How has Scotland fared on health inequalities since devolution? At one level the answer is simple. It begins as a story of steady improvement, then stalling and, most recently, of shockwaves.

Inequity in health outcomes is, of course, affected by access to health care and treatment. But it is wider socioeconomic factors – the determinants of health – that do the heavy lifting. So the answer is also complex.

Despite undoubted policy ambition, effective implementation in Scotland has fallen short and inequalities persist. Worse still, they are growing. The effects of the pandemic and the current crisis in living standards, following a decade of stagnation, compound the risks to health ahead.

This review is the most comprehensive of its kind since devolution began. Its evidence suggests that progress in building a healthier and fairer nation is possible. But it also raises a stark question – for all our good intentions, have we taken our eye off the ball?

The most glaring predicament revealed by the review is that the fortunes of those living in our most deprived communities are becoming detached from the rest. Among a plethora of challenges for Scotland it points to are the health prospects of infants and young children, and the plight of young and middle-aged men experiencing multiple disadvantage.

The recent report of the Scottish Parliament’s Health, Social Care and Sport Committee rightly acknowledges that a more coordinated whole-government approach is urgently needed. Joined-up policy design and delivery matters. As does the right balance between universal and targeted intervention. But this is not simply a public policy problem. Employers, for example, must do more too. Government cannot act alone.

The causes of inequalities in health outcomes are deep rooted and structural – exposed and exacerbated by short-term crises. And they can only be resolved by a sustained, long-term response across society. This is a problem for every one of us.

It is heartening therefore that the review suggests a well-informed and engaged public will back bold action to tackle the causes of health inequalities, rather than merely the symptoms. There are those who argue that to respond effectively, Scotland needs more powers – in turn leveraging greater investment. Of course, this could make a difference, but there is already significant scope to act. Either way the actions of the UK government matter too – the damage to health created by austerity over the past decade is unarguable.

But with or without additional powers, and whatever path Westminster chooses, the cost of inaction in Scotland is simply too great to contemplate. We cannot give in to intractability or fatalism and allow the most disadvantaged in our communities to be set adrift.

This is a report not only for government, but for all of Scotland – its institutions, businesses and citizens. We do not need another grand strategy. We need practical collaboration, up and downstream, to sweat the considerable assets we already have – public, third and private sectors, collaborating with communities. Each of us has our part to play.

It is not for the Health Foundation or any expert group to prescribe what that collaboration should look like. Our task now is to act – together – to call time on health inequalities.

Chris Creegan

Chair of the expert advisory group

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