Tackling Scotland’s health gap

Life expectancy in Scotland has come to a standstill in recent years and is now lower than other parts of the UK and several countries in Western Europe. How and why are the Scots getting left behind when it comes to health and what can be done about it? Sarah Harrop takes a look.

What is the single biggest health issue in Scotland?

According to the Scottish Public Health Observatory (ScotPHO), the greatest public health challenge facing Scotland is a stall in life expectancy. Across all Scottish socio-economic groups in the country, life expectancy has stayed the same and it has actually decreased in the poorest areas. 

“This means that health inequalities are worsening and that socioeconomic position is increasingly impacting on how long we live for, and how long we live in good health. The best evidence currently available suggests that this is due to austerity and that pressure on health and social care services are also contributing,” says Public Health Scotland.

A 2022 review led by the Health Foundation states that Scotland has the lowest life expectancy of the four UK nations (England, Northern Ireland, Scotland and Wales) since the 1950s. What is more, its ranking compared with other western European countries has fallen. 

What are health inequalities?

This term is used in the world of public health to describe the unfair and avoidable differences in health across the population, and between different groups of people within society. Such differences include:

• health status, such as how long people are likely to live
• health conditions people experience
• care that is available to people, and its quality
• behavioural risks to health, such as smoking rates.
• the conditions in which people are born, grow, live, work and age (the so-called ‘wider determinants of health’). 

Health inequalities are often analysed and addressed by policy across:

• socio-economic factors, for example, income
• geography, eg by region or urban areas versus rural ones
• specific characteristics, such as sex, ethnicity or disability
• socially excluded population groups, for example, those who are homeless.

These things are often linked. For example, a person who is unemployed is more likely to live in poorer quality housing, further from green spaces, with more difficulty accessing healthcare/health services and perhaps even in a ‘food desert’, with little or no access to good quality, fresh, healthy food.

This means that the odds are stacked against some groups and communities compared with the general population when it comes to health and wellbeing.

Health inequalities in Scotland: some facts and figures

The Health Foundation’s 2022 independent review of health and health inequalities in Scotland was carried out amid concerns about widespread, persistent health inequalities in the country – which the pandemic may have further worsened. Its aim was to provide an in-depth analysis of the key health trends and wider factors shaping Scottish people’s health and ill health over the last two decades. The health inequalities report’s findings revealed:

• There was a 24-year gap in healthy life expectancy between people living in the most and least socioeconomically deprived 10% of local areas in Scotland in 2019.
• Growing inequality in drug deaths: overall mortality rates relating to drug use increased from 6.2 per 100,000 in 2001 to 25.1 per 100,000 in 2019 - 18 times as high in the least deprived areas
• Life expectancy projections have been falling: a person born in 2012 is now expected to live to 86 - that's 4.4 fewer years then they were expected to live in 2013.
• Income is strongly linked with health: people living in the poorest two-fifths of households are almost 8 times as likely to report poor health as the richest fifth.
• Wages have stagnated: median weekly earnings were around £80 per week lower in 2021 than they would have been had earnings growth followed its long run trend after 2010.
• Poverty is rising: since the mid-2010s the proportion of the population in both relative poverty and extreme poverty has been on a slow but persistent upward trend, which is particularly marked for child poverty.
• There’s a 200-fold difference in income between the richest 10% and poorest 10% of households in Scotland.

What are the reasons behind Scottish health inequalities?

According to Public Health Scotland, the fundamental causes of health inequalities in Scotland boil down to the unequal distribution in society of income, wealth and power (ie the ability or capacity to do things or to control, force or influence others by various means).

These three factors shape the wider environmental influences on health, access to services and wider society, translating to gaps in health between Scotland’s richest and poorest communities.

There is a growing body of evidence showing that the only way to tackle these unfair differences in health and access to care is by undoing this uneven spread across society of income, wealth and power.

To understand more about the problem ScotPHO explored this question in a 2013 report on tackling health inequalities. It looked at 30 years of health trends in Scotland and the rise and fall of particular causes of death.

Findings revealed that the gap in deaths across different social groups for specific causes decreased, while others emerged. Over 30 years there was little difference in death rates from non-preventable diseases like brain and ovarian cancers, but large differences in preventable causes like obesity, alcohol-related deaths and heart disease.

Causes of death responsible for inequalities have shifted over time, from heart disease and tuberculosis in the 1970s and 1980s to drugs and alcohol-related deaths more recently, the report showed. 

Social inequalities were revealed to be the root cause of persistent health inequalities. This has important policy implications for the Scottish government in its ongoing efforts to level the playing field for health in Scotland.

What’s the Scottish government doing to tackle the problem?

Both the 2023 Health Foundation report on inequalities in Scotland and a 2022 Health, Social Care and Sport Committee report clearly showed that action was needed at all levels of government to make sure that public services recognise and address the needs of the most disadvantaged people in Scotland.

Further to this, the Scottish Government committed up to £1.3 million funding in 2022/23 and 2023/24 to a new Inclusion Health Action in General Practice programme. This provides funding targeted to the most deprived GP practices in NHS Greater Glasgow and Clyde; of the 100 poorest practices in the whole of Scotland, 81 currently sit within this part of the country.

Announcing the funding in April 2023, First Minister Humza Yousaf said: “At a time when the cost of living crisis is widening health inequalities, this is an important step that supports our commitments to prevention and early intervention with patients at highest risk of poor health.”

The Scottish Government has also committed £4,125,000 over three years to pilot so-called Welfare Advice and Health Partnerships (WAHPs). These provide an integrated approach to advice, allowing GP practices to refer patients directly to a dedicated welfare rights advisor who can advise those in need on social and economic issues.

Now there are advisors in 180 GP practices across Scotland's most deprived areas and early findings showed that between January 2022 and March 2023, the financial gain for the almost 10,000 patients accessing the service was £16.2 million, stemming from a Scottish Government investment of £1.46 million, according to a progress report by the Scottish Government’s Primary Care Health Inequalities Short Life Working Group.

Further work to tackle inequalities in Scotland as recommended by the working group include research on barriers that people face to accessing primary health care; a lived experience reference group; and developing proposals for multi-disciplinary fellowships and training focused on health equity. There are also a range of related initiatives in the pipeline, including:

• The Care and Wellbeing Portfolio: cross government action on recovery, population health and inequalities
• Place and Wellbeing: anchor institutions, supporting communities and third sector, local voice and decision; and
• The Whole Family Wellbeing Fund.

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