Benjamin Franklin famously said that ‘nothing is certain except death and taxes’. Well, it used to be pretty certain that this generation would live longer than the last – but no more. Life expectancy was improving until 2011 when it started to decline in Scotland.
This was my opening pitch when moving the Socialist Health Association Scotland motion on health inequalities at the recent Scottish Labour Party conference. The key point is that as health inequalities underpin most of the challenges facing our health and care systems, political parties should put radical action on health inequalities at the heart of their manifestos.
Let's start with why we should be concerned that life expectancy in Scotland is no longer rising. While deaths relating to COVID-19 play a part in explaining recent falls, the deviation from the long-run trend dates back to the early 2010s. More people in Scotland are in relative poverty, more are likely to be inactive due to long-term illnesses, and food insecurity, homelessness, and fuel poverty are all higher than they were. The SHERU report found that key outcomes related to health and inequalities are not significantly improving and are, in some cases, worsening. The biggest difference in female healthy life expectancy is between the Orkney Islands (77.5 years) and North Ayrshire (54.0 years) – over 23 years difference. A gap that applies to almost all the leading causes of death.
This isn't an easy debate for political parties. The health debate in Scotland focuses almost entirely on the NHS, partially driven by a less than edifying parliamentary scrap each week, but it reflects how the public thinks about health. Health equals the NHS. It is of course vital that we continue to make the case for the NHS when you have Farage and his Reform private company arguing for privatisation. The US healthcare corporations who have created the most expensive and inefficient healthcare system in the world are rubbing their hands with glee – and they have Trump to press their case through trade deals.
However, the actual pressure on our health and social care system comes from poor health outcomes caused by inequalities. When household income is too low to afford essential goods and services like food and warm homes, participation in everyday social activities leads to greater social isolation. This is not about behavioural factors – it’s about the big issues like income support, wages, employment rights, housing, air pollution, crime and fuel poverty. I remember running a fuel poverty course for health visitors who vented their frustration at returning time and time again to the same families with the same health problems caused by cold, damp housing.
We have many strategies in Scotland, beautifully laid out in glossy documents. What we rarely have is measurable action and outcomes. We have some isolated initiatives, like the excellent Scottish Child Payment, but no comprehensive plan to fully meet the statutory target of 10% of children in relative poverty by 2030/31. As the SHERU report and others have highlighted, there is limited evidence that current policies have effectively reduced inequalities.
All of this was highlighted by the Christie Commission over 13 years ago. I was an expert advisor to that Commission, and we calculated that 40% of all public spending was related to failure demand - putting right the impact of inequality. So, when ministers and others talk about public service reform, the solution isn’t going to be found in efficiency targets and the like. It requires preventative spending that tackles inequality before creating the failure demand, which costs much more. I remember talking to a lecturer running a pilot course for single mothers, helping them to keep their children out of care. The course was successful, but no one could fund the £450 per head to continue it. It can cost over £5,000 per week to place a child in a private care home. How bonkers is that!
Despite our economic challenges, we are a rich country, but the investment in preventative spending has to be paid for. This is spending to save, so we need to look at ways of increasing current spending and how long-term investment can be financed. In the short to medium term, the work of Tax Justice Scotland is essential. In the longer term, we might look at what the EU, with the UK, is considering with bonds to pay for increased defence spending. Now, I am all for financing the defence of Ukraine and the rest of Europe against Putin and his useful idiot Trump. But if we can spend to save for that eventuality, we should be able to do the same for health inequalities. This is an investment in our country’s future.
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