Glasgow Effect’:Evaluating Why the Do Impactequally Deprivedof the ‘Big UK Eat Cities In’ Secondaryexperience School Different Pilot Health Outcomes?

BRIEFING PAPER 2725 FINDINGS SERIES

Investigating a ‘Glasgow Effect’:Evaluating why the do Impactequally deprivedof the ‘Big UK Eat cities In’ Secondaryexperience School different Pilot health outcomes?

SeptemberDecember 2010

10224_GCPH_Briefing Paper 25.indd 1 06/09/2010 16:52 FINDINGSFINDINGS SERIESSERIES 252725 BRIEFINGBRIEFING PAPERPAPER

KEYKEYACKNOWLEDGEMENTS FINDINGSFINDINGS

• The• This ThisScottish report report Centre summarises summarises for Social a a range range Research of of analyses analyses (ScotCen) undertaken undertaken (www.scotcen.org.uk to to investigate investigate the the) conducted so-called so-called the qualitative‘Glasgow‘Glasgow‘Glasgow and Effect’, Effect’,Effect’, observational a aa term termterm used usedused data in inin recent recentrecentcollection, years yearsyears analysis to toto describe describedescribe and the write-up.thethe higher higherhigher The levels levelslevels research of ofof mortality mortalitymortality team comprised:andand poor poor Andy health health MacGregor, experienced experienced Susan in in Glasgow Glasgow McConville, over over Judithand and above above Mabelis, that that Louiseexplained explained Marryat by by its its and Irene Miller.socio-economicsocio-economic A full research profile. profile. report is available on the Glasgow Centre for Population Health (GCPH) • website• TheThe aims aims(www.gcph.co.uk). of of the the research research were were to to establish establish whether whether there there is is evidence evidence of of such such an an ‘effect’, ‘effect’, eveneven when when comparing comparing Glasgow Glasgow to to its its two two most most similar similar and and comparable comparable UK UK cities: cities: Liverpool Liverpool Quantitative data collection and analysis was conducted by Fiona Crawford (GCPH) and andand Manchester. Manchester. Helena Hailstone (Cordia) with help from Bruce Whyte (GCPH). • • TheThe analyses analyses were were based based on on the the creation creation of of a a three-city three-city deprivation deprivation index, index, and and the the Manycalculationcalculation thanks to of of everyone a a series series of ofwho standardised standardised gave their mortality mortalityassistance ratios ratios to the (SMRs) (SMRs) research for for Glasgow Glasgowteam especially relative relative to pupils,to parentsLiverpoolLiverpool and staff and and Manchester.who Manchester. participated A A range range in of theof historical historical focus groups census census and and and interviews. mortality mortality data data were were also also analysed.analysed. • Thanks• TheThe alsoresults results to showed theshowed ‘Big thatEat that In’ the the steering current current group deprivation deprivation who provided profiles profiles of ofsupport Glasgow, Glasgow, and Liverpool Liverpool advice during and and the evaluation,ManchesterManchester finalisation are are almost almost of identical. resultsidentical. and production of final reports. • • DespiteDespite this, this, premature premature deaths deaths in in Glasgow Glasgow for for the the period period 2003-2007 2003-2007 were were more more than than 30% 30% Steeringhigherhigher groupthan than in in members Liverpool Liverpool and comprised:and Manchester, Manchester, with with all all deaths deaths around around 15% 15% higher. higher. • • ThisThis ‘excess’ ‘excess’ mortality mortality was was seen seen across across virtually virtually the the whole whole population: population: all all ages ages (except (except the the Alexveryvery Byres, young), young), Glasgow both both males Lifemales (formally and and females, females, known in in deprived asdeprived Culture and and and non-deprived non-deprived Sport Glasgow, neighbourhoods. neighbourhoods. CSG) • Fiona• ForFor Crawford, premature premature Glasgowmortality, mortality, Centre SMRs SMRs tended fortended Population to to be be higher higher Health for for the the more more deprived deprived areas areas (particularly(particularly amongamong males),males), andand aroundaround aa halfhalf ofof ‘excess’‘excess’ deathsdeaths underunder 6565 werewere directlydirectly Louise(particularly Falconer, among Glasgow males), City and Council around Leader’s a half ofOffice ‘excess’ deaths under 65 were directly relatedrelated to to alcohol alcohol and and drugs. drugs. Helena Hailstone, Cordia • • AnalysesAnalyses of of historical historical data data suggest suggest it it is is unlikely unlikely that that the the deprivation deprivation profile profile of of Glasgow Glasgow has has Ruthchangedchanged Kendall, significantly significantly NHS Greater relative relative Glasgow to to Liverpool Liverpool & Clyde and and Manchester Manchester in in recent recent decades; decades; however, however, the the Gerrymortalitymortality Lyons, gap gapAll Saints’appears appears Secondary to to have have widened widened School in (Chair)in the the last last 30 30 years, years, indicating indicating that that the the ‘effect’ ‘effect’ may may bebe a a relatively relatively recent recent phenomenon. phenomenon. Julia McCreadie, Cordia • • TheThe results results emphasise emphasise that that while while deprivation deprivation is is a a fundamental fundamental determinant determinant of of health health Maureenand,and, therefore, therefore, McKenna, an an important Glasgowimportant City driver driver Council of of mortality, mortality, Education it it is is Services only only one one part part of of a a complex complex picture. picture. AsAs currently currently measured, measured, deprivation deprivation does does not not explain explain the the higher higher levels levels of of mortality mortality experiencedexperienced by by Glasgow Glasgow in in relation relation to to two two very very similar similar UK UK cities. cities. Additional Additional explanations explanations areare required. required. • • ThisThis research, research, in in particular particular the the creation creation of of the the small small area area based based three-city three-city deprivation deprivation measure,measure, has has allowed allowed identification identification of of communities communities in in Glasgow Glasgow which, which, although although almostalmost identical identical to to similar similar sized sized areas areas in in Liverpool Liverpool and and Manchester Manchester in in terms terms of of their their socio-economicsocio-economic characteristics, characteristics, have have significantly significantly poorer poorer health health outcomes. outcomes. These These will will Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience nownow be be the the focus focus for for a a second, second, qualitative, qualitative, phase phase of of research. research.

10224_GCPH_Briefing10224_GCPH_Briefing Paper Paper 25.indd 25.indd 2 2 06/09/201006/09/2010 16:52 16:52 FINDINGS SERIESBRIEFING25 BRIEFING PAPER PAPER2725 FINDINGS SERIES FINDINGS SERIES 25 BRIEFING PAPER UK cities experience different health outcomes? Investigating a ‘Glasgow Effect’: why do equally deprived Evaluating of the the Impact ‘Big Eat In’ Pilot School Secondary

INTRODUCTIONKEY IMPLICATIONS FINDINGS FOR POLICY AND PRACTICE KEY FINDINGS

lThe• The Thislink Big betweenreport Eat Insummarises socio-economic(BEI) pilot a was range successful circumstances of analyses in encouragingundertaken and health to isS1 investigatewell pupils established. to staythe so-called within However, • This report summarises a range of analyses undertaken to investigate the so-called the schoolextent‘Glasgow toat lunchtimewhichEffect’, the a term poorand used schoolhealth in recent mealprofile uptakeyears of Scotland to rates describe by– the S1 the pupilsnation higher remainedwith levels the of highest higher mortality than ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality mortalitytheand previous poor rates health and year. lowest experienced S1 pupils life expectancy were in Glasgow positive in westernover about and theirEurope above experience that– can explained be explainedof the by BEI its inand terms the of and poor health experienced in Glasgow over and above that explained by its socio-economicmajoritysocio-economic of respondents factors profile. is less were clear. in Historically, favour of the Scotland’s S1 stay onunenviable site policy position being incontinued being what in socio-economic profile. the• pilotpressThe aims schoolshas labelledof the and research extended‘The Sick were Man to toother of establish Europe’ secondary whetherhas been schools. there attributed There is evidence almostis clear of exclusivelypotential such an ‘effect’, for to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, relativelyGlasgoweven whenhigh City levels comparing Council of socio-economic toGlasgow sustain to and its deprivation, extendtwo most lunchtime similar principally and stay comparable in on comparison site policies UK tocities: in England secondary Liverpool even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool schools in Glasgow. The success of the BEI also has implications for secondary school and andWales. Manchester. However, a number of publications over the past five years have highlighted a and Manchester. phenomenonlunchtime speculatively policy elsewhere entitled in Scotland. the ‘Scottish Effect’, a term used to describe the country’s • The analyses were based on the creation of a three-city deprivation index, and the • The analyses were based on the creation of a three-city deprivation index, and the higher levels of morbidity and mortality over and above that explained by deprivation. One l calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to such School analysis lunchtime showed this policies ‘Scottish in primary Effect’ schoolsto exist inare all also geographical important regions and should of Scotland and Liverpool and Manchester. A range of historical census and mortality data were also Liverpool and Manchester. A range of historical census and mortality data were also at allcomplement levels of deprivation, rather than but contradict that it was secondary most evident school in the policies. most deprived At present post there industrial is a analysed. analysed. regionclear of discrepancyWest Central in Scotland, approach. with A siteGlasgow survey at ofthe head region’s teachers, core. Thisconducted led to talk by Glasgowof a ‘Glasgow• CityThe Councilresults Effect’, showed (GCC)a notion Education that reinforced the current Services by other deprivation in 2008,recent found profilesresearch that of showing approximatelyGlasgow, that Liverpool mortality half andof in those the • The results showed that the current deprivation profiles of Glasgow, Liverpool and 1 formerwhoManchester industrial responded are areas almostpermitted of West identical. Centralpupils to Scotland leave school was higher, at lunchtime and was to improving access local more shops. slowly, If Manchester are almost identical. primary school pupils have permission to leave school at lunchtime then it will be more than• Despite in the vast this, majority premature of other,deaths similar, in Glasgow post-industrial for the period regions 2003-2007 of Europe, were including more than those 30% • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% difficult to implement stay on site policies in their first year of secondary school. whichhigher currently than inexperience Liverpool worse and Manchester, socio-economic with allconditions. deaths around 15% higher. higher than in Liverpool and Manchester, with all deaths around 15% higher. This ‘excess’ mortality was seen across virtually the whole population: all ages (except the This ‘excess’ mortality was seen across virtually the whole population: all ages (except the l• School meal uptake rates in secondary schools with stay on site policies should be • Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of monitoredvery young), and both compared males and to females, schools inwith deprived no stay and on non-deprived site policies to neighbourhoods. gauge impacts very young), both males and females, in deprived and non-deprived neighbourhoods. poor• ofFor health these premature andpolicies, deprivation. mortality, not only SMRsLiverpool on S1 tended school and to Manchester meal be higher uptake forare rates thetwo morebut other also deprived cities on other which areas year stand groups’ out in • For premature mortality, SMRs tended to be higher for the more deprived areas this uptakeregard,(particularly rates.with highamong levels males), of poverty and around and thea half lowest of ‘excess’ life expectancy deaths under of all 65 cities were indirectly England. (particularly among males), and around a half of ‘excess’ deaths under 65 were directly The relatedapproach to takenalcohol in andthis drugs.project, therefore, was to investigate this ‘Scottish Effect’ or related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, l• ProvisionAnalyses ofof historicallunchtime data activities suggest was it is one unlikely of the that major the successesdeprivation of profile the BEI. of Partnership Glasgow has • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have workingchanged betweensignificantly school relative staff, to Culture Liverpool and and Sport Manchester Glasgow in(CSG) recent (now decades; Glasgow however, Life), the changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to communitymortality gap groups appears and to volunteers have widened (and in possibly the last 30senior years, pupils) indicating should that be the consolidated ‘effect’ may mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive andbe a strengthened relatively recent in orderphenomenon. to sustain the provision of lunchtime activities and, where be a relatively recent phenomenon. measurepossible, of deprivation build on and than develop was previously this provision available to includeto researchers other iyear. groups.

• The results emphasise that while deprivation is a fundamental determinant of health • The results emphasise that while deprivation is a fundamental determinant of health and, therefore, an important driver of mortality, it is only one part of a complex picture. l Schools implementing stay on site policies should consider the introduction of and, therefore, an important driver of mortality, it is only one part of a complex picture. measuresAs currently tested measured, out in deprivationthe BEI that does ameliorate not explain the shortage the higher of levels time atof lunchtime,mortality As currently measured, deprivation does not explain the higher levels of mortality allowingexperienced S1 pupils by Glasgow to eat inlunch relation and to participate two very similarin a lunchtime UK cities. activity. Additional Examples explanations of experienced by Glasgow in relation to two very similar UK cities. Additional explanations measuresare required. that could be considered include queue rotas, priority for those pupils taking are required. • partThis inresearch, an activity, in particular provision the of creation lunch pre-ordering of the small systems,area based and three-city staggered deprivation lunch breaks. • This research, in particular the creation of the small area based three-city deprivation measure, has allowed identification of communities in Glasgow which, although measure, has allowed identification of communities in Glasgow which, although l Duringalmost theidentical pilot, toschool similar staff sized members areas in gave Liverpool up some and Manchesterof their free intime terms to superviseof their and almost identical to similar sized areas in Liverpool and Manchester in terms of their monitorsocio-economic the canteen characteristics, and the school have gates,significantly as well poorer as running health and outcomes. assisting These with will socio-economic characteristics, have significantly poorer health outcomes. These will Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience activities.now be the If schoolsfocus for do a implementsecond, qualitative, such a programme phase of research. thought should be given to why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research. human resource implications for teaching staff.

l School staff and parents want further action taken on vans and outlets selling unhealthy food and drinks that target school pupils at different times of the day, not just at lunchtime. Further attempts should be made by Glasgow City Council and partners to work with the proprietors of vans and food outlets to provide healthier choices for i Previouspupils. analyses Licensing were based and on planning the Carstairs policies & Morris couldindex, a becomposite better measure utilised of deprivationto enhance calculated efforts from to censuscreate data. healthier This measure environments is now out of date around (the most schools recent data and being research for 2001), could but crucially be undertaken was also calculated to for different-sized geographies north and south of the border: the relatively large size of these areas (especially in the twoassess English the cities), nutritional and the variation value in sizeof food between and the drinks Scottish sold and English in outlets geographies near isschools. potentially problematic in 2 measuring the effects of area-based deprivation. 32

10224_GCPH_Briefing10224_GCPH_Briefing Paper 25.indd Paper 2 25.indd 3 06/09/201010224_GCPH_Briefing06/09/2010 16:52 16:52 Paper 25.indd 2 06/09/2010 16:52 FINDINGSFINDINGS SERIESSERIES 252725 BRIEFINGBRIEFING PAPERPAPER

KEYKEYINTRODUCTION FINDINGSFINDINGS

• Scottish• ThisThis report reportchildren summarises summarises and young a a range rangepeople of of followanalyses analyses a dietundertaken undertaken that falls to to short investigate investigate of national the the so-called so-called recommendations‘Glasgow‘Glasgow‘Glasgow Effect’, Effect’,Effect’, and a aa term termterm is less used usedused healthy in inin recent recentrecent than years yearsyears that to totoof describe describedescribeother European the thethe higher higherhigher countries. levels levelslevels of ofof2 mortality Poormortalitymortality diet contributesandand poor poor to health health excessive experienced experienced weight-gain. in in Glasgow Glasgow3 Increasing over over and and levels above above of childthat that explained andexplained adult by obesityby its its are alreadysocio-economicsocio-economic damaging health profile. profile. and wellbeing; experts have called for greater, concerted, system wide action on what they regard as a ‘public health time bomb.’ 4 According to recent data • • TheThe aims aims of of the the research research were were to to establish establish whether whether there there is is evidence evidence of of such such an an ‘effect’, ‘effect’, on obesity prevalence in OECD (Organisation for Economic Co-operation and Development) eveneven when when comparing comparing Glasgow Glasgow to to its its two two most most similar similar and and comparable comparable UK UK cities: cities: Liverpool Liverpool countries, Scotland ranks second only to the United States. 5 Over recent years, the Scottish andand Manchester. Manchester. Government has published a number of strategic documents and plans aiming to improve • diet• The Theand analyses analyses reduce were obesitywere based based levels. on on the the creation creation of of a a three-city three-city deprivation deprivation index, index, and and the the calculationcalculation of of a a series series of of standardised standardised mortality mortality ratios ratios (SMRs) (SMRs) for for Glasgow Glasgow relative relative to to ThereLiverpoolLiverpool is wide andagreementand Manchester. Manchester. that A schoolA range range foodof of historical historical policy has census census an important and and mortality mortality role data todata play were were in also provisionalso andanalysed. analysed.promotion of a healthy diet amongst Scottish children and young people. The Schools • Health• TheThe Promotionresults results showed showed and that Nutritionthat the the current current Act (Scotland deprivation deprivation 2007) profiles profiles has built of of Glasgow, Glasgow,on earlier Liverpool Liverpool policies and suchand as HungryManchesterManchester for Success are are almost 6almost to embed identical. identical. school based provision and promotion of healthy food and drinks into legislation.7 The most recent Scottish Government (SG) publication, ‘Preventing • • DespiteDespite this, this, premature premature deaths deaths in in Glasgow Glasgow for for the the period period 2003-2007 2003-2007 were were more more than than 30% 30% Overweight and Obesity in Scotland: A route map towards healthy weight’ states that one higherhigher than than in in Liverpool Liverpool and and Manchester, Manchester, with with all all deaths deaths around around 15% 15% higher. higher. of its priorities will be to control exposure to foods that are high in energy.8 Examples of • preventative• ThisThis ‘excess’ ‘excess’ actions mortality mortality include: was was seen “Exploringseen across across measures virtually virtually the tothe restrict whole whole accesspopulation: population: by children all all ages ages to (except nutritionally(except the the inappropriateveryvery young), young), meals both both and males males high and and energy females, females, and in inenergy-dense deprived deprived and and foods non-deprived non-deprived from businesses neighbourhoods. neighbourhoods. located in the • vicinity• ForFor premature ofpremature schools.” mortality, mortality, SMRs SMRs tended tended to to be be higher higher for for the the more more deprived deprived areas areas (particularly(particularly(particularly among amongamong males), males),males), and andand around aroundaround a aa half halfhalf of ofof ‘excess’ ‘excess’‘excess’ deaths deathsdeaths under underunder 65 6565 were werewere directly directlydirectly Glasgowrelatedrelated City to to alcohol Councilalcohol and providesand drugs. drugs. a broad spectrum of initiatives and services designed to • provide• AnalysesAnalyses and of promoteof historical historical healthy data data suggest suggestfood and it it isdrinksis unlikely unlikely throughout that that the the deprivation deprivationall Glasgow profile profile schools of of duringGlasgow Glasgow has has the changedschoolchanged day. significantly significantly Previous relative researchrelative to to and Liverpool Liverpool evaluation and and Manchester hasManchester shown thatin in recent recent these decades; decades;programmes however, however, and the the initiativesmortalitymortality have gap gap had appears appears a positive to to have have impact widened widened on pupils’ in in the the attitudeslast last 30 30 years, years, and indicating indicatingbehaviour that that in relation the the ‘effect’ ‘effect’ to may may healthybebe a a eatingrelatively relatively and recent recent they phenomenon. havephenomenon. been well received, particularly within the primary school sector, by pupils, parents and school staff. 9 • • TheThe results results emphasise emphasise that that while while deprivation deprivation is is a a fundamental fundamental determinant determinant of of health health In contrastand,and, therefore, therefore, to the primaryan an important important school driver driver sector, of of changesmortality, mortality, to it it schoolis is only only foodone one part partpolicy of of a anda complex complex practice picture. picture. within secondaryAsAs currently currently schools measured, measured, have been deprivation deprivation more difficult. does does not not Increasing explain explain the the numbers higher higher levels levelsof secondary of of mortality mortality school pupils are experiencedleavingexperienced school by by premisesGlasgow Glasgow in atin relation relationlunchtime to to two twoto purchase very very similar similar food UK UK and cities. cities. drinks Additional Additional high in explanations fat,explanations sugar andare aresalt required. required. from high street food outlets and mobile vans. 10 Nonetheless, qualitative research • conducted• ThisThis research, research, by the in in Scottish particular particular Centre the the creation creationfor Social of of Researchthe the small small (ScotCen)area area based based with three-city three-city primary deprivation deprivation and secondary pupilsmeasure,measure, and parents has has allowed allowed found identification identification that, despite oftheirof communities communities reservations in in Glasgow aboutGlasgow the which, which, changes although although to school based provisionalmostalmost of identical identical food and to to drinks,similar similar pupilssized sized areas areasand parentsin in Liverpool Liverpool thought and and Manchester thatManchester healthy in in school terms terms foodof of their their provision andsocio-economic socio-economicpromotion was characteristics, havingcharacteristics, a positive have have influence significantly significantly in school poorer poorer and health health at homeoutcomes. outcomes. and that These These it shouldwill will 11 12 Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience continue.nownow be be the the One focus focus of thefor for arecommendations a second, second, qualitative, qualitative, from phase phase the of of research, research. research. discussed at a research seminar in 2007, was that a pilot exercise to encourage secondary school pupils to remain on the school premises at lunchtime should be considered after consultation with relevant school staff and pupils. 11

422

INTRODUCTIONKEY BACKGROUND FINDINGS KEY FINDINGS

GlasgowThe• Thislink between reportCity Council summarises socio-economic (GCC) a Education range circumstances of analyses Services undertaken inand collaboration health to is investigatewell with established. other the stakeholdersso-called However, • This report summarises a range of analyses undertaken to investigate the so-called inthe the extent‘Glasgow school to sector,whichEffect’, the decideda term poor used healthto implement in recent profile years of a pilotScotland to describeinitiative – the the (Glasgow’s nation higher with levels Big the Eat of highest mortalityIn) in eight ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality secondarymortalityand poor rates schools health and inlowest experienced Glasgow, life expectancy commencing in Glasgow in westernover in August and Europe above 2009 that– and can explained running be explained forby aits fullin terms academic of and poor health experienced in Glasgow over and above that explained by its year.socio-economicsocio-economic A steering groupfactors profile. was is less established clear. Historically, with representation Scotland’s unenviable from GCC position Education in being Services, what socio-economic profile. Cordiathe• pressThe (formerly aims has labelledof the GCC research ‘TheDirect Sick andwere Man Care to of establish Services),Europe’ whetherhas Culture been there attributedand Sportis evidence almostGlasgow of exclusively such (CSG), an Glasgow‘effect’, to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, Centrerelativelyeven for whenhigh Population levels comparing of Health socio-economic Glasgow (GCPH), to andits deprivation, two NHS most Greater similar principally Glasgow and comparable in & comparison Clyde (NHSGGC) UK tocities: England toLiverpool plan, even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool implement and evaluate the initiative. and andWales. Manchester. However, a number of publications over the past five years have highlighted a and Manchester. phenomenon speculatively entitled the ‘Scottish Effect’, a term used to describe the country’s • The analyses were based on the creation of a three-city deprivation index, and the • The analyses were based on the creation of a three-city deprivation index, and the higher levels of morbidity and mortality over and above Thethat aimexplained of the byBig deprivation. Eat In (BEI) Onewas calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to such analysis showed this ‘Scottish Effect’ to exist in all geographicalto encourage regions secondary of Scotland one (S1) and Liverpool and Manchester. A range of historical census and mortality data were also Liverpool and Manchester. A range of historical census and mortality data were also at all levels of deprivation, but that it was most evident inpupils the most to stay deprived within postthe school industrial analysed. analysed. region of West Central Scotland, with Glasgow at the region’sgrounds core. at This lunchtime led to talk to eat of a ‘Glasgow• The results Effect’, showed a notion that reinforced the current by other deprivation recent profilesresearchhealthy of showing Glasgow, lunch thatand Liverpool mortalityparticipate and in inthe a • The results showed that the current deprivation profiles of Glasgow, Liverpool and formerManchester industrial are areas almost of West identical. Central Scotland was higher,lunchtime and was activity. improving Eight more secondary slowly, Manchester are almost identical. schools located in different areas of than• Despite in the vast this, majority premature of other,deaths similar, in Glasgow post-industrial for the period regions 2003-2007 of Europe, were including more than those 30% • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% Glasgow volunteered to participate. whichhigher currently than inexperience Liverpool worse and Manchester, socio-economic with allconditions. deaths around 15% higher. higher than in Liverpool and Manchester, with all deaths around 15% higher. Preparatory work was conducted This ‘excess’ mortality was seen across virtually the whole population: all ages (except the • with secondary school pupils, • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of very young), both males and females, in deprived andparents/carers non-deprived andneighbourhoods. school staff in very young), both males and females, in deprived and non-deprived neighbourhoods. poor• For health premature and deprivation. mortality, SMRsLiverpool tended and to Manchester be higher forarethe thetwo schools more other involveddeprived cities which inareas the stand pilot out as in • For premature mortality, SMRs tended to be higher for the more deprived areas this regard,(particularly with highamong levels males), of poverty and around and thea half lowest of ‘excess’ lifewell expectancy deaths as with under upper of all 65 primarycities were indirectly England.pupils, (particularly among males), and around a half of ‘excess’ deaths under 65 were directly The relatedapproach to takenalcohol in andthis drugs.project, therefore, was to investigateparents/carers this ‘Scottish and school Effect’ staff or in related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, • Analyses of historical data suggest it is unlikely that theassociated deprivation primary profile schools. of Glasgow has • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have changed significantly relative to Liverpool and Manchester in recent decades; however, the changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to mortality gap appears to have widened in the last 30Publicity years, indicating accompanied that the the ‘effect’ launch may of mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive be a relatively recent phenomenon. the pilot at which the Leader of GCC be a relatively recent phenomenon. measure of deprivation than was previously available to researcherspledged hisi. support for the initiative.

The results emphasise that while deprivation is a fundamental determinant of health • Information leaflets were issued to • The results emphasise that while deprivation is a fundamental determinant of health and, therefore, an important driver of mortality, it is only one part of a complex picture. parents/carers prior to the end of the and, therefore, an important driver of mortality, it is only one part of a complex picture. As currently measured, deprivation does not explain2009 the higher summer levels term. of mortalityTaster sessions As currently measured, deprivation does not explain the higher levels of mortality experienced by Glasgow in relation to two very similarwere UK organised cities. Additional in many explanations of the experienced by Glasgow in relation to two very similar UK cities. Additional explanations are required. associated primary schools to allow are required. • This research, in particular the creation of the small areaparents/carers based three-city to sample deprivation menu items • This research, in particular the creation of the small area based three-city deprivation measure, has allowed identification of communities offeredin Glasgow by thewhich, school although meals service measure, has allowed identification of communities in Glasgow which, although and almostprimary identical seven pupils to similar had sizedthe opportunity areas in Liverpool to have and lunch Manchester in their futurein terms secondary of their almost identical to similar sized areas in Liverpool and Manchester in terms of their schoolsocio-economic canteens during characteristics, orientation havevisits significantly to their respective poorer healthschools. outcomes. These will socio-economic characteristics, have significantly poorer health outcomes. These will Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research. why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research. Each pilot school drew up its own individual implementation plan, establishing a package of initiatives to provide a positive incentive for S1 pupils remaining on the school premises. Initiatives varied from school to school and included recreational physical activity, sport and lunchtime clubs, as well as provision of access to school libraries and informal social space.

i Previous analyses were based on the Carstairs & Morris index, a composite measure of deprivation 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: 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 2 measuring the effects of area-based deprivation. 523

KEYKEYRESEARCH FINDINGSFINDINGS AIM AND OBJECTIVES

• In• orderThisThis report toreport assess summarises summarises the impact a a range range of the of of pilot analyses analyses in the undertaken undertaken participating to to investigate investigate schools and the the to so-called so-called inform future school‘Glasgow‘Glasgow‘Glasgow food policyEffect’, Effect’,Effect’, and a aa term termterm practice, used usedused in aninin recent recent recentaccompanying years yearsyears to toto describe describedescribe evaluation the thethe higher was higherhigher conducted levels levelslevels of ofof mortality bymortalitymortality GCPH and a researchandand poor poor team health health from experienced experienced ScotCen. The in in Glasgow Glasgowaim of the over over evaluation and and above above was that that to explained explainedassess the by by impact its its of the pilotsocio-economicsocio-economic on secondary pupils’profile. profile. attitudes and behaviour regarding their lunchtime experience, school meals, and healthy eating and elicit views of parents/carers and school staff • • TheThe aims aims of of the the research research were were to to establish establish whether whether there there is is evidence evidence of of such such an an ‘effect’, ‘effect’, regarding the pilot. eveneven when when comparing comparing Glasgow Glasgow to to its its two two most most similar similar and and comparable comparable UK UK cities: cities: Liverpool Liverpool andand Manchester. Manchester. Objectives were as follows: • • TheThe analyses analyses were were based based on on the the creation creation of of a a three-city three-city deprivation deprivation index, index, and and the the calculation1.calculation To explore of of a a theseries series impact of of standardised standardised of the BEI on:mortality mortality ratios ratios (SMRs) (SMRs) for for Glasgow Glasgow relative relative to to Liverpool Liverpool a) and andSchool Manchester. Manchester. meal uptake A A range range of of historical historical census census and and mortality mortality data data were were also also analysed. analysed. b) Pupils’ attitudes and behaviour relating to school meals and healthy eating • • The The results resultsc) showed showedSchool thatstaffthat the themembers’ current current anddeprivation deprivation collaborating profiles profiles partners of of Glasgow, Glasgow, views Liverpool Liverpool regarding and and pupils’ Manchester Manchester are attitudesare almost almost and identical. identical. behaviour, the management of school lunchtime and the sustainability of the approach • • DespiteDespite this, this, premature premature deaths deaths in in Glasgow Glasgow for for the the period period 2003-2007 2003-2007 were were more more than than 30% 30% d) Parents/carers views and opinions regarding school lunchtime policies FINDINGShigherhigher than than SERIES in in Liverpool Liverpool and 25and Manchester, Manchester,BRIEFING with with all all deaths deaths PAPERaround around 15% 15% higher. higher. • • This2.This To‘excess’ ‘excess’ identify mortality mortality differences was was seen seen in the across across approach virtually virtually used the the by whole whole pilot population: population:schools all all ages ages (except (except the the very3.very Toyoung), young), ascertain both both whatmales males worked and and females, females, well or in in less deprived deprived well and and non-deprived non-deprived neighbourhoods. neighbourhoods. • • ForFor premature premature mortality, mortality, SMRs SMRs tended tended to to be be higher higher for for the the more more deprived deprived areas areas (particularly(particularly(particularly among amongamong males), males),males), and andand around aroundaround a aa half halfhalf of ofof ‘excess’ ‘excess’‘excess’ deaths deathsdeaths under underunder 65 6565 were werewere directly directlydirectly relatedrelated to to alcohol alcohol and and drugs. drugs. • KEY• APPROACHAnalysesAnalyses FINDINGS of of historical historical AND data data METHOD suggest suggest it it is is unlikely unlikely that that the the deprivation deprivation profile profile of of Glasgow Glasgow has has changedchanged significantly significantly relative relative to to Liverpool Liverpool and and Manchester Manchester in in recent recent decades; decades; however, however, the the Data• This were report collected summarises and analysed a range usingof analyses both qualitativeundertaken andto investigate quantitative the methods. so-called mortalitymortality gap gap appears appears to to have have widened widened in in the the last last 30 30 years, years, indicating indicating that that the the ‘effect’ ‘effect’ may may The ‘Glasgowqualitative Effect’, evaluation a term was used conducted in recent years by ScotCen. to describe Baseline the higher and follow levels upof datamortality were bebe a a relatively relatively recent recent phenomenon. phenomenon. collectedand poor from health pupils, experienced school staff in and Glasgow partners over in and each above school that using explained a variety by its of methods • including• TheThesocio-economic results results focus emphasise emphasise groups, profile. face that that to while while face, deprivation anddeprivation telephone is is a a fundamental interviews.fundamental Staff determinant determinant interviewed of of health health had a strategicand,and, therefore, therefore, or operational an an important important role and driver driver included: of of mortality, mortality, head/depute it it is is only only head one one part teachers;part of of a a complex complexS1 heads; picture. picture. PE • The aims of the research were to establish whether there is evidence of such an ‘effect’, teachers;AsAs currently currently CSG representatives, measured, measured, deprivation deprivation volunteers, does does catering not not explain explain managers the the higher higher and levels levelscatering of of mortality mortalitystaff. Parents/ even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool carersexperiencedexperienced were interviewed by by Glasgow Glasgow as partin in relation relation of the to followto two two upvery very data similar similar collection. UK UK cities. cities. Additional Additional explanations explanations and Manchester. areare required. required. • The analyses were based on the creation of a three-city deprivation index, and the • The• This Thisqualitative research, research, research in in particular particular design the the and creation creation time lineof of the the is shown small small area areabelow. based based three-city three-city deprivation deprivation calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to measure,measure, has has allowed allowed identification identification of of communities communities in in Glasgow Glasgow which, which, although although Liverpool and Manchester. A range of historical census and mortality data were also almostalmost identical identical to to similar similar sized sized areas areas in in Liverpool Liverpool and and Manchester Manchester in in terms terms of of their their analysed. June 2009 August - September 2009 March - June 2010 socio-economicsocio-economic characteristics, characteristics, have have significantly significantly poorer poorer health health outcomes. outcomes. These These will will l The results showed thatl the 16 currentinterviews deprivation with profilesl of Glasgow, Liverpool and Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating • 17 interviews with secondary school staff Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience nownow8 interviews be be the the focus focus with for for a a second, second, qualitative, qualitative, phase phase of of research. research. Manchesterhead teachers are almost identical. secondary school l 16 focus groups with S1 pupils l 4 focus groups with staff l Focus groups/interviews with 10 • DespiteP7 pupils this, premature ldeaths 12 focus in Glasgowgroups with for the periodparents/carers 2003-2007 of S1 were pupils more than 30% higher than in Liverpool andS1 Manchester,pupils with all deathsl 5 interviews around with 15% CSG higher. representatives This ‘excess’ mortality was seen across virtually the wholeand volunteers population: involved all inages running (except the • lunchtime activities very young), both males and females, in deprived andl Observational non-deprived research neighbourhoods. • BaselineFor premature data collection mortality, SMRs tended to be higherFollow-up for the more data collection deprived areas (particularly among males), and around a half of ‘excess’ deaths under 65 were directly related to alcohol and drugs. 622 • Analyses of historical data suggest 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 in the last 30 years, indicating that the ‘effect’ may be a relatively recent phenomenon.

10224_GCPH_Briefing10224_GCPH_Briefing Paper Paper 25.indd 25.indd• 2 2 The results emphasise that while deprivation is a fundamental determinant of health 06/09/201006/09/2010 16:52 16:52 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. Additional explanations are required. • This research, in particular the creation of the small area based three-city deprivation measure, has allowed identification of communities in Glasgow which, although almost identical to similar sized areas in Liverpool and Manchester in terms of their socio-economic characteristics, have significantly poorer health outcomes. These will

Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research.

10224_GCPH_Briefing Paper 25.indd 2 06/09/2010 16:52 BRIEFING PAPER 2725 FINDINGS SERIES FINDINGS SERIES 25 BRIEFING PAPER UK cities experience different health outcomes? Investigating a ‘Glasgow Effect’: why do equally deprived Evaluating of the the Impact ‘Big Eat In’ Pilot School Secondary

INTRODUCTION KEY FINDINGS

The quantitativelink between evaluationsocio-economic comprised circumstances the collection, and health collation is well and established. analysis of However, school • This report summarises a range of analyses undertaken to investigate the so-called mealthe extent uptake to datawhich by the year poor group health during profile the of course Scotland of the – the pilot nation for each with school the highest from the ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality beginningmortality rates of September and lowest 2009 life expectancy until the beginning in western of Europe May 2010. – can Data be explained were collected in terms by of and poor health experienced in Glasgow over and above that explained by its Cordia;socio-economic collation factorsand analysis is less wasclear. conducted Historically, by Scotland’s GCPH. Uptake unenviable data forposition 2008/09 in being were whatalso socio-economic profile. collatedthe press and has analysedlabelled ‘The for each Sick Manschool of toEurope’ allow has comparisons been attributed with thealmost previous exclusively academic to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, year.relatively Data high were levels aggregated of socio-economic for the eight deprivation, schools to principally examine and in comparison present overall to England trends and even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool patterns. and Wales. However, a number of publications over the past five years have highlighted a and Manchester. phenomenon speculatively entitled the ‘Scottish Effect’, a term used to describe the country’s • The analyses were based on the creation of a three-city deprivation index, and the ScotCenhigher levels also of conducted morbidity observational and mortality researchover and duringabove that May/June explained 2010 by to deprivation. gain a picture One of calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to thesuch different analysis approachesshowed this ‘Scottishutilised and Effect’ to identify to exist anyin all unexpected geographical consequences. regions of Scotland and Liverpool and Manchester. A range of historical census and mortality data were also at all levels of deprivation, but that it was most evident in the most deprived post industrial analysed. Dimensionsregion of West included Central in Scotland, the observation with Glasgow were: 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 • The results showed that the current deprivation profiles of Glasgow, Liverpool and l former Presence industrial of burger/ice areas of West cream Central vans Scotlandin close proximity was higher, to and the was school improving gates; volumemore slowly, of Manchester are almost identical. pupil customers; and type of food sold than in the vast majority of other, similar, post-industrial regions of Europe, including those • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% l Presence of other food outlets in close proximity to schools which currently experience worse socio-economic conditions. higher than in Liverpool and Manchester, with all deaths around 15% higher. l Approaches used by schools to encourage S1 pupils to stay on the school premises at lunchtime • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of l Types of lunchtime activities offered very young), both males and females, in deprived and non-deprived neighbourhoods. poor health and deprivation. Liverpool and Manchester are two other cities which stand out in l Management of lunchtime in canteens, including queuing systems • For premature mortality, SMRs tended to be higher for the more deprived areas this regard, with high levels of poverty and the lowest life expectancy of all cities in England. (particularly among males), and around a half of ‘excess’ deaths under 65 were directly TwoThe approachmembers taken of the in research this project, team therefore, visited each was ofto theinvestigate eight schools this ‘Scottish at lunchtime Effect’ onor an related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, agreed date (between May and June 2010). Using a proforma developed by the evaluation • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have team and approved by the steering group and pilot head teachers, one researcher observed changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to the internal school environment (canteen, associated lunchtime activities), while the other mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive focused on the external school environment (school gates/grounds, burger vans, local be a relatively recent phenomenon. shops,measure etc). of deprivationThe researchers than wasmade previously notes immediately available to after researchers their observationi. session, and

then typed these up more fully. • The results emphasise that 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. Additional explanations are required. • This research, in particular the creation of the small area based three-city deprivation measure, has allowed identification of communities in Glasgow which, although almost identical to similar sized areas in Liverpool and Manchester in terms of their socio-economic characteristics, have significantly poorer health outcomes. These will

i Previous analyses were based on the Carstairs & Morris index, a composite measure of deprivation 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: 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. 723

10224_GCPH_Briefing Paper 25.indd 3 10224_GCPH_Briefing06/09/2010 16:52 Paper 25.indd 2 06/09/2010 16:52 FINDINGSFINDINGS SERIESSERIES 252725 BRIEFINGBRIEFING PAPERPAPER

KEYKEYRESULTS FINDINGSFINDINGS

• Observational• ThisThis report report summarises summarises findings a a range range of of analyses analyses undertaken undertaken to to investigate investigate the the so-called so-called ‘Glasgow‘Glasgow‘Glasgow Effect’, Effect’,Effect’, a aa term termterm used usedused in inin recent recentrecent years yearsyears to toto describe describedescribe the thethe higher higherhigher levels levelslevels of ofof mortality mortalitymortality Observationalandand poor poor health health findings experienced experienced are presented in in Glasgow Glasgow first over overeven and andthough above above data that that explained wereexplained gathered by by its itstowards the end of thesocio-economicsocio-economic pilot as they provideprofile. profile. helpful contextual information regarding approaches used in • the• TheimplementationThe aims aims of of the the research research of the BEI were were as to wellto establish establish as a valuable whether whether commentary there there is is evidence evidence on the of of physical such such an an and ‘effect’, ‘effect’, social environmenteveneven when when in comparing comparing and around Glasgow Glasgow the pilot to to its schools.its two two most most similar similar and and comparable comparable UK UK cities: cities: Liverpool Liverpool andand Manchester. Manchester. External school environment • • TheThe analyses analyses were were based based on on the the creation creation of of a a three-city three-city deprivation deprivation index, index, and and the the calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to At thecalculation beginning of aof series the pilot, of standardised it was clear mortalityfrom participant ratios (SMRs) responses for Glasgow that schools relative had to used a spectrumLiverpoolLiverpool of modelsand and Manchester. Manchester. of implementation A A range range of of ofhistorical historical the BEI, census rangingcensus and and from mortality mortality fairly strict data data enforcementwere were also also to encouragementanalysed.analysed. and promotion. Even in schools using more of an ‘enforcement’ approach • at• theTheThe beginning results results showed showed of the that thatpilot, the the there current current was deprivation deprivationlittle evidence profiles profiles towards of of Glasgow, Glasgow, the end Liverpool Liverpoolof the pilot and and of active policingManchesterManchester of school are are gates almost almost by identical. identical. school staff to prevent S1s leaving. For those schools using an • encouragement• DespiteDespite this, this, premature prematureapproach, deaths schooldeaths in instaff Glasgow Glasgow considered for for the the that period period participation 2003-2007 2003-2007 should were were more more be voluntary than than 30% 30% ratherhigherhigher than than than compulsory. in in Liverpool Liverpool and and Manchester, Manchester, with with all all deaths deaths around around 15% 15% higher. higher. • • ThisThis ‘excess’ ‘excess’ mortality mortality was was seen seen across across virtually virtually the the whole whole population: population: all all ages ages (except (except the the Seven schools had a burger and/or ice cream van situated outside the school and these veryvery young), young), both both males males and and females, females, in in deprived deprived and and non-deprived non-deprived neighbourhoods. neighbourhoods. were said to be very popular with pupils, and were all described as selling poor quality food, • such• ForFor as premature prematureburgers, ‘Pot mortality, mortality, Noodles’, SMRs SMRs sweets tended tended and to tofizzy be be higher higherdrinks. for forMost the the schoolsmore more deprived deprived had a large areas areas number of outlets(particularly(particularly(particularly nearby among amongamong catering males), males),males), for theand andand lunchtime around aroundaround a aa half halfhalfmarket, of ofof ‘excess’ ‘excess’‘excess’ many deaths deathsofdeaths which under underunder advertised 65 6565 were werewere specialdirectly directlydirectly lunchtimerelatedrelated dealsto to alcohol alcohol for pupils and and drugs. drugs.which were often more expensive than school meals. In addition, • portion• AnalysesAnalyses sizes of ofwere historical historical much datalargerdata suggest suggest than in it it school.is is unlikely unlikely Many that that of the the these deprivation deprivation outlets wereprofile profile extremely of of Glasgow Glasgow has has popularchangedchanged with significantly significantly pupils, and relativeasrelative a result to to LiverpoollongLiverpool queues and and wereManchester Manchester reported. in in recent Also,recent pupils decades; decades; at times however, however, opted the the to eatmortalitymortality at outlets gap gap at appears appears least 10-15 to to have have minutes widened widened from in in the the last school,last 30 30 years, years,with theindicating indicating result thatthat that thethe the entire‘effect’ ‘effect’ lunch may may breakbebe wasa a relatively relatively taken up recent recent with phenomenon. phenomenon.the journey to and from these outlets, with pupils eating and drinking their purchases on the way back to school. • • TheThe results results emphasise emphasise that that while while deprivation deprivation is is a a fundamental fundamental determinant determinant of of health health and,and, therefore, therefore, an an important important driver driver of of mortality, mortality, it it is is only only one one part part of of a a complex complex picture. picture. Pupil behaviour was noted to be generally good but researchers highlighted road safety AsAs currently currently measured, measured, deprivation deprivation does does not not explain explain the the higher higher levels levels of of mortality mortality as a potential issue of concern. Many pupils were reported as negotiating very busy dual experienced by Glasgow in relation to two very similar UK cities. Additional explanations carriagewaysexperienced and by ignoring Glasgow pelicanin relation crossings to two asvery they similar ran toUK their cities. outlet Additional of choice. explanations This might are required. helpareare explain required. required. the reluctance of senior school staff to maintain an exclusion zone for licensed • vans• ThisThis in certainresearch, research, schools. in in particular particular the the creation creation of of the the small small area area based based three-city three-city deprivation deprivation measure,measure, has has allowed allowed identification identification of of communities communities in in Glasgow Glasgow which, which, although although Internalalmostalmost school identical identical environment to to similar similar sized sized areas areas in in Liverpool Liverpool and and Manchester Manchester in in terms terms of of their their socio-economicsocio-economic characteristics, characteristics, have have significantly significantly poorer poorer health health outcomes. outcomes. These These will will Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Observationnownow be be the the was focus focus largely for for a focusseda second, second, qualitative, onqualitative, school canteens phase phase of of butresearch. research. researchers did also observe lunchtime activities underway.

Canteens were generally bright and spacious with menu choices often displayed clearly on large flat screens. Vending machines and water coolers were present and top-up facilities for swipe cards were situated either inside or just outside canteens. Researchers noted a welcoming atmosphere, with catering staff and other school staff members making efforts to create a relaxed, convivial environment for pupils despite a fairly swift turn over due to limited time. Many catering staff seemed to know pupils by name. Senior members of staff and/or teaching staff supervised at lunchtime, and senior pupils also assisted in one school. 822

10224_GCPH_Briefing10224_GCPH_Briefing Paper Paper 25.indd 25.indd 2 2 06/09/201006/09/2010 16:52 16:52 BRIEFING PAPER 2725 FINDINGS SERIES FINDINGS SERIES 25 BRIEFING PAPER UK cities experience different health outcomes? Investigating a ‘Glasgow Effect’: why do equally deprived Evaluating of the the Impact ‘Big Eat In’ Pilot School Secondary

INTRODUCTION KEY FINDINGS

SomeThe link teachers between who socio-economic were not supervising circumstances ate at andthe Fuelhealth Zone, is well but established. the majority However, appeared • This report summarises a range of analyses undertaken to investigate the so-called tothe eat extent lunch to elsewhere. which the poorIn many health schools, profile the of canteenScotland did – the not nation appear with to bethe large highest enough ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality tomortality enable ratesall pupils and loweston the lifeschool expectancy roll to have in western lunch atEurope the same – can time, be explained particularly in termsduring of a and poor health experienced in Glasgow over and above that explained by its relativelysocio-economic short lunch factors break. is less It clear. was alsoHistorically, apparent Scotland’s that some unenviable canteens position were used in being as a general what socio-economic profile. multi-purposethe press has labelled space. ‘The Sick Man of Europe’ has been attributed almost exclusively to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, relatively high levels of socio-economic deprivation, principally in comparison to England even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool The Fuel Zones were split into a number of areas providing access to particular menu and Wales. However, a number of publications over the past five years have highlighted a and Manchester. choicesphenomenon including speculatively ‘sub’ zones entitled (providing the ‘Scottish baguettes Effect’, etc), a burger term used bars, to ‘bake describe and thetake’ country’s (baked • The analyses were based on the creation of a three-city deprivation index, and the potatoes),higher levels hot of meals morbidity and ‘graband mortality and go’. Soup over and abovefresh fruit that wereexplained also available,by deprivation. with water One calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to andsuch milk analysis to drink. showed Some this schools ‘Scottish had Effect’ queuing to exist rotas in inall operation,geographical with regions different of Scotland years having and Liverpool and Manchester. A range of historical census and mortality data were also priorityat all levels depending of deprivation, on the butday that of the it was week. most In oneevident school in the S1s most were deprived allowed postout of industrial class first analysed. toregion ensure of West they wereCentral first Scotland, in the withqueue. Glasgow Most canteens at the region’s were core.busy Thison the led day to talkof observation. of a Younger‘Glasgow pupilsEffect’, were a notion visible reinforced in large bynumbers other recent although research pupils showing of all ages that appearedmortality into the eat in • The results showed that the current deprivation profiles of Glasgow, Liverpool and canteens.former industrial areas of West Central Scotland was higher, and was improving more slowly, Manchester are almost identical. than in the vast majority of other, similar, post-industrial regions of Europe, including those • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% The most popular menu choices tended to be burgers, pizza and fish and chips. Vending which currently experience worse socio-economic conditions. higher than in Liverpool and Manchester, with all deaths around 15% higher. machines and water coolers did not appear to be used to a large degree. There was some evidence that girls were eating more healthily than boys. Girls seemed to be more likely to • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of add salad to their meal and opt for baked potatoes or vegetables. Pupils generally cleared very young), both males and females, in deprived and non-deprived neighbourhoods. uppoor after health themselves, and deprivation. although Liverpool occasionally and Manchester staff supervising are two would other ask cities them which to do stand so. out in • For premature mortality, SMRs tended to be higher for the more deprived areas this regard, with high levels of poverty and the lowest life expectancy of all cities in England. (particularly among males), and around a half of ‘excess’ deaths under 65 were directly MostThe approach of the schools taken inhad this organised project, therefore, activities atwas lunchtime, to investigate although this ‘Scottish in some Effect’ cases theseor related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, were a feature of normal school based lunchtime activities and clubs rather than being • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have directly related to the BEI. CSG staff, community and voluntary sector workers, school staff changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to and senior pupils were observed helping to run activities. These included: art; drama and mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive music activities; youth clubs; access to library and resource rooms, chill-out zones; basketball; be a relatively recent phenomenon. football,measure etc.of deprivation Attendance than varied, was previouslyand some availableof the normal to researchers lunchtimei. activities involved

different school year groups, although other year groups also appeared to participate in BEI • The results emphasise that while deprivation is a fundamental determinant of health related activities for S1 pupils. All those taking part appeared to be enjoying themselves, and, therefore, an important driver of mortality, it is only one part of a complex picture. and appeared to want the session to go on when it was time to go back to class. Both boys As currently measured, deprivation does not explain the higher levels of mortality and girls took part, although some of the activities were attended by one sex only. experienced by Glasgow in relation to two very similar UK cities. Additional explanations are required. Quantitative findings: school meal uptake • This research, in particular the creation of the small area based three-city deprivation measure, has allowed identification of communities in Glasgow which, although Figures 1 and 2 overleaf show that S1 school meal uptake rates across the eight schools almost identical to similar sized areas in Liverpool and Manchester in terms of their remained consistently higher during the BEI pilot year than during the previous academic socio-economic characteristics, have significantly poorer health outcomes. These will

year although there was a downward trend in uptake as the year progressed. Where why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research. possible, the analysis took account of shorter school weeks due to holidays or ‘in service’ days but some fluctuations in uptake rate are still noticeable, particularly in Figure 1. There was also some individual variation in uptake rates between year groups from school to school – these data are reported elsewhere.

i Previous analyses were based on the Carstairs & Morris index, a composite measure of deprivation 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: 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. 923

10224_GCPH_Briefing Paper 25.indd 3 10224_GCPH_Briefing06/09/2010 16:52 Paper 25.indd 2 06/09/2010 16:52 Younger pupils were visible in large numbers although pupils of all ages appeared to eat in canteens.

The most popular menu choices tended to be burgers, pizza and fish and chips. Vending machines and water coolers did not appear to be used to a large degree. There was some evidence that girls were eating more healthily than boys. Girls seemed to be more likely to add salad to their meal and opt for baked potatoes or vegetables. Pupils generally cleared up after themselves, although occasionally staff supervising would ask them to do so.

Most of the schools had organised activities at lunchtime, although, in some cases, these were a feature of normal school based lunchtime activities and clubs rather than being directly related to the BEI. CSG staff, community and voluntary sector workers, school staff and senior pupils were observed helping to run activities. These included: art; drama and music activities; youth clubs; access to library and resource rooms, chill-out zones; basketball; football, etc. Attendance varied, and some of the normal lunchtime activities involved different school year groups, although other year groups also appeared to participate in BEI related activities for S1 pupils. All those taking part FINDINGSFINDINGSappeared SERIESSERIES to be enjoying 2527themselves,25 BRIEFING BRIEFINGand appeared to want the session PAPERPAPER to go on when it was time to go back to class. Both boys and girls took part, although some of the activities were attended by one sex only.

Quantitative findings: school meal uptake

Figures 1 and 2 below show that S1 school meal uptake rates across the eight schools remained consistently higher during the BEI pilot year than during the previous academic year although there was a downward trend in uptake as the year progressed. Where possible, the analysis took account KEYKEY FINDINGSFINDINGSof shorter school weeks due to holidays or ‘in service’ days but some fluctuations in uptake rate are still noticeable, particularly in Figure 1. There was also some individual variation in uptake rates between year groups from school to school – these data are reported elsewhere. • Figure• ThisThis 1 report report summarises summarises a a range range of of analyses analyses undertaken undertaken to to investigate investigate the the so-called so-called Comparison‘Glasgow‘Glasgow of Effect’, Effect’, S1 Rate a a ofterm term Uptake, used usedFigure 2008/9 1:in in Comparison recent recent and of S1years years2009/10 Rate of Uptake, to to describe (Aggregateddescribe2008/9 and 2009/10 the the datahigher higher from levels levels 8 pilot of of mortality schools)mortality (Aggregated data from 8 pilot schools) andand poor poor 100%health health experienced experienced in in Glasgow Glasgow over over and and above above that that explained explained by by its its S1 2009/10 S1 2008/09 socio-economicsocio-economic90% profile. profile. • • TheThe aims aims of of80% the the research research were were to to establish establish whether whether there there is is evidence evidence of of such such an an ‘effect’, ‘effect’, eveneven when when70% comparing comparing Glasgow Glasgow to to its its two two most most similar similar and and comparable comparable UK UK cities: cities: Liverpool Liverpool andand Manchester. Manchester.60% • • TheThe analyses analyses50% were were based based on on the the creation creation of of a a three-city three-city deprivation deprivation index, index, and and the the calculationcalculation40% of of a a series series of of standardised standardised mortality mortality ratios ratios (SMRs) (SMRs) for for Glasgow Glasgow relative relative to to LiverpoolLiverpool and 30%and Manchester. Manchester. A A range range of of historical historical census census and and mortality mortality data data were were also also Younger pupils were visible in large numbers although pupils of all ages appeared to eat in analysed.analysed.canteens. 20%

10% • • TheThe results resultsThe most showed showed popular thatmenuthat the choicesthe current current tended todeprivation deprivation be burgers, pizza profiles profiles and fish of andof Glasgow, Glasgow,chips. Vending Liverpool Liverpool machines and and ManchesterManchesterand water0% are are coolers almost almost did notidentical. identical. appear to be used to a large degree. There was some evidence that girls were eating more healthily than boys. Girls seemed to be more likely to add salad to their meal and 1_31 Aug2_07 Sep3_14 Sep4_21 Sep5_29 Sep6_05 Oct7_19 Oct8_26 Oct9_02 Nov 17_5 Jan • • DespiteDespiteopt this, this, for baked premature premature potatoes ordeaths deaths vegeta10_09bles. Novin 11_16in Nov12_23Glasgow Glasgow Pupils Nov13_30 Nov14_07 Dec 15_14generally Dec for for18_11 Jan 19_18the thecleared Jan20_25 Jan21_01period period Feb22_08 up Feb23_17 after Feb24_22 2003-2007 Feb2003-200725_01 themselves, Mar26_08 Mar27_15 Mar28_22 Mar29_29 although Mar30_19were were Apr31_26 Apr32_04 more Maymore than than 30% 30% Date higherhigher than occasionally than in in Liverpool Liverpool staff supervising and and Manchester,wouldManchester, ask them towith with do so. all all deaths deaths around around 15% 15% higher. higher. Figure 2 • S1• AverageThisThis ‘excess’ ‘excess’ MostUptake of mortality mortalitythe by schools Term had was(2008/9was organised seen seenFigure and 2:across activitiesacross S1 2009/10)Average virtually virtuallyUptakeat lunchtime, by Term the the(2008/9 although, whole wholeand 2009/10) in population: somepopulation: cases, these all all were ages ages a (except (except the the feature of normal school based lunchtime activities and clubs rather than being directly related to 8 60% Figure 2: S1 Average Uptake by Term (2008/9 and 2009/10) veryvery young), young),the BEI. both both CSG staff,males males community and and females, females, and voluntary in in deprived deprived sector workers, and and school non-deprived non-deprived staff and senior neighbourhoods. neighbourhoods. pupils were observed60% helping to run activities. These included: art; drama and music activities; youth clubs; • • ForFor premature premature mortality, mortality, SMRs SMRs51% tended tended to to be be higher higher for for the the more more deprived deprived areas areas access50% to library and resource rooms, chill-out zones; basketball; football, etc. Attendance varied, 51% (particularly(particularlyand some50% among among of the normal males), males), lunchtime and and around aroundactivities a involveda half half of ofdifferent ‘excess’ ‘excess’ school deaths deaths year groups,S1 under under-2008/09 although 65 65 were were other directly directly S1 -2009/10 year groups also appeared to participate in BEI related activities for S1 S1pupils. -2008/09 All those taking part relatedrelated to to alcohol 40%alcohol and and drugs. drugs. appeared to be enjoying37% themselves, and appeared to want37% the session toS1 -2009/10go on when it was time to 40% 33% • • AnalysesAnalysesgo backof of historical historical to class. 37%Both data data boys suggest andsuggest girls took it it is ispart, unlikely unlikely33% although37% that that some the theof the deprivation deprivation activities were profile attendedprofile byof of oneGlasgow Glasgow has has 33% 29% 33% sex only.30% changed significantly relative to Liverpool and Manchester29% in recent decades; however, the changed significantly30% relative to Liverpool and Manchester in recent decades; however, the mortalitymortality gap gap appears appears to to have have widened widened in in the the last last 30 30 years, years, indicating indicating that that the the ‘effect’ ‘effect’ may may Quantitative20% findings: school meal uptake bebe a a relatively relatively 20% recent recent phenomenon. phenomenon. Figures 1 and 2 below show that S1 school meal uptake rates across the eight schools remained • • TheThe results results10% emphasise emphasise that that while while deprivation deprivation is is a a fundamental fundamental determinant determinant of of health health consistently10% higher during the BEI pilot year than during the previous academic year although there and,and, therefore, therefore,was a downward an an important important trend in uptake driver driver as the of of year mortality, mortality, progressed. it itWhere is is only only possible, one one thepart part analysis of of a a tookcomplex complex account picture.picture. 0% of shorter0% school weeks due to holidays or ‘in service’ days but some fluctuations in uptake rate are AsAs currently currently measured, measured,winter (14 deprivation deprivationweeks) does does not springnot (12 explainweeks)explain the the higher highersummer levels levels (3 weeks) of of mortality mortality still noticeable, particularlywinter (14 weeks) in Figure 1. Therespring (12 wa weeks)s also some individualsummer (3variation weeks) in uptake rates experiencedexperiencedbetween by byyear Glasgow Glasgow groups from in in school relation relation to school to to two –two theseTerm very Termvery Termdata aresimilar similar reported UK UK elsewhere. cities. cities. AdditionalAdditional explanations explanations Figure 3 areare required. required. Combined Rate of Uptake by YearFigure Group, 1: Comparison 8 Pilotof S1 Rate Schools, of Uptake, 2008/9 Aug and 2009/1009 - May 10 FigureFigure 3: 3:Combined Combined Rate Rate of Uptake of Uptake by Year by YearGroup, Gr 8oup, Pilot 8 Schools, Pilot Schools, Aug 09 Aug - May10 09 - May10 • ThisThis research, research, in in particular particular the the creation creation(Aggregated dataof of fromthe the 8 pilot small small schools) area area based based three-city three-city deprivation deprivation • 100%100% S1 S2 S1 S32009/10 S4 S1S5 2008/09S6 measure, has allowed identification of communities in GlasgowS1 S2 which,S3 S4althoughS5 S6 measure, has90% allowed identification of communities in Glasgow which, although 90% almostalmost identical identical to to similar similar sized sized areas areas in in Liverpool Liverpool and and Manchester Manchester in in terms terms of of their their 80% socio-economicsocio-economic80% characteristics, characteristics, have have significantly significantly poorer poorer health health outcomes. outcomes. These These will will 70% 70% Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience nownow be be the the focus focus for for a a second, second, qualitative, qualitative, phase phase of of research. research. 60% 60%

50% 50% 40% 40% 30% 30% 20%

20% 10%

10% 0%

0% 6_05 Oct7_19 Oct8_26 Oct 17_5 Jan 1_311_31 Aug Aug2_072_07 Sep Sep3_143_14 Sep Sep4_214_21 Sep 5_29Sep5_29 Sep Sep6_05 Oct7_19 Oct8_269_02 Oct9_02 Nov Nov 17_518_11 Jan Jan19_18 Jan20_25 Jan 30_19 Apr31_26 Apr 10_0910_09 Nov11_16 Nov11_16 Nov12_23 Nov12_23 Nov13_30 Nov13_30 Nov14_07 Nov14_07 Dec15_14 Dec15_14 Dec Dec 18_11 Jan19_18 Jan20_2521_01 FebJan21_0124_22 FebFeb22_0825_01 FebMar23_1726_08 MarFeb24_2227_15 MarFeb28_2225_01 Mar 29_29Mar26_08 Mar Mar27_15 Mar28_2232_04 Mar29_29 May33_10 Mar30_19 May34_17 Apr31_26 May35_24 Apr32_04 May May Date 1_31 Aug2_07 Sep3_14 Sep4_21 Sep5_29 Sep6_05 Oct7_19 Oct8_26 Oct9_02 Nov 17_5 Jan 10_09 Nov11_16 Nov12_23 Nov13_30 Nov14_07 Dec15_14 Dec 18_11 Jan19_18 Jan20_25 Jan21_01 Feb24_22 Feb25_01 Mar26_08 Mar27_15 Mar28_22 Mar29_29 Mar30_19 Apr31_26 Apr32_04 May33_10 May34_17 May35_24 May 1022 Figure 3 above shows that S1 uptake rates remained consistently higher than all of the other year groups over the course of the pilot. It is interesting to note that S6 uptake rates were second highest Figureuntil the 3 beginningabove shows of May that 2010 S1 uptake when rates rates dropped remained which consistently is possibly higher unsurprising than all given of the that other8 this year groupsyear group over would the course be leaving of the school pilot. at Itthe is end interes of theting summer to note term. that S6 uptake rates were second highest until the beginning of May 2010 when rates dropped which is possibly unsurprising given that this yearOverall, group quantitative would be analysis leaving provides school atclear the evidence end of the that summer implementation term. of the BEI resulted in an 10224_GCPH_Briefing10224_GCPH_Briefing Paper Paper 25.indd 25.indd 2 2 increase in S1 school meal uptake rates in relation to previous years and in relation to other year 06/09/201006/09/2010 16:52 16:52 Overall,groups. quantitative analysis provides clear evidence that implementation of the BEI resulted in an increase in S1 school meal uptake rates in relation to previous years and in relation to other year groups.

9 BRIEFING PAPER 2725 FINDINGS SERIES FINDINGS SERIES 25 BRIEFING PAPER UK cities experience different health outcomes? Investigating a ‘Glasgow Effect’: why do equally deprived Evaluating of the the Impact ‘Big Eat In’ Pilot School Secondary

INTRODUCTION KEY FINDINGS

FigureThe link 3 betweenshows that socio-economic S1 uptake rates circumstances remained consistently and health ishigher well established.than all of the However, other year • This report summarises a range of analyses undertaken to investigate the so-called groupsthe extent over to the which course the ofpoor the health pilot. profileIt is interesting of Scotland to note– the that nation S6 uptakewith the rates highest were second ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality highestmortality until rates the and beginning lowest life of expectancy May 2010 when in western rates Europedropped – canwhich be isexplained possibly in unsurprising terms of and poor health experienced in Glasgow over and above that explained by its givensocio-economic that this year factors group is less would clear. be Historically, leaving school Scotland’s at the unenviableend of the summerposition interm. being what socio-economic profile. the press has labelled ‘The Sick Man of Europe’ has been attributed almost exclusively to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, Overall,relatively quantitative high levels ofanalysis socio-economic provides clear deprivation, evidence principally that implementation in comparison of to the England BEI even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool resulted in an increase in S1 school meal uptake rates in relation to previous years and in and Wales. However, a number of publications over the past five years have highlighted a and Manchester. relationphenomenon to other speculatively year groups. entitled the ‘Scottish Effect’, a term used to describe the country’s • The analyses were based on the creation of a three-city deprivation index, and the higher levels of morbidity and mortality over and above that explained by deprivation. One calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to Qualitativesuch analysis showed Findings this ‘Scottish Effect’ to exist in all geographical regions of Scotland and Liverpool and Manchester. A range of historical census and mortality data were also at all levels of deprivation, but that it was most evident in the most deprived post industrial analysed. Baselineregion of West results 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 • The results showed that the current deprivation profiles of Glasgow, Liverpool and a)former P7 pupil industrial responses areas of (prior West to Central implementation Scotland was of higher, BEI) and was improving more slowly, Manchester are almost identical. than in the vast majority of other, similar, post-industrial regions of Europe, including those • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% P7which respondents currently experienceexpressed mixedworse socio-economicviews regarding conditions. the prospect of participating in the BEI in higher than in Liverpool and Manchester, with all deaths around 15% higher. their respective secondary schools. Some respondents thought that staying in school would • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the enable them to get to know their new school more quickly and that they would be punctual Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of very young), both males and females, in deprived and non-deprived neighbourhoods. for afternoon classes. They also thought that staying within the confines of the school poor health and deprivation. Liverpool and Manchester are two other cities which stand out in • For premature mortality, SMRs tended to be higher for the more deprived areas wouldthis regard, be safer with and high that levels the of food poverty available and the would lowest be better.life expectancy There was of general all cities support in England. and enthusiasm for the healthy menu as the following quotes illustrate: (particularly among males), and around a half of ‘excess’ deaths under 65 were directly The approach taken in this project, therefore, was to investigate this ‘Scottish Effect’ or related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, A healthy school is a happy school ….The toasties are well better up there….And the baguettes • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have an’ that. changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive You get a much, much wider choice o’ the food coz there…You can get a sub if you want as well. be a relatively recent phenomenon. measure of deprivation than was previously available to researchersi.

• The results emphasise that while deprivation is a fundamental determinant of health You can make your own sandwich or you can get something hot. 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 Negative views centred on the lack of freedom in being allowed to leave the school grounds. experienced by Glasgow in relation to two very similar UK cities. Additional explanations This was felt to be unfair, as previous S1 year groups had been allowed out. Some pupils are required. were also disappointed not to be able to visit the vans outside the school gates, although peers pointed out that it would be possible to ask older siblings and friends to bring food • This research, in particular the creation of the small area based three-city deprivation and drinks back in from such outlets. measure, has allowed identification of communities in Glasgow which, although almost identical to similar sized areas in Liverpool and Manchester in terms of their It’s no fair cause like the first years before us they never got kept in an that but in a way like we’re socio-economic characteristics, have significantly poorer health outcomes. These will

going to be fitter than all them but it’s no fair cause they’re going oot and they’re getting what why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research. they like an that and then some people might no like it from the Fuel Zone.

i Previous analyses were based on the Carstairs & Morris index, a composite measure of deprivation 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: 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. 1123

10224_GCPH_Briefing Paper 25.indd 3 10224_GCPH_Briefing06/09/2010 16:52 Paper 25.indd 2 06/09/2010 16:52 FINDINGSFINDINGS SERIESSERIES 252725 BRIEFINGBRIEFING PAPERPAPER

KEYKEY FINDINGSFINDINGS

• b)• S1ThisThis pupil report report responses summarises summarises (at a baseline)a range range of of analyses analyses undertaken undertaken to to investigate investigate the the so-called so-called ‘Glasgow‘Glasgow Effect’, Effect’, a a term term used used in in recent recent years years to to describe describe the the higher higher levels levels of of mortality mortality Overall,andand poorthepoor BEI health health was experienced generallyexperienced very in in Glasgow wellGlasgow received over over and byand pupils above above at that that the explained explainedbeginning by by of its its the pilot andsocio-economic socio-economicthere did not appear profile. profile. to be an increase in the number of packed lunches being taken • into• The Theschool aims aims as of of a the theresult research research of the were wereinitiative. to to establish establish Healthy whether whether eating, theretakingthere is is partevidence evidence in physical of of such such activity an an ‘effect’, ‘effect’, at lunchtimeeveneven when when and comparing comparingsafety were Glasgow Glasgow highlighted to to its its astwo two important most most similar similar benefits and and comparable comparable by pupils. UK UK cities: cities: Liverpool Liverpool andand Manchester. Manchester. Because you get…the kids into activities and if you do it one week then you get to go and do it • the• ThenextThe analyses week,analyses and were were then based based the next on on the week,the creation creation so…its of of like a a three-city three-cityyou have gotdeprivation deprivation a wee plan index, index, of what and and the youthe want to do...calculationcalculation of of a a series series of of standardised standardised mortality mortality ratios ratios (SMRs) (SMRs) for for Glasgow Glasgow relative relative to to JustLiverpool Liverpoolso they can and and eat Manchester. Manchester. healthier food A A range range instead of of historical ofhistorical always census eatingcensus and likeand chips,mortality mortality curries, data data and were were noodles also also and all that.analysed.analysed. • • TheThe results results showed showed that that the the current current deprivation deprivation profiles profiles of of Glasgow, Glasgow, Liverpool Liverpool and and BasicallyManchesterManchester it’s just are arefor almost almostyour health… identical. identical. the Big Eat In, because it’s helping you stay fit and healthy, • but• Despite thenDespite its this, this,also premature helpingpremature you deaths deaths keep in insafe Glasgow Glasgow as well for for so… the the period period 2003-2007 2003-2007 were were more more than than 30% 30% higherhigher than than in in Liverpool Liverpool and and Manchester, Manchester, with with all all deaths deaths around around 15% 15% higher. higher. Not all pupil respondents liked the lunchtime menu observing that food served in the This ‘excess’ mortality was seen across virtually the whole population: all ages (except the • canteen• This ‘excess’ could be mortality bland and was tasteless, seen across and virtually that although the whole there population: were a number all ages of (except options the available,veryvery young), young), these both didboth not males males tend and and to females, varyfemales, much. in in deprived deprived As one focus and and non-deprived non-deprived group commented: neighbourhoods. neighbourhoods. • • ForFor premature premature mortality, mortality, SMRs SMRs tended tended to to be be higher higher for for the the more more deprived deprived areas areas Don’t(particularly(particularly know…. Dinnae among among like males), males), them…..Coz and and around around the a taste...a half half of ofThought ‘excess’ ‘excess’ they deaths deaths were under under manky…Because 65 65 were were directly directly it’s alwaysrelatedrelated healthy to to alcohol alcohol and it’s and andthe drugs. samedrugs. menu all like over and over…And it gets pure boring coz like • it’s• alwaysAnalysesAnalyses salad of of historical historicalan’ healthy data data stuff…And suggest suggest it iteven is is unlikely unlikely if you don’t that that thelikethe deprivation anythingdeprivation else, profile profile you have of of Glasgow Glasgow to get that has has everychangedchanged single daysignificantly significantly coz you don’t relative relative like to anythingto Liverpool Liverpool else. and and Manchester Manchester in in recent recent decades; decades; however, however, the the mortalitymortality gap gap appears appears to to have have widened widened in in the the last last 30 30 years, years, indicating indicating that that the the ‘effect’ ‘effect’ may may Pupils’bebe aviewsa relatively relatively about recent recent the amount phenomenon. phenomenon. of information received varied; some stated that they had been given sufficient information but others claimed that the information provided had not The results emphasise that while deprivation is a fundamental determinant of health • been• The clear. results Some emphasise pupils reported that while that deprivation they were is not a fundamental given any information determinant by of their health primary school,and,and, and therefore, therefore, they did an an notimportant important know that driver driver the of of BEI mortality, mortality, would continueit it is is only only one toone operate part part of of aftera a complex complex the first picture. picture. couple of weeksAsAs currently currently of S1. measured, measured, deprivation deprivation does does not not explain explain the the higher higher levels levels of of mortality mortality experiencedexperienced by by Glasgow Glasgow in in relation relation to to two two very very similar similar UK UK cities. cities. Additional Additional explanations explanations Em arewhenare required. required. we came we didn’t think that it was going to be the full year, we thought it was just • going• ThisThis to research, beresearch, a couple in in particular ofparticular weeks, theythe the creation didn’tcreation really of of the the explain small small that area area to based based you. three-city three-city deprivation deprivation measure,measure, has has allowed allowed identification identification of of communities communities in in Glasgow Glasgow which, which, although although c) Schoolalmostalmost staffidentical identical responses to to similar similar (at sized sizedbaseline) areas areas in in Liverpool Liverpool and and Manchester Manchester in in terms terms of of their their socio-economicsocio-economic characteristics, characteristics, have have significantly significantly poorer poorer health health outcomes. outcomes. These These will will Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience As withnownow pupils,be be the the manyfocus focus for stafffor a a respondentssecond, second, qualitative, qualitative, were positivephase phase of of regarding research. research. the quality of food in school canteens at lunchtime.

I think there’s a fabulous quality, I think there’s always improvements that can be made and I think they’ve been made over a couple of years, certainly my experience of working in another Glasgow school is that it’s constantly reviewed,… and I think you know my observations of downstairs for the Fuel Zone is that you know they’re meeting all the requirements that they have to meet and there’s a huge range of healthy options that children have.

1222

INTRODUCTION KEY FINDINGS

DifferentThe link between models socio-economicof implementation circumstances were used inand the health eight is participating well established. schools. However, Some • This report summarises a range of analyses undertaken to investigate the so-called schoolthe extent staff to members which the felt poor that health it had profile to be madeof Scotland clear to– theS1 pupils nation that with they the highestwere not ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality allowedmortality outside rates and the lowest school life at expectancyall at lunchtime, in western and the Europe gates – were can be actively explained monitored, in terms of and poor health experienced in Glasgow over and above that explained by its whereassocio-economic others arguedfactors thatis less the clear. pupils Historically, should be Scotland’s encouraged unenviable to stay positionin the school in being by what socio-economic profile. makingthe press the has lunchtime labelled ‘The experience Sick Man as of pleasurable Europe’ has asbeen possible attributed rather almost than usingexclusively enforcement to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, measures.relatively high levels of socio-economic deprivation, principally in comparison to England even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool and Wales. However, a number of publications over the past five years have highlighted a and Manchester. Lunchtimephenomenon activities speculatively were run entitled by school the ‘Scottish staff, CSG Effect’, staff, avolunteers term used andto describe pupils. Resourcingthe country’s • The analyses were based on the creation of a three-city deprivation index, and the schoolhigher levelslunchtime of morbidity activities and was mortality seen as overproblematic and above by that some explained school staff by deprivation. and, in some One calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to schools,such analysis there showed were clear this differences‘Scottish Effect’ in expectations to exist in all between geographical school regions staff andof Scotland CSG staff and Liverpool and Manchester. A range of historical census and mortality data were also regardingat all levels the of deprivation,role of CSG inbut providing that it was resources most evident and input. in the However,most deprived a wide post spectrum industrial analysed. ofregion activities of West was Central offered Scotland, in participating with Glasgow schools, at theranging region’s from core. physical This led activity to talk (sports, of a aerobics,‘Glasgow etc)Effect’, to arta notion classes, reinforced library and by otherICT. recent research showing that mortality in the • The results showed that the current deprivation profiles of Glasgow, Liverpool and former industrial areas of West Central Scotland was higher, and was improving more slowly, Manchester are almost identical. At the moment we have got…basketball, dodgeball, badminton, football, and fitness so that’s than in the vast majority of other, similar, post-industrial regions of Europe, including those • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% like our five lunchtimes. There is one of them each lunchtime and we are going to add in which currently experience worse socio-economic conditions. higher than in Liverpool and Manchester, with all deaths around 15% higher. gymnastics, and a kind of fitness DVD type thing, a more aerobics type thing so there will be two things on a couple of days. • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of very young), both males and females, in deprived and non-deprived neighbourhoods. Negativepoor health views and expresseddeprivation. by Liverpool some staff and regarding Manchester lunchtime are two activities other cities (apart which from stand out in • For premature mortality, SMRs tended to be higher for the more deprived areas resourcethis regard, issues) with highwere levels that theof poverty school lunchand the break lowest was life sometimes expectancy perceived of all cities as tooin England. short (particularly among males), and around a half of ‘excess’ deaths under 65 were directly toThe accommodate approach taken the in consumption this project, therefore, of a school was meal to investigate and participation this ‘Scottish in an Effect’activity, or the related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, school lacked sufficient space to carry out activities (and there could be overlap between • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have the eating area and main social space) and pupils were sometimes late for afternoon classes changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to if an activity overran. However other respondents took the opposite view proposing that mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive pupils tended to be punctual for afternoon classes (and arguably more relaxed) as they had be a relatively recent phenomenon. notmeasure left school of deprivation during a than relatively was previously short lunch available break. to researchersi.

• The results emphasise that while deprivation is a fundamental determinant of health Other positive impacts of the BEI that were reported at baseline by staff respondents and, therefore, an important driver of mortality, it is only one part of a complex picture. included the development of a more social, relaxed environment in the school canteen As currently measured, deprivation does not explain the higher levels of mortality (in one of the pilot schools in particular), and a view that catering staff would remain in experienced by Glasgow in relation to two very similar UK cities. Additional explanations employment if the perceived increase in school meal uptake was maintained. are required. • This research, in particular the creation of the small area based three-city deprivation Negative impacts of the BEI at baseline included a perceived lack of resources resulting in measure, has allowed identification of communities in Glasgow which, although school staff losing time off during lunchtime if they helped with any aspect of the pilot, and almost identical to similar sized areas in Liverpool and Manchester in terms of their a concomitant inability to have monitors placed on the school gates. Pupils who ate outside socio-economic characteristics, have significantly poorer health outcomes. These will

school from vans and local shops were thought to eat almost exclusively unhealthy options, why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research. with ‘Pot Noodles’, chips and curry sauce, burgers and fizzy drinks mentioned as favourite lunchtime choices. As one respondent commented:

Oh, the quality o’ food’s terrible. Really, really bad. It’s a van that provides hot rolls, but he’s not got facilities for hot rolls. He makes them in the house and brings them up. I don’t know how he keeps them warm. And there’s no handwashing facilities or... so he’s takin’ money an’ servin’ food. I’vei Previous been analyseson to Environmental were based on the Health, Carstairs and& Morris so has…index, a thecomposite Head measure Teacher... of deprivation but they’re calculated still there. 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: 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. 1323

10224_GCPH_Briefing Paper 25.indd 3 10224_GCPH_Briefing06/09/2010 16:52 Paper 25.indd 2 06/09/2010 16:52 FINDINGSFINDINGS SERIESSERIES 252725 BRIEFINGBRIEFING PAPERPAPER

KEYKEY FINDINGSFINDINGS

• Follow• ThisThis report report Up Resultssummarises summarises a a range range of of analyses analyses undertaken undertaken to to investigate investigate the the so-called so-called ‘Glasgow‘Glasgow Effect’, Effect’, a a term term used used in in recent recent years years to to describe describe the the higher higher levels levels of of mortality mortality a) S1andand pupil poor poor responses health health experienced experienced in in Glasgow Glasgow over over and and above above that that explained explained by by its its socio-economicsocio-economic profile. profile. • The• The Themajority aims aims of of thepupilsthe research research remained were were positiveto to establish establish about whether whether the BEI there there towards is is evidence evidence the end of of of such such the an pilot.an ‘effect’, ‘effect’, Some respondentseveneven when when thought comparing comparing they Glasgow Glasgow would haveto to its its left two two school most most similaratsimilar lunchtime and and comparable comparable if the BEI hadUK UK cities: cities:not been Liverpool Liverpool operating.andand Manchester. Manchester. There were a few examples of pupils trying school lunches and being won over as the following response illustrates: • • TheThe analyses analyses were were based based on on the the creation creation of of a a three-city three-city deprivation deprivation index, index, and and the the calculationcalculation of of a a series series of of standardised standardised mortality mortality ratios ratios (SMRs) (SMRs) for for Glasgow Glasgow relative relative to to One of my friends was always bringing a packed lunch because they didn’t really like the school LiverpoolLiverpool and and Manchester. Manchester. A A range range of of historical historical census census and and mortality mortality data data were were also also dinners in primary, and they didn’t really try anything, then they came up to secondary and they analysed. realisedanalysed. that some of the stuff was really quite nice. And now that’s got them trying new foods… • • TheThe results results showed showed that that the the current current deprivation deprivation profiles profiles of of Glasgow, Glasgow, Liverpool Liverpool and and ThereManchesterManchester were mixed are are opinionsalmost almost identical. identical. on what the pupils would have done if the BEI had not been run • in• theirDespiteDespite schools. this, this, premature Somepremature pupils deaths deaths said theyin in Glasgow Glasgow would for forhave the the stayed period period in 2003-2007 2003-2007 to have school were were more lunches,more than than some 30% 30% wouldhigherhigher have than than gone in in Liverpool Liverpoolout occasionally, and and Manchester, Manchester, and some with with would all all deaths deathshave brought around around 15% 15%in packed higher. higher. lunches. • • ThisThis ‘excess’ ‘excess’ mortality mortality was was seen seen across across virtually virtually the the whole whole population: population: all all ages ages (except (except the the Most of the pupils praised school lunches for the choice of food on offer. Pupils enjoyed veryvery young), young), both both males males and and females, females, in in deprived deprived and and non-deprived non-deprived neighbourhoods. neighbourhoods. a good selection and were able to pick what food they wanted, with the option to add • additional• ForFor premature premature salad or mortality, mortality, vegetables SMRs SMRs to theirtended tended meal. to to be beOthers higher higher liked for for the thatthe more more the fact deprived deprived that the areas areas menu changed(particularly(particularly daily, which among among meant males), males), they and and were around around less a a halflikely half of of to ‘excess’ ‘excess’ get bored deaths deaths with under under the food65 65 were were on directly offer.directly relatedrelated to to alcohol alcohol and and drugs. drugs. • I• thoughtAnalysesAnalyses the of reallyof historical historical good pointdata data suggestwassuggest like it whenit is is unlikely unlikely you go that that for something,the the deprivation deprivation like you profile profile thought of of Glasgow Glasgow “Wait. I’mhas has a bitchangedchanged hungrier”, significantly significantly and then there relative relative was to tolike Liverpool Liverpool the salad. and and You Manchester Manchester could get beetrootin in recent recent an’ decades; decades; all that, however, however,like so you the the couldmortalitymortality just go theregap gap appears appearsand take... to to havelikehave think widened widened that in thatin the the could last last 30dae30 years, years, me. Likeindicating indicating just take that that your the the plate ‘effect’ ‘effect’ up. may mayBut I thoughtbebe a a relativelythatrelatively was reallyrecent recent good phenomenon. phenomenon. that there was mare to take. • • TheThe results results emphasise emphasise that that while while deprivation deprivation is is a a fundamental fundamental determinant determinant of of health health In addition, school meals were viewed as being good value for money (average price was and,and, therefore, therefore, an an important important driver driver of of mortality, mortality, it it is is only only one one part part of of a a complex complex picture. picture. £1.15), of quite good quality, and healthy. It was noted that there was very little if any salt AsAs currently currently measured, measured, deprivation deprivation does does not not explain explain the the higher higher levels levels of of mortality mortality or sugar in the food with healthy options such as salad, baked potatoes and fruit with milk experiencedexperienced by by Glasgow Glasgow in in relation relation to to two two very very similar similar UK UK cities. cities. Additional Additional explanations explanations or water to drink. The food on offer encouraged pupils, who might otherwise have eaten areare required. required. outside school, to buy lunch from the Fuel Zone. • • ThisThis research, research, in in particular particular the the creation creation of of the the small small area area based based three-city three-city deprivation deprivation Becausemeasure,measure, like ahas has lot allowedofallowed the stuff’s identification identification like freshly of of made communities communities so like you in in know Glasgow Glasgow what’s which, which, going although although into it and there’s no anythingalmostalmost identical identical like extra to to salt similar similar or that sized sized in it…areas areas in in Liverpool Liverpool and and Manchester Manchester in in terms terms of of their their socio-economicsocio-economic characteristics, characteristics, have have significantly significantly poorer poorer health health outcomes. outcomes. These These will will Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience It’s goodnownow becausebe the the likefocus focus basically for for a a second, second, everything’s qualitative, qualitative, gone by phase phase break of of time…And research. research. it’s like encouraging us to eat more healthily

Lunchtime activities were considered to be one of the best aspects of the BEI as they gave the pupils something to do with their friends at lunchtime. There was also a good selection of activities available at most schools that were well attended, and that those attending appeared to enjoy greatly. The following quotes illustrates one focus group’s opinion on the best aspects of the BEI:

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INTRODUCTION KEY FINDINGS

The…you link get between to have socio-economic a laugh and all that circumstances and you don’t and need health to isjust well go established.outside in the However, cold, you can • This report summarises a range of analyses undertaken to investigate the so-called actuallythe extent do to something which the at poor lunchtime. health profile of Scotland – the nation with the highest ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality mortality rates and lowest life expectancy in western Europe – can be explained in terms of and poor health experienced in Glasgow over and above that explained by its Yousocio-economic get to choose factors what you is less want clear. to do. Historically, You can go Scotland’s up to the unenviable library, you position can go into in being the gym what socio-economic profile. hall,the press you can has play labelled badminton ‘The Sick on Man a Monday of Europe’ and allhas that. been attributed almost exclusively to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, relatively high levels of socio-economic deprivation, principally in comparison to England even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool Pupils acknowledged that there were positive effects of staying in school. Many pupils and Wales. However, a number of publications over the past five years have highlighted a and Manchester. seemedphenomenon to become speculatively accustomed entitled to thestaying ‘Scottish in school Effect’, over a term the courseused to of describe the BEI theand country’s felt that • The analyses were based on the creation of a three-city deprivation index, and the theyhigher did levels not ofhave morbidity to go out and if theymortality did not over want and to.above It was that also explained added thatby deprivation. it made it easier One to calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to avoidsuch analysis peer pressure, showed and this also‘Scottish possibly Effect’ made to exist bullying in all and geographical teasing of regions those whoof Scotland wanted and to Liverpool and Manchester. A range of historical census and mortality data were also remainat all levels within of deprivation,school less likely.but that it was most evident in the most deprived post industrial analysed. region of West Central Scotland, with Glasgow at the region’s core. This led to talk of a b)‘Glasgow School Effect’, staff and a notion collaborators’ reinforced responsesby other recent research showing that mortality in the • The results showed that the current deprivation profiles of Glasgow, Liverpool and former industrial areas of West Central Scotland was higher, and was improving more slowly, Manchester are almost identical. Staff respondents reported that there had been many positive impacts of the BEI than in the vast majority of other, similar, post-industrial regions of Europe, including those • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% throughout the pilot year. They cited the improved safety offered by the pilot, as well as which currently experience worse socio-economic conditions. higher than in Liverpool and Manchester, with all deaths around 15% higher. the fact that it reduced the opportunity for lateness and truancy, and allowed the S1s to socialise more. It was also said to allow teachers to engage with pupils more, and monitor • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of the S1 pupils perceived as being most vulnerable. The majority view over the pilot year was very young), both males and females, in deprived and non-deprived neighbourhoods. thatpoor the health uptake and ofdeprivation. school meals Liverpool had increased; and Manchester and more are S1stwo in other particular cities whichhad been stand eating out in • For premature mortality, SMRs tended to be higher for the more deprived areas inthis the regard, canteen with than high in levels previous of poverty years. andIt was the also lowest said, life though, expectancy that it ofwas all difficult cities in England.to gauge (particularly among males), and around a half of ‘excess’ deaths under 65 were directly uptakeThe approach accurately taken as in pupils this project, often shared therefore, their was swipe to investigate cards. However, this ‘Scottish uptake Effect’ of school or meals related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, was seen to vary from day to day depending on what was on the menu. • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have Nevertheless, the pupils eating within school were said to be having a nutritious meal, of changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to good quality. Also, catering staff were said to change the menu as a result of pupil feedback mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive and this, allied with encouragement of staff, was thought to promote use of the canteen. be a relatively recent phenomenon. measure of deprivation than was previously available to researchersi.

..So even if we’re not managing to get them all going to the Fuel Zone, some of them are bringing • The results emphasise that while deprivation is a fundamental determinant of health packed lunches and so on but the message about nutrition, value et cetera is, its across, its and, therefore, an important driver of mortality, it is only one part of a complex picture. getting across. And yes I would think the more pupils are going to the Fuel Zone than would have As currently measured, deprivation does not explain the higher levels of mortality gone under normal circumstances. experienced by Glasgow in relation to two very similar UK cities. Additional explanations are required. The lunchtime activities in the majority of pilot schools were reported as being very • This research, in particular the creation of the small area based three-city deprivation popular and well attended. Overall, improvements in links with CSG had been noted as measure, has allowed identification of communities in Glasgow which, although the pilot progressed. In many of the schools, activities were run with the help of school almost identical to similar sized areas in Liverpool and Manchester in terms of their staff members. It was pointed out that many staff members were happy to give up their socio-economic characteristics, have significantly poorer health outcomes. These will

lunchtime as the pupils enjoyed the activities. Indeed, in one school, about 10 members why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research. of staff were involved in running activities. Schools had also forged links with volunteers and trainers working in the community, as well as allowing senior pupils to help facilitate sessions. As a result of these other growing collaborations, it was thought more likely that the activities would become sustainable over time.

So we’re finding that the children are really quite enthusiastic about the activities, too enthusiastic.i Previous analyses We were can’t based meet on thethe Carstairsdemand & Morrisin some index, cases, a composite so we’ve measure started of deprivation these rotas, calculated but they from reallycensus quite data. committedThis measure isto now coming out of datealong. (the most recent data being for 2001), but crucially was also calculated for different-sized geographies north and south of the border: 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. 1523

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KEYKEY FINDINGSFINDINGS

• CSG• ThisThis respondents report report summarises summarises gave examples a a range range ofof of a analyses analyseswide range undertaken undertaken of activities to to investigate investigate which they the the considered so-called so-called were enjoyed‘Glasgow‘Glasgow by pupils Effect’, Effect’, across a a term term most used used of in in the recent recent pilot years years schools. to to describe describe These lunchtime the the higher higher sessionslevels levels of of weremortality mortality run by CSGandand staff, poor poor volunteers, health health experienced experienced paid coaches, in in Glasgow Glasgowschool staff over over and and and senior above above pupils.that that explained explained Activities by by ranged its its from dramasocio-economicsocio-economic classes, ‘Wii’ sports, profile. profile. relaxation classes/chill-out zones, football, basketball, play pods, • playground• TheThe aims aims equipment,of of the the research research library were were sessions, to to establish establish IT clubs, whether whether etc. In there there many is is casesevidence evidence these of of hadsuch such been an an ‘effect’, ‘effect’, well attendedeveneven when when by S1 comparing comparing boys and Glasgow girlsGlasgow over to tothe its its course two two most most of a similar similarnumber and and of comparable comparableweeks, and UK occasionallyUK cities: cities: Liverpool Liverpool they had been extended to pupils in other secondary years as they had generated a great deal andand Manchester. Manchester. of interest. • • TheThe analyses analyses were were based based on on the the creation creation of of a a three-city three-city deprivation deprivation index, index, and and the the A minoritycalculationcalculation of school of of a a series series staff of respondentsof standardised standardised thought mortality mortality that ratios ratios numbers (SMRs) (SMRs) attending for for Glasgow Glasgow the relative canteenrelative to to had decreasedLiverpoolLiverpool over and and the Manchester. Manchester. course of theA A range range school of of historical year,historical as visiting census census outlets and and mortality mortality outside data dataschool were were and also also the consumptionanalysed.analysed. of packed lunches had become more common. In addition, it was claimed that • takings• TheThe results wereresults down showed showed within that that a the thefew current current schools deprivation deprivation as a result profiles profilesof this trend,of of Glasgow, Glasgow, as well Liverpool Liverpool as the decreased and and popularityManchesterManchester among are are pupilsalmost almost of identical. identical. vending machines due to the predominantly healthy food that • was• Despite Despiteon offer. this, this, The premature premature consensus, deaths deaths even ininin GlasgowschoolsGlasgow infor for which the the period period pupils 2003-2007 2003-2007 taking lunches were were more wasmore perceived than than 30% 30% to havehigherhigher increased, than than in in Liverpool Liverpoolwas that andlargerand Manchester, Manchester, numbers ofwith with S1s all all were deaths deaths buying around around lunch 15% 15% outside higher. higher. school as the pilot progressed. Disappointment was expressed as a result of this as efforts had been made This ‘excess’ mortality was seen across virtually the whole population: all ages (except the • to• encourageThis ‘excess’ S1s mortality to stay inwas school seen acrossand also virtually to promote the whole activities population: and an all environment ages (except that the wasvery veryappealing young), young), to both both pupils. males males However, and and females, females, schools’ in in deprived lunchtimedeprived and and restriction non-deprived non-deprived policies neighbourhoods. neighbourhoods. tended to become • more• ForFor lax premature premature as the pilot mortality, mortality, progressed SMRs SMRs through tended tended to theto be be academic higher higher for for year. the the more more deprived deprived areas areas (particularly(particularly among among males), males), and and around around a a half half of of ‘excess’ ‘excess’ deaths deaths under under 65 65 were were directly directly In somerelatedrelated schools, to to alcohol alcohol the canteen and and drugs. drugs. and lunchtime environment were felt to be off-putting for • pupils.• AnalysesAnalyses Queues, of of historicallackhistorical of time data data and suggest suggest space, it it lackis is unlikely unlikely of seating, that that thedecreased the deprivation deprivation food profile profilechoice of offor Glasgow Glasgow those has has towardschangedchanged the significantlyendsignificantly of queues relative relative and increasedto to Liverpool Liverpool number and and Manchester Manchester of younger in in pupils recent recent displacing decades; decades; however, however,older pupils the the weremortalitymortality all thought gap gap toappears appears reduce to to school have have widened widened meal uptake, in in the the aslast last indeed 30 30 years, years, was indicating indicating the fact thatthat that notthe the all‘effect’ ‘effect’ pupils may may likedbebe the a a relatively relatively food on recent offer.recent A phenomenon. phenomenon.few catering staff respondents said that supervision could be a problem during lunchtime. • • TheThe results results emphasise emphasise that that while while deprivation deprivation is is a a fundamental fundamental determinant determinant of of health health Theand, and,catering therefore, therefore, staff membersan an important important felt driverthatdriver they of of mortality, mortality, were not it italways is is only only able one one topart part provide of of a a complex complex the types picture. picture. of foodAsAs that currently currently the pupils measured, measured, wanted, deprivation deprivation due to nutritional does does not not explain regulations.explain the the higher higherThis could levels levels result of of mortality mortality in some pupils bringingexperiencedexperienced in their by byown Glasgow Glasgow cans of in in juice relation relation from to to the two two van very very because similar similar UK theyUK cities. cities. did not Additional Additional like the explanationsjuiceexplanations the schoolareare required. supplied,required. or ‘voting with their feet’ as they found the school food to be bland with • lower• ThisThis fat, research, research, salt and in insugar particular particular content. the the Somecreation creation catering of of the the staffsmall small felt area area that based based the three-cityattemptsthree-city todeprivation deprivation mimic the fast foodmeasure,measure, on offer has hasoutside allowed allowed the identification identificationschool did not of of alwayscommunities communities work, andin in Glasgow Glasgow that the which, which, quality although although of food was also dependentalmostalmost identical identicalto some to toextent similar similar on sized sized those areas areas supplying in in Liverpool Liverpool it. and and Manchester Manchester in in terms terms of of their their socio-economicsocio-economic characteristics, characteristics, have have significantly significantly poorer poorer health health outcomes. outcomes. These These will will Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience …wenownow do bedobe theburgers.the focus focus They’re for for a a second, second,healthy qualitative, qualitative,burgers, but phase phase they’re of of thatresearch. research. healthy they’re horrible! I mean, you know, you’ve taken everything out of them. There’s no fat in them…

I think the quality… depending on the supplier as well, you know? Some… sometimes it’s good, and other times it’s not. … you’ve to monitor it all the time, you know what I mean?

Catering staff reported that external food outlets, including vans, in close proximity to the school gates undermined the pilot. As was reported at baseline by school staff respondents, the consensus was that pupils who ate outside school almost always chose the unhealthy options. 1622

INTRODUCTION KEY FINDINGS

…They’reThe link between going out socio-economic to buy burgers circumstancesor they’re going and out health to buy is those well noodlesestablished. which However, are • This report summarises a range of analyses undertaken to investigate the so-called absolutelythe extent horrible.to which the poor health profile of Scotland – the nation with the highest ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality mortality rates and lowest life expectancy in western Europe – can be explained in terms of and poor health experienced in Glasgow over and above that explained by its …theysocio-economic would still factors rather isgo less to the clear. van Historically, and buy a creamScotland’s bun. unenviable And the amount position o’ sweets in being they what buy socio-economic profile. isthe unbelievable. press has labelled The amount ‘The Sick o’ rubbish Man of we Europe’ clean hasup… been That’s attributed all you see almost in this exclusively school, is bottlesto its o’ • The aims of the research were to establish whether there is evidence of such an ‘effect’, Irnrelatively Bru, because high levels they’re of buyingsocio-economic it off the van deprivation, first thing principally in the morning, in comparison and that’s to all England we clean up. even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool and Wales. However, a number of publications over the past five years have highlighted a and Manchester. c)phenomenon Parent/carer speculatively responses entitled the ‘Scottish Effect’, a term used to describe the country’s • The analyses were based on the creation of a three-city deprivation index, and the higher levels of morbidity and mortality over and above that explained by deprivation. One calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to Parents/carerssuch analysis showed were generally this ‘Scottish very Effect’ positive to aboutexist in the all BEI,geographical particularly regions in relation of Scotland to pupil and Liverpool and Manchester. A range of historical census and mortality data were also safety.at all levels Many of felt deprivation, that S1 pupils but that were it wastoo youngmost evident to be outside in the most school deprived at lunchtime post industrial and were analysed. concernedregion of West about Central the risk Scotland, of injury with from Glasgow road traffic, at the region’sgetting core.into fightsThis led and to talkstranger of a danger. The‘Glasgow knowledge Effect’, thata notion their reinforced child was byin schoolother recent at lunchtime research reassured showing thatthem. mortality They also in the • The results showed that the current deprivation profiles of Glasgow, Liverpool and regardedformer industrial the BEI areasas providing of West anCentral opportunity Scotland for was pupils higher, to andsocialise was improving and make more friends slowly, in a Manchester are almost identical. safe, structured environment. As one parent said: than in the vast majority of other, similar, post-industrial regions of Europe, including those • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% which currently experience worse socio-economic conditions. higher than in Liverpool and Manchester, with all deaths around 15% higher. Well I know exactly where my daughter is at lunchtime……I’m not kind of left wondering ‘oh is she at the shops or has she went to a friend’s house’ or whatever…So from a parent’s point of • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of view it’s peace of mind….. very young), both males and females, in deprived and non-deprived neighbourhoods. poor health and deprivation. Liverpool and Manchester are two other cities which stand out in • For premature mortality, SMRs tended to be higher for the more deprived areas Athis small regard, number with highof parents levels ofalso poverty commented and the that lowest the lifeBEI expectancyreduced peer of pressureall cities into England.leave (particularly among males), and around a half of ‘excess’ deaths under 65 were directly schoolThe approach at lunchtime. taken in this project, therefore, was to investigate this ‘Scottish Effect’ or related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have …I know that X wanted to stay in at lunchtime anyway but maybe some of her other friends changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to might have been going out but the fact that the teachers are encouraging them to stay in it’s mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive kind of taken the emphasis off her, she’s kind of able to say ‘well the teachers would prefer us to be a relatively recent phenomenon. staymeasure in so of this deprivation is just what than I’m goingwas previously to do.’ So availableit’s kind of to taking researchers a weei .bit of the pressure off her.

• The results emphasise that while deprivation is a fundamental determinant of health Many parents did not have much knowledge of what food was on offer at lunchtime; and, therefore, an important driver of mortality, it is only one part of a complex picture. however, those that were aware generally praised the food on offer and considered it to As currently measured, deprivation does not explain the higher levels of mortality be good value for money. It was felt that there was a good choice and that the meals were experienced by Glasgow in relation to two very similar UK cities. Additional explanations healthy. It was also reported that the BEI was creating greater awareness amongst young are required. people of the importance of eating a healthier diet. Furthermore, the activities were viewed • This research, in particular the creation of the small area based three-city deprivation very positively by parents as they were said to give pupils a chance to try out something measure, has allowed identification of communities in Glasgow which, although new while meeting other pupils. almost identical to similar sized areas in Liverpool and Manchester in terms of their socio-economic characteristics, have significantly poorer health outcomes. These will

.. it’s an opportunity... to maybe speak to people that’s not in their class. You know? ... They why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research. maybe find that they go to play football and they’ve seen somebody in the football... and that’s, again, a social aspect I think more than anything else.

A minority of parents were less positive about the food, voicing concerns about the appropriateness of the lunchtime menu even though it was recognised as good value for money. For example, it was said that the food was almost too healthy and therefore alienatedi Previous analyses pupils were if they based were on the not Carstairs used & Morristo foods index, low a composite in fat, sugar measure and of deprivation salt. Some calculated parents 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: 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. 1723

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KEYKEY FINDINGSFINDINGS

• thought• ThisThis report reportthat there summarises summarises was not a a enoughrange range of of variationanalyses analyses undertaken inundertaken menu choices to to investigate investigate and that the thetheir so-called so-called children quickly‘Glasgow‘Glasgow got bored Effect’, Effect’, of a athe term term food used used on in in offer. recent recent Queuing years years to to and describe describe lack of the the availability higher higher levels levels of the of of mostmortality mortality popular foodandand options poor poor health werehealth also experienced experienced cited as concerns.in in Glasgow Glasgow over over and and above above that that explained explained by by its its socio-economicsocio-economic profile. profile. • F1:• whenTheThe aims aims there of of is the the something research research nicewere were on to to the establish establish menu... whether whether He likes there thethere fish. is is evidence evidence Now .. and of of such hesuch says an an ‘effect’,unless ‘effect’, you run even..even when when comparing comparing Glasgow Glasgow to to its its two two most most similar similar and and comparable comparable UK UK cities: cities: Liverpool Liverpool F3: …you don’t get that. It’s gone. andand Manchester. Manchester. M1: Aye. It’s gone. Aye. • F1:• …it’sTheThe analyses analysesrun oot cozwere were there’s based based no on on enough the the creation creation provided of of a fora three-city three-city the amount deprivation deprivation o’ kids that’s index, index, in and thisand school.the the calculationcalculation of of a a series series of of standardised standardised mortality mortality ratios ratios (SMRs) (SMRs) for for Glasgow Glasgow relative relative to to In relationLiverpoolLiverpool to and theand activities,Manchester. Manchester. a few A A range rangeparents of of historical historicalfelt that therecensus census were and and notmortality mortality enough data data activities were were also also which appealedanalysed.analysed. directly to girls, such as singing or dancing. • • TheThe results results showed showed that that the the current current deprivation deprivation profiles profiles of of Glasgow, Glasgow, Liverpool Liverpool and and F2: …moreManchesterManchester activities are are almost almost for girls… identical. identical. you know? Things like that. • F1:• DespiteAye.Despite Because this, this, premature prematurethese activities, deaths deaths as in inyou’ve Glasgow Glasgow just for pointedfor the the period periodoot – the 2003-2007 2003-2007 sports, the were were football more more – than thanthey 30% 30%are basicallyhigherhigher boys. than than Girls…in in Liverpool Liverpool Very very and and fewManchester, Manchester, girls are interested with with all all deaths deaths in kicking around around a football 15% 15% higher. higher. about the park… This ‘excess’ mortality was seen across virtually the whole population: all ages (except the • Parents• This ‘excess’considered mortality that the was availability seen across of virtually unhealthy the foodwhole and population: drinks from all vansages (exceptand shops the in closeveryvery proximityyoung), young), both both to malesthe males school and and females, females,was a major in in deprived deprived disincentive and and non-deprived non-deprived to their children neighbourhoods. neighbourhoods. eating in school at • lunchtime.• ForFor premature premature mortality, mortality, SMRs SMRs tended tended to to be be higher higher for for the the more more deprived deprived areas areas (particularly(particularly among among males), males), and and around around a a half half of of ‘excess’ ‘excess’ deaths deaths under under 65 65 were were directly directly They’rerelatedrelated doing to to awayalcohol alcohol wi’ and andthe drugs. machine.drugs. They’re no getting sweeties in the machine. They’re getting • healthy• AnalysesAnalyses drinks, of of healthy historical historical crisps, data data but suggest suggest then theyit it is is unlikely justunlikely walk that that 20 yardsthe the deprivation deprivation oot and get profile profile to a sweetie of of Glasgow Glasgow van. has has changedchanged significantly significantly relative relative to to Liverpool Liverpool and and Manchester Manchester in in recent recent decades; decades; however, however, the the Somemortalitymortality parents gap gap felt appears appearsunder pressureto to have have widened widenedto provide in in thetheirthe last last children 30 30 years, years, with indicating indicating the same that that amount the the ‘effect’ ‘effect’ of money may may thatbebe their a a relatively relatively friends wererecent recent receiving phenomenon. phenomenon. and they recognised that they themselves, either by writing notes to allow their child to go out at lunchtime or by providing additional funds to eat The results emphasise that while deprivation is a fundamental determinant of health • outside• The resultscould undermineemphasise that the whileBEI. It deprivationwas also argued is a fundamental that as the yeardeterminant passed, childrenof health began to argueand,and, therefore, therefore,that they anshouldan important important be allowed driver driver ofto of leavemortality, mortality, school it it is isat only only lunchtime one one part part for of of increased a a complex complex freedom picture. picture. andAs Asresponsibility. currently currently measured, measured, deprivation deprivation does does not not explain explain the the higher higher levels levels of of mortality mortality experiencedexperienced by by Glasgow Glasgow in in relation relation to to two two very very similar similar UK UK cities. cities. Additional Additional explanations explanations Well,areare he’s required. required. just started it, so now he’s pushing ‘Can I get oot once a week? Can I get out twice a • week?• ThisThis Once research, research, a week, in in particularletparticular me oot’, the the and creation creation I’m gonna of of the eventuallythe small small area area have based based to say three-city three-city ‘Yes’ to that. deprivation deprivation measure,measure, has has allowed allowed identification identification of of communities communities in in Glasgow Glasgow which, which, although although Notalmost almostunexpectedly, identical identical those to to similar similar parents sized sized who areas areas wanted in in Liverpool Liverpool their children and and Manchester Manchester to eat school in in terms terms lunches of of their their were verysocio-economicsocio-economic much in favour characteristics, characteristics,of the BEI and have alsohave pupilsignificantly significantly participation poorer poorer inhealth health the lunchtime outcomes. outcomes. activities. These These will will These Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience respondentsnownow be be the the indicated focus focus for for that a a second, second, they encouraged qualitative, qualitative, phase theirphase children of of research. research. to stay in school, and in some instances they prohibited them from leaving school at lunchtime and refused to give them money to spend in shops and vans.

Some parents thought that an ‘enforcement’ model imposing a blanket ban on pupils going out at lunchtime would be more straightforward than the more prevalent ‘encouragement’ model.

1822

INTRODUCTION KEY FINDINGS

IfThe they link tell between them that socio-economic they can’t go out, circumstances there’s no exception. and health You is wellknow? established. They have However, to take part • This report summarises a range of analyses undertaken to investigate the so-called inthe the extent Big Eat to In.which They the have poor to stayhealth in. profileBut this... of saying Scotland one – thing the nation and meaning with the another highest ….. You ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality know?mortality Like rates if they’re and lowest told that... life expectancy the first years in westerncan’t go Europeout, well – canwhy say...be explained ‘if you bring in terms a letter of in ... and poor health experienced in Glasgow over and above that explained by its sosocio-economic that you can go factors out.’ So is lessI don’t clear. agree Historically, wi’ that. Scotland’s unenviable position in being what socio-economic profile. the press has labelled ‘The Sick Man of Europe’ has been attributed almost exclusively to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, Itrelatively was apparent high levels that ofsome socio-economic parents knew deprivation, very little about principally the BEI, in comparison with their children to England even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool reporting only snippets of information (if at all). Many parents felt that if they had been and Wales. However, a number of publications over the past five years have highlighted a and Manchester. betterphenomenon informed speculatively about the entitledpilot (food the available, ‘Scottish activitiesEffect’, a termetc), usedthrough to describe a letter thein the country’s • The analyses were based on the creation of a three-city deprivation index, and the posthigher (not levels school of morbidity bag) or through and mortality information over and on above the school’s that explained website, by they deprivation. would have One calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to encouragedsuch analysis theirshowed child this to ‘Scottish participate Effect’ by suggesting to exist in all meals geographical that they regions might oflike Scotland to try or and by Liverpool and Manchester. A range of historical census and mortality data were also helpingat all levels to choose of deprivation, an activity. but Athat leaflet it was explaining most evident the inrationale the most behind deprived the postBEI orindustrial asking for analysed. parentalregion of supportWest Central would Scotland, have been with warmly Glasgow received. at the region’sParents core. suggested This led that to thistalk ofinformation a should‘Glasgow be Effect’, provided a notion in the reinforced future. by other recent research showing that mortality in the • The results showed that the current deprivation profiles of Glasgow, Liverpool and former industrial areas of West Central Scotland was higher, and was improving more slowly, Manchester are almost identical. than in the vast majority of other, similar, post-industrial regions of Europe, including those • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% which currently experience worse socio-economic conditions. higher than in Liverpool and Manchester, with all deaths around 15% higher. • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of very young), both males and females, in deprived and non-deprived neighbourhoods. poor health and deprivation. Liverpool and Manchester are two other cities which stand out in • For premature mortality, SMRs tended to be higher for the more deprived areas this regard, with high levels of poverty and the lowest life expectancy of all cities in England. (particularly among males), and around a half of ‘excess’ deaths under 65 were directly The approach taken in this project, therefore, was to investigate this ‘Scottish Effect’ or related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive be a relatively recent phenomenon. measure of deprivation than was previously available to researchersi.

• The results emphasise that 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. Additional explanations are required. • This research, in particular the creation of the small area based three-city deprivation measure, has allowed identification of communities in Glasgow which, although almost identical to similar sized areas in Liverpool and Manchester in terms of their socio-economic characteristics, have significantly poorer health outcomes. These will

i Previous analyses were based on the Carstairs & Morris index, a composite measure of deprivation 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: 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. 1923

10224_GCPH_Briefing Paper 25.indd 3 10224_GCPH_Briefing06/09/2010 16:52 Paper 25.indd 2 06/09/2010 16:52 FINDINGSFINDINGS SERIESSERIES 252725 BRIEFINGBRIEFING PAPERPAPER

KEYKEYTHE FINDINGSFUTUREFINDINGS OF THE BIG EAT IN

• Pupils’• ThisThis viewsreport report summarises summarises a a range range of of analyses analyses undertaken undertaken to to investigate investigate the the so-called so-called ‘Glasgow‘Glasgow‘Glasgow Effect’, Effect’,Effect’, a aa term termterm used usedused in inin recent recentrecent years yearsyears to toto describe describedescribe the thethe higher higherhigher levels levelslevels of ofof mortality mortalitymortality Mostandand pupils poor poor felt health health that experienced experiencedthe BEI should in in Glasgow Glasgowcontinue over over for and S1sand (butabove above not that that other explained explained year groups) by by its its using an ‘encouragement’socio-economicsocio-economic rather profile. profile. than ‘enforcement’ model. It was regarded as being successful, safe, • good• TheThe for aims aims health of of the theand research research enjoyable. were were Pupils to to establish establish were also whether whether aware there there that is theiris evidence evidence parents of of valuedsuch such an an the ‘effect’, ‘effect’, safety aspect.eveneven Most when when groups comparing comparing were Glasgow Glasgow in favour to to of its its the two two BEI most most being similar similar extended and and comparable comparable to other schools UK UK cities: cities: in Glasgow Liverpool Liverpool but considered that it should be restricted to S1 pupils due to practical constraints such as andand Manchester. Manchester. size of school canteens, length of lunchtime etc. The following quote illustrates one focus • group’s• TheThe analyses responseanalyses were were to a based questionbased on on the regardingthe creation creation whether of of a a three-city three-city or not thedeprivation deprivation BEI should index, index, be runand and inthe the other secondarycalculationcalculation schools of of a a inseries series Glasgow of of standardised standardised or Scotland: mortality mortality ratios ratios (SMRs) (SMRs) for for Glasgow Glasgow relative relative to to LiverpoolLiverpool and and Manchester. Manchester. A A range range of of historical historical census census and and mortality mortality data data were were also also Yeah.analysed.analysed. Definitely!…To let them see how it is, how it’s more safe because like most other schools • it’s• quiteTheThe results resultsdangerous showed showed going that that outside, the the current current like sometimes deprivation deprivation the profiles profiles area and of of stuff,Glasgow, Glasgow, so they Liverpool Liverpool should andtry and it and see howManchesterManchester it works. are are almost almost identical. identical. • • DespiteDespite this, this, premature premature deaths deaths in in Glasgow Glasgow for for the the period period 2003-2007 2003-2007 were were more more than than 30% 30% Basicallyhigherhigher it’s than than just in infor Liverpool Liverpool your health… and and Manchester, Manchester, the Big Eat In,with with because all all deaths deaths its helping around around you 15% 15% stay higher. higher. fit and healthy, but then its also helping you keep safe as well so. • • ThisThis ‘excess’ ‘excess’ mortality mortality was was seen seen across across virtually virtually the the whole whole population: population: all all ages ages (except (except the the Supportveryvery young), young),for the both continuationboth males males and and of females, females,the pilot in in was deprived deprived not unanimous: and and non-deprived non-deprived pupils from neighbourhoods. neighbourhoods. two schools were • less• For Forpositive premature premature and one mortality, mortality, group SMRs convenedSMRs tended tended in to eachto be be ofhigher higher these for for schools the the more more concluded deprived deprived that areas areas the BEI should(particularly(particularly(particularly be stopped, among amongamong although males), males),males), the and andand lunchtime around aroundaround a aa half halfhalfactivities of ofof ‘excess’ ‘excess’‘excess’ should deaths deathsdeaths continue. under underunder Otherwise65 6565 were werewere directly directlydirectly the pupils calledrelatedrelated for the to to alcohol pilotalcohol to and beand extended drugs. drugs. across Glasgow at the very least. • • AnalysesAnalyses of of historical historical data data suggest suggest it it is is unlikely unlikely that that the the deprivation deprivation profile profile of of Glasgow Glasgow has has Manychangedchanged pupils significantly significantlywho supported relative relative the to tocontinuation Liverpool Liverpool and and and Manchester Manchester potential extensionin in recent recent decades; decades;of the BEI however, however, to other the the schoolsmortalitymortality suggested gap gap appears appears modifications to to have have widened widenedto the approach in in the the last last including 30 30 years, years, indicating betterindicating quality that that food the the ‘effect’ ‘effect’and drinks, may may shorterbebe a a queues,relatively relatively longer recent recent lunch phenomenon. phenomenon. breaks and more equitable access to lunchtime activities. The results emphasise that while deprivation is a fundamental determinant of health • Staff• The views results emphasise that while deprivation is a fundamental determinant of health and,and, therefore, therefore, an an important important driver driver of of mortality, mortality, it it is is only only one one part part of of a a complex complex picture. picture. StaffAsAs respondents currently currently measured, measured, were generally deprivation deprivation positive does does about not not explain explain the BEI, the the and higher higher saw levels manylevels of benefitsof mortality mortality with suchexperiencedexperienced a model running by by Glasgow Glasgow in schools. in in relation relation Some to to conflict two two very very wassimilar similar expressed UK UK cities. cities. between Additional Additional the contrastingexplanations explanations approachesareare required. required. of active restriction or encouragement of pupils to stay on site at lunchtime, • but• This theThis consensusresearch, research, in in wasparticular particular that pupils the the creation creation could not of of thebethe forcedsmall small area areato stay based based in atthree-city three-city lunchtime, deprivation deprivation and that promotionmeasure,measure, of has has the allowed allowed BEI was identification identification the way forward. of of communities communities in in Glasgow Glasgow which, which, although although almostalmost identical identical to to similar similar sized sized areas areas in in Liverpool Liverpool and and Manchester Manchester in in terms terms of of their their (Bigsocio-economic socio-economicEat In should continue) characteristics, characteristics, because have Ihave think significantly significantly if we don’t dopoorer poorer something, health health outcomes. we’reoutcomes. letting These These ourselves will will in Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience for big,nownow big, be be bigthe the problems focus focus for for latera a second, second, on … qualitative, qualitative,when they phaseget phase older. of of research. Andresearch. the obesity rate in Scotland and… we’re no very healthy as it is.

The minority who favoured the restriction model were concerned that numbers would eventually dwindle in school canteens and catering jobs could be put at risk. However, there was broad agreement that schools faced an uneven playing field in terms of competing with vans and fast food shops which were still able to target school pupils with unhealthy options, usually in very large helpings, and often in very close proximity to the school gates. There were suggestions made to ban the vans, or for the current licensing policy imposing 2022

INTRODUCTION KEY FINDINGS

aThe 300 link metre between exclusion socio-economic zone to be strengthenedcircumstances whichand health could is addresswell established. this in some However, way, but • This report summarises a range of analyses undertaken to investigate the so-called itthe was extent also toacknowledged which the poor that health the food profile consumed of Scotland by pupils– the nationat home with was the likely highest to be much ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality lessmortality healthy rates than and the lowest food lifeand expectancy drink provided in western within Europe school. – As can a resultbe explained a few respondents in terms of and poor health experienced in Glasgow over and above that explained by its suggestedsocio-economic that the factors current is less approach clear. Historically, to meeting Scotland’s nutritional unenviable guidelines position should in be being relaxed what to socio-economic profile. somethe press extent. has labelled ‘The Sick Man of Europe’ has been attributed almost exclusively to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, relatively high levels of socio-economic deprivation, principally in comparison to England even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool The school staff argued that the involvement of parents was very important if initiatives and Wales. However, a number of publications over the past five years have highlighted a and Manchester. likephenomenon the BEI were speculatively to succeed, entitled although the this ‘Scottish was perceived Effect’, a term as being used ato major describe challenge. the country’s For • The analyses were based on the creation of a three-city deprivation index, and the example,higher levels it was of morbiditysuggested and that mortality there should over and be more above taster that explained sessions, parentby deprivation. evenings One or calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to sessions,such analysis and showedinformation this ‘Scottish in the form Effect’ of letters, to exist leaflets, in all geographical and newspapers, regions even of Scotland if these and Liverpool and Manchester. A range of historical census and mortality data were also attemptsat all levels to of engage deprivation, with parents but that had it was been most relatively evident unsuccessful in the most deprived previously. post industrial analysed. region of West Central Scotland, with Glasgow at the region’s core. This led to talk of a Well‘Glasgow I mean Effect’, some a kids notion it’s thereinforced way (they by are) other brought recent up, research they’re showing not taught that healthy mortality eating, in the its • The results showed that the current deprivation profiles of Glasgow, Liverpool and justformer a case industrial o whatever, areas I ofmean West I know Central one Scotland wee boy was myself… higher, I don’tand was think improving he’s ever morehad meat, slowly, Manchester are almost identical. potatoes and veg, you know what I mean so I think that, if you get them young for their healthy than in the vast majority of other, similar, post-industrial regions of Europe, including those • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% eating I think aye they’ll continue when they get older, I do think that. which currently experience worse socio-economic conditions. higher than in Liverpool and Manchester, with all deaths around 15% higher. Other suggested changes included the introduction of staggered lunch breaks, in order • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of that S1s would be able to eat their lunch and take part in an activity, as well as reducing very young), both males and females, in deprived and non-deprived neighbourhoods. thepoor pressure health and of numbers deprivation. in the Liverpool canteen. and A Manchesternumber of incentives are two other for pupils cities whichstaying stand in school out in • For premature mortality, SMRs tended to be higher for the more deprived areas andthis regard,eating withschool high lunches levels wereof poverty also proposed. and the lowest Continual life expectancy review of the of allfood cities on inoffer England. within (particularly among males), and around a half of ‘excess’ deaths under 65 were directly school,The approach and the taken opportunity in this project, for pupils therefore, to provide was to feedback investigate on changesthis ‘Scottish that Effect’could beor made, related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, were said to be common practice within schools already but it was a process that seen as • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have important to continue. changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive Lunchtime activities were said to be an integral part of the BEI, but issues such as staffing, be a relatively recent phenomenon. fundingmeasure andof deprivation sustainability than had was to previously be considered. available Schools to researchers which reportedi. a difficult

relationship with CSG called for improved links to be made, and for more activities to be • The results emphasise that while deprivation is a fundamental determinant of health laid on for pupils. Activities would also arguably only become sustainable if the funding and, therefore, an important driver of mortality, it is only one part of a complex picture. and staffing (including the use of volunteers) issues were resolved, and importantly if pupils As currently measured, deprivation does not explain the higher levels of mortality from other years could also take part in these activities in the future. experienced by Glasgow in relation to two very similar UK cities. Additional explanations are required. I think as well what would help us is if the National Government passed legislation that said to • This research, in particular the creation of the small area based three-city deprivation parents that ‘you’re duty bound to ensure that your child remains inside the school grounds until measure, has allowed identification of communities in Glasgow which, although the end o’ 2nd year’. Now I know there’s a very small number/small percentage of young people almost identical to similar sized areas in Liverpool and Manchester in terms of their who will directly defy such an announcement from the Government, as they’re doing just now socio-economic characteristics, have significantly poorer health outcomes. These will

with the nutritional value, but the vast majority of parents would actually conform… if there why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research. was some way of rewarding young people for doing the right thing, that would be helpful. I’m not saying that offering a reward is gonna get them all back in again, but it might get 10% or so back at the thought of a reward, and actually if we could get the numbers up to 10% I’m sure we’d be delighted.

I think it’s all very well for our city to say “this is what we need, this is a great idea”, but not (provide)i Previous analysesany additional were based resources. on the Carstairs So to& Morris run the index, Eat a compositeIn with existing measure resourcesof deprivation I think calculated is a bit…from notcensus naughty, data. This but measure it’s a… is nowit’s a out bit of difficult date (the mostfor usrecent then data to beingsay, forWell, 2001), … butwhat crucially activities was also do calculated young for different-sized geographies north and south of the border: the relatively large size of these areas (especially in the peopletwo English do? cities), and the variation in size between the Scottish and English geographies is potentially problematic in measuring the effects of area-based deprivation. 2123

10224_GCPH_Briefing Paper 25.indd 3 10224_GCPH_Briefing06/09/2010 16:52 Paper 25.indd 2 06/09/2010 16:52 FINDINGSFINDINGS SERIESSERIES 252725 BRIEFINGBRIEFING PAPERPAPER

KEYKEY FINDINGSFINDINGS

• The• This Thismajority report report of summarises summarisesstaff respondents a a range range perceivedof of analyses analyses that undertaken undertaken the BEI hadto to investigate investigate been successful the the so-called so-called overall, the benefits‘Glasgow‘Glasgow outweighed Effect’, Effect’, a a term termthe used drawbacks,used in in recent recent and years yearsthere to to wasdescribe describe merit the inthe its higher higher continuation levels levels of of mortality mortalitywithin the pilotandand schools poor poor healthandhealth its experienced experiencedextension to in in other Glasgow Glasgow secondary over over and and schools. above above that Asthat has explained explained been mentioned, by by its its active restrictionsocio-economicsocio-economic of S1s leaving profile. profile. the school gates at lunchtime was deemed as being impractical • and• The Theinadvisable aims aims of of the theby research mostresearch respondents. were were to to establish establish There waswhether whether some there there support is is evidence evidence for encouraging of of such such an an S2s ‘effect’, ‘effect’, to stay in schooleveneven when whenat lunchtime comparing comparing too, Glasgow Glasgow but the to toconsensus its its two two most most was similar similarthat space and and comparableandcomparable time were UK UK cities: toocities: limited Liverpool Liverpool to target years other than S1. The provision of healthy lunches, the safety agenda and the andand Manchester. Manchester. perceived benefits of the activities were all thought to contribute to the qualified success • of• theTheThe pilot. analyses analyses Respondents were were based based from on on thetwo the creation creationschools of of a thea three-city three-city eight pilot deprivation deprivation schools wereindex, index, less and and positive, the the andcalculation calculationone staff interviewee of of a a series series of offrom standardised standardised one of these mortality mortality schools ratios ratios said (SMRs) (SMRs)that the for for BEI Glasgow Glasgow was unsuccessful, relative relative to to and shouldLiverpoolLiverpool not be and and continued. Manchester. Manchester. A A range range of of historical historical census census and and mortality mortality data data were were also also analysed.analysed. • Views• TheThe of results results parents/carers, showed showed that that CSG the the staffcurrent current and deprivation deprivation volunteers profiles profiles of of Glasgow, Glasgow, Liverpool Liverpool and and ManchesterManchester are are almost almost identical. identical. • Parents/carers• DespiteDespite this, this, felt premature premature that the deathsBEIdeaths should in in Glasgow Glasgow be extended for for the the to period period other 2003-2007 2003-2007schools across were were Glasgowmore more than than and 30% 30% Scotland.higherhigher Theythan than feltin in Liverpool Liverpool this might and and also Manchester, Manchester, make it easier with with forall all deaths pupilsdeaths toaround around accept 15% 15% this higher. higher. type of lunchtime policy if they realised that pupils at other schools were treated in a similar way. • • ThisThis ‘excess’ ‘excess’ mortality mortality was was seen seen across across virtually virtually the the whole whole population: population: all all ages ages (except (except the the On verythevery whole, young), young), parents/carers both both males males and and thought females, females, that in in deprived deprivedthe BEI should and and non-deprived non-deprived only apply toneighbourhoods. neighbourhoods. S1s due to their • age• For Forand premature premature to provide mortality, mortality, protection SMRs SMRs and tended tended support to to tobe be allowhigher higher them for for the the to more adaptmore deprived deprivedto secondary areas areas school. From(particularly(particularly a practical among amongviewpoint, males), males), parents and and around around felt that a a half halfmany of of ‘excess’schools ‘excess’ deaths diddeaths not under under have 65the65 were were capacity directly directly to accommodaterelatedrelated to to alcohol alcohol all pupils and and in drugs. drugs. the canteen at the same time. In addition, they argued that • it• wasAnalysesAnalyses important of of historical historical for their data datachildren suggest suggest to haveit it is is unlikely unlikelyresponsibility that that the the and deprivation deprivation freedom profile profileso they of of should Glasgow Glasgow be hashas allowedchangedchanged out significantly atsignificantly lunchtime relative relative at some to to stage Liverpool Liverpool in their and and school Manchester Manchester careers. in in recent recent decades; decades; however, however, the the mortalitymortality gap gap appears appears to to have have widened widened in in the the last last 30 30 years, years, indicating indicating that that the the ‘effect’ ‘effect’ may may I thinkbebe athe a relatively relatively whole idea recent recent of coming phenomenon. phenomenon. to secondary school is that they’re a big person now you know that you only had packed lunches really when you were at primary school and you were a bit of The results emphasise that while deprivation is a fundamental determinant of health • a• babyThe if results you like…Em emphasise you that were while too young deprivation to be responsible is a fundamental with your determinant money to of actually health go and physicallyand,and, therefore, therefore, buy your an anlunch important important but I think driver driver when of of mortality, youmortality, come ittoit is issecondary only only one one part schoolpart of of itsa a complex ..complex you know picture. picture. you’re a big AspersonAs currently currently now andmeasured, measured, you have deprivation deprivation to take responsibility does does not not explain explain for this… the the higher higher levels levels of of mortality mortality experiencedexperienced by by Glasgow Glasgow in in relation relation to to two two very very similar similar UK UK cities. cities. Additional Additional explanations explanations CSGareare representatives required. required. and volunteers favoured the continuation of the activities element of • the• ThisBEIThis atresearch, research, lunchtime in in particular particular in the pilot the the schools, creation creation even of of the the if theysmall small were area area notbased based always three-city three-city able todeprivation deprivation comment on the measure,schoolmeasure, lunch has has allowed allowedcomponent identification identification of the pilot. of of communitiesIdeally,communities it was in inalso Glasgow Glasgow stated which, which,that the although although activities should be offeredalmostalmost identical toidentical other secondaryto to similar similar sized sized pupils areas areas within in in Liverpool Liverpool the same and and school, Manchester Manchester as well in asin termstoterms pupils of of their theirin other secondarysocio-economicsocio-economic schools in characteristics, characteristics, Glasgow. However, have have significantly significantly it was acknowledged poorer poorer health health that outcomes. outcomes. there may These These not be will will the Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience resourcesnownow be be – the thestaff focus focus or volunteers for for a a second, second, and qualitative, qualitative,finances –phase phaseto allow of of research.research.such an extension of the activities. The CSG representatives, in particular, were concerned that the model should be sustainable in the future, and it would send out the wrong message to S1 pupils if they were no longer permitted to take activities they had enjoyed during the pilot in S2. On the other hand, if the BEI were to be extended to other schools, they did not think it would be possible to run activities with S1 pupils in additional schools whilst extending the programme in existing schools.

2222

INTRODUCTION KEY FINDINGS

IThe think link there between has probably socio-economic been quite circumstances a lot of success and in health it; um…I is well think established. there is probably However, more to • This report summarises a range of analyses undertaken to investigate the so-called comethe extent because to which people the now poor have health a much profile better of understanding.Scotland – the nationI would with say therethe highest is a number of ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality pupilsmortality out ratesthere and that lowest have engaged life expectancy in activities in western that they Europe wouldn’t – can have be explainedengaged in in or terms even of the and poor health experienced in Glasgow over and above that explained by its sidesocio-economic of probably maybefactors never is less felt clear. confident Historically, in going Scotland’s out of theunenviable school and position that allowedin being them what to socio-economic profile. buildthe press up their has labelledconfidence ‘The for Sick that Man first of yearEurope’ and has get beenused attributedto the school almost without exclusively it being toseen its that • The aims of the research were to establish whether there is evidence of such an ‘effect’, yourelatively are the high person levels that of doesn’tsocio-economic want to go deprivation, out. principally in comparison to England even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool and Wales. However, a number of publications over the past five years have highlighted a and Manchester. Iphenomenon think you take speculatively the model of entitled how we thedo it‘Scottish in (name Effect’, of school) a term and used copy to it describe but I think the you’d country’s • The analyses were based on the creation of a three-city deprivation index, and the probablyhigher levels would of morbidityneed to have and money mortality to provide over and for above the activities, that explained I don’t know by deprivation. if every area One has calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to likesuch what analysis X’s got showed the voluntary this ‘Scottish sector Effect’ that are to providingexist in all the, geographical the activities, regions I don’t of know Scotland if every and Liverpool and Manchester. A range of historical census and mortality data were also oneat all in levels Scotland of deprivation, would have but that… that it was most evident in the most deprived post industrial analysed. 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 • The results showed that the current deprivation profiles of Glasgow, Liverpool and former industrial areas of West Central Scotland was higher, and was improving more slowly, Manchester are almost identical. than in the vast majority of other, similar, post-industrial regions of Europe, including those • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% which currently experience worse socio-economic conditions. higher than in Liverpool and Manchester, with all deaths around 15% higher. • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of very young), both males and females, in deprived and non-deprived neighbourhoods. poor health and deprivation. Liverpool and Manchester are two other cities which stand out in • For premature mortality, SMRs tended to be higher for the more deprived areas this regard, with high levels of poverty and the lowest life expectancy of all cities in England. (particularly among males), and around a half of ‘excess’ deaths under 65 were directly The approach taken in this project, therefore, was to investigate this ‘Scottish Effect’ or related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has cities which share similar histories of industrialisation and deindustrialisation, and which have changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive be a relatively recent phenomenon. measure of deprivation than was previously available to researchersi.

i Previous analyses were based on the Carstairs & Morris index, a composite measure of deprivation 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: 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. 2323

10224_GCPH_Briefing Paper 25.indd 3 10224_GCPH_Briefing06/09/2010 16:52 Paper 25.indd 2 06/09/2010 16:52 FINDINGSFINDINGS SERIESSERIES 252725 BRIEFINGBRIEFING PAPERPAPER

KEYKEYCONCLUSIONS FINDINGSFINDINGS

• The• This Thisgeneral report report consensus summarises summarises of thea a range range pupils, of of analyses parents/carers,analyses undertaken undertaken school to to staff,investigate investigate CSG representatives the the so-called so-called and volunteers‘Glasgow‘Glasgow‘Glasgow who Effect’, Effect’,Effect’, took a aa partterm termterm in used usedused the in evaluationinin recent recentrecent years yearsyears was to toto that describe describedescribe the BEI the thethe had higher higherhigher been levels levelslevels very of successful,ofof mortality mortalitymortality shouldandand continuepoor poor health health in pilotexperienced experienced schools inandin Glasgow Glasgow should over overbe extended and and above above to that that other explained explained schools. by by According its its to the respondents,socio-economicsocio-economic numbers profile. profile. of pupils taking school lunches had increased (this was confirmed by the quantitative data); the food and drink provided was healthy and mostly of good quality; • • TheThe aims aims of of the the research research were were to to establish establish whether whether there there is is evidence evidence of of such such an an ‘effect’, ‘effect’, S1s were able to adjust to the new school environment and felt safe within the confines of eveneven when when comparing comparing Glasgow Glasgow to to its its two two most most similar similar and and comparable comparable UK UK cities: cities: Liverpool Liverpool the school; and the lunchtime activities were enjoyed by all pupils who took part. Parents/ andand Manchester. Manchester. carers particularly valued the safety dimension provided by the pilot in terms of reduced • risk• The ofThe road analyses analyses traffic were were injury, based based bullying on on the the andcreation creation stranger of of a a three-city danger.three-city The deprivation deprivation BEI was also index, index, regarded and and the the as helpful by parents/carerscalculationcalculation of of a ina series series providing of of standardised standardised an opportunity mortality mortality for theirratios ratios child (SMRs) (SMRs) to socialisefor for Glasgow Glasgow and relative relativemake friends to to in a safe,LiverpoolLiverpool structured and and Manchester. environmentManchester. A A during range range of ofan historical historical important census census educational and and mortality mortality transition. data data were were also also analysed.analysed. • The• The Theaims results results of the showed showed Scottish that that Curriculum the the current current for deprivation deprivationExcellence profiles areprofiles to help of of Glasgow, Glasgow,children Liverpool becomeLiverpool and “successfuland learners,ManchesterManchester confident are are individuals,almost almost identical. identical. responsible citizens and effective contributors.” 13 There is good evidence that the BEI supported educational as well as public health goals. • • DespiteDespite this, this, premature premature deaths deaths in in Glasgow Glasgow for for the the period period 2003-2007 2003-2007 were were more more than than 30% 30%

higherhigher than than in in Liverpool Liverpool and and Manchester, Manchester, with with all all deaths deaths around around 15% 15% higher. higher. In terms of future approaches, the majority of respondents proposed an ‘encouragement’ • model• ThisThis in ‘excess’ ‘excess’ which mortality S1smortality would was was be seen encouragedseen across across virtually virtually to stay the withinthe whole whole school, population: population: eat school all all ageslunchages (except (except and the the participateveryvery young), young), in a lunchtimeboth both males males activity. and and females, females, Although in in deprived deprived some school and and non-deprived non-deprived staff respondents neighbourhoods. neighbourhoods. supported more • restrictive• ForFor premature premature approaches, mortality, mortality, especially SMRs SMRs tendedat tended the beginning to to be be higher higher of for thefor thepilot,the more more including deprived deprived a blanket areas areas ban on pupils(particularly(particularly(particularly leaving the among amongamong school, males), males),males), the majorityand andand around aroundaround view a aa half halfwashalf of ofofthat ‘excess’ ‘excess’‘excess’ this was deaths deathsdeaths not under underunderonly inadvisable65 6565 were werewere directly directlydirectly but also impractical.relatedrelated to to alcohol alcohol and and drugs. drugs. • • AnalysesAnalyses of of historical historical data data suggest suggest it it is is unlikely unlikely that that the the deprivation deprivation profile profile of of Glasgow Glasgow has has Schoolchangedchanged vans significantly andsignificantly shops in relative relative close proximity to to Liverpool Liverpool to theand and schools Manchester Manchester were in inperceived recent recent decades; decades; as undermining however, however, thethe healthymortalitymortality eating. gap gap A appears GCCappears licensing to to have have policy widened widened was in inintroduced the the last last 30 30 in years, years, January indicating indicating 2009, imposingthat that the the ‘effect’ ‘effect’ a 300 may may metrebebe a exclusiona relatively relatively zone recent recent for phenomenon. phenomenon.any mobile street trader operating near secondary schools. As this policy can only be applied to traders renewing or applying for a new license, it had • not• The hadThe results resultstime to emphasise emphasise fully embed that that before while while deprivation thedeprivation BEI was is implemented.is a a fundamental fundamental 14 determinant Theredeterminant was clear of of health healthevidence duringand,and, the therefore, therefore, latter stages an an important important of the BEI, driver driver of vans of of mortality, mortality, continuing it it is is to only only operate one one part part in close of of a a complex proximitycomplex picture. picture. to seven outAs ofAs currently thecurrently eight measured, pilotmeasured, schools. deprivation deprivation It is assumed does does not notthat explain explain these vansthe the higher higher were levelsyet levels to of haveof mortality mortality their licenses renewedexperiencedexperienced and thus by by wereGlasgow Glasgow not in subjectin relation relation to to tothe two two new very very policy. similar similar School UK UK cities. cities. staff Additional Additionaland parents explanations explanations have repeatedlyareare required. required. voiced concerns regarding food purchased from these outlets by pupils, as well • as• expressingThisThis research, research, worries in in particular particular regarding the the road creation creation safety of of ofthe the pupils small small visitingarea area based based these three-city three-city outlets anddeprivation deprivation have called for themmeasure,measure, to be has has banned. allowed allowed A identification identification preliminary analysisof of communities communities of the impacts in in Glasgow Glasgow of introduction which, which, although although of a 300 metre exclusionalmostalmost zone identical identical by GCC to to similar similarLeader’s sized sized Office, areas areas publishedin in Liverpool Liverpool in and andSeptember Manchester Manchester 2009, in in recommended terms terms of of their their that a furthersocio-economicsocio-economic review of the characteristics, characteristics, policy should have takehave significantly placesignificantly to determine poorer poorer health itshealth practical outcomes. outcomes. effect These These and whetherwill will 15 Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience an extensionnownow be be the the to focus focusthe exclusion for for a a second, second, zone qualitative, qualitative, would be phase desirable.phase of of research. research.

The Scottish Government Route Map Towards Healthy Weight has called for policy responses that “go beyond individual initiatives requiring systemic and far-reaching change in infrastructure, environments, culture and social norms.” 8 Initiatives such as the BEI offer a very promising way forward for policy makers and practitioners to develop further approaches to school-based promotion of healthy eating in partnership with children, young people and their parents/carers.

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INTRODUCTIONKEYREFERENCES FINDINGS KEY FINDINGS

1The• Glasgow Thislink betweenreport City summarises Council. socio-economic Hungry a range for circumstances of Success- analyses Site undertaken and Survey health of to is Head investigatewell Teachers.established. the so-calledUnpublished However, • This report summarises a range of analyses undertaken to investigate the so-called thereport, extent‘Glasgow 2008. to whichEffect’, the a term poor used health in recent profile years of Scotland to describe – the the nation higher with levels the of highest mortality ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality mortalityand poor rates health and lowest experienced life expectancy in Glasgow in westernover and Europe above that– can explained be explained by its in terms of and poor health experienced in Glasgow over and above that explained by its 2socio-economic Langsocio-economic T, Dowler factors E, Hunter profile. is less D. Reviewclear. Historically, of the Scottish Scotland’s Diet Actionunenviable Plan: position Progress in and being Impacts what socio-economic profile. 1996-2005. Edinburgh: NHS Health Scotland, 2006. the• pressThe aims has labelledof the research ‘The Sick were Man to of establish Europe’ whetherhas been there attributed is evidence almost of exclusively such an ‘effect’, to its • The aims of the research were to establish whether there is evidence of such an ‘effect’, relativelyeven whenhigh levels comparing of socio-economic Glasgow to its deprivation, two most similar principally and comparable in comparison UK tocities: England Liverpool even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool 3 Harnack LJ, Schmitz KH. The role of nutrition and physical activity in the obesity epidemic and andWales. Manchester. However, a number of publications over the past five years have highlighted a and Manchester. phenomenonin obesity prevention speculatively and entitled public thehealth ‘Scottish (ed. Crawford Effect’, a D,term Jeffery used RW), to describe Oxford: theOxford country’s • The analyses were based on the creation of a three-city deprivation index, and the • The analyses were based on the creation of a three-city deprivation index, and the higherUniversity levels ofPress, morbidity 2005. and mortality over and above that explained by deprivation. One calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to such analysis showed this ‘Scottish Effect’ to exist in all geographical regions of Scotland and 4 Liverpool and Manchester. A range of historical census and mortality data were also Liverpool and Manchester. A range of historical census and mortality data were also at Governmentall levels of deprivation, Office for butScience. that itTackling was most obesities: evident futurein the mostchoices. deprived Summary post industrialof key analysed. analysed. regionmessages. of West London: Central Department Scotland, with of GlasgowInnovation at theUniversities region’s core. and Skills,This led 2007. to talk of a http://www.foresight.gov.uk/Obesity/20.pdf ‘Glasgow• The results Effect’, showed a notion that reinforced the current by other deprivation recent profilesresearch of showing Glasgow, that Liverpool mortality and in the • The results showed that the current deprivation profiles of Glasgow, Liverpool and formerManchester industrial are areas almost of West identical. Central Scotland was higher, and was improving more slowly, Manchester are almost identical. 5 Grant I, Fischbacher C, Whyte B. Obesity in Scotland. An epidemiological briefing. than• Despite in the vast this, majority premature of other,deaths similar, in Glasgow post-industrial for the period regions 2003-2007 of Europe, were including more than those 30% • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% Edinburgh: ScotPHO, 2007. whichhigher currently than inexperience Liverpool worse and Manchester, socio-economic with allconditions. deaths around 15% higher. higher than in Liverpool and Manchester, with all deaths around 15% higher. 6• ScottishThis ‘excess’ Executive’s mortality Expert was Panel seen acrosson School virtually Meals. the Hungry whole population:for Success: allA Wholeages (except School the • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the WithinApproachvery a young),UK context, to School both however, males Meals and in Glasgow Scotland.females, is in notEdinburgh: deprived alone in and HMSO,experiencing non-deprived 2003. relatively neighbourhoods. high levels of very young), both males and females, in deprived and non-deprived neighbourhoods. poor• For health premature and deprivation. mortality, SMRsLiverpool tended and to Manchester be higher forare thetwo more other deprived cities which areas stand out in • For premature mortality, SMRs tended to be higher for the more deprived areas 7this Scottish regard,(particularly Parliament.with highamong levels Schools males), of poverty and(Nutrition around and and thea half lowestHealth of ‘excess’ lifepromotion) expectancy deaths (Scotland)under of all 65 cities were Act. indirectlyEdinburgh: England. (particularly among males), and around a half of ‘excess’ deaths under 65 were directly TheHMSO, relatedapproach 2007. to takenalcohol http://www.legislation.gov.uk/asp/2007/15/contents in andthis drugs.project, therefore, was to investigate this ‘Scottish Effect’ or related to alcohol and drugs. ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has • Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has 8cities which share similar histories of industrialisation and deindustrialisation, and which have Scottishchanged Government. significantly Preventingrelative to Liverpool Overweight and and Manchester Obesity inin Scotland.recent decades; A Route however, Map the changed significantly relative to Liverpool and Manchester in recent decades; however, the high mortality associated with known problems of deprivation. Furthermore, we sought to Towardsmortality Healthy gap appears Weight. to Edinburgh: have widened The in Scottish the last Government, 30 years, indicating 2010. that the ‘effect’ may mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may improve on previous related analyses by employing a more up to date and spatially sensitive be a relatively recent phenomenon. be a relatively recent phenomenon. 9measure Glasgow of deprivationCentre for Population than was previously Health. Healthy available Food to researchers Provision andi. Promotion in Primary

• School:The results What emphasise impact is itthat having while on deprivation food choices? is a fundamental Glasgow: GCPH, determinant 2007. of health • The results emphasise that while deprivation is a fundamental determinant of health and, therefore, an important driver of mortality, it is only one part of a complex picture. and, therefore, an important driver of mortality, it is only one part of a complex picture. 10 TheAs Scottishcurrently Government. measured, deprivation School meals does innot Scotland explain 2010.the higher Edinburgh: levels of The mortality Scottish As currently measured, deprivation does not explain the higher levels of mortality Government,experienced 2010. by Glasgow http://www.scotland.gov.uk/Resource/Doc/317525/0101141.pdf in relation to two very similar UK cities. Additional explanations experienced by Glasgow in relation to two very similar UK cities. Additional explanations are required. are required. 11• ScottishThis research, Centre infor particular Social Research. the creation Healthy of the food small provision area based and three-citypromotion deprivation in schools. • This research, in particular the creation of the small area based three-city deprivation Finalmeasure, report. has Glasgow: allowed GCPH, identification 2007. of communities in Glasgow which, although measure, has allowed identification of communities in Glasgow which, although almost identical to similar sized areas in Liverpool and Manchester in terms of their almost identical to similar sized areas in Liverpool and Manchester in terms of their 12 Glasgowsocio-economic Centre for characteristics, Population Health. have significantly Healthy food poorer provision health and outcomes. promotion These in primary will socio-economic characteristics, have significantly poorer health outcomes. These will Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience andnow secondary be the focus school: for aimpacts second, in qualitative, school and phase beyond. of research. Glasgow: GCPH, 2007. why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research.

13 Learning and Teaching Scotland website http://www.ltscotland.org.uk/understandingthecurriculum/whatiscurriculumforexcellence/index.asp

14 Glasgow City Council. Conditions Contained in a Street Traders Licence. http://www.glasgow.gov.uk/NR/rdonlyres/26F588EB-5D05-4C18-86BA-0525A03B02BE/0/STConditions.DOC i Previous analyses were based on the Carstairs & Morris index, a composite measure of deprivation calculated from 15 censusGlasgow data. ThisCity measure Council’s is now Leader’s out of date Office. (the most Briefing: recent data Exclusionbeing for 2001), zones but cruciallyfor ‘burger was also vans’. calculated Glasgow: forGlasgow different-sized City geographiesCouncil, 2009. north and south of the border: 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 2 measuring the effects of area-based deprivation. 2523

CONTACT KEY FINDINGS DavidFiona CrawfordWalsh • This report summarisesGlasgow CentreCentre a range forfor of PopulationPopulation analyses undertakenHealth Health to investigate the so-called ‘Glasgow Effect’,House a term6, 94 94 usedElmbank Elmbank in recent Street Street years to describe the higher levels of mortality and poor healthGlasgow experienced G2 G2 4DL 4DL in Glasgow over and above that explained by its socio-economic profile. Tel: +44 (0)141 287 6742 • The aims of Tel:the research0141 287 were 6880 to establish whether there is evidence of such an ‘effect’, even when comparingEmail: [email protected] [email protected] Glasgow to its two most similar and comparable UK cities: Liverpool and Manchester. Web: www.gcph.co.uk • The analyses were based on the creation of a three-city deprivation index, and the calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to Liverpool and Manchester. A range of historical census and mortality data were also analysed. • The results showed that the current deprivation profiles of Glasgow, Liverpool and Manchester are almost identical. • Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% higher than in Liverpool and Manchester, with all deaths around 15% higher. • This ‘excess’ mortality was seen across virtually the whole population: all ages (except the very young), both males and females, in deprived and non-deprived neighbourhoods. • For premature mortality, SMRs tended to be higher for the more deprived areas (particularly among males), and around a half of ‘excess’ deaths under 65 were directly related to alcohol and drugs. • Analyses of historical data suggest 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 in the last 30 years, indicating that the ‘effect’ may be a relatively recent phenomenon. • The results emphasise that 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. Additional explanations are required. • This research, in particular the creation of the small area based three-city deprivation measure, has allowed identification of communities in Glasgow which, although almost identical to similar sized areas in Liverpool and Manchester in terms of their socio-economic characteristics, have significantly poorer health outcomes. These will Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience Evaluating the Impact of the ‘Big Eat In’ Secondary School Pilot In’ ‘Big Eat the Impact of the Evaluating Investigating a ‘Glasgow Effect’: why do equally deprived why do equally deprived Effect’: a ‘Glasgow Investigating outcomes? health different UK cities experience now be the focus for a second, qualitative, phase of research.

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