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 a number of 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.
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 has been shown to be approximately 30% for premature mortality, and around 15% for deaths at all ages.
The key features of this excess are:
- it is observed in all parts of Scotland compared with the rest of Great Britain, but is greatest in and around the post-industrial West Central Scotland (WCS) conurbation and, in particular, Glasgow
- it is increasing over time
- it is seen across all adult age groups, but is highest among those of working age (especially younger working age)
- it is observed across all social classes, although for premature mortality, it is more pronounced in comparisons of the poorest populations
- it is observed for a broad range of causes of death, although with important distinctions between excess premature mortality (particularly influenced by higher rates of death from alcohol, drugs and suicide) and excess mortality at all ages (driven particularly by higher numbers of deaths from cancer, heart disease and stroke)
- and given the relationship between socioeconomic factors and health behaviours, the excess persists even after statistical adjustment for differences in behaviours such as smoking, physical activity, diet etc.
Explaining excess mortality
In May 2016, the Glasgow Centre for Population Health (GCPH) and NHS 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 made was 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.
Selected key references
Bloor M. et al. Contribution of problem drug users’ deaths to excess mortality in Scotland: secondary analysis of cohort study. BMJ 2008; 337: a478
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 May;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 126 (2012) 378-385
Gray L. Comparisons of health-related behaviours and health measures in Greater Glasgow with other regional areas in Europe. Glasgow Centre for Population Health, 2008
Hanlon P, Lawder RS, Buchanan D, Redpath A, Walsh D, Wood R, Bain M, Brewster DH, Chalmers J. 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 Centre for Population Health, April 2013
McCartney G., Collins C., Walsh D., Batty G.D. Accounting for Scotland's Excess Mortality: Towards a Synthesis. Glasgow Centre for Population Health, April 2011.
McCartney G., Collins C., Walsh D., Batty G.D. Why the Scots die younger: Synthesizing the evidence. Public Health (2012), doi:10.1016/j.puhe.2012.03.007.
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, doi:10.1371/journal.pone.0038860
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 and. 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. J Epidemiol Community Health (2012) doi:10.1136/jech-2011-200855
Popham F., Boyle P.J., Norman P. The Scottish excess in mortality compared to the English and Welsh. Is it a country of residence or country of birth excess? Health & Place (2010); doi:10.1016/j.healthplace.2010.03.007
Popham F., Boyle P.J. Is there a ‘Scottish effect’ for mortality? Prospective observational study of census linkage studies. Journal of Public Health; pp. 1–6; doi:10.1093/pubmed/fdr023.
Popham F. Is there a ‘Scottish effect’ for self reports of health? Individual level analysis of the 2001 UK census. BMC Public Health 2006, 6:191
Schofield L., Walsh D., Munoz-Arroyo R., McCartney G., Buchanan D., Lawder R., Armstrong M., Dundas R., H Leyland A.H. Dying younger in Scotland: trends in mortality and deprivation relative to England and Wales, 1981-2011. Health & Place 2016; 40: 106-115
Taulbut M., Walsh D. Poverty, parenting and poor health. Glasgow Centre for Population Health, May 2013
Taulbut M., Walsh D., McCartney G. Collins C. Excess mortality and urban change: Investigating similarities and differences in the extent of urban change in Glasgow, Liverpool and Manchester and their surrounding regions from 1945, and the extent to which this might be part of the excess mortality explanation. Edinburgh: NHS Health Scotland; 2016
Taulbut M., Walsh D., Parcell S., Hanlon P., Hartmann A., Poirier G., Strniskova D. Health and its determinants in Scotland and other parts of post-industrial Europe: the ‘Aftershock of Deindustrialisation’ study - phase two. Glasgow Centre for Population Health, 2011.
Walsh D., Bendel N., Jones R., Hanlon P. It’s not ‘just deprivation’: Why do equally deprived UK cities experience different health outcomes? Public Health 124 (2010), 487-495.
Walsh D., Bendel N., Jones R., Hanlon P. Investigating a ‘Glasgow Effect’: Why do equally deprived UK cities experience different health outcomes? Glasgow Centre for Population Health, April 2010
Walsh D., McCartney G., Collins C., Taulbut M., Batty G.D. History, politics and vulnerability: explaining excess mortality in Scotland and Glasgow. Glasgow: Glasgow Centre for Population Health; 2016
Walsh D., McCartney G., McCullough S., van der Pol M., Buchanan D., Jones R. Exploring potential reasons for Glasgow's 'excess' mortality: results of a three-city survey of Glasgow, Liverpool and Manchester. Glasgow Centre for Population Health, June 2013
Walsh D, Taulbut M, Hanlon P. The aftershock of deindustrialization – trends in mortality in Scotland and other parts of post-industrial Europe. European Journal of Public Health 2010 20: 58-64
- This section was last reviewed in June 2016.
- The next review of the section is due to be carried out by end September 2017.