No magic cure for Scotland’s stubborn health inequality

Scottish devolution began in 1999 with high aspirations and ambitions that the new form of Scottish government would be transformative. Recent evidence of the  failure to reduce health inequality casts doubt that increasing powers will necessarily lead to enhanced governance and effectiveness in any one particular policy area. 

The mantra of ‘increased powers’ for the Scottish Parliament fuels both the movement for Scottish independence and current proposals for further devolution such as those proposed by the multi-party Smith Commission and the additional demands of the Scottish National Party. The assumption of such demands is that enhanced powers will lead to increased effectiveness and competence in government. The examination of health policy, which has been the most important spending area and the major functional responsibility of the Scottish Parliament and Scottish Government in the last decade and a half of devolution, suggests, however, that this is far from the case.

In the current financial year health expenditure in Scotland, almost completely under the control of the devolved institutions of the Scottish Government and the Scottish Parliament, will total £12 billion or 35 per cent of the total devolved budget – averaging an expenditure of £2400 per Scot, child or adult alike – ten per cent higher than in England.

The gap grows wider

The relevant budget document states that it ‘supports services and initiatives designed to help people in Scotland to live longer and healthier lives with reduced health inequalities and to provide more sustainable, high quality and continually improving healthcare services close to home’

The reduction of health inequalities has been, indeed, a central theme of health policy under all devolved administrations since 1999 but there is little evidence that there has been any substantial impact on this objective – a conclusion strongly reinforced by the recent release of a report on the topic by the Health and Sport Committee of the Scottish Parliament.

The report points out that the disadvantaged sectors of the Scottish population have been falling behind, in their health levels, from the 1960s onwards. It states that, according to the former Chief Medical Office for Scotland, Sir Harry Burns: ‘What had happened in the past 40 or 50 years was that a large part of the population has failed to improve its health at the same rate as the more affluent in the population had’.

The continuation and amplification of health inequalities in Scotland has occurred under three different health policy regimes. Until 1999 health policy in Scotland was administered by usually Scottish parliamentarians and civil servants responsible to the Westminster UK Parliament. Since then responsibility has been taken by Scottish ministers recruited from the governing parties and by civil servants accountable to them and the Scottish Parliament. From 1999 to 2007 there was a Scottish Labour/Scottish Liberal Democratic coalition; from 2007-11 a minority SNP government; and then from 2011 a majority SNP administration. Under all these regimes there were a number of regional health boards and specialist national health agencies controlled by the Scottish Government which were tasked with policy implementation.

The reduction of health inequalities has been a major priority for all these administrations but the Health and Sport Committee concludes that the several related major policy initiatives have been unsuccessful and may have even, in the case of, for instance, public health policies on alcohol, tobacco, diet and exercise, actually intensified inequalities. The committee concludes that ‘although health is improving, it is doing so less rapidly than in other European countries and although the latest figures are a little more encouraging, health inequalities remain persistently wide’.

Chaotic lifestyles and health inequality

Evidence to the committee from academic advisors and health policy specialists suggested the need, some 15 years after the establishment of current arrangements for the governance of health in Scotland, for a fundamental review of policy to make it more effective. The overall tenor of the evidence was that health inequalities were embedded in, and derived from, wider patterns of social inequality in employment, education, wealth and income.

It would be a mistake to assume that poverty is the cause: Sir Harry Burns 

The main difference of opinion in the advice rendered was that Sir Harry Burns argued that chaotic lifestyles – particularly among the poor and deprived – was a contributory factor in health inequality. Some of these wider socio-economic influences on health, such as education, are the responsibility of other committees of the Parliament and departments of the Scottish Government. The Health and Sport committee is thus initiating a round of consultations with several other major committees such as Education and Culture and Equal Opportunities to see how policy in these functional areas might contribute to new cross-disciplinary initiatives to mobilise additional resources in the search for more coordinated and effective policies to improve health outcomes and minimise health inequalities.

Children who experience adverse events in early life are far more likely to have mental health problems and are far less likely to succeed at school. That creates a generational cycle of failure in a number of domains of living. Sir Harry Burns

The case of health policy demonstrates that the assumption of increased powers for the Scottish Parliament and the Scottish Government does not thus necessarily lead to enhanced governance and effectiveness in any one particular policy area. Despite the easy claims of politicians, changing policies and ensuring effectiveness and competence in newly acquired fields of responsibility are very difficult challenges. And while increased powers in ancillary areas may, in theory, enhance capacity to deal with health policy challenges, the failure of Scottish health policy to make any major impact on health inequalities in the last decade and a half, even despite the scale of resources made available, raises inevitable scepticism about whether increased powers and funding for the Scottish Parliament and the Scottish Government will, in general, lead to any fundamental transformations in other policy areas.

This slightly amplified article was first published on the London School of Economics blog and is republished here with permission. 

Additional comments by Sir Harry Burns are from the Scottish Parliament Health and Sport Committee inquiry January 2013

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