West of Scotland health riddle: the mystery surge in rural death rates - and it's not down to ageing

But today a bombshell report leaked to the Herald on Sunday reveals a strange new trend in the region: a mysterious deterioration in the health of residents in the rural west of Scotland.

It details how, since the economic downturn of 2009, Forth Valley, Argyll and Bute, Ayrshire and Arran and Dumfries and Galloway have experienced "far greater" increases in their death rates than the Greater Glasgow and Clyde region which cannot be explained even once their comparatively more elderly populations are taken into account.

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In Forth Valley, it rose by 5.4% compared to 1.4% in Greater Glasgow and Clyde. In Argyll & Bute, Ayrshire & Arran and Dumfries & Galloway the increases ranged from around 3-4%.

Determining the 'why' behind the figures is tricky, although the report's author - respected public health consultant Dr Helene Irvine - suggests that factors such as rural GP closures and centralisation of healthcare services may be at play.

She states: "Consideration needs to be given to the possibility that the more rural parts of the west of Scotland, including less affluent parts of Dumfries & Galloway, Ayrshire & Arran and Argyll & Bute, are at risk because of economic stagnation, austerity, changes in lifestyle, depopulation by the more affluent subgroups, reduced access to health and social care services because of closures of GP practices, changes in access to community services and recruitment failures."

The 356 page 'New West of Scotland: Health Needs Assessment' report, which was completed in March this year, has been widely circulated behind the scenes - but not made public.

Although Greater Glasgow and Clyde - which covers Glasgow City, Inverclyde, West Dunbartonshire as well as the more affluent suburbs of East Dunbartonshire, East Renfrewshire and Renfrewshire - still has higher mortality rates in most categories, the study consistently reveals that the gap between the GGC and non-GGC parts of the west of Scotland is narrowing.

The clear message from the report is that while residents of Greater Glasgow and Clyde continue to suffer higher levels of ill health largely as a legacy of deprivation, the situation is improving. Potentially at the expense of its more rural neighbours.

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One of the starkest illustrations in the report compares the standardised mortality ratio (SMR) between GGC and non-GGC regions.

SMR is a tool used to identify 'excess deaths' - that is, where the actual number of deaths within a particular group is greater than predicted based on its demographic profile.

It has been used to root out substandard care in hospitals with usually high patient death rates, famously in the Mid-Staffordshire scandal, but can also track more complex declines in population health.

Scottish Mortality Ratio - green line shows excess deaths in non-GGC region increasing

When the SMR is tracked from 2000 to 2016 for GGC and non-GGC areas it shows a clear decline in excess deaths within Greater Glasgow and Clyde that is mirrored by an upturn elsewhere in the west of Scotland.

Although excess deaths remain higher overall in Greater Glasgow and Clyde, Dr Irvine stresses that "these higher death rates are improving while the lower death rates in the non GG&C part are getting worse".

She adds that the rural areas may have "lost ground" as health investment was prioritised to urban areas in the form of a "steep rise" in consultant provision within Great Glasgow & Clyde's acute hospitals.

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However, the report goes on to question whether this investment was really worth it, having delivered only a 2% reduction in excess deaths since 2007.

Dr Irvine states: "What can be said is that the steep rise in hospital consultant provision in GG&C over this time period is far steeper than the fall in both [mortality rates] and the SMR trend, suggesting that the concentration of resources in acute hospitals in GG&C has not provided sufficient return on investment and may have been carried out at the expense of the neighbouring health boards."

Unexpectedly, this excess mortality was highest - and high enough to be considered statistically significant - among 20 to 39-year-olds, the most economically and reproductively active age group.

In 2016, there were 294 deaths among 20-39-year-olds in Greater Glasgow & Clyde compared to 427 for the non-GG&C part of the west of Scotland.

This translated to a mortality rate of 11.9 deaths per 10,000 people in that age group in Lanarkshire, Ayrshire & Arran, Dumfries & Galloway, Argyll & Bute and Forth Valley, compared to 8.6 per 10,000 for Greater Glasgow and Clyde.

Dr Irvine states: "This suggests that GG&C has left the remaining five areas behind in terms of its progress in reducing mortality in this key demographic...This provides an irrefutable source of the rising excess in deaths in the affected parts of the [west of Scotland] region that needs further study."

There were also eight deaths among children aged one to four in three rural health boards - Ayrshire & Arran, Dumfries & Galloway and Argyll & Bute - which "require further study and monitoring" as it was only one fatality short of becoming statistically significant.

Dr Irvine warns there may be a link.

She states: "Monitoring of the death rate for this very young age group should continue given the fact that the death rates in the reproductively and economically active age group (20-39 year olds) in these same geographies are also elevated, and given that there is a possible mechanism between the two in the form of parental alcohol misuse as a common cause of death and injury in children of alcoholic parents as a result of abuse or neglect".

The report also picks apart the mortality rates and causes of death among under-75s in general. It throws up some staggering results.

In Argyll and Bute, the death rate - adjusted for age, and measured per 100,000 population - had surged by 18.2% between 2014 and 2016.

This compared to an increase of just 0.7% during the same period in Greater Glasgow and Clyde and 3.9% for Scotland.

These were deaths from all causes - cancers, strokes, dementia and other fatal illnesses, as well as accidents, drug and alcohol deaths, and suicide - but included a "marked rise" of 17.8% in the death rate from cancer within Argyll & Bute which she stressed "must be a cause of concern".

Over the same two-year period, the mortality rate from cancer in Greater Glasgow and Clyde fell by 11.7%.

The rural boards have also experienced a deterioration in mortality from coronary heart disease relative to Greater Glasgow and Clyde.

Dumfries & Galloway went from having the lowest mortality rate from heart disease in 2006 to the highest by 2015, with similar deterioration in Argyll & Bute and Ayrshire & Arran.

The report states: “This suggests that despite being a relatively prosperous rural part of Scotland, [Dumfries & Galloway] has lost considerable ground in terms of health prospects as measured by mortality from heart disease.

“Argyll and Bute moved from being the second lowest in 2006 to the third highest in 2015, experiencing a similar fate that is probably linked, in part, to its rurality.

“Ayrshire & Arran was in the top two in both years, suggesting that it has experienced persistently high death rates from heart disease that cannot be attributed to the age and gender distribution of the population.

“This suggests it has suffered from a combination of long-term economic disadvantage, depopulation, and related medical/clinical recruitment failures superimposed on faulty health service planning and policy that include disinvestment in general practice and district nursing, downgrading of community hospitals and centralisation of acute services.”

Professor Phil Wilson, of Aberdeen University's Centre for Rural Health, said the findings "could well reflect increasing difficulties in rural health service delivery" - but stressed it merits further scrutiny. 

He added: "The recent decline in health of Scottish rural people breaks the trend of steady improvement that we have seen in the past century. 

"The causes are not clear, but it is likely that centralisation of acute services, closure of GP practices and community hospitals in rural areas and recruitment difficulties have all contributed to the problem."

The report also hones in on life expectancy to reveal some sharp dips in parts of the west of Scotland.

It comes after National Records of Scotland confirmed that life expectancy for babies born in Scotland in the last few years has fallen for the first time in 35 years. The drop was low, however, shaving just over a month on average off longevity for both boys and girls.

In Dr Irvine's report, she finds that girls born in Dumfries & Galloway between 2013 and 2015 had a life expectancy around seven months shorter than if they had been born in 2010-12. In Greater Glasgow & Clyde, life expectancy for baby girls was still on the rise.

Among those aged 85, there were even steeper drops in life expectancy in the past decade. This is in line with UK-wide trends - but not global ones.

In countries including France, Spain, Italy, Canada, Australia, Japan and Singapore, ongoing increases in life expectancy among the very elderly are still being achieved.

Sir Michael Marmot, former president of the BMA and a professor of epidemiology at University College London, has blamed the trend in England and Wales on reductions in funding for elderly social care.

In the west of Scotland, Dr Irvine finds that life expectancy at age 85 has "dropped considerably" for both sexes in nearly all areas - including Greater Glasgow and Clyde.

However, it is most pronounced in Dumfries and Galloway. At the turn of the millennium, 85-year-olds in the region had the longest life expectancy in the west of Scotland.

Fifteen years on, it has one of the worst - well below GGC in the case of women - and for both sexes is actually below 2000-2002 levels.  

Like Prof Marmot, Dr Irvine believes the explanation probably lies in real terms cuts to social care funding from 2010 onwards, just as there was a surge in 90-year-olds.

The point is hammered home by a graph illustrating that real terms per capita expenditure on social care for the elderly in the west of Scotland fell by 6% - from £2077 to £1956 - between 2009/10 and 2015/16.

At exactly the same time, there was a 24% increase in the proportion of people aged over 90 within the region's 65+ age group.

Elderly social care spending in west of Scotland

In short, states Dr Irvine, "the availability of a wide range of services for the elderly was reduced at precisely the same time that demand could be expected to rise".

However, she also points to a second "complicating factor" - specific to Scotland - which was the roll-out between 2010 and 2015 of the Scottish Government's £320 million 'Change Fund' which bankrolled "a wide-range of initiatives aimed at preventing unnecessary emergency hospital admission of the elderly".

She concludes: "Although more analysis is required to attribute any rises in death for the 65+ and 85+ in Scotland after 2010 to either the reductions in real terms per capita funding of social care for the elderly, which affected most councils after 2010/11, or the concerted attempts to prevent unnecessary admissions, which affected all councils between 2010 and 2015, it is suggested here that these are two obvious risk factors that have escaped proper scrutiny."

A Scottish Government spokeswoman said: “We note this report which was prepared to support planning of services in the West of Scotland and discussions will continue on how to tackle the complex issues raised.

"Over the long term, life expectancy and healthy life expectancy in Scotland have increased, and premature mortality rates in the most deprived areas are down 13 per cent since 2007.

“We remain focussed on addressing the underlying causes that drive health inequalities, which has income inequality at its heart.

"Our bold package of measures to help tackle key issues such as smoking, obesity, inactivity, and alcohol misuse will support people to live longer healthier lives.

"We are also tackling the wider causes of health inequalities through measures such as investing in affordable housing, providing free school meals and continuing commitments like free prescriptions and free personal care, and are investing more than £100 million every year to mitigate the UK Government’s welfare cuts.”