Scotland's Future: Inequalities will only be solved with more power

And then only a few weeks ago, the Health Foundation, a London-based charity, launched their own “independent review into health inequalities in Scotland” – one in which they are asking very similar questions. 

And let’s be clear: these are big questions. But in fact, we already know the answers. For the first, the Scottish Government produces an annual statistical publication with the self-explanatory title of the “Long-term monitoring of health inequalities in Scotland”. 

And for the second, a few years ago the Government commissioned NHS Health Scotland (now Public Health Scotland) to undertake a review of all the international evidence of what works, and what doesn’t work, to reduce health inequalities in society.

So the answers to these really important questions are already there in black and white. 

And for different reasons they make for really troubling reading.

Without going into in-depth statistical detail, the most recent instalment of the Government’s annual inequalities publication shows that in the last decade things have become worse. Across many different indicators, inequalities have widened considerably. 

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This is alarming, not least because even before these most recent changes, and even before we factor in the effects of the pandemic, health inequalities in Scotland were already the widest in Western Europe. 

Really importantly, we already know why this is the case. There is no mystery here. Inequalities in health are an extension of broader societal inequalities.

The relationship between health and wealth means that where a country has wide wealth inequalities, it will also have wide health inequalities: this is clear from evidence spanning not just decades, but arguably centuries. 

And in Scotland, as elsewhere in the UK, socioeconomic inequalities have widened enormously since 1979.  

While that era of Thatcherism is seen – perhaps particularly in Scotland – as emblematic of a time of widening inequality, the impact of more recent UK Government policy on health inequalities has been arguably even more profound.

As is laid out in a University of Glasgow/Glasgow Centre for Population Health report to be published next week, there is now clear evidence that UK Government “austerity” policies, in cutting tens of billions of pounds both from the income of the poorest and most vulnerable, and from the vital public services on which people rely, has had a quite calamitous effect on the health of large sections of the population since their introduction in 2010. 

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The ultimate result of this is that death rates have risen in communities the length and breadth of the UK.

Put simply, increasing numbers of people have died before their time. And in a country as wealthy as the UK, this is nothing less than a scandal.

This also means that we are currently witnessing a new form of health inequality in Scotland.

Previously, inequalities widened because the health of the more affluent was improving faster than the health of the less affluent.

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Importantly, however, the health of the less affluent was still improving. But now inequalities have widened more sharply because the health of the less affluent is actually becoming worse. And this was happening well before the pandemic.

This evidence of what drives health inequalities is important; the evidence of what to do about them equally so.

That Health Scotland review of international evidence published a few years ago provided very clear answers.

To narrow inequalities in society you need action (policies) at three different levels.

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First, and most crucially, address those “fundamental” socioeconomic causes of health inequalities: redistribute income across society and reduce (or eliminate) poverty through policies such as progressive taxation, a comprehensive social security system, and labour market legislation.

Second, take action on broader “environmental” factors – housing, education, air pollution, neighbourhood quality, transport.

And third, address individuals’ experiences of inequality (eg help those at particular risk such as the homeless and children in care.)

But here’s the really important bit: if you don’t do the first one – narrow economic inequalities in society – you are simply not going to succeed. 

To quote the report:  “Action to address [the other levels] is important, but will not solve the problem”. 

And therein lies the difficulty. The big difficulty. To narrow those economic inequalities, you need the relevant legislative powers.

In Scotland we have a small number of those: income tax bands and rates can be changed, and some social security benefits have been devolved or created.

But these are dwarfed by the relevant powers that are reserved to Westminster: employment legislation, most taxation, the vast majority of social security benefits.

Borrowing powers are not available. That means that when it comes to effectively addressing health inequalities, the balance of power is uneven. 

Scotland has developed some important and progressive policies. It has committed itself to reducing child poverty, introduced the Scottish Child Payment for low-income families, abolished “Right to Buy” and instead invested in a social housing building programme, expanded early years childcare provision, introduced the effective policy of alcohol MUP, and more – many actions that stand in stark contrast to policy and pronouncements in England. 

But what happens when we try and balance those commendable policies with the effects of billions of pounds being slashed from the income of the poorest through the UK Government’s austerity agenda?

Unfortunately, the Scottish Government’s annual statistical publication has provided us with the answer.

However, we must remain optimistic and committed. And there are certainly more things that the Scottish Government could do.

And there is also clearly a role for others – local government, the third and private sectors. But the big question is: would they be enough to rebalance the scales?

There is a desperate need for honesty in this. The Parliamentary Committee, and the Health Foundation charity, and whatever other reviews or enquiries that may follow, cannot and must not ignore the political essence of health inequalities, and the political reality of Scotland’s relatively unique situation in trying to address them.

We need an honest appraisal of what can be meaningfully achieved in the current context and, as we emerge from the pandemic, we need an honest discussion of what else needs to be done to shape a future, more equal, Scotland.

Dr David Walsh is Public Health Programme Manager at Glasgow Centre for Population Health