Unequal, top-down ‘democracy’ is making us so unwell we may not recover without radical surgery, writes Lesley Riddoch
How much clearer does it need to get? Scotland now lies just behind America in the obesity league table, children of overweight Scottish mums are more likely to die early and obese Scots have been left off the records for years – by accident. Poor urban Scots reach intensive care faster than healthier Scots and the cost of sickness benefits here is one-third higher than in the rest of the UK.
Last week’s headlines prove that despite some improvements, Scotland is still the sick man and woman of Europe.
But how have the authorities reacted to this little nosegay of misery? With buck-passing and statements of the obvious.
Stirling University researchers say higher sickness benefit costs arise from Scotland’s poor health record whereby would-be workers claim sickness benefits rather than working. “Health experts” say people need more education, UK ministers say the higher cost of sickness welfare in Scotland proves we are “Better Together” while Scottish ministers say lower welfare costs in other sectors mean an independent Scotland could easily cope.
Talk about fiddling while Rome burns. Does no-one want to tackle the Big Question?
Why are Scots sicker than the rest of the UK? Have poor health and premature death become totems of Scottish identity we have learned to live with?
If so, we better unlearn fast and question far more than the NHS or our own dodgy health habits.
In 2009-10, the NHS in Scotland spent almost £1.5 billion on emergency admissions of old people – the majority of whom had no serious clinical problem. Some had a minor fall, felt unwell or were in pain. None were really “medical emergencies”. But without support in their own locality, they were taken to hospital to be on the safe side.
That’s an admission of social and systemic failure. Once in a hospital bed, those old people stay.
Health finds the cash to keep them while housing cannot find the funding for adaptations to let them go home, community care cannot fund the professionals to drop by, children cannot afford the time and no politician will seriously consider the massive shift of resources and power to community level that might break this vicious circle.
Good public health is a product of good social and democratic health. We lack vitality in all three areas. Public money is trapped in professional silos. And yet years after the Christie Commission, those barriers are still going strong.
Things will get worse. Health professionals estimate our ageing population requires the construction of a hospital every 18 months. That cannot be afforded – and shouldn’t even be contemplated.
Instead, we need a new non-medicalised, non-professional-led vision of health where equality and empowerment are recognised as the most important public health issues – not afterthoughts.
Dr Phil Hanlon and researchers at the Centre for Population Health have compared life, incomes and health outcomes in Glasgow, Liverpool and Manchester. They found “deprivation profiles” were almost identical, but premature deaths in Glasgow were 30 per cent higher.
This excess mortality ran across almost all ages, males and females and deprived and non-deprived neighbourhoods. Why? Surprisingly, lung cancer, heart and liver disease were not the factors tipping Glaswegians over the UK average (although compared to healthier European neighbours no part of Britain fares well).
Higher levels of drug and alcohol misuse, suicide and death through violence account for almost all of Glasgow’s “excess” deaths. Which begs the next question: why are some Glaswegians so prone to self-harming and life-shortening behaviours?
There’s no easy answer, and absolutely none that sits conveniently within the confines of medical science alone.
Chief Medical Officer Harry Burns cites the work of Aaron Antonovsky, who maintained that a sense of coherence (SOC) is necessary for adult health.
The Israeli medical sociologist defined the SOC as “the extent to which one has a feeling of confidence that the stimuli deriving from one’s internal and external environments are structured, predictable and explicable, that one has the internal resources to meet the demands posed by these stimuli and, finally, that these demands are seen as challenges, worthy of investment and engagement”.
In other words, good health is a mixture of optimism and control that relies on life being comprehensible, manageable and meaningful.
Comprehensibility allows people to perceive events as ordered, consistent, and structured. Manageability allows people to feel they can cope. Meaning allows life to make sense, and challenges to seem worthy of commitment.
So what is stopping deprived Glaswegians in particular from seeing structure and order in their world or regarding their own lives as worthwhile challenges?
Some think it’s the grief and hopelessness created when Margaret Thatcher dismantled the craft-base of the Clyde. Some think it’s the absence of engaged, consistent parenting which inhibits the life chances of each successive generation in areas of multiple deprivation. I’d suggest there are two other political ingredients in Scotland’s deadly health cocktail.
The first is rigid inequality – if you live in Scotland’s 10 per cent poorest neighbourhoods you are five times more likely to experience crime, twice as likely to have health problems resulting in emergency hospital admission and your kids will score only half the combined academic results of their more affluent peers.
In Scotland each important aspect of living (and public spending) is correlated with background. Life chances, performance and outcomes are high in rich neighbourhoods, low in poor ones. Not loosely, randomly or occasionally, but absolutely, always and rigidly. Not last century but right now.
The second health-inhibiting factor is a paternalistic, top-down society.
Cash, power, jobs and status – all the tools needed for healing – are retained at the professional heart of Scottish life, not its disempowered localities. Scots have deferred to doctors, lawyers, teachers, professors and other experts for so long we now believe professionals alone can fix broken people. Instead, an over-reliance on professionals is part of the reason sick Scots cannot fix themselves.
Scotland cannot flourish while so many people are stuck in mapped-out, meaningless lives they cannot improve, with the power only to self-medicate using painkillers, drugs, booze or food.
A completely new “whole society” approach is needed because nothing less will shift the structurally embedded patterns of Scotland’s ill health. I realise that’s a taller order than point-scoring over independence, but surely that’s what the Scottish Parliament is really for.