Key messages
Health inequalities in 
Scotland
Prepared for the Auditor General for Scotland and the Accounts Commission
December 2012

Key facts
£170 million 
2011/12 allocations to the NHS for schemes related to health inequalities
£11.7 billion 
Total amount spent by the NHS in 2011/12
40 per cent least deprived* / 15 per cent most deprived
Exclusive breastfeeding rate at 6-8 weeks
28 least deprived* / 62 most deprived
GP consultations for anxiety per 1,000 patients
11 per cent least deprived* / 40 per cent most deprived
Percentage of adults who smoke
214 least deprived* / 1,621 most deprived
Alcohol-related hospital admissions per 100,000 population
81.0 years least deprived* / 70.1 years most deprived
Average life expectancy of men
84.2 years least deprived* / 76.8 years most deprived
Average life expectancy of women
* These comparisons refer to people living in the one-fifth most deprived and one-fifth least deprived areas.

Overall health in Scotland has improved over the last 50 years but there remain significant differences owing to deprivation and other factors
•	There have been long-term increases in average life expectancy and major improvements in overall health but health inequalities remain a significant and long-standing problem in Scotland. Health inequalities are highly localised and vary widely within individual NHS board and council areas. 
•	Deprivation is a major factor in health inequalities, with people in more affluent areas living longer and having significantly better health. The average healthy life expectancy is around 18 years lower among people in the most deprived areas compared with those in the least deprived areas. People in more deprived areas also have higher rates of coronary heart disease, mental health problems, obesity, alcohol and drug misuse problems, diabetes and some types of cancer. Children in deprived areas have significantly worse health than those in more affluent areas. 
•	Reducing health inequalities has been a priority for successive governments in Scotland but most indicators show that inequalities are not reducing. 
Formulae for allocating money to NHS boards and councils take account of local needs but it is not clear how resources are targeted within local areas
•	The Scottish Government takes account of local needs, including deprivation, in allocating funding to NHS boards and councils but it is not clear how NHS boards and councils allocate resources to target local areas with the greatest needs. 
•	It is difficult to track direct spend by the NHS and councils on addressing health inequalities. The Scottish Government allocated around £170 million to NHS boards in 2011/12 to address directly health-related issues associated with inequalities. This included around £15 million for programmes specifically aimed at reducing health inequalities by targeting particular groups within the population. 
•	Recent changes in quality payments to GPs mean that GP practices in deprived areas should receive additional resources to help address problems related to health inequalities.  
Better access to health services may help to improve outcomes for disadvantaged groups
•	GPs have a critical role to play in helping to reduce inequalities but their distribution across Scotland does not fully reflect the higher levels of ill health found in deprived areas. The distribution of other primary health care services, such as pharmacies and dentists, is more closely matched to need. 
•	People in the most deprived areas also require greater access to hospital services but they have poorer access and worse outcomes. They are also more likely to miss hospital appointments due to various factors such as a lack of access to transport. 
•	Policies designed to improve the health of the whole population, including cancer screening services and free eye tests, can increase inequalities due to higher uptake among people from more affluent areas. 
There is limited evidence that strategies and initiatives for reducing health inequalities have made a significant impact. Better partnership working is needed
•	National strategies which aim to improve health and reduce health inequalities have so far shown limited evidence of impact. Changes will only be clear in the long term but measures of short- and medium-term impact are important to demonstrate progress. 
•	Many initiatives for reducing health inequalities lack a clear focus on cost effectiveness and outcome measures. This means that assessing value for money is difficult. 
•	Current performance measures do not provide a clear picture of progress. Community Planning Partnerships’ (CPPs’) reports on delivering their Single Outcome Agreements (SOAs) are weak in the quality and range of evidence used to track progress in reducing health inequalities, and differences among SOAs means that a Scotland-wide picture is hard to identify. 
•	Reducing health inequalities is challenging and requires effective partnership working across a range of organisations. However, there may be a lack of shared understanding among local organisations about what is meant by ‘health inequalities’ and greater clarity is needed about organisations’ roles and responsibilities. 
Key recommendations 
The Scottish Government should:
•	introduce national indicators to specifically monitor progress in reducing health inequalities and report 
on progress.
The Scottish Government and NHS boards should:
•	review the distribution of primary care services to ensure that needs associated with higher levels of deprivation are adequately resourced
•	include measurable outcomes in the GP contract to monitor progress towards reducing health inequalities, and ensure that the Quality and Outcomes Framework is specifically designed to help reduce health inequalities.
The Scottish Government and CPPs should:
•	ensure that cost effectiveness is built into evaluations of initiatives for reducing health inequalities from the start
•	align and rationalise the various performance measures to provide a clear indication of progress.
CPPs should:
•	ensure that all partners are clear about their respective roles, responsibilities and resources in tackling health inequalities, and take shared ownership and responsibility for actions aimed at reducing health inequalities
•	build robust evaluation, using all available data and including outcome measures and associated costs, into local initiatives aimed at reducing health inequalities
•	include in SOAs clear outcome measures for reducing health inequalities which demonstrate impact, and improve their performance reporting.
NHS boards should:
•	monitor the use of primary care, preventative and early detection services by different groups, particularly those from more deprived areas. If this identifies systemic under-representation of particular groups, take a targeted approach to improve uptake
•	monitor the use of hospital services by different groups and use this information to identify whether specific action is needed to help particular groups access services.
NHS boards and councils should:
•	identify what they collectively spend on reducing health inequalities locally, and work together to ensure that resources are targeted at those with the greatest need.
What happens now?
The full report can be accessed on our website – 
www.audit-scotland.gov.uk. We will present our report to the Scottish Parliament’s Public Audit Committee. The Committee can call relevant people at the Scottish Government and other public bodies to discuss the issues our audit has raised.
We will also monitor progress against our recommendations through our audit work.