Bridging the implementation gap

The past two decades have shown that in times of crisis those facing greatest disadvantage are hit the hardest. The societal fault lines shown starkly by the cost-of-living crisis and the COVID-19 pandemic reflect patterns witnessed in the aftermath of the 2008 financial crisis. It is time to take action to tackle inequalities and provide greater protections for the most affected groups.

Differences exist in health and the social and economic outcomes that influence health across the population of Scotland. Health inequalities reflect historical social and economic inequalities and their scale leads to Scotland having lower life expectancy than other countries in the UK, falling behind other European countries. Many, especially people living in poverty or more deprived areas, already have poor health at risk of further deterioration. The experience of multiple disadvantage, including a minority experiencing severe multiple disadvantage, is contributing to a growing gap in health outcomes.

A society acting together to improve health and reduce inequalities

Political progress in moving towards more mature governance structures, institutions and shaping a more progressive society in Scotland has stalled in recent years. This reflects a combination of political inertia – related to the fallout from Brexit and renewed focus on independence – and a series of crises: weak economic growth post-2008, the pandemic and cost-of-living crisis.

The austerity of the 2010s was more than a reduction in spend on public services and social security. The effects of wage stagnation have led to an unprecedented slowdown in improvements in living standards that in turn has placed greater strain on families, particularly those with lower incomes, to maintain or improve their living standards. UK government policy decisions have exacerbated the situation through a series of cuts to working-age social security and public services. The consequence for an already vulnerable population is playing out in widening inequalities across a range of health outcomes, and signs of increasing poverty.

Progress in reducing inequalities in social and economic outcomes has been slight, with wide gaps remaining in educational attainment, a growing share of people living in the less secure private rented sector, and persistence of insecure work. This lack of progress provides little indication of health inequalities narrowing in future.

The broader economic and fiscal context does not excuse the persistent implementation gap in Scotland – between policy intent, delivery and people’s experiences. Government has a role to play in setting the tone for a relentless pursuit of meaningful change and championing what is possible, providing the leadership and influence to enact it. Making headway will require a whole-society response including at all levels of government, business, the voluntary and community sector and the public.

There is also a strong mandate for action in Scotland. The public is concerned about inequalities and supports action, including greater investment in public services to support better health and raising taxes to do so. While an emphasis on health and inequalities can initially be interpreted as needing to focus on health care services or individual actions, our deliberative work has shown that the public supports long-term preventative action.

Stakeholders described an implementation gap pervading each stage of the policy process, from policy design to delivery, across sectors. The diagnosis offered by stakeholders varied but can be characterised as driven by short-termism, over-centralisation, a failure to prioritise and a perceived lack of trust between different actors in the system. Existing policy plans were often characterised as highly burdensome and constrictive of innovation and tailoring for local areas. This contrasts with an intent for greater community engagement and development of policy solutions in local areas.

The pandemic galvanised actors across the policy system to support immediate need. In many instances, necessity provided the catalyst to overcome barriers within the system. The lessons of success from such collaboration and cross-sector working should not be lost and can be built on.

Turning the tide

Tackling health inequalities requires sustained focus over the long term. Action in the short term needs to build the foundations for longer term change, rather than creating near-term successes that are limited in scope and ultimately overwhelmed by wider pressures. Failure to prioritise the myriad issues that need to addressed is likely to diminish impact. Instead, appropriate short, medium and long-term measures need to be identified for sustained impact.

Fundamentally, all policy areas in Scotland must ensure that their activity helps to prevent the poorest and most disadvantaged in Scotland falling further behind. Our review also highlights three specific areas of concern that require immediate attention given current trends: drug-related deaths, the health of infants and children, and outcomes for young and middle-aged men. These should not take away from the need for wider action across all parts of society, and action here and elsewhere must mitigate the risk of narrowly focused interventions that treat symptoms rather than causes.

Our review has not aimed to create a set of detailed recommendations and achieving progress does not require another new strategy. Many of the elements identified as lacking from current policy processes are those set out over a decade ago by the Christie Commission. The shift required now is in the pace and focus of delivery, and recognition of the scale of reform required.

Existing strategies need to be built on and adapted to ensure there is collaboration across the delivery system based on practical action and shared goals. These should be captured within the National Performance Framework to provide a clearer link between overarching ambitions and specific policy goals. Achieving this requires taking greater steps to empower and engage all parts of society in developing and delivering solutions.

Supporting renewed ambition and delivery

Our commitment to improving health and tackling inequalities in Scotland does not stop here. The Health Foundation plans to support renewed ambition in delivery, but this can only be successful if it is developed with and led by the public and actors within the policy system. Building on our independent review we will seek to support collaborative activity focused on:

  • Maximising the delivery contribution at all levels and across sectors, determining and attributing appropriate responsibility with targets that reflect the change being sought on the ground.
  • Evaluation and learning from existing policy interventions to recognise what does and does not work and ensure policy development is based on evidence – and how best to share and adapt what works across different localities and policy streams.
  • Setting clear, focused and achievable short-term goals that are part of a longer term preventative approach to policy design, delivery and resourcing.
  • Cross-sector working that allows for the pooling of resources and shared goals.

There are some obvious constraints on progress. The difficult fiscal context must be recognised and there are limits to change without greater collaboration between Scotland and the UK government.

Even so, the scale of health inequalities in Scotland is not inevitable. Existing funding can be reshaped to support a different approach to the delivery of hard-pressed public services. The pandemic demonstrated that agility in policy delivery and local practice is possible. The need to act at pace in tackling recent crises presents an opportunity for renewal.

Taking action is essential. Progress can be achieved within existing powers and by maximising their use. For Scotland, the human and economic cost of inaction is simply too high, particularly for the poorest and most disadvantaged groups. The time to create a sustainable approach to closing the gap in health outcomes is now.

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