Health and Home
Race Equality Framework for Scotland Vision
Minority ethnic communities in Scotland have equality in physical and mental health as far as is achievable, have effective healthcare appropriate to their needs and experience fewer inequalities in housing and home life.
26. Minority ethnic communities and individuals experience better health and wellbeing outcomes
27. Minority ethnic communities and individuals experience improved access to health and social care services at a local and national level to support their needs
28. Scotland's health and social care workers are better able to tackle racism and promote equality and community cohesion in delivery of health and social care services
29. Scotland's health and social care workforce better reflects the diversity of its communities
30. Minority ethnic communities experience fewer housing inequalities
The final area of the Race Equality Framework covers health, housing, social work and social care issues.
Over the past twenty years, a fairly small amount of race equality policy has focussed on these areas. Only 89 actions and commitments were drawn out of the various publications examined in this review.
This is likely to be partly as a result of race equality policy in the health sector focussing less on strategies produced at centralised Scottish Government / Executive level, and more on health sector specific policy, such as the recommendations of NHS Scotland's Fair for All report.
Of the 89 actions and commitments identified, 29 consisted of basic commitments to consider race equality within a mainstream policy or service. 16 of these related to health and social care, 1 to child protection and 12 to housing.
Involving minority ethnic people in health policy was the subject of 10 commitments, and a further 3 related to involvement in housing policy. 12 related to data gathering (7 in health, 4 in housing). 9 related to promotion of services (7 in health and 2 in housing).
The remaining commitments were on subjects including:
- Diversity in the health and social care workforce
- Tackling inequalities in the housing and planning system affecting Gypsy/Travellers
- Policy development matters in the health sector, such as work to meet the public sector equality duties, action planning and formation of advisory groups
No examples of measurable change impacting minority ethnic people in these policy areas were identified in any of the progress reports included in this review.
Evidence on inequalities and change over time
- Although minority ethnic groups are less likely to have long-term limiting health conditions and disabilities (see Figure 22), there are differences among minority ethnic groups, with worse outcomes for Gypsy/Traveller and Pakistani communities
- Minority ethnic groups are less likely to report health damaging behaviours such as smoking, excessive alcohol consumption and drug misuse; however, there is a mixed picture in relation to other health and wellbeing indicators, such as participation in physical activity and obesity levels
- Some specific health conditions are more likely to be experienced by people in particular minority ethnic groups, but data on these issues for Scotland is patchy
- Racial disparities in housing have persisted for decades - housing deprivation is not exclusive to BME groups, but the persistence of racial discrimination means that such groups are at greater risk
- Minority ethnic households are generally younger, more likely to be experiencing overcrowding and more likely to be privately renting (with associated higher financial costs)
- Non-white individuals are more likely to be homeless than white individuals
Lack of effective data collection and small sample sizes mean reliable data is lacking in home-related policy areas, particularly focusing on family units; reliable and up-to-date evidence that differentiates by housing tenure is an essential first step towards solutions to inequality in housing for BME people
In many cases there is a lack of adequate data over time in relation to health and ethnicity in Scotland. CRER research in 2020 highlighted that for the Health outcome of the Scottish Government's National Performance Framework, no ethnicity data is currently published on Equality Evidence Finder.
Health indicators such as health risk behaviours, healthy life expectancy, healthy weight, active travel journeys, physical activity and premature mortality had no ethnicity data despite often having information available by age, disability, gender, SIMD and urban-rural classification. Racial equality in health is crucial for improving life chances and it is known that improvements are needed to better meet the needs of minority ethnic people.
The Expert Reference Group on Ethnicity and Covid-19 stated that data on ethnicity has been recorded in many NHS Scotland administrative systems for some time, but levels of recording and data quality have often been too poor to allow meaningful analysis.
Scottish Health and Ethnicity Linkage Study (SHELS)
- Pakistani men and women had the highest rates of hospitalisation and death due to heart attack
- Chinese men and women, other South Asian men and Pakistani women have substantially higher rate of hospitalisation for liver disease
- Compared to the White Scottish population, the highest rates of hospital admission for respiratory conditions were in Pakistani males and females and Indian males, whilst the lowest rates were seen in Chinese males and females
Additionally, SHELS data has demonstrated that 23 years after the introduction of the UK's national breast screening programme, the uptake at first invite is substantially lower for almost every BME group in Scotland, particularly for Pakistani and African women. This matters because research shows that women who attend breast screening at first invitation are more likely to attend for subsequent screens. The consequent ethnic inequity in the extent of preventable cancer mortality may be marked, especially for Pakistani and African women.
The Scottish population has, by international standards, high rates of cardiovascular diseases, both coronary heart disease and stroke, and of type 2 diabetes. SHELS research has highlighted that the South Asian ethnic groups in Scotland, comprising mostly of people of Pakistani and Indian origins, have substantially higher rates of cardiovascular diseases and of type 2 diabetes compared to the White Scottish population.
Through analysis of data over 2001-2013, SHELS also found that African men were over twofold higher risk of 'late' HIV diagnosis than white Scottish men. The implication is therefore of more advanced HIV in African men and reduced opportunity for treatment which affects the survival rate of African men who are HIV positive.
Long-term health conditions and general health
As minority ethnic groups tend to be younger than the majority population, it is important to adjust for age to in order to analyse the health of minority ethnic groups and their comparable population. In 2015, the Scottish Government published 'Which ethnic groups have the poorest health?' which used age standardised rates to compare ethnic groups of similar age. CRER analysis found the following points of note:
Bangladeshi and Pakistani women are roughly 10% more likely to suffer from health inequality than white women
Ethnic inequalities in health are most pronounced at older ages:
- 56% of all women aged 65 or older reported a limiting long-term illness, but over 70% of Pakistani, Bangladeshi and Gypsy/Traveller women at this age reported a limiting long-term illness
- Arab and Indian older women also reported high percentages of limiting long-term illness (66% and 68% respectively)
- 50% of all men aged 65 or older reported a limiting long-term illness, but 69% of Bangladeshi and Gypsy/Traveller older men reported a limiting long-term illness
- The Chinese ethnic group reported persistently better health in 1991, 2001 and 2011, with half or under half the white ethnic group illness rates for both men and women
In 2017, it was reported by NHS Health Scotland that Gypsy/Travellers had low rates of outpatient appointments, hospital admissions, accident and emergency attendances, cancer registrations and maternity hospital admissions. It was suggested that this may be due to the under-recording of Gypsy/Travellers compared with the proportions reported in the census, and issues with accessing services.
The 2019 Inpatient Census, which is designed to provide an understanding of patients in mental health, addiction and learning disability beds, has published statistics on ethnicity of patients. This showed that Asian, Asian Scottish or Asian British people made up 2% of the patients, while African, African Scottish or African British made up a further 1%. These proportions are relatively unchanged from previous years. However, this data does not show further information such as the gender, length of stay or type of bed occupied - psychiatric, addiction or learning disability – by ethnicity.
In 2013 the University of Edinburgh reported that minority ethnic populations in Scotland received varying levels of support for their mental health. Its findings reported that South Asian and Chinese individuals in particular were often much later in entering mental health support services than those from other ethnic groups. In most minority ethnic groups in the study, those that went to hospital were significantly more likely to be treated under the Mental Health Act.
The report authors noted that difficulties in diagnosing and treating mental illness among minority ethnic groups at an early stage goes some way to explaining their findings. In general, a lack of awareness of support services available and reluctance to seek medical help due to social stigma within minority ethnic groups also contributed to this.
In 2017, the Scottish Government's independent adviser on race equality in Scotland recommended that the Scottish Government should commission research to identify the barriers and put forward a plan to address the unmet need and persistent ethnic inequalities in mental health care.
The Scottish Government's report 'Growing up in Scotland: Birth Cohort 2' revealed the following:
- 75% of children whose main carer was white had 'very good' health, with a further 20% having good health; in contrast, 65% of those with non-white carers had 'very good' health, with 31% reporting 'good' health
- The mean number of different health problems was higher for children of white carers than for children of non-white minority ethnic carers (2.4 vs 2.2)
- Children with non-white carers were less likely to sleep through the night than children with white main carers (33% vs 21% respectively)
On children's social and physical development, CRER research has found that there are significant differences in the percent of children being recorded as with concerns or with some domains incomplete or missing by ethnicity at their 27-30-month health visitor review.
Over the period 2015-2018, BME children were consistently less likely to have no recorded concerns. In particular, Asian children are less likely than the majority population of white Scottish children to have no recorded concerns, with this decreasing year on year.
For all children, the percentage recorded as without a concern but with some domains incomplete or missing has increased year on year. Significantly, this increase has impacted BME children disproportionately: in 2017/18, 43% of Black, Caribbean or African children and almost half of Asian children (47%) were categorised as without a concern but with some domains incomplete or missing.
It is not clear what the reasons for this are. Early child development is influenced by both biological factors (such as being born prematurely) and environmental factors (such as learning opportunities children receive). There may also be questions around the reliability of development assessments for BME children and families. Public Health Scotland have previously noted that the proportion of review records containing meaningful information for every developmental domain was noticeably lower for children from certain ethnic groups, those living in a household where English was not main language spoken and those living in a bi-lingual or multi-lingual household. They therefore emphasise the importance of access to appropriate translation services.
However, the data shows that white Polish children have review results almost identical to the other white groups and do not seem to be impacted by the disproportionate percentage of reviews with some domains incomplete or missing. This reduces the credibility of the assessment that differences in results are solely a result of language barriers, as Polish children are likely to be bilingual, potentially living in a household where English is not the main language spoken, and much more likely than the Asian group to be first generation migrants.
UK based research has found previously that social care services are failing to meet the needs and wants of minority ethnic older people, despite efforts at improvements. Research published in 2000, 'Researching Social Care for Minority Ethnic Older People: Implications of Some Scottish Research', focussed on the Pakistani community in Glasgow and their relationship, or lack of, to formal social care. This concluded that, despite efforts of the staff to make social care 'user friendly' for this group, there remained considerable issues, with the very real needs of older Pakistani people often being left unmet.
As noted by the Expert Reference Group on Ethnicity and Covid-19, the need for social care provision that is tailored to an ethnically diverse population is likely to increase substantially in coming years, as the proportion of older people who are minority ethnic increases. This will also necessitate better data collection.
Housing Cost Induced Poverty
Over the period 2014-19, despite already higher relative poverty rates before housing costs, data shows that housing costs substantially affect poverty rates for minority ethnic groups (see Figure 23). Housing costs had much less of an impact on poverty rates for the majority white British group, with the biggest impact on people from white other background and Asian or Asian British background.
Much of the available data on housing and ethnicity in Scotland is derived from the Census, and so trends over time will only be identifiable once results from the 2022 Census are published.
According to the 2011 Census, BME people in Scotland are generally underrepresented in the social housing sector. Asian groups are particularly underrepresented within social housing, with only 11% of Pakistani and 5% of Indian groups residing with social housing compared to the majority group of white Scottish people at 22%.
More recently, the Scottish Housing Regulator provided statistics on ethnicity of social tenants showing that, in 2014/15, ethnicity was unknown for a third of tenants and the known percentage of tenants from a BME group was only 2.3%.
The 2011 Census also showed rates of housing ownership are lower for BME groups than the white population. All minority ethnic groups are underrepresented in the home ownership tenure rate aside from the Pakistani group.
It should be noted that while overall home ownership is higher in certain non-white minority ethnic groups than the overall population, this is not necessarily an indicator of financial success; in fact, according to the Joseph Rowntree Foundation, some individuals feel forced to buy their own homes due to a lack of viable alternatives in other tenures.
All minority ethnic groups in Scotland had an above average tenure rate recorded as private rent or living rent free in the 2011 Census. While the flexibility of private renting is attractive to some people, the insecurity can be problematic for others. The connections between privately rented housing and poverty are well documented: rent is typically higher than in social housing, rental rates often rise above the level of inflation or wages and there can be challenges in obtaining the money necessary for deposits, contributing to a risk of homelessness.
Levels of private rent are often not fully covered by Local Housing Allowance, which in effect can reduce the volume of private rented sector accommodation available to low-income households. Given that BME people in Scotland are twice as likely to be in poverty as white British people they may be more likely to utilise Local Housing Allowance support and any shortfall since the rates were previously frozen may be likely to lead to an enhanced risk of poverty.
Among Gypsy/Travellers, there are higher rents and electricity charges on sites compared to costs in social housing, contributing to a significantly disadvantaged socioeconomic status.
The housing tenure rates from the 2011 Census are in line with findings from Scottish Household Survey from 2001 to 2018. These all showed that non-white minority ethnic groups are over-represented in private renting, but under-represented in home ownership and social housing.
BME communities in Scotland tend to have a younger age profile and younger people are more likely to reside within private rents, whereas older people are more likely to own their own home. However, age profile alone does not explain the different tenure types by ethnicities.
Research has found that minority ethnic households are more likely to suffer overcrowding.
Analysis of the 2011 Census demonstrated that 'White: Polish' households had the highest rate of overcrowded households (30%), followed by 'Bangladeshi' and 'African' households (28%). Conversely 'White: Scottish' and 'White: Other British' households were the least likely to be overcrowded (8% and 6% respectively) According to the Equality and Human Rights Commission, in 2013 a higher proportion of ethnic minority than white households lived in overcrowded housing in Scotland (11.8% compared with 2.9%).
Similarly, data from the Scottish House Condition Survey 2016-2019 demonstrated that a significantly higher proportion of households with a minority ethnic highest income householder were overcrowded (7%), compared to households with a white Scottish/British highest income householder (2%). This suggests that racial inequalities in overcrowding are persistent.
There is little consistent evidence on homelessness amongst BME communities in the current Scottish context, again making trends difficult to identify. In 2004, Scottish research found that there was an over-representation of BME people who present as homeless and called for an appropriate response in terms of policy and practice.
In 2011, the Scottish Census results showed that the non-white minority ethnic population had a greater rate of individuals in 'hostels for homeless or temporary shelter', representing 6.5% of the residents.
In relation to statutory homelessness, in 2018/2019 2728 BME people in Scotland made a homelessness application (approximately 7.4% of total applications). This represents an increase of approximately 11% from the previous year.
Measures which the Joseph Rowntree Foundation suggest to reduce homelessness in minority ethnic communities include:
- Provision of high-quality advice and information
- Increased recognition of the existence of hidden homelessness and the particular accommodation needs of minority ethnic families
- Ethnic monitoring of service provision and regular review of services
The poor quality of housing and surrounding neighbourhoods is another significant issue faced by minority ethnic individuals, including access to key facilities.
Research on migrant communities found evidence of substandard accommodation, including unsafe living conditions, poor furnishings and inadequate heating. Poor living conditions were also found among asylum-seekers and refugees, with high-rise flats identified in research as inappropriate for families with young children and those with disabilities or long-term health conditions.
Data from 2016-19 has shown higher rates of disrepair for minority ethnic households. Higher rates of disrepair in the private rented sector combined with the higher prevalence of this tenure for minority ethnic households is suggested to be a likely contributor to these higher rates of disrepair.
There is a lack of data over a longer period detailing how housing quality affects minority ethnic groups. However, housing conditions have been suggested as one of the possible explanations for the disproportionate impact of Covid-19 on BME groups showing how vital data in this area is.
Considerations for future policy
The policy environment in relation to race and health has changed dramatically over the course of the Coronavirus pandemic. Scottish Executive's 2002 Race Equality Scheme highlighted evidence of additional vulnerability to infectious diseases amongst some minority ethnic communities, and this would be tragically echoed in the dramatic health inequalities exposed by the pandemic in 2020.
In recognition of this, Scottish Government convened a multi-agency Expert Reference Group (ERG) on Covid-19 and Ethnicity, bringing together senior professionals from the health sector, third sector and academia with expertise on race and health.
The recommendations of the ERG were set out in two reports, one covering data and evidence gaps and one covering systemic issues and risks. The latter set out a wide variety of evidence demonstrating the impact of factors including housing inequalities, employment inequalities and structural racism on minority ethnic people's health.
The ERG's recommendations provide a solid foundation for beginning to address these inequalities through national policy.
Areas which Scottish Government may wish to consider in its future approach to race equality policy include:
- How best to implement the recommendations of the Expert Reference Group on Covid-19 and Ethnicity
- Co-ordinated approaches to capacity building on race equality in the health sector, taking into account its size and complexity
- Strengthening the availability of consistent, robust housing data disaggregated by ethnicity
- Targeted work to address minority ethnic communities' disproportionate concentration in the private rented sector and disparities in overcrowding and housing quality