Putting the local into reducing health inequalities

While national strategies are essential in reducing health inequalities, we need to emphasise local action. 

This week the Scottish Government statistics division published its long-term monitoring of health inequalities. Spoiler alert, it doesn’t make happy reading. Male Healthy Life Expectancy at birth was 46.8 years for those living in the most deprived areas, 23.7 years lower than those living in the least deprived areas (70.4 years), and it’s getting worse. For women, the gap was almost identical at 23.6 years. Moreover, in 2020 the premature mortality rate in the most deprived areas was four times higher than the rate in the least deprived areas.

So, what is the Scottish Government doing about it? Well, there was a public health ‘review’ in 2015. There are many glossy documents and websites that say they are ‘working towards’ reducing health inequalities, ‘defining’ their priorities, and a lot of similar guff. What’s missing is any sense of urgency to actually implement these plans.

Let me give just one small example. The Scottish Government rightly says that Fair Work is an important tool in reducing health inequalities, and procurement is an important lever. Last year, SHA Scotland spotted that NHS Education for Scotland (a health quango) had awarded a contract to Amazon. Given Amazon’s notorious employment practices, they wondered how they passed the Scottish Government’s Fair Work criteria that are supposed to be applied to the evaluation of contract bids. So, they sent off an FoI request and were told that the Fair Work Criteria wasn’t applied to this contract. Here we have a government health quango who couldn’t even be bothered to apply the policy. It is no wonder that there is a considerable gap between rhetoric and policy delivery.

Important though national action is, many of the services and actions required to reduce health inequalities need to happen locally. No serious plan to tackle health inequalities in Scotland can ignore the pivotal role of local government. Councils make a vital contribution to weaving the social fabric of their areas and seeking to create and sustain healthy places for people to be born, grow, live, work and age. 

I drafted a paper that SHA Scotland launched this week, which sets out some of the ways that local government can make a difference. Planning, public spaces, leisure and cultural services all make up the vital social infrastructure that promotes wellbeing in our communities. This helps tackle poor mental health through stronger social cohesion and social support. They can also create sustainable communities tackling air pollution and food poverty. However, this cannot be achieved while the Scottish Government cuts councils' funding by nearly a billion pounds. Fair funding for local government is crucial to tackling health inequalities. In addition, centralising services in Edinburgh, as with the proposed National Care Service, is also the opposite of what is needed to reform social care.

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Local action on health inequalities requires councils to lead the way with a community health strategy that puts reducing health inequalities at the heart of everything they do. When we focus on the social determinants of health, we see that local government services are health services. Without local government, adults and children would die sooner, live in worse conditions, lead lives that made them ill more often, and experience less emotional, mental and physical wellbeing than they do now.

The Scottish Government should set the framework for reducing health inequalities and take appropriate actions at the national level. That doesn’t mean micromanaging from Edinburgh. They must also ensure that the local government is funded fairly, not just pass on Tory austerity to councils while protecting their budgets. Local communities understand what needs to be done in their area, and they need the leadership and resources to do it.