Health and wealth in Scotland

The health of the population is one of any nation’s greatest assets. Good health is a prerequisite for prosperity and a flourishing society – allowing people to play an active role in their communities and the economy. A failure to maintain and support good health can reduce people’s ability to work, or reduce their productivity at work, limiting economic potential.

A person’s health is largely determined by their day-to-day experiences and the places in which they live, work and grow. Almost every aspect of life shapes health and longevity – our jobs and homes, access to education, the quality of our surroundings and whether we experience poverty. These are called the wider determinants of health.

The inextricable link between health and wealth has been evident through the COVID-19 pandemic and the current cost-of-living crisis. Both have brought underlying poor health and structural inequalities to the fore. COVID-19 mortality rates were over twice as high in the most deprived areas, driven by poorer underlying health and increased risk of exposure to the virus. As the cost-of-living crisis bears down, the poorest families are least able to cope with higher costs of food and fuel. These crises are exacerbating long-established health inequalities, placing greater urgency on the need for comprehensive and sustained action across society.

Increased wellbeing and sustainable development are part of the core purpose of Scotland’s National Performance Framework, which includes health as one of 11 national outcomes. This encompasses several national indicators including healthy life expectancy and premature mortality. The other 10 national outcomes include fair work and business, education, children, the economy and poverty. Each of these in turn encompasses indicators that relate to the wider determinants of health, such as secure work, educational attainment, child social and physical development, income inequalities and wealth inequalities.

Working to achieve such goals means that Scottish government policy is implicitly and explicitly focused on improving health and reducing inequalities.

From devolution to 2020

In the 22 years since devolution the powers available to the Scottish government have gradually increased. Alongside devolved power for the NHS, social care and public health, many of the policy levers that shape the determinants of health, and decisions over where resources are focused, are now held by the Scottish government.

There are potential limitations in the efficacy of these powers given the significant policy levers still held by the UK government, and other influences that sit outside the direct scope of government. For instance business has a significant influence on health through procuring employment opportunities, and the quality of that work, as well as the goods and services produced.

Over this period, the Scottish government’s approach to developing and implementing policy has evolved. So too have its relationships with local government, the voluntary and community sector, public bodies and the public.

Devolution followed a half century of significant economic change. Deindustrialisation led to a large move away from employment in sectors including mining, quarrying and manufacturing, shifting instead towards retail and services. The service sector orientated economy brings with it increased risk of job insecurity and low pay. The longer term consequences of deindustrialisation play out in the pattern of inequalities in Scotland with earnings inequality widening as a result of economic structural change. Areas once dominated by heavy industry are now more likely to have higher levels of deprivation. This shift underlies differences in health in other parts of the UK (and other countries), but the greater health inequality in Scotland suggests the population is more vulnerable to the health consequences of disadvantage. Research suggests that while there have been similar industrial declines in other parts of the UK, in Scotland the population has been left behind.

Recent decades have also seen a shift in risk bearing, and with it higher insecurity for individuals. This is evident in forms of employment contract and reduced ability to acquire assets for the younger generation, including home ownership and final salary pension arrangements. The aftermath of the 2008 financial crisis reinforced a pre-existing trend of stagnating productivity growth, which led to little improvement in living standards over the past decade. After a decade of little progress, the economic situation has been weakened further by the COVID-19 pandemic followed quickly by the cost-of-living crisis.

Significant political events and developments – such as the independence referendum in 2014, followed by Brexit and the shifting make-up of governments at Holyrood and Westminster – mean that the ongoing debate about Scotland’s constitution has remained high on the agenda. This has contributed to a consistent divergence of policy direction between the Scottish and UK governments.

Life expectancy

Against this backdrop, the story of Scotland’s health has been mixed. In 1998–2000, period life expectancy at birth (a measure of current health)* was 75.6 years in Scotland. By 2017–19 it had reached 79.1 years, but there was no improvement after 2011–13. Largely reflecting deaths related to COVID-19, life expectancy fell to 78.7 years in 2019–21. Scotland has had the lowest life expectancy of UK nations since the 1950s and its ranking compared with other western European countries has fallen.

Inequalities in life expectancy were widening in the years before the pandemic, as shown in Figure 1. Between 2013–15 and 2017–19 the gap in period life expectancy at birth between people living in the least and most deprived tenth of local areas widened by 1 year to 13.3 years for men, and by 1.7 years to 9.8 years for women.

Cohort life expectancy better captures how long people are expected to live by reflecting the expected mortality rates at each age of their future lifetime. Using this measure, the expected lifespan of people born in Scotland in 2012 has fallen by 4.4 years over the past decade.

Figure 2 shows that projected cohort life expectancy at birth has been revised down from 90.4 years for the 2012 birth cohort (under 2012-based assumptions) to 86 years under 2020-based assumptions. In cohort projections the impact of the COVID-19 pandemic is minimal because mortality rates at older ages relate to future years rather than pandemic years.

The stalled progress in health improvements over the past decade is mirrored by stalled progress in living standards. For example, typical household incomes are no higher than they were before the financial crisis. Given long-term health outcomes are a consequence of experiences over the lifetime, the past decade of little improvement in incomes is likely to act as a drag on future improvement in health.

The overall lack of progress on health and widening inequalities comes despite continued policy focus and detailed surveillance and data collection. There remains a gap between policy intent, delivery and the extent to which this has led to meaningful change in people’s lives. Recognition of the scale of existing inequalities, and the need for greater collaboration between areas of government policy and delivery, were among the core conclusions of the Health, Social Care and Sport Committee health inequalities inquiry in 2022.

Crises have exposed existing societal fault lines

The COVID-19 pandemic was an unprecedented shock to health: directly through increased mortality and infections; indirectly through the restrictions put in place to reduce the spread of the virus. The full consequences for health inequalities are yet to be fully understood. The cost-of-living crisis, which is set to leave household finances in a worse position than the pandemic, presents a further risk to health.

Recent crises have added greater pressure to already strained public services and follow a period of austerity, as part of efforts to reduce UK borrowing in the wake of the financial crisis. This had left services in a fragile state by 2020. Audit Scotland has highlighted the need to reform public services so that they are ‘delivered to people in a way that more effectively meets both their needs and the government’s policy aspirations’.

These crises have affected the population largely along existing societal fault lines – with the most disadvantaged tending to experience the worst outcomes. Action to remedy the structural inequalities that cause such disadvantage would increase resilience to future shocks. The scale of the challenge in doing so, however, and of sticking to the long-term action required, cannot be underestimated. But there is public support for doing more to invest in health and activities that support good health.

Recent attitudinal data show the British public increasingly favour raising taxes to spend on health, education and social benefits. Figure 3 shows that there has tended to be a greater level of support for this in Scotland. When the same question was asked of the Scottish public in 2021, 64% were in support compared with 52% in Great Britain.

The next section details the key trends and inequalities in Scotland’s health over the past two decades, as well as the social and economic determinants of health.

* Period life expectancy is an estimate of the number of years that someone is expected to live based on mortality rates that apply at different ages at a given point in time. It reflects a population at a moment in time, rather than a cohort of people over their lifetime.

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