Tackling health inequalities in Scotland

Structural pressures, policy levers and prevention

This is the second in a series of blogs on our latest mortality trends research. Here, David Jack, Senior Knowledge Exchange Fellow at SHERU (Scottish Health Equity Research Unit) explores the data and implications for policymakers in Scotland.

Scotland's persistently poor health outcomes reflect deep-rooted structural challenges, shaped by a long history of inequality and compounded by more recent economic pressures. Turning this around will require sustained, long-term policy action that addresses the underlying social and economic determinants of health.

New research from the London School of Hygiene and Tropical Medicine (LSHTM), funded by the Health Foundation, found that improvements in mortality rates slowed across all UK nations during the 2010s, based on comparisons with 21 other high-income countries. This slowdown occurred alongside declining productivity, wage stagnation and public service pressures – trends that have hit already disadvantaged communities hardest. Scotland stands out with especially high mortality rates – in 2021, only the US had a worse rate among the countries studied. We know from the latest data that Scotland continues to have the lowest life expectancy in Western Europe, a stark and persistent pattern that has long been cause for concern.

To understand the realities behind such national headlines, it’s important to look more closely at trends in particular places and populations. Glasgow offers a powerful illustration. A data linkage study found that 1 in 20 adults living in Glasgow City between 2010 and 2014 had experienced at least one of: homelessness / imprisonment / criminal justice / social work involvement / opioid dependence / psychosis. People with one or more of these experiences were almost four times as likely to die young (before the age of 75) during the follow-up period (2014–2019) than people without such experiences. The risk was even higher when these disadvantages co-occurred – underlining how social exclusion can have devastating consequences for health. 

With health inequalities widening and improvements to life expectancy stalling, it is vital to understand both the long-term structural drivers and the shorter term policy choices behind these trends, as well as the policy levers available to tackle them. While many underlying patterns are shared across the UK, Scotland’s challenges are, in some respects, particularly acute. The research by the LSHTM reinforces this: by 2019, drug-related mortality for both men and women in Scotland was approximately four times higher than in England. Scotland not only recorded the highest drug-related death rates in the UK, but also saw the steepest increase during the 2010s. More recent data show these challenges persist, with people living in the most deprived areas of Scotland more than 15 times more likely to die from drug misuse than people living in the least deprived areas.

Beneath these outcomes lie the wider determinants of health: poverty, housing, education, employment and access to services. These social and economic factors shape people’s life chances and health trajectories – and they are closely intertwined with how powers and responsibilities are shared between Holyrood and Westminster.

Structural pressures and devolved levers for tackling inequality

Like the rest of the UK, Scotland has faced significant challenges in recent years: the cost-of-living crisis, long-term wage stagnation, growing concerns around economic inactivity and overstretched public services. Despite a concerted focus by the Scottish government leading to reduced child poverty rates in Scotland, the issue persists for many families, with interim targets missed. For example, the government aimed to reduce relative child poverty to 18% by 2023/24, but it still stood at 22% according to the most recent data.

These pressures continue to shape the environments in which people are born, grow, live, work and age, with direct consequences for physical and mental health.

Scotland does have substantial devolved powers over areas that shape wider determinants of health. For example:

• Health and public health: the Scottish government runs NHS Scotland and is responsible for most aspects of public health and health policy in Scotland.
• Housing: social housing provision and housing policy are devolved to Scotland, allowing tailored approaches to address local needs.
• Education, skills and employability programmes: all under Scottish government control, enabling targeted interventions to improve life chances.
• Income support: some social security benefits, including disability payments and the Scottish Child Payment, are administered by Social Security Scotland, providing important income levers to reduce poverty and support wellbeing.
• Local government funding and strategy: Scotland’s local authorities are funded primarily by a mix of central government grants, local taxes (council tax, non-domestic rates) and service income, with resource allocation coordinated between the Scottish government and the Convention of Scottish Local Authorities (COSLA).

While Scotland holds these powers, it does so within the broader fiscal and policy context of the UK. Changes in UK government spending on devolved areas typically lead to proportional adjustments in the Scottish government’s funding, which in turn has discretion over how funding is allocated. But UK-level policy decisions can still create ripple effects, even in devolved areas. For example, proposed reforms to Personal Independence Payment (PIP) may affect Scotland’s Adult Disability Payment, creating financial pressures and difficult policy choices for the Scottish government.

A prevention-first ambition?

In policy terms, prevention refers to tackling the root causes of poor outcomes before they escalate, rather than responding after the fact. It has long been part of the Scottish government’s stated approach, notably since the 2011 Christie Commission on the future delivery of public services. However, the broader shift to preventative approaches has proven challenging. A recent report highlights that public services are ‘finding it almost impossible to pivot towards prevention in the ways that they know are needed’. Challenges such as workforce shortages, fragmented local delivery and short-term fiscal pressures often pull focus away from prevention.

To help drive progress, the Scottish government and COSLA, supported by Public Health Scotland, are co-developing a new Population Health Framework, due to be published in late June 2025. This framework aims to strengthen cross-government and cross-sector collaboration to improve health and reduce inequalities, with a strong focus on prevention, early intervention and addressing wider determinants like poverty, education, and housing through whole-systems approaches. Its success will ultimately depend on how well it translates into tangible actions, with clear ownership and delivery across sectors.

Prevention also featured prominently in the Scottish government’s Programme for Government 2025 to 2026 (published May 2025), which announced a Public Service Reform strategy to be published in June 2025. This strategy will outline joint actions (with local authorities, public bodies, the third sector and trade unions) to improve outcomes – especially for those with the greatest need. A stated aim is to redirect investment toward agencies and services that embed a prevention-first approach.

A key example of upstream action is the Scottish Child Payment, now £27.15 per week per eligible child. While its full impact on health will take time to assess, early data suggest Scotland’s child poverty rates may be diverging positively from the rest of the UK, where the payment is not available. By supporting families with young children, the policy aims to reduce poverty during critical stages of development, laying the groundwork for improved life chances and healthier futures for the next generation. Though it is too soon for definitive conclusions, the Scottish Child Payment signals a clear commitment to tackling the root causes of poverty and its long-term effects.