Health inequalities are both created and exacerbated when policies, legislation, services and our economy impact on our lives in very real and sometimes devastating ways; consider the impact of welfare reform on poverty and isolation[i], and the increased presentation of people in absolute destitution to the third sector. Our briefing also argues that:
- Tackling inequality must be the key driver of government policy and legislation and should underpin our approach to the economy. More inclusive approaches are needed to address this e.g. participatory budgeting and ensuring people shape the policies which affect their lives.
- Parliamentary scrutiny (e.g. committee work) and the recent recommendations made by the Standards Committee should help in determining how successful we are in achieving this.
- We invest billions in health care in Scotland, primarily aimed at acute care and helping people to deal with illness – we must recognise that health care is so much more than dealing with ill health. Policy needs to focus on community based preventative solutions, often delivered by the third sector.
- The damage being done by austerity, welfare changes and service cuts will only make inequality worse. Evidence from the third sector demonstrates the tragic human costs.
SCVO’s policy work is driven by three strategic aims – Society, Economy and Democracy. Our briefing is structured around these aims:
Society – ensuring that policy making reflects our changing society and the importance of empowering and supporting people, their connections and overall wellbeing. We must consider, for example, areas such as planning and transport – where and how we build houses, how those in outlying areas (rural and urban) stay connected to their communities[ii]. Ensuring we protect and enhance social capital[iii] is just as important as a focus on economic growth.
Economy – The “ties” between health inequality and how our economy and labour market operate. The likely impact of austerity and welfare reform on health inequalities cannot be underestimated.
Democracy – Ensuring people have more control over their lives and the services and policies which interact with them. Building the capacity of people and communities to develop solutions to their concerns requires a shift of power.
The key determinants of health inequalities lie in the imbalance between these three ‘spheres’. Our essential argument is this – tackling health inequalities is so much more than “medical wellness”. It’s about people’s ability to maintain social connections; their ability to feel secure; in control of life and in control of the services and policies which interact with their lives.
Better connected policy which reflects changing society
“Demographic change is bringing about a fundamental shift in how we all live, work and care… – rising life expectancy, shrinking family networks … huge progress in women’s workforce participation, greater incidence of disability and learning disability and advances …meaning that far more severely disabled children live into adulthood. For many families this is bringing a new mix of work, childcare and care for older and disabled loved ones – new challenges which previous generations have simply not faced.” Carers UK, 2013
Policy creation that aims to tackle health inequalities must take account of the changes outlined above. Traditional transitions e.g. from child to adult life, into old age are blurring and family life is increasingly complex. Therefore, having separate, ‘compartmentalised’ approaches to policy are no longer appropriate.”[iv]
We also need to step back and consider how areas of policy which are not directly associated with health outcomes play a key role in tackling inequality. This means we need to view employment, transport, housing and planning policy, and capital investment, through with a wider ‘inequality’ lens.
Consider the increasing risk of isolation amongst older people and the link between loneliness and ill health; a number of commentators have suggested that this is one of the most significant policy challenges we face. [v] Transport and housing policy; infrastructure developments; support for community groups to respond to local needs – all of these are often seen within separate ‘portfolios’, but decisions in one area can have multiple and sometimes unintended impacts. An example would be the loss of a local bus service which is not deemed to be financially viable. This short term cut can lead directly to increased isolation with tangible health impacts; people unable to shop for food, attend doctor appointments or meet friends. This can lead, in turn, to more costly interventions e.g. the need for home care or an emergency hospital admission.
A recent IPPR report picks up on these issues and makes links between previously unconnected policy areas. It highlights, for example, the need to consider how employment rights can be adapted to meet the increasing demand for unpaid care. It also urges investment in community groups which capitalize on the contribution of older people and help them to build relationships, In turn, such investments contribute to better health and wellbeing. [vi]
Honest discussion and exploration of these approaches will be vital in tackling health inequalities; we need to acknowledge the links between our environment, housing, relationships and community connections and people’s health.More widely, as outlined by the Scottish Community Alliance, the goal in creating better policy must be to break down “silo walls” that operate within public agencies. The Health and Sport Committee acknowledged this challenge in its concluding paragraphs:
“..we have emphasised the importance of action across a range of portfolios, joined-up-working, inter-agency collaboration and “getting out of silos”.[vii]
A focus on outcomes, including genuinely tackling health inequality, can enable public bodies to move beyond “who does what” and where budgets lie/with whom.[viii] Until policy and policy makers truly move into this realm, existing health inequalities will continue.
The link between our economy and health inequality
“If people at the bottom don’t have the minimum necessary for a healthy life, then their health suffers… I think that people at the upper end of the income scale have no idea of what’s going on down at the bottom of the scale. They don’t realise how much people are really hurting.” Sir Michael Marmot, health inequality expert at University College London, and author of Fair Society, Healthy Lives.
The link between income and health inequality was addressed with understanding and compassion by the Committee.
How our economy operates contributes to health inequalities in Scotland. Along with charities such as Oxfam[ix], and prominent economists[x], our view is that current economic approaches have perpetuated poverty and inequality – key determinants of health and wellbeing.
We do, however, welcome the changing focus within the Scottish Government’s refreshed economic strategy to consider wider measures of “success” such as wellbeing and equality. This changing focus must underpin and connect government policy across every portfolio.
Employment positively impacts on a wide range of wellbeing indicators, including educational attainment, health and crime[xi] Whilst there may be increases in a country’s GDP, such increases can mask large, often increasing disparities between regions or individuals. More widely, we need to see a focus on “good work” in policy, where in-work poverty and cycling between low pay and no pay are tackled. Work may be good for our collective health – bad work is not:
“The implications for population health and wellbeing of …. changes to poverty and work are generally negative. The detrimental impact of low quality, precarious and insecure work on mental health and wellbeing is especially concerning amid an economic recession which itself represents a significant risk factor for population health generally and mental health specifically. Moreover, evidence suggests that the retrenchment of social protection, outlined in the planned UK welfare reforms, will further compound these risks and lead to increased poverty rates and the exacerbation of health inequalities.”[xii]
There are various analyses which show that the current (precarious) return to growth has been predicated on low skilled, low paid and insecure jobs. This has been particularly the case for women[xiii], whilst the austerity approach driven by Westminster has reduced the incomes of women significantly since 2010[xiv].
Austerity measures have hit groups which are already unequal e.g. people with disabilities. When GPs and public health experts talk about a potential public health crisis arising from austerity and devastating welfare cuts, then it’s time to listen and act.[xv]
Any policy developments which seek to tackle health inequalities must take account of the damage currently being done to people and communities across Scotland. Consider for example, the challenges facing people under the age of 35, where suicide is still the biggest cause of death[xvi]. Isolation and lack of control can affect the health and wellbeing of allage groups in our society. Almost a quarter of disabled people say that welfare cuts have led to increased loneliness and isolation[xvii].
The human costs of inequality are nothing short of tragic. If we ignore this basic and disturbing fact, then we will already have failed. Parliament, local government, public bodies and civil society all have a crucial role to play.
Empowering, Enabling and Democratising
There needs to be a much wider argument about power balance; people must have greater control over the policies and services which impact on their lives[xviii]. This is acknowledged by the Scottish Government in its’ 20:20 vision which, building on Christie’s recommendations, outlines the need to:
- shift the balance of power to, and build on the assets of, individuals and communities
- support the self-management of long-term conditions and personal action, and
- support partnership working which includes a clear role for the third sector, in Community Planning Partnerships (CPPs) and new Health and Social Care Partnerships[xix]
It is not at all clear that health and social care integration will achieve these ‘aims’. The continuing focus on process, budgets and structures takes away from the very real challenges facing our society and mutes the voices of people most affected by integration activity.
Tackling health inequalities is not about having things “done to” people– this is a concept which the public sector often struggles with[xx]. Much faith is placed in community planning as a way of creating more ‘connected’ policies. As the Scottish Community Alliance outlines:
“Few would deny that Community Planning has had a bumpy ride since its introduction in 2003. While there has been undeniable progress in getting public agencies to work together and plan their services more effectively, the perennial problem has been the extent of its disconnect with communities.”[xxi]
Whether or not the Community Empowerment Bill will help in this regard remains to be seen.
To truly ‘open up’ service planning, delivery and implementation; for people to have a real say in how health inequalities are tackled, there needs to be a focus on building capacity within communities to ensure that the most disadvantaged can be a central part of this.[xxii] This has been the focus of Scottish Government funded work being taken forward by SCVO and partners in East Dunbartonshire[xxiii]. Participatory budgeting also offers opportunities to bring communities and policy makers together in a new and more equal relationship.
The Third Sector’s Role
The role, contribution and resources brought to the table by the third sector must be a key element of planning to tackle health inequalities. Yet the sector still struggles to be recognised as an equal partner in policy, service planning and design.
The role of community organisations in building ‘social capital’ and people’s wider wellbeing was recognised by IPPR[xxiv] and others. The value of services such as befriending, local transport, food and shopping services, carer and family support must be recognised in the drive to tackle health inequalities. These services are still not inherently valued or indeed supported to continue on a long term basis.
Community owned assets can be part of the fight against health and wider inequalities. Community, health and “digital” hubs run by local people must be valued on an equal par with public sector run facilities. Community Care Assynt is one such example offering lunch clubs, activities and transport to help with local shopping. It also offers a hearing aid replacement service, supported bathing facilities and weight management services.
Other examples include Community Development Trusts with space and with a range of activities which tackle isolation in both rural and urban areas, such as Annexe Communities in Glasgow, with its Community Health Navigator role[xxv]; the Twechar Healthy Living Centre which provides a full time pharmacy service, satellite GP services, a café, shower facilities and Mothers and Toddlers provision[xxvi] . There is also the McTaggart Leisure Centre in Bowmore, Islay, which offers physiotherapy, lunch clubs and digital help for older people to use phones/tablets etc., so they can keep in touch with family/friends.[xxvii]
Tackling health inequalities must be about more than people being medically well. It’s about their connections to each other, to society and to economic wellbeing. The impact of place, work, pay, housing, access to services and supports are increasingly being recognised as key factors which contribute to health inequality.
Tackling the wider determinants of health inequality requires big thinking because this requires a new approach to the economy and a more equal distribution of wealth and power. This is acknowledged in the 2013 Equally Well review.[xxviii]
Eradicating inequality must be the primary goal of national and local government and public bodies; parliamentary scrutiny must investigate how well proposed policies, and legislation contribute to this overall goal. We welcome the First Minister’s recognition of the critical role that the third sector can play in this regard.[xxix].
More importantly, the human costs of inequality must be the fuel which drives planning, policy creation and the legislative process. We must be completely honest about the unintended consequences of policy decisions at national and local level – there is a need for full and effective equality impact assessments.
Families are suffering – we do not apologise for using such strong language. Our fellow citizens do not have the same life chances; people with disabilities and their carers fight for support just to live, never mind being able to access the support they need to thrive and achieve their own aspirations. We have increasing social isolation; children who are hungry and families who cannot afford the most basic of human necessities[xxx].
This is what inequality means in Scotland today. Parliament, political parties, Government – both national and local – and civil society, must stop talking and start “doing”; working collectively and across boundaries to turn the tide towards a fairer and more equal society. Our people, families and communities deserve nothing less than this.
[ii] SCVO submission to Expert Working Group on Welfare, 2013
[ix] Revising Scotland’s National Performance Framework, Oxfam http://www.oxfam.org.uk/our-work/poverty-in-the-uk/~/media/0862E084A0E24125AA29E9914EA178F3.ashx
[x] E.g. Stiglitz – Macroeconomic Fluctuations, Inequality and Human Development; Wilkinson and Pickett – The Spirit Level.
[xi] See, for example, West, A. (2007), Benefits 15 (3), Poverty and Educational Achievement: why do children from low-income families tend to do less well at school?
[xix] Voluntary Health Scotland – Briefing for Scottish Labour Health Inequality Inquiry
[xxii] Voluntary Health Scotland – Briefing for Scottish Labour Health Inequality Inquiry
Lynn Williams,Policy Officer
Tel: 0141 559 5036
E mail: email@example.com
Scottish Council for Voluntary Organisations
Mansfield Traquair Centre,
15 Mansfield Place
Edinburgh EH3 6BB
The Scottish Council for Voluntary Organisations (SCVO) is the national body representing the third sector.There are over 45,000 voluntary organisations in Scotland involving around 138,000 paid staff and approximately 1.3 million volunteers. The sector manages an income of £4.9 billion.
SCVO works in partnership with the third sector in Scotland to advance our shared values and interests. We have over 1,600 members who range from individuals and grassroots groups, to Scotland-wide organisations and intermediary bodies.
As the only inclusive representative umbrella organisation for the sector SCVO:
- has the largest Scotland-wide membership from the sector – our 1,600 members include charities, community groups, social enterprises and voluntary organisations of all shapes and sizes
- our governance and membership structures are democratic and accountable – with an elected board and policy committee from the sector, we are managed by the sector, for the sector
- brings together organisations and networks connecting across the whole of Scotland
SCVO works to support people to take voluntary action to help themselves and others, and to bring about social change.
Further details about SCVO can be found at www.scvo.org.uk