Chief Medical Officer - annual report: 2022

Appendix 1: The Health of our Nation

Our health is central to our lives individually and as a population, and health is recognised as a human right.^[34] A healthier population is essential if we are to realise our ambitions of providing opportunities for all, creating sustainable and inclusive growth and ultimately a more successful country. This chapter provides a summary of the current data and evidence, and use this to describe issues affecting Scotland’s population health. Many of those communities that have experienced the worst effects of COVID-19 are those who were already disadvantaged by inequalities in the wider determinants of health; including income, housing, employment opportunity and wider access to services.

COVID-19 continues to have a substantial impact on the health of our nation, including many tragic deaths due to the virus, and the stresses that necessary lockdowns and restrictions have placed on our health. We also continue to see marked inequalities in health, and there has been a stalling of overall improvements in health, as measured by life expectancy, since around 2012. A full understanding of how Scotland’s health has been affected by the pandemic will take time. Some effects could be delayed or may only be detected later. In addition, many of the tools we usually use to understand and measure health have been paused or changed due the pandemic, including surveys and how people use of health care.^[35]

Life expectancy and excess mortality

Scotland’s life expectancy data allows us to summarise the health of our population measured by rates of death and allows comparisons to be made over time.

Around 2012 there was a shift in life expectancy in Scotland.^[36] Steady improvements – which had been observed for more than 50 years – stopped, and only very small increases in life expectancy occurred between 2012 and 2019 (see figure 6). These adverse changes in mortality trends reflect people dying younger than they should.^[37] The impact was not equal across all groups, mortality rates among people living in our more socioeconomically deprived areas actually increased during this period.^[38]

In 2020, 6,048 people died with COVID-19 as the underlying cause in Scotland, and a further 4,830 people died in 2021.^[39] Also, more deaths occurred from other causes in both years than would be expected in comparison to the five years prior to the pandemic. This measure of the number of deaths, compared to the number expected, is known as “excess mortality”. It is not fully accounted for by deaths where COVID-19 was the underlying cause. There are several contributing factors, including the economic and social effects , and changes in health, social care and other services in the context of the pandemic.

The full effect of this may not be known for some years, however, information for the period 2018-2020 still shows a marked reduction in life expectancy in Scotland (see figure 6). Deaths from COVID-19 had the most substantial negative effect on life expectancy, but changes in drug-related deaths, and those due to external causes (such as accidents, poisoning and assaults) also had an adverse effect (see figure 7).^[40]

Measures of health and illness

Beyond mortality, healthy life expectancy (HLE) is a measure which provides an indication of the length of time that people consider themselves to be in “good” or “very good” health. In 2018-20 healthy life expectancy was 61.8 years for females and 60.9 years for males. It also demonstrates marked socioeconomic inequalities; females living in the most deprived tenth of areas can expect to live fewer than 50 years in good health, whilst for those in the least deprived areas the figure is more than 70 years (2018-2020) (see figure 8). ^[41,42]

Disability-adjusted life years (DALYs) is a way to quantify the “healthy years of life lost” to ill health and early death.^[43] This allows us to understand which health conditions are preventing people in Scotland from living longer lives in better health. The most recent overall data available, from 2019, shows that the number of “healthy years lost” increases with age, peaking at 70-74 years. The most substantial causes of healthy years lost are cancers and cardiovascular disease, with mental health conditions, injuries, substance misuse and musculoskeletal conditions also important in younger adult age groups (see figure 9).

Recent changes in health and determinants of health

The past two years has been a period of huge change in our social interactions, education, work, travel, our economic circumstances, and the provision of health and social care.^[44] Some of these changes were sudden and brief, others are more sustained and still evolving. These factors are known to be important building blocks of a healthy society, and it has been predicted that such changes will impact on the health of the population.^[45,46]

Positive changes

There are a number of areas in which the changes during the pandemic appear to have had a positive influence on our health. Car traffic fell markedly during the first and second lockdowns, there was less HGV traffic during the first lockdown, and the total vehicle distance driven was 20% lower in 2020 than the previous five years’ average.^[47] The lower traffic volume is likely to have contributed to the fall in deaths in transport accidents, which were 20% lower than average over the previous five years.^[48,49] Monitoring showed that air quality was markedly better in 2020 than in previous years, and this has also been attributed to traffic changes.^[50,51]

The measures taken to restrict the spread of COVID-19 also influenced the transmission of other infectious diseases. Levels of influenza infections were exceptionally low over winter 2020/21 and 2021/22.^[52]

Mental health and wellbeing

Information from a survey carried out by the Office for National Statistics (ONS) show that, in February 2022, 1 in 20 respondents in Scotland felt lonely often or always, and one third reported high levels of anxiety. Nearly one third also reported that their wellbeing is being affected by the COVID-19 pandemic.^[53]

Data from the Scottish COVID Mental Health Tracker Study show that young adults aged 18-29 years reported the highest rates of symptoms of poor mental health, and lower mental wellbeing.^[54] Young women were particularly affected, as were those with caring responsibilities, and those with pre-existing physical or mental health conditions.

Determinants of health

Information from a number of sources indicates that the material circumstances of some groups, in particular the self-employed and minority ethnic communities, have been adversely affected by changes in employment and the cost of living.^[55,56] While the furlough scheme and uplift in Universal Credit helped mitigate the effect on household incomes in the short term, evidence suggests that many people are now struggling to make ends meet.^[57] In survey responses 1 in 4 people reported that their employment had been affected by the pandemic, and household finances for around 1 in 7.^[58]

Education is a key way in which all children and young people can be provided with the socialisation and skills that positively influence health.^[59] The impact of the pandemic period on education has been considerable, with children in Scotland estimated to have had, on average, 119 fewer days in school, from March 2020 to April 2021, compared with pre-pandemic levels.^[60] Children of Primary 3 age are only now experiencing their first full year of school without nationwide closures.

Access to and use of health care

In February, 1 in 2 respondents to the ONS Opinions and Lifestyle survey in Scotland reported that access to healthcare and treatment for non-COVID-19 issues was being affected by the pandemic.^[61] Emergency admissions to hospital were around a third lower in March and April 2020 than in the same period in 2018-19 and remained about 10% lower in February 2022.^[62] Planned admissions remain around 25% lower in February 2022 than in the same period in 2018-19.^[63]

There are several factors contributing to these differences, including changes in how services are delivered, reluctance among some people to seek care due to fear of COVID-19 infection, not wishing to burden healthcare services and constraints within services due to the COVID-19 response.

It is possible to identify some concerning patterns that are important. It’s estimated there were nearly 5,000 fewer diagnoses of cancer made in 2020 than would be expected.^[64]

Across all hospital specialties and illnesses, there were nearly 120,000 people waiting for inpatient or day-case treatment at the end of December 2021, compared with nearly 80,000 in December 2019.^[65] Over the same period, the number of people waiting to be seen for a new outpatient appointment has increased by nearly 50%.^[66]

In addition, illness associated with COVID-19 has also had a substantial impact both acutely, and the emerging effects of long COVID, about which our understanding of the impact, causes and extent is still growing.^[67]

Impact on population groups

All the measures of health described thus far have in common stark inequalities between groups of people living in Scotland. These inequalities reflect the unequal access to the building blocks of good health that existed pre-pandemic.

Socioeconomic position and occupation are also associated with the rate of death from COVID-19, with this being up to 2.5 times higher in our most deprived communities compared with the least deprived (see figure 10).^[68,68,69]

These inequalities in death from COVID-19 are significant and have widened as the pandemic has progressed.^[71]

People have been constrained by circumstances, such as whether they are able to work from home, or the amount of space available in their home to isolate if someone is unwell.

There have also been marked inequalities in COVID-19 outcomes between ethnic groups, with those identifying as Pakistani having around a four-fold higher rate of hospitalisation or death due to COVID-19 than people in the White Scottish group.^[72]

Research has found that the pandemic has worsened the inequalities for those living with a disability or long-term condition. Factors include disruption to services, isolation and a feeling of being invisible.^[73] Those with a disability have consistently reported higher levels of loneliness and poorer wellbeing than non-disabled people, as well as a higher impact on household finances and on access to healthcare.^[74] This includes the parents of children with a long-term condition.^[75]

Many children and young people, although less likely to have severe COVID-19 illness,^[76] have experienced substantial effects on their health and wellbeing.^[77] Delivery of routine childhood immunisations has been well maintained, and timely uptake of these improved over the pandemic.^[78] In other areas of health and health services for children there are concerning signs. The proportion of children at two and a half years of age for whom there is a concern about their development was higher in 2021 than in the pre-pandemic period.^[79] There has been an increase in the percentage of children who are at risk of being overweight or obese at the age of 5 years. Fewer children have seen a dentist, with under two-thirds (64%) having been seen in the past two years in September 2021, compared with 97% in 2019, accompanied by a marked widening in the socioeconomic inequalities in dental care (see figure 11).

Unfortunately, the challenges of the past two years have compounded the faltering progress on improving population life expectancy observed in the years since 2012. The impact of this period on our health and wellbeing may continue to be felt for years to come.