Without a doubt Scotland’s poorest children are suffering the most. We know this from the Health Foundation’s recently launched report ‘‘Leave no one behind: The state of health and health inequalities in Scotland’ was the culmination of a multi-stranded review undertaken over the past 12 months, focusing on how the health of Scots has fared the two decades since devolution.
Some of the starkest findings revealed that the health of those in the most deprived areas is falling behind that of the rest of the population. And that the poorest children are at particular risk of experiencing worsening health outcomes, which will have consequences for the rest of their lives. In the fifth most deprived areas, the numbers of children dying before their first birthday is rising. A stark contrast to the rest of the population where deaths in infancy are static or improving. By 2016–18 infant mortality rates in the most deprived areas were 2.6 times the rate in the least deprived areas.
A similar pattern can be seen across several health indicators where children in the most deprived areas are falling behind the rest. In the last decade, children living in the most deprived areas are falling further behind those in the least deprived. Whether in terms of infant immunisation uptake, childhood obesity and low birth weight. There has also been no significant improvement in the poverty-related attainment gap for primary school and secondary age pupils. Poor outcomes in childhood can have significant implications in later life by hindering educational readiness, attainment and eventual access to job opportunities. A failure to act will have serious consequences for health, now and in the future.
In Scotland, since 2015 the poorest households have become both poorer when compared to average household incomes – so called ‘relative poverty’ – and in absolute terms. Between 2017 and 2020, nearly a quarter of Scottish children were living in relative poverty. And those that were living in extreme poverty – struggling to cover basic needs – rose from 13% in 2009-11 to 17% in 2017-20. This trend – even before the pandemic and cost of living crisis – is alarming and demonstrates the critical nature of the problem. And yet, between 1999 and 2012, the proportion of the population living in relative poverty fell significantly from around 23% to 18% - so reducing poverty is not only possible, it’s been done before.
At the core of these shocking statistics are real people who are struggling to survive week to week, bringing home the urgency of acting now. The number of children registered for free school meals has increased year on year in Scotland, demand for warm banks continues to rise and the cost-of-living crisis is means more people are unable to reliably access sufficient, affordable and nutritious food. Many, especially those living in poverty or more deprived areas, already have poor health at risk of further deterioration. The experience of multiple disadvantages, when people face multiple, interacting inequalities at once, such as poor quality housing, mental ill health and lack of access to health services. For a small number of people, these multiple disadvantages are more severe, which contributes to an ever-growing gap in health outcomes. These issues are not new, and, despite political intent, improvements are not forthcoming. For people in these groups, time is ticking on.
The overall trends in poor health mask the uneven experiences of poverty across the country. In Shetland and East Dunbartonshire around 10% of children live in poverty whereas in Glasgow it is around 30% of children. A wide range of local factors, such as limited employment opportunities or a lack of affordable housing, are driving the higher rates of child poverty. Locally led action, attuned to needs of communities, is required but cannot exist in a vacuum. There must also be sustained, national policy efforts that go beyond setting the policy agenda to a focus on delivering and evaluating the action.
Through our review we were told, repeatedly, that despite good policy intent, there was a gap when it came to implementation. Stakeholders referred to short-termism, over-centralisation, poor prioritisation and a perceived lack of trust between different parts of the system. Policies were cited as being highly burdensome and difficult to tailor to local need. Failure to resolve these issues and address the policy implementation gap will hinder much needed progress in reducing inequalities and tackling poverty. The COVID-19 pandemic showed us that actors across the policy system can come together when the chips are down. It has shown that change in policy delivery and more effective, agile collaboration is possible in Scotland.
No single entity can reduce health inequalities and address poverty rates alone. Practical collaboration is needed across all parts of society - the Scottish government, local authorities, businesses, the third sector and local communities. Such cross-sector working requires setting clear, focused goals for both short action and a longer-term preventive approach to tackling inequalities and poverty. Underpinned by a commitment to learn from what works – and what doesn’t – with flexibility to adapt to different localities.
Such an approach might be daunting and there are some obvious factors that may hinder progress. The difficult fiscal context must be recognised and without better partnership between Scottish and UK government there are limits to change. Yet the scale of health inequalities and poverty in Scotland is not inevitable. Nor is it justifiable to those experiencing the worst outcomes. The pandemic demonstrated what is possible, and we now need to act at pace, taking the opportunity for renewal. Such a shift might be considered radical, but it is desperately needed now more than ever, not least for the 210, 000 children living in absolute poverty in Scotland.