Health inequalities are pervasive across Scotland, and with the gap in health between the wealthiest and most deprived widening in recent years, an independent review from the Health Foundation investigates the variety of factors impacting the health of Scots. This looks across four strands to understand changes since devolution and ultimately look forward to improving Scotland’s inequalities landscape.

Two reports from the review are now fully published by the University of Glasgow’s MRC/CSO Social and Public Health Sciences Unit and the University of Strathclyde’s FAI and, here we look at some of the key conclusions and perspectives of the lead researchers in each.

The four broad themes are: health and socio-economic trends, public understanding, and stakeholder perspectives and these reports cover the first two strands. First released, the University of Glasgow’s report investigates public health trends and last month’s report looking at socio-economic factors influencing health outcomes from Strathclyde’s Fraser of Allander Institute (FAI).

Ahead of their release we spoke with strategic advisor to The Health Foundation’s independent review of health inequalities in Scotland, Chris Creegan and Poverty Alliance’s Parliamentary and Policy Officer, Ashley McLean. Ms McLean said such reviews are essential to helping solve health inequalities as is listening to people’s lived experience and organisations on the ground that are getting it right already.

More recently, Mr Creegan chaired a webinar with some of the researchers involved with the two reports published since alongside a panel of experts to discuss the findings. Introducing Glasgow’s report, Dr Anna Pearce, MRC/CSO Fellow and lead author said:

“Scotland has one of the best systems for monitoring health inequalities in the world and is home to world-leading research in this area. Health inequalities are also widely acknowledged in policy circles, with several government inquiries into health inequalities – including one a few months ago.

“Unsurprisingly perhaps, death rates and inequalities had been falling in the first decade of the 21^st century in Scotland, but these improvements have since stalled – and inequalities in some cases have widened.”

She explained that the team began work to provide a more accessible picture of health inequalities, accounting for intersecting inequalities “beyond just area-level deprivation”, including disability, ethnicity and individual socio-economic position.

The report found worsening health with deprivation across outcomes including drugs and alcohol deaths, health appointment bookings and attendance, low birthweight and child development. By 2019, those in the most deprived areas were 20 times as likely to die from drug-related deaths as those from the least deprived areas.

Dr Pearce said that young to middle-aged men appear to be fairing particularly badly, with greater levels of homelessness and most drug-related deaths occurring among young to middle-aged men. Young to middle aged men were also more likely to not attend outpatient appointments and healthy life expectancy has fallen among men living in the most deprived areas in Scotland since 2015, to just 45 years.

Avoidable mortality rates among men have remained higher for those from the most deprived areas, and although previously trending down, decreases in avoidable mortality stalled in 2013 and have recently begun to rise for all groups. Not only have avoidable deaths increased, but the gap between the most deprived and least deprived has worsened. This can be seen with 4.1 times as high rates for those from the most deprived compared to the least deprived in 2019, compared to 3.1 times as high in 2001.

The Scottish parliament’s inquiry into tackling health inequalities in Scotland investigated progress, challenges, and potential pathways for reducing and preventing further health inequalities. Its report found a lack of progress, with previous actions having “largely failed” and the committee has called for urgent “bold and strategic action” across employment, income, housing and education.

One area Dr Pearce highlighted that requires clear action is early childhood health and wellbeing. She shared findings around children not immunised with the MMR vaccine:

“We saw a general improvement before 2010, so the proportion of children not immunised were falling and by 2013, we’re seeing the near elimination of inequalities.

“However, since then the proportion of children not immunised have started to go up in more deprived areas to the point where we are no longer meeting WHO targets in these areas. So this leaves some people susceptible to infection but these trends are also a signal to wider societal barriers in access to health services.”

Dr Pearce added that children’s start in life is not equal in Scotland, which could be “storing up” problems for the future, with 11 times as many babies are exposed to smoking in utero compared to the least deprived groups. Outside of obvious poor health outcomes, she explained that this can also increase stigma and lead to difficulties accessing healthcare services.

Socio-economic changes

Mr David Eiser, lead author of the second report from the University of Strathclyde’s FAI, explained its starting point:

“Health is strongly influenced by broader socio-economic factors: the type of job people do, their income, financial security, the circumstances of where they live – both in terms housing and the broader characteristics of the neighbourhoods.

“As a result, the inequalities in health that Anna [Dr Pearce] is talking about is strongly influenced by and shaped by these socio-economic factors. So we describe trends in key socio-economic determinants of health since 1999 in Scotland.”

Mr Eiser says that inequalities in real earnings were growing for men and women until around 2008/9 and household incomes experienced an “unprecedented stagnation” post-2010 following the financial crisis:

“Scotland – while lower than in England – showed slightly higher earnings inequality than other comparable countries among fulltime employees, though more insights are needed for non-standard contracts.”

He adds that net household income inequality in the UK is really high internationally and while lower for Scotland it remains above the average.

From the 1990s to early 2010s, a fall in rates of poverty was observed but appears to be reversing since mid-2010s – public spending and services changing.

Mr Eiser highlights the “striking” change in trends for spending per capita on health, with the health budget increasing consistently by 4-5% per annum before 2010 and less than 1% per annum for the following decade.

Dr Pearce highlighted that while a deeper investigation is needed, the clear trends reveal that worsening health with poverty is pervasive across almost all aspects of health in Scotland. She added:

“Health consistently worsens as deprivation increases – there is a clear social gradient in health, but the most deprived appear to be fairing especially badly. A closer look at what is going on in the most deprived areas is required but we see this trend across several different outcomes.”

Dr Pearce explained that the gap between the most deprived and second most deprived area for rates for drug-related deaths is higher than even the second most deprived and the least deprived area, showing that over half of all drugs deaths occur in the most deprived fifth of areas. We recently reported on the Scottish Health Survey’s findings for the health and wellbeing of Scotland’s adults and children in 2021, including an analysis of the drug and alcohol findings.

Five reports in full are expected from the Health Foundation’s independent review, with three to follow in the coming weeks. Dr Pearce concluded on the insights thus far:

“The trend data have shown that it is possible to reduce health inequalities and it is crucial for us to bear this in mind in the face of the cost-of-living crisis.”

Meanwhile, the Cabinet Secretary for Health and Care, Humza Yousaf responded to the parliamentary inquiry on tackling health inequalities last week, outlining the adoption of a “health in all policies” approach which he says is already underway.

Mr Yousaf said that coherence “will be key” and he is aware much more work is needed to overcome the nation’s health challenges.

Read more: Social deprivation linked to frailty; RADAR system to spot drug death risks; Can Scotland make health fairer?

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