1. Making a bad situation worse? The impact of welfare reform and the economic recession on health and health inequalities in Scotland Gerry McCartney Consultant in Public Health Head of Public Health Observatory January 2014

2. Aims 1.Provide a background picture of health in Scotland 2.Describe the changes in economic context and welfare policy over time 3.Summarise the evidence on the likely impacts

3. Historical international trends in life expectancy Data extracted from the Human Mortality Database for all available nations: Australia, Austria, Belgium, Belarus, Bulgaria, Canada, Chile, Czech Republic, Denmark, East Germany, England & Wales, Estonia, Finland, France, Germany, Hungary, Ireland, Iceland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Russia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan, West Germany, Ukraine & USA.

4. Higher overall mortality than comparable nations Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales, Finland, France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Spain, Sweden, Switzerland, Taiwan & West Germany.

5. Higher overall mortality than comparable nations Scotland Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales, Finland, France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, Spain, Sweden, Switzerland, Taiwan & West Germany.

6. Life expectancy drops by 2.0 years for males and 1.2 years for females for each station on the railway line between Jordanhill and Bridgeton McCartney G. Illustrating Glasgow’s health inequalities. JECH 2010; doi 10.1136/jech.2010.120451.

7. Trends in mortality inequalities in Scotland 1981-2010 (sources: NRS and Scottish Government)

8. Inequalities in male mortality (early 2000s, all ages) Sources: Mackenbach (2008) and Popham (2010)

9. Inequalities in female mortality (early 2000s, all ages) Sources: Mackenbach (2008) and Popham (2010)

10. All-cause age-standardised mortality (men, 15-44y) in Scotland compared to 16 other European countries Source: Whyte B, Ajetunmobi T. Still “the sick man of Europe”? Scottish mortality in a European context1950 – 2010: an analysis of comparative mortality trends.

11. All-cause age-standardised mortality (women, 15-44y) in Scotland compared to 16 other European countries

12. 1. Summary of Scottish mortality epidemiology Health in Scotland is improving, but remains worse than in the rest of west and central Europe Health inequalities in Scotland are wider than the rest of west and central Europe, and on many measures are getting worse There has been little or no improvement in mortality for young adults for 30 years

13. 2. Changes in economic context and welfare policy

14. Timeline of selected welfare changes (from 1975) SDA – Severe Disablement Allowance IS – Income Support DLA – Disability Living Allowance AA – Attendance Allowance IB – Incapacity Benefit JSA – Job Seekers Allowance ESA – Employment and Support Allowance WCA – Work Capability Assessments CPI – Consumer Price Inflation UC – Universal Credit PIP – Personal Independence Payments

15. Timeline of selected welfare changes (from 1975) Decreasing universality Increasing conditionality Increasing stigma Increased privatisation

16. Equivalised real average weekly household incomes, after housing costs, by income deciles for Scotland 1994-2010 (£) Source: NHSHS analysis of IFS data derived from FRS – published as part of the third annual Monitoring and Evaluation Scotland’s Alcohol Strategy (MESAS) report. Note: The shaded area represents years of economic downturn.

17. Trends in economic growth (Gross Value Added) and income inequality (Gini coefficient) (Sources: IFS and SG)

18. 2. Changes in economic context and welfare policy 30 years of welfare change have reduced universalism, increased conditionality, increased stigma and privatised the process No increase in income for poorest for 10 years Recession has reduced middle/high income groups most Income inequality is higher now than 30 years ago, but has declined in the last 2 years Note – various policies are expected to exacerbate income inequalities in the next few years

19. 3. What are the likely impacts of recession? Some aspects get better and other worse; some contradictory impacts in short-term v long-term The impacts are dependent on the policy response and social protection available 1,2 Moving into unemployment increases mortality by 63% 3 Suicide has increased, 2 and mental health worsened, in many countries 4 Short-term decreases in substance misuse 1.Suhrcke M, Stuckler D. Will the recession be bad for our health? It depends. Social Science and Medicine 2012; 74: 647-53. 2.Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crises and alternative policy responses in Europe: and empirical analysis. Lancet 2009; 374(9686): 315-23. 3.Roelfs D, Shor E, Davidson K, Schwartz J. Losing life and livelihood: a systematic review and meta-analysis of unemployment and all-cause mortality. Social Science and Medicine 2011; 72: 840-54. 4.Katikireddi SV, Niedzwiedz CL, Popham F. Trends in population mental health before and after the 2008 recession: a repeat cross- sectional analysis of the 1991-2010 Health Surveys of England. BMJ Open 2012; 2(5).

20. What are the likely impacts of welfare changes? Some similar and some contradictory to predicted recession impacts: Increases in cardiovascular, respiratory and obesity- related illness Worse mental health Higher winter mortality Increased substance misuse Increased unprotected sex and associated STIs Increased health inequalities

21. Differential impacts across population groups – young adults particularly badly affected Many losing multiple sources of income Some particularly badly affected (e.g. those sanctioned from JSA) Rising energy prices affecting those in worst housing Regional differences in availability of work (almost 5 times as many jobseekers in Glasgow than available jobs) Increasing stigmatisation Cuts to public services reducing available support Compounding factors

23. Summary Economic recession is likely to be bad for health – especially when accompanied by neoliberal policy responses The changes to welfare policy predate the 2010 coalition, but have intensified the drive away from universalism and towards conditionality and privatisation These changes to welfare are likely to compound the problem It is too early to detect much change in the routine administrate health data

24. A copy of the baseline report containing most of this material is available at: www.scotpho.org.uk under the ‘reports and publications’ tab. Thanks gmccartney@nhs.net