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The extent and persistence of health inequalities in Scotland are well known. The 24-year gap in years lived in good health between the most and least deprived areas of Scotland is one of many statistics that captures stark differences in health. But this isn’t just data: it is a tragic difference in quality and length of life (and opportunities) between groups of people.

Despite awareness of the problems and an understanding of the policy solutions, inequalities are widening. There is therefore a vital need to understand why previous and existing plans of action have failed to consistently improve health and reduce inequalities.

In search of meaningful, long-term solutions, the Health Foundation is carrying out an independent review of health and health inequalities in Scotland. To do so we are working with Scotland-based partners: the Fraser of Allander Institute, the University of Glasgow, the Diffley Partnership and Nesta. Together, we will produce a comprehensive body of work bringing together robust evidence, public perspectives and thinking from policy and practice.

An early focus has been understanding the latest public views and understanding of health inequalities through a survey of 1,079 adults in Scotland, designed by the Diffley Partnership. It is a forerunner of a series of deliberative workshops – now underway – to delve far deeper into public perceptions and priorities.

Past surveys have shown that the public tend to think the individual has most responsibility for ensuring people stay healthy. Yet in smaller group discussions, they show appreciation of the nuanced ways that factors like employment or housing influence health. This chimes with a project by the FrameWorks Institute, funded by the Health Foundation, which investigated the common but implicit assumptions and patterns of thinking through which people understand health inequalities. It found that the role of the individual tends to dominate.

In the recent survey, awareness of health inequalities was high, with 86% agreeing that people in better off areas of Scotland tend to be healthier than people in worse off areas. The same percentage also thought that the difference in health between those areas was a big problem.

Asked to rate how large an impact on people’s health a set of factors can have, health care services and lifestyle and individual behaviours came out as the greatest. This was of little surprise: both are consistently pointed to by the British public.

It is therefore interesting that financial and professional circumstances and personal circumstances were close behind in the recent survey. It shows a recognition of the role these wider factors play in determining people’s health.

Whether this is influenced by the 71% who reported that the COVID-19 pandemic had made them more aware of the ways in which our social, economic and personal circumstances can affect our health isn’t clear. This is something to explore further in future.

Despite individual behaviours being considered to have a large impact on health, nine in ten people think it is better to prevent poor health than to treat it. When considering action to reduce health inequalities, only 25% thought initiatives to improve people’s understanding of healthy living were very effective.

There was greater support for more upstream action, with 51% stating that improving day-to-day living conditions would be ‘very effective’ in reducing health inequalities, and 44% saying that policies to tackle poverty and income inequality would be ‘very effective’. This also suggests a more nuanced view of the role of wider factors, governments and individuals in determining health inequalities.

This polling is, deliberately, merely a scratch of the surface to kick off our work. Getting beneath the headlines and understanding how people consider the role that life circumstances play in determining our health, and whether these attitudes have changed over time, or differ in Scotland, comes next. We also hope to better understand how far policies to improve health are recognised as doing so and where they are thought to be successful.

Over the coming months we will be providing further updates and more detailed findings – watch this space.

David Finch (@davidfinchthf) is assistant director of Healthy Lives at the Health Foundation.

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