IntroductionBackground : This document uses routinely collected health service and mortality information to provide an up-to-date overview of inequalities in health with respect to material deprivation in Scotland. The document is designed to support work on the new strategic priority, tackling inequalities in health, in the National Health Service in Scotland.1 The national clinical and strategic priorities from the Priorities and Planning Guidance 1998-9 are used as a framework for the examples.1
The document has three main aims :
to provide a brief overview of the current relationship between material deprivation and ill health in Scotland ;
to demonstrate some ways in which analysis of the routine health data may be used to examine inequalities in health and access to health care services in Scotland associated with deprivation ;
to raise general issues for discussion regarding the measurement of deprivation in relation to health in Scotland.
Main findings : The main findings concerning the relationship between material deprivation (as measured by the Carstairs index) and ill health in Scotland and the main ways in which the datasets have been used, are summarised as follows :
Mental Health : There is an increasing risk of suicide with deprivation that is more marked in younger age groups. For schizophrenia, the incidence rates in general practice are markedly higher in people from the most deprived areas. A common feature of the mental health data examined is a tendency for there to be high rates among the most deprived with relatively little variation in rates between other groups. The hospital data show clear gradients in first admission ratios for depression, anxiety and schizophrenia with the most deprived having the highest admission rates. These variations in admission rates may reflect differences in factors other than incidence.
Further research is required into the relationship between socio-economic deprivation and psychiatric morbidity. Exploration of inequalities in care pathways and clinical outcome by deprivation is important, as is exploration of variations in incidence and prevalence of the conditions.
Coronary Heart Disease : Incidence of, and mortality from, acute myocardial infarction in those aged under 65 are higher in those from more deprived areas. There is no correlation with deprivation for mortality from acute myocardial infarction in those over 65. However, the frequency of coronary artery bypass graft procedures in people over 65 is highest in those from the less deprived areas. There is a tendency for men (0-64 and 65+) and women (0-64) from less deprived areas to have angiography and coronary artery bypass graft / angioplasty following first hospitalised acute myocardial infarction earlier, and more often, than those from more deprived areas.
Inequalities in procedure rates, by deprivation, should be further investigated, especially for people prior to first acute myocardial infarction when the greater proportion of such procedures are carried out. While the routine data can describe the patterns of provision of these procedures, they are not able to determine their appropriateness.
Reduction of socioeconomic inequalities in mortality from coronary heart disease is likely to be mainly achieved by appropriate and effective primary and secondary preventive measures matching need wherever people live.
Stroke : There is an increased risk of mortality from stroke in the under 65 population with increasing deprivation category. This relationship is not seen in those aged 65 or more. The incidence of first hospitalised stroke in those over 55 also shows a clear rising gradient with deprivation. There is increased survival at 30 days after first hospitalised stroke in men from the most deprived areas. However, there are no significant differences in the proportions, by deprivation, of hospitalised stroke patients discharged to their own homes within 56 days of stroke.
Reduction of socioeconomic inequalities in stroke mortality is likely to require equitable access to effective primary and secondary prevention and effective health care.
Cancer : The incidence rates for lung and cervical cancer rise with increasing deprivation category, while for large bowel cancer the rates are similar across all deprivation categories. The trend for breast cancer differs with lower incidence rates with increasing deprivation. The percentage uptake of breast screening from 1992-95 is lower in women from more deprived areas. For all four of these common cancers there is decreasing survival with increasing deprivation. There is no apparent difference in the likelihood of dying at home between cancer patients from different deprivation categories.
The patterns of cancer incidence by deprivation indicate the importance of primary prevention, while the variations in survival indicate the importance of monitoring equity of access to effective secondary prevention and treatment. Government targets are often framed in terms of cancer mortality, which can be improved through action on both incidence and survival.
General aspects : A deprivation measure, ideal for all purposes, does not exist. There should be clarity about the strengths and weaknesses of any measure of deprivation. The Carstairs index is well known and, although not perfect, is likely to continue to be useful. Exploring the use of non health datasets to help develop different ways of measuring deprivation or for validating existing measures may also be helpful. For many health conditions routine data can only provide part of the picture. The datasets are better developed for hospital inpatients and daycases, although the Continuous Morbidity Recording project is providing useful information about community morbidity. The utilisation of non-routine data sources may be required to help complete the picture. Data linkage is a powerful tool for analysis of clinical pathways and clinical outcomes, although at present these do not extend to the community. Care should be taken in the interpretation of trends in inequalities by deprivation using area measures. Indicators of inequality should take account of the fact that overall population figures are unlikely to be improved to a great extent by progress at the extremes. The national datasets need to be flexible to support a rolling programme of national strategic and clinical priorities.