Chik Collins' presentation at at North Lanarkshire Council's event Self Directed Support: The Bigger Picture on 8th November 2011.

1. ‘Grasping’ Health in Scotland: The
role of politics and policy in
creating the ‘Scottish Effect’?
Chik Collins, School of Social Sciences, University of the West of Scotland
(presentation based on work conducted in collaboration with Gerry
McCartney, Public Health Observatory, NHS Health Scotland)
Self Directed Support in North Lanarkshire: The Bigger Picture
Ravenscraig Regional Sports Facility, Motherwell
8 November 2011

2. Lagging Outcomes I: The Scottish Effect
Excess mortality in Scotland, compared to England and Wales,
after accounting for deprivation: Increases after 1981
Source: Hanlon et al, 2005
118
Directly standardised mortality ratio
115.1
115
(England & Wales = 100)
113.8
112.4
112
109 107.9 108.1
106 104.7
103
100
1981 1991 2001
Year
Scotland SMR (age & sex) Scotland SMR (age, sex & deprivation)

3. Lagging Outcomes II: Broader comparisons
Source: Extracted from The Human Mortality Database (www.mortality.org)

4. Lagging outcomes III
Causes
• Post 1950: Cardiovascular, stroke, respiratory and
cancer.
• Post 1980: + Alcohol- and drug-related deaths,
suicide, violent deaths and RTAs.
Where this leaves us
• Scottish life expectancy between that of Eastern
and Western Europe.

5. What’s up doc?
• Deindustrialisation hypothesis?
• Walsh, Taulbut and Hanlon, 2008: The Aftershock of Deindustrialisation?
Glasgow Centre for Population Health
• Answer: Clearly very important, but not ‘the answer’.
• Deepens the problem.
• A ‘political attack hypothesis’?
• Not ‘our’ hypothesis.
• Impact of Thatcherite neo-liberalism after 1979: ‘political attack’.
• + Encompasses deprivation, deindustrialisation ...
• + Temporal aspect – ‘Scottish Effect’ emerges in 1980s ...
• Evidence from elsewhere: Russia, EE, Baltics ...
• AIM: To influence the agenda of the health researchers ...
Collins and McCartney, “The impact of neo-liberal ‘political attack’ on health:
the case of the ‘Scottish Effect’”, International Journal of Health Services, 2011

6. Political Attack and Health in
Scotland: A prominent ‘hypothesis’
• Ian Bell: “The passage of 30 years does not alter the
fact that a great many people were hurt, and hurt
very badly, because of Margaret Thatcher. … she
willed an economic catastrophe. A large part of a
generation never recovered. Some sickened; some
died too soon. It's true”
• Iain MacWhirter : “The social cost of this
socioeconomic disruption lingers to this day in the
appalling mortality figures from heart disease,
suicide and depression in West Central Scotland”.

7. The UK ‘political attack’
• 1950s/60s: Neo-liberal economic and political thought - Hayek,
Friedman
• Early implementation in Latin America: “planned misery” (Rudolfo
Walsh).
• Mid-1970s: Keith Joseph and the IEA – advocating Friedmanite “shock
treatment” on lines of Chile.
• Post 1979: Engineered recession, forced deindustrialisation, mass
unemployment, attacks on trade unions and on social
provision/welfare state – esp. council housing.
• ‘The lady is not for turning’ ….. The Ridley Report (1977): “there is no
point in undertaking it if we are not prepared to go through with it”.
• Scotland doubly targeted – “to seek revenge for the various
humiliations of the early 1970s” (Phillips, 2008, p. 138).
• Christopher Harvie: “sado-monetarism” - inevitability of acute social
and psychological distress.

8. LINKING POLITICAL ATTACK TO
HEALTH OUTCOMES
“The deep fried Mars Bars and Buckfast wine are a symptom, not the
cause. The communities that gave meaning to the lives of hundreds of
thousands of working-class Scots disintegrated” (Iain MacWhirter, 2009).

9. Determinants of Health
• Downstream: Buckfast and deep-fried Mars Bars
...(health behaviours)
• Upstream: deprivation, deindustrialisation,
inequalities .... (“causes of the causes” – Marmot).
• Evidence base for upstream determinants linked to
political attack: unemployment, welfare provision,
inequality, material deprivation and privatisation.
• What are ‘pathways’ which connect?

10. Pathways :‘political attack’ to poor health outcomes
Use of rising Unemployment and fear of
Breakdown in confidence of Substance
unemployment to unemployment
working class communities misuse
disempower workers
and control wages Harshening welfare
regime/stigmatisation of
Decrease in
claimants
Privatisation and Declining social mobility; well-being
Political decision marketisation of the stigmatisation and shame;
Rise in inequality and poverty
to attack the economy lowering self-
Poor health
economic and esteem/efficacy' negative
Adverse impact on labour outcomes as
socio-political outcome expectancies;
market 'pathways' for working compared with
bases of a decline in coping
Attacks on trade union class youth other
working class
movement deindustrialised
culture Lack of
Individuation and competition areas
threatening the control
agenda of the Disempowerment of Economic and geographical
Thatcher elected local polarisation of communities Higher
government authorities and Breakdown in cohesion and
levels of
centralisation self-regulation of working
Reduced ability of working class stress
class communities
communities to respond to
problems and act in common
Attack on council Increase in
interest
housing - sales and violence
funding cuts leading
to rent increases,
Disempowerment of council
stock deterioration
tenants
and residualisation

11. The UK and Neo-liberalism
“The UK followed a different policy course
from the European comparison nations
identified by the GCPH for its
deindustrialization study – one which involved
a significantly more resolute pursuit of a neo-
liberal policy agenda.” (Collins and McCartney,
2011)

12. Scotland’s heightened vulnerability to
‘political attack’
Notion of heightened vulnerability widely
articulated – Phillips, Foster, Harvie, Devine ...
Key markers of vulnerability:
– Economic: Industrial employment
– Social: Council housing
– Cultural: Power and control
Cumulative effect ….

13. Economic: Industrial Employment
Source: Walsh, Taulbut and Hanlon (2008)
Proportion of industrial employment at peak (1971)
70% Proportion of industrial employment lost 1971-2005
59.9% 58.1%
60%
50.9%
50% 47.5%
44.9% 45.4%
40% 37.3% 35.9%
30%
20%
10%
0%
Northern Ireland Swansea & South Merseyside West of Scotland
Wales Coalfields
UK deindustrialised region

14. Social: Council Housing
1979: Council
housing twice 0.2
proportion in
houses per capita (1979)
England (54%)
Number of council
0.16
Glasgow – two
thirds.
0.12
Motherwell (96% of
households – ’70s)
0.08
Residualisation –
concentrating 0.04
poverty; esp.
Glasgow (Hirsch/JRF,
2004)
0
Figure: Data from Wales North-West West North-East Scotland
Regional Trends (not Midlands
ideal, but enough).
UK deindustrialised region

15. Cultural: Disempowerment and loss of
control
• Disempowerment and loss of control - a well-
established cause of ill-health and barrier to
management of chronic illness and changing
behaviours.
• Deindustrialising regions – Labour voting
• Scottish ‘region’ – compounded by national
dimension – the ‘doomsday scenario’ and the
‘democratic deficit’.

16. Conservative Voting by Region
West of Scotland Other regions Mean UK vote
45
constituencies within each region at
40
Mean % Conservative vote in
35
general election
30
25
20
15
10
5
0
1974 October 1979 1983 1987 1992 1997
General Election

17. Conclusion
• UK experience of deindustrialisation different from elsewhere
in Europe.
• Within UK, Scotland, and esp. WoS, seems more exposed to
damaging impacts.
• “The ‘political attack’ hypothesis offers an important avenue
for researchers seeking an explanation for the Scottish Effect
... Clearly Scotland in the 1980s is not quite Russia in the
1990s, but it seems slightly anomalous, if not entirely
inexplicable that more of the kind of thinking which has been
brought to bear on the latter has not more clearly shaped the
kind of thinking brought to bear on the Scottish experience”
(Collins and McCartney, 2011).

18. Impact?
• Constructive and supportive dialogue with key GCPH staff in
developing the case – Phil Hanlon and David Walsh.
• Positive indications that being taken seriously.
• Input to next stage of ‘three cities’ research programme –
Glasgow, Liverpool, Manchester.
• Accounting for Scotland’s Excess Mortality: Towards a
Synthesis (McCartney, Collins, Walsh and Batty, forthcoming
GCPH publication).
• “Has Scotland always been the ‘sick man’ of Europe? An
observational study from 1855-2006”, McCartney, Walsh,
Whyte and Collins, European Journal of Public Health.

19. Closing Remarks I
• Scottish health and mortality is not
inevitable/fated (Austria, Finland, Portugal, NI).
• Not making some simplistic link between politics
and health regardless of context and
circumstances: pathways, mediations and
transitions.
• Contemporary relevance ... The return of TINA …

20. Closing Remarks II
• Grasping health…. “the self”, community/culture,
and “socio-economic structure” (politics): ‘inside’
and ‘outside’
• Analogy with ‘rediscovery of poverty’ and ‘culture
of poverty’ in the 1960’s/70’s: What was learned
then?
• Community development and Helping the
Community to Organise (Strathclyde Regional
Council)

21. Closing Remarks III
• Vocal/resistant/campaigning v’s
quiescent/docile/co-opted.
• Where are these community organisations now?
• Too few and far between: BUT: The Clydebank
Independent Resource Centre (see The Right to
Exist, Oxfam, 2008)