Low life expectancy in Glasgow, and what to do about it Episode 10 of the Health Foundation podcast

Jennifer Dixon 

Hello and welcome to the Health Foundation's podcast. I'm Jennifer Dixon, chief executive of the Health Foundation. In this podcast we look at the most important issues affecting the future of health and care for the people in the UK. And we discussed these are very interesting guests. Today we're focusing on Glasgow. Why is that? Well, if you think of health in the UK as a fabric, it is the most threadbare in Glasgow. Here, life expectancy is lowest, and one in four men will die before their 65th birthday. We all know about the widening health gap between rich and poor in the UK, particularly in the under 65s. But even after adjusting for poverty and deprivation, next to comparable de-industrialised cities such as Liverpool and Manchester, Glaswegians have a higher risk of dying prematurely than anywhere else in the UK. That's from cancer, heart disease, stroke, as well as the so called deaths of despair, from suicide, drugs and alcohol. It isn't getting any better. And that's not even taking into account the pandemic. One resident remarked, we die young here, but you just take the hand that life deals you and get on with it. So we're exploring today, what is fraying health to this remarkable degree in Glasgow, what's being done to help, and as we across the UK attempt to build back better and level up, what can we all learn from Glasgow's long standing efforts to try to mend the health fabric. With me today to discuss all this I'm truly delighted to introduce two people who have for many years been central to the story. Dr David Walsh is honorary senior lecturer at the University of Glasgow, and a senior academic at the Glasgow Centre for Population Health. Over the years, David has carried out a lot of careful work to understand Scotland's and Glasgow's high level of excess mortality. He's also researched deindustrialization and health across European regions, and the impact of the government's austerity measures on mortality. And also, Sir Harry Burns, who is the professor of global public health, University of Strathclyde, Harry was the chief medical officer for Scotland for almost 10 years from 2005 to 2014. And he's well known for his tireless work on health inequalities. He's a member of the Council of Economic Advisers in Scotland, and he's also a local boy, he went to school and then medical school in Glasgow. Well, welcome to you both. Let's just start off with a few. Just paint a picture for us, David with some of the stats, can you tell us a little bit more about what we know about the trends of health in Glasgow, and perhaps relative to Scotland and the UK as a whole.

David Walsh 

It's no secret, as you've alluded to that, you know, health in Glasgow is poor relative to other urban areas, both in the UK and actually across a large parts of Europe. A huge part of that relates to poverty. You know, poverty is the biggest driver of poor health in any society, as you know, be that in Glasgow, be that in Scotland, be that in the UK, or in Europe. And related to that is the you know, the sheer scale of inequalities of health inequalities in Glasgow, from the data we've got, I'd be reasonably confident saying that health inequalities in Glasgow are wider than any other European city. So there are clearly things that are very different about Glasgow compared to other parts of the UK. But I'd also say that a lot of things that are similar, you know, inequalities, extensive inequalities that are characteristic of all parts of the UK. And we know the reasons for that, because since the late 1970s, early 1980s, there's been a dramatic transformation in levels of inequality across all of the UK. So Glasgow are wider though, and also the changes that we've seen in mortality since the early 2010s. From around 2011, 2012 have been pretty catastrophic, you know, so female mortality rates and glass will have not changed in 10 years. And that's a dramatic statistic when you look at the the previous decades of improvement, but that overall, what's been referred to as a stalling of improvement is actually masking increasing death rates among the poorest in society, but that is not specific to Glasgow. We're seeing that in all parts of the UK. And they're clearly linked to the UK government's austerity measures, which has impacted on the most vulnerable and poor in society. The life expectancy in Glasgow is roughly around 74 years, which is four years below Scotland or three less than Liverpool and Manchester with five less than Bradford, like Bristol and Sheffield down south. So yes, overall, near life expectancy, maybe around 60 to 73 years, but that will range in areas of Glasgow from, you know, from 83 in the more affluent parts to down to the 65 and in the more deprived areas.

Jennifer Dixon 

Thank you and can you say something about the gap between socioeconomic quintiles over the last 10 years or so? Do I understand it right that it is widening? And the gains in increasing life expectancy are just not being felt in the most impoverished communities?

David Walsh 

Again, I'd like to emphasise this isn't just about Glasgow, this is about the whole of the UK, we've done a study, which looked at Scotland as a whole England and Wales as a whole Northern Ireland, and then a whole number of UK cities. So what we're seeing is actually a different type of inequality developing. Historically, what we've seen are widening inequalities, because although the health of the poorest was improving, it was improving more slowly than the health of the more affluent. So you get this relative gap. But actually, what's happened in the last decade is that the health of the poorest and we can define that in different ways, but the 20% most deprived the value of the cities, the 20% was deprived of England and Wales, of Scotland has actually started to go up. People in the more deprived areas of the whole of the UK are actually dying in increasing numbers. I don't quite know if people over there really get this, but it's a staggering change in a really wealthy country like the UK.

Jennifer Dixon 

What sort of conditions are are driving that?

David Walsh 

Well, there's been all sorts of work done internationally and within the UK, and a lot of still a lot of conversation about it. It seems reasonably clear that this is about the effects of the UK government's austerity measures. You know, they have slashed £47bn of the Social Security budget alone in the UK. Who is affected by that? Tt's the poorest, it's the most vulnerable. Social Security is there to be a safety net to help people in times of difficulty. And that's been taken away.

Jennifer Dixon 

Harry, we interviewed Angus Deaton on a previous podcast and he did point to austerity being one of the reasons for fraying and health fabric in in the population in the UK. But he was also very strong on the longer-run structural economic changes, that he said had crushed communities, certainly in the US that they were documenting. So I wondered whether, on top of what David just said, you might either comment on what David had to say, but also tell us a little bit about what's been happening, particularly in Glasgow. Why is Glasgow so different?

Harry Burns 

So my interest in this area goes back to the time when I was a surgeon, my first career in medicine, as a surgeon or consultant surgeon at the Royal Infirmary in Glasgow for five years, the Royal Infirmary in the east end of the city had the most deprived population coming into it. And I was particularly struck by the interactions I had with people who were, for example, coming in with serious alcohol-related problems, acute pancreatitis, and so on. And you would see people coming in three or four times with acute pancreatitis, which is sometimes fatal on the first go. But I remember a conversation where I said, look, if you don't stop drinking, you're gonna die. And the response was, I know, I know I'm gonna die. But I don't care because life is crap. The booze is the only pleasure I've got in life. And that story, in various forms kept coming back to me. And that's what prompted me to give up surgery and to go into public health to try and understand what was going on. Doctors are taught about disease and the causes of disease. What I realised in my public health training was it was wellbeing and the causes of wellbeing we needed to focus on more. David's report on the Glasgow effect, the comparison between Glasgow and Liverpool and Manchester was a real blockbuster. You know that the assumption up until then had been that poverty and so on, influenced the same population, different populations in the same way, something had happened in Glasgow that made it worse. And looking back at the history of Glasgow, you know, post war Glasgow began to spiral downwards in the sense that it began to lose a lot of jobs, men who had worked all their lives and jobs that gave them a sense of status in the in the shipyards, for example, the those jobs just disappeared. And the other thing that was happening in Glasgow at the same time was a complete change in the social structure of the city. The city engineer at that time decided that it was going to knock down all the old traditional communities and he was going to build high-rise flats. So people who were able to look to their neighbours for support and tenements and so on which were not the most salubrious bits of accommodation by any means, suddenly found themselves being taken away from those houses, taken away from their friends, decanted into temporary accommodation, high rise flats. So the communities were broken up the friends that folk had for years that they could rely on for a bit of support and advice and so on. Suddenly they solemn no longer there were no mobile phones in those days. So the communities were broken up, and the jobs disappeared, and people were left feeling helpless. The helplessness, poverty and so on, came together to create this huge gulf in self-esteem and self-control between rich and poor in the city.

Jennifer Dixon 

And how has that affected life expectancy?

Harry Burns 

The gap in in life expectancy has widened dramatically since the 1950s.

Jennifer Dixon 

And how different is Glasgow from Liverpool and Manchester?

Harry Burns 

When David published this paper on Glasgow, Liverpool and Manchester, the first person I spoke to was our colleague who was director of public health in Liverpool at the time, and I asked her what why is Liverpool different from Glasgow? Why do you guys had the Toxteth riots and so on? We've never had riots in Glasgow, maybe if we had it would be different. And her take on post-Toxteth Liverpool was the city council went out of its way to try and create stronger communities. So I think we can see ways out of this for Glasgow, but it will take a lot of political determination to do so.

Jennifer Dixon 

David, Harry was just describing the differences that might be existing between Glasgow and the health of the population in other de-industrialised cities, Manchester, Liverpool, and I know you did some very detailed work on this. Can you chart what you think are the major differences that could be contributing to the difference in health between these cities?

David Walsh 

The paper Harry mentioned, was came over 10 years ago, which showed that Glasgow Liverpool and Manchester were very similarly deprived cities using the the kind of area based measures of deprivation that we have, and actually that they weren't, they were similar in lots of different ways. But despite that, Glasgow's health was, you know, far, far worse. So premature mortality at that time was about 30% higher than in Liverpool and Manchester, despite these similar socioeconomic profiles, so that's been spawned a lot of conversations of the type that Harry's just described.  And a lot of speculation, some of which was quite helpful, and some of it which wasn't very helpful. So everyone had their own pet theories about what was going on. So to try and bring some resolution to this, we embarked on a very large piece of work in which we systematically and scientifically examined no fewer than 40 proposed theories for what was different about Glasgow that was contributing to its higher mortality. And what emerged from that was a very complicated story, but at its heart was a toxic combination of worse living conditions historically, and a lot of really bad political decision making at different levels of government. And if you go back to that post war era, and indeed, if you look across a number of decades of the latter half of the 20th century, if you use measures of low income, then Glasgow, Liverpool and Manchester, their poverty levels seems quite similar. But actually, in those post-war decades, the actual housing conditions in Glasgow were males worse, in part responds to that is some of the stuff that Holly touched on in terms of the changes that were made to the city in those post-war decades, which has a much worse effect than they did in the comparator cities of Liverpool, Manchester. So the slum clearance that Harry mentioned in terms of how that broke up existing communities is highly relevant. And in terms of the building of really poor quality, peripheral housing estates. This happened in lots of cities in the UK, but it was done at a much larger scale in Glasgow, where there's lots of evidence of negative impacts of that type of high-rise living on mental health. And we know the links between mental health and physical health but on top of all that, fundamentally was at key points in time, they actually just invested less money. In looking after these properties. We then had an additional disadvantage conferred in the city at that time by actions of the UK government or to be more precise the Scottish office. We instead embarked on a whole series of policies that you can only really describe as a sort of writing off the city is kind of giving up on the city. So Glasgow was officially declined to be a declining city. And all economic investment was to be made away from the city, not in the city. And as part of that, industry was moved away when they built the new towns to deal with the housing shortage. Not anyone could move to a new town like the kids in the new towns built around Liverpool. Though there was a selection process in operation so they, they targeted people who had jobs, who had skills, who had trades, they were particularly interested in younger families with children. And then another Scottish office report, this is the Scottish office who were actually implementing these actions. They refer to the fact that this was this was a huge concern, because we were creating a population in Glasgow that was basically old, unemployable and sick. So a completely vulnerable population, but despite knowing that they kept doing these policies for a number of decades, and just to finish this kind of very quick run through the story, you know, it wasn't that that may have put Glasgow at disadvantage, it wasn't one single thing, it's a whole lot of different things. And by the time we got to the 1980s, when we had the Conservative party in power in London, Mrs. Thatcher in charge of that, embarking a number of policies that were widening inequalities, and having a big effect on post-industrial or soon to be post-industrial cities, like Manchester, and Liverpool and Glasgow, there are different actions taken by local governments in the different cities. And as Harry alluded to, there were actions taken in Liverpool, which better protected the population. So what was going on at that time resulted in a big, a much more politically engaged population. And in contrast, in Glasgow, in the 1980s, there was a different thing going on, there was a kind of business-led model of regeneration, which focused on regenerating the city centre, for example, it's been a whole cycle of problematic factors conferred on Glasgow.

Jennifer Dixon 

Exactly. I mean, that's an absolutely fascinating story, David, and I think that account, I mean, partly written very fully in the 2016 report from the Glasgow centre, I absolutely recommend. It's called History, politics and vulnerability: explaining excess mortality in Scotland and Glasgow. It's absolutely compelling reading. And I think it's really very relevant now as we attempt to level up across the country, if that, indeed is a serious strategy, to learn from the decades of what has happened in Glasgow, even though it was quite unique, is going to be absolutely important. So a lot of factors, deep structural factors, as well as the austerity that you mentioned earlier, David and Harry. I think what might be useful now is just to turn to the types of solutions that have been tried. I think, looking at the various Scottish documents, what's absolutely clear is over the last 20 years, there's been enormous commitment and concern about these issues, not just in Glasgow, but across Scotland as a whole to address inequalities since 1999. And I know that Harry, you as CMO in Scotland, were central to a lot of this because you were in post during a lot of that period, where indeed, Scottish Government instituted its first reducing inequalities in health policy. Can you just chart for us, Harry, in Scotland, the key kinds of attempts and policies over the last 20 years to try to do something about these long run issues, long and short run issues?

Harry Burns 

So part of the problem in dealing with inequalities is an over simplistic analysis of the causes. The outcome that any society has, or delivers is based on a complex interaction of things. And we've already talked about housing, jobs, support in all sorts of ways. Part of the difficulty I think every country has had is that the politicians want to do a thing, you know, we know have the answer to obesity and inequalities in obesity is to banned advertising of fat, fat containing foods in the evening and all this kind of stuff that's grossly over simplistic. The Adverse Childhood Experiences study in America started off as a weight reduction clinic. And it's very plain that adversity and families and an early life and so on, creates a sort of metabolic response that leads to all sorts of health problems in later life. So you're not going to defeat obesity by just having an obesity policy. It has to be a person supporting policy, various things like banning smoking in public places, and Scotland, taxing alcohol, containing drinks and so on. They have had an effect. But interestingly, the effect is often not what you would expect because it's a complex system. For example, I remember when we were talking about banning smoking in pubs a member of the licenced trade said to me, oh, you're just harm children with that because people will buy a carry out and they'll go home and or sit at home and smoke and the children will suffer. And find out was completely the other way around us there was a significant reduction in admissions of children with asthmatic attacks after we had been smoking in public places. The Institute for Healthcare Improvement in Boston had done the patient their patient safety programme now 100,000 lives campaign. And we introduced this, and it was a way of improving complex system dynamics. What I've been talking about over the past year or two is we should have an inequalities improvement collaborative. And that the answer to improving things is do it from the bottom up. Don't tell people who already feel hopeless, and not in control of our lives, don't tell them to do things, ask them what they need to live better lives. And there have been lots and lots of projects. In England, interestingly, that have worked out we, the beacon and old Hill project and farmers were places a warzone. And here's all strictly and call, went out and asked people what would make a difference to their lives, and they helped them achieve it. Stoke on Trent did a similar approach. And they saw huge reductions in demand for social services for healthcare services and so on, simply by helping by identifying people that are living really pretty chaotic lives and supporting them, you know, we need as part of support to improve the well being of people by making sure they have enough money to live on. And the behaviour of politicians over the 20 pound food for children stuff was, again, scandalous. We need to make sure that we deal with poverty. But we also need to make sure that we support people in achieving aims and aspirations, and show them that they can be more in control of their lives. That will make a difference.

Jennifer Dixon 

Yeah, and just to backtrack a minute, Harry, I noticed in amongst the many 20 years of initiatives in Scotland, which are impressive. A notable one was something that we're calling for in England at the moment, which is a cross government strategy to reduce inequalities in health. And in 2008, of course, there was a ministerial Task Force set up by the Scottish Government called equally well, which was really about across a serious attempt to reduce inequalities. And can you just chart out that what did this equally well policy try to do and hasn't been successful?

Harry Burns 

I don't know what happened to equally well, it's gone. You know, no one talks about it anymore. I mean, if you leave things in the hands of politicians rather than front line workers, then when the politicians change when their attention is drawn elsewhere, the impetus behind policies will slow down. And, you know, nothing will happen. It's got to be the frontline staff are dealing with the difficulties every day that come up with solutions, implement them, and you will get change happening.

David Walsh 

Yeah, my understanding is... This may not be yet official by the way... My understanding is that there's a new strategy going to come out from the Scottish Government. But I think there's there's a bigger issue here in terms of, you know, if we're talking about the impacts of austerity, if we're talking about excess mortality, they're all forms of health inequality. So the question is, the first question is, do we know what works in addressing health inequality? And the answer to that is yes, because they've been all sorts of policy reviews. It was one a few years ago by NHS health Scotland, which has no become public health Scotland. And the outlined very, very clearly and very effectively, the policies that work, the policies that don't work, and what therefore, we need to do, and it sounds what we need to do it fundamentally, it's about what are the fundamental causes of health inequalities, and we know from all the evidence that they are socio economic. So it's all about actions around trying to narrow income inequality, socio economic inequalities, there's also actions you can do your own one environmental things, in terms of some of the stuff that Heidi mentioned, like like alcohol, or pollution, these things, but there's when it comes to the question of Scotland, there's a big elephant in the room here, which is about Scotland talks about trying to narrow health inequalities. We have an economic strategy at the heart of government, which is a big change in that or economic inequalities and the that would, you know, have an impact on health inequalities. But the big question is, do we, in the current devolved situation, actually have the powers to address effectively health inequalities and socio economic inequalities, there's lots of things that we can do. But if you look, for example, at, I don't know, the the increase in in work poverty, for example, over the last few years, linked to, you know, the Zero Hour contracts, the gig economy, etc, etc, changes to that requires changes to employment law, and that is reserved to the UK Government, Scotland can do very much around that if you look at the scandalous changes to Social Security, which as we've discussed, has impacted so much in the poorest Scotland has miniscule perils over Social Security. So there's a big, big question about, although the Scottish Government talks really admirably about the need to address inequalities, but the big question is, you know, are the powers at their disposal sufficient to address socio economic inequalities, and therefore, health inequalities?

Harry Burns 

I agree 100% percent. David, I think you're right, if Scotland is going to make a difference, it's got to have the powers to do so.

David Walsh 

There have been positive developments. So, you know, as part of the package of austerity, people in England and Wales are subject to the so called bedroom tax, and that was that was mitigated in Scotland, by by basically pre paying people with additional housing grants. And they've just brought in a Scottish child payment, which is basically an additional low income, benefit for it for low income families. And that's going to be doubled to 20 pounds a week. I think in the next balance, well, there are things happening. But the problem is, it's a balance about what powers we have in Scotland to address these issues, that are massively outweighed by the powers we don't have which have such an effect on them. When they're using the way they've been used by the UK Government recently,

Jennifer Dixon 

Inequalities policy review document that was in June 2013, from NHS health Scotland, the the key components of the health inequalities strategy and what you know how to mitigate them, were grouped into fundamental causes that do look like UK government in the bailiwick of the UK government, but then there are wider environmental influences of the type you mentioned, David, which look a lot to do with the powers that the Scottish Government have. And then individual experiences, for example, you know, focusing on young children and early years and so on, which equitable experience of public services that look very local. Sure, it sounds as though there's significant power in the hands of the UK Government. But there's also significant power locally.

David Walsh 

Yeah, as I said, you know, really helpful things have been done and the breakdown of sort of policy interventions, you've mentioned there. sound very similar to the ones in the health Scotland report I mentioned before I learned what works best around inequalities. I was talking to a colleague recently, and he put it this way, if you look at if you can imagine that I can assess skills, you know, in terms of a Scottish Government powers versus UK government power. So there's all these really helpful things we can do and have done lots of good things happening. But the problem is, they are they are currently outweighed by the powers that are reserved to the UK Government. Because that's when we start talking about you know, what I've been referred to correctly as the fundamental causes of health inequalities being socio economic, so all the economic leavers, Social Security, etc, they've had the biggest step there, they can have the biggest impact and do have the biggest impact and the example of austerity. And what happens if you slash Social Security is a great example of you can do all the great things you like in one place. But if somewhere else, completely removes the safety net and removes the income of the poorest causing more and more people to die, then that clearly balances the good things that we've been trying to do, for sure.

Jennifer Dixon 

So turning to the post pandemic situation where all the language at least is of build back better, to recover to level up to recover from the pandemic, everyone's consciousness is seared about the sort of distribution of hurt caused by the pandemic, both economically and health wise. And given all the policies that have been tried in Scotland and effort over the last 20 years. I guess the basic question there is, where do you go from here, particularly in Scotland, to start off with Harry, you are advising the Scottish Government, it sounds as though there is going to be a refreshed health inequalities strategy. What can be different about this? What should it be doing learning from the last 20 years do you think to take us forwards?

Harry Burns 

My argument would be that we make change. We create gene from the bottom up, policy should be permissive. It should allow local agencies to support people in the way that they the people themselves find helpful. The whole idea of asking people what matters To them, what is it the need has come out of all the successful projects that I know that the 100,000 homes campaign in America where they set out, to use this technique to, to get rough sleepers into permanent accommodation, I went over to visit them. And they said that the thing that really made change happen was talking to the individual and finding out what had happened to them and helping support them to take control over their lives. And do that on an individual basis. We need to do that young people, and who are experiencing domestic violence and all this kind of thing. But we also need to create the policies that will support the change from happening. And that is largely about making sure that there's jobs for them, making sure that those jobs are well paid, making sure that schools and so on, give young people a sense of achievement and self esteem and so on. So, I would hope that the politicians the SNP who have provided over the improvement science approach that have used in early years and in patient safety, and so on, would would want to have and inequalities collaborative that spanned the whole of society, from the bottom up. Over the past few years, we've been talking to the Scottish Government about the well being economy, an economy that works for everyone, and which allows people to be engaged, my hope is that the well being economy idea will create, after we come out of this pandemic, will create momentum towards a better economic relationship with people who are more in control of our lives and who want to achieve better things in our lives.

Jennifer Dixon 

And are you saying, Harry that? How would that come about this this grassroots starting from the people, would it be through councils? Would it be through the third sector, what would have to change? It's all of these things.

Harry Burns 

When we did the early years collaborative, we every five or six months, we would get about 800 people in a very, very large room. And sitting around a table for each county and each house board. There would be local councillors, there would be local clinicians, there would be police, there would be social workers, and so on from that area. And they would sit and they would hear what other areas were doing. He would see what was working, they would share ideas, he would test interventions and so on. And we began, you know, Scotland started that with the highest infant mortality of the four UK countries and ended up with the lowest infant mortality of the four UK countries. That's just one example. So it's, it's about bringing people together.

Jennifer Dixon 

Thank you so much. So David, your take on this, the next steps forward, would be very helpful. On top of what Terry has said, you agree, grassroots support was become

David Walsh 

an almost hackneyed phrase is that the pandemic has has shone a light on existing inequality, if it shone a light on inequalities, addressed was inequalities, what we're seeing from the data, the moment is, you know, we're gonna have an impact on mortality rates, or life expectancy, from 2020 and in 2021, and then we'll go back to previous levels, my real concern is what those previous levels are, because they weren't improving and for some of the population, they're getting worse. So So what do we do so we need somehow to try and get the UK Government to reverse some of of the cuts they have made to help people the fact that they're going to not going to continue this 20 pound Universal Credit uplift as despicable frankly, we need the Scottish Government to do everything they can, with their more limited powers to try and help those people that have been affected by these cuts. And we have to think about, as I've said before, those fundamental socio economic causes of health inequalities, the Scottish Government's economic recovery plan is really ambitious. And unlike a lot of the documents the Scottish Government produces, it's, it's, it's, it's really helpful, and it's really positive. And it's talking about doing all the right things I just worried personally about, as I said in the last bit of conversation about whether we actually have sufficient powers to do the things that we need to do and clearly the government wants to do. And so I think another part of it, and I've heard some, some MSPs talk about this, you know, advocating to get to get additional powers around employment law, for example, to try and address some of these issues, including some of the things that Harry mentioned, are really, really important because otherwise, you know, it's fighting a really difficult battle.

Jennifer Dixon 

So a great deal for us all still to do. I'd like to thank our two guests, David Walsh and Harry burns for what I think you'll agree was a great dissection of the issues, as well as some ways forward. You'll notice we didn't discuss the scourge of drug deaths in Glasgow, which is contributing to the higher mortality there. And that's because we'll be devoting an entire pod to drugs in the future. for links to key reading on the things we did discuss today, as ever, please find them in our show notes wherever you find this podcast. And next month, we'll be looking at an everyday substance that deeply affects our health food. We are what we eat, how can our approach to food boost the UK is health, be good for the environment, and most importantly, tastes good. I hope that wets your appetite and thanks for listening and see you next time.