Policies to reduce health inequalities: where were we in Scotland pre-pandemic?

As we start to emerge from the current COVID-19 crisis, the future seems to be shrouded in uncertainty. Optimistic references to the chance to ‘build back better’, to envisage a new society based on a different economic model, are counterbalanced by both the likely impact of a hugely damaging economic recession, as well as – following a decade of UK government ‘austerity’ policies that have been devastating for our poorest communities – the fear of what future, debt-addressing, economic policies may emerge from Westminster. And this uncertainty doesn’t even consider the impact of other challenges such as Brexit and climate change.

But there are some things we understand well. We understand the well-evidenced, crucial, impact that economic factors – and thereby economic policy-making – has on population health, and on health inequalities. And we understand that the type of
post-pandemic society that emerges in Scotland can be influenced significantly by national (Scottish) and local policy-making. However, to ‘build back better’ requires us to understand where, policy-wise, we were in Scotland prior to the pandemic. Our new report seeks to help us do that.

In 2016 we published a report which identified the most likely causes of the high levels of ‘excess mortality’ seen in Scotland and, especially, Glasgow. In the city’s case this is what the media often refers to as a ‘Glasgow effect’: an unhelpful and outdated term, which lacks any real meaning. The explanation was complex, but at its heart lay a toxic combination of poor historical living conditions and adverse policy-making at different levels of government.

The report set out 26 policy recommendations, aimed primarily at the Scottish Government and local government (principally in Glasgow). Although the focus was ‘excess mortality’, in essence the recommendations were about ways to narrow socioeconomic – and thereby health – inequalities in Scotland, using existing powers. Given that Scotland has, tragically, the widest health inequalities in Western Europe, this is enormously important. Our new report assesses progress in relation to those recommendations. It asks: what’s happened in Scotland since 2016 with regards to inequalities-related policies? Where were we pre-pandemic?

The answer, predictably, is not simple. There are a number of recent policy initiatives of which the Scottish Government can be proud, not least in relation to social housing provision, public sector pay, pre-school education, and the Child Poverty Act. The latter, for example, commits the Scottish Government to reducing child poverty to 10% by 2030: contrast that with the UK government which, in 2016, abolished child poverty targets altogether. However, a number of recommendations have seen very little progress, and for others we argue that changes have not gone far enough e.g. in relation to income tax rates and bands. There are also lots of initiatives which will require time and/or evaluation to properly understand their impact.

The report also raises important questions regarding the extent to which the devolved Scottish administration has the capacity to achieve its stated aim of narrowing inequalities in society.

For example, how do you meaningfully address the drivers of
in-work poverty – low pay, zero hours contracts, the so-called ‘gig economy’ – when employment law remains reserved to Westminster? How do you protect the vulnerable in society when the majority of social security powers are not in the Scottish Government’s gift? How do you protect the health of the poorest when Westminster austerity measures have resulted in increased mortality rates in disadvantaged neighbourhoods across the UK?

At the same time, however, these questions – the last one in particular – also emphasise the importance of using all existing powers and opportunities that exist in Scotland to mitigate the effects of such policies, and thereby to improve the lives of the most vulnerable in society; and the report highlights the many areas where national and local government in Scotland can indeed make a difference. In doing so, it also provides an indication of progress in those areas over the past four years and thus serves as a reference document for where we were prior to the current crisis.

This is important because not only are we indeed in a crisis – and facing additional crises driven by the economic downturn – but we were already in an inequalities crisis even before all this. It’s vitally important to understand that context: by doing that, and by reviewing what has been done to date, we can better understand what more is required to ensure we emerge from the current situation into a better future.