Health inequalities: policy context

Reserved and devolved powers

The fundamental causes of health inequalities are inequalities in income, wealth and power. Responsibility for many relevant policy areas lies primarily with the UK Parliament (e.g. fiscal, economic and monetary policy, many aspects of social security and employment). How much 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.

Income and health

For much of the 20th century income inequalities had narrowed. However, since the late 1970s income inequalities widened dramatically across the UK (Chart 1). The increase has been attributed largely to the UK Government’s economic policy during the 1980’s and beyond.

You can also see the association between income inequalities and health inequalities, with trends in health inequalities across (here the gap in mortality rates between areas of Britain) mirroring trends in income inequality (here defined as the share of national income received by the highest-earning 1% of the UK population).

  

Current policy in Scotland

The Scottish Government is developing a 10-year population health framework, with details potentially to be published in 2025 (referenced here).

Tackling inequalities in health and their determinants – such as poverty, access to employment, etc. - has also featured in the Scottish Government's recent Programme for Government documents, including the current one (see Programme for Government 2024-25).

Narrowing of economic inequality (a fundamental cause of health inequality) is one of two ‘key pillars’ in the Government’s and sits at the heart of their recently published National Strategy for Economic Transformation (NSET). A refresh of the strategy is 2025. Scottish Parliament Information Centre (SPICe) provided a commentary on the progress of NSET.

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 and young people, health, and more. The framework explicitly links to the United Nation's Sustainable Development Goals, which includes a goal to reduce inequalities.

 In 2018 the Scottish Government published a 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 second Equally Well review, NHS Health Scotland (now Public Health Scotland) undertook a review of policy and evidence regarding what works to address health inequalities. 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 (LTMHI) reports. The most recent is from 2023.