By Professor John Robertson
‘Revealed: scandal of Scotland’s rich-poor life expectancy divide for women’ (Herald, 6th March 2016).
Writing a few days ago (August 28th) on the good news about falling mortality in Scotland’s hospitals and the less good news on the same matter in English hospitals (see ref below), I was reminded of a fascinating research paper, in the Journal of the Royal Society of Medicine (JRSM, March 2016), on mortality among the over 85’s in England, which the authors suggested that Tory austerity cuts between 2007 and 2003 were increasing mortality rates among this particularly vulnerable group.
In an email exchange with one of the authors, I asked about Scottish figures. They had none and it was clear that gathering them, via FOI requests to all local authorities, would be beyond my resources. However, they did agree that the absence of many of these cuts in Scotland might reasonably be expected to have prevented similar increases in mortality among Scottish over 85’s. Unsurprisingly, Scotland’s mainstream media were to miss the report and continued as before with uninterrupted negativity on health matters in Scotland such as that above highlighting the admittedly disturbing life-expectancy divide between women in Scotland’s more and less affluent areas.
Directly comparable statistics are rarely available for Scotland and England so confident conclusions can never be made. This situation tends to favour Unionist arguments. However, this situation does not stop us asking serious questions, presenting what evidence there is and offering reasonable if contingent conclusions on the relative health, in this case, of the Scottish and English NHS.
Careful scrutiny offers two important pieces of information. First in the Herald article, based on a report from the Glasgow Centre for Population Health, we read: ‘life expectancy has increased for women from most socio-economic levels [2008-2102]’. Clearly, that might as easily have been the headline but it might have encouraged us to think better of ourselves and we can’t have that, can we? Second, we read in a 2014, BBC report based on figures from The National Records of Scotland: ‘Life expectancy for men and women in Scotland has risen to between 76 and 80 in the last few years [2011-2013].’ Note that these reports, like the JRSM report on increased deaths of over 85’s in England, cover the same period of austerity measures imposed by the UK Conservative Government.
So, accepting the limitations, could the increases in the mortality rates of over 85s, especially in women, which have been linked to Tory austerity cuts there, have been prevented in Scotland due to Scottish Government measures to protect the NHS and welfare systems here? I can’t be sure, but it looks a possibility worth further study by a Scottish research team.
A fuller explanation of the English research is need, admittedly, to make convincingly the case for their hypothesis that austerity cuts are directly reducing the life expectancies of over 85s in England and this is offered below.
‘Rising mortality rates among pensioners aged 85 and over were linked to reductions in spending on income support for poor pensioners and social care. Findings suggest austerity measures in England have affected vulnerable old-age adults.’
In the report titled ‘Austerity and old-age mortality in England: A longitudinal cross-local area analysis, 2007-2013’ published in the highly-rated Journal of the Royal Society of Medicine, the authors from Oxford and four other English universities make a very strong assertion that these falls in life expectancy for the over-85s have been caused by reduced payments to, and care of, older pensioners. They also point out that while there had been a steady decline in mortality rates for over-85s in England, under Labour, this was reversed with increased mortality in 2010, for men and in 2011, for women under the Coalition.
These increases, they point out, coincided with reduced benefits for the poorest pensioners and reduced local authority care spending. Reducing these benefits and the care expenditure for these elderly people will have caused increased anxiety, raising the risk of heart attack and stroke, they argue. Further, reduced income will have affected these pensioners’ ability to pay for heating, food and transport. Commenting in the Daily Telegraph on 21st March 2016, Caroline Abrahams, charity director at Age UK, said:
‘This decrease in life expectancy, after many years of improvement, is like ‘the canary in the coal mine‘: it is telling us that something has changed for the worse, so that fewer people are thriving in later life than they could or should. The most obvious likely culprit is the rapid decline of state-funded social care in recent years, which is leaving hundreds of thousands of older people to struggle on alone at home without any help.’
Commentators in England have suggested that changing lifestyles of female ‘baby-boomers’ might partly explain these results along with the decline in care. Women are smoking and drinking at increasingly comparable levels to men and, it is argued by Prof John Ashton, president of the UK Faculty of Public Health (in the same Daily Telegraph piece). This is taking its toll decades later, for women in their 60s, 70s, 80s and 90s. Thus mortality rates for men and women have begun to converge.
So, it can be argued that the increase in female mortality across all age groups is a consequence of lifestyle and welfare changes while those of men can be more accurately linked to the latter, only and this has a particular resonance for the Scottish context,
In Scotland, there were similarly, falls in life expectancy for female over-85s and for younger groups perhaps due to lifestyle changes of the kind mentioned, but not for men at 65, 70, 75, 85 or 95! For this group, particularly the over 85s, with unchanged unhealthy lifestyle choices, Scottish Government protection against austerity now emerges as a strong factor.
Could this then mean that the Scottish Government’s protection of the Scottish NHS and of the costs of care for the elderly are getting results of a dramatic nature which contrast favourably with the situation in England? I have neither the energy nor the expertise to replicate the Oxford study with Scottish data so my conclusions must be more hesitant. However, remember that heart attack and stroke are the main killers of the elderly with an environmental basis (housing, home-care, transport, A&E performance) which can be affected by policy and action by governments. See this from the Scottish Public Health Observatory in 2016:
‘The age-sex standardised mortality rate for CVD and stroke has fallen steadily in the last 10 years. The rate for stroke decreased by 39.0% over the last ten years, from 79 per 100,000 population in 2005 to 48 per 100,000 in 2014. The age sex standardised incidence rate for cerebrovascular disease (CVD) has fallen over the last ten years in Scotland. Between 2005/06 and 2014/15 the rate fell by 15.6% from 309 per 100,000 population to 261.
These quite dramatic improvements coincide with the period of SNP government. Notably, in the light of the Oxford research, the fall was most steep in the over-75 group, the group most in need of care and, of course, in need of effective A&E services (more later on this).
Accepting the thesis that improvements in income and in the level and quality of care, and not changes in personal lifestyle, will be a better explanation for the survival of elderly males in Scotland, what might these have been? The well-known free personal care arrangements, introduced by Labour in 2002 but then protected by the SNP government over the last 8 years seems a likely though partial explanation. Also, there are other indicators of effectiveness in the Scottish NHS which may be further factors in this phenomenon. In earlier articles (references below) I’ve presented hard evidence of relative success. First, here’s the Royal College of Emergency Medicine in 2016:
‘The UK has the best A&E performance in the world (measured by process indicators). Scotland has the best A&E performance among the UK nations.’
Remembering the particular risks of heart failure and stroke for the elderly, what could be more likely to improve mortality rates than the best A&E service in the World? Second, the role of GPs, who know the elderly patients well and who can then coordinate the care provided by different professionals, seems critical. See this table based on data for UK GPs extracted from a US-based Commonwealth Fund study in 2015:
Q19C. During the past month, did the following occur with any of your patients? A patient experienced problems because care was not well coordinated across multiple sites or providers.
While by no means perfect, the Scottish system appears to be performing much better than elsewhere in the UK. For more on this, see my report below (Robertson, 2016) based on data I had to request and to persist in demanding, from the Commonwealth Fund to reveal the UK breakdown.
Now, I know my limitations, unlike some BBC Scotland Health Correspondents, it seems. The Oxford study has, shockingly, produced very convincing evidence that Tory welfare cuts have shortened the lives of over 85s in England. I’ve succeeded in showing that something different is happening with Scottish males of 85 years or more.
I’ve also offered convincing evidence of better performance in the Scottish NHS by comparison with the ENHS which must be, in part at least, the result of differential funding. You can probably add the bus pass as another health-promoting factor. I can’t prove beyond doubt that the Scottish Government has been saving lives by its actions on health care and in managing the Scottish NHS over the last eight years but in the absence of contradictory evidence it looks pretty probable. I welcome responses to weaken or to strengthen my case, I do!
Heart Disease and Stroke at: http://www.wired-gov.net/wg/news.nsf/articles/Heart+disease+and+stroke+26012016134800?open
Loopstra, R. et al. (2016) ‘Austerity and old-age mortality in England: A longitudinal cross-local area analysis, 2007-2013’. Journal of the Royal Society of Medicine
Daily Telegraph: ‘Alarm over sudden drop in female life expectancy’ Monday 21 March 2016 at: http://www.telegraph.co.uk/news/health/news/11507678/Alarm-over-sudden-drop-in-female-life-expectancy.html
Royal College of Emergency Medicine (2016) PRESS STATEMENT – For immediate release RCEM Scotland launches Essential Facts regarding A&E services in Scotland at: http://www.rcem.ac.uk/
Robertson, J. (2016) Scottish GPs: Most satisfied and least stressed in the UK and possibly the world at: http://newsnet.scot/?p=116523