Scotland's health is getting worse and people are now dying younger than in any other western European country, the head of the country's public health body has warned.

Paul Johnston, the chief executive of Public Health Scotland, said there must be an "increased focus on prevention" with figures showing that £2.3 billion of health boards' budgets are being spent tackling the consequences of poverty.

In a blog published today by independent think tank Reform Scotland as part of its NHS 2048 series - looking at how to sustain the health service to its 100th birthday - Mr Johnston stressed that the NHS "cannot bear all the responsibility" for health and wellbeing.

He added: "Tackling poverty impacts on health, as does the availability of good work, high quality education and childcare, affordable housing, addressing climate change, and tackling racism."

The Herald: Paul JohnstonPaul Johnston (Image: NHS)

Life expectancy has begun to decline in Scotland for the first time since the creation of the NHS, dipping to 76.5 for males and 80.7 for females.

However, women living in the most deprived parts of Scotland tend to remain in good health only until the age of 47 and just under 45 for men, compared to 72 and 71 respectively for those in the most affluent areas.

Mr Johnston, a lawyer and former director general for the Scottish Government who was appointed chief executive at PHS in March 2023, said there was a need for "collective focus and resolve".

He said: "People in Scotland now die younger than in any other western European country. People spend more of their lives in ill health.

"The gap in life expectancy between the poorest and the wealthiest is growing. We have seen great progress in the past but, at the moment, Scotland’s health is getting worse.

"There are further challenges facing us too. The Scottish Burden of Disease Study forecasts a 21% increase in disease by 2043, as our population continues to age.

"Two thirds of this will be due to a rise in the numbers of cancer cases, cardiovascular disease, and neurological conditions.

"All these present a significant challenge to the long-term sustainability of the health and social care system."

The Herald: Scotland fares worse than the UK average and other western European countries on life expectancy at birth (data for 2020)Scotland fares worse than the UK average and other western European countries on life expectancy at birth (data for 2020) (Image: NRS)

The Herald: Healthy life expectancy in Scotland by deprivation, and compared to UK averageHealthy life expectancy in Scotland by deprivation, and compared to UK average (Image: NRS)

Mr Johnson called for a "collective focus on prevention" in order to "stop problems from happening in the first place and help reduce demand on public services".

He noted that a report in May 2023 by the Institute of Public Policy Research (IPPR) found that £2.3bn of health boards’ budgets in Scotland "is being directed at responding to the impacts of poverty".

He added: "The annual cost to the UK of obesity and overweight is estimated to be approximately £98 billion, with costs to the NHS of £19 billion.

"A concerted focus on these two areas alone has the potential to contribute significantly to reducing demand on our health system as well as having a positive social and economic impact.

"An increased focus on prevention raises fundamental questions about how and where we invest already stretched resources and capacity where they will have the biggest impact.

"There are new ideas emerging which could, if adopted, fundamentally change our approach to delivering health care."


Mr Johnston’s contribution is the latest article by clinicians, service users and politicians for Reform Scotland’s NHS2048 programme, which explores how reforming the public sector can help to restore the NHS to better health.

Chris Deerin, director of Reform Scotland, said: “This is a thoughtful and significant intervention by the Chief Executive of Public Health Scotland, which does not seek to hide from the crisis we face in our national health and in our health service.

“His focus on the preventative agenda makes good sense both in terms of population health and public expenditure, and his stark admission that people in Scotland die younger than people in other Western European countries, and that the gap in life expectancy between the poorest and wealthiest is growing, is a call to action for our political leaders.”

A Scottish Government spokeswoman said: “Economic austerity, the Covid pandemic and the cost crisis have all contributed to slowing progress in health outcomes over the past decade.

"However, we are using all the powers and resources available to us to tackle poverty, reduce inequality, increase healthy life expectancy - and thus create a fairer Scotland.

“Our public health initiatives, such as the universal healthcare visitor Pathway, minimum unit pricing of alcohol, shown by research to contribute to reducing alcohol related health inequalities, and action to create a smoke-free generation by raising the age of sale of tobacco are complemented by wide-ranging action to reduce poverty and mitigate the impact of the rise in the cost of living.

"By increasing fair access to employment, education and training, and improving our physical and social environments we make people’s lives better. 

“Research commended by internationally-renowned public health experts estimated that our world-leading Minimum Unit Pricing (MUP) policy has saved hundreds of lives, likely averted hundreds of alcohol-attributable hospital admissions and contributed to reducing health inequalities.”