VHS welcomes the report Tackling health inequalities in Scotland published by the Scottish Parliament’s Health, Social Care and Sport Committee on 28th September 2022. VHS’s contributions to the Inquiry are referred to a number of times during the report. We are pleased to have made a significant contribution to the Committee’s Inquiry on behalf of our members and the wider voluntary health sector, and to see this reflected in the report. The influence of Scottish charities, voluntary organisations and community groups is evident, with over 20 third sector and community organisations directly quoted in the report. The Committee received 114 written responses, and held 5 formal evidence sessions with a range of experts, including our Chief Executive, Claire Stevens. VHS also helped the Committee in establishing, facilitating and chairing 4 informal engagement events, enabling Committee members to engage with 48 organisations, the majority third sector, and with people with lived experience. We published a blog with key messages from those sessions, and the Committee report refers to this blog several times.
The report is long, with 76 pages of narrative, but it repays close reading (and includes an Executive Summary). In this blog, we give a flavour of some of the key evidence highlighted in the report, with an emphasis on contributions from our sector. We highlight some of the Committee’s key conclusions and recommendations, but they are extensive, so for a comprehensive insight into these, please read the report itself or the Executive Summary.
Health inequalities are the unjust and avoidable differences in people’s health across the population and between different groups. The Committee heard that actions to date to reduce health inequalities have largely failed, with health inequalities widening instead of narrowing. For example, the gap in healthy life expectancy in males has increased from 22.5 years in 2013-15 to 23.7 years in 2018-20.
To say that the Covid-19 pandemic has had significant direct and indirect effects on people’s lives is an understatement, but the harms produced by the pandemic have not been equally distributed across all groups in society. Likewise, the increasing cost of living, since early 2021, is an important factor affecting health inequalities.
Wider community and environmental influences
Housing is one of the first themes examined in the report, and the Hub in Dumfries and Galloway, Diabetes Scotland and Cyrenians make important points about the relationship between poor, insecure housing and health (page 23). Families Outside point out that, “simply not having an address is a barrier to people being able to register with a GP and get much needed medication” (page 24). VHS quotes Community Link Workers who had told us that poor housing leads to poor mental health, but that this doesn’t get you extra consideration in housing applications (page 24).
Community planning and access to social and cultural opportunities is the next theme in the report, with the Committee focusing on issues like transport, planning, and obesogenic environments. Claire Stevens’ points about the association between lower levels of social capital and health inequalities are highlighted, as is VHS’s The Zubairi Report and its call for loneliness and social isolation to be considered a public health issue (page 26). Dr Peter Cawston, a Deep End GP in Drumchapel, is critical of the fragility and disappearance of community resources and stresses the need for strong general practice support by communities with lots of resources for wellbeing, including Community Link Workers (page 27). Quotes from the Mental Health Foundation back his position (page 28). VHS’s development of the Scottish Community Link Worker Network is referenced (page 28). The Committee concludes and recommends that Community Link Workers to be embded across all GP surgeries (page 29).
Education and early years
The report turns to education and children’s early years next and reflects on what it heard during the informal evidence sessions about the lack of accessible nursery and childcare for those caring for disabled children and how this means that these vulnerable families are experiencing de facto exclusion from free childcare provision. The Committee calls on the Scottish Government to conduct an urgent review of the deployment of the free childcare policy and to resource and act urgently to ensure families receive the support they are entitled to.
Focusing next on employment, the report refers to evidence from PAMIS and the Coalition of Carers Scotland during one of the informal engagement sessions (page 33). Employment can protect adult caregivers from mental and physical health problems, by giving them a sense of identity and self-worth and promoting emotional well-being. However, carers experience barriers when trying to access work, and employment can be incompatible with social security restrictions. Older women may no longer be able to care for grandchildren due to the rise in pension age and Universal Credit rules, for example. VHS emphasises that employment is no longer automatically a route out of poverty (page 34). The report discusses the role of good employment, in-work poverty, the living wage, and the consequences of the disparity in powers between the Scottish Government and the UK Government.
In its section on public services, the Committee reflects on the recommendations of the Christie Commission in 2011 on the future delivery of public services, highlights the challenges in integrating health and social care services repeatedly described in Audit Scotland reports, and references the 2021 Feeley Review of adult social care and its description of progress as ‘patchy’ (pages 38-39). Dr Peter Cawston is quoted again, to illustrate the way public services can exacerbate health inequalities, “one of the most soul destroying things for me as a health professional has been witnessing on a daily basis how the NHS sometimes unwittingly and sometimes deliberately widens health inequalities and perpetuates divisions in many ways’ (page 39). Dr Cawston argues for much better integration of community assets with health services at a local level (pages 41-42). The impact of poorly coordinated public services was highlighted in the informal engagement sessions, and the report talks about the need to tackle stigma and discrimination in public services, as well as the need for a ‘no wrong door’ approach.
Health in all areas
Health Inequality Impact Assessments (HIIAs) are discussed at some length, with Claire Stevens arguing that HIIAs are valuable tools but must not become a tick-box exercise (page 44). The Committee concludes that work should be undertaken o measure and value the benefit of HIIAs and that further consideration be given to the idea of legislative action to make HIIAs a statutory requirement of public bodies, as is the case in Wales.
Informal caring as a social determinant of health
There is a detailed section about unpaid caring as a social determinant of health, with evidence from Carers Scotland, Carers Trust Scotland and the ALLIANCE to the forefront (pages 45-49). The failure to provide systematic support for carers has created a public health crisis, the Committee was told, and the longer a person has been a carer, the greater the impact on their physical health, which deteriorates at a faster rate than for non-carers. The emotional impact of caring includes stress, depression and burnout. The Committee concludes that the Scottish Parliament and the Scottish Government should formally recognise caring as a social determinant of health and that, together with Public Health Scotland, they must ensure there is more targeted support.
Fundamental cause of health inequalities
Extensive evidence was given to the Committee on the role of poverty. The Child Poverty Action Group tells the Committee that poverty must be treated as a public health crisis (page 51). Professor Gerry McCartney of Glasgow University argues that relying on behavioural science approaches to address health inequalities has been ineffective, and the fundamental causes must be addressed, including the management of the economy and ways in which this can widen income, wealth and power inequalities (page 51). The Mental Health Foundation cautions that, “It is not enough to put more money in someone’s pocket: that must be done in such a way that they do not have many hoops to jump through to get access to that income” (page 53). Bill Scott, Chair of the Poverty and Inequality Commission, discusses the stigma and shame associated with poverty, the negative effects of poverty on children, and the case for a minimum income guarantee (page 53). The report considers a minimum income in some detail (pages 53-55).
On social security, the report highlights participants’ inputs at the informal engagement sessions, and the largely negative experiences of accessing Universal Credit, including welfare conditionality, sanctions, and benefit deductions. This increases people’s stress, anxiety and other mental health issues. Understanding your rights to social security is hard and people want a more easily navigable, fair and compassionate system. More work is needed to increase uptake rates and widen eligibility criteria. The report highlights issues concerning those parts of the social security system that are controlled by the UK Government, and the limitations and opportunities that the Scottish Government has in relation to benefits.
The Covid-19 pandemic
Next comes a section on the impact of the Covid-19 pandemic, and attention is drawn to the disproportionate harm that some communities have experienced, for example, people in black and ethnic minority communities. Systemic racism existed in society already, but the pandemic has served to shine a light on these issues. Likewise, income inequality was exacerbated by the pandemic: 36% of low income households had to increase their expenditure but 40% of people with the highest incomes were able to decrease their costs (page 63). People with disabilities and parents with disabled children faced particular challenges, because services they relied on in their own homes disappeared, due to Covid-19 restrictions.
At the same time, the pandemic was an opportunity to do things differently, with evidence of innovations in health and social care delivery, increased community connectedness, and greater awareness of public health messages. Here there are a number of positive examples from the third and public sectors. Renfrewshire Disability Resource Centre’s breast screening project for people with disabilities increased participation in screening. Voluntary Action South Lanarkshire distributed small grants to tackle social isolation and loneliness. Grampian Humanitarian Assistance Hub provided psychological support and access to food and other daily products. BEMIS set up the Vaccination Information Fund. The work of Community Link Workers is cited. VHS is quoted, on just how quickly many voluntary organisations were able to adapt and respond at the onset of the pandemic in order to meet new as well as existing needs, and the role funders and commissioners played by being flexible about how grants and contracts could be deployed. VHS warns against returning to former bureaucratic barriers and inflexibility (page 65). Obesity Action Scotland also emphasises that we cannot simply return to pre-pandemic levels of service in order to tackle health inequalities, action must be prioritised (page 66). The Committee commends the Covid-19 Recovery Committee’s commitment to prioritise its scrutiny on Covid-19, with a special focus on health inequalities.
Cost of living
The cost of living section draws strongly on the informal engagement sessions and the evidence that the 48 organisations and the people with lived experience gave at those sessions; for example, the increasing number of households having to choose between eating or heating. VHS’s associated blog is highlighted, where we drew attention to the particularly severe impact on anyone with a complex health condition and on older people, and how financial pressures are also impacting on people’s social and recreational activities, continuation of treatment and self-management (pages 67-68).
Future scrutiny and action
The Committee agrees that policy action has been insufficient and that additional action is urgently needed across all levels of Government to resolve this. It proposes that a toolkit be developed to enable policy makers to quickly and easily audit all relevant policies to determine their impact on health inequalities. The Committee also calls for a more joined up approach across the Scottish Parliament’s Committees. It advocates a ‘health in all areas’ approach to future Scottish Parliament scrutiny and criticises silo working. It notes that the Minister for Public Health, Women’s Health and Sport was the only Minister who agreed to attend the Ministerial evidence session and it finds the lack of engagement by other Ministers regrettable.
Localities and communities
This section highlights the important role of local authorities in mitigating the effects of some of the underlying causes of health inequalities. One area that the Committee thinks local authorities could help is by investing in wellbeing communities, including increasing social capital and participation, and protecting and promoting community assets. The work of Chance to Change and of MECOPP’s Community Health Matters programme is cited. At the informal engagement sessions, the Committee had heard about the importance of engaging with local communities to design and deliver public services in a way that reflects their needs and preferences. The report discusses the funding challenges local authorities face and also issues in relation to coordination and capacity. Bill Scott is quoted, “We hold public bodies to account for financial and access targets, but we do not hold public leaders to account as strongly for reducing inequality”. He calls for budgets and spend across Scotland to be more closely aligned to impact (page 75).
Scottish Government strategy and action
The overwhelming consensus amongst those giving evidence is that action to eradicate poverty must be the first priority in tackling health inequalities. The report quotes Claire Stevens calling for, “above all, a cross-Government strategy that is centred on ending poverty” (page 77). The Royal Society of Edinburgh calls for a line of accountability to be established to ensure more consistent outcomes, “with the Cabinet being responsible for its efforts in reducing health inequalities. The fundamental determinants of health inequalities are social inequalities, so every Cabinet member and their department has a role”. The Committee effectively concurs with this, saying it believes there is a need for an over-arching strategy or set of principles to guide policy-making and foster active collaboration across the Government. It calls on the Scottish Government to provide the Committee with regular updates on progress, and refers its report to the UK Government and the Scottish Affairs Select Committee at Westminster.
Access the full report: Tackling health inequalities in Scotland.