scottish Government’s Cabinet Secretary for Communities and Local Government, highlighted projects such as Clyde Gateway in Glasgow and the Bellsbank Initiative in East Ayrshire as successful examples of placemaking. Their success, said the minister, lies in focusing on what’s important to the people and communities of these areas, with the support of government and local authorities.

This international conference also heard from Monika Kosinska from the World Health Organisation, who noted that the problems facing Scotland are not unique. Around the world, countries and communities are experiencing the challenges associated with ageing populations and health inequalities. In this sense, she observed, all countries are developing countries.

Sir Harry Burns
Image: Jason Kimmings

A sense of coherence

The World Health Organisation’s assertion that health is a complete state of wellbeing, not merely the absence of disease, was at the heart of a powerful presentation delivered by Sir Harry Burns, Director of Global Public Health at the University of Strathclyde.

His research has underlined that poverty is not the result of bad choices. The real problem is that, without a sense of coherence and purpose, people are not in a position to make good choices.

As Sir Harry explained, a child experiencing chaotic early years (featuring parental substance abuse and/or domestic violence) is already on a path to mental health problems which can culminate in a loss of control and long periods of worklessness and poverty. But the implications can be even more serious: “The more adverse experiences you have as a child, the more likely you are to have a heart attack.”

A eureka moment for Sir Harry Burns occurred when he read a book by an American sociologist. Aaron Antonovsky spent the latter half of his career in Israel studying adults who as children had been in concentration camps. He found that the children who survived had developed what he termed a “sense of coherence” – a feeling of confidence that one has the internal resources to meet the challenges of life, and that these challenges are worth engaging with.

That sense of coherence, Sir Harry believes, lies in giving people in poverty greater control over their own resources: “People who have a sense of purpose, control and self esteem are more positive and secure about the places they live in, and a greater ability to make the right choices.”

He concluded that rather than being passive recipients of services, all of us have to be given the opportunity to become active agents in our own lives: “‘Ask people to take control of their lives, build their trust, and people can make choices that support their health. We must create places that do that’.

Woodside Health Centre
Image: Jason Kimmings

Placemaking in action

This theme of active engagement in placemaking was demonstrated during a site visit to a new health centre in Woodside, one of the most deprived parts of Glasgow. The aim of the new health centre is to reshape health services from the patient’s point of view, helping them to manage their own health and improve the care they receive. The new centre will bring together GP services, along with dental, pharmacy and physiotherapy services.

The health centre and its surroundings have been created by engaging with the local community. Using ideas from local people, the exterior of the building features designs reflecting the natural and industrial history of the area. Natural light from large windows in the roof floods the centre of the interior, giving a sense of brightness and tranquility, while wooden slats feature designs linking the centre with natural features nearby.

Claypits Local Nature Reserve. Image: Jason Kimmings

That connection with the natural environment will be reinforced with the development of a community green space close to the new health centre. The Forth and Clyde Canal is just a few minutes’ walk from the health centre, and a new foot and cycle bridge linking the centre to the local nature reserve is under construction. Other features will include new and improved pathways and new wildlife habitats. The natural space is already attracting walkers, joggers, families and cyclists, and local people report feeling they can now visit this area in greater safety than ever before.

Mark Beaumont and Glasgow Disability Alliance. Image: Jason Kimmings

The Place Standard

One of the threads running through this conference was the Place Standard, a practical tool developed in Scotland to help communities assess and redesign their own places.

For the final session of the afternoon, round-the-world cyclist Mark Beaumont introduced members of the Glasgow Disability Alliance (GDA) who shared results from their day as the Place Making Team using The Place Standard Tool. The results highlighted some of the elements of place that are important to people with disabilities – but also to others: lack of accessible toilets, poor transport links, networking events with no seating, inaccessible information, no social care support.

Final thoughts

This conference provided some important ideas on what’s wrong with our places, and some examples of places that are getting it right. And even for those that are on the right track, everyone was left with a clear message: when it comes to placemaking, good enough is not enough!

Merchant City, Glasgow
Image: Jason Kimmings

A road less travelled: celebrating Gypsy, Roma and Traveller History Month – part 2

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June is Gypsy, Roma and Traveller History Month (GRTHM), which aims to raise awareness of and promote GRT history and culture.

It is widely recognised that raising awareness of different cultures is a key part of addressing prejudice and discrimination.

In this post – the second of two for GRTHM – we look at the inequalities and discrimination that GRT face across education, employment and health.  We also highlight work to address these inequalities and raise awareness of GRT communities’ rich cultural heritage.

GRT communities experience many educational and health inequalities

The recent House of Commons report, ‘Tackling inequalities faced by Gypsy, Roma and Traveller communities’, sets out a comprehensive review of the available evidence across a range of areas.

In education, Gypsy and Traveller children leave school at a much earlier age and have lower attainment levels than non-GRT children, and only a handful go on to university each year.  They also experience much higher rates of exclusions and non-attendance.

There are many reasons for this – from discrimination and bullying, to a lack of inclusion of GRT within the educational curriculum. There are also cultural issues to be addressed within the GRT community itself.

Scottish Traveller activist Davie Donaldson has spoken about the discrimination he faced in school where a teacher refused to “waste resources” by marking his homework because he was a Traveller, who she assumed was “not going to do anything with his education anyway”.  He also discusses how many Travellers within his own community felt he was betraying his roots by attending university. This clearly illustrates the multi-faceted nature of the issue of supporting GRT children in education.  The Traveller Movement addresses this and other related issues in their recently published guide to supporting GRT children in education.

Health outcomes for GRT communities are also very poor compared to other ethnic groups.  Their life expectancy is 10 to 12 years less than that of the non-Traveller population.  Maternal health outcomes are even more shocking – with one in five Gypsy Traveller mothers experiencing the loss of a child, compared to one in 100 in the non-Traveller community.

Poor health outcomes can be partially attributed to the difficulties that many experiences when accessing or registering for healthcare services due to discrimination or language and literacy barriers.  There is also a lack of trust among GRT communities which can result in a lack of engagement with public health campaigns.

Historic fear of engagement with public services

Indeed, there is a historic wariness of public services among many in the GRT community.

In the 1800s, many Travellers had a well-placed fear of the ‘burkers’ – body-snatchers looking to provide the medical schools with bodies for dissection.  Travellers felt particularly at risk because they lived on the margins of society.  There are many Traveller stories about burkers that have been passed on from generation to generation.

Similarly, a fear of social services intervention also exists, following the forced removal of children from Traveller families.  Some were taken into care, and others were deported to be servants in Canada or Australia.

Being aware of these cultural issues, along with the historic criminalisation and continued discrimination that GRT communities face, can help health and social services to understand and empathise with the GRT community when reaching out to them.

Poor employment outcomes and a lack of target support

Gypsies and Travellers were an essential part of the economy in the 19th Century and early 20th Century.  Many were skilled tinsmiths, silversmiths, basketmakers or other crafters.  They also played an important role as seasonal agricultural workers – for example, in the berry fields of Blair and farms of the north east of Scotland.  They moved from place to place, and bringing news and selling and trading their wares.  In the days before roads and motor vehicles, they were a lifeline for rural crofting communities who may have been many days travel away from the nearest settlement.

Time has rendered many traditional Traveller occupations redundant, and today employment outcomes for GRT groups are generally poor.

While more likely to be self-employed than the general population, the 2011 England and Wales Census found that Gypsies and Irish Travellers were the ethnic groups with the lowest employment rates, highest levels of economic inactivity, as well as the highest rates of unemployment.

However, unlike other minority groups, there has been no explicit government policies that support Gypsies or Travellers to enter employment or to take up apprenticeships and/or other training opportunities.  Many Gypsies and Travellers have also reported being discriminated against by employers, making it more difficult for them to find and stay in work.

A lack of robust data

There is a lack of robust data about the different GRT groups in the UK – even something as seemingly simple as how many GRT people there are.

This is because most data collection exercises – including the Census and in the NHS – do not include distinct GRT categories.  If an option exists at all, often it conflates the different GRT ethnicities into one generic tickbox, with no way to differentiate between the different ethnic minorities.  This is an issue that is being increasingly addressed and there are plans to include a Roma category in the 2021 census.

However, there are also issues with under-reporting.  Many people from GRT communities are reluctant to disclose their ethnicity, even when that option is available to them.  This stems both from a lack of trust and the fear of discrimination.

So, while the 2011 Census recorded 58,000 people as Gypsy/Traveller in England and Wales, and a further 4,000 in Scotland, it is estimated that there are actually between 100,000 to 300,000 Gypsy/Traveller people and up to 200,000 Roma people living in the UK.

Raising awareness of GRT culture

While this all may make for some pretty depressing reading, there are some promising signs of progress.

From Corlinda Lee’s Victorian ‘Gypsy Balls’ – where the curious public could pay to come and see how a Gypsy lived and dressed, to Hamish Henderson catalysing the 1950s Scottish Folk Revival with the songs and stories of Scottish Travellers – there have been attempts to promote Gypsy and Traveller culture among the settled population.

Today, organisations and individuals such as The Traveller Movement, Friends, Families and Travellers, and Scottish Traveller activist Davie Donaldson strive to promote awareness of and equality for the GRT community.

The recent Tobar an Keir festival held by the Elphinstone Institute at Aberdeen University sought to illustrate traditional Traveller’s skills such as peg-making, and there is a wonderful Traveller’s exhibition – including two traditional bow tents – at the Highland Folk Museum in Newtonmore.

There are even more events planned for GRTHM – including an exhibition of Travellers’ art and photography at the Scottish Parliament.

The hard work may be beginning to pay off – just last week, the government announced a new national strategy to tackle the inequalities faced by Gypsies, Roma and Travellers.

Using knowledge to fight prejudice

While there is without doubt an urgent need for practical measures to address the inequalities that the GRT community face – such as an increase in the number of authorised sites available – addressing the fundamental lack of awareness and knowledge of GRT culture is a key step towards eradicating prejudice towards GRT communities.

As well as raising awareness among the general public, there is also a need to for people working in public services – from health and social services to education and even politics – to have a better awareness and understanding of Traveller culture and history, and how this affects their present day needs and experiences.

Gypsy, Roma and Traveller History Month is an ideal opportunity to address the huge gap that exists in society’s collective knowledge about the GRT way of life, their history, culture and contribution to society. All of which can help to combat the prejudice and discrimination that they continue to face.

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A road less travelled: celebrating Gypsy, Roma and Traveller History Month – part 1

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Traditional Scottish Traveller bow tent at the Highland Folk Museum, Newtonmore

This month is Gypsy, Roma and Traveller History Month (GRTHM).

GRTHM aims to celebrate and promote awareness of Gypsy, Roma and Traveller (GRT) history, culture and heritage, and the positive contribution that GRT groups have made and continue to make to society.  It also seeks to challenge negative stereotypes, prejudices and misconceptions associated with GRT groups.

Over the next two blog posts, we will raise awareness of the many issues faced by GRT communities in the UK today, and highlight some lesser known aspects of GRT culture and heritage.

Gypsies and Travellers are not a homogenous group

One common misconception is that Gypsies, Travellers and Roma are a homogenous group.

In fact, GRT is a term which encompasses many distinct ethnic groups with their own cultures, histories and traditions.

This includes Romany Gypsies, who today are generally of English or Welsh heritage.  Gypsies first arrived in Britain in the 16th Century. The term ‘Gypsy’ was coined due to a common misconception that Gypsies originated from Egypt. However, recent DNA studies suggest that they actually originated from the Indian subcontinent.  Some Gypsies may prefer to be known as either English Gypsies or Welsh Gypsies specifically.

Irish Travellers are Travellers with Irish roots, however, a recent DNA study suggests they have been genetically distinct from the settled Irish community for at least 1000 years. Irish Travellers have their own language – Shelta (also known as Cant).

Scottish Gypsies/Travellers are indigenous to Scotland.  Their exact origins are uncertain, but it is thought that they may be descended from the Picts, and/or the scattering of the clans following the Battle of Culloden in 1746.  Certainly, Scottish Travellers tend to share many of the same Clan surnames – including Stewart, McMillan, McPhee and McGregor.

Scottish Travellers also have their own language – the Gaelic-based Beurla Reagaird.

European Roma are descended from the same people as British Romany Gypsies, and they are Gypsies/Travellers who have moved to the UK from Central and Eastern Europe more recently.  Some have arrived as refugees and asylum seekers. While they face many of the same issues as Gypsies, Irish and Scottish Travellers, they are also subject to a number of additional challenges.

There are also other groups that are considered ‘cultural’ rather than ‘ethnic’ Travellers.  These include Occupational Travellers such as fairground and circus owners and workers and New Age Travellers – individuals who have chosen a travelling lifestyle for ideological reasons.

Distinct ethnic minorities protected by law

Whilst there are some similarities between GRT groups in terms of lifestyle, economic, family and community norms and values – and certainly in terms of the discrimination and poor outcomes that they experience – there are clear genetic differences between each of the groups.

As such, Gypsies, Irish Travellers and Scottish Travellers are each considered ethnic minorities in their own right and protected as “races” under the Equality Act 2010.  Migrant Roma are protected both by virtue of their ethnicities and their national identities.

However, despite this protection, GRT groups are still subject to high levels of discrimination.

‘The last acceptable form of racism’

Indeed, prejudice and discrimination has affected GRT groups throughout history.

In the 16th century, any person found to be a Gypsy could be subject to imprisonment, execution or banishment.  Even after anti-Gypsy laws were repealed, discrimination continued.  In the 19th and early 20th centuries, it was not uncommon for doctors to refuse to attend to Travellers.  And despite Travellers’ strong Christian beliefs, churches would often refuse to bury their bodies within their grounds.

And today, GRT people have the worst outcomes of any ethnic group across a huge range of areas, including education, health, employment and criminal justice.  They have the poorest health and the lowest life expectancy of any ethnic group in the UK, and are subject to high levels of racism and hate crime.

GRT groups still face barriers to accessing health services.  As part of a mystery shopper exercise by the Friends, Families and Travellers (FFT) charity, 50 GP practices were contacted by an individual posing as a patient wishing to register without a fixed address or proof of identity. They found that almost half would not register them, despite NHS guidance to the contrary.

And while racism towards most ethnic groups is now seen as unacceptable and less frequently expressed in public, racism towards GRT groups is still common and often overt – even among those who would otherwise consider themselves ‘liberal’ or ‘forward thinking’.  This had led it to be termed “the last acceptable form of racism”.

The 2015 Scottish Social Attitudes Survey found that over 30% of people in Scotland would be unhappy with a close relative marrying a Gypsy or Traveller, and 34% felt that Gypsies or Travellers were unsuitable as primary school teachers.

Research by Travellers Movement has found that four out of five (77%) of Gypsies, Roma and Travellers have experienced hate speech or a hate crime – ranging from regularly being subject to racist abuse in public to physical assaults.

Prejudice and discrimination against GRT groups is not limited to the public – there is also evidence of discrimination against GRT individuals by the media, police, teachers, employers and other public services.

Even politicians have openly displayed anti-GRT sentiment.  In 2017, the Conservative MP for Moray Douglas Ross, stated that he would impose “tougher enforcement against Gypsy Travellers” if he were Prime Minster for the day.

His remarks were widely criticised.  Amnesty International’s Scottish director, Naomi McAuliffe, said “When our elected leaders use this sort of blatantly partisan speech, they set a terrible example that only serves to foster further discrimination and prejudice.”.

A lack of sites has led to a ‘housing crisis’

Mr Ross’s remarks reflect another common misconception about GRT communities – that they all live in caravans, purposefully choosing to set up on unauthorised sites.

The truth is that while Gypsies and Travellers have traditionally lived a nomadic life, living in bow tents, wagons – and even caves – over 70% of Gypsies and Travellers no longer live in caravans, having chosen, or being forced for one reason or the other – disability, old age, lack of suitable sites – to move into traditional ‘bricks and mortar’ accommodation.

For those who do still live in caravans, it is widely recognised that they face a ‘housing crisis’ – an urgent shortage of authorised sites to set up on, which threatens their travelling heritage.  It is this shortage that drives much of the use of unauthorised sites.

Of those sites that do exist, quality has been raised as a key issue.  Many sites can lack even the most basic amenities, and some are sited near recycling plants or in other undesirable locations.  Poor conditions and sanitation contributes to poor levels of health, exacerbating existing health inequalities.

Further inequalities

In our next blog post, we will look in more depth at the inequalities that GRT communities face – in health, education and employment.  We also highlight work to address these inequalities and raise awareness of GRT communities’ rich cultural heritage.

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Tackling health inequalities: what does the data tell us and how can it help?

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Health inequalities in Scotland are significant. Every year we hear about how Scotland has some of the biggest gaps in the health and wellbeing of the poorest and richest in society. In some cases, Scotland has the largest gaps in equality in the whole of Europe. And in many instances, they are rising. Scotland also has the lowest life expectancy of all UK countries.

A number of studies and research projects have been commissioned to try to identify the key indicators and factors that are creating and reinforcing these inequalities, and what sorts of interventions would work best to try and reduce or eradicate them altogether. It is hoped that by conducting research, and compiling data, policymakers can use this to identify groups and geographic areas where health inequalities are significant, and to intervene to reduce them, with data to help back up and evaluate the effectiveness of these interventions. In Scotland, work is being done by a number of organisations including the Scottish Government, Glasgow Centre for Population Health (GCPH) and Public Health Innovation Network Scotland (PHINS).

What indicators and factors are being measured?

Income inequality has a related impact on health inequalities, and the scale of low pay is significant. The relationship between health inequalities, poverty and household income is one which has been explored at length and is often highlighted as one of the main factors which influences health inequalities. Studies which look at income, and also at relative levels of deprivation can provide useful comparison points, with comparable datasets on employment status and income readily available at a national and local level. Data also considers trends over time, comparing pre- and post-economic crash data, as well as relative earnings and expenditure relative to inflation and the rising cost of living. Other factors include age (those under 25 and earning a lower minimum wage for example) and by gender, with more women in lower paid, lower skilled and part time or insecure work.

How usable is the research being created?

The research which examines health inequalities explores a whole range of interrelated factors, and highlights just how complex the landscape of inequalities is. Creating a clear and holistic picture of all of the factors which contribute to health inequalities is not easy. Many studies, while detailed and effective, are niche, and focus on a very limited number of factors across a limited demographic source. As a result, questions have been raised about the utility of this research and its applicability and scalability at a national level. In an attempt to tackle this, combined data sets are being produced which provide opportunities for comparison across data from a range of studies.

The “Triple I” tool from NHS Health Scotland is designed to help policy designers to create effective interventions to reduce health inequalities. A second edition of the tool is due to be released in 2018/19. Triple I aims to provide national and local decision makers with practical tools and interpreted research findings about investing in interventions to reduce health inequalities in Scotland. It does this by modelling the potential impact of different interventions and policies on overall population health and health inequalities.

 

What can be done to act on the data?

While the research being produced is high quality, and thorough in relation to findings, the real question is what can actually be done with the research, and what steps can policymakers and practitioners take to use the findings to inform their own practice.

There are, researchers suggest, significant opportunities presented by the recent research which has been done on income inequality. In particular, they cite the public sector and public sector pay as a key way to reduce the income, and therefore the inequality gap, particularly among higher earners and those who would be considered “working poor” or “just about managing”. In Scotland, significantly more people are employed in the public sector than in any other part of the UK, and there is, researchers suggest, an opportunity to better align and increase low wages to help to reduce the gap.

The adoption of new initiatives, such as the “housing first model”, which is due to be rolled out in Glasgow to help homeless people break the cycle of homelessness, are also opportunities not only to address inequalities, but to ensure that long term help and support is in place to prevent any relapse into chaotic or risky behaviour. In relation to housing first, the savings on front line services such as emergency admissions to hospital, or contact with the police after committing a crime are significant, and while more in depth research is needed to create a full cost benefit analysis model of the scheme and its effectiveness, early studies show that the impact on health and wellbeing on those who had previously been homeless is huge in terms of reducing inequalities and improving wellbeing. However further data on homelessness in Scotland shows how far we have to go, and that housing first is only one mechanism which can be used to begin this process of reducing inequalities among the most and least deprived communities in Scotland.

Alternatively, some have suggested a more radical overhaul of how we distribute welfare and wealth within the country. Research has been coming thick and fast on the subject of a “citizens basic income”, particularly following the trial which was rolled out in Finland (the findings of which have not yet been published). Research on how this could impact on inequalities is not widespread yet, as pilots have been small scale, However, it is suggested that a total overhaul of welfare, replacing it instead with a citizen’s basic income would be a more effective way to reduce inequalities across the board, including in health.

Summing up

Health inequalities are significant in Scotland. Much of the research focuses on the impact of deprivation, poverty and low income on health inequalities and how, in order to tackle health inequalities in Scotland we must also tackle some of the other significant social problems within our communities, including low income and insecure work, and the impact of homelessness or chaotic lifestyles on health.

Data can be used in a number of ways to help inform policy decisions, some more radical than others. But creating a complete understanding of inequality in Scotland is challenging. It is up to researchers and policymakers to work together to create a better understanding of the conditions and factors which contribute to inequality, and what can be done to help tackle systemic and entrenched inequalities in our communities through policy levers and evidence based policy making.

If you liked this article you may also be interested in:

Universal basic income: too good to be true?

A world of evidence … but can we trust that it is any good?

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