Austerity, Covid, and the cost of living: a health tragedy

For reasons that are difficult to pinpoint to any single factor, that gulf has accelerated dramatically over the past decade.

READ MORE: The rise of two-tier healthcare amid 'unprecedented' demand for private treatment

By 2019, the discrepancy was almost 20-fold, before narrowing down to 15-fold in 2021, according to the latest annual report on drug misuse deaths from the National Records of Scotland.

At both ends of the spectrum the drug death rate has increased over the past 20 years, but the growth has been faster for the most deprived (up by a factor of four since 2001, compared to 2.5 for the least deprived).

Source: National Records of Scotland

The overall rise in deaths - from 332 in 2001 to 1,330 last year - speaks to the culmination of years of frailty and multi-morbidity exacerbated by heroin addictions which gripped the so-called ‘Trainspotting generation’ in the post-industrial 1980s and early 1990s.

The average age of those dying has increased from 32 in 2001, to 43 last year.

As for the past 10 years, the austerity agenda has left public services poorer across the board, but for those at the bottom cuts to benefits, increases in homelessness, and the erosion to safety nets such as addiction and mental health services has almost certainly tipped the most vulnerable over the edge.

READ MORE: Cancer screening deprivation gap persists 

Anything which increases deprivation will increase health inequalities, and there is plenty of evidence that these gaps are widening across the board - not only for drug deaths.

You are now 30 per cent more likely to be diagnosed with cancer in Scotland if you live in the most deprived areas of Scotland, and the average mortality rate from all forms of the disease is 78% higher.

This reflects everything from a higher concentration of risk factors in the first place (higher rates of smoking, obesity, harmful alcohol consumption, higher probability of exposure to toxins such as asbestos) to a lower probability of tumours being picked up at an earlier, more curable stage, because people from more deprived areas are less likely to take part in routine screening programmes but also have comparatively less access to GPs to pick up on potentially worrying symptoms.

Age-standardised death rates by Scottish Index of Multiple Deprivation (SIMD) quintile between 1st March 2020 and 31st May 2022; most deprived to least deprived (L-R) Source: National Records of Scotland

Even before the pandemic, research suggested that there were around 15% more patients per GP in the tenth most deprived postcodes, compared to the most affluent - not because there were more patients in these areas, but because there were fewer doctors.

One of the oddities of the most recent Scottish GP contract, agreed in 2018, was that the revised funding formula allocated extra resources based on the the average number of appointments carried out each day as a measure of each surgery’s workload.

This had the effect of disproportionately benefitting practices in more affluent areas where large numbers of elderly patients (wealthier postcodes have longer life expectancy, and middle class patients are more likely to go to GPs even with minor ailments) would fill up the appointment books.

Surgeries based in areas of high deprivation - some of which had designed their services to provide longer, but fewer, consultations to deal with complex patients with multiple chronic conditions - lost out.

At the time, critics warned that this would only disrupt the imbalance in GP access even further by drawing new recruits to wealthier areas and spurring burned-out doctors based in more deprived communities to retire early or relocate, exacerbating unmet healthcare needs even further.

READ MORE: New GP contract fails to meet needs of patients in deprived areas 

Then along came the pandemic.

Waiting times to see GPs have ballooned, face-to-face consultations have had to be rationed to cope with demand and prioritise the most urgent cases, and it is a certainty that demand has increased most in exactly those postcodes least equipped to cope.

A report by Public Health Scotland in April noted that the gap in the number of cancer cases diagnosed between the most and least deprived areas had actually narrowed during the pandemic, but stressed that this was “more likely to indicate a greater level of under-diagnosis rather than greater falls in cancer occurrence in more deprived areas”.

For example, lung cancer diagnoses fell by 12% in people from the most deprived areas compared to 5% in the least deprived areas.

Covid itself underlined the vast discrepancy in health between the least and worst off: the poorest were 2.4 times more likely to die from the infection during the first year of the pandemic, partly because they were more likely to be exposed to the virus in the first place (for example, through crowded accommodation or from working in occupations that could not be done from home), and secondly because they were more likely to have an underlying health condition which put them at higher risk.

The UK has some of the highest levels of income inequality on the OECD index, exceeded only by the US, Turkey, Bulgaria, Mexico, Chile, Costa Rica, and South Africa (top; source OECD); Excess death rate from all causes (source: Our World in Data)

It is also notable that many of the countries with the highest excess death rates from all causes over the past two years - including the UK, US, South Africa and Mexico - are also among those ranked highest for income inequality by the OECD.

Now supposedly in the “recovery phase” (but still nowhere near returning to pre-pandemic elective activity) those who can afford it are increasingly turning to private providers for everything from scans and operations to dental treatment to avoid lengthy NHS waits.

READ MORE: What can Scotland learn from Ireland's surge in life expectancy?

Austerity was blamed for stalling Scottish (and UK) life expectancy, but really - once unpicked - that plateau masked a longer term decline in health for the poorest, for whom life expectancy was already on a downward slide even before 2012 amid benefit cuts, growing in-work poverty and real-term falls in income.

The cost of living crisis will only cement that trend.

Without a concerted effort to tackle deprivation, health inequalities seem destined only to widen in a way that could soon see many more mortality statistics mirror the kind of gulf already seen in this week's drug death rates.