Chief Medical Officer's annual report 2024-2025: Realistic Medicine - Critical Connections

Chapter 5: Health of the Nation

The health and wellbeing of the population lie at the heart of Scotland’s prosperity; it must continue to be an aim to reduce preventable disease and enable everyone in Scotland to live in good health for as long as possible. Improving and sustaining health requires action across multiple areas to influence the wide range of factors that determine our health.

I eagerly anticipate that creating good health and preventing poor health will be the focus of the Population Health Framework, due to be published in June. This represents a shift in culture from illness management to prevention, and a shift towards a more whole-system approach to prevention with greater emphasis on strengthening the fundamental determinants of health across society. I am convinced that this broad approach is necessary if we are to reduce the significant burden of preventable disease experienced by our population now and the anticipated increase yet to come.

It has been informed by Sir Michael Marmot’s, and the King’s Fund Population Health Pillars.

1. Give every child the best start in life.

2. Enable all children, young people and adults to maximise their capabilities and have control over their lives.

3. Create fair employment and good work for all.

4. Ensure a healthy standard of living for all.

5. Create and develop healthy and sustainable places and communities.

6. Strengthen the role and impact of ill health prevention.

7. Tackle racism, discrimination and their outcomes.

8. Pursue environmental sustainability and health equity together.

I welcome this approach. We all have an important role in creating and maintaining good health and wellbeing for the people we care for and the communities we serve.

The Population Health Framework will be complementary to the Scottish Government’s wider reform and renewal efforts, including the Public Service Reform Strategy and the forthcoming Health and Social Care Service Renewal Framework. It also seeks to contribute to addressing the four concurrent challenges to population health in Scotland that I described in my previous annual report: the ongoing threat of infectious disease, widening health inequalities, the need to create a more sustainable health and care system, and the need to address the planetary crisis.

In this chapter on the Health of the Nation, I highlight some of the main challenges facing Scotland’s health and wellbeing today – challenges which have informed the issues and topics that I discuss in the preceding chapters of my report.

Poverty

People living in Scotland’s most deprived communities live more than a third of their lives in poor health compared to around 15% in the least deprived areas.

Relative poverty (defined as total income less than 60% of the median) remains significant, affecting one in five people. This means that more than a million people live in relative poverty, including one in every four children. For children from ethnic minority backgrounds this rises to one in every two.

Figure 1 shows that from 1994–1997 to 2020–2023, children living in poverty fell from over 30% in 1994–1997 period but then rose from 2007–2010 period to nearly 25% by 2020–2023. Working age adults living in poverty initially remained stable but has increased more recently. Poverty amongst pensioners dropped sharply and has remained low. Child poverty remains the highest of the three categories.

Life Expectancy and Healthy Life Expectancy

Scotland continues to have the lowest life expectancy of UK countries.

Figure 2 shows that life expectancy in Scotland rose from 2000–2014, but this rise slowed from 2012–2019, falling sharply during 2017–2022. While life expectancy increased between 2020-2022 and 2021-2023, it remains below pre-pandemic levels. Women consistently live longer than men.

The gaps in Healthy Life Expectancy between those in our most deprived and least deprived communities persisted and widened over the last decade.

In 2019 to 2021, there was a 24.9-year gap in Healthy Life Expectancy in women and 26-year gap for men (Figure 3).

Inequalities

The leading causes of health loss are also where the greatest health inequalities are found, both in absolute and relative terms. Addressing these inequalities would not only improve equity but also reduce the overall burden of these conditions.

While the premature mortality rate (considered as deaths occurring before the age of 75) declined steadily from the late 1990s to around 2014, this progress has now stalled or even reversed- particularly in our most deprived communities.

In 2021, the gap in premature mortality rates between the most and least deprived areas increased to its highest point since 2003 (684.2 per 100,000 and 703.5 per 100,000 respectively) and is higher than at the start of the time series (648.7 per 100,000 in 1997). Relative inequalities have widened over the long term and are now at the highest point in the time series (1.56). In 2021, premature mortality rates were 4 times higher in the most deprived areas compared to the least deprived, an increase from 3 times higher in 1997.

Contributing factors to increased premature mortality include COVID-19, especially in disadvantaged groups. R - as has austerity, hitting deprived areas hardest.

Non-communicable diseases with diet and behaviour-related risk factors disproportionately affect the most deprived in our society.

Smoking, Alcohol and Substance Misuse

Smoking remains a significant risk factor for cardiovascular disease, cancer and vascular dementia. Next year (2026) will mark twenty years since the ban on smoking in enclosed public places— which was world leading and has shown to be highly effective in reducing smoking and smoking-related morbidity (Figure 4 Tobacco Use, Smoking in Scotland). However, stark inequalities in smoking remain. Thirty five percent of adults living in the most deprived communities report smoking compared to just 10% in the least deprived.

According to the Scottish Health Survey in 2023, around one in seven (14%) adults were current smokers, similar to the level in 2022 (15%). Smoking was least prevalent among those aged 75 and over (6%).

The four UK Chief Medical Officers (England, Scotland, Wales, and Northern Ireland) publicly endorsed the Tobacco and Vapes Bill which we viewed as a vital step towards creating a smoke-free nation and addressing the health risks associated with smoking, including the potential gateway effect of vaping on cigarette use. The UK Government and devolved administrations are now bringing forward measures to create the first smokefree generation and tackle the rise in youth vaping.

Scotland continues to experience some of the highest rates of alcohol-specific deaths and hospital admissions in the UK, with 1,277 deaths in 2023: a 15-year high-and persistent, stark inequalities, as people in the most deprived areas are over four times more likely to die and six times more likely to be hospitalised due to alcohol than those in the least deprived areas. While Minimum Unit Price (MUP) is estimated to have reduced alcohol specific deaths and contributed to tackling health inequalities, it forms part of a wider approach to reducing the harmful effect of alcohol on society.

By 2020, drug deaths were Scotland’s fourth leading cause of premature mortality, exceeding UK rates. The latest figure for drug-related deaths in Scotland in 2024 is 1,065 suspected drug deaths, which represents an 11% decrease compared to 2023 (1,197 suspected deaths). Yet Scotland continues to have the highest drug-related death rate in Europe, three times higher than the next highest country. The latest confirmed figure for drug deaths in Scotland in 2023 is 1,172, an increase of 12% on 2022. Interim published data for 2024 reports 1,065 “suspected drug deaths”, which represents an 11% decrease compared to 2023 (1,197 suspected deaths).

Obesity & Overweight

Obesity remains a major risk factor for type 2 diabetes, cardiovascular disease, cancers and other causes of ill-health, and the problem is growing.

It is critical that we intervene upstream by tackling the underlying issues that fundamentally determine health. This includes tackling harmful food environments and physical inactivity which contribute to rising levels of obesity.

In the 2023 Scottish Health Survey, 32% of adults were living with obesity— the highest recorded to date. Sixty-four per cent of adults had at least an increased risk of ill health based on BMI and waist circumference. Sixty-eight per cent of children were a healthy weight, however 17% were at risk of obesity (>95th percentile for their age and sex) putting them at increased risk of health consequences in later life.

At the same time, the evidence from the 2023 Scottish Health Survey shows only 63% of adults meeting the recommended guidelines on physical activity levels, which remains within the overall range recorded between 2012 and 2022 (62-69%). As in previous years, a higher proportion of men reported having met the guidelines (68%) compared with women (59%).

The potential benefits of physical activity to both individuals and wider society are discussed in Chapter 2 when I consider the roots of ill health in later life through interventions in the working age population. In Chapter 3, I discuss the ways in which nature can be harnessed to encourage physical activity for the benefit of both physical and mental health.

Ill Health

Cardiovascular Disease (CVD), Type 2 Diabetes, Asthma and Chronic Obstructive Pulmonary Disease (COPD) are significant contributors to the burden of disease in Scotland.

Figure 6 compares the prevalence and mortality rates of these conditions. Asthma has the highest prevalence (6.5%) but lowest mortality (0.2%), while Heart Disease has the highest mortality (11%) with a lower prevalence (3.7%). This mismatch between prevalence and mortality highlights the varied burden of Long Term Conditions – some are widespread, but more manageable (e.g. asthma), while others are less common but have higher mortality (e.g. heart disease).

In Scotland, Long Term Conditions account for a large proportion of both illness and health service use. Inequalities are stark: rates of heart disease, COPD, and Type 2 Diabetes are significantly higher in more deprived areas, contributing to Scotland’s widening health inequalities gap. Trends show increasing multimorbidity, earlier onset in deprived populations, and rising costs to the NHS. Focusing on prevention, addressing missingness (as discussed in chapter 4), early diagnosis, and equitable care are all essential if we are to reduce the burden and close these health inequality gaps.

Mental Health

Evidence from the Scottish Health Survey suggests that following two years of decline, adult mental wellbeing improved in 2023, but remains lower in deprived groups.

While an improvement is encouraging, it is too early to be certain whether this increase represents a trend.

Source: Public Health Scotland

An Ageing Population

In Chapter 2, I examine the demographic shifts of Scotland’s ageing population and highlighted the opportunities for everyone in Scotland of recognising and investing in the virtuous cycle that exists between health and wealth.

I also highlight the contribution of older people to Scotland’s workforce. As workers age, those who remain healthy are more likely to have less episodes of long-term sickness absence.

Since 2015, there have been fewer births than deaths. The gap between births and deaths is predicted to widen over the next 25 years. However, positive net inward overseas migration is projected to bridge the gap between births and deaths over this period.

Figure 8 shows the projected number of people aged 75 and over in Scotland by 2047. Over the same period the number of younger people is projected to fall whilst the number of people between aged between 30 and 55 will also likely increase.

Much of the disease that we face in the future can be prevented and we must pursue the objective of prevention with urgency. The Scottish Burden of Disease study suggests that there will be a 21% rise in illness experienced by our population by 2043, two thirds of which is accounted for by cardiovascular disease, cancer and neurological conditions.

The Scottish Fiscal Commission (SFC) also forecasts healthcare funding could increase. Health spending is the largest and fastest-growing area of the Scottish Budget. As a proportion of the Scottish population, people aged over 85 are predicted to nearly double, an increase predicted to occur earlier than elsewhere in the UK. The commission suggests this could contribute to an average annual budget shortfall of 1.5% between 2030–2031 and 2049–2050. How the population’s health changes as it ages can influence the scale of health-related public spending. If we can support the people we care for to age well and remain healthier for longer, significant improvements in health could be achieved as well as supporting people to be economically active for longer too.

Dementia

Dementia and other main causes of ill health in older people share many preventable risk factors. The research evidence-based estimate of the number of people living with Dementia in Scotland is approximately 90,000 people.

It is notable that the Lancet commission report of Dementia prevention, intervention and care highlighted that up to 45% of all Dementia is potentially preventable through lifestyle and structural changes. It is commendable that the Scottish Government has invested in the development of Dementia data and has commissioned Public Health Scotland to develop a new Dementia Index which will help us better understand the size and scope of the challenge to our population’s health.

In 2023, the registered cause of death of 6,491 people was Dementia in Scotland- a 3% increase from 2022, with a mortality rate of 125 deaths per 100,000 people- more than double the rate in 2005. Around two-thirds (66%) of deaths were among females, and over 84% of all deaths occurred in those aged over 80. Most deaths from dementia occurred in care homes (63%), followed by hospitals (22%) and then home settings (14%).

While dementia was once under-reported as a cause of death, it is now more commonly listed on death certificates. This reflects growing recognition that dementia often plays a central role in the decline that leads to death, even if another condition (such as delirium or aspiration pneumonia) is the principal cause.

Loneliness

In chapter 2, I discuss the contribution of loneliness to ill health. Loneliness is a significant public health challenge in Scotland impacting both physical and mental wellbeing. Individuals who experience loneliness are reportedly twice as likely to be diagnosed with depression. Loneliness is also a significant independent risk factor for dementia (30% increased risk).

Conclusion

If we are to address the health challenges that lie ahead, it is not only our health and care system that must have a greater focus on prevention, but all parts of society, including national and local government, public services and the voluntary and commercial sectors. I remain optimistic that the forthcoming Population Health Framework will provide this much needed focus.

If we can support the people we care for to be healthier for longer, significant improvements in their health could be achieved, allowing them to experience life, contribute to their families and communities and remain economically active for longer too.