What makes Scotland so sick?

Scotland - particularly the west of the country - has long carried the reputation as the "sick man of Europe", with high rates of heart disease, cancer and stroke. Once a thriving centre of shipbuilding and heavy engineering, the economic decline of the region and associated social deprivation is often cited as the reason for continuing poor health. Millions of pounds has been ploughed into campaigns and schemes to try and tackle disease and improve lifestyles, but with only limited effect.

A new study, carried out by the Glasgow Centre for Population Health (GCPH) and NHS Health Scotland, examined for the first time how death rates in the west of Scotland compare with those in 20 other similar post-industrial regions across the UK and Europe. It found that, despite enjoying better education, greater employment and more wealth, life expectancy is improving more slowly in the Scottish area than anywhere else - and within a decade, it will be the lowest of all the regions studied.

Death rates among young Scots men are rising due to violence, suicide, drugs and alcohol, a pattern that is not repeated elsewhere. And a higher rate of middle-aged women in the west of Scotland are dying because of cancer, heart attacks, stroke and liver disease.

Many of the factors directly contributing to this ill-health - such as smoking, excess alcohol consumption, obesity and poor diet - are well known. But according to the researchers, the results have raised serious questions over the focus of efforts to improve the health of Scots. Report co-author Professor Phil Hanlon, of Glasgow University, said while deprivation was major factor, it was not the whole picture.

"As far as we can see, Scotland is currently wealthier, better-educated and more employed than most of these other areas, yet continues to suffer less good health," he said. "Other areas which are spectacularly poorer than us are experiencing a rapid growth in terms of life expectancy and have already overtaken us, and if the current trends continue, will continue to do so."

He added: "There has been an almost lazy assumption of what else can you expect from a country like Scotland - actually I think we can expect a lot more from a place like Scotland."

Study leader David Walsh, public health programme manager at the GCPH, said the aim had been to compare the west of Scotland with other regions which had gone through a similar historical experience. Regions studies ranged from Silesia in Poland and Northern Moravia in the Czech Republic, to Alsace in France and Merseyside in England.

"Post-industrial decline is frequently cited as one of the main reasons behind poor health in Scotland, particularly in the west of Scotland," Walsh said. "The obvious question then is how other regions that have gone through a similar de-industrialisation process compare in terms of health trends?"

Anticipating a mixture of results, the researchers admitted they were surprised by their findings, which ranked the west of Scotland as having the poorest health in many areas, despite showing it was performing comparatively well in terms of education, employment and wealth. Higher mortality rates were driven by an increase in deaths involving suicide, alcohol, drugs and violence among men in the 15 to 44 age group, and higher rates of cancer, heart disease, stroke and liver disease in women aged 45 to 64.

The study puts forward several theories which could explain the poor health, such as greater inequalities in society or Scots choosing to adopt damaging behaviours, for reasons which could be related to deprivation. Genetic factors have largely been ruled out as a major cause because of other studies which show, for example, that when Scots emigrate "down under" they have similar disease and death rates as Australians within two generations.

Another possible explanation, Hanlon argued, was that there was an issue related to broader culture which makes Scots different from the people in the other regions, such as a greater impact from de-industrialisation.

"We were very much a nation defined by shipbuilding and steel and we got a sense of identity and national character from these things," he said. "The amount of decline was big compared with some of these other places and we have replaced it with a very consumerist, individualistic lifestyle in a way that many other places have not.

"In Mediterranean countries, the extended family unit and a young man's role within it seems to have remained stronger and it may have protected them from some of these effects."

He also questioned whether recent initiatives such as the smoking ban would have a major impact on health when numerous others have failed.

"The history since the second world war has been policy initiative after policy initiative to try and address this problem, so the smoking ban is but one good example of a recent manifestation of that," said Hanlon. "But why would we imagine that would succeed where all the others have not?"

He added: "It is a real challenge to us as a nation and the attitudes we adopt, in recognising there is a problem and in terms of looking for solutions. We understand all these problems in terms of individuals and the life choices they have made - we don't ask what it is about our nation that creates wave after wave of these problems."

Representatives from the other regions have been invited to visit Scotland in June so researchers can explore the differences between the countries. Professor Carol Tannahill, GCPH's director, suggested a policy change may be needed to take a broader view of how to improve health. With high numbers of people on incapacity benefit in the west of Scotland, getting people back to work has been seen as a priority - but she argued that the assumption that you could only have a useful role in society if you had a job could be challenged.

"There are important roles and activities outside the workplace that are also productive and have considerable benefits to society," she said. "Things like parenting or caring for older relatives, but also having a strong network of close friends and neighbours brings health benefits and can have a positive influence on mental health, crime rates and feelings of safety."

Dr Stuart Scott, an Aberdeen GP who chairs the BMA's Scottish GP committee, said looking what was improving health in the other regions should be a priority.

"Putting money into health doesn't seem to be making an awful lot of difference to life expectancy. It is whether more should be done with regards to the social factor, such as housing, education and changing people's attitudes to work and what they do," he said.

Mary Scanlon MSP, the Tory health spokeswoman, said tackling the problem was more complex than "simply throwing money" at it, and it was vital to understand the reasons why motivation to lead a healthier lifestyle was so low.

"There is almost a fatalistic approach that, regardless of what you do, your life chances are going to be the same," she said. "Until that attitude changes and politicians, teachers and others help to change that cultural attitude, there is little chance of making the progress we all hope."

Margaret Curran, Labour's shadow health secretary, said the report raised valid points about deprivation being just one of several factors which contribute to ill-health. She added: "Labour recognised the impact deprivation played in Scotland's health, but we also recognised other factors such as education, tackling addiction and promoting physical activity can help promote a healthier society."

Health minister Shona Robison said it was clear that health in Scotland was improving, but not fast enough. She pointed to work that was being done to tackle inequalities, including the setting up of a taskforce which is expected to report its findings next month.

She said: "It embodies the government's new way of working, by looking across ministerial portfolios to address the underlying causes of health inequalities and bring together thinking on poverty, lack of employment, children's lives, support for families, and physical and social environments, as well as on health and wellbeing.