Scotland Health and social care

In Conversation With… Gerry McCartney, NHS Health Scotland

Image via Gerry McCartney

LGiU Scotland’s Kim Fellows is talking with Gerry McCartney  from NHS Health Scotland, who is head of the Public Health Observatory.

Would you just start off by telling us about what you do and what the observatory is?

The Scottish Public Health Observatory is a collaboration between various public health organisations in Scotland. Our role is to describe and explain the trends in health and health inequalities for Scotland, and then to advise policymakers at different levels – whether it’s Scottish Government, international organisations, local government or NHS – about what they could do.

Can you tell us about what’s happening with life expectancy in Scotland and the trends?

Yes, life expectancy in Scotland has been largely improving from 1950 up until about 2012. The life expectancy had always been unequally shared across the population, with more affluent areas having longer life expectancies than more deprived areas, and that had narrowed between 1950 and 1975 or thereabouts, before those inequalities in life expectancy widened again. But since 2012 we’ve seen life expectancy stalling, which is really unusual. It stalled in Scotland but it also stalled in many other high-income countries including England, Wales, Northern Ireland and the USA. As a consequence of that stalling we’ve also seen health inequalities widening rapidly, so life expectancy in our poorest communities has started to go down quickly, and that’s obviously a huge concern to us. There are a number of factors behind that and there are a few important things to note.

This change in life expectancy has happened in both men and women and it’s affected all age groups. So it’s not that people who used to die at, say, age 80 are now dying at age 79, meaning that mortality rates are going up at all ages of the population and that’s contributing to life expectancy changes. It’s also happening across almost all causes of death, so it’s not just deaths due to one particular disease group, but it’s deaths due to drug related causes, cardiovascular diseases and stroke, and dementia is also on the rise. There are a huge number of different causes that are all going up at the same time, and previous rates of improvement have faltered, so that tells us something about what’s behind these overall trends.

I think it would be useful for readers to understand what’s happened to people in lower socioeconomic groups?

So as I mentioned, life expectancy is going down in Scotland’s poorest areas, and there are a number of different causes of death that are driving that change and it’s happening across the age spectrum and for men and women. There have been a number of different theories put forward about what might be behind these overall trends, but we’ve been working really hard over the last 18 months to try and understand that evidence base and be clearer about what those causes are. We’re fairly confident now that the economic circumstances in which people are living is the most important driver of stalling life expectancy, and by economic drivers I mean that there are a number of different pathways that are important here. So, for example, the social security benefits that people need and rely upon have, in real terms, not kept up with inflation and people have become poorer as a result, and that has both direct and indirect impacts on health.

We’ve also seen pressures on a number of public services, whether that’s health services or social care services, or other public services that people rely upon. Again, that opens up a number of pathways that impact people’s health. In addition, changes in the labour market, for example precarious employment, has become more common and people are having to work 2 or 3 jobs to make ends meet. All of that taken together means that people are more stressed, they’re under more pressure, they have less disposable income to keep up with friends and maintain their social networks and this just makes life more difficult for people. The rates of poverty are going up, and that’s just fundamentally unfair and unnecessary. Because of the poverty that people are now experiencing, their health will suffer – both their mental and physical health. So economic circumstances are a big driver of what’s going on with the life expectancy trends.

We are undertaking other research to make sure that we’re not missing other causes that might be contributing, so we’re not excluding other things being important as well, but we do think that economic circumstances is the most important factor at the moment.

Building on that issue, you’ve got the new Scottish Child Benefit and the Best Start Grants, but can you just explain what more might be done at a local level?

Yeah, I think that there are things that all public sector organisations can contribute to reversing these trends, and at a local level there are a lot of things that can be done and are already being done. So we know that making sure that people are on the benefits that they are due is really important, and that helps to reduce poverty, and so local government is very important in ensuring that they provide services, and that benefit maximisation initiatives are working well within their communities, so that everybody is getting benefits to which they are entitled. We also know that services are really important, whether that’s social work services or housing services or leisure services, all these things matter to people’s health. Ensuring that the public services that local agencies run are accessible to all and are of high quality is really important, so it’s kind of bread and butter issues for local government. Doing that job well and efficiently and making sure they reach the populations with greatest need does make a big difference, but there are also other things that local governments in particular have got an influence over that are less obvious.

So for example, both local government and the NHS are big spenders within their local communities, they employ staff, they procure services, they locate services in particular areas, and they partner up with other agencies. How we do these things is important so they can have some of the best knock on benefits.  For example if we procure goods and services through our supply chains that have more of a knock-on effect on local communities to  keep more of that money in our more deprived communities and create better quality jobs, that can have a bigger impact than perhaps spending less time and resources thinking about what we’re doing with our money. If we ensure that through our staffing policies we’re reaching those that need employment the most, and those that maybe need a wee bit more support to get into stable jobs, that can make a huge difference in some communities.

Where we locate our services can make a big difference. Having services in places that are accessible to all, whether from public transport or walking, rather than perhaps assuming that people have access to a car, can be really important to making a difference in people’s lives.

It would be interesting to hear what your priorities are for the next 12 to 18 months, especially for what local government might contribute?

The priorities are to make sure that people understand this evidence well and that people understand that life expectancy improvements have stalled, and that’s an important public policy issue that we need to take seriously. Clearly lots of agencies have some role in trying to reverse that, whether that’s UK government, Scottish government or local government, or indeed the NHS and all their partners. So I think beyond what I’ve said I think that being clear that we prioritise those who are in poverty that are suffering most at the moment from poor health is really important, and that can often mean doing more of the kind of things that I’ve mentioned already – making sure that people are getting the incomes that they’re entitled to, making sure that services are oriented toward needs – I think those are the priorities.

To conclude, what are your key messages for local government?

Income and wealth and poverty really matter for people’s health and the population’s health, and I think it’s important that people understand that we can change that, we can change the life expectancy trends for the future, so poverty is not inevitable and having wide health inequalities are not inevitable. We’ve been here before, we’ve encountered huge economic problems, but we overcame them and we can do this again in Scotland. For example, in the 1950s and 1960s we built up the NHS, pensions, the social security system and reduced poverty and inequality, all of which were crucial in the improvements seen in life expectancy and reducing health inequalities. It will take a similar kind of policy focus for the future if we’re to do that again. I’m confident we can do this to create the fairer, healthier Scotland we all need.

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