Current challenges to public health in Scotland Dr

Current challenges to public health in Scotland Dr Gerry Mc. Cartney Head of Public Health Observatory Division NHS Health Scotland gmccartney@nhs. net

Is Scotland the ‘sick man’ of Europe?

Historical international trends in life expectancy Data extracted from the Human Mortality Database for all available nations: Australia, Austria, Belgium, Belarus, Bulgaria, Canada, Chile, Czech Republic, Denmark, East Germany, England & Wales, Estonia, Finland, France, Germany, Hungary, Ireland, Iceland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Russia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan, West Germany, Ukraine & USA.

Higher overall mortality than comparable nations Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales, Finland, France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Spain, Sweden, Switzerland, Taiwan & West Germany.

Higher overall mortality than comparable nations Scotland Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales, Finland, France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, Spain, Sweden, Switzerland, Taiwan & West Germany.

Higher overall mortality than comparable nations USA Scotland Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales, Finland, France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, Spain, Sweden, Switzerland, Taiwan, West Germany & USA.

Higher overall mortality than comparable nations USA Slovenia Scotland Czech R. Poland Slovakia Hungary Estonia Bulgaria Lithuania Latvia Belarus Ukraine Russia Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Belarus, Bulgaria, Canada, Chile, Czech Republic, Denmark, East Germany, England & Wales, Estonia, Finland, France, Germany, Hungary, Ireland, Iceland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Russia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan, West Germany, Ukraine & USA.

Higher overall mortality than comparable nations Portugal N. Ireland Scotland Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Belarus, Bulgaria, Canada, Chile, Czech Republic, Denmark, East Germany, England & Wales, Estonia, Finland, France, Germany, Hungary, Ireland, Iceland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Russia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan, West Germany, Ukraine & USA.

All cause death rates, men 0 -64 y, 2001 Glasgow City Inverclyde West Dunbartonshire Dundee City Eilean Siar North Ayrshire Renfrewshire North Lanarkshire Alastair H Leyland, Ruth Dundas, Philip Mc. Loone & F Andrew Boddy. Inequalities in mortality in Scotland 1981 -2001. Glasgow, MRC SPHSU, 2007.

What is getting better about health and the things that influence health? • Life expectancy & mortality – – Infectious diseases Heart disease Cancers Stroke disease • Medical treatment and innovation • Absolute poverty

Source: Scottish CMO report 2009

What is getting worse about health and the things that influence health? • Inequalities in health and the determinants of health (national and international) • Obesity • Alcohol related harm • Mental health • Threats of climate change, resource scarcity • ‘Scottish Effect’

General acute inpatient discharges with an alcohol-related diagnosis in any position, by gender, Scotland, 1982/3 - 2009/10

Hanlon P, Walsh D, Whyte B. Let Glasgow Flourish. Glasgow, Glasgow Centre for Population Health, 2006.

BMI distribution of GG&C adults (1995) 1995 Source: adapted from the Scottish Health Survey

BMI distribution of GG&C adults (1995 -8) 1995 1998 Source: adapted from the Scottish Health Survey

BMI distribution of GG&C adults (1995 -2003) 1995 1998 2003 Source: adapted from the Scottish Health Survey

BMI distribution of GG&C adults (1995 -2008) 1995 1998 2003 2008 Source: adapted from the Scottish Health Survey

MDP = Measure of Domestic Progress SWB = Subjective Well-Being Source: Chasing progress. Beyond measuring economic growth. London, New Economics Foundation, 2004.

Why is well-being not improving? • • • Creation of a ‘hedonic treadmill’ Choice anxiety Loss of deeper meaning and purpose to life Loss of hope with satiation Uncertainty and insecurity Homogenisation of culture Deterioration in interpersonal relations Stresses caused by the ‘pace of life’ Personal identity defined by own consumption

Health inequalities

All-cause deaths by deprivation decile: directly age/sex standardised rates per 100, 000 population, Scotland, 2007 Source: Scot. PHO 2009

Male age specific mortality rates by occupational social class. Scotland 1990 - 92 Alastair H Leyland, Ruth Dundas, Philip Mc. Loone & F Andrew Boddy. Inequalities in mortality in Scotland 1981 -2001. Glasgow, MRC SPHSU, 2007.

Alastair H Leyland, Ruth Dundas, Philip Mc. Loone & F Andrew Boddy. Inequalities in mortality in Scotland 1981 -2001. Glasgow, MRC SPHSU, 2007.

Alastair H Leyland, Ruth Dundas, Philip Mc. Loone & F Andrew Boddy. Inequalities in mortality Age specific contribution to inequalities of specific causes of death across in Scotland 1981 -2001. Glasgow, MRC SPHSU, 2007. SIMD income quintiles. Men, Scotland 2000 -02.

Age specific contribution to inequalities of specific causes of death across SIMD income quintiles. Women, Scotland 2000 -02. Alastair H Leyland, Ruth Dundas, Philip Mc. Loone & F Andrew Boddy. Inequalities in mortality in Scotland 1981 -2001. Glasgow, MRC SPHSU, 2007.

Percentage change in age- and cause-specific mortality rates among men between 1991 and 2001. Alastair H Leyland, Ruth Dundas, Philip Mc. Loone & F Andrew Boddy. Inequalities in mortality in Scotland 1981 -2001. Glasgow, MRC SPHSU, 2007.

Percentage change in age- and cause-specific mortality rates among women between 1991 and 2001. Alastair H Leyland, Ruth Dundas, Philip Mc. Loone & F Andrew Boddy. Inequalities in mortality in Scotland 1981 -2001. Glasgow, MRC SPHSU, 2007.

Each stop on the Argyll line travelling East represents a drop of 1. 7 years in male life expectancy Males - 75. 8 y Females - 83. 1 y Hillhead St George’s Cross Jordanhill Hyndland Partick Exhibition Centre Buchanan Street Charing Cross Anderston Argyll St. Govan Ibrox Cessnock QUEEN STREET CENTRAL St Enoch Bridgeton Males - 61. 9 y Females - 74. 6 y Life expectancy data refers to 2001 -5 and was extracted from the GCPH community health and well-being profiles. Adapted from the SPT travel map by Gerry Mc. Cartney.

Why are health inequalities getting worse? • Black’s 4 hypotheses: – Artefact – Selection – Behavioural or cultural – Structural Rising inequalities in income • Increasing power differences between groups – income, location, wealth, status etc.

Emergence of the ‘Scottish Effect’ Source: Hanlon P, Lawder RS, Buchanan D, et al. Why is mortality higher in Scotland than in England Wales? Decreasing influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a 'Scottish Effect'. Journal of Public Health. 2005; 27: 199 -204.

Synthesis for the divergence of Scottish mortality from mid-20 th Century

Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’

Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’ Political attack by the Thatcher government post 1979

Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’ Political attack by the Thatcher government post 1979 Source: Mc. Cartney G, Collins C, Walsh D, Batty GD. Explaining Scotland’s higher mortality: towards a synthesis. Glasgow, Glasgow Centre for Population Health, 2011 (forthcoming).

What explains the Scottish Effect? • • No single ‘cause’ is likely to explain the mortality phenomena There is a greater degree of uncertainty about the divergence of mortality from the mid-20 th Century ‘Downstream’ causes are necessary but insufficient to explain the Scottish Effect and Glasgow Effect Politics of the 1980 s and the cultures arising from this are likely to be important in explaining the recent divergence

Future challenges for Scotland’s health

Demographic change Alastair H Leyland, Ruth Dundas, Philip Mc. Loone & F Andrew Boddy. Inequalities in mortality in Scotland 1981 -2001. Glasgow, MRC SPHSU, 2007.

Climate change

Source: Bodagaj, IPCC, 2008

Climate change impacts often missed • Failure of food supply and accompanying mass migration • Economic disruption • Health impacts more likely to be mediated through economic and social determinants of health than direct climate impacts

Resource scarcity: oil

Source: James L. Williams, WTRG Economics, Houston, Texas.

Economic impact of peak oil • Liquidation of sectors of the economy, increased costs for others • Increased costs for trade in manufactured goods • Global trade in financial services for manufactured goods interrupted • Food prices

Overall sustainability

Planetary ecological footprint trends The ecological footprint is all the cropland, grazing land, forest and fishing grounds required to produce the food, fibre and timber consumed and to absorb the wastes emitted in generating the energy used and need to provide space for infrastructure. Living planet report 2006. Gland, WWF, 2006 [downloaded from http: //www. panda. org/news_facts/publications/living_planet_report/index. cfm on 18 th April 2008].

Financial problems

Source: Hellowell M , Pollock AM. The impact of PFI on Scotland’s NHS: a briefing. Edinburgh, Centre for International Public Health Policy, 2006.

Summary • Many aspects of health in Scotland are getting better • Some aspects are not improving, or are getting worse • Some important challenges have to be overcome if health improvement is to be continued into the future