Sick to death: Why poverty remains at the centre of Scotland's public health divide

The Scottish Parliamentary constituency of Glasgow Southside is routinely described as one of the country’s most diverse. Home to speakers of dozens of different languages, it has been represented by former first minister Nicola Sturgeon since it was created in a 2011 boundary review which saw the disappearance of Glasgow Govan, a constituency which swung from Labour to SNP following the latter’s historic election win in 2007. Sturgeon, who is standing down at the election, won’t be on the ballot this time around but equalities minister Kaukab Stewart will be, up against candidates including the now forever-fedoraed George Galloway. 

As well as being multicultural, the constituency is also socio-economically mixed, from the red and blonde sandstone mansions of Pollokshields to areas of deep poverty in Ibrox and the Gorbals. It’s in these areas, among the most deprived in the country according to the Scottish Index of Multiple Deprivation (SIMD), where so-called healthy life expectancy, the number of years lived in ‘good’ or ‘very good’ health, has fallen to just 44.8 for men and 44.2 for women.

Those aged 44 at the time of May’s election are still young enough that they would not have been able to vote at the first Holyrood election in 1999. And yet a failure to address Scotland’s deep-seated public health inequalities in the devolution years means – at least for those in the most-deprived communities – many will now be entering a period of their lives punctuated by ill health of the sort not experienced by wealthier Scots well into their 60s and 70s.

Healthy life expectancy, an estimate based on how people perceive their own health, has been falling since the mid-2010s, a period marked by austerity, Brexit and Covid. While overall life expectancy had also been in decline, it has seen a small increase in recent years, meaning that while people are living longer, more are doing so in poor overall health, although Scotland continues to have the lowest life expectancy in Western Europe. Figures for 2022-24 show that women in the most deprived parts of the country are expected to live in good health for around 26.7 years less than those in the least deprived areas; for men the figure is 25.6 years. On average, healthy life expectancy is 59.4 for women and 59.1 for men, lower than in England where the corresponding figures are 61.3 and 60.9.

“Healthy life expectancy, along with life expectancy and the gap in inequalities, are the main target measures we use in public health,” says Dr Fatim Lakha, a consultant in public health medicine at Public Health Scotland. 

“They’re quite shocking [figures]. For a long period of time, healthy life expectancy was increasing – right up until around 2012 to 2014. Since then, it’s been declining gradually over time. There are multiple reasons, one of them being austerity and persistent high levels of poverty and financial insecurity. There are also increasing levels of multi-morbidity and co-morbidity, so [there are] more and more long-terms conditions, especially in more deprived communities.”

Lakha, whose organisation has a 10-year strategy to improve average life expectancy by at least one year by 2035 alongside reducing the poverty-related gap, says the situation has been compounded by issues including housing supply, work insecurity and the growing burden of mental ill health across the population, not to mention the impact of the pandemic. 

Created as a special health board in April 2020, PHS was pitched in at the deep end, charged with leading Scotland’s response to the unfolding public health emergency. With the pandemic now thankfully receding into the distance, the organisation can get on with the work it was initially set up to do, namely reducing the country’s entrenched health inequalities which have remained stubbornly fixed for decades. It seeks to do this by applying the Marmot principles, a systematic approach to public health devised by epidemiologist Michael Marmot whose 2010 landmark report for the then Labour government outlined a series of measures to prevent ill health and reduce inequalities in England.

Despite being well received, the report was followed by a change of government and a period of economic austerity which a 2022 report from the Glasgow Centre for Population Health linked to 335,000 excess deaths in England, Scotland and Wales between 2012 and 2019. In his follow-up report, Marmot Review: 10 Years On, Marmot and his colleagues at the Institute of Health Equity were highly critical of UK Government policy, highlighting a drop in life expectancy, an increase in ‘deaths of despair’ (those caused by suicide, drugs and alcohol abuse), rising child poverty and a housing crisis.

Scrutiny of Scotland’s idiosyncratic public health challenges is, of course, nothing new. The term ‘Glasgow effect’, used in a 2010 academic paper, describes a long-observed phenomenon whereby those living in Scotland’s largest city suffer worse outcomes than those in similar post-industrial British cities with comparable levels of poverty and unemployment. But despite more than a quarter of a century of devolved government, with power to shape education, health, and now social security, Scotland’s population health challenges, which once earned it the ‘sick man of Europe’ epithet, remain as intractable as ever. 

When it comes to ‘deaths of despair’, a term first used by Scottish-born Nobel laureate Angus Deaton to describe the situation afflicting the white working class in the United States, Scotland continues to lead the way in a UK context. Despite a 13 per cent fall in fatalities on the previous year, the 1,017 drug deaths recorded in 2024 remained the highest rate in Europe. And Scotland has a higher rate of alcohol-related deaths than other parts of the UK, albeit the figure fell last year from 2023’s 15-year high. Meanwhile, around one in five children start school in Scotland at risk of being overweight or obese. 

“The massive gaps [in healthy life expectancy] between the richest and poorest areas really underlines that poverty is one of the unifying factors in all this,” says Chris Birt, associate director for Scotland at the Joseph Rowntree Foundation. 

“Fundamentally in Scotland, we still have these deep disparities between different bits of the country. Whoever is in the next Scottish Government will have to think really carefully about this. Eradicating child poverty is not going to happen through tweaks to the status quo; we need to rip up some of the wiring of how Scotland works or we’ll keep getting the same results.”

The SNP government at Holyrood has received praise for the introduction of the Scottish Child Payment, a means-tested benefit of £27.15 a week per child, which has gone some way to tackle levels of child poverty. The so-called two-child cap, which has been blamed for pushing around 350,000 children into poverty, was scrapped by the UK Government in the Budget, a measure also likely to have a significant impact.

But on explicit public health measures, including those promised in the party’s 2021 manifesto, the SNP has either been slow to act or has U-turned completely. The party had pledged to introduce restrictions on alcohol advertising, particularly where children would be exposed to it. But in 2023, then first minister Humza Yousaf dropped plans to ban advertising on TV, billboards and in sport amid pressure from the alcohol industry. 

“I believe that all of us want to reduce the harm caused by alcohol, particularly to young people – but without undermining Scotland’s world class drinks industry or tourism sector,” Yousaf said. 

Perhaps ministers felt battle-scarred from their fight against the alcohol industry to introduce minimum unit pricing (MUP), arguably the biggest public health intervention at Holyrood since the smoking ban, which marks its 20-year anniversary this month. Scotland became the first country in the world to introduce unit pricing in 2018 after a five-year legal battle with the Scotch Whisky Association.

An evaluation of the policy carried out by PHS in 2023 found it had reduced deaths directly caused by alcohol consumption by more than 13 per cent and alcohol-related hospital admissions by more than four per cent, with the greatest reductions among those living in the country’s most deprived communities. A review of MUP in Scotland, Wales, Ireland, Australia and Canada, carried out by the Institute of Alcohol Studies, a charity, found it led to a fall in alcohol use and an improvement in public health. The study concluded that concerns about the policy – that it would lead to heavy drinkers cutting back on essential spending or there would be an increase in alcohol withdrawal – were largely unfounded.

And yet despite the policy’s apparent efficacy, Scotland continues to have a higher rate of alcohol-specific deaths than England, where there is no minimum unit pricing, although the gap has narrowed in recent years. While the overall number of alcohol-related deaths has fallen, there remains a deep inequality at the heart of the figures, with mortality rates four-and-a-half times higher in the most deprived areas than in the least deprived. 

Indeed, one of the challenges for politicians in an era of shrinking attention spans and populists promising quick fixes is that improvements in public health tend to happen glacially, a point made by epidemiologist Dr Grant Wyper, who describes it as a “long game”.

“Anything that seeks to tackle availability and affordability will bring the most positive gains in terms of alcohol harm,” he says. “We look at life expectancy and healthy life expectancy as the overarching signals for population health. A lot of these things take a long time to change, a long time to worsen. It will take several decades for [interventions] to translate through into life expectancy.”

For evidence of the long game that Wyper speaks of you need only look at Scotland’s relationship with smoking. Hailed as one of the great achievements of the devolution era, the Smoking, Health and Social Care (Scotland) Act came into force on 26 March 2006, making Scotland the first part of the UK to outlaw smoking in enclosed public spaces. Two decades on, it has been credited with reducing exposure to second-hand smoke, improving childhood asthma rates, lessening the number of pregnancy complications, cutting the number of heart attacks and strokes, and encouraging more people to quit. 

But while the legislation has been an undoubted success from a public health standpoint, helping to make smoking increasingly socially unacceptable, there is still work to do. While the percentage of Scots smoking has consistently fallen over the past two decades, 15 per cent classed themselves as smokers in 2022 – up from 11 per cent the previous year. Again, there is a societal divide, with 25 per cent of those in the most deprived areas continuing to light up compared with just seven per cent in more affluent areas. The Scottish Government’s strategy is to make Scotland “smoke free” (rates below five per cent of the population) by 2034. 

On childhood obesity too, progress has stalled. In its 2021 manifesto the SNP pledged to halve childhood obesity rates by half (to seven per cent) by 2030, a commitment first set out in 2018. But the most recent figures show rates are increasing, with nearly one in five children aged two to 15 at risk of obesity, with the risk much greater for those living in deprived areas. In 2022/23, the proportion of children starting primary school at risk of being obese was 10.5 per cent. 

If health, namely the state of the NHS, is likely to be one of the big issues at May’s election, then the same probably cannot be said about public health, which despite the pandemic and the impact it had on all our lives, remains a somewhat esoteric topic for most voters. And yet despite nearly 30 years of devolution, with the SNP in charge for around three-quarters of that time, many Scots will instinctively feel that their lives have not improved, that inequalities remain wide, and that the blight of poor health is affecting many of us at a younger age. 

“We need politicians to be bold,” says Birt. “Tweaking the health service in some way, putting £2 more on a particular payment – those things are not going to change the fundamentals. I think people understand you can’t just change things overnight, but that you have to make difficult, political decisions.” 

Birt says there has been “massive cowardice” about doing difficult things such as reforming council tax, something successive government have talked about and then failed to deliver on.

“Whether it’s the SNP [after the election] or whoever is in government, they will be on a burning platform of public opinion,” he says.

Following the publication of the healthy life expectancy figures last month, Scottish Labour hit out at what it called a “damning indictment” of the SNP’s record in power. The party, which is yet to publish its Holyrood manifesto, has promised to create a new National Clinical Council to advise ministers and to reduce the number of NHS regional boards from 14 to three. It also wants to create a new emergency mental health response service so that patients in an acute mental health crisis are responded to by medical professionals rather than the police. Reform UK, which some polls have put ahead of Labour, has pledged to establish an independent Scottish Healthcare Reform Commission to carry out a review of healthcare delivery.

The creation of Public Health Scotland may, in time, prove to be one of the more important public health interventions when it comes to reducing health inequalities. England has moved in the opposite direction, scrapping its own dedicated agency six months into the pandemic under then health secretary Matt Hancock and dividing its responsibilities between the UK Health Security Agency and the Office for Health Improvement and Disparities, a decision criticised by many public health experts. Writing in the British Medical Journal (BMJ) in late 2024, David J Hunter, Peter Littlejohns and Albert Weale accused the UK Government of undermining the approach to public health and pursuing a policy of “vulgar individualism” lest it be accused of nanny statism. 

Lakha is clear that progress in public health is not “undone by a single administration or a single policy” but should be a cross-party mission both at Holyrood and Westminster. 

“It’s the top agenda for pretty much every individual in the population – it’s the first thing they think of when they think about their family; they want them to be in good health. It should be a high priority for any government and the direction of travel that we’re posing is the same, whatever government is in power.”