Executive summary


The two decades since devolution in Scotland have seen major external shocks change the underlying social and economic context, create new challenges and shift the relationship between Scotland and Westminster. These shocks include the 2008 financial crisis and prolonged period of real wage growth stagnation that has followed and, more recently, the COVID-19 pandemic and alarming rises in the cost of living. These events have drawn attention to the inextricable link between health and wealth, bringing society’s underlying poor health and existing inequalities to the fore.

Good health has a significant influence on overall wellbeing and allows people to participate in family life and in their community. There is a bidirectional relationship between health and social and economic outcomes. Social and economic factors – like income – affect our health, and our health affects social and economic outcomes. Failing to maintain and support good health can also reduce people’s ability to work, or their productivity at work, limiting economic potential.

Since the 1950s, Scotland has had the lowest life expectancy of UK nations and in recent decades its position has deteriorated relative to other western European countries. Inequalities in life expectancy between people living in the most and least deprived areas widened in the years prior to the pandemic – with the gap growing to 13.3 years for men, and to 9.8 years for women by 2017–19. Projections of how long people will live have been falling. A person born in 2012 is now expected to live to 86 years, 4.4 fewer years than expected in 2013.

The COVID-19 pandemic has been a shock to health, while the current cost-of-living crisis risks eroding the population’s health even further. These crises, though distinct in nature, share an impact that has largely reflected existing societal fault lines – with the most disadvantaged tending to experience the worst outcomes.

No single institution or sector can turn the tide of declining health and widening inequalities on its own. Despite existing policy plans for action across sectors to tackle health inequalities, intent is not reflected in practice. Progress will require central and local government, business, the third sector, local communities and the public to apply a shared and sustained focus on multiple factors that influence health.

What is driving health trends and inequalities in Scotland?

Almost every aspect of our lives shapes our health and how long we will live – our jobs and homes, access to education and the quality of our surroundings. These are called the wider determinants of health. Income is particularly important because it enables other advantages such as higher levels of educational attainment or high-quality, secure housing. People living in the poorest two-fifths of households are almost eight times as likely to report poor health as the richest fifth. The association between income and health has potentially grown stronger in Scotland over the past decade.

Health inequalities are a consequence of unfair differences in people’s living conditions and life experiences. In 2019, there was a 24-year gap in the time spent in good health between people living in the most and least socioeconomically deprived 10% of local areas in Scotland. This gap has been widening since 2016. There are also wide income and wealth inequalities. Income inequality grew significantly during the 1980s and early-1990s and has remained high since. The 10% of households with most wealth in Scotland had median wealth of £1.65m compared with £7,600 in the 10% of households with the least wealth – this is over a 200-fold difference.

Health inequalities in Scotland are concentrated in particular areas, having been sustained over a long period of time. Scotland’s health inequalities are a consequence of historical socioeconomic inequalities and deindustrialisation. Although these factors underly differences in health in other parts of the UK (and other countries), the greater health inequality in Scotland suggests the population is more vulnerable to the health consequences of disadvantage.

The persistence of health inequalities in Scotland over the past decade is related to three underlying factors:

  • The accumulation of severe multiple disadvantage: Living in more deprived areas, living in a lower income household, or living in poor-quality housing are just some of the forms of disadvantage that lead to worse health outcomes and are associated with much higher rates of mortality. Experiencing two or more of these factors creates a greater risk to people’s health. Severe forms of disadvantage present even greater risks of higher mortality and include homelessness, opioid dependence, imprisonment and psychosis. A study from 2019 has estimated that 5,700 people in Scotland had experience of homelessness, substance dependency and offending; 28,800 people had experience of two out of the three, and 156,700 had experience of one.
  • A lack of improvement in living standards: Better living conditions, greater access to opportunities, and help and support with negotiating systems such as higher education or finding a higher paid job, can all contribute to living a healthier life. But more than a decade of stagnation in pay and a lack of growth in living standards is acting as a brake on health improvement. In 2019/20 median household income in Scotland was £70 per week lower than if pre-2010/11 growth trends had continued. Median household income in Scotland was no higher in 2015 than it was in 2007.

This is compounded for people starting off in life with fewer resources and lower income because, as in the rest of the UK, occupations of workers in Scotland are strongly associated with those of their parents. People with parents who worked in higher paid managerial or professional occupations are twice as likely to work in similar occupations as people whose parents did not.

  • Austerity has left public services in a fragile state and reduced provision for supporting healthier lives: Public services play an important role in building and maintaining good health across areas including education, housing and employment as well as health and social care services. In the decade prior to devolution there were sustained real-terms increases in public spending, but through the 2010s the policy of austerity led to a much tighter settlement for public services. By 2016/17, the Scottish government’s resource block grant was 6% lower in real terms than in 2010/11, and had only just returned to 2010/11 levels by 2019/20.

Across a range of aspects of health there is a widening health gap between people living in the most deprived fifth of areas and the rest of the population. Trends in the socioeconomic factors that influence health provide little indication that health inequalities will improve in future, underlined by increasing rates of extreme poverty.

Three particular areas of concern

Our report highlights three specific areas that must be prioritised given the actual or potential scale of harm:

  • Prevalence of drug-related deaths in Scotland: The overall rate of drug deaths increased from 6.2 per 100,000 in 2001 to 25.1 per 100,000 in 2020. This has been driven by the increase in deaths in the most deprived areas to 68.2 deaths per 100,000 people in 2020 – 18 times as high as in the least deprived areas. In 2020, deaths from drugs were 3.6 times higher in Scotland than the UK average and 2.6 times higher than Northern Ireland and the Northeast of England (which had the next highest rates).
  • Health and experiences of infants and children in their early years: Relative and absolute inequalities have widened for infant immunisation uptake and risk of obesity at the start of primary school. Absolute inequalities widened in low birth weight, relative inequalities have widened in infant mortality and development concerns at age 27–30 months. Meanwhile there has been no significant improvement in the poverty-related attainment gap for primary school and secondary age pupils.
  • Health and socioeconomic outcomes of young and middle-aged men: Suicide, alcohol and drugs are leading causes of death for men aged 15–44 years old, accounting for two-thirds of absolute inequalities in total mortality at that age. Socioeconomic trends also point to younger men being at greater risk of poor future health through reduced earnings potential. The gender gap in higher education participation is wide and has been growing – in 2020/21, male participation rates in higher education were 16 percentage points lower than for women. Employment rates for men aged 16–24 years in Scotland have fallen by 7.7 percentage points, from 65.1% to 57.4% between 2004 and 2019.

Failing to act early to maintain good health and prevent deterioration will create future costs for the health care system, the economy and society. It will also mean greater harm to people living with poor health day to day. Understanding how various factors combine to create a greater risk to people’s health can direct policy attention to where it is needed most.

What is holding back progress?

With a tight fiscal settlement for public services, identifying the barriers to successful policy delivery and enacting reform will be critical to improving future health. We argue that resources exist but must be used more effectively. Doing so will require action and collaboration across all parts of the delivery system: central and local government, the third sector, delivery agencies, health services, business and from the public.

Discussions with stakeholders and a survey undertaken as part of this review identified a series of perceived tensions and challenges. These included policy short-termism, over centralisation and a failure to scale up success. Overcoming these challenges is an opportunity to reform fragile public services and bring about the necessary focus on implementation by:

  • Adopting a longer term planning approach: Budgets are stretched and often relate to specific interventions used in specific areas, but there is an opportunity to use them more effectively and achieve more with a joined-up, long-term approach to planning the best use of resources.
  • Creating greater coherence across policy streams: Policy design can in isolation be good, yet fail to recognise the context in which it is then applied – either in relation to other existing policy strands, the wider economic and political context or local conditions. Developing structures that enable policy design and delivery across government, sectors and local areas can facilitate greater coherence.
  • Restoring trust and empowering communities: A lack of trust can exist between institutions involved in delivery – across national government, local government, agencies and the voluntary sector. This appeared to be caused in particular by a lack of empowerment among actors in the system or in engagement between sectors. Provisions in the Community Empowerment Act 2015 to promote and facilitate public participation in local decision making can be brought to the fore so that community involvement enables successful change locally.
  • Learning from evaluation and scrutiny: The need for growing the maturity of the policy system was shown in several ways, including the need for greater evaluation of what has worked, what has not and why. People perceived a lack of an independent voice, scrutiny and challenge, with a fear of failure throughout the system preventing innovative approaches to delivery. Policymaking can be enhanced by effective use of data and evidence in decision making and policy design and an openness to the challenge brought by independent scrutiny.
  • Scaling up success and innovation: There has been little sign of change in the policy system to support the greater take-up of successful approaches. Instances of policy success were not being adopted at scale. Examples of best practice and successful delivery exist and should be used to scale up to have greater impact in a larger number of geographical or policy areas.

The National Performance Framework provides a means by which a cross-societal approach can be implemented. But stakeholders felt there was a disconnect between the high-level aims to achieve greater wellbeing in Scotland, and the specific indicators that underly them and are targeted by policies, reducing its effectiveness.

Some barriers can be overcome within the current parameters, while others will require longer term reform. Short-term political cycles mean that effective policy development and delivery is difficult when in fact long-term gradual change is necessary for success. Many of the elements identified as lacking in current policy are those set out over a decade ago by the Christie Commission (see Box 3). The tight fiscal position places greater urgency on the need for reform of public service delivery if policy ambitions are to be successfully met.

Workshops with the public highlighted considerable concern at the scale of health inequalities in Scotland, a strong sense that these disparities are unfair, and a clear appetite for greater action to reduce inequalities. They suggest that the public is receptive to longer term preventative interventions aimed at the fundamental causes of health inequalities, rather than a shorter term focus on health care or individual behaviours.

A radical shift but not another strategy

There is a difference between the policy intent and the reality on the ground for people experiencing services – a persistent and growing ‘implementation gap’. It is apparent at different points through the continuum of policymaking – between intent, design, delivery and experience – and ultimately results in a lack of progress in reducing health inequalities.

Many of the elements underlying the implementation gap relate to a lack of progress in delivering on longstanding policy ambitions of the Scottish government. Recognition of this inertia and taking action to reinvigorate progress in delivering in a radically different way to now is necessary or risks failing to deliver on the long-term policy needed for a healthier and more equal Scotland.

The pandemic led to considerable changes in policy and local practice. This raises the question of how that pace of change can be applied to addressing both the immediate cost-of-living crisis and a longer term reduction in inequalities. Kickstarting delivery means setting clear, focused and achievable short-term goals – ensuring these are part of a longer term preventative approach to policy design and resourcing.

It is our hope that this review will help to galvanise change. Yet for that change to have lasting impact it must be developed and owned by Scotland. Taking action and making progress is possible and can be achieved within existing powers, and by maximising their use. The human and economic cost of inaction for Scotland is simply too high, particularly for the poorest and most vulnerable groups. The time to create a sustainable approach to closing the gap in health outcomes is now.

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