One of the key functions of public health is to help populations to be as healthy as possible. People in different social circumstances experience differences in health outcomes and life expectancy, with people living in deprived circumstances being more likely to die at a younger age. These deaths could be avoided. We now understand the links between poverty and ill-health better than ever before. There is a substantial body of evidence which demonstrates the gradient in health experience across all social groups and the magnitude of avoidable poor health that separates those in more deprived circumstances from the rest [1, 2]. Scottish Government policy supports a focus on early intervention; Equally Well , the Early Years Framework  and Achieving our Potential  all set out to address the underlying causes of Scotland’s health and other inequalities. Within Europe a strategic framework for combating poverty was produced in 2010  and work continues to focus on improving the health of people from vulnerable groups . The WHO report on the social determinants of health Fair Society, Healthy Lives’, known as the ‘Marmot Review’, was published in the spring of 2010 and sets out the link between social and economic inequalities and their impact on health . The Review highlights the need for action at both national and local level across all the social determinants of health if health inequalities are to be reduced. Six key objectives have been highlighted which need to be addressed to make health more equitable:
- Give every child the best start in life;
- Enable all children, young people and adults to maximise their capabilities and have control over their lives;
- Create fair employment and good work for all;
- Ensure a healthy standard of living for all;
- Create and develop healthy and sustainable places and communities; and
- Strengthen the role and impact of ill health prevention.
Life expectancy in Lothian
Figures 1 & 2 show life expectancy for men and women in the least deprived and most deprived 15% of the population by council area across Lothian . These figures illustrate clearly the variation in life expectancy across each of the deprivation categories, with those in the most affluent section of the population having a greater life expectancy.
Male Life Expectancy at birth in Council areas (most deprived and least deprived) 2004–2008 
Female Life Expectancy at birth in Council areas (most deprived and least deprived) 2004–2008 
Please note that the figure for East Lothian females should be interpreted with caution, the confidence interval in this locality is wide and overlaps with life expectancy of the least deprived.
The Equally Well national framework  for action on health inequalities has supported two developments in Lothian, ‘Support from the Start’. The Equally Well Early Years test site in East Lothian and Keep Well. ‘Support from the Start’ and Keep Well comprise programmes of interventions that focus on improving the health of those in more deprived circumstances and aim to make health more equitable for all.
‘Support from the Start’, was established in East Lothian in March 2009. The Council, NHS and community organisations have been working together to improve access to support services which will help to close the health gap. The aim is to improve existing service pathways and/or develop new ones for addressing health inequalities in the early years. Engaging communities in working with partner organisations to identify and implement the actions required to improve the health of their youngest members is an essential feature of this programme. All the interventions focus on collectively improving the health outcomes for the youngest members of the community. Examples include: supported development of local projects such as play and literacy groups, story telling groups, music and literacy; created space for learning and reflections of staff and communities through action learning sets and conferences; building of leadership through a network of service, community and strategic champions; targeting of breakfast provision and redesign of oral health promotion in two local community areas. The expected outcome is to prevent the risk of disadvantage in health outcomes being passed from one generation to the next. Four broad outcomes have been identified: increased community engagement; improved support for parents and carers; improved support for families; the creation of child friendly environments .
Keep Well was launched as a pilot in fourteen General Practices located in areas of deprivation across Edinburgh in 2006/7. People aged 45-64 and registered at these practices were invited to have a cardiovascular health check. In 2009, Keep Well was extended to include five West Lothian practices. The project also expanded to include other groups in Lothian at particularly high risk of heart disease. These vulnerable groups include people who are homeless, also offenders and ex-offenders. Some people from particular ethnic backgrounds are known to have higher risk and those include South Asian people and Gypsy/Traveller populations. The programme is integrated into existing General Practice activity and all of the patient information collected is added to a patient’s routine health record. This makes it significantly different to other health improvement initiatives that have occurred in the past.
At the heart of Keep Well is recognition of the importance of making health more equitable and the important role of the health service in achieving this . The health checks are delivered to those in greatest need  and focus on ill-health prevention, rather than waiting for people to develop health problems like angina or stroke. Since the start of the project 17,564 people in Edinburgh have received a health check (to end of October 2010), 1,775 people in West Lothian (December 2009 – end of October 2010) and 547 people from key vulnerable populations (January – end of October 2010).
Addressing health inequalities and closing the gap in health outcomes between the most and least affluent requires multifaceted action with individuals, families and communities. This article has highlighted two recent programmes and work in NHS Lothian. They are two examples of a range of interventions taking place across our communities. The importance of such a range continuing to progress supports the need for a multi-faceted approach which targets those most in need.
“Best thing I ever done, the nursing staff make you feel so relaxed, your MOT for the Body is an excellent way of finding out what you have to do to get back on track. Do not be afraid- what I found out has made me a better person for the check, and now I know how to look after my body. Would highly recommend to anyone and free of charge.”
Quote from a keep well patient.
- We require a progressive multi-faceted approach to reducing health inequalities.
- The benefits of action in the first five years of life are well evidenced and should continue to be prioritised.
- Universal health services should be targeted to meet areas of greatest need and focus on primary prevention, to stop ill-health wherever possible.
- There should be a holistic model of health improvement embedded in existing primary care services.
- We should strengthen pro-active primary prevention to avoid health problems occurring in the first place.
- All agencies should ensure that they take action to break the cycle of poverty.
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