Excess mortality in Scotland and Glasgow

There has been a considerable amount of attention in the media on the notions of ‘The Scottish Effect’ and ‘The Glasgow Effect’. These terms were coined by researchers many years ago in relation to a specific epidemiological issue: the higher levels of mortality in Scotland (and especially in and around Glasgow) compared to elsewhere in the UK that cannot be explained in terms of differences in material deprivation and socioeconomic circumstances alone.

However, the precise meanings of these expressions have arguably become blurred, and tend to no longer be used by researchers: the term 'excess mortality' is generally employed instead. This page briefly outlines the main features of the excess and the most likely underlying causes.

(Note: further details of why these terms - 'Glasgow Effect', 'Scottish Effect' - are unhelpful are provided within this GCPH blog . In addition, a later GCPH blog (published in 2021) explains why excess mortality in Glasgow is better described as a 'political effect' rather than a 'Glasgow effect').

Overview

The poor health profiles of Scotland, and especially that of its largest city, Glasgow, are well known. Much of this is explained by recent experiences of deindustrialisation, deprivation and poverty: the latter are the root causes of poor health in all societies, not just Scotland. However, in addition, high levels of excess mortality – that is, higher mortality over and above that explained by differences in socioeconomic deprivation – have been observed for Scotland compared with England & Wales, as well as for Glasgow compared with similar post-industrial UK cities such as Liverpool, Manchester and Belfast.

The scale of this excess is considerable. It accounts for approximately 5,000 extra, 'unexplained', deaths per year in Scotland, and makes a substantial contribution to the other principal mortality 'phenomena' associated with Scotland in recent times: the lowest, and most slowly improving, life expectancy in Western Europe; the widest mortality inequalities in Western Europe; and the persistently high rates of mortality among those of younger working ages. After adjustment for differences in deprivation, premature mortality (<65 years) in Scotland is 20% higher than in England & Wales (10% higher for deaths at all ages); similarly, the excess for Glasgow compared with Liverpool, Manchester and Belfast was shown (in research published in 2010 and 2012 respectively) to be approximately 30% for premature mortality, and around 15% for deaths at all ages. Updated analyses of deprivation and mortality in Glasgow, Liverpool and Manchester published in 2021 showed that high levels of excess mortality still persist (although the excess for female premature mortality had reduced, in large part because of worsening death rates in the English cities (likely related to the impact of UK Government austerity measures)).

Explaining excess mortality

In May 2016, the Glasgow Centre for Population Health (GCPH) and NHS Health Scotland (now Public Health Scotland), in collaboration with the University of the West of Scotland and University College London, published a synthesis report, entitled History, politics and vulnerability: explaining excess mortality in Scotland and Glasgow, which identified the most likely underlying causes of this excess.

Those causes are complex, multiple and interwoven.

In Glasgow’s case, the main finding was that the city’s population was made more vulnerable to factors which impacted on health across the UK (e.g. poverty, deprivation, deindustrialisation, economic decisions taken at UK government level), consequently leading to poorer health than in other places which had similar experiences.

The city’s population was made more vulnerable due to:

• high levels of deprivation (specifically overcrowding) over a long period of time
• urban planning decisions in the post-war decades (e.g. the creation of larger, relatively poor quality, peripheral housing estates)
• UK government Scottish Office regional economic policies in the 1950s-1970s
• local government responses to UK government policy in the 1980s.

There was also evidence of some ‘protective factors’ in Liverpool and Manchester which helped to reduce the adverse impact on health in those cities.

And a wide range of other, smaller factors were identified which may come together to add to the excess, alongside recognition of the difficulties of capturing the ‘lived experience’ of deprivation in the standard deprivation measures currently used.

Because of geographical scale (i.e. given the large percentage of the Scottish population that live in and around Glasgow), many of the factors identified as underpinning the excess mortality in Glasgow are also relevant to the excess observed at the national level. In addition, a number of other vulnerabilities – related to, for example, other aspects of UK government Scottish Office regional economic planning – were identified as being linked to excess mortality in other parts of Scotland.

You can download the report here. An infographic, produced by GCPH, to explain the excess in Glasgow can be downloaded here.

Film of a 2017 conference presentation which summarises these research findings can be accessed here.

Selected key references

Carstairs V, Morris R. Deprivation: explaining differences in mortality between Scotland and England and Wales. BMJ 1989; 299(6704):886–889.

Collins C. and Levitt I. The ‘modernisation’ of Scotland and its impact on Glasgow, 1955-1979: ‘unwanted side effects’ and vulnerabilities.  Scottish Affairs 2016; 25(3).

Collins C., McCartney G. The impact of neoliberal ‘political attack’ on health: the case of the ‘Scottish effect’. International Journal of Health Services 2011; 41(3): 501-523.

Connolly S, Rosato M, Kinnear H, O'Reilly D. Variation in mortality by country of birth in Northern Ireland: a record linkage study. Health & Place 2011; 17(3): 801-6.

Graham P., Walsh D., McCartney G. Shipyards and sectarianism: How do mortality and deprivation compare in Glasgow and Belfast? Public Health 2012; 126(5): 378-385.

Gray L. Comparisons of health-related behaviours and health measures in Greater Glasgow with other regional areas in Europe. Glasgow: Glasgow Centre for Population Health; 2008.

Hanlon P,. Lawder R.S., Buchanan D., Redpath A. 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(2): 199-204.

Livingston M., Walsh D., Whyte B. Bailey N. Investigating the impact of the spatial distribution of deprivation on health outcomes. Glasgow: Glasgow Centre for Population Health; 2013.

McCartney G., Bouttell J., Craig N., Craig P. et al. Explaining trends in alcohol-related harms in Scotland, 1991-2011 (I): the role of incomes, effects of socio-economic and political adversity and demographic change. Public Health 2016; 132: 13-23

McCartney G., Bouttell J., Craig N., Craig P. et al. Explaining trends in alcohol-related harms in Scotland 1991-2011 (II): policy, social norms, the alcohol market, clinical changes and a synthesis. Public Health 2016; 132: 24-32

McCartney G., Collins C., Walsh D., Batty G.D. Accounting for Scotland's Excess Mortality: Towards a Synthesis. Glasgow: Glasgow Centre for Population Health; 2011.

McCartney G., Collins C., Walsh D., Batty G.D. Why the Scots die younger: Synthesizing the evidence. Public Health 2012;126(6): 459-70.

McCartney G., Russ T.C., Walsh D., Lewsey J., Smith M., Smith G.D., Stamatakis E., Batty G.D. Explaining the excess mortality in Scotland compared with England: pooling of 18 cohort studies. Journal of Epidemiology & Community Health 2015; 69(1): 20-7.

McCartney, G., Shipley, M., Hart, C., Davey Smith, G., Kivimaki, M., Walsh, D., Watt, G., Batty, G.D. Why do males in Scotland die younger than those in England? Evidence from three prospective cohort studies. PLoS ONE 2012; 7(7): e38860.

Mitchell R, Fowkes G, Blane D and Bartley M. High rates of ischaemic heart disease in Scotland are not explained by conventional risk factors. Journal of Epidemiology & Community Health 2005; 59: 565-567

Mok PLH, Leyland AH, Kapur N, et al. Why does Scotland have a higher suicide rate than England? An area-level investigation of health and social factors. Journal of Epidemiology & Community Health 2013; 67(1): 63-70.

Parkinson J., Minton J., Lewsey J., Bouttell J., McCartney G. Drug-related deaths in Scotland 1979–2013: evidence of a vulnerable cohort of young men living in deprived areas. BMC Public Health 2018; 18: 357