The Sickness of Austerity

Gerry McCartney explores why health improved in the past and isn’t improving now.

For the sixty-five years following the creation of the NHS, life expectancy in Scotland consistently improved. However, since around 2012, average life expectancy stopped improving, and life expectancy in the poorest 30-40% of areas actually started to decline. In this article, I describe what was behind the remarkable improvement in health, and why this has gone into reverse now for so many.

Life expectancy only consistently increased since the 1860s (before that it had fluctuated at around forty years depending on the frequency of disease outbreaks, wars and famine). Improved sanitation, housing, nutrition and broader economic development were important between 1860 and 1920. After this, housing improvements remained important, but so was the building of the welfare state and pension entitlements, the creation of new public services and institutions, wealth and income redistribution facilitated by public ownership and greater trade union power, improved gender equity in some domains, and continued economic development. The creation of the NHS to make healthcare free at the point of need and accessible to all was an important part of this, not least by increasing the uptake of low cost and effective treatments such as vaccination. Between 1945 and 1975, the widespread improvement and narrowing inequalities was reflected across many countries, and is referred to by Thomas Piketty and others as Les Trente Glorieuses.

After 1980 many of these positive trends reversed. Income and wealth inequalities rapidly increased, public assets were privatised, public services were under-funded, trade unions were fought, and many Scottish health trends started to falter. Drug- and alcohol-related deaths rapidly increased, and inequalities in health worsened, such that by the 2000s these were wider than the rest of Western and Central Europe. Although these health trends were dreadful, and clearly related to the political and economic changes introduced during the 1980s, average life expectancy did continue to increase.

Between 2012 and 2019, Scotland, the rest of the UK, the USA and other countries such as Germany, experienced life expectancy trends that were almost unprecedented and terrifying. Average life expectancy stopped improving, and started declining in the poorest areas, long before the pandemic hit. Only in times of war or pandemic has this been previously seen.

The causes of this are now clear. Austerity policies implemented across countries in the wake of the 2007 financial crisis ripped vital threads of already frayed public services and social security systems. Across the UK this has led to cuts across services, but most markedly in local government. Social security has also been a target, both in terms of the real terms value of benefits and through increased conditionality for recipients. Precarious and low paid work has also become much more common.

As if things couldn’t get any worse, the pandemic then hit, reducing life expectancy overall, and exacerbating pre-existing inequalities. The pandemic damaged health in three ways. The direct impact of the virus impacted most on the elderly, people with pre-existing health conditions (disproportionately in poorer groups), and amongst people who were the ‘essential’ (but often lowest paid) workers who were more likely to be exposed. Second, healthcare provision was disrupted, leading to many people not receiving the care that they would have benefited from. For example, cancer diagnoses dropped by about a third in the first year of the pandemic, meaning more late diagnoses and worse outcomes. Third, the widespread disruption to people’s lives, though disruption to work, education, social support and incomes, created immediate and longterm damage to people’s lives and health.

As we emerged from the early waves of the pandemic, inflation increased, but wages and benefits lagged behind. Real-terms incomes have fallen, particularly for the poorest groups for whom inflation is higher. We estimate that this has increased premature mortality by 6%, further compounding the negative impacts of 1980s neoliberalism, austerity and the pandemic.

What all this shows is that the health of the population is determined much more by the economic and social policies of government than the operation of the NHS. Damaging policies make the population sicker, and create more demands on the NHS and social care, which can only go so far in addressing the unprecedented healthcare needs of the population. Forty years of neoliberal policies, compounded by austerity, the pandemic, and now the ‘costs of living crisis’, have given us a population with extensive and complex health problems. The postponement of routine healthcare during the pandemic, alongside the well-meaning actions of so many to ‘not bother their GP’ during that busy time, have created a massive backlog of ill-health, diagnostic tests, outpatient appointments and operations.

Fifteen years ago reports were written which called for urgent action to reduce the levels of ill-health in the population so that healthcare needs would not increase as the population got older. The economic and social policies that might have delivered improved population health didn’t materialise, and instead we got austerity which made that situation worse. If we are to bring the need for healthcare in the population down and bring the rate of mortality down (or at least stop them rising), we need more equitable economic and social policies urgently. We need the NHS more than ever, but we can’t expect the NHS to fix the current health trends.

For more details on the evidence discussed, see:

McCartney G, Walsh D, Fenton L, Devine R. ‘Resetting the course for population health: evidence and recommendations to address stalled mortality improvements in Scotland and the rest of the UK.’ Glasgow, Glasgow Centre for Population Health & University of Glasgow, 2022.

Walsh D, McCartney G, Collins C, Taulbut M, Batty GD. ‘History, politics and vulnerability: explaining excess mortality in Scotland and Glasgow.’ Glasgow, Glasgow Centre for Population Health, 2016.

Richardson E, McCartney G, Taulbut M, Douglas M, Craig N. ‘Population mortality impacts of the rising cost of living in Scotland: scenario modelling study.’ BMJ Public Health 2023.