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The Health Foundation’s report Leave no one behind: The state of health and health inequalities in Scotland has published this week. It is the summation of a multi-stranded review undertaken over the past 12 months, focusing on how Scotland has fared on health and health inequalities in the two decades since devolution. 

The report distils a wealth of evidence collected by the review’s Scotland-based research partners – the MRC/CSO Social and Public Health Sciences Unit at the University of Glasgow, the Fraser of Allander Institute at the University of Strathclyde, Nesta Scotland and the Diffley Partnership. But most importantly it provides a call to action. We can – and must – act now.  

A case of inaction?  

In his latest book, The Social Distance Between Us, the writer Darren McGarvey argues that we have known for 40 years ‘rapid deindustrialisation was a public health time bomb’ – but that ‘we chose not to act’.  

The evidence from the review – the most comprehensive undertaken since devolution – is that we have acted and continue to do so. But despite a wealth of good intentions, the gap in health inequalities, which was closing, is now widening.  

The most glaring predicament the review reveals is that the fortunes of those living in our most deprived communities are becoming detached from the rest. Among a plethora of challenges for Scotland it points to are the health prospects of infants and young children, and the plight of young and middle-aged men experiencing multiple disadvantage. And the risks to our future health, in particular to those who are most disadvantaged, if we allow that trend to continue, are very grave indeed. 

Through the first decade of this century, we did move forward. But over the past decade, buffeted by external headwinds and internal pressures, it appears that we have, albeit unintentionally, taken our eye off the ball. So how can we reverse the tide? 

The recent report of the Scottish Parliament’s Health, Social Care and Sport Committee rightly acknowledges that a more coordinated whole-government approach is urgently needed.  

But in his recent REAL Centre lecture, Health is wealth?, Andy Haldane, Chief Executive of the RSA, went much further. Haldane argued that the key is a multi-pronged and multi-year strategy that bridges across economic, financial, social and health systems. 

In other words, this is not merely a problem that government can solve by pulling policy levers. Joined-up policy design and delivery clearly matters. The right balance between universal and targeted intervention is critical. But the state cannot act alone. That is why Leave no one behind is not only a report for government, but for all of Scotland – its institutions, businesses and citizens.  

The causes of inequalities in health outcomes are deep rooted and structural – exposed and exacerbated by short-term crises that don’t come much bigger than the pandemic and the cost-of-living crisis we are now faced with. And they can only be resolved by a sustained, long-term response across society. This is a problem for every one of us. 

Haldane’s predecessor, Matthew Taylor, now Chief Executive of the NHS Confederation, argued that government may even be more effective as ‘first follower’, in doing so ‘providing the final piece of the jigsaw in a process of change started by citizens’. 

What does the Scottish public think?  

It is worth asking therefore, where do Scotland’s citizens stand? In his book, McGarvey concludes that the most shocking aspect of our public health discourse (too often centred on notions of individual responsibility) is ‘[…] how distant most people remain from the ugly, irrefutable truth: poor health is absolutely a choice – a political one.’  

But here, the Health Foundation’s review finds more than a glimmer of an opportunity. Research conducted by the Diffley Partnership suggests that a well-informed public gets the problem, does not blame individuals, and will support a bold, collective response. 

The Diffley findings echo recent data from the British Social Attitudes survey that reveal the majority of the Scottish public understand poverty is the root cause of health inequalities.  

There will be those who argue, popular support for action notwithstanding, to respond effectively Scotland needs more powers and that vital policy levers lie out of reach with the UK government. Of course, more powers could make a difference, not least borrowing to leverage greater investment. The actions of the UK government clearly matter too – the damage to health created by austerity over the past decade is unarguable, whatever Scotland’s considerable efforts to mitigate it.  

But there is already significant scope to act. With or without additional powers, and whatever path Westminster chooses, the cost of inaction in Scotland is simply too great to contemplate. We cannot give in to intractability or fatalism and allow the most disadvantaged in our communities to be set adrift. 

We do not need another grand strategy. We need practical collaboration, up and downstream, to sweat the considerable assets we already have – public, third and private sectors, collaborating with communities. Each of us has our part to play. 

It is not for the Health Foundation or any expert group to prescribe what that collaboration should look like. Our task now is to act – together – to call time on health inequalities. We must leave no one behind in our quest to do so. 

Chris Creegan (@Chris_Creegan) is chair of the expert advisory group for the independent review of health and health inequalities in Scotland.

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