Without walls: towards health and wellbeing in the 21st century

Scotland’s poor health record has its roots in income inequality, says Dr RICHARD SIMPSON


We have some of the worst health in Europe, despite our very good health service. And that’s because of the gap between the rich and the poor and an NHS where hospitals are too powerful.

In the last couple of decades we’ve built many new hospitals and trained thousands more doctors and nurses. But even though we now spend up to the European average on the NHS, our health in the UK, and especially in Scotland, remains one of the worst in Europe. People in Scotland can still expect to live shorter lives than most of their European counterparts.

We have confused good medicine with good health.  We have lots of “good medicine” – but our poor health is now even threatening to overwhelm some parts of the NHS. The massive increase in obesity, for example, which hospitals can’t control, is sending more and more people into hospitals for cancers, for diabetes, and for fat-reducing surgery. At a time when public services are having to watch every penny, letting our nation’s health slide, as the government may do, is going to be very expensive.

So why, when our medicine is good, is our health not as good as it should be? The “wrong” lifestyles and poverty are two of the reasons normally given. But those aren’t the root causes. The poor health record of Scotland, indeed the whole UK, exists not just because poor people in poor communities are less healthy than they should be, though they are. Our poor health is a consequence of inequality, the size of the income gap between rich and poor.

People don’t like to hear that, but you look around the world and you see it’s true. The USA is richer than us, spends more on health but is more unequal, and people die younger. Spain is poorer than us, spends less on health services but is more equal, and people live longer. Thatcher and Major increased the gap between rich and poor. That’s had a massive impact on people’s health.

There are important lessons for us now. The drastic changes the Conservative/Liberal Democrat government wants to make to the way we deliver medicine in England are unlikely to mean better health. In fact, our nation’s health will likely get still worse as cuts and higher taxes hit the poorest hardest; even more so if they cut all the cheaper things, like proper home care for elderly people, that keep people out of hospital. Worse health will pile even more pressure on the NHS.

The lesson is simple: in times when money is short, government needs to focus on health, not just medicine. We should think beyond just what the NHS does in hospitals because our health is more to do with all the other community and local public services – protect them and you protect the NHS. That’s why, in their last manifesto, Scottish Labour set out plans to merge the national primary and community health budget with the local budgets for elderly social care, learning disability and mental health. Run by existing Scottish Community Health Partnerships, this national care service would have been more accountable through the increased involvement of local councillors.

Our health will improve if we narrow the gap between rich and poor. For the sake of our health, the government should recognise the public mood to increase fairness and take radical steps to reduce income inequality, placing the heaviest burden on the broadest shoulders. If we want to be better, in health and much else, we have to be fairer.

Dr Richard Simpson MSP is Labour’s Shadow public health spokesman in the Scottish Parliament. This article is based on the Socialist Health Association discussion document written by Dr Simpson and Professor Trevor Davies. The full discussion paper can be downloaded here.

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14 thoughts on “Without walls: towards health and wellbeing in the 21st century

  1. Inequality is there whoever is in power, and that is a reflection on the last period of Labour power, what was done in the NHS then.

    There is a recent examle where the Drug to combat Prostate Cancer(Aberiterone?) was developed at the Cancer Research Institute in the UK and is available and very successful in the USA(and some Lybian Pharmacies) but is not yet available in UK. Why?

    Is it undergoing tests in the UK? if so, how do you get on the test?

    By the time NHS patients see an Oncologist they are probably not eligible for any test studies because they have had interim treatment.

    It’s not only money that private medicine gives it’s also time advantages.

  2. One thing that I cant understand is why income inequality affects health in a society that provides free education, free health services, free health information and a basket of sin taxes designed to make doing bad things expensive.

    I agree that the health service needs to focus more on prevention but even if there were 10,000 JK Rowlings in this country moving me well down the “inequality scale” my daily life and health care services would be no different.

    Just why does this inequality affect health – what is it that makes inequality that makes poorer people eat fatty foods when an apple is cheaper? What is it about inequality that makes poorer people spend more on a takeaway than low fat microwave meal? What is it about inequality that makes poorer people stay in watching endless reality TV shows as opposed to going out for a walk?

    I just dont get it.

    1. An apple isn’t cheaper. The reason poor people choose to eat unhealthy food is because it is cheaper. Go into any supermarket and you will find a bag of 6 apples costs about £2 and a tray of 12 doughnuts costs about a £1. Perhaps someone ought to look into minimum pricing for food as well as for alcohol?

      1. Granted that Tesco do 6 apples for 90p and Custard Doughnuts at 55p for 5.

        Now, at the absolute margins I can see how that 35p could make a significant difference to some people. However, that is to do with poverty and the cost of food.

        How, though, is it to do with “income inequality” as set out in the article?

      1. I have read a couple of his presentations. Again, I can’t totally see why and how poverty is a health problem. No argument from me.

        But, again, why does “income inequality” cause health problems? There is a big difference between poverty and “income inequality”. As forfar-loon points out there are real differences in across the world in peoples relationships with food and exercise. I just don’t get why JK Rowling earning hundreds of millions means I need to go and eat a deep fried pizza.

        1. Douglas, yes. There is a big difference between poverty and income inequality. And strangely it’s inequality, not poverty, that has a bigger impact on health, at least in western developed countries. Greece is poorer than the USA – but Greece has longer life expectancy than the USA. The USA is the most unequal of all the developed countries and has poorer health. Try reading “The Spirit Level” for a full explanation of why. Or if you have a look at our full paper which can be downloaded from the link at the bottom of Richard Simpson’s item and which tries to give a summary of the arguments.

  3. Our poor health is a consequence of inequality, the size of the income gap between rich and poor.

    I don’t think inequality explains the differences between the UK, the US and Spain (or any other countries) at all. Like Douglas McLellan I’d love to understand why inequality in and of itself makes people choose unhealthy lifestyles.

    Instead, could it simply be that Spanish food is generally healthier than UK food, which in turn is generally not as unhealthy (or served in such huge amounts) as American food? Perhaps the fat and salt rich ready-meal phenomenon hasn’t taken such hold in Spain? Perhaps the Spanish eat fresher, less processed foods? Perhaps they see food as an art form, worth taking time over, not something to be shovelled down and got out of the way? Maybe that different food tradition plays a role in overall health?

    A few years back forfar-quine did some research into the relationships different nationalities have to the food they eat and their well-being. One highlight was that the Japanese believe very strongly that what you eat determines how healthy you are. They really live out the adage that you are what you eat, down to choosing what foods to buy and which ones to avoid.

    One lowlight was that the UK people interviewed didn’t see that connection very strongly at all. Health seemed to be some mysterious, intangible thing that bore little relation to what food we put into our bodies. Perhaps that attitude is what needs to be changed, along with attitudes to exercise. Perhaps we need to understand more fully the role that climate and genetics plays. The gap between rich and poor that has widened over the last 50 years should also be tackled, but I’m not sure it would help overall health if done in isolation.

  4. This article is a classic of its kind. Indeed I think I will print it out and send it to Nicola Sturgeon. I am sure she will enjoy it. You might want to pass it on to Jackie Baillie who has spent most of the past few years opposing every attempt made to tackle the causes of poor health as well as treat them. Minimum pricing? No thanks, Jackie just bangs on and on about the number of hospital nurses.

    MIL it is not really true that healthy food is more expensive than unhealthy food. It’s a lot more complex than that. In the old days poor people made more of their own food – they made soup and stews that were mainly vegetables like potatoes, carrots, onions etc with a bit of meat to give it flavour and which could feed a family of six for the cost of a fish supper. But a lot of younger people have lost those skills, indeed I would say the poor eat fast food to a much greater extent than the middle class.

    Go to any poor area of Glasgow and you will find many more fast food outlets than in middle class areas. Of course while there are more chippes, kebab shops and burger joints there are also fewer outlets selling fresh food. (That is one of the reasons incidentally why having a Tesco or Asda move in to a low income area is an unmitigated Good Thing). Even if people did have access to more fresh food it is not a given that they would choose that rather than choosing unhealthy fast food. The reasons for that are psycholigical as much as economic. It is because of poverty but it’s not only about financial poverty – there are other kinds of poverty.

  5. Agree with the thrust to prevention, rather than cure. Cheaper, better, more social benefits etc.

    No discussion here of tackling the vested in interests of the medical- pharmaceutical establishment core belief in the damaging concept that we should “drug our way back to health” with ever fancier and more expensive pill-popping, equipment, skilled staff, complex facilities and unaffordable escalating health costs.

    As usual, the dimension conspicuously missing in UK health debates of this kind is the mental wellbeing dimension. The US, Canada, OZ, NZ are a generation ahead in considering the psychological aspects of health. I see no awareness of Scottish/UK policymakers awareness of key concepts such as Glasser’s Control Theory or Goleman’s Emotional Intelligence.

    Another dimension missing is the politically explosive link between political subjugation, cultural imperialism and the devastating effects of such cultural domination on indigenous cultures. The classic impact of Western civilisations on native cultures (eg Oz aborigines, some Pacific cultures, Native Americans, Amerindians in the Amazon etc) is to cause such phenomena as drastic drop in birth rate, catastrophic falls in physical and mental health, shorter life spans, cultural social and political demoralisation, social disintegration, drink and drug abuse epidemic, social crime waves and anti-social behaviour explosion, sexual abuse and family violence, In short, the indigenous culture goes into self destruct mode. Note how social indicators have started trending upwards since the SNP first took office. It may cause Scots to suck lemons to view themselves as an ‘indigenous culture’ subject to ‘English/Brit cultural imperialism’ but the social symptoms strongly point that way. This debate is not been conducted in braid Glaswegian, is it? A large part of the population conduct daily life in entirely different linguistic and oral fashion.

    A distinction needs to be made between absolute poverty – total lack of cash; relative poverty – can’t afford the latest gizmo/trendy clothes; and self-imposed “poverty” The latter is the key ingredient in social deprivation and physical, emotional and spiritual decay. Self imposed poverty is a form of self-destruction. In the face of being totally powerless to influence all other environmental factors, people turn the anger inwards and self destruct by ignoring healthy eating, sleeping and exercise – in favour of fast food, fags and cheap booze. It is a shocking choice, but it is a choice. Work back the logic chain. Reverse the process – so how do we empower individuals, groups, communities, to be able to and want to have a positive impact on themselves and their environment. And no I do not accept that changing political colours at Westminster is the catch-all answer. There needs to be a back to basics, ground up, self empowerment. Try looking at what has worked with other culturally impoverished peoples such as the Canadian Native Americans and Australian aborigines. (Noel Pearson, Cape York articulates issues well)

    One comment is about loss of cooking skills. I vividly remember my parents talking about the cheap abundant tropical. semi-tropical fruit stalls in Scotland before WWII (I noted a curious reference in an article on insurance claims that the most common 19th century insurance claim was for falls caused by skidding on orange peel) A cultural influence that has dropped out of consideration is the impact of years of war/post war rationing on cooking habits and skills. Antipodean visitors are variously shocked, appalled, amused at the low quality of eating in the UK. Mostly too polite to tell you directly. Even so-called better eating is very ‘ordinary’ in Australian terms and ‘ordinary’ is equivalent to ‘crook’ or ‘rs’.

    Another aspect is the tendency to silo thinking. The medical profession has captured the health debate – and made it about ‘ill-health’ referred to as ‘health’ as the article rightly points out. The NHS is NOT a ‘health service – it is an ‘Ill-health service’. The medical profession solely on the physical body. Ie “medicine as sophisticated plumbing” ignoring mind-body interaction, mental orientation and behavioural habits; except in tokenistic fashion. They are ever more specialists in treating the symptoms, not the causes. At ever faster rising cost and ego gratifying specialist knowledge for the practitioners. A fundamental shift in definition, of direction, policy and resource allocation is badly needed and will unleash the mother of all vested interest campaigns of reaction. Standard advice is : Don’t start a fight till you are sure to win it.

    On the link between inequality, diet and health my assessment is that the “inequality causes poor health” is false logic. The argument fails to consider that “coincidence is not automatically causation”. The missing dimension of causality is cultural mores and habit patterns. for example, American consumerist culture (an influence in UK, Australia etc) is driven by consumption “more is better” hence the “supersize me” obesity explosion. There are cultural aberations such as the French wine consumption not translating into equivalent severe health statisitics which point to perhaps mental attitude influencing bodily reaction (?) The interaction of lifestyle, diet, mental attitudes, spirituality, mental health, physical tendency to disease patterns and actual ill-health is much more complex than simplistic linking of inequality and ill-health. The latter linking might play to left-leaning prejudices, that does not mean that it is a good driver for health policy formulation.

    Lastly, the past policy was to “merge the national primary and community health budget with the local budgets for elderly social care, learning disability and mental health” This may be desirable/advantageous/ more cost effective. But and a major BUT, it is still within the existing mindset of the NHS “tackling ill-health means we are a health service” This is not prevention, it is still about sticking plasters on sores.

    So: I suggest the addition to the above policy of preventative policies:
    These are thought starters, not definitive suggestions.

    Be the change you purport to espouse. Self realising expectations work to create either negative downward spirals, or positive upward spirals.
    Labour has bad history of focusing on the negative. Then carping, criticising, obstructing, diminishing and opposing. If you point in that direction is it any wonder that you end up where you point? A negative culture, negative symptoms and drastic negative outcomes. Labour needs to rediscover faith in a Scottish future, a reinvigorated and improving society, economy and physical and mental wellbeing. Who the hell would want to pursue anything else?

    Dietary education in schools. The used to be ‘domestic science’ till the politically correct phased it out. Put it back – for all.
    Introduce Australian-style ‘cost-for weight’ pricing. So called ‘cheap’ fast foods are often dearer when price-for-weight equivalent comparisons are made.
    Minimum pricing for alcohol. Forget the partisan opposition-for-opposition-sake of the recent past. It makes sense and is happening in other countries.
    Shift school snacks, meals etc to fresh fruit and vegetables.
    Wean Scots off sugar – worst offenders in Europe as I recall.
    Wean Scots off salt – strong link to heart disease – the national pastime.
    Re-socialise the soulless housing estates by building mini-shopping areas with fresh fish, meat, vegetables, bread available locally.
    Use social/political pressure as Australians have done to force the fast food manufacturers and retail chains to put increasing amounts of healthier (fruit/veg) ingredients in products and diminish the salt/fat/sugar content by progressive amounts to wean tastes off ill-health creators.
    Force supermarkets to shift liquor into separare shop-within-the shop areas as is normal in other countries. No more sellingi ll-health in the form of loss leading cheap liquor at the checkout. If they scream, good.
    Make a serious commitment to lead by example in shifting from gross over-indulgence in alcohol, to enjoyment, cheerful social drinking in moderation.
    Vastly increase physical activity, all age groups, all sectors of the community.
    Walking Bus to school clubs, more pre-school, primary and secondary sports. Instead of carping and criticising passively, embrace the SNP initiatives around the Commonwealth Games to build on and excel those initiatives.
    Get behind the police initiatives of football for gang members etc of the Strathclyde initiative and boost it nation-wide, making it for all.
    More sports outreach programs See http://www.afl.com.au/development/schools/ambassadorprogram/tabid/10264/default.aspx
    Introduce Neighbourhood House programs. See http://www.anhlc.asn.au/about-anhca
    Tackle depression and its root causes along the lines of Beyond Blue http://www.beyondblue.org.au/index.aspx?link_id=7.980
    with special ref to Aboriginal and Torres Strait Islander guidelines.
    Aim at and bring about a Scottish working class revival See http://www.cyi.org.au/welfarereform.aspx

    That’s my tuppence worth.

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