Shedding light on widening health inequalities in Scotland

It has become a cliché to assert that the COVID-19 pandemic brought health inequalities into sharp focus. And yet it bears repeating, not merely because it is true, but because it underlines the scale – and urgency – of the challenge it brings. A challenge for policy design, but even more significantly for policy delivery.  

What we know so far 

Before the pandemic, the Health Foundation’s report on mortality and life expectancy trends in the UK found that improvements in life expectancy had stalled, even going into reverse for some groups. The picture in England was explored further in the Health Foundation’s funded review of health inequalities ten years on from Professor Sir Michael Marmot’s landmark report Fairer Society, Healthier Lives.  

The Foundation’s subsequent COVID-19 impact inquiry report, Unequal pandemic, fairer recovery, found that the pandemic had further exposed growing differences in health between people living in different areas and circumstances across the UK.  

Consistently this work has highlighted the role that the circumstances and opportunities which shape our lives – including education, jobs, housing, green spaces and communities – and our day-to-day experiences all influence our health. How these vary between people and places is a key reason for the inequality that is all too apparent.  

Why a focus on Scotland? 

Scotland has for many years been dubbed the ‘sick man of Europe’. So there has been no shortage of research attention and policy focus on the issue here. Indeed, it might be argued that we have world leading policy on health in Scotland. And yet those inequalities remain widespread and persistent across the country.  

This is illustrated most clearly by statistics on life expectancy. Life expectancy in Scotland increased from the 1980s to the late 2000s, but over the last decade most areas saw a slow down or a stall in life expectancy growth. And now, many areas have decreasing life expectancy.  

A 24-year gap in years of good health 

While life expectancy has stalled across the UK, and even fallen in some areas, Scotland has the lowest life expectancy at birth of all UK countries. Even more troubling is that the gap in life expectancy between the most and least deprived areas has widened over the last 5 years. Most strikingly, National Records of Scotland (NRS) 2021 revealed that men and women born in the most deprived areas can expect about 24 fewer years in good health than people born in the least deprived areas. In the most deprived areas, men and women spend more than a third of their life in poor health. 

Look beyond those headlines and the NRS statistics also show that people in Scotland’s most deprived communities are 18 times more likely to have a drug-related death and more than four times more likely to have an alcohol specific death. The rate of deaths by suicide is three times the rate in the least deprived fifth of areas, and COVID-19 death rates are more than double those in the least deprived fifth. 

Since 2008, long-term monitoring of health inequalities in Scotland has focused on 15 indicators including life expectancy, hospital admissions, general health and limiting long-term conditions, and mental wellbeing in adults. The latest report shows that while absolute inequalities (the gap between the most and least deprived areas) have fallen for five indicators, they have widened for almost all others. And relative inequalities (the extent to which outcomes are worse in the most deprived areas compared to the average throughout Scotland) are generally either not shifting or widening.  

What can we do about it? 

That this is unacceptable is surely not contentious. The pressing issue however, never more so than in the wake of the COVID-19 pandemic, is how can we close the gap and improve people’s health over the long term.  

This will mean understanding and responding to recent changes in the factors that influence health – rising poverty pre-pandemic, the education gaps which opened through the pandemic, and the shape and extent of post-pandemic employment recovery. Scotland’s fortunes are, of course, tied to the UK. Most aspects of social security, employment regulation and overall public spending in Scotland are determined by the UK government. However, both health policy and policy related to several of the socio-economic determinants of health are devolved matters.  

Health inequalities in Scotland: An independent review 

With (we must hope) the worst of COVID-19 behind us but health inequality trends moving in the wrong direction and exacerbated by the pandemic, the Health Foundation’s investment in a robust, independent review of health inequalities in Scotland is timely. It will shed light on how trends in health inequalities and the socio-economic determinants of health have evolved since devolution. This is crucial if we are to understand what we must do to stem the tide and reverse it. 

But the Health Foundation’s review will go much further than analysis. It will also include both stakeholder and public engagement to ensure that its conclusions about policy direction are co-designed with experts and citizens. Informed by an expert advisory group bringing a wide-ranging mix of experience and knowledge, the intention is to create a rich body of work to inform action – to ensure Scotland’s policy aspirations are realised by policy implementation. We will publish interim findings in the autumn, with a final report published by the end of the year. You can follow our progress on the review's page on the Health Foundation’s website. 

As the pandemic tightened its grip in 2020, the Health Foundation asked whether COVID-19 could be a watershed moment for health inequalities. It called for a new social compact harnessing the efforts of government, the voluntary and community sector and business. Two years on, after so much talk of building back fairer, it is time to put that question to the test in Scotland. We cannot afford not to.  

Chris Creegan (@Chris_Creegan) is chair of the expert advisory group for Health inequalities in Scotland: An independent review. 

This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.