Elsevier

Public Health

Volume 124, Issue 9, September 2010, Pages 487-495
Public Health

Original Research
It's not ‘just deprivation’: Why do equally deprived UK cities experience different health outcomes?

https://doi.org/10.1016/j.puhe.2010.02.006Get rights and content

Summary

Background

The link between deprivation and health is well established. However, recent research has highlighted the existence of a ‘Scottish effect’, a term used to describe the higher levels of poor health experienced in Scotland over and above that explained by socio-economic circumstances. Evidence of this ‘excess’ being concentrated in West Central Scotland has led to discussion of a more specific ‘Glasgow effect’. However, within the UK, Glasgow is not alone in experiencing relatively high levels of poor health and deprivation; Liverpool and Manchester are two other cities which also stand out in this regard. Previous analyses of this ‘effect’ were also constrained by limitations of data and geography.

Objectives

To establish whether there is evidence of a so-called ‘Glasgow effect’: (1) even when compared with its two most similar and comparable UK cities; and (2) when based on a more robust and spatially sensitive measure of deprivation than was previously available to researchers.

Study design and methods

Rates of ‘income deprivation’ (a measure very highly correlated with the main UK indices of multiple deprivation) were calculated for small areas (average population size: 1600) in Glasgow, Liverpool and Manchester. All-cause and cause-specific standardized mortality ratios were calculated for Glasgow relative to Liverpool and Manchester, standardizing for age, gender and income deprivation decile. In addition, a range of historical census and mortality data were analysed.

Results

The deprivation profiles of Glasgow, Liverpool and Manchester are almost identical. Despite this, premature deaths in Glasgow are more than 30% higher, with all deaths approximately 15% higher. This ‘excess’ mortality is seen across virtually the entire population: all ages (except the very young), both males and females, in deprived and non-deprived neighbourhoods. For premature mortality, standardized mortality ratios tended to be higher for the more deprived areas (particularly among males), and approximately half of ‘excess’ deaths under 65 years of age were directly related to alcohol and drugs. Analyses of historical data suggest that it is unlikely that the deprivation profile of Glasgow has changed significantly relative to Liverpool and Manchester in recent decades; however, the mortality gap appears to have widened since the early 1970s, indicating that the ‘effect’ may be a relatively recent phenomenon.

Conclusion

While deprivation is a fundamental determinant of health and, therefore, an important driver of mortality, it is only one part of a complex picture. As currently measured, deprivation does not explain the higher levels of mortality experienced by Glasgow in relation to two very similar UK cities. Thus, additional explanations are required.

Introduction

The link between socio-economic circumstances and health is well established. However, the extent to which the poor health profile of Scotland – the nation with the highest mortality rates and lowest life expectancy in Western Europe1, 2 – can be explained in terms of socio-economic factors is less clear. Historically, Scotland's unenviable position in being what the press has labelled ‘The Sick Man of Europe’ has been attributed almost exclusively to its relatively high levels of socio-economic deprivation, principally in comparison with England and Wales.3, 4 However, a number of publications over the past 5 years have highlighted a phenomenon speculatively entitled the ‘Scottish effect’; a term used to describe the country's higher levels of morbidity and mortality over and above that explained by deprivation. For example, Mitchell et al.5 showed people in Scotland to have a 50% higher risk of being diagnosed with ischaemic heart disease compared with those in England, even after controlling for individual social circumstances (and other risk factors such as smoking, alcohol consumption), while Hanlon et al. showed that Scotland's excess mortality relative to England and Wales – that is, mortality which could not be explained by area-based measures of socio-economic deprivation – increased between 1981 and 2001 to approximately 8%.6 The latter analysis showed this ‘Scottish effect’ to exist in all geographical regions of Scotland and at all levels of deprivation, but it was most evident in the most deprived post-industrial region of West Central Scotland, with Glasgow at the region's core. This led to talk of a ‘Glasgow effect’; a notion reinforced by other recent research showing that mortality in the former industrial areas of Scotland was higher, and was improving more slowly, than in the vast majority of other, similar, post-industrial regions of Europe, including those which currently experience worse socio-economic conditions.7

Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of poor health and deprivation. Liverpool and Manchester are two other cities which stand out in this regard, with high levels of poverty and the lowest life expectancy of all cities in England.8, 9, 10, 11 Therefore, this study has investigated this ‘Scottish effect’ or ‘Glasgow effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow; cities which share similar histories of industrialization and deindustrialization, and which have high mortality associated with known problems of deprivation. Furthermore, this study sought to improve on previous related analyses6, 9 by employing a more up-to-date and spatially sensitive measure of deprivation. These previous analyses were based on the Carstairs and Morris deprivation index,4 calculated from census data. This measure is now out of date (the most recent data being for 2001), but crucially was also calculated for different-sized geographies north and south of the border: postcode sectors in Scotland and electoral wards in England. In 2001, postcode sectors in Glasgow had an average population size of approximately 5500; however, the equivalent figures for wards in Manchester and Liverpool were 11,900 and 13,300, respectively. The relatively large size of these areas (especially in the two English cities), and the variation in size between the Scottish and English geographies is potentially problematic in measuring the effects of area-based deprivation.

Given all the above, this research sought to answer the question – is there evidence of a so-called ‘Glasgow effect’:

  • when based on comparisons with its two most similar and comparable UK cities?

  • when based on a more robust and spatially sensitive measure of deprivation than that previously available to researchers?

Section snippets

Methods

Data were assembled for the populations of the three cities: Glasgow, Manchester and Liverpool. A measure of ‘income deprivation’ was created for similarly sized small areas in each city. Income deprivation is derived from Department of Work and Pensions (DWP) benefits data, and was used in the 2006 Scottish Index of Multiple Deprivation (SIMD).12 It is a measure of the proportion of the population in receipt of key income-related benefits in 2005, as well as children dependent on adult

Deprivation profiles

Overall levels of deprivation in Glasgow, Liverpool and Manchester were almost identical, with almost one-quarter of the total population in each city classed as income deprived: 24.8%; 24.6%; and 23.4%, respectively. The distribution of deprivation across each city's small areas was also almost identical (Fig. 1), with the ratio of most deprived/least deprived decile in each city being: 9.7; 10.0; and 10.1, respectively.

All-cause mortality by age and gender

Despite these near-identical deprivation profiles, all-cause mortality in

Main findings

The main finding of this study is that despite displaying near-identical levels and patterns of deprivation as Liverpool and Manchester, Glasgow has a profoundly different mortality profile; premature deaths are more than 30% higher, and all deaths are approximately 15% higher. Importantly, these higher levels of mortality are seen across virtually the entire population: all ages (except the very young), both males and females, in deprived and non-deprived neighbourhoods. Indeed, it is notable

Conclusion

The important link between socio-economic circumstances and health is well established, and this paper adds to the evidence that deprivation is an important driver of mortality. However, this study has shown that Glasgow experiences significant levels of ‘excess’ mortality, even when compared with cities with almost identical profiles of deprivation. Thus, while deprivation is a fundamental determinant of health, it is only one part of a complex picture.

As the reasons behind the ‘Glasgow

Acknowledgements

Grateful thanks are due to a number of organizations and individuals. In particular, the authors wish to thank the following for their help, time and efforts: Jamie Reid, ISD Scotland; Anna Wasielewska, NHS Manchester; John Pritchard, formerly of the SASI Research Group at the University of Sheffield; Richard Lawder, ISD Scotland; Paula Aucott and the University of Portsmouth's Great Britain Historical GIS Project; the GRO(S); the ONS, especially Tony Hitching; the DWP, in particular Andrew

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