Exploring Scottish attitudes towards health inequality

Scotland experiences some of the greatest health inequalities in Western Europe, with gaps in life expectancy between the most and least deprived areas exceeding 13 years for men (and 10 for women). Since the 1950s, Scotland has continuously had one of the lowest average life expectancies in Europe, and has not seen any significant improvement in the last 15 years. 

For years, the Scottish government has discussed the importance of policies to prevent poor health outcomes. In 2011, the Christie Commission brought to light the need for preventative action to address the rising demand for and cost of public services. Last year’s Population Health Framework reaffirmed Scotland’s commitment for preventative action to reduce health inequalities. At the same time, Scotland has struggled to implement cross-government action and maintain funding for the policies needed to achieve these goals. 

With this context in mind, the Scottish Health Equity Research Unit (SHERU) funded 11 questions in the Scottish Social Attitudes survey. These asked how people in Scotland understand health inequalities, what they think about the social and structural conditions that shape health and what they believe should be done to address these issues. 

We found that, in general, people in Scotland are supportive of a sustainable shift to prevention; action on poverty, housing and employment; and policies to help those experiencing the most significant health inequalities.

What people in Scotland think about health inequality

People in Scotland are concerned about health inequalities, with 94% saying it’s important for the Scottish government to reduce the gap in health between those who are better and worse off. As we might expect, around half of the Scottish population felt that smoking, diet and alcohol are the main reasons this massive gap in health exists. This reflects a common narrative across the UK; for decades, research has found that people often cite individual behaviours as a reason for health inequity. Despite this, 23% of people cited the less discussed social and structural drivers of poor health, including housing and employment.

What people in Scotland think about preventative policies

People in Scotland also overwhelmingly felt that the Scottish government should finance prevention. Over 60% of people in Scotland felt that the government should spend equal amounts on preventing illness and treating illness, while 26% favoured spending more on prevention. People responded similarly to a question about preventing homelessness.

The balance between crisis and preventative spend is a consistent topic of conversation in Scotland. We do not know how much Scotland spends on prevention at this point, so we don’t have a way of knowing what this balance actually is. 

What people in Scotland think about action on poverty, housing and employment

Deaths from drugs, alcohol and suicide all have higher rates in Scotland compared with the other UK countries. These deaths are significantly more likely to occur in the most deprived parts of Scotland.

24% of people acknowledged this gap in outcomes for people in the most and least deprived areas in Scotland and stated that addressing poverty would be the most effective method of reducing drug and alcohol deaths. Around 16% of people also felt that poverty reduction would be the most effective way of reducing deaths from suicide, although most people (53%) felt that increased spending on mental health services would be more effective. 

Other questions examined preventative policies around housing and employment. Scotland has a high number of people who are out of work, with more than 30% of people who are out of the workforce citing their health as the reason. A roughly even number of people felt that the government should support people in ill health to get back into work and that the government should support employers to provide better jobs for people in ill health. 

This sentiment aligns with recent policy findings in the UK. The recent Keep Britain Working review highlighted the shared responsibility of individuals, employers and government to improve employment outcomes for people who are out of work due to health reasons. The report followed the Commission for Healthier Working Lives, supported by the Health Foundation, which encouraged the government to incentivise employers to improve the labour market for people in ill health and incentivise employees to continue engaging with work.

At the same time, Scotland is currently facing a housing emergency, with tens of thousands of people living in temporary accommodation. Nearly 60% of people in Scotland felt that costs associated with housing were the main reason behind the housing shortage, citing housing affordability, spending on social housing or the cost of rent. People also cited social housing investment as the most effective way of improving housing quality.

This is a tricky situation – Scotland does not have a clear definition of what constitutes ‘affordable housing’, despite how critical affordability is to both the Scottish public and to addressing health inequality more generally. 

A mandate for action in a challenging context

With Scottish parliamentary elections taking place in May, these findings offer important insights for political parties and policymakers alike. They suggest that the population would be broadly supportive of a preventative shift in policy and action to reduce health inequalities. To develop sustainable policy options, this mandate will need to be balanced with pressure to reduce public spending, which has grown significantly since 2021 thanks to rising costs, especially related to the devolution of social security. Ongoing challenges with siloed working across government and a lack of knowledge about preventative versus crisis government spending across Scotland will also need to be overcome.

Allison Catalano is an Economics Fellow with the Scottish Health Equity Research Unit.