Glasgow Centre for Population Health:   Evidence for Scottish Affairs Committee.

Lower life expectancy in Scotland and Glasgow[1]

Over the last 15 years life expectancy has improved in Scotland and in Glasgow, but figures for both remain lower than the UK average with Glasgow having the lowest life expectancy of any major city in the UK. Moreover, there is no sign of a narrowing of the gap in life expectancy between the Scotland and the UK (which is about 2 years lower for Scottish men and 1.7 years lower for women [in 2012-14]) or between Glasgow and Scotland (4 years lower for Glaswegian men and 2.4 years for women).  Our most recent research also points to the persistency of socio-economic inequality in life expectancy in Glasgow; the gap between male life expectancy in the most and least deprived deciles is 14 years, while for women the equivalent gap has widened over the last 15 years to nearly 11 years.  It is also of concern that there has been a relatively poorer trajectory for female life expectancy in the city compared to males over the last 15 years.

Glasgow suffers excess levels of mortality compared to other, similarly deprived, UK cities such as Liverpool, Manchester and Belfast. Premature mortality rates in Glasgow are around 30% higher than in those cities. Recent research has identified the most likely underlying causes of this excess.  In large part these relate to the fact that Glasgow’s population has been made more vulnerable to the important influences on population health (poverty, deprivation, deindustrialisation, economic decisions taken at UK government level), consequently leading to poorer health than in other places in the UK which have had similar experiences. And this greater vulnerability has been created by a toxic combination of a whole series of historical factors, processes and political decisions. The findings of this new research re-emphasise the importance of socio-economic circumstances (and the political decisions that underpin them) as the key determinant of health in Glasgow and Scotland[2].

Demographic trends

National population projections forecast that Scotland’s population will grow and that the size and proportion of the elderly population is set to increase significantly, particularly among the over 75s whose population size is set to increase by 85% over the next 25 years.  Clearly there are implications for many services, particularly in relation to increased levels of need for health and social care as a result of this shift.  

Scotland and Glasgow’s population have grown in the last decade in part due to an increase in the birth rate but more importantly due to inward migration.  As a result, and also because of the impact of re-housing refugees and asylum seekers, Scotland’s largest city has become much more ethnically diverse.  The population from a black and minority ethnic background increased from 5% in 2001 to 12% in 2011.

Local trends in Glasgow indicate that the trend toward further ethnic diversity is continuing.  In the absence of more detailed research, analysis and modelling of the future impacts of increasing ethnic diversity, it is difficult to predict the likely health impact of having a larger, more ethnically diverse population in Glasgow and in Scotland.

Social context changes

There are important changes in people’s economic circumstances that are likely to play an important part in determining health and health inequality trends

Poverty remains a critical issue in much of Scotland and particularly in urban centres such as Glasgow. A third of children are living in poverty in Glasgow and with predictions (from independent experts such as the IFS) of further increases to come.  Fuel poverty affects 36% of households in Scotland and other poverty-related issues such as in-work poverty, under-employment and food poverty have emerged as key concerns in the last 5 years.

There are related housing issues. Private renting has increased in Scotland and across Glasgow since the global financial crisis of 2007/2008.  This in part reflects lower income levels, a shortage of affordable housing and greater difficulties in accessing a mortgage.

Low levels of income, high unemployment and low educational attainment (and associated inequalities) remain key issues that underpin health problems in many parts of Scotland.

Funding to address low life expectancy

Clearly government priorities and funding can be vitally important in addressing poor health trajectories and reducing health inequalities.  Action on the latter is also about distributing the effort in relation to need across a population - proportionate universalism.  Efforts to address the fundamental causes of health and social inequality are about tackling inequalities in income, wealth, resources and power.  At a practical level, approaches that aim to promote equal opportunity in education and employment are important, as are efforts to reduce income and wealth inequality, for example, through progressive taxation, support for a living wage, etc.  A welfare system that is adequately funded and protects the most vulnerable in society is also necessary. The provision of universal free healthcare for all is very important but many of the main levers for addressing health inequality lie outwith the health service.  In particular, it is fiscal, welfare and economic policies that can have positive and detrimental impacts on health inequalities and these policies are clearly influenced by political power and political choices.  In a UK and Scottish context, there is an overlap in responsibility and control over many areas of policy between the UK and Scottish governments, for example around taxation and welfare.  

Policy to address low life expectancy needs to be multifaceted, requires political will and will require effective joint-working between the UK and Scottish governments.

One final point to make is that taking account of demographic change alone in terms of age and ethnicity will not be sufficient in ensuring resources match need, and any distribution of resource should take account of both poverty/deprivation and need accumulated over many years.  Additionally, in a city like Glasgow the population is growing older from a starting point of poorer health, and more years are likely to be spent in ill-health, exacerbating the impact of an ageing population.  The most recently published healthy life expectancy figures for men in the city, estimate male life expectancy at birth in the period 2009-2013 to be 72.6 years overall, but with only 55.9 years being in good health, equating to 16.7 years on average lived not in good health. The equivalent estimates for Glaswegian women over the same period are 78.4 years of life expectancy and 58.5 years of healthy life expectancy, equating to nearly 20 years lived not in good health.

Bruce Whyte, David Walsh, Lorna Kelly, GCPH, June 2016