An Unhealthy Situation: Rising inequality in Scotland is reducing life expectancy

“It is perhaps easy to forget,” wrote experts from the Glasgow Centre for Population Health (GCPH) in a paper on mortality rates, that we live in “one of the wealthiest countries on earth”.

In such a wealthy society, they went on, “the health of the population should be improving, not becoming worse”. But healthy life expectancy is decreasing, as is life expectancy overall, with the gap between richer and poorer widening, according to figures released in February.

Life expectancy at birth fell to 76.6 years for men and 80.8 years for women, according to National Records of Scotland. It is the second year in a row that a decrease has been recorded, and last year’s was the sharpest since the early 1980s.

Scotland has the lowest life expectancy of all UK countries, and behind this, health inequalities are on the rise, undoing so much progress of the 2000s and 2010s. A raft of reports say the cost-of-living crisis will make this worse. Childhood obesity, early years development, drug deaths – choose a demographic and you will find a troubling statistic linked, the GCPH authors say, to austerity, the continued fallout from the Covid pandemic and the current cost-of-living crisis.

Premature mortality is likely to increase by more than six per cent in Scotland over 2022-23, modelling suggests, with the greatest impact felt by our worst-off populations. “The appalling trends, and broader evidence, reported here require urgent action,” the authors said.

Professor Flora Douglas, of Robert Gordon University, is unsurprised by the findings. “It’s been a really profoundly depressing period,” she says. “I have been discussing this with colleagues. It feels like it’s never been so bad.”

Things have just got worse, significantly worse

Like GCHP, which is part of the University of Glasgow, Douglas is focused on health inequalities. Working predominately with the communities of the north east, she’s done extensive work on poverty-related food insecurity and its impacts on families, and she’s paid close attention to the findings of GCHP and others. This includes the independent Health Foundation charity, which in January published what it claims to be the most comprehensive paper on health qualities in the history of devolution. 

The report makes grim reading, raising the “glaring” problems faced by those at the lowest end of the socioeconomic scale. There is an “implementation gap” between policy and delivery, it says, and many of the issues identified were “set out over a decade ago” by the landmark Christie Commission, which charted a way forward for public service reform.

“We have been here before,” Douglas says of the picture revealed about the health of the nation. “One of the things that stunned me about having to do yet another review is we have quite a lot of evidence generated over a number of years about what’s happening in public health in Scotland,” says Douglas, who specialises in food insecurity. “What was once known as the ‘Scottish effect’ became the ‘Glasgow effect’, with profound inequality replicated in similar communities across Scotland.

“Income-driven food insecurity is a manifestation of people living with deep poverty. The picture we have been getting is in relation to that. We have parents and pregnant women who are not feeding themselves properly because they can’t afford to, and then we are expecting them to grow healthy babies, we are expecting them to breastfeed. For me, that’s a big pressing issue.

“There has been a transformational shift in life expectancy,” she goes on. “That’s an incredibly worrying indicator about the health of our nation.

“Since 2014 things have just got worse, significantly worse.”

This is a problem for every one of us

Up until the early 2010, mortality rates in Scotland and the UK had been improving for decades. But around 2012, progress stalled. More than four years has been shaved from life expectancy for most Scots over the last decade, according to the Health Foundation, and as of 2019 a 24-year gulf had opened up between the richest and poorest people in the time spent in good health. 

The overall life expectancy gap between these groups is a staggering 13.3 years for men and 9.8 years for women, the report found, and infant mortality rates in our most deprived communities were 2.6 times higher than those in the least deprived, as of 2016-18. Youngsters from struggling areas were more likely to be obese as they started primary school, the report found, and more likely to be the subject of developmental concerns as toddlers.

“The causes of inequalities in health outcomes are deep rooted and structural – exposed and exacerbated by short-term crises,” wrote Chris Creegan, who chaired the expert advisory group behind the report, “And they can only be resolved by a sustained, long-term response across society. This is a problem for every one of us.”

It’s a point also made by the Royal Society for Public Health (RSPH) in its recent pan-UK report on “the price we will pay for the cost-of-living crisis”, which argued that the situation is also a public health crisis with the potential to “leave a generation in poorer health than their predecessors”. “Prevention of ill-health is key to the financial growth and wellbeing of the nation,” wrote its chief executive William Roberts. “To ensure we are all supported to live healthier lives, more needs to be done to support households that have no way to respond to situations outside of their control.”

The cost-of-living crisis follows more than a decade of austerity policies. The UK Government brought those in to reduce the budget deficit in the wake of the 2008 financial crisis, undertaking cuts to public spending. The Con-Lab coalition pursued cuts of around £85b, and research has since associated this with negative shifts in public health and mortality rates. 

For Creegan, “the damage caused to health created by austerity over the past decade is unarguable”, and there is some merit, he says, in the argument so often made about services in Scotland, that the limitations of the devolved budget and powers restricts the Holyrood government’s capacity to act. However, he rails against any sense of “fatalism”, that there is an inevitability about the current situation. 

We have a capacity to act in Scotland that we are not fully utilising

“To a certain extent, we have taken our eye off the ball,” he says, and the Health Foundation report argues that an “implementation gap” between policy and practice is having a strong detrimental effect on public health. 

That gap is “apparent at different points through the continuum of policymaking”, the report says, and many of the underlying elements relate to “a lack of progress in delivering longstanding policy ambitions of the Scottish Government”. Unless the inertia ends, it argues, there is a risk of failure to deliver on the long-term policy needed for a healthier and more equal country.

“We have a capacity to act in Scotland that we are not fully utilising,” Creegan says. 

“You can argue that we need more powers, and you can argue that the effects of UK Government – in particular, austerity – have had a profound effect on Scotland’s fortunes and ability to act. We didn’t dodge that.

“Of course it’s the case that more powers could make a difference. But there was a very, very strong sense from the people that we spoke to, both in extensive stakeholder engagement and when we spoke to the public, that there is an implementation gap in this area that’s not unique to health inequalities. 

“The frustration amongst the stakeholders was enormous. It is very clear.”

It’s these profound structural factors playing a role

For Douglas, it will take “big ticket” interventions to turn the tide. That takes investment, but it also takes workforce planning and a shift in focus to prevention. She points to the Scottish Child Payment and the Community Link Worker programme, which places non-medical staff into GP practices to support patients with personal, social, emotional and financial issues. These, she says, are examples of what can be done where there is the will. 

“We have been focusing so much on behaviour change,” she says of recent initiatives on diet and health, “but what’s holding people back is not a lack of motivation, it’s not a lack of knowledge, it’s not even a lack of skill.

“It’s only recently I have been hearing officials being honest about saying we have got to look at this more broadly. We can fix this situation by acknowledging it’s these profound structural factors playing a role and inhibiting people.”