We would like to thank all who have contributed to, supported and engaged with our independent review of health inequalities in Scotland. This particularly includes:

• The advisory group for their time, expertise and insights which have helped to steer the research and conclusions of the review: David Bell, Sarah Davidson, Cam Donaldson, Anna Fowlie, Mubin Haq, Katie Kelly, Michael Marmot, Jim McCormick, Dona Milne, Shantini Paranjothy and Carol Tannahill.
• Partner organisations who have provided such a comprehensive evidence base, guidance and for their commitment to the project: Anna Pearce, Gillian Fergie, Naomi Miall, David Eiser, Emma Congreve, Ciara Crummey, Allison Catalano, Katherine Smith, Adam Lang, Frances Bain, Grant Collinson, Mark Diffley, Nik Heslop, Fiona Hutchison, Lucia Mackenzie, Megan Dickson, Andy Maciver, Louise Robertson, Alison Moore, David Hawkey, Casey Smith and Philip Whyte.
• Participants in the deliberative panel and attendees at stakeholder workshops and roundtables to help inform various research strands and to shape our final conclusions and a further phase of work.
• Colleagues at the Health Foundation who have helped deliver the review and inform our conclusions: Carolyn Mill, Rita Ranmal, Beth Kay, Sean Agass, Jenny Cockin and Nadia Kalam, Jennifer Dixon.
• Finally, we would like to thank Chris Creegan for his guidance, support and wisdom throughout the review – it has been invaluable.

Leave no one behind: The state of health and health inequalities in Scotland is published by the Health Foundation.

When referencing this publication please use the following URL: https://doi.org/10.37829/HF-2023-HL01

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

About this review

Rooted in Scotland and informed by Scottish experts, this review brings together evidence of trends in health inequalities and wider determinants of health over the past two decades since devolution.

It explores public perceptions of what affects people’s health and what future action they support to tackle health inequalities. It also draws on perceptions of barriers to progress from people working in the voluntary and community sector, public bodies and health services. This material is drawn on extensively in this report and is the source of evidence unless otherwise referenced.

The review aims to support improvements in health and health inequalities in Scotland, providing a picture of past and present health and inequalities to inform future efforts to improve both.

Our research partners

The Health Foundation has worked with four research organisations in Scotland as part of the review:

• The MRC/CSO Social and Public Health Sciences Unit, University of Glasgow synthesised a wide range of existing data and new analysis including trends in social inequalities in health, health-related behaviours, and health and social care services in Scotland.
• The Fraser of Allander Institute analysed trends in the wider determinants of health such as work, education and housing, and how these are experienced differently across the population.
• Nesta in Scotland conducted in-depth workshops with health-related stakeholders to help understand implementation challenges for policy and delivery services that support better health.
• The Diffley Partnership undertook a series of deliberative workshops with members of the public, exploring public perceptions of the reasons behind health inequalities, informed by the evidence from the other strands of research. A survey of stakeholders supported Nesta in Scotland’s qualitative work.

The public engagement project was complemented by a review of existing research on lay perspectives of health inequalities and determinants of health in Scotland, conducted by the School of Social Work and Social Policy at University of Strathclyde.

A further research project delivered by IPPR Scotland set out the extent of devolved powers in Scotland and produced a set of case studies to draw insights about policy implementation.

These projects, the interpretation of the evidence and the conclusions drawn in this report have been guided by our advisory group, bringing together experts from across academia, civil society, delivery and policy.

Scope and structure of this report

This report sets out the key findings and conclusions of the review, drawing on and synthesising evidence from each of the funded research projects. It concludes by considering how Scotland can build on strong policy intent to reduce stubbornly high inequalities in the socioeconomic determinants of health and create a sustainable approach to closing the gap in health outcomes.

• Section 1 provides the background and context in which the review and associated research projects are situated.
• Section 2 sets out key trends and inequalities in health and social and economic determinants of health over the past two decades.
• Section 3 explores core reasons underlying current health trends and inequalities.
• Section 4 considers key risks to future health and inequalities in Scotland.
• Section 5 discusses public perceptions of health inequalities and the views of policy and delivery stakeholders on the barriers to implementation.
• Section 6 concludes by setting a direction of travel for making progress in tackling health inequalities.

The health of the population is one of any nation’s greatest assets. Good health is a prerequisite for prosperity and a flourishing society – allowing people to play an active role in their communities and the economy. A failure to maintain and support good health can reduce people’s ability to work, or reduce their productivity at work, limiting economic potential.

A person’s health is largely determined by their day-to-day experiences and the places in which they live, work and grow. Almost every aspect of life shapes health and longevity – our jobs and homes, access to education, the quality of our surroundings and whether we experience poverty. These are called the wider determinants of health.

The inextricable link between health and wealth has been evident through the COVID-19 pandemic and the current cost-of-living crisis. Both have brought underlying poor health and structural inequalities to the fore. COVID-19 mortality rates were over twice as high in the most deprived areas, driven by poorer underlying health and increased risk of exposure to the virus. As the cost-of-living crisis bears down, the poorest families are least able to cope with higher costs of food and fuel. These crises are exacerbating long-established health inequalities, placing greater urgency on the need for comprehensive and sustained action across society.

Increased wellbeing and sustainable development are part of the core purpose of Scotland’s National Performance Framework, which includes health as one of 11 national outcomes. This encompasses several national indicators including healthy life expectancy and premature mortality. The other 10 national outcomes include fair work and business, education, children, the economy and poverty. Each of these in turn encompasses indicators that relate to the wider determinants of health, such as secure work, educational attainment, child social and physical development, income inequalities and wealth inequalities.

Working to achieve such goals means that Scottish government policy is implicitly and explicitly focused on improving health and reducing inequalities.

From devolution to 2020

In the 22 years since devolution the powers available to the Scottish government have gradually increased. Alongside devolved power for the NHS, social care and public health, many of the policy levers that shape the determinants of health, and decisions over where resources are focused, are now held by the Scottish government.

There are potential limitations in the efficacy of these powers given the significant policy levers still held by the UK government, and other influences that sit outside the direct scope of government. For instance business has a significant influence on health through procuring employment opportunities, and the quality of that work, as well as the goods and services produced.

Over this period, the Scottish government’s approach to developing and implementing policy has evolved. So too have its relationships with local government, the voluntary and community sector, public bodies and the public.

Devolution followed a half century of significant economic change. Deindustrialisation led to a large move away from employment in sectors including mining, quarrying and manufacturing, shifting instead towards retail and services. The service sector orientated economy brings with it increased risk of job insecurity and low pay. The longer term consequences of deindustrialisation play out in the pattern of inequalities in Scotland with earnings inequality widening as a result of economic structural change. Areas once dominated by heavy industry are now more likely to have higher levels of deprivation. This shift underlies differences in health in other parts of the UK (and other countries), but the greater health inequality in Scotland suggests the population is more vulnerable to the health consequences of disadvantage. Research suggests that while there have been similar industrial declines in other parts of the UK, in Scotland the population has been left behind.

Recent decades have also seen a shift in risk bearing, and with it higher insecurity for individuals. This is evident in forms of employment contract and reduced ability to acquire assets for the younger generation, including home ownership and final salary pension arrangements. The aftermath of the 2008 financial crisis reinforced a pre-existing trend of stagnating productivity growth, which led to little improvement in living standards over the past decade. After a decade of little progress, the economic situation has been weakened further by the COVID-19 pandemic followed quickly by the cost-of-living crisis.

Significant political events and developments – such as the independence referendum in 2014, followed by Brexit and the shifting make-up of governments at Holyrood and Westminster – mean that the ongoing debate about Scotland’s constitution has remained high on the agenda. This has contributed to a consistent divergence of policy direction between the Scottish and UK governments.

Life expectancy

Against this backdrop, the story of Scotland’s health has been mixed. In 1998–2000, period life expectancy at birth (a measure of current health)* was 75.6 years in Scotland. By 2017–19 it had reached 79.1 years, but there was no improvement after 2011–13. Largely reflecting deaths related to COVID-19, life expectancy fell to 78.7 years in 2019–21. Scotland has had the lowest life expectancy of UK nations since the 1950s and its ranking compared with other western European countries has fallen.

Inequalities in life expectancy were widening in the years before the pandemic, as shown in Figure 1. Between 2013–15 and 2017–19 the gap in period life expectancy at birth between people living in the least and most deprived tenth of local areas widened by 1 year to 13.3 years for men, and by 1.7 years to 9.8 years for women.

Cohort life expectancy better captures how long people are expected to live by reflecting the expected mortality rates at each age of their future lifetime. Using this measure, the expected lifespan of people born in Scotland in 2012 has fallen by 4.4 years over the past decade.

Figure 2 shows that projected cohort life expectancy at birth has been revised down from 90.4 years for the 2012 birth cohort (under 2012-based assumptions) to 86 years under 2020-based assumptions. In cohort projections the impact of the COVID-19 pandemic is minimal because mortality rates at older ages relate to future years rather than pandemic years.

The stalled progress in health improvements over the past decade is mirrored by stalled progress in living standards. For example, typical household incomes are no higher than they were before the financial crisis. Given long-term health outcomes are a consequence of experiences over the lifetime, the past decade of little improvement in incomes is likely to act as a drag on future improvement in health.

The overall lack of progress on health and widening inequalities comes despite continued policy focus and detailed surveillance and data collection. There remains a gap between policy intent, delivery and the extent to which this has led to meaningful change in people’s lives. Recognition of the scale of existing inequalities, and the need for greater collaboration between areas of government policy and delivery, were among the core conclusions of the Health, Social Care and Sport Committee health inequalities inquiry in 2022.

Crises have exposed existing societal fault lines

The COVID-19 pandemic was an unprecedented shock to health: directly through increased mortality and infections; indirectly through the restrictions put in place to reduce the spread of the virus. The full consequences for health inequalities are yet to be fully understood. The cost-of-living crisis, which is set to leave household finances in a worse position than the pandemic, presents a further risk to health.

Recent crises have added greater pressure to already strained public services and follow a period of austerity, as part of efforts to reduce UK borrowing in the wake of the financial crisis. This had left services in a fragile state by 2020. Audit Scotland has highlighted the need to reform public services so that they are ‘delivered to people in a way that more effectively meets both their needs and the government’s policy aspirations’.

These crises have affected the population largely along existing societal fault lines – with the most disadvantaged tending to experience the worst outcomes. Action to remedy the structural inequalities that cause such disadvantage would increase resilience to future shocks. The scale of the challenge in doing so, however, and of sticking to the long-term action required, cannot be underestimated. But there is public support for doing more to invest in health and activities that support good health.

Recent attitudinal data show the British public increasingly favour raising taxes to spend on health, education and social benefits. Figure 3 shows that there has tended to be a greater level of support for this in Scotland. When the same question was asked of the Scottish public in 2021, 64% were in support compared with 52% in Great Britain.

The next section details the key trends and inequalities in Scotland’s health over the past two decades, as well as the social and economic determinants of health.

Health inequalities are largely a consequence of differences in people’s living conditions and experiences through life. Inequalities in power, money and resources at a local and national level can make people’s daily lives more challenging. In turn, this can make people more vulnerable to poor health.

In 2018–20, there was a 24-year gap in healthy life expectancy between people living in the least and most deprived 10% of local areas in Scotland. This inequality has been widening since 2015–17, due to worsening trends among more disadvantaged groups.

Poorer health in Scotland is concentrated in areas with higher levels of deprivation, with little improvement in the past decade. This is related to three underlying factors:

• The accumulation of severe multiple disadvantage is associated with much higher rates of mortality, with people experiencing this tending to live in the most deprived areas.
• The limited extent to which people can improve their living standards due to a long period of wage stagnation and in comparison to their parents.
• The past decade has been typified by a period of austerity, which has left public services and social security in a fragile state and reduced the extent to which these elements of provision have been able to support healthier lives.

Multiple disadvantage

Living in more deprived areas, living in a lower income household, having low or no earnings and insecure work, or living in poor-quality housing leads to worse health outcomes. Experiencing two or more of these factors creates an even greater risk to people’s health. This is likely because there are strong associations between the factors and how they interact. For instance, having low income may lead to living in poor-quality housing and both have negative effects on health, compounding disadvantage.

Severe forms of disadvantage include (but are not limited to) homelessness, opioid dependence, imprisonment and psychosis. A data linkage study considering adults living in Glasgow between 2010 and 2014 found that 1 in 20 adults experienced at least one of these severe forms of disadvantage. Experience of one or more of these is linked to significantly higher mortality rates, while the impact on mortality of experiencing two or more is greater still.

A further study from 2019 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. Greater numbers were estimated to have these experiences over the life course (21,000 all three, 226,000 two and 876,000 one) with homelessness the most common of these experiences. The highest risks of multiple disadvantage were associated with being younger than 40 years, single, white and male. People experiencing multiple disadvantage are also more likely to be concentrated in more deprived areas.

Qualitative evidence also suggests that people with multiple disadvantage are more likely to have adverse experiences throughout their lives, from childhood through to young adulthood. There is also evidence of greater exposure to violence for people who experience severe multiple disadvantage in a range of settings – home, school and local communities. Violence is a factor that can be difficult to capture through surveys or crime data because both will to some extent rely on self-reporting. But violence is consistently reported as a factor driving health inequalities in qualitative studies.

Even where health-related behaviours are distributed more evenly between people living in areas with different levels of deprivation, related health outcomes are worse in more deprived areas, suggesting that other exposures leave people in those areas less protected from worse health outcomes. This is the case when comparing alcohol consumption to the pattern of alcohol-related deaths and comparing physical activity rates to the pattern of obesity rates in children.

Stagnation in living standards

Better living conditions, greater access to opportunities such as extracurricular activities, help and support with negotiating systems such as higher education or finding a higher paid job, can all contribute to a healthier life. However, the long period of wage stagnation has limited the extent to which people can improve their living standards. In 2019/20 median household income in Scotland was £70 per week lower than if pre-2010/11 growth trends had continued. Such a pattern can be exacerbated by the accumulation of poorer health associated with worse socioeconomic outcomes.

As in the rest of the UK, the 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 than people with parents who did not. There is no evidence that occupational mobility between cohorts is increasing.

People who grew up in a household where nobody was in work are themselves more likely to be out of work, and much more likely to have poor health when adults. That more limited income due to a lack of work increases the likelihood of experiencing poor health can become self-reinforcing. Poorer health can in turn limit chances of being able to work or to find work.

Through life, the household income§ that people experience fluctuates, moving between higher and lower levels of income, which may reflect changes in household composition or employment and pay. However, some people experience persistently low income. Almost two-thirds of households with the lowest 10% of incomes in 2010/11 still had income among the poorest 30% of incomes 10 years later. Over half of people (56%) in the bottom 30% of incomes in 2010/11 were still in that part of the distribution 10 years later.

Fragility of public services and fiscal austerity

Public services play an important role in building and maintaining good health across a wider range of mechanisms including education, housing and employment, as well as health and social care services. The quality and accessibility of public services plays a role in determining the extent that the factors discussed – multiple disadvantage and a lack of social mobility – are allowed to form or persist.

In the decade prior to devolution, there were sustained real-terms increases in public spending. But austerity policies in the 2010s 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 it had been in 2010/11, and only just returning to 2010/11 levels by 2019/20.


Health and social care

Spending on health care in Scotland is now 4% higher per person than in the rest of the UK, falling from 10% higher in the 2000s. It has previously been estimated that relative to the rest of the UK, Scotland requires around 10% more per person funding due to differences in the population’s age structure and additional health needs. In the decade to 2009/10, the Scottish government increased health spend¶ by an average of 5% a year in real terms. Between 2010/11 and 2019/20, increases in average spend reduced to 1% a year in real terms, despite the Scottish government estimating that real-term increases of 3–4% a year would be necessary to meet demographic and cost pressures. By 2019/20, health spending in Scotland was £3bn to £4bn lower than it would have been had it grown at 3–4% per annum from 2009/10.

There is no evidence that reductions in health care spending were offset by increased social care activity – per capita spending on social care had been broadly flat for most of the last decade. This slowdown in health spending is arguably the channel by which austerity made its most immediate contribution to Scotland’s stalling of mortality improvements between 2012 and 2019. This is because it had a direct impact on the ability to maintain the quality of care and support for people with acute health needs.

Local government spending

The core local government revenue settlement reduced by £750m in real terms between 2013/14 and 2017/18, equivalent to a 7% real-terms reduction. This led to real-term cuts for public services funded by local government, although these were lower overall than in England due to the greater priority for additional funding placed on health services in England. As shown in Figure 11, cuts were not experienced evenly. Spending on schools and social work were back at 2010/11 levels by 2021/22, although schools experienced several years of reduced spend. Spending on environmental services fell by 10%, while roads and transport, planning and economic development, and cultural services by over 20%.

Regardless of efforts by local authorities to increase efficiencies to meet the demands of reduced budgets, spending cuts on this scale will lead to a reduction in the level or quality of service provision. While these may not have a direct and immediate impact on mortality, cuts to services can have an immediate impact on health through reduced provision of services such as free school meals and children’s centres. And over a longer term, an indirect impact on health by limiting education provision and reducing the quality of local community services and the environments that people live in.

Austerity and health

Estimating the effect of austerity measures on health is complicated. This is because of the variety of ways different factors can be affected by austerity and then in turn can influence health in different ways; the time lags between changes in spend and the eventual impact on health; and the various ways in which services may have been altered. The most immediate direct impacts are likely through reduced access to or quality of services such as health care, social care and public health that have a direct impact on the most acute health need and mortality. An impact on broader health outcomes, such as mental health or longer term effects on mortality, is more likely through provision affecting the wider determinants of health, such as education, housing, and social security support.

The longer term deterioration in funding and the quality of services has also reduced the resilience of institutions, communities and individuals to cope with future shocks. Consequentially, individuals with acute health need have an increased mortality risk and people experiencing disadvantage are at greater exposure to the impact of shocks, such as the cost-of-living crisis.

Some population groups are experiencing deteriorations in several different health outcomes or influences at the same time, compounding the likelihood of persistent, or even widening, health inequalities. These range from early childhood development to the impact of the cost-of-living crisis and access to services for acute health need. It is a significant cause for concern that these factors appear to combine, leaving people in the most deprived areas to fall further behind.

Failing to take early action 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 challenges for people living day-to-day with poor health. Understanding how these factors are combining to create a greater risk to health than any one taken in isolation – and often the cumulative affect amplifies the risk – can guide policy attention where it is most needed.

Children not getting the best start in life

Early childhood development and the school years play a crucial role in determining future health. Poor outcomes in childhood can continue to have significant implications in life. For example, school readiness affects educational attainment, eventual access to job opportunities and can negatively affect lifetime income and ultimately health.

There are already wide health inequalities in the very earliest stages of childhood. These are compounded by inequalities in determinants of health which, if unaddressed, risk a further relative deterioration in health for the most disadvantaged children. In the past decade, inequalities have widened for infant immunisation uptake, infant mortality, low birthweight and childhood obesity.

Since 2013, while the proportion of 27–30-month-old children with development concerns has fallen across all levels of deprivation, the rate of fall has been faster in the least deprived areas compared with the most deprived areas. Relative inequalities have slightly widened and outcomes of children from the most deprived areas in 2019/20 only matched outcomes of the children from the next deprived fifth of areas recorded in 2013/14.

There is also a significant poverty-related attainment gap for primary school pupils in Scotland: pupils living in the most deprived fifth of local areas have lower levels of educational attainment than those from less deprived neighbourhoods. This has not closed over the past two decades. A similar gap exists for secondary age children and, despite signs of an improvement by 2019/20, the impact of the pandemic has reversed any progress.

These inequalities are a result of the circumstances in which children live, including child poverty. This has likely been exacerbated by the cost-of-living crisis. Families with children are also increasingly likely to live in the private rented sector, which tends to be of lower quality and affordability than other tenures.

Men in the poorest communities

Young to middle-aged men in Scotland are at particular risk of poorer health. There has been declining engagement with health services among this group, who are most likely not to attend hospital appointments.

This group is also the most likely to suffer from deaths of despair,** with the exponential rise in drug deaths concentrated among men in their mid-30s to early-60s. Within cohorts the greatest risk of drug deaths is for people in their 30s. Suicide, alcohol and drugs are leading causes of death for men aged 15–44 years. For this age group they also account for two-thirds of absolute inequalities in total mortality. This greater risk of deaths of despair relates to a higher likelihood of experiencing multiple disadvantage (discussed in Section 3). Being younger than the age of 40 years, single, white and male was most strongly associated with experiencing severe multiple disadvantage.

Economic trends also point to younger men being at greater risk of poor health in the future through reduced earning potential. Meanwhile the gender gap in higher education participation is wide and has been growing over time. By 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 fell by 7 percentage points, from 65% to 58% between 2004 and 2019. Men born since 1985 have started work in lower paid occupations than cohorts that came before them and are less likely to experience earnings progression in the following years. Young men are more likely to work in lower paid and part-time roles in the service sector than previous generations, who were more likely to work in manufacturing roles.

Declining access to preventative health care and treatment

In Scotland, use of some preventative services has been declining, with greater falls among people living in the most deprived areas. For example, childhood immunisation rates – previously a success story in Scotland – are falling and differences in rates between the most and least deprived areas have been widening. For women there have also been worrying declines in overall rates of cervical screening.

There have been some improvements such as in timely antenatal screening and take up of bowel screening, though in the case of the latter rates in the most deprived areas still fall below national targets.

In some areas there has been little change in outcomes in the past decade. Amenable mortality rates (ie deaths that can be prevented by treatments after the onset of disease) were improving in the 2000s, but the past decade has seen little progress. Amenable mortality rates in the most deprived fifth of areas have only caught up to where rates in the next most deprived fifth of areas were in around 2007. Inequalities have remained wide. Amenable mortality in the most deprived fifth of areas is almost three times that in the least deprived.

Regardless of changes over the past two decades, wide gaps remain in the rate of access for treatment between people living in the least and most deprived areas. Even where improvements have been made in bowel screening and missed hospital outpatient admissions, for example, access for people in the most deprived areas is still worse than in the least deprived areas two decades ago. Multiple emergency admissions have remained over twice as high in the most deprived fifth of areas compared with the least.

Barriers to accessing health care services that create inequalities include the extent to which the timing and flexibility of appointments align with people’s lives, mistrust of services and whether people realise that an ongoing health problem requires treatment. Without meaningful change to service provision, these longstanding inequalities will remain and leave a significant risk of harm to those with acute health who do not receive treatment.

Similar to the situation in England, the NHS in Scotland continues to be under huge pressure with increasingly long waits in emergency departments and delays in treatments. This will make progress on delivering services more challenging. Dealing with the COVID-19 pandemic meant refocusing limited resources, which led to a backlog of planned treatments or new assessments. Social restrictions also reduced the extent to which people accessed health care. Explanations for increased delays also include a lack of capacity, both from staffing and physical capacity within hospitals due to a shortage of social care capacity. Longer waits or an inability to access treatments risks worsening health and deepening existing poor health.

The impact of the cost-of-living crisis on the poorest

The cost-of-living crisis will have a greater impact on the poorest households who spend a much greater share of their budgets on essentials. These essentials – such as food and fuel – are experiencing the greatest rises in cost. This will have significant impact on health through limiting individuals’ ability to afford basics and necessities for a healthy standard of living, such as a warm home and enough nutritious food.

Increased financial strain also risks a greater share of people across the income spectrum falling into problem debt. This may also increase the burden of mental health issues through stress and anxiety.

Significant mitigation has been put into place by the UK and Scottish governments. The UK government has implemented an Energy Price Guarantee equivalent to £2,500 a year, rising to £3,000 from April. It is also providing a number of lump sum payments giving additional financial support to lower income, disabled and pensioner households. It has also committed to the usual uprating practices of increasing working-age benefits by CPI inflation and to maintain the state pension triple lock.

The Scottish government has gone further by including an additional child payment to low-income families, a Winter Heating Payment Allowance and measures to prevent problem debt and evictions. Despite these efforts UK household incomes are expected to drop by 7% between 2021 and 2023, primarily due to high inflation. It remains uncertain how families will be able to cope particularly given that the pandemic has left many families, especially low-income and single-parent families, in a less resilient position for further financial shocks.

Outcomes for the most disadvantaged communities are becoming detached from the majority

Across all health indicators, people living in the most deprived areas have the worst outcomes. There is a similar pattern in health outcomes across areas of social disadvantage, such as income and occupational status. This is a well-established pattern, with the health gap between the most deprived 20% and the next most deprived fifth often greater than between any two other adjacent groups. Of particular concern is the widening gap in health between people living in the most deprived fifth of areas and the rest of the population over the past decade.

Figure 12 shows how this gap – whether relative, absolute or both – has widened across a range of health measures.†† This is shown most starkly in the greater rate of drug deaths among people in the most deprived areas. Between 2001 and 2020, the overall rate of drug deaths increased from 6.2 per 100,000 to 25.1 per 100,00. This has been driven by the increase in deaths in the most deprived areas, reaching 68.2 deaths per 100,000 people by 2020 – this is18 times as high as in the least deprived areas.

In the area of child health, the absolute gap in MMR vaccine uptake in 24-month-olds between the most and least deprived areas has increased from 0.8% in 2014 to 4.5% in 2021 – driven by an increased uptake in less deprived areas. For infant mortality, rates have improved or stayed steady for all except those in the most deprived areas where there has been an increase in infant mortality rates since 2015. The gap in the risk of childhood obesity between most and least deprived areas had increased to 7 percentage points by 2019.

Overall improvements in the prevalence of smoking during pregnancy have led to a widening of relative inequalities. The absolute difference between women living in the most and least deprived fifth of areas has fallen, but because it has fallen faster in the least deprived areas, relative inequalities have widened. The prevalence of smoking during pregnancy was over 10 times higher among pregnant women living in the most deprived fifth of areas compared with the least in 2020. There is a similar pattern in the prevalence of children with early development concerns at age 27–30 months and birthweight.

An exception is adolescent mental health outcomes, where the gap between the most and least deprived has closed. However, this is because the share of people in the least deprived areas with mental health problems has increased, leading to a ‘levelling down’.

In the case of drug deaths and the risk of childhood obesity, the gap between the second and third quintile is also growing. This suggests there are early signs that this widening of inequalities is no longer predominantly confined to the most deprived areas.

These trends, as demonstrated by Figure 12, are concerning as they suggest that the experiences of people living in the most deprived areas will lead to increasingly worse health outcomes compared with other groups, storing up further problems for the future.

Even where risk factors and behaviours are distributed more evenly, actual health outcomes are worse in more deprived areas, suggesting that other exposures and multiple factors mean people are less protected from worse health outcomes than other groups. This implies policies and interventions that focus only on health behaviour change (such as reducing alcohol consumption or increasing physical activity) are unlikely to have a meaningful impact on health inequalities.

Early action can prevent inequalities widening further

There are clear emerging trends that appear to be exacerbating health inequalities. If left unaddressed these are likely to widen further in future. Some outcomes are longstanding where insufficient progress has been made historically, such as education and inequalities in accessing health care services. Others are the result of emerging trends, such as the decline in younger men’s health, or stem from more immediate developments, such as the cost-of-living crisis.

These outcomes are contributing to a broader and concerning trend that people living in the most deprived areas are falling further behind everyone else. Immediate action is needed to reverse the lack of policy delivery progress of the past decade to head off and reverse these trends.

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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Research published as part of the review

Diffley Partnership. Health inequalities in Scotland: Public engagement research. Report by The Diffley Partnership; 2022 (www.diffleypartnership.co.uk/wp-content/uploads/2022/12/health-inequalities-panel-report-diffley-nov2022.pdf).

Fraser of Allander. Health inequalities in Scotland: Trends in the socio-economic determinants of health in Scotland; 2022 (https://fraserofallander.org/publications/health-inequalities-in-scotland-trends-in-the-socio-economic-determinants-of-health-in-scotland).

IPPR Scotland. Tackling the social determinants of health inequalities: A review of Scottish powers; 2023.

IPPR Scotland. Translating ambition into outcomes: A review of three policy case studies; 2023.

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow. Health inequalities in Scotland. Trends in deaths, health and wellbeing, health behaviours, and health services since 2000; 2022 (www.gla.ac.uk/media/Media_892338_smxx.pdf).

Nesta. Review of health inequalities in Scotland: Stakeholder engagement insight; 2022 (https://media.nesta.org.uk/documents/Review_of_Health_Inequalities_in_Scotland_Stakeholder_Engagement_Insight.pdf).