Swimming against the tide: challenges faced by delivery partners in tackling health inequalities in Scotland

Scotland has the worst health inequalities in western and central Europe. The gap in healthy life expectancy between the most and least deprived areas in Scotland for men sits at around 23 years, and this is even higher for women at 24 years.

This is not the Scotland we want to be living in. Health inequality need not be inevitable. Through restructuring our society to be fairer and more equitable, we can take action to reduce, and eventually eradicate these inequalities.

In a recent report commissioned by the Health Foundation, Translating ambition into outcomes, we found that although policy effort has been exerted for over a decade, effectiveness needs to be improved.

So - when taking action to tackle health inequalities, what are the practical experiences and challenges faced by policymakers and delivery agencies in translating policy objectives into outcomes? Do the current structures policymakers and practitioners operate under help or hinder change? If the latter, what can be done?

Translating ambition into outcomes

These are the questions that we were asked to look at in the Health Foundation’s report.

They commissioned us to analyse three policy interventions as part of their review of health and health inequalities in Scotland. We focused specifically on the gap between what policies hoped to deliver, and what was actually achieved.

The three policy interventions we looked at related to a number of social determinants of health – the non-medical factors which influence health outcomes, such as the unequal distribution of power, wealth and income; and wider influences such as the availability of work, education and good quality housing.

We wanted to explore the practical experiences and challenges of translating policy objectives into outcomes – in this sense, our research focused primarily on this process as opposed to solely the outcome of interventions alone.

What did we look at?

We evaluated three policy interventions currently being employed by the Scottish government:

• Fair Start Scotland. Fair Start Scotland delivers a mixture of traditional employability support alongside more specialist support such as help with addiction or debt management. By contrast with historic DWP programmes which made participation a condition for receiving benefits, participation in Fair Start Scotland is voluntary.

• Local Child Poverty Action Reports. Local authorities and regional NHS boards jointly prepare and publish an annual Local Child Poverty Action Reports (LCPARs). These reports should demonstrate how local authority and health boards’ policy programmes are contributing to meeting child poverty targets.

• Housing First. This is a policy model which prioritises unconditional access to a safe and permanent home for people who are homeless and have complex needs. It also provides people with additional person-centred support, tailored to their needs.

We chose these as case studies, as all of these interventions address particular social determinants of health inequalities. Additionally, they have been operating long enough to afford insight into their operation – and thus whether their stated ambitions have been matched in delivery and outcome.

Our analysis was based on a rapid literature review and interviews with experts familiar with the three policies.

What did we find, and what does this say for health inequality in Scotland?

Overall, all three policies show a mixture of success and ongoing challenges in translating policy objectives into practice. While the ambitions and aims of the policy objectives evaluated are sound, struggles persist in implementation.

Some of our main findings were:

• All three policies have produced positive outcomes. However, reaching their anticipated potential has been challenging, in part due to the pandemic.
  
  For example, Fair Start Scotland had a positive effect for 65% of participants’ motivation to find work. However, 46% of people who started Fair Start Scotland have been ‘early leavers’ – those who left before the end of the employment support period and without sustaining employment for at least three months. In addition, there is an overrepresentation of clients with less intense support needs. For example, 41% of clients in the core group were classed as having ‘less intense support needs’ - however the original plan aimed to have only 18% of spaces reserved for these clients who are often already close to the labour market, with the policy intended to reach those most disenfranchised.

• Adopting a person-centred approach has positive outcomes– but implementing and maintaining this is challenging
  
  The stakeholders we spoke to, spoke highly of Fair Start Scotland’s objective to embed dignity and respect within the employability service. They suggest this has been beneficial in users’ engagement with the service - the removal of compulsion and risk of sanction means the programme is not a source of stress, and the effort to tailor support to individuals’ specific needs (rather than a narrow traditional focus only on CVs and interview skills) has also been welcomed. The service also helps with broader challenges to employability, such as mental health or drug addiction for those clients who face these issues.
  
  Similarly, the practitioners we spoke with at Housing First told us a person-centred approach had positive effects across their sector, including a more compassionate and trauma-informed approach being adopted across homelessness services.
  
  However, the responsiveness of services to individuals’ needs can be undermined by bureaucratic processes, particularly funding formulae. This was the case for certain elements of Fair Start Scotland’s programme, which tried to use financial incentives to concentrate support on clients with greater need. While well intentioned, this approach failed to produce its intended outcome, resulting in an overrepresentation of clients with less challenging needs.

• Pressures around resourcing have created an uncertain environment which can impact the effectiveness of service delivery
  
  The funding pressures that these policies operate under can mean that the longevity and scale of interventions are constrained. Short funding horizons and reliance on existing budgets can lead to low of ambitions. This is particularly problematic where sustained effort to tackle the social determinants of health is required. For example, concerns were raised about the uncertain long-term funding for Housing First and how this can be reconciled with the open-ended support which is core to their policy philosophy.

Further research is needed to evaluate the effectiveness of Scottish (as well as local and UK Government) policies to address the full range of issues conditioning the social determinants of health.

However, from the scope of our research we can say with certainty that aspects of the health inequality problem are recognised in Scotland, and that there is a dedicated network of policy and service providers willing to work together to tackle them. However, these efforts to date have not been enough to turn the tide, and our review found constraints within policy delivery contributed to this. In short, we saw - strokes in the right direction, but not enough to swim against the powerful currents driving inequalities.

What needs to change?

The Health Foundation’s full review, which includes our findings, states: “Taking action and making progress is possible and can be achieved within existing powers, and by maximising their use. The human and economic cost of inaction for Scotland is simply too high, particularly for the poorest and most vulnerable groups. The time to create a sustainable approach to closing the gap in health outcomes is now.”

We agree. If we want to see a Scotland free from health inequity, we must redouble our efforts to tackle the social determinants of health inequalities. Part of this, by necessity, will involve ramping up ambitions and closing the gap between those ambitions and policy outcomes.