What is holding back progress?


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.

Box 2: The gradual devolution of powers to Scotland


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


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.

Box 3: The Christie Commission

Reporting in 2011, the Christie Commission set a vision for the effective delivery of public services in Scotland. Many of today’s delivery difficulties demonstrate the significant progress needed for that vision to be realised. Many of the core principles set out chimed strongly with the issues blocking progress on health inequalities identified in this review.

Key principles of reform from the Christie Commission

The commission looked across the whole field of public service delivery, rather than specific aspects of public service reform. The work examined the challenges, obstacles and opportunities for public service policy and delivery. The commission mapped out a way forward for the reform of public services in Scotland. This included recognition of how services should be designed and then implemented, to identify and understand a particular issue.

The approach can be summarised by the following four priorities:

  • People: Reforms must aim to empower individuals and communities by involving them in the design and delivery of the services.
  • Partnership: Public service providers must work more closely in partnership, integrating service provision to improve their outcomes.
  • Prevention: Expenditure must be prioritised on public services which prevent negative outcomes.
  • Performance: The public services system – public, third and private sectors – must reduce duplication and share services to become more efficient.

A 10-years-on roundtable identified a lack of sufficient progress. It concluded that achieving greater progress in the delivery of public services in Scotland requires a shift to more preventative action, delivery at a local level and by local actors, with a greater level of public scrutiny.

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.


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.

Box 4: Principles for tackling health inequalities in Scotland from public and stakeholder engagement

Deliberative public engagement

  • Use robust evidence and expertise on the most effective ways to tackle health inequalities to develop impactful interventions.
  • Work in collaboration across political parties to develop a long-term plan for tackling health inequalities in Scotland to ensure consistency and continuity, rather than adversarial politics.
  • Develop an effective and viable strategy to tackle health inequalities in Scotland that brings together all relevant stakeholders, including experts, practitioners (from health care and community services) and members of the public.
  • The Scottish government should lead and stimulate a national conversation around health inequalities rooted in principles of fairness, and with transparency and honesty around its decision making.

Stakeholder workshops and interviews

  • To get better at learning from different actors within the policy delivery system, understanding what works in different places and why as well as learning from international examples.
  • Take a longer term approach to policymaking and service resourcing.
  • Get better about sharing what works and how to deliver it across different localities.
  • Be much more radical about the kind of change we want to see both in terms of structural change, operational change (with a recurring theme being the need for more relational and preventative services) and cultural change in terms of pooling resources and sharing accountability openly.

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.

‡‡ University of Glasgow. The Christie Commission 10 Years on: Reflections on progress and areas for action; 2021. www.gov.scot/publications/commission-future-delivery-public-services/pages/4

Previous Next