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.

The past two decades can be characterised as having two distinct periods in changes to health and living standards. Through the 2000s there were robust improvements in period life expectancy (an indicator of health) and real earnings (an indicator of living standards). But this is followed by a period of stagnation and departure from historical growth trends through the 2010s (see Figure 4). The large fall in life expectancy in 2020 mainly reflects COVID-19 mortality.

These parallels between life expectancy and pay growth cannot be taken to indicate a direct causality in either direction, but the ways in which changes in standards of living affect health suggest, at the least, an association. Some negative changes in socioeconomic factors may have an immediate impact on health, such as stress and anxiety when struggling to budget on a limited income, or respiratory diseases due to living in damp and mouldy housing. However, such factors may not always immediately feed through to higher mortality rates in the short term. Rather, they exert a growing influence on health over the lifetime. This begins with deterioration in people’s physical and mental health, leading to more years spent in poor health and, ultimately, shorter lifespans.

It has been argued that reductions to the value of working-age social security since 2010 have contributed to an increase in mortality rates, with an effect on aspects of mortality such as drug deaths or infant mortality (which in large part reflect maternal health). Near-term changes in mortality are likely to relate to:

• a sudden shock or disaster such as the COVID-19 pandemic – the impact of which will likely relate to the existing vulnerability of certain groups
• deterioration or improvement in health services providing treatments that may extend life or diagnose otherwise terminal diseases early enough to treat, and
• historical population-wide changes to health, such as immunisation or reduction in smoking rates.

While inequality in life expectancy has widened in the past decade, after improving in the decades before, income inequality widened in the 1980s and 1990s and has remained high since, with little change in the extent of inequality over the past two decades. Inequality in socioeconomic conditions interacts with other factors – such as the lack of availability of affordable healthy food – widening inequalities in health, as observed through increased mental ill health, obesity rates and non-communicable diseases.

Key trends in health outcomes

In the past two decades health outcomes have broadly followed a similar trend to life expectancy, although with some noticeable differences. This section shows the main trends by drawing on a set of metrics that track headline measures of health and then outcomes at different life stages.

We are concerned with both the overall change in health for the population and how different parts of the population fare. To enable consistent comparison across metrics we use a segmentation of the population by levels of deprivation, as measured by the SIMD. However, where data allow a similar pattern tends to exist across other measures such as occupation or income. There are also wide geographic inequalities which tend to align with where neighbourhoods with higher levels of deprivation are concentrated.

These are arranged from those where there has been steady improvement overall and a narrowing of inequalities through to others where outcomes have deteriorated, and inequalities widened. These are illustrated in Figure 6. It is important to note that inequalities in health measured on a relative or absolute basis may not always move in the same direction but a deterioration in either can be considered a worsening of inequality. We highlight the specific type of change in inequalities.†

Sustained overall improvements and narrowing of absolute inequalities

Alcohol-related deaths

Deaths from alcohol are more common among men than women. The overall rate of alcohol deaths has fallen in the past two decades and both absolute and relative inequalities have fallen, driven by a reduction in mortality rates of around a third in the most deprived fifth of areas. Rates of alcohol-specific deaths are still higher in Scotland than the rest of the UK, at 21.5 deaths per 100,000 people in 2020 compared with 19.6 in Northern Ireland, 13.9 in Wales and 13.0 in England. Even with this improvement, people living in the most deprived fifth of areas are five times as likely to die due to alcohol than those living in the least deprived fifth of areas.

Smoking in pregnancy

Smoking in pregnancy increases the risk of babies being born small for their gestational age, post-natal mortality, and being hospitalised for respiratory illnesses in the early years. The proportion of women who report smoking at the time of their first antenatal booking has halved over the past two decades, falling from 29% in 2000 to 14% in 2020. This reduction occurred across all levels of area deprivation and the absolute difference between the most and least deprived fifths has fallen. However, the relative inequality has increased, with the prevalence of smoking during pregnancy now 11 times higher in the most deprived fifth compared with the least in 2020.

Earlier overall improvement followed by an overall stalling or deterioration and widening of inequalities

Healthy life expectancy

Healthy life expectancy provides a broader measure of health than life expectancy by reflecting how many people in the population report they are in good health. Healthy life expectancy increased between 1995 and 2009 by around 9 years, but then decreased by approximately 2 years between 2011 and 2019. Relative inequalities in healthy life expectancy remained broadly similar between 2013–15 and 2017–19, with people in the least deprived 10% of local areas expected to live 1.5 times longer in good health than people in the most deprived 10% of local areas. Absolute inequalities for men widened by 2.6 years to a gap of 25.1 years by 2017–19 (due to declining healthy life expectancy in the most deprived 10% of local areas). For women the gap narrowed slightly to 21.5 years over the same period.

Avoidable mortality

In 2020, 27% of deaths in Scotland were avoidable – higher than the overall UK share of 23%. The leading causes of avoidable deaths in Scotland were cancers, diseases of the circulatory system and alcohol and drug-related disorders. Avoidable mortality among men was falling up until 2013, but the trend has since been flat.

Absolute inequalities declined across the first decade or so of the 21st century, but then increased again slightly. Relative inequalities increased across the entire period, with the rate of avoidable mortality for men in the most deprived fifth of areas four times that of those in the least deprived fifth of areas in 2019.

Birthweight

Birthweight is an indicator of foetal health, the mother’s health and is also a predictor of health throughout the life course. In Scotland, the relative difference in low birthweight (excluding multiple births such as twins) between the least and most deprived 20% of local areas decreased between the early 2000s and 2014 but has since widened.

Absolute inequalities have increased since 2014. In 2020, those in the most deprived areas were twice as likely to have low birthweights than in the least. The causes of low birthweight may be driven by an increase in premature births (which may partly be down to improved survival rates) and declining maternal health.

Little change or gradually increasing prevalence and sustained inequalities

Infant mortality

The infant mortality rate is the number of infant deaths (before first birthday) for every 1,000 live births. This measure is an indicator of societal health and can act as an early indicator of future health trends. Since 2000 infant mortality has declined overall and in Scotland rates are lower than many other high-income countries. However, since around 2014 infant mortality rose in the most deprived fifth of areas and fell in the least deprived 60% of areas. By 2016–18 infant mortality rates in the most deprived areas were 2.6 times the rate in the least deprived areas.

Childhood obesity

At the population level, the proportion of childhood obesity has remained stable over the past 20 years in Scotland, with around 1 in 10 children at the start of school at risk of obesity. Risk of childhood obesity has fallen slightly in the least deprived areas, whereas it has increased slightly in the most deprived areas, leading to a widening of absolute and relative inequalities. By 2018/19 children living in the most deprived fifth of areas were twice as likely to be at risk of obesity, with an absolute gap of 7.2 percentage points.

Asthma hospitalisations

Asthma prevalence in Scotland is high, affecting around 17% of adults, a prevalence that has remained broadly stable over time. For severe instances of asthma (indicated by asthma-related hospitalisations), people in the most deprived fifth of areas were three times as likely to be hospitalised than those in the least deprived fifth in 2018–21, widening from 2.4 times as likely in 2002–05. Hospitalisations reflect uncontrolled or exacerbated asthma, likely occurring from air pollution, occupational exposures or damp housing – all of which are more common or worse in more deprived areas.

Mental health

Adult mental health, using a measure of psychological distress, has slightly increased in prevalence from 16% to 18% between 2012/13 and 2018/19. In 2018/19 people living in the most deprived fifth of areas were almost twice as likely to experience psychological distress as those in the least deprived fifth. This has remained broadly similar over time.

Overall deterioration and widening of inequalities

Drug deaths

While drug deaths are increasing for all socioeconomic groups, people in the most deprived areas face a far greater burden of the total drug deaths and have experienced a far faster rise in the problem. By 2019, those living in the most deprived fifth of Scottish areas were 20 times as likely to die from a drug-related death as those living in the least deprived fifth of areas (after accounting for age). This corresponds to an additional 65 per 100,000 deaths in the most compared with the least deprived areas.

The age and cohort patterns of drug-related deaths are similar in England and Wales, but overall rates are far higher in Scotland. In 2020, deaths from drugs were 3.6 times higher in Scotland than the UK average and 2.6 times higher than those in Northern Ireland and the Northeast of England (which had the next highest rates).

Socioeconomic influences on health

Beneath the overarching trend of much weaker growth in living standards over the past decade there are different trends across the individual socioeconomic factors that support good health. This section explores key aspects of living conditions and how they have changed over the past two decades.

The weak real-terms earnings growth over the past decade – now expected to fall in 2022 and 2023 due to high inflation – is a key driver of weakened income growth (which accounts for other forms of income, such as benefits) over the same time period.

The depth and duration of this wage stagnation is unprecedented and this has implications for current and future standards of living and health. Limited overall growth, however, does not mean progress cannot be made in closing inequalities because these are influenced by how existing resources are shared.

Income

Having sufficient money and resources is important for health. It allows people to maintain an adequate standard of living, affording essentials such as food and a home, and to participate in society. Insufficient income, or problem debt, can have an additional impact on health through the stress and anxiety of trying to make ends meet. Stress itself can lead to physical health problems.

Income is perhaps the most key determinant of health because it also enables people to access other determinants of health, such as higher levels of educational achievement or high quality and secure housing. There is a strong association between income and health, which has potentially grown stronger in Scotland in the past decade as highlighted by Figure 7.

Income inequality

Driven by trends in earnings growth, income growth was relatively robust through the 2000s but weakened in the decade prior to the pandemic. Over the same period, inequalities in income have remained high compared with most western European countries. There have been some fluctuations in income inequality over the past two decades, but the most significant increase in inequality occurred through the 1980s and early 1990s. Although overall household income inequality did not widen during the 2000s, the growth for the very highest income households was faster than the rest, while the lowest tenth of incomes grew more slowly than the rest.

Sustained income inequality will be a factor in differential health outcomes. This will either be directly through day-to-day consumption, or through wider experiences, such as education, social, and cultural activities, to which a relatively higher income enables greater access. Through similar mechanisms, even wider inequalities in wealth will play a part in the scale of health inequalities: 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.

Figure 8 shows that there are income inequalities between family structure, education level, ethnicity, disability and housing tenure. Not having a degree, renting, having children and being from an ethnic minority background are all characteristics typically associated with a lower income. The relative differences within these groups have remained largely unchanged over the past two decades.

Poverty

Compared with the rest of the UK Scotland has a slightly lower rate of relative poverty, largely because of lower housing costs – ie the cost of housing represents a smaller proportion of lower income household budgets. The proportion of the population living in relative poverty fell significantly from around 23% in 1999 to around 18% in 2012.

Since around 2015, however, the proportion of the population in both relative poverty and extreme poverty has been on a slow but persistent upward trend. This is particularly marked for child poverty. The share of children in relative poverty has gradually increased by two percentage points to reach 24% in 2017–20. The share of children in extreme poverty has increased from 13% in 2009–11 to 17% in 2017–20. These upward trends largely reflect changes to working-age social security benefits that have had a downward effect on working-age incomes.

Social security

Some changes to social security for working-age families by the UK government since 2010 have had a direct impact on income, and therefore indirectly on health, with lowest income families most negatively affected. Taken in their entirety, and once the policies are fully in place,‡ reductions in the value of support are estimated to reduce the incomes of the poorest 10% of UK households by 10%, compared with a reduction of 2% for all families. These measures include the 1% cap on increases in most working-age benefits between April 2013 and 2015 and limiting support to two children.

The Scottish government has provided some mitigation of social security cuts through offsetting the ‘bedroom tax’ and cuts to council tax support that both started in 2013. For affected families this is likely to have had a significant impact. However, the estimated £50m a year spent on these measures is only a fraction of the estimated £3.7bn a year total UK government welfare cuts in Scotland. More recently, the introduction of the Scottish Child Payment is providing an important top-up for low-income families with children. That said, the size of the effect on poverty is not fully known, particularly given the cost-of-living crisis.

Compounding these income effects is the growing body of evidence that shows welfare reforms have increased the prevalence of mental health problems. This has been shown through higher prevalence of depression or anxiety among those at risk of having their benefits capped compared with those who have not; an increase in psychological distress from the introduction of Universal Credit (UC) in local areas; and evidence that becoming unemployed under UC is worse for mental health than becoming unemployed under the legacy system for lone parents and single adults (but not couples). Stress and anxiety can also eventually lead to deteriorating physical health.

Employment

Employment is the main route by which people can secure income and is also important for health by providing day-to-day routine, societal participation, and a sense of status and purpose. Employment rates have overall been high in Scotland over the past two decades, aside from the 2009 recession following the financial crisis. There has been a steady increase in female employment since 1999, especially at older ages. Growing levels of employment through the 2010s provided an income boost to lower income households.

Figure 9 shows a concerning reduction in employment for those younger than 24 years, particularly for men, where employment rates for 16–24 year olds have fallen from 65.1% to 57.4% between 2004 and 2019. This mirrors a broader trend in the UK of worsening labour market outcomes for young men.

Work quality and security

The quality of work people do – including whether it provides a lasting and stable income, the autonomy and flexibility it provides, or the extent to which it takes a physical toll or increases stress for employees – is also important for health. Working in a low-quality job can be more detrimental to health than remaining unemployed.

Part of the employment growth that followed the financial crisis was an increase in less secure zero-hour contracts and low-paid self-employed work. On subjective measures of job insecurity – such as whether workers feel they will lose their job in the next year, or negative emotions they associate with their job – there is little evidence of a sustained increase over the past decade. But there is evidence of a persistent level of insecurity.

A further measure to consider is underemployment – the extent to which there are workers who want to work longer hours. Underemployment rates in Scotland increased from 7% to 11% immediately after the financial crisis but had gradually reduced to 8% by 2021.

Insecure work and underemployment are much more likely to be experienced by younger people, particularly men, and workers in lower-paid occupations. Zero-hour contracts are also increasingly concentrated among migrants and workers from ethnic minority backgrounds.

Economic activity and health

There is a two-way relationship between health and employment, with good-quality employment supporting good health but poor health reducing chances of employment.

In Scotland, the working-age economic inactivity rate due to long-term health problems reduced from 7.5% in the mid-2000s to 5% in the mid-2010s, reflecting a fall in the prevalence of musculoskeletal and cardiovascular problems. Since the mid-2010s, the economic inactivity rate has increased, driven by a rise in the prevalence of depression and mental health problems. Both trends broadly follow the experience of the rest of the UK, where economic inactivity due to poor health has been gradually increasing and has become more apparent since the start of the pandemic.

Compared with the rest of the UK, the proportion of working-age people living in Scotland who are economically inactive for health reasons has consistently been around 1–2 percentage points higher. Scots appear to be more likely to cite health as the main reason for inactivity than other factors, such as caring responsibilities.

Housing

Housing has a significant influence on health, including the quality of housing and its affordability. Housing quality relates to the actual physical state of a property and how suitable it is for residents. This can encompass a wide range of potential flaws, such as lacking sufficient insulation, being damp or mouldy, or containing risks such as trip hazards.

Housing affordability is the extent to which a household can meet the direct and indirect costs of housing, including rent and mortgage repayments, council tax and utilities. Housing affordability is associated with housing security but can also contribute directly to poorer mental health through stress and anxiety. Affordability can also create pressure on other elements of household expenditure associated with health, such as food or social participation.

Over the past two decades, the private rented sector has become a larger part of the housing mix in Scotland, as shown in Figure 10. This has direct implications for health via its impact on housing quality and affordability.

The increase in private renting also has implications for household finances. Housing costs have increased for social and private renters in absolute terms and as a share of income since devolution. Overall housing costs have fallen as a proportion of income in Scotland, but they have increased for families with the lowest fifth of incomes. Relative to the rest of the UK, housing costs in Scotland tend to be lower, which has helped to keep poverty rates lower.

Inequalities in housing costs exist between other groups of the population. Younger people and people from minority ethnic backgrounds are more likely to have higher housing costs. Disabled people are more likely to live in owner occupied or social housing and therefore have housing costs that are slightly below average.

Housing quality is generally worse in the private rented sector, although in the case of damp and condensation, local authority owned social housing performs poorly. These differences between groups and tenures will contribute to health inequalities either directly (in the case of conditions such as damp) or indirectly (in the case of financial pressures on household finances from housing costs).

Two decades of change

Scotland’s health trends over the past two decades present cause for both optimism and alarm. There are clearly concerning trends that indicate a lack of improvement in the decade before the pandemic and, in many cases, widening inequalities, with signs that the most disadvantaged are being left behind. This is underlined by increasing rates of extreme poverty.

Trends in the socioeconomic factors that influence health outcomes provide little indication that health inequalities will improve in future. Large-scale income and wealth inequalities have not changed and levels of job insecurity persist, deepening for some workers in less secure forms of employment.

But the 2000s show that progress in health, inequalities and advances in wider living standards are possible. That some aspects of health inequalities continued to improve rather than deteriorate in the past decade shows that, even in a more difficult context, stagnation and decline are not inevitable and progress can be made on these complex issues.

---

Scotland has the greatest powers of any of the UK’s devolved nations, with areas of responsibility including health and social care, education and elements of social security and tax. The extent of these powers means that the Scottish government holds many of the levers to improve health and reduce health inequalities

There are challenges to maximising the impact of existing powers, including increasing divergence in policy direction at Westminster and the broader context of weak economic growth. Scotland’s productivity levels have historically been lower than the rest of the UK and are now projected to grow more slowly in Scotland over the longer term due to an older population. Maximising the health of the population and reducing inequalities, while in itself an important aim, could also boost economic growth.

Despite these headwinds, failing to act could bring social and economic costs. Progress can be made by maximising the impact of action within current constraints. But doing so requires action across the whole of society – and collaboration across central and local government, public bodies, the voluntary and community sector, business and employers and the public.

Scottish powers

The powers available to the Scottish government have gradually increased since the Scottish Government Act 1998. The timing and evolution of these powers are important in understanding the extent to which Scotland has taken the opportunity to reduce health inequalities over the past two decades. They also show the opportunities for future action.

Most recently, the Scotland Act 2016 provided for control of rates and bands of income tax and elements of social security including disability and carer benefits and the ability to top up existing benefits. This resulted in the establishment of the Scottish Child Payment (set out in more detail in Box 2).

The relatively recent introduction of new social security benefits, and the limited utilisation of tax powers to date, mean that the full impact of these measures is as yet unknown. The combination of the two provides the potential for significant redistribution of income within Scotland, with the child payment an important step in this direction. But this could go further, for example by reforming the council tax regime in ways that simultaneously contribute to reducing inequalities in wealth while also providing increased revenues.

	Scotland Act 1998	Scotland Act 2012	Scotland Act 2016
Health and social services	Health (with some exceptions)
Education and early years	Education and early years		Maternal expense benefits
Employment and quality of work	Economic development Employment training and careers advice		Employment programmes
Living standards			Disability and carer benefits Top-ups of reserved benefits Discretionary housing payments Universal Credit – vary housing element and payment frequency Energy efficiency and fuel poverty Consumer advice and advocacy
Housing, sustainable places and communities	Local government and local taxes Sport, tourism and the arts Transport (with some exceptions) Housing and homelessness Environment Agriculture, forestry, fishing and food Justice, policing and fire service	Stamp duty and landfill tax	Onshore oil and gas licensing Further transport
Revenue raising powers	Limited variation of income tax rates	Capped infrastructure and resource borrowing powers Introduce Scottish rate of income tax	Rates and bands on non-savings, non-dividend income tax Air Passenger Duty and Aggregates Tax

Scotland does not own all the levers to improve health or reduce inequalities. Other factors may set constraints on what is achievable. But the extent to which Scotland uses the levers available will determine how far those external factors bite. Mortality trends will partly relate to external factors (such as economic growth and living standards) and longer term factors that predate devolution (such as changes in smoking or obesity prevalence).

A contradictory direction of policy travel between the Scottish and UK governments can act as a brake on progress. Or, as in the case of elements of social security and in tackling child poverty, resources in Scotland are diverted from other areas to mitigate UK government policy effects.

The ability of governments to act also extends to soft powers, whether to influence at other levels of government, delivery partners or business without using formal regulatory powers. For instance, in relation to business – which has an important impact on health through employment opportunities as well as the goods and services it produces – government can set standards of best practice, which for the Scottish government is shown in its commitment to be a living wage employer, as well as through other terms and conditions of employment being offered to staff or contractors.

The manifesto of the elected government sets the broad direction and tone for the type of society a country wants to be. Convening powers can be used to bring key actors together to agree aims, raise awareness or mediate issues.

Delivering with local government

The relationship between central and local government in Scotland is important in the effective delivery of the policies enabled by the Scottish government’s powers. However, stakeholders felt that delivery can be limited by a centralised approach to budgeting that led to multiple small pots being allocated for specific policy areas. Budgets also tend to be set year to year, reducing the scope for longer term planning.

The period of fiscal austerity means that Scottish local authorities have experienced significant funding cuts over the past decade. They have also had increased statutory requirements placed on them that had to be prioritised over the delivery of other functions. That said, compared with England, cuts to local authority funding in Scotland were smaller. This is because the Scottish government chose to allocate less spend towards the NHS than in England, enabling it to use the extra funding to reduce the scale of cuts elsewhere.

The implementation gap

Improving outcomes in any sector is consistently found to depend on the will to act, policies and ideas that are known to be effective, and the ability to implement these in a sustained manner. When it comes to improving health and reducing inequalities, action is needed across sectors. This places even greater emphasis on the importance of effective implementation and collaboration.

Public health policy since devolution

Since devolution, several health policy plans and strategies in Scotland have focused to a greater or lesser extent on tackling health inequalities, notably:

• Improving Health in Scotland: The Challenge in 2003 centred on individual risk factors such as obesity, tobacco and alcohol.
• Closing the opportunity gap in 2004 was a cross-departmental strategy aimed at reducing poverty with specific targets across employment, health, skills, income and recognised challenges in rural areas.
• Equally Well, the report of the Scottish government’s Ministerial Task Force on health inequalities published in 2008 set out a programme for change across key priority areas including early years, cardiovascular disease and cancer, drug and alcohol problems and links to violence, and mental health and wellbeing. Its implementation plan included the establishment of eight test sites with a cross-sector approach to service improvement, recognising progress could not be achieved through health care alone.
• Most recently the 2018 Public Health Priorities for Scotland and the establishment of Public Health Scotland in 2020, have provided a platform to set out national and local government priorities for health over the next decade.

Despite this sustained policy attention, inequalities in health remain wide. In part this reflects the tendency for the policy implementation stemming from these strategies to emphasise downstream interventions. Unless the upstream conditions that shape health inequalities are tackled, progress will be limited to trying to pick up the consequences of social and economic inequality.

Recognising the cross-sector nature of the action required to improve health and reduce inequalities, the reasons for this lack of progress were explored as part of this review. This involved a series of workshops, interviews and surveys with stakeholders from across the wider health policy system.

It was generally accepted that tackling historical circumstances and entrenched inequalities is not easy. Nevertheless, there was recognition of a difference between the policy intent and the reality on the ground for people experiencing services – a persistent and growing ‘implementation gap’ – ultimately resulting in communities facing increasing inequalities. This implementation gap was seen to arise in multiple ways and at different points through the continuum of policymaking – between intent, design, delivery and experience.

Why the lack of progress?

A survey of people working in the voluntary and community sector, delivery agencies and health services showed a strong recognition of an implementation gap, with 82% of those responding feeling it was a large or very large problem. This implementation gap was attributed to the following factors:

• Short-termism in planning: Already stretched budgets not being used most effectively because there is a failure to take a long-term approach to planning the best use of resources. This was related to the short-term nature of politics where rapidly designed policies are brought forward without enough time spent on understanding resourcing or delivery. It also reflects the annual budgeting nature of the Scottish block grant.
• A centralised approach to policymaking: While some policies – such as income redistribution – tend to benefit from centralised delivery, the coordination of more operational policy interventions tends to result in centralisation with a sense of micro-management of delivery from the centre. Community involvement in the policy development process is still too limited despite this forming a core part of policy rhetoric and widespread recognition of its importance. The efficacy of Community Planning Partnerships has been questionable and provisions in the Community Empowerment Act 2014 to promote and facilitate public participation in local decision making have not yet been fully exploited.
• Poor use of money in the system: Where there are separate pots of money for different policy priorities this can make it is difficult to deploy resources to reflect need in different local areas, or to adapt to emerging issues. It is not always the case that there is not enough money, rather that existing resources at times could be used to greater effect.
• Scaling up success: Examples of best practice and successful delivery exist but the level and quality of evaluation varies leaving a lack of understanding as to the impact of outcomes as well as more mechanistic delivery challenges. This hampers the ability to scale these either in different local areas or applying the approach to other policy areas. There has been little sign of change in the policy system to support the identification and greater take-up of successful approaches.
• Lack of coherence across policy areas: There was too little joining up between key policy areas where aims and outcomes aligned, preventing joint working. This approach is also built into operating structures and finances making it too easy to default to the practice.

Stakeholder participant:

‘Our policies are generally well conceived with the intention of trying to make a positive and progressive difference, but are not delivered, resourced or thought through well in terms of delivery. We lack the spaces in Scotland for long-term thinking that joins up investment, planning and resource allocation.’

Figure 13 shows the most-cited barriers to implementation in our survey were a lack of long-term and joined-up strategic thinking/planning (49%); insufficient resourcing, funding and investment (47%); and short-termism in politics and consequent risk aversion (31%).

Three broad themes emerge in relation to the perceived barriers to implementation, from both the survey and in-depth discussions undertaken during the review.

• 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.
• A lack of trust 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.
• The need for a growing maturity of the policy system. This was shown in several ways including the need for greater evaluation of what has worked, what has not and why. It was felt that policymaking was not led enough by evidence, with insufficient effective use of data and evidence in decision making and policy design. People perceived the lack of an independent voice, scrutiny, and challenge, with a fear of failure throughout the system preventing innovative approaches to delivery.

Business also plays a key role in determining health, through generating employment opportunities as well as the goods and services it produces and the way in which products are marketed. These can all have powerful positive and negative impacts on health and must be part of any successful society-wide approach to improving health and reducing inequalities. One such example, which was beyond the focus of this review, is the critical role businesses play in shaping the food environment. In Scotland, this currently fails to support access to healthy food with excessive calorie intake leading to higher obesity rates.

The cost of inaction to both individuals’ health, and ultimately the economy and public services, means that achieving the maximum within existing constraints should be a priority. And all sectors need to play a role. Some barriers can be more easily overcome within current parameters, while others will require longer term reform to improve the parameters of the system in which people operate.

The context for delivery in Scotland

Many of the issues highlighted apply in other nations and places. There are two features of the Scottish context that are important to consider in understanding the implementation gap.

Geography

Scotland is the least densely populated country in the UK. It has a greater share of sparsely populated countryside with its most populous areas concentrated in the lowlands – the south and south-east coast. The largest urban areas have smaller populations than the largest in England and there is a much smaller share of medium-sized towns. This presents challenges for provision of public services given disperse populations and fewer large population centres to achieve economies of scale. Public service delivery has historically been higher on a per capita basis than on average in England, which may partly reflect these additional delivery costs.

Figure 14 shows how period life expectancy at birth and the range of period life expectancy at birth within an area vary across local authorities. The range of life expectancy is measured by the absolute difference in life expectancy at birth between the least and most deprived 20% of neighbourhoods within a local authority. The figure also shows the rural-urban classification that applies to the largest share of the population within a local authority. The size of the bubble denotes population size. It highlights that lower life expectancy is correlated with higher inequality in life expectancy, but there is no clear pattern associated with rural-urban classification or population size.

Glasgow City and Dundee City are predominantly large urban areas with below average life expectancy and above average absolute inequality in life expectancy. North Lanarkshire, West Dunbartonshire and Inverclyde also have relatively low life expectancy and high absolute inequality in life expectancy but are predominantly classified as ‘other urban areas’. East Lothian and the Scottish Borders are examples of predominantly accessible rural areas with above average life expectancy and below average inequality in life expectancy.

Within local authorities health outcomes and levels of deprivation can also vary significantly. Urban areas tend to have concentrations of both very deprived and very advantaged populations. Less populated rural areas tend not to contain the most deprived neighbourhoods, and some areas have none.

There are also significant variations in socioeconomic outcomes between different local areas in Scotland. For instance, 24.6% of children living in Glasgow City live in child poverty compared with 8.3% of children living in East Dunbartonshire. There is also wide variation in economic inactivity rates. In Midlothian, 83.7% of 16–64 year olds were economically active, compared with 69.4% in North Lanarkshire.

A National Performance Framework

The National Performance Framework provides a set of outcomes aimed at creating a future Scotland that reflects the country’s values and aspirations. It can also track progress in reducing inequality. The framework is broadly aligned with the United Nation’s sustainable development goals. It also provides an opportunity to focus action across the policy system.

The framework gives a range of detailed indicators designed to encourage progress towards a wider goal. For instance, the broad goal ‘children and young people growing up loved, safe and respected so they realise their full potential’ has a supported indicator (one of several) of equality of children services, measured as the percentage of settings providing funded early learning and childcare achieving Care Inspectorate grades of good or better across four themes.

Stakeholders suggested that the focus of policy delivery tended to be on achieving improvements in previously identified specific metrics, rather than coming back to broader aims, such as improving children’s wellbeing and development. The consequence was felt to be a lack of accountability across different actors in the system for the broader aim, a sense of disempowerment when a different approach – outside of the metrics – could help achieve the wider aim, and failing to recognise opportunities for joint action across the system that could lead to greater overall improvements.

Stakeholder participant:

‘We have the National Performance Framework, but we don’t use it well enough. We should use this more proactively to inform and drive decision making and resourcing across existing silos or organisational structures.’

Building support for a radical shift in action

Deliberative work with the public conducted as part of this review has shown appetite for more radical action on health inequalities. Effective public support could help to galvanise a longer term preventative approach to tackle the fundamental drivers of health inequalities. A focus on lifestyle factors and acute health need is not inevitable. Rather our panel have called on government to lead a national conversation for a long-term, strategic, cross-sector approach. This echoes the calls of stakeholders shown in Box 4.

The cost of inaction to both individuals’ health, and ultimately the economy and public services, means that achieving the maximum within existing constraints should be a priority. Effective policy development and delivery is difficult, and success often requires sustained, long-term action, leading to gradual change. However, the latest report from Audit Scotland emphasises the need for immediate and extensive public service delivery reform if policy goals are to be successfully met within tight fiscal constraints.

The final section concludes by setting out a future path for making greater progress in improving health and reducing inequalities in Scotland, arguing for a radical shift in the scale and pace of policy delivery.

---