Dr Carey Lunan is chair of the Royal College of General Practitioners Scotland, and a partner in a general practice in Craigmillar with the highest deprivation rating of any patient population in Edinburgh. “We’re one of a group of practices in Scotland that calls itself the ‘Deep End Group’,” she explains. The group, established in 2009 with funding from the RCGP and the Scottish government, unites 100 of Scotland’s 940 GP practices into a network serving the most deprived patient populations in the country. It is one of a number of projects that have been created in recent decades to attempt to counteract what doctors call “the Scotland effect” of lower life expectancy and higher morbidity in the country.
The “Deep End” practices are not evenly distributed across the country. Fully 80 per cent are in Glasgow, a reflection of the fact that the Scotland effect is often referred to, more specifically, as the Glasgow effect. But by bringing these practices together with others in deprived areas, the project aims to share challenges and come up with solutions to the persistent problem of poor health outcomes.
“Working in an area like Craigmillar,” says Lunan, “there’s a huge amount of resilience in local populations given the adversity they face. But for a GP in those areas there’s a huge intensity of workload, because people tend to develop chronic diseases at a much younger age than they would if they were living in more affluent areas.” For Lunan, providing proper resources to frontline and primary care services has to be part of the solution to health inequalities. “We have higher consultation rates,” she says. “We tend to see more problems within a consultation, and they tend to be more socially complex. And we tend to see much higher levels of mental health issues, and often addiction issues, which are often a symptom of living with high levels of adversity. That can create, as a GP, a lot of emotional labour.”
Scottish citizens of the United Kingdom can expect, on average, to die approximately two years younger than their English counterparts. According to statistics published by National Records of Scotland, the life expectancy of people born in Scotland between 2015 and 2017 is 79 – that’s 77 for males and 81 for females – which is the lowest in Western Europe. Improvements in life expectancy have stalled since 2015, as they have in the rest of the UK. In England, the average life expectancy currently stands at 81.4 years of age. But this relatively small two-year difference masks much greater disparities between the wider UK and Glasgow, where life expectancy is 73.3 years for men and 78.7 years for women – an average of 76.
In the rankings of all 44 European countries by life expectancy, Scotland as an independent country would stand somewhere between Cyprus and Albania, states with per capita GDPs of around $29,000 and $13,000 respectively. But Scotland’s GDP per capita is far higher, at $44,000 per person. Glaswegian men have a lower life expectancy than men in Algeria, Mexico, Jamaica or Iran.
This stubborn discrepancy between Scottish and English life expectancies has flummoxed public health experts and policymakers since it was first identified in the 1980s. But what explains it? “Lifestyle is hugely important,” says Lunan. “We have a very complicated relationship with alcohol in Scotland, which accounts for a lot of our healthcare problems and may account for some of the persisting health inequalities we see across the rest of the UK.” The so-called “excess mortality” amongst younger age groups in Scotland is driven by higher rates of death from alcohol and drug misuse, suicide and violence. “The use of alcohol is a really complex area,” Lunan explains, “because often people use it to treat psychosocial distress as much as anything else. So helping people to reduce their alcohol intake requires you to understand why they drink in the first place, and whether some of it is cultural, some of it is social, or some of it is to deal with trauma.”
A common, and logical, response to the Scotland effect is to cite poverty as a root cause. Scotland can certainly be said to have suffered disproportionately from the loss of traditional industries and deindustrialisation, particularly on the banks of the Clyde, where shipbuilding went into steady decline in the latter half of the 20th century. The links between health outcomes and wealth, income, class and socio-economic indicators such as employment and concentration of welfare claimants is undisputed, and has long been established by public health research. Socioeconomic deprivation is the primary factor behind poor health across the world, and in this regard Scotland is no exception.
But other factors are also at play. A 2016 report, History, politics and vulnerability: explaining excess mortality in Scotland and Glasgow, co-authored by the Glasgow Centre for Population Health, NHS Health Scotland, the University of the West of Scotland and University College London, showed that deprivation was not an adequate explanation for poor health outcomes and differentials. Scotland, and Glasgow, are not alone in experiencing above average levels of deprivation as a result of economic changes, and many places in England were not immune to the often painful transition from a manufacturing economy to one based on services and high finance.
Liverpool and Manchester are the two most similar and comparable cities in the UK when measured by multiple indices of deprivation. Together with Glasgow, they are former industrial and trading powerhouses. The three cities are almost identical in terms of their deprivation indicators, with around a quarter of the total population of each classified as income deprived. They also have similar distribution patterns of deprivation across the cities. Liverpool and Manchester have the lowest life expectancies in the UK. And yet, when they’re compared with Glasgow, premature mortality (deaths before the age of 65) in Scotland’s largest city is 30 per cent higher, and death rates across all age groups are 15 per cent higher. Across the whole of Scotland, premature mortality is 20 per cent higher than in England and Wales. “Adjusting for differences in poverty and deprivation (the main cause of poor health in any society),” says the report, “5,000 more people die every year in Scotland than should be the case.”
The mortality statistics of Glaswegians, compared to their counterparts in equally deprived Liverpool and Manchester, make for concerning reading. Deaths caused by lung cancer amongst Glaswegians were 27 per cent higher, by suicide 70 per cent higher, by alcohol-related causes 130 per cent higher, and by drug-related poisonings 250 per cent higher. But Scotland’s status as the “sick man of Europe” isn’t simply down to poor diet, tobacco and alcohol intake. The History, politics and vulnerability report shows that high mortality persists even after “adjustments for differences between countries in a range of well-established behavioural (e.g. smoking status, alcohol consumption, diet, physical activity) and biological (e.g. body mass index, blood pressure) risk factors.” The differences continue both amongst resident Scots and those who have moved to separate parts of the UK. The Scotland effect, then, is more than a side-effect of unhealthy habits. It is a symptom of public policy failures.
Cited in the report are a series of controversial schemes launched by local and national governments that have had adverse effects on public health across Scotland. In the 1950s, in response to post-war housing, health and economic problems, the Scottish Office embarked on a programme of “modernisation” that relocated thousands from their homes in the city to nearby New Towns. Places such as East Kilbride, Irvine, Glenrothes and Houston became a priority for private investment and public infrastructure, whilst the city itself was neglected. “Redeployed” New Town residents were generally younger, employed, skilled workers and their families. Meanwhile, the old, unskilled and unemployed became concentrated in the city proper, leading some to describe the policy as “skimming the cream of Glasgow.”
Later, in the 1980s, as councils across the UK were forced to make swingeing cuts to their budgets, Glasgow’s local authority became early promoters of inner-city gentrification and commercial development. This is in contrast to the actions of its comparator cities, Manchester and Liverpool, which attempted to ameliorate the worst effects of austerity and, in the case of Liverpool, launched a mass council-house building programme that mobilised and politicised large swathes of the population. In the post-war era, Scottish city planners favoured large, low-quality, within-city but peripheral high-rise council estates. Historically, less has been spent per capita in housing repairs and maintenance. Other factors include the actual “lived experience” of poverty in Scotland compared with the rest of the UK, which goes beyond what is usually measured by statistics, including more negative physical environments, proximity to vacant or derelict land, and lack of social capital.
Health policy is now devolved to the Scottish government in Holyrood, and the Scottish National Party has made much of its record, which includes abolishing prescription charges and presiding over improved patient satisfaction. Joe FitzPatrick, Scottish Government Minister for Public Health, told Spotlight: “The Scottish government has been working to address the underlying causes that drive health inequalities – not just in Glasgow but right across Scotland. Our bold package of measures to help tackle key issues such as smoking, obesity, inactivity, and alcohol misuse will support people to live longer healthier lives. We are also investing in affordable housing, providing free school meals and continuing commitments like free prescriptions and free personal care. This is on top of an investment of more than £125m a year to mitigate the worst impacts of welfare reforms and to protect those on low incomes.”
Dr Lunan will continue to work in Craigmillar, one of the many places across Scotland where the cold statistics on public health, still the worst in Western Europe, manifest themselves in the sickness, pain, loss and grief of real people. “That’s where the NHS is needed most and that, in many ways, was one of its founding principles.”