Last month the Health Foundation concluded its independent review on health inequalities in Scotland – its past, present and future challenges. At a seminar, the review’s stark findings came under the spotlight. Along with strong impetus for action, one question Scotland’s story of health inequalities was discussed by all panellists: why has progress been slow?

In this review of that meeting, healthandcare.scot reports on the call to address austerity, and for the Scottish government to lead by adopting bold long and short-term strategies to close the gaps between most and least deprived.

As the Health Foundation condensed the findings from across expert groups on the state of health and health inequalities into a final 70-page report, the story of Scotland’s widening health inequalities unravelled.

Introducing the report ‘Leave no one behind’, the Health Foundation highlights the 24-year gap for living in good health between Scots in the most deprived and least deprived 10% of local areas in 2019.

On the review’s findings, Chair of the expert advisory group, Chris Creegan opened the session by saying, while “sadly not” surprised, much of what was set out remained shocking:

“When you read it – you have to catch your breath. I think for me, the stand out from that is the plight of those in Scotland’s most deprived areas, specifically the bottom fifth.

“And the sense that the fortunes of those people are not only detached from the rest of the population but also many cases from the fourth quintile – for me that was a standout finding, it is shocking, it is alarming.”

There has been a stark rise in drug-related deaths in the most deprived areas in Scotland, with the least deprived areas maintaining relatively similar levels. Current rates reveal drug-related deaths are 18 times higher in the most deprived areas compared to the least deprived areas, with the review highlighting lower levels of engagement with health services.

The deprivation map is itself changing. Extreme poverty – households whose income after housing costs is below 50% of the median income – has also been rising, particularly among people on the lowest incomes.

The Health Foundation says a lack of progress to reduce gaps in educational attainment and income alongside the ‘fragility of public services’ from a decade of austerity means this gap between the most disadvantaged could continue to grow.

Mr Creegan was joined by Assistant Director of the Health Foundation, David Finch, Professor Linda Bauld, the Scottish government’s Chief Policy Advisor, Mubin Haq, Chief Executive of independent funder, abrdn Financial Fairness Trust and Michael Kellet, Director of Strategy, Governance and Performance for Public Health Scotland, to explore these findings.

Responding to the condensed report ahead of this discussion, Mr Finch had called for a radical shift in approach across:

“Scotland's wide and sustained health inequalities are being driven by the accumulation of severe multiple disadvantages, a lack of improvement in living standards and public service fragility due to the ongoing impact of austerity.

“Understanding the causes is not enough; a radical shift in approach is needed. The Scottish government, local authorities, businesses and the third sector must come together and collaborate closely with communities.”

Doing nothing is not neutral

During the discussion, Mr Creegan agreed that this inequality is “not abstract”, adding that Scotland has a duty to act:

“If we don’t use our agency to act, actually what we’re doing is setting those people adrift. So, doing nothing – or even not doing enough – is not neutral.”

In 2020, over a quarter (27%) of deaths in Scotland were avoidable and panellist Mubin Huq highlighted improving people’s incomes and avoiding a siloed approach as being effective in improving health outcomes. He said that the social security safety net is failing, though there has been progress with the living wage in recent years.

From many of the researchers, health and social care professionals and third sector workers attending the discussion of the review’s findings, concerns were expressed that addressing austerity and making the right political decisions impacting rising health inequalities were a priority to addressing the crisis.

Getting to the underlying reason why Scotland has not seen improvements in health inequalities, panellist Linda Bauld agreed with these concerns, saying:

“The root cause of the worsening of some of these outcomes is austerity – it’s underinvestment. The real-term decline in the value of social security for those who need it most is serious; the block grant for Scotland has only now returned to 2010 levels.

“There is less money in the system and the new social security benefits in Scotland are of course important, but they’re really only going to scratch the surface.”

Professor Bauld added that preventative action is essential but the bottom line is, she said, that “we need to provide more resources to individuals” as it is so strongly linked to health.

In the report, three underlying factors were outlined as core drivers of the persistence of health inequalities in Scotland – with one being the 2010 policy of austerity which has left public services in a ‘fragile state’, reducing provisions which support health living.

Chris Creegan recalled the Health, Social Care and Sports Committee’s report on tackling health inequalities which called for cross-sectoral, coordinated whole government approach, adding:

“But this isn’t just about policy choices, it’s actually about social change – it’s about local communities, it’s about businesses, it’s about citizens. I think the public do get it, increasingly the public get it – and we have to respond to that.

“I don’t buy, however, the argument that you take politics out of the argument. It’s not about taking politics out, it’s about doing politics differently. There’s something about matching our consensus of aspiration with a consensus of implementation.”

The role of government

Others at the session agreed that policy decisions and politics must remain central in discussing health inequalities, including Professor Gerry McCartney and Dr David Walsh from the University of Glasgow who contributed to parliament’s report.

Addressing the Health and Social Care Committee in their consultation of parliament’s report, Professor McCartney outlined that ‘austerity has further widened health inequalities since 2010’ while Dr Walsh identified positive actions from the Scottish government to mitigate the effects of Westminster austerity measures. Dr Walsh said:

“The Scottish government has done good things. For example, at the start of austerity, when the bedroom tax came in, the Scottish Government helped by basically making up for it through discretionary housing payments. As Gerry McCartney mentioned, it has also brought in a new social security payment—the Scottish child payment—for those on low incomes.”

Such measures were also identified in the Health Foundation’s review, wherein it states that the Scottish government’s efforts to offset the bedroom tax and cuts to council tax support in 2013 like had a ‘significant impact’ for those affected.

Yet, the review caveats that the estimated £50m a year spent by the Scottish government is ‘only a fraction’ of the estimated £3.7bn a year total UK government welfare cuts in Scotland.

Reflecting on income inequality and the “real choices” that can be made to reduce these inequalities and their consequences, panellist Mubin Huq said:

“None of this is inevitable and we’ve got two really interesting examples – one was austerity which we’ve touched upon. As the [Health Foundation] highlights, we’ve cut out £3.7bn a year from the social security budget – which is a huge amount, having a real impact on people’s lives.”

He added that the pandemic was the second example, wherein support at different levels for finances was implement to a certain extent, limiting the worsening income and consequent health outcomes.

Mr Huq said that since the cost-of-living crisis, those people facing ‘serious financial difficulties’ has increased from 10% to 17%, and more recently to 21% in a survey conducted with YouGov, due to a “wholly inadequate” current response to the crisis – particularly from the UK government.

He said overall the government must support boosting incomes and adds that a “really positive move” from the Scottish government is the cross-party support for a minimum income guarantee.  

The long term look forward

The Health Foundation said it found good support from the public for more ‘radical action’ and policies.

Chris Creegan highlighted that actions and policies must not fall into ‘short-termism’, with funding of projects on a year-to-year basis limiting progress, explaining that both short and long term solutions are needed:

“They’re not mutually exclusive, it’s about how they work together – and it’s about responding to short-term crises in a way that contributes to a foundational support system.”

Michael Kellet said that the key thing now is what do we do differently to address health inequalities and agrees that “we can’t take the politics out of it” and national-level action can go hand-in-hand with supporting local action to improve health.

Looking forward, Chris Creegan said that while community empowerment is not a panacea, all sectors have a role in solving health inequalities, from the government to communities.

The government’s Linda Bauld added that relationships between national and local government, the third sector and community groups must be improved, while echoing calls for the social security system for Scots to provide more people with more resources.

All panellists agreed that prioritising more bold action to address child poverty is essential in Scotland. Mr Creegan said that Scotland has not yet “got to grips with” the essential role of preventative spend on health inequalities, adding that from this review they hope to not only engage but also collaborate on action.

He explained that while he was anxious and frustrated with the current state of health inequalities, he is optimistic that collaborative and bold action can help tackle health inequalities across Scotland:

“This is a crisis and I think we have to treat it as a crisis, that’s the level of boldness that we need to inject into our response to this.”

Read more: Social deprivation linked to frailty; Can Scotland make health fairer?; Unpaid carers “spiralling” in cost-of-living crisis; RADAR system spots drug risks

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