What would be sufficient to reduce health inequalities in Scotland?

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1 What would be sufficient to reduce health inequalities in Scotland? Gerry McCartney NHS Health Scotland November

2 Summary Mortality rates and health inequalities are worse in Scotland than in the rest of central and western Europe. Many people die prematurely each year as a result of health inequalities in Scotland. This is a human tragedy, but it also causes a reduction in economic output and social problems. Of all the challenges facing Scotland, the gaping health inequalities and high mortality rates are clearly our biggest. However, health inequalities are not inevitable: between 1920 and the mid 1970s in the UK and USA health inequalities declined dramatically, but the changes in political direction in both countries after this date created a context in which health inequalities rose rapidly. The ways in which the determinants of health (e.g. income, employment, housing, transport and social networks) are distributed within a population explain the health inequalities in a population. This can include the access that different population groups have to positive assets and influences and the differential exposure to damaging factors. As the World Health Organisation (WHO) Commission on the Social Determinants of health said, the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live, work, and age. In their turn, poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics. The most important locus for actions on health inequality is therefore policies which determine the distribution of income, wealth and power. Although Scotland has become a world leader in devising public health legislation (e.g. the ban on smoking in public places and minimum unit pricing for alcohol), there has been much less progress in reducing economic and social inequalities. Given that income, wealth and power inequalities are the key determinants of health inequalities, it is unlikely that health inequalities will decline if substantial progress on reducing these economic and democratic inequalities is not achieved. It is also known that public health interventions which require individuals to opt in, or to respond to the provision of information, are the least likely to be effective at reducing health inequalities. In contrast, action to reduce economic inequalities and policies which use legislation or taxation are more likely to be effective. Public services can make a contribution to reducing health inequalities. Providing services in proportion to need (e.g. by making GP consultation times longer for more deprived individuals) or providing intensive support for groups at high risk (e.g. homeless people or looked after children) are likely to be effective. If health inequalities in Scotland are to be reduced, this will require leadership at all levels to reduce the stark inequalities in the socioeconomic circumstances prevalent today. There are numerous reasons why these socioeconomic inequalities should be reduced, but the resultant health inequalities and human misery on a grand scale which arises as a consequence is possibly the most important. 2

3 Contents Summary... 2 Introduction... 4 Background: health inequalities epidemiology... 5 What would be sufficient to reduce inequalities in health? How can public services make a contribution to reducing health inequalities? Conclusions Acknowledgements References

4 Introduction success will be assessed in terms of a decline in inequalities in health outcomes (Equally Well: report of the ministerial taskforce on health inequalities, 2008) The Scottish Government (SG) are committed to reducing inequalities a in health outcomes measured in terms of: healthy life expectancy; premature mortality; mental wellbeing, low birth weight; coronary heart disease hospital admissions and deaths; cancer incidence; and alcohol related hospital admissions and deaths [1]. The role of the Taskforce on Health Inequalities is to review progress in reducing health inequalities and review the extent to which changes to policy or practice are required. Equally Well, the report of the ministerial taskforce on health inequalities published in 2008, gave an evidence informed view of the causes of health inequalities and of the types of interventions which would be successful in reducing health inequalities. Despite the implementation of a number or interventions which have the reduction of health inequalities as their primary aim (including Keep Well, the Equally Well test sites, and a range of NHS HEAT targets) the health inequality outcome measures have not improved. Although it may be too early to fully appreciate all of the impacts of these interventions, many of these built upon pre existing interventions and policies and so it is opportune to re evaluate whether the current policy and practice mix is likely to be sufficient to reduce health inequalities in Scotland. Reducing health inequalities is hugely important. Behind the statistics are the early, unnecessary and unjust deaths of people in Scotland. As Scotland looks towards its future position in the world, improving the health of its citizens and reducing these mortal injustices should clearly be a priority. This paper outlines what combination of policy and practice would be sufficient to reduce these inequalities in Scotland. a Some authors use inequalities to denote differences between groups and inequities to denote unjust differences between groups, but this distinction is not consistently applied across the literature. The more commonly used term inequality has been adopted throughout this report to describe unjust differences. 4

5 Background: health inequalities epidemiology Despite the vast reductions in mortality in Scotland over the last 150 years, overall life expectancy remains lower, and average mortality remains higher, in Scotland compared to the rest of west and central Europe ( Figure 1) [2 4]. Even within eastern Europe, deprived de industrialised regions are improving more rapidly than the similarly de industrialised area around Glasgow [5,6]. Within Scotland, mortality inequalities between those with the most and least education are higher than in the rest of west and central Europe amongst men (Figure 2) and women (Figure 3). Figure 1 Life expectancy at birth for men and women in Scotland compared with other western European countries from 1950 [3] 5

6 Figure 2 Mortality inequalities between the most and least educated men in selected European countries circa 2001 [7,8] Scotland Figure 3 Mortality inequalities between the most and least educated women in selected European countries circa 2001 [7,8] Scotland 6

7 These inequalities in mortality by educational attainment (the only means of comparing Scotland with the rest of Europe) is also reflected in stark inequalities in mortality by social class, occupational group, area deprivation and geography within Scotland [9]. For example, the difference in life expectancy between Jordanhill in Glasgow s west end and Bridgeton in the east, across a distance of only four miles, is a startling 13.9 years for men and 8.5 years for women [10]. Spatial inequalities (i.e. the differences in mortality between geographical areas) in Great Britain declined from the 1920s until the 1970s before increasing to the beginning of the 21 st Century [11]. Although it is of great concern that inequalities have risen so rapidly over the last 30 years, it does suggest that health inequalities can be radically reduced when the context is conducive (as was the case between the 1920s and 1970s), fitting what we know about the causes of health inequalities being largely structural and due to income, wealth and power differentials within societies [12]. This fall and subsequent rise in health inequalities was also witnessed in the USA [13]. Figure 4 The stark health inequalities in Glasgow are demonstrated by the drop in life expectancy of 2.0 years for males and 1.2 years for females for each station on the railway line between Jordanhill and Bridgeton [10] Males y Females y Jordanhill Hillhead St George s Cross Buchanan Street Hyndland Partick Exhibition Centre Charing Cross QUEEN STREET Anderston Argyll St. Govan Ibrox Cessnock CENTRAL St Enoch Bridgeton Males y Females y Life expectancy data refers to and was extracted from the Glasgow Centre for Population Health community health and wellbeing profiles. Adapted from the Strathclyde Partnership for Transport travel map by Gerry McCartney. 7

8 Figure 5 Ratio of standardised mortality ratios (0 64years), UK local authorities, [11] Ratio of best to worst deciles for area-based mortality Year Mortality in Scotland was 15% higher in Scotland than in England & Wales in 2001, yet only half of this excess was explained by area deprivation [14]. Similarly, mortality in Glasgow for all ages is 15% higher (and premature mortality 30% higher) than in equally deprived Liverpool and Manchester [15]. The excess mortality in Scotland and Glasgow, over and above that explained by deprivation, has been termed the Scottish Effect or Glasgow Effect. The causes of these effects are not entirely understood, but are most likely to be related to a combination of changed politics, high income inequalities, disempowerment and deindustrialisation impacting on health through a variety of pathways (including unhealthy behaviours such as alcohol, diet, tobacco and illicit drugs, psychosocial stress and poverty) [16]. Further research to understand more clearly the causes of the higher mortality in Scotland is being led by the ScotPHO collaboration (which includes NHS Health Scotland, the Glasgow Centre for Population Health and various academic departments). In summary, there are four mortality phenomena which afflict Scotland: 1. Overall (average) life expectancy in Scotland has improved more slowly than other west and central European countries since 1950 such that it is now lower than all others. 2. Mortality inequalities between more and less educated groups within Scotland are greater than those within other west and central European countries. 3. Mortality in Scotland is higher than in England & Wales after accounting for area deprivation this excess is termed the Scottish Effect. 4. Mortality in Glasgow is higher than in equally deprived Liverpool and Manchester this excess is termed the Glasgow Effect. 8

9 The specific causes of mortality which have are responsible for Scotland s relatively poor health record have changed over time. Infectious disease (such as typhoid and tuberculosis), maternal deaths and infant deaths dramatically reduced with improvements to housing and living conditions, reductions in absolute poverty, the introduction of the welfare state and improvements in medical care and access. However, there was then a rise in chronic diseases such as heart disease, cancer, stroke and respiratory disease which was more profound in Scotland than was seen in most of Europe. Mortality from these conditions is now in decline (although the ageing of the population means that more people are living with chronic conditions into old age). We have witnessed dramatic improvements as living conditions, absolute poverty and medical care and smoking rates have declined. Since the 1980s and 1990s, new epidemics have occurred (e.g. alcohol related deaths, drug related deaths and suicide) mostly affecting young adults. However, there is evidence that alcohol related deaths and suicide are now in decline [2,4]. The persistence of health inequalities through time despite the rise and fall of particular specific causes of mortality has provided evidence that the fundamental causes of health inequalities are the most important, and the only sufficient, explanation of how health inequalities arise and persist [17]. The fundamental causes are the socio economic inequalities in society (i.e. inequalities in income, wealth and power). In essence, effective action which reduces a specific cause of death can reduce overall mortality in a population (e.g. alcohol related deaths might reduce as a result of alcohol pricing policy), but other competing causes (e.g. obesity related disease in the current context) will maintain the inequalities in overall mortality unless the inequalities in underlying socioeconomic conditions are also reduced. The ways in which the determinants of health (e.g. income, employment, housing, transport and social networks) are distributed within a population explain the health inequalities in a population. This can include the access that different population groups have to positive assets and influences and the differential exposure to damaging factors. Access to health improving assets (e.g. health services or community networks) is influenced by social position and the way in which different people are perceived by society [18]. For example, a low income as a result of basic employment or dependence on welfare benefits would reduce opportunities for buying a house in a safe and pleasant environment, or for ensuring access to the best education for children. Health inequalities can also be compounded in some population groups either through neglect (e.g. by reducing the accessibility of services to non English speakers) or by active discrimination (e.g. racism). 9

10 What would be sufficient to reduce inequalities in health? There have been numerous reviews of the evidence on what policies and interventions should be pursued to reduce health inequalities [1,19 23]. The Commission on the Social Determinants of Health is the most recent comprehensive review and brought the issue to the political centre stage internationally [24]. The conclusions these reviews draw are broadly similar, and perhaps have been best summarised by Macintyre in a paper produced to inform the first convention of the Scottish Government s Taskforce on health inequalities [25]. The WHO Commission on Social Determinants of Health made three broad recommendations: 1. To measure and understand the problem 2. To improve daily living conditions 3. To tackle the inequitable distribution of power, money and resources In Scotland, we have a robust infrastructure in place to measure health inequalities [26] and a world class academic and practice community who are constantly improving our understanding of the causes of the health inequalities and the policy and practice solutions. Scotland has also seen a massive improvement in daily living conditions over the last 100 years, with vast improvements in housing and a substantial reduction in absolute poverty rates [27]. However, in relation to the third recommendation, inequalities in power, money and resources have increased rapidly and to historically high levels in the UK over the last 30 years [28]. This makes it very unlikely that health inequalities will decline in Scotland until these inequalities in power, money and resources are also reduced. The rising income inequalities in recent years are likely to be compounded in the near future by cuts to welfare benefits which will impact on the poorest and most vulnerable groups in Scotland [29 31]. The Scottish Government has limited powers to influence these matters at present as economic and welfare policy is largely determined by the UK Government. However, there remains scope for more to be done by the Scottish Government and by local government to create a context in which health inequalities can be reduced. For example, reductions in income inequalities could result from changing local taxation. The current policy on local taxation (council tax) takes a greater proportion of the income from low income groups than it does for high income groups, and is therefore one of the causes of health inequalities in Scotland. Similarly, the job security, pensions and salaries offered by local government could be made more equal across employees. The introduction of a living wage would also contribute towards a narrowing of income, and therefore health, inequalities. 10

11 It is only a reduction in the current inequalities in income, wealth and power, which are contributed to by policies across the UK, Scottish and local government, that would be sufficient to generate a reduction in health inequalities. How can public services make a contribution to reducing health inequalities? Individual behaviour change The overwhelming balance of evidence is that interventions which tackle individual behaviours and those that rely on voluntary uptake are least likely to be effective in reducing health inequalities, and indeed may increase health inequalities (Table 1) [21,25,32 35]. This is important. Traditionally the provision of information and health education to individuals was seen to be the mainstay of improving health in Scotland. However, if they are effective at all (which is often in doubt), they are more likely to be taken up by more affluent individuals and those who have the resources to act upon the messages. A recently created model of the impact of various health improvement interventions in Scotland suggests that their overall impact, even with very optimistic assumptions about uptake and effectiveness, is very modest [36]. Table 1 Characteristics of interventions less effective in reducing inequalities in health (from Macintyre) [25] Information based campaigns (mass media information campaigns) Written materials (pamphlets, food labelling) Campaigns reliant on people taking the initiative to opt in Campaigns/messages designed for the whole population Whole school health education approaches (e.g. school based anti smoking and alcohol programmes) Approaches which involve significant price or other barriers Housing or regeneration programmes that raise housing costs In contrast, the interventions which are more likely to reduce health inequalities are those which utilise taxation, legislation, regulation and changes in the broader distribution of income and power in society (Table 2) [21,25,32 35]. There are positive examples of such policies in Scotland. The ban on smoking in public places and the introduction of minimum unit pricing for alcohol are both more likely to reduce health inequalities in the smoking related diseases and alcohol related diseases respectively. However, as noted above, people living in deprived communities are more likely to suffer from competing causes of ill health and so the overall impact on mortality inequalities is likely to be muted in the absence of 11

12 action on the fundamental causes of inequalities: inequalities in power, income and wealth [17,37]. Table 2 Characteristics of policies more likely to be effective in reducing inequalities in health (from Macintyre) [25] Structural changes in the environment: (e.g. area wide traffic calming schemes, separation of pedestrians and vehicles, child resistant containers, installation of smoke alarms, installing affordable heating in damp cold houses) Legislative and regulatory controls (e.g. drink driving legislation, lower speed limits, seat belt legislation, smoking bans in workplaces, child restraint loan schemes and legislation, house building standards, vitamin and folate supplementation of foods) Fiscal policies (e.g. increase price of tobacco and alcohol products) Income support (e.g. tax and benefit systems, professional welfare rights advice in health care settings) Reducing price barriers (e.g. free prescriptions, school meals, fruit and milk, smoking cessation therapies, eye tests) Improving accessibility of services (e.g. location and accessibility of primary health care and other core services, improving transport links, affordable healthy food) Prioritising disadvantaged groups (e.g. multiply deprived families and communities, the unemployed, fuel poor, rough sleepers and the homeless) Offering intensive support (e.g. systematic, tailored and intensive approaches involving face to face or group work, home visiting, good quality pre school day care) Starting young (e.g. pre and post natal support and interventions, home visiting in infancy, pre school day care) Public service provision A lack of access to, or differential uptake of, health and other social services is not the most important cause of health inequalities in the UK. It is however important that the services provided by the NHS and all other public services do not exacerbate health inequalities and, wherever possible, contribute to a decrease. For services to avoid exacerbating inequalities, resource allocation for services should be based on need rather than demand, and should be equitable rather than equal. This is in essence the proportionate universalism advocated by Marmot in Fair Society Healthy Lives [21]. For example, the availability of general practitioners across the population is broadly equal across deprivation groups. Yet, there is huge variation in the needs of the populations within the deprivation groups in terms of higher mortality and morbidity, greater case complexity and greater complication with social factors [38 40]. This is the inverse care law which is that: 12

13 the availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced [41]. A more equitable approach to providing public services is therefore to remove market incentives (which can exist for some independent contractors to the NHS such as dentists and opticians) and provide services in proportion to the needs of the population served. The Royal College of General Practitioners in Scotland have recently proposed that the length of consultation with GPs should be in proportion to the need of the individual patient (and therefore longer for those living in deprived circumstances) [43]. Such a change would make it more likely that primary care services in Scotland contribute to a reduction in health inequalities. Other barriers to good quality services for more vulnerable groups should also be tackled (e.g. language availability or cultural sensitive practice). There is also some evidence that intensive support for particularly vulnerable population sub groups (e.g. homeless people or looked after children) can be effective [25]. The idea of proportionate universalism does not take away from the need for universal policy interventions (e.g. health and safety regulations, bans on smoking in public places) or universal service provision. Indeed, there are numerous dangers with a policy approach which reduces universal provision of services (e.g. meanstesting prescription charges, school meals, dentistry and pensions) as this undermines the collectivism which supports taxation to pay for these services, increases stigma for those who use the services and results in reduced investment and reduced service quality [44]. However, the provision of universal public services needs to be considered alongside taxation so that the provision of one particular service does not simply reduce the resources available to other services. Whole-population approaches, targeted approaches and the link with overall population health Benach and Craig have summarised how policies and intervention can have differential impacts on inequalities and overall population health [45,46]. These impacts are summarised in the case studies below (drawn from Benach) [46,47] (the approach which would reduce inequalities by reducing the health of the best off is not considered here): 1. The ideal scenario: improving mean population health and reducing inequality (Levelling Up) The ideal scenario for policy and practice is where mean (overall) health in a population improves at the same time as inequalities reduce. In this scenario, the risk for all people in the population reduces, and reduces most for the most disadvantaged individuals who are also at the highest risk. This also has the effect of reducing the gradient as described by Craig [45]. 13

14 2. Improving mean population health and increasing inequalities This is the most common (and unintended) scenario in public health is where the mean population health improves but inequalities in health widen. This pattern is mainly associated with interventions which require exercising choice or individual agency (e.g. mass media campaigns, health education programmes). 3. Targeting the worst off The most commonly expressed strategy for reducing health inequalities is for a target group to be identified who are at greatest need (e.g. Health Action Zones, Keep Well and Social Inclusion Partnerships). This would have the effect of reducing inequalities and also (marginally) improving mean population health. There are several difficulties with this approach in practice. In Scotland, the most commonly used means for identifying the population at greatest risk of mortality and morbidity is to use an area based measure of deprivation such as the Scottish Index of Multiple Deprivation (SIMD). The evidence for this approach has thus far been disappointing [48,49] and many of the interventions to date have been very difficult to evaluate quantitatively (e.g. Keep Well). This is also problematic because not all deprived people live in deprived areas, and not all people living in deprived areas are deprived. For example, using data from 1991, it was found that only 41% of unemployed people and 34% of low income households lived in the 20% most deprived areas [50]. Furthermore, even where a targeted approach is implemented, it is often the case that the least needy individuals within a target population take up the service which means that the impact on inequalities can be mixed. However, there remains a case for tailored, intensive support to be provided for particularly high risk groups (e.g. looked after children). 14

15 How to create change It is much easier to gain broad agreement on the need for health inequities to be reduced than it is to deliver coherent policies that achieves this aim (Hunter and Wilson, BMJ 2012) [51]. It is one thing to introduce a public health policy (e.g. ban on smoking in public places) or to change how health services are provided. It is quite another to narrow the socio economic inequalities endemic in Scotland which drive health inequalities. However, without action to reduce the income, wealth and power inequalities which currently plague Scotland it is very unlikely that we will reduce the human tragedy which is represented in the health inequalities statistics. If socioeconomic inequalities are to be reduced in Scotland this will require action by central government and local government, but it will more importantly require leadership and advocacy at all levels in civic society to create the demand for such a shift. Health inequalities represent human misery on a grand scale [24], and are therefore one of the very good reasons why the case should be made for reducing health inequalities. It is also known that countries which have narrower income inequalities are also the countries which have better average health and social outcomes [52,53]. The extent to which Scotland is different from the UK as a whole in terms of its political outlook has long been debated, but it now seems that there is some limited evidence that there is a greater appetite for redistribution in Scotland (although this appetite has dramatically reduced over the last 15 years in both Scotland and England) [54]. There is some (albeit limited) evidence that the policy context to reduce health inequalities has been more favourable here than in England [55]. The planned referendum on Scottish independence in 2014 introduces the possibility of a much more radical change in political direction from that of the rest of the UK, although this may not necessarily or automatically be in favour of greater redistribution. Socio economic inequalities are not inevitable or immutable. Income inequalities had been relatively narrow in the UK and USA from 1945 to the late 1970s, but rose rapidly during the 1980s and 1990s before rising at a slower rate from 1997 [56,57]. This trend did not happen by accident, nor did it occur in all countries around the world. Some governments made decisions which prioritised the needs of business and the financial sector, reduced the power of organised labour (e.g. by reducing trade union rights) and changed the tax and benefits structure to be less redistributive. Together, this political direction can be described as neoliberalism and was pursued in the USA, UK, New Zealand with vigour during the 1980s, and throughout the former USSR during the 1990s [58]. These changes have led to a maldistribution of power in society, whereby those with higher incomes and greater wealth have gained greater influence [57] and large multinational businesses have been able to profit at the expense of the population s 15

16 health [59]. Indeed, changes to the welfare and tax systems currently being undertaken are likely to widen the socioeconomic differences across society even more [60 62]. Conclusions Mortality rates and health inequalities are worse in Scotland than in the rest of central and western Europe. Thousands of people die prematurely each year as a result of health inequalities and the higher mortality rates. This is a mortal human tragedy and causes human suffering, social crises and lost economic output. Of all the challenges facing Scotland, the gaping health inequalities and high mortality rates are clearly our biggest. However, health inequalities are not inevitable: between 1920 and the mid 1970s in the UK and USA health inequalities declined dramatically, but the change in political direction in both countries after this date created a context in which health inequalities rose rapidly. The ways in which the determinants of health (e.g. income, employment, housing, transport and social networks) are distributed within a population explain the health inequalities in a population. This can include the access that different population groups have to positive assets and influences and the differential exposure to damaging factors. As the World Health Organisation (WHO) Commission on the Social Determinants of health said, the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live, work, and age. In their turn, poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics. The most important locus for actions on health inequality is therefore policies which determine the distribution of income, wealth and power. Although Scotland has become a world leader in devising public health legislation (e.g. the ban on smoking in public places and minimum unit pricing for alcohol), there has been much less progress in reducing economic and social inequalities. Given that income, wealth and power inequalities are the key determinants of health inequalities, it is unlikely that health inequalities will decline if substantial progress on reducing these economic and democratic inequalities is not achieved. Public health interventions which require individuals to opt in, or to respond to the provision of information, are the least likely to be effective at reducing health inequalities. In contrast, action to reduce economic inequalities and policies which use legislation or taxation are more likely to be effective. If health inequalities in Scotland are to be reduced, this will require leadership at all levels to reduce the stark inequalities in the socioeconomic circumstances prevalent today. There are numerous reasons why these socioeconomic inequalities should be 16

17 reduced, but the resultant health inequalities and the human misery on a grand scale which arises as a consequence is possibly the most important. 17

18 Acknowledgements Thanks to Pauline Craig, Neil Craig, Erica Wimbush, Andrew Fraser, Christine Duncan, Matt Lowther and Phil Eaglesham for helpful comments and suggestions on an earlier draft. References 1. (2008) Equally Well: report of the ministerial taskforce on health inequalities. Edinburgh: Scottish Government. 2. Leon D, Morton S, Cannegieter S, McKee M (2003 (Accessed at s/int_mortality_comparisons.asp on 20th April 2010). ) Understanding the health of Scotland s population in an International context: a review of current approaches, knowledge and recommendations for new research directions. London: London School of Hygiene and Tropical Medicine & Public Health Institute for Scotland. 3. McCartney G, Walsh D, Whyte B, Collins C (2011) Has Scotland always been the 'sick man' of Europe? An observational study from 1855 to European Journal of Public Health: 1 5 (doi: /eurpub/ckr1136).. 4. Whyte B (2007 [downloaded from on 20th April 2010]) Scottish mortality in a European context : an analysis of comparative mortality trends. Edinburgh Scottish Public Health Observatory. 5. Walsh D, Taulbut M, Hanlon P (2008) The Aftershock of Deindustrialisation: Trends in mortality in Scotland and other parts of post industrial Europe. Glasgow: Glasgow Centre for Population Health. 6. Walsh D, Taulbut M, Hanlon P (2010) The aftershock of deindustrialization trends in mortality in Scotland and other parts of post industrial Europe. The European Journal of Public Health 20: (doi: /eurpub/ckp1063). 7. Popham F, Boyle P (2010) Assessing socio economic inequalities in mortality and other health outcomes at the Scottish national level. Edinburgh: Scottish Collaboration for Public Health Research and Policy. 8. Mackenbach JP, Stirbu I, Roskam A JR, Schaap MM, Menvielle G, et al. (2008) Socioeconomic inequalities in health in 22 European countries. New England Journal of Medicine 358: Leyland A (2004) Increasing inequalities in premature mortality in Great Britain. Journal of Epidemiology & Community Health 58: McCartney G (2010) Illustrating health inequalities in Glasgow. Journal of Epidemiology & Community Health doi /jech Thomas B, Dorling D, Davey Smith G (2010) Inequalities in premature mortality in Britain: observational study from 1921 to BMJ 341: c

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20 32. Krieger N (2011) Krieger N. Epidemiology and The People s Health: Theory and Context. New York: Oxford University Press. 33. Bioethics NCo (2007) Public health: ethical issues. London: Nuffield Council on Bioethics. 34. Capewell S, Graham H (2011) Will cardiovascular disease prevention widen health inequalities? PLoS Med 7: e Lorenc T, Petticrew M, Welch V, Tugwell P (2012) What types of interventions generate inequalities? Evidence from systematic reviews. Journal of Epidemiology & Community Health. 36. Mitchell R, Fischbacher C, Stockton D, McCartney G (2012) Modelling the impact of interventions on health inequalities: a commentary. Edinburgh: ScotPHO. 37. Link BG, Phelan J (1995) Social conditions as Fundamental Causes of Disease. Journal of Health and Social Behaviour: Mercer S, Watt G (2007) The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland. Annals of Family Medicine 5: Watt G (2011) Time to make a difference. British Journal of General Practice Tomlinson J, MacKay D, Watt G, Whyte B, Hanlon P, et al. (2008) The shape of primary care in NHS Greater Glasgow and Clyde. Glasgow Glasgow Centre for Population Health. 41. Tudor Hart J (1971) The inverse care law. Lancet 1: Differential impacts of health care in Australia: Trend analysis of socioeconomic inequalities in avoidable mortality. Feb (2010) Time to Care: Health Inequalities, Deprivation and General Practice in Scotland. Glasgow: Royal College of General Practitioners Scotland. 44. McKee M, Stuckler D (2011) The assault on universalism: how to destroy the welfare state. BMJ 43: d Craig P (2011) The development of a framework for monitoring and reviewing health and social inequalities. Glasgow: Glasgow Centre for Population Health. 46. Benach J, Malmusi D, Yasui Y, Martinez JM, Muntaner C (2011) Beyond Rose s strategies: a typology of scenarios of policy impact on population health and health inequalities. International Journal of Health Services 41: Benach J, Malmusi D, Yasui Y, Martinez JM (2012) A new typology of policies to tackle health inequalities and scenarios of impact based on Rose's population approach. Journal of Epidemiology & Community Health. 48. Judge K, Bauld L (2006) Learning from Policy Failure? Health Action Zones in England. European Journal of Public Health 16: (2009) Health Committee Third Report: Health Inequalities London: House of Commons. 50. McLoone P, Boddy F (1994) Deprivation and mortality in Scotland, 1981 and BMJ 309: Hunter DJ, Wilson J (2012) Promoting health equity. BMJ 345: e Wilkinson R, Pickett K (2009) The Spirit Level: why more equal societies almost always do better. London: Penguin. 53. Wilkinson RG, Pickett KE (2006) Income inequality and health: a review and explanation of the evidence. Social Science & Medicine 62: Curtice J, Ormston R (2011) Is Scotland more left wing than England?. London: Natcen. 20

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