Health inequalities: policy context

Scotland within the UK

The policy context for health inequalities in Scotland is complex. The ‘fundamental causes’ of health inequalities are recognised as inequalities in income, wealth and power. Responsibility for many relevant policy areas (e.g. fiscal, economic and monetary policy, social security and employment) lies primarily with the UK Parliament; the extent to which Scotland has the capacity to narrow such inequalities has therefore been questioned (e.g. Walsh et al 2020). Nonetheless, some relevant powers (e.g. income tax rate and bands, some aspects of social security) are devolved to the Scottish Parliament.

In a UK context, Chart 1 shows that income inequalities have widened dramatically since the late 1970s (following a long-term narrowing during much of the 20th Century), attributable principally to UK Government economic policy over the subsequent decades. This Figure also highlights the association between income inequalities and health inequalities, with parallel trends evident for income inequality (here defined as the share of national income received by the highest-earning 1% of the UK population) and mortality inequality (here the gap in mortality rates between areas of Britain).

Current policy in Scotland

Reducing health inequalities is a major component of the Scottish Government's overall purpose of achieving ‘sustainable and inclusive economic growth’. This purpose is underpinned by the National Performance Framework, made up of 11 National Outcomes, with progress measured by 81 indicators.  A number of the Outcomes are relevant to health inequalities and their determinants, particularly ‘We tackle poverty by sharing opportunities, wealth and power more equally’, as well as those in relation to the economy (including income inequalities), education, children & young people, health, and more. The framework explicitly links to the United Nation's Sustainable Development Goals, which includes a goal to reduce inequalities.

The tackling of inequalities in health and their determinants - e.g. poverty - has also featured prominently in the Scottish Government's recent Programme for Government documents, including the current one (see 2022/23 Programme for Government), while the narrowing of economic inequality (a fundamental cause of health inequality) is one of two ‘key pillars’ in the Government’s economic strategy, and sits at the heart of their recently published 'National Strategy for Economic Transformation'.

In 2018 the Scottish Government published a set of six Public Health Priorities for Scotland. These reflect agreement between the Scottish Government and Local Government on what they regard as the most important things to focus on in the next decade in order to improve the health of the population. It has been followed by publication of specific policies related to diet and healthy weight, alcohol harm prevention, alcohol and drugs treatment, and tobacco control (and are thus less about the fundamental causes of inequalities).

Previous policy in Scotland

In a Scottish context, since devolution the need to reduce health inequalities in Scotland has been highlighted within a number of high profile policy documents. These include:

In 2007 the SNP-led administration established a Ministerial Task Force on Health Inequalities. This oversaw the publication of a number of policy documents which both highlighted the importance of health inequalities and sought to monitor progress in their reduction:

As part of the work to produce the 2014 report, NHS Health Scotland (now Public Health Scotland) undertook a review of policy and evidence regarding what works to address health inequalities: that report was also published in 2014. These reviews also established the indicators that are used to monitor progress in tackling inequalities: these are outlined in the Long-term monitoring of health inequalities reports.