Every few years, headlines emerge about how Scots have the lowest life expectancy in western Europe. This was true in 2005, 2010, and most recently earlier this month, when Paul Johnston, the head of Public Health Scotland, highlighted that life expectancy stalled around 2014 to 2016, then declined in recent years. At the moment men and women in Scotland are expected to die just over two years earlier than those in England.
What exactly is happening in Scotland to explain this pattern, and are we (I say “we” given that I’ve lived in the nation for roughly a decade) really that different from other parts of the UK and Europe? The first issue to highlight is that life expectancy differs based on where you live. In Glasgow, life expectancy varies hugely between the richer and poorer parts of the city. In 2021, if you lived in Pollokshields West, life expectancy was 83 years, while in Greater Govan it was 65.4 – a gap of 18 years. Averages hide a deeper story linked to deprivation and inequality within Scotland. Where and how you live plays a crucial role in how long you live.
Another issue is that life expectancy has declined in almost all countries (including the UK overall) because of the Covid-19 pandemic: of the 204 countries and territories analysed in a new Lancet study, 84% saw a decline in life expectancy in 2020 and 2021. In 2021, Covid was the second leading cause of death globally and reduced global life expectancy by 1.6 years. The lead author of the study, Austin Schumacher, said that: “For adults worldwide, the Covid-19 pandemic has had a more profound impact than any event seen in half a century, including conflicts and natural disasters.”
The pandemic also put additional strain on the NHS, and the higher mortality in Scotland is partly linked to difficulties accessing healthcare. But only focusing on acute care – that provided in hospitals once someone is sick – would be a mistake. It is the final line of defence in saving someone. I use the football analogy with students: focusing on hospitals is like expecting the goalie to save the team.
What makes up the rest of the team? Secondary prevention – identifying early indications of potential disease and intervening earlier, for example high blood pressure, pre-diabetes and cancer screening – is the equivalent of the defence. Moving further up the pitch, the rest of the life expectancy team should be focused on primary prevention or underlying population risk factors. In short, what’s causing these diseases to develop?
The causes are well-known in Scotland: high alcohol consumption (especially binge drinking), unhealthy diet (leading to high numbers of people who are overweight or obese), sedentary behaviour (not helped by the weather and the shutdown of public gyms and leisure centres) and smoking rates (which are slightly higher in Scotland than England). Scotland also has the worst drug death rate in Europe, at 248 deaths per million people aged 15-64, compared with 88 across the whole of the UK, although the rate has fallen in recent years. Deaths are linked to deprivation. Julie Ramsay, from the National Records of Scotland, said that: “Those living in the most deprived areas of Scotland are almost 16 times as likely to die from drug misuse compared to people living in the least deprived areas.”
The causes of early death have been recognised for years by the Scottish government. Investing more in secondary prevention and screening is a step forward, but difficult within a limited healthcare budget and with a focus on saving lives in hospitals (acute care) versus identifying earlier markers of disease. Beyond the healthcare system, the Scottish government has made relative progress on reducing smoking, implementing alcohol regulation such as minimum pricing, and on tackling the drug crisis. Changing diet and activity patterns has been more challenging: the number of people in Scotland (and England) who are overweight or obese remains stubbornly high and is implicated in almost a quarter of deaths.
The elephant in the room for each of these issues is deprivation, with an estimated 21% of the Scottish population living in relative poverty after housing costs. The Scottish government has attempted to address this with a range of policies, including the Scottish child payment programme, launched in 2021: a £26.70 weekly payment for each child under the age of 16 to those receiving income-related benefits. Scotland’s child poverty rate remains high at 24%, but is still lower than Wales’s (28%) and England’s (31%).
Looking forward, the cost of living crisis, a new disease in Covid layering on top of the existing causes of death, and very high rates of obesity and people who are overweight means that increasing healthy life expectancy is sticky. Recent analysis suggests that austerity policies at UK level over more than a decade have had a negative effect. In short, reduced spending on social security and public services by the UK government has decreased the amount of funding allocated to Scotland to keep pace with health challenges. Scotland was already behind on life expectancy metrics, and without further investment, this simply won’t change.
Prof Devi Sridhar is chair of global public health at the University of Edinburgh
