Scotland has long been the “sick man of Europe”. Scots' physical and mental health compares poorly to that other western countries and neighbours within the UK. Glasgow, the largest city, is notably unhealthier than most other parts, and the most affluent 10% live far longer than the most deprived.
Glasgow also compares poorly to similar UK cities such as Manchester and Liverpool. The reasons for Glasgow’s bad health have long been a mystery to those studying it. A major new report argues it can be blamed partly on successive local and UK governments letting the city dwindle after the decline of heavy industry, combined with particularly poor quality housing. The report, due out in the coming days, has 26 recommendations for turning these Glasgow and Scottish figures around by tackling some of the broader societal causes of ill health.
It comes at a time when the SNP has just won the Scottish election comfortably – albeit losing its majority – and Nicola Sturgeon has been sworn in as first minister for another five years. After nine years in power, the SNP needs to do something different to change the fact that the country’s health inequalities have not narrowed for most measures since devolution in 1999.
What’s to be done?
Past SNP and mainstream political policies in this area have broadly fallen into two categories: public health campaigns targeting the whole population; and moves to tackle the worst aspects of poverty, highlighted in a recent poverty report.
While both can help, they have arguably been neither intense enough nor sufficient for what is required. There is extensive evidence that inequalities are driven by much more than poverty, hence people’s health gets steadily worse with every step down the socioeconomic ladder they go. In this context, “stop smoking” campaigns and a focus on poverty won’t make the difference on their own.
Interventions must bring increasingly greater benefits to those more in need – certain tax changes, for example, or not marketing unhealthy options to those that can least afford them. They also need to take into account that targeting early childhood brings the greatest benefit, particularly if policies continue and adapt throughout people’s lives.
Here’s what the Scottish government, according to its recent manifesto, has in store:
The SNP is backing proposals from a recent report to establish a Poverty and Inequality Commission and re-appoint an independent advisor on poverty. It intends to implement the report’s recommendations in full, including disclosing pay ratios, promoting family flexible working practices and closing the gender pay gap. Yet we’re only talking about steps in the right direction. Disclosing pay ratios is not the same as tackling them, for example. And as highlighted above, poverty is a symptom of inequality and focusing on it alone avoids tackling issues such as wealth inequality.
The Scottish government also plans to promote and enforce payment of the Living Wage and ban zero hours contracts. Although positive, this stops short of proposals from the left-wing RISE party to introduce a £10 minimum wage for over-16s. And while the SNP has plans to “end austerity”, it is not clear what this means in practice.
There are plans to keep the basic 20% rate unchanged. To reduce inequalities via taxation, taxes would need to rise for most groups. You would see the biggest changes for those in the higher tax bands (and the formation of more tax bands, potentially).
While Labour and the Greens want a higher top rate, the SNP only plans to block the rise in the 40% tax-band threshold and make the personal allowance for the lowest earners slightly more generous. The SNP will also end the council tax freeze and make higher band houses pay more.
The SNP proposes 50,000 affordable homes over the next five years. It is overseeing land reforms that will reduce the power of landowners, though they look weak next to proposals from the Greens and RISE for better rent controls, limiting ownership of large areas, and the cheaper purchasing of land for public use.
4. Healthcare and public health
The government’s focus remains on improving health services and changing bad health behaviours. The SNP has championed minimum unit pricing for alcohol, which should reduce consumption across the board but have the greatest benefit in more deprived groups where consumption is relatively greater. Supporting Labour’s sugar tax proposals would fall into the same category.
There are not many signs of attempts to reverse the inverse care law, where the least NHS funds go to those most in need of healthcare. There also remains a lack of joined-up thinking between social and health policies – by treating a health problem by looking at a patient’s housing or job status for instance.
The SNP’s manifesto highlights this confused thinking: “public health challenges and health inequalities require a broad response … We will bring forward a new strategy on diet and obesity …”
5. Education and childcare
The Scottish government’s plans to increase maternity grants for low income mothers are positive, but would likely need to be extended (by need) beyond the poorest to have an effect across the population.
Plans to improve the quality and flexibility of pre-school education will likely benefit all socioeconomic groups, but could increase inequalities if the greatest benefits end up being provided to more affluent families. On the plus side, the Scottish government is promising increased bursaries for lower income students going to university while also continuing free tuition.
What should we make of it?
Many policies look like steps towards a healthier Scotland, but the overall package looks suspiciously like an approach that will maintain the status quo: public health campaigns, focusing on poverty, and initiatives that are big on rhetoric, but limited in having a real impact on Scotland’s inequalities.
Scotland’s minority parliament could represent an added threat. The limited number of references to inequality in the Conservative manifesto (one mention compared to over 20 by the SNP and Greens, and 17 by Labour) is particularly worrying given that they are now the second largest party in the country.