Risks to future health

Some population groups are experiencing deteriorations in several different health outcomes or influences at the same time, compounding the likelihood of persistent, or even widening, health inequalities. These range from early childhood development to the impact of the cost-of-living crisis and access to services for acute health need. It is a significant cause for concern that these factors appear to combine, leaving people in the most deprived areas to fall further behind.

Failing to take early action to maintain good health and prevent deterioration will create future costs for the health care system, the economy and society. It will also mean greater challenges for people living day-to-day with poor health. Understanding how these factors are combining to create a greater risk to health than any one taken in isolation – and often the cumulative affect amplifies the risk – can guide policy attention where it is most needed.

Children not getting the best start in life

Early childhood development and the school years play a crucial role in determining future health. Poor outcomes in childhood can continue to have significant implications in life. For example, school readiness affects educational attainment, eventual access to job opportunities and can negatively affect lifetime income and ultimately health.

There are already wide health inequalities in the very earliest stages of childhood. These are compounded by inequalities in determinants of health which, if unaddressed, risk a further relative deterioration in health for the most disadvantaged children. In the past decade, inequalities have widened for infant immunisation uptake, infant mortality, low birthweight and childhood obesity.

Since 2013, while the proportion of 27–30-month-old children with development concerns has fallen across all levels of deprivation, the rate of fall has been faster in the least deprived areas compared with the most deprived areas. Relative inequalities have slightly widened and outcomes of children from the most deprived areas in 2019/20 only matched outcomes of the children from the next deprived fifth of areas recorded in 2013/14.

There is also a significant poverty-related attainment gap for primary school pupils in Scotland: pupils living in the most deprived fifth of local areas have lower levels of educational attainment than those from less deprived neighbourhoods. This has not closed over the past two decades. A similar gap exists for secondary age children and, despite signs of an improvement by 2019/20, the impact of the pandemic has reversed any progress.

These inequalities are a result of the circumstances in which children live, including child poverty. This has likely been exacerbated by the cost-of-living crisis. Families with children are also increasingly likely to live in the private rented sector, which tends to be of lower quality and affordability than other tenures.

Men in the poorest communities

Young to middle-aged men in Scotland are at particular risk of poorer health. There has been declining engagement with health services among this group, who are most likely not to attend hospital appointments.

This group is also the most likely to suffer from deaths of despair,** with the exponential rise in drug deaths concentrated among men in their mid-30s to early-60s. Within cohorts the greatest risk of drug deaths is for people in their 30s. Suicide, alcohol and drugs are leading causes of death for men aged 15–44 years. For this age group they also account for two-thirds of absolute inequalities in total mortality. This greater risk of deaths of despair relates to a higher likelihood of experiencing multiple disadvantage (discussed in Section 3). Being younger than the age of 40 years, single, white and male was most strongly associated with experiencing severe multiple disadvantage.

Economic trends also point to younger men being at greater risk of poor health in the future through reduced earning potential. Meanwhile the gender gap in higher education participation is wide and has been growing over time. By 2020/21, male participation rates in higher education were 16 percentage points lower than for women.

Employment rates for men aged 16–24 years in Scotland fell by 7 percentage points, from 65% to 58% between 2004 and 2019. Men born since 1985 have started work in lower paid occupations than cohorts that came before them and are less likely to experience earnings progression in the following years. Young men are more likely to work in lower paid and part-time roles in the service sector than previous generations, who were more likely to work in manufacturing roles.

Declining access to preventative health care and treatment

In Scotland, use of some preventative services has been declining, with greater falls among people living in the most deprived areas. For example, childhood immunisation rates – previously a success story in Scotland – are falling and differences in rates between the most and least deprived areas have been widening. For women there have also been worrying declines in overall rates of cervical screening.

There have been some improvements such as in timely antenatal screening and take up of bowel screening, though in the case of the latter rates in the most deprived areas still fall below national targets.

In some areas there has been little change in outcomes in the past decade. Amenable mortality rates (ie deaths that can be prevented by treatments after the onset of disease) were improving in the 2000s, but the past decade has seen little progress. Amenable mortality rates in the most deprived fifth of areas have only caught up to where rates in the next most deprived fifth of areas were in around 2007. Inequalities have remained wide. Amenable mortality in the most deprived fifth of areas is almost three times that in the least deprived.

Regardless of changes over the past two decades, wide gaps remain in the rate of access for treatment between people living in the least and most deprived areas. Even where improvements have been made in bowel screening and missed hospital outpatient admissions, for example, access for people in the most deprived areas is still worse than in the least deprived areas two decades ago. Multiple emergency admissions have remained over twice as high in the most deprived fifth of areas compared with the least.

Barriers to accessing health care services that create inequalities include the extent to which the timing and flexibility of appointments align with people’s lives, mistrust of services and whether people realise that an ongoing health problem requires treatment. Without meaningful change to service provision, these longstanding inequalities will remain and leave a significant risk of harm to those with acute health who do not receive treatment.

Similar to the situation in England, the NHS in Scotland continues to be under huge pressure with increasingly long waits in emergency departments and delays in treatments. This will make progress on delivering services more challenging. Dealing with the COVID-19 pandemic meant refocusing limited resources, which led to a backlog of planned treatments or new assessments. Social restrictions also reduced the extent to which people accessed health care. Explanations for increased delays also include a lack of capacity, both from staffing and physical capacity within hospitals due to a shortage of social care capacity. Longer waits or an inability to access treatments risks worsening health and deepening existing poor health.

The impact of the cost-of-living crisis on the poorest

The cost-of-living crisis will have a greater impact on the poorest households who spend a much greater share of their budgets on essentials. These essentials – such as food and fuel – are experiencing the greatest rises in cost. This will have significant impact on health through limiting individuals’ ability to afford basics and necessities for a healthy standard of living, such as a warm home and enough nutritious food.

Increased financial strain also risks a greater share of people across the income spectrum falling into problem debt. This may also increase the burden of mental health issues through stress and anxiety.

Significant mitigation has been put into place by the UK and Scottish governments. The UK government has implemented an Energy Price Guarantee equivalent to £2,500 a year, rising to £3,000 from April. It is also providing a number of lump sum payments giving additional financial support to lower income, disabled and pensioner households. It has also committed to the usual uprating practices of increasing working-age benefits by CPI inflation and to maintain the state pension triple lock.

The Scottish government has gone further by including an additional child payment to low-income families, a Winter Heating Payment Allowance and measures to prevent problem debt and evictions. Despite these efforts UK household incomes are expected to drop by 7% between 2021 and 2023, primarily due to high inflation. It remains uncertain how families will be able to cope particularly given that the pandemic has left many families, especially low-income and single-parent families, in a less resilient position for further financial shocks.

Outcomes for the most disadvantaged communities are becoming detached from the majority

Across all health indicators, people living in the most deprived areas have the worst outcomes. There is a similar pattern in health outcomes across areas of social disadvantage, such as income and occupational status. This is a well-established pattern, with the health gap between the most deprived 20% and the next most deprived fifth often greater than between any two other adjacent groups. Of particular concern is the widening gap in health between people living in the most deprived fifth of areas and the rest of the population over the past decade.

Figure 12 shows how this gap – whether relative, absolute or both – has widened across a range of health measures.†† This is shown most starkly in the greater rate of drug deaths among people in the most deprived areas. Between 2001 and 2020, the overall rate of drug deaths increased from 6.2 per 100,000 to 25.1 per 100,00. This has been driven by the increase in deaths in the most deprived areas, reaching 68.2 deaths per 100,000 people by 2020 – this is18 times as high as in the least deprived areas.

In the area of child health, the absolute gap in MMR vaccine uptake in 24-month-olds between the most and least deprived areas has increased from 0.8% in 2014 to 4.5% in 2021 – driven by an increased uptake in less deprived areas. For infant mortality, rates have improved or stayed steady for all except those in the most deprived areas where there has been an increase in infant mortality rates since 2015. The gap in the risk of childhood obesity between most and least deprived areas had increased to 7 percentage points by 2019.

Overall improvements in the prevalence of smoking during pregnancy have led to a widening of relative inequalities. The absolute difference between women living in the most and least deprived fifth of areas has fallen, but because it has fallen faster in the least deprived areas, relative inequalities have widened. The prevalence of smoking during pregnancy was over 10 times higher among pregnant women living in the most deprived fifth of areas compared with the least in 2020. There is a similar pattern in the prevalence of children with early development concerns at age 27–30 months and birthweight.

An exception is adolescent mental health outcomes, where the gap between the most and least deprived has closed. However, this is because the share of people in the least deprived areas with mental health problems has increased, leading to a ‘levelling down’.

In the case of drug deaths and the risk of childhood obesity, the gap between the second and third quintile is also growing. This suggests there are early signs that this widening of inequalities is no longer predominantly confined to the most deprived areas.

These trends, as demonstrated by Figure 12, are concerning as they suggest that the experiences of people living in the most deprived areas will lead to increasingly worse health outcomes compared with other groups, storing up further problems for the future.

Even where risk factors and behaviours are distributed more evenly, actual health outcomes are worse in more deprived areas, suggesting that other exposures and multiple factors mean people are less protected from worse health outcomes than other groups. This implies policies and interventions that focus only on health behaviour change (such as reducing alcohol consumption or increasing physical activity) are unlikely to have a meaningful impact on health inequalities.

Early action can prevent inequalities widening further

There are clear emerging trends that appear to be exacerbating health inequalities. If left unaddressed these are likely to widen further in future. Some outcomes are longstanding where insufficient progress has been made historically, such as education and inequalities in accessing health care services. Others are the result of emerging trends, such as the decline in younger men’s health, or stem from more immediate developments, such as the cost-of-living crisis.

These outcomes are contributing to a broader and concerning trend that people living in the most deprived areas are falling further behind everyone else. Immediate action is needed to reverse the lack of policy delivery progress of the past decade to head off and reverse these trends.

** Deaths of despair is collective term referring to deaths relating to suicide, drug overdoses and alcoholism.

†† Where data are an average of multiple years, we refer to the final year of the period, and in the case of financial years the year starting in April.

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