Can Scotland achieve its aim of narrowing health inequalities in a post-pandemic world?

In this commentary we explore the potential for the devolved Scottish Government to achieve its stated aim of narrowing health - and broader societal (including economic) - inequalities within both the restrictions of limited devolved powers, and in the context of post-pandemic uncertainty. We do so by focussing on two questions: first, where were we with regards to inequalities policy in Scotland before the pandemic? And second, what are the likely implications of the pandemic for inequalities, and inequalities policymaking, in the country?

The reduction of health inequalities has been a stated aim of many Western governments. This is certainly true of the devolved government in Scotland, both historically [[1], [2], [3], [4]] and also currently: the need to narrow inequalities in health and its determinants has been emphasised by the present administration in all its recent parliamentary legislative programmes [[5], [6], [7], [8]]. Indeed, the narrowing of economic inequality – a fundamental cause of health inequality [[9], [10], [11], [12]] – is one of the two ‘key pillars’ of the Scottish Government’s overall economic strategy [13]. However, as we seek to emerge from the current COVID-19 emergency, how will these laudable aims stand up in a post-pandemic world?

To answer that we need to ask two further, important, questions. First, where were we with regards to inequalities policy in Scotland before the pandemic? And second, what are the likely implications of the pandemic for inequalities, and inequalities policymaking, in the country?

To answer the first, the authors recently undertook a review of inequalities-related policies in Scotland in the last few years [14]. This was a follow-up to a series of policy recommendations made in response to research into the high levels of mortality and inequality observed both in Scotland, and in its largest city, Glasgow [15,16]. Predictably, what emerged from this review was not a simple picture.

On the one hand, there are a number of policy areas where the Scottish Government (SG) deserves enormous credit – and where the contrast with UK Government policymaking for England is stark. The expansion of social house building is one such area, with the SG having committed to building 50,000 affordable homes by early 2021, almost three-quarters of which will be in the social rented sector [8]. Public sector pay policy, including a commitment to paying a minimum of the real living wage to all employees of devolved public bodies in Scotland [17], seems to have had a positive impact on earnings inequalities, including the gender pay gap [18]. The number of free nursery places for children is to be expanded from 600 to 1140 ​hours per year for all three and four year-olds [19]. Free bus travel is to be provided for those aged under 19 years [20]. Most importantly, by means of the 2017 Child Poverty Act, the SG has committed itself to reducing child poverty to 10% by 2030 [21]: in contrast, the UK government has abolished child poverty targets altogether [22].

However, we also highlighted that there had been little progress in a number of other important policy areas – reducing the poverty premium, for example – while in others, policy had not been sufficiently ambitious e.g. in relation to recently-devolved powers over income tax rates and bands. We also highlighted a number of policies where time and/or evaluation will be required to properly understand their impact: these included the establishment of the (now statutory) Poverty & Inequality Commission, the promised parliamentary discussions on changes to a fairer system of council tax, and the ongoing process of public health reform [14].

However, the policy review also raised important questions regarding the extent to which the SG actually has the capacity – in terms of the legislative powers at its disposal – to meaningfully narrow societal inequalities, and thereby achieve its stated aims in this area. In recent years, for example, levels of in-work poverty have been an increasingly important contributor to overall poverty rates, driven by low pay, zero hours contracts, the so-called ‘gig economy’, and more [23]. But how can the devolved Scottish administration meaningfully address those issues without control over employment law (which remains reserved to the UK Government at Westminster)? Similarly, without key social security powers (the majority of which are also reserved), how can the Scottish Government provide the social ‘safety net’ to protect the most vulnerable in society? Entirely related to this last point, how can the SG protect the health of the poorest when Westminster ‘austerity’ measures – including a staggering £47 billion reduction in the UK social security budget [24] – have resulted in increased mortality rates in disadvantaged neighbourhoods across the UK, thereby widening health inequalities further [[25], [26], [27]]?

These are difficult issues. However, they will undoubtedly be made yet more difficult by the effects of the COVID-19 pandemic. Some of the policies highlighted in our review have already been affected: the expansion of free nursery places and the introduction of free public transport for young people have been postponed [28,29], the delivery of 50,000 affordable homes delayed [30]. However, the SG has also responded by publishing its economic recovery plan: building on previous, pre-pandemic, statements from the First Minister [31], this puts forward the idea of establishing a ‘well-being economy’, one built on ‘the principles of sustainable economic growth, accompanied by tackling inequalities, and delivered as a green recovery to meet our climate change targets’ [32]. In the context of both limited devolved powers, and post-pandemic economic uncertainty, it is difficult to ascertain to what extent this laudable ambition can be realised. Indeed, with regard specifically to the narrowing of health inequalities, there are many reasons to be pessimistic.

First, the impact of the economic ‘lockdown’, and the imminent recession, is clearly likely to exacerbate existing inequalities – in Scotland, as in other parts of the UK and, indeed, globally. Related to this, it should be remembered that the temporary economic measures introduced by the UK Government in an attempt to mitigate the effects of the pandemic did not include any reversal of previous ‘austerity’-driven cuts to social security payments.

Second, there are additional – and highly important – unintended consequences of the policy responses to the pandemic which are likely to impact on inequalities. These were summarised in a recently published health impact assessment [33] and include: loss of income (not just in relation to loss of employment, but also caused by caring responsibilities or the need to self-isolate); social isolation (including impacts on mental health, domestic violence, increased fuel poverty and changes to health behaviours e.g. increased physical inactivity); disruption to health and social care services; disruption to education; and psychosocial impacts (e.g. increased fear and anxiety).

Third, there are the health effects of the pandemic itself, including those that may occur as part of a possible ‘second wave’, and its associated socioeconomic and ethnic inequalities.

However, there are of course some reasons to be more optimistic. To a degree the Scottish Government’s economic recovery plan reflects the much discussed desire for a different, more inclusive, economic model to emerge from the pandemic – the chance to ‘build back better’. Included in this are other potential benefits in terms of changes to transport (e.g. increases in active travel) and associated improvements to air pollution and other aspects of well-being. However, it is obviously far too early to know whether or not, or to what extent, any such positive developments may emerge in a post-pandemic society.

The future, therefore, is uncertain. Optimistic references to new, more progressive and sustainable economic models are counterbalanced by both the likely impact of a hugely damaging economic recession, as well as – following a decade of ‘austerity’ policies – the fear of what future, debt-addressing, economic policies may yet emerge from Westminster. The many challenges of Brexit and climate change still hover threateningly in the background. In that context, and with the powers currently at the Scottish Government’s disposal, the narrowing of socioeconomic and health inequalities seems an unlikely outcome – certainly in the short term. At the same time, however, these multiple threats mean it is also more important than ever that the SG uses all its available existing powers to mitigate their adverse effects.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.