Health and social care - service renewal framework: equality impact assessment

Key Findings

The development of the Framework has been informed by evidence, provided through our evidence narrative discussing the current state of the health of our population and through vital insights provided by our stakeholders and partners throughout the extensive engagement process in 2024. To support this, an initial scoping of the key health inequalities facing each demographic group has been carried out, with the key points set out below.

Age

Age plays a significant role in shaping health and social outcomes in Scotland. While 57% of 16–24-year-olds were within a healthy weight range in 2023, the adult average was only 33%.^[1] Self-reported health status declined with age, with 85% of young adults rating their health as very good or good, compared to only 55% of those over 75. Chronic conditions such as cardiovascular disease and COPD were markedly more prevalent in older age groups.

Mental health issues also vary across age groups. In 2023, 10% of adults reported feeling lonely most or all of the time, a rate that peaked among 16–24-year-olds and those in the most deprived areas.^[2] Younger adults also showed the poorest mental wellbeing scores. Data from the 2022 Census reveals that the number of individuals reporting a mental health condition has doubled over the past decade, with younger people now more likely to report such conditions than older age groups^[3].

Older adults were more likely to consume alcohol at hazardous or harmful levels, particularly men aged 65–74. Drug use and vaping, however, were more common among younger adults. E-cigarette use was highest among those aged 16–24 and lowest in the 75+ age group.

Obesity remains a concern across all age groups, with 17% of children at risk of obesity and 30% considered overweight or obese — a pattern that has stayed consistent since 1998.^[4]

If they are enabled, older people can see improved opportunities to access health and social care information from their homes if they choose to do so, for example people living with long-term conditions or reduced mobility that can cause them to experience social isolation.^[5] In 2023, 89% of people aged 50 and over had access to the internet at home – this was across all age groups although access tended to decrease with age. Older people are most likely using the internet to email friends/family (77%), to find out information (76%), and online shopping (71%)

Scotland’s unpaid carers reflect a wide age distribution. In 2023–24, 58% of carers were working-age adults, 26% were aged 65+, and 16% were under 18. Young carers were more likely to live in deprived areas and reported high levels of stress and inadequate support from schools or colleges. Suicide rates were highest among those in the cohort aged 25–64, highlighting a critical public health concern among mid-life adults.^[6]

Sex

Sex-based disparities are evident across Scotland’s health and social data. Women make up 51.4% of the population, and 43% report living with a long-term condition or disability that limits daily activities. Although women tend to live longer than men, they also spend more years in poor health. In 2021–2022, anxiety symptoms were most common among young women aged 16–24, affecting 33% of this group, compared to 13% of young men. Access to menopause care in Scotland varies significantly, leading to women in rural areas facing additional challenges due to longer travel distances to essential services. The use of Near Me and Connect Me digital services is established in pregnancy and maternity services.

The labour market reflects persistent sex based inequalities. Women are significantly more likely than men to work part-time — 39.1% compared to 13.2%. ^[7]A growing area of concern is the economic impact of menopause, with around 60,000 UK women out of work due to symptoms, contributing to an estimated £1.5 billion loss to the economy each year.^[8]

Health behaviours also vary by sex. Men are more likely than women to drink at hazardous levels, use drugs, and smoke. In 2023, 28% of men drank at harmful levels compared to 14% of women. Similarly, 18% of men reported drug use, while only 11% of women did.^[9] Men are more physically active on average, with 68% meeting national guidelines compared to 59% of women. Among children, physical activity among girls tends to decline sharply during adolescence.^[10]

Women are disproportionately impacted by caring responsibilities. In 2023–24, 73% of all carers were female, and 80% of working-age carers were women.^[11] Women typically begin caregiving responsibilities at age 45, 12 years earlier than men. Women are also more likely to be victims of domestic abuse, with 83% of incidents involving a female victim and male perpetrator.^[12] Additionally, suicide remains significantly more common among men, who are 3.2 times more likely than women to die by suicide. ^[13]

Gender Reassignment

Transgender and non-binary individuals in Scotland face substantial health and social inequalities. Discrimination and negative experiences with healthcare providers are prevalent. Over half of non-binary people reported that their GP did not understand their needs, and 40% of trans people described negative or harmful encounters in medical settings, including being ignored or subjected to inappropriate questions. ^[14]These barriers often lead to avoidance of essential healthcare and reports indicate that these delays lead to severe mental health issues, including heightened anxiety and depression.^[15]

Mental health concerns are also acute in this population: 66% of trans youth reported suicidal thoughts — nearly double the rate of their cisgender peers.^[16]

The introduction of the Digital Front Door can be an opportunity to improve access to services and well-being for trans people, supporting wellbeing and improving access to services, for example GP services and screening programmes.

Sexual Orientation

LGBT+ individuals in Scotland are at greater risk of poverty and poor mental health. From 2020 to 2023, 25% of non-heterosexual adults lived in poverty, compared to 19% of heterosexual adults.^[17] Loneliness and mental health issues are more prevalent, with half of LGBT youth in 2023 reporting suicidal ideation and 43% saying they had self-harmed.^[18] Only one in four LGBT+ survey respondents rated their mental and emotional health positively

Nearly one in three (31%) LGBT+ individuals reported having attempted suicide, with the highest rates among trans masculine (49%) and non-binary people (47%).^[19]

In terms of general physical health, only 59% of LGBT+ people rated their health positively, with gay men and gay/lesbian women being more likely to report good health, while trans masculine and non-binary people were the least likely.²²

These health disparities are not inherent to sexual orientation or gender identity but are a direct consequence of societal prejudice, discrimination, social isolation, loneliness, and often poor socioeconomic situations. ²²

This indicates that addressing these inequalities requires a holistic approach that tackles discrimination, improves social inclusion, and provides culturally competent and affirming health and social care services, moving beyond a purely medical model to address the broader social determinants of health for LGBT+ communities.

Direct and perceived discrimination within the health and social care system creates significant barriers to access and contributes to unmet needs for LGBT+ individuals. Nearly half (44%) of LGBT+ people reported experiencing discrimination in the last year, with significantly higher rates for non-binary (65%), trans masculine (62%), and trans women (55%) individuals.²² Furthermore, LGBT+ adults are more likely to report unmet social care needs. ^[20]

Race

Scotland's population is becoming increasingly ethnically diverse. In the 2022 Census, 87.1% of the population identified as white, while 12.9% were from a minority ethnic background. This represents a significant increase in ethnic diversity, doubling from 4% in 2011. ^[21] Despite this, within the social care system, approximately 98% of people receiving social care in 22/23 were white ^[22]

Health inequalities between different ethnic groups exist. Ethnic minority populations experience higher rates of conditions such as diabetes and cardiovascular disease and were disproportionately affected by COVID-19 mortality. ^[23]

Mental health outcomes for minority ethnic groups are under-researched, but available data suggests that some groups are at increased risk of poor mental health and have less access to culturally appropriate support services.^[24]

In the workforce, racism remains an issue. A recent survey revealed that 64% of ethnic minority doctors in Scotland have either experienced or witnessed racist incidents in the workplace ^[25]

Some evidence suggest that navigating the healthcare system can be challenging for refugees and asylum seekers or those whose first language is not English. ^[26]

We appreciate that digital options may present barriers to access for some groups. In addition to recommending support for such services in a range of media and language options to mitigate this, we are exploring how the findings for the Digital Inclusion Programme can be embedded and co-design mandated for digital options and services as part of their development.

Religion or Belief

Religious affiliation correlates with varying levels of poverty in Scotland. Between 2018 and 2023, Muslims experienced the highest poverty rate after housing costs, at 61%, compared to 16% among members of the Church of Scotland and 18% of those with no religion.^[27] Discrimination and harassment based on religion were also reported, particularly among individuals identifying with minority religions.^[28] These experiences can affect health, employment opportunities, and access to services.

Disability

In Scotland, approximately 24% of the population reported having a long-term health problem or disability that limits their day-to-day activities in 2022.

The prevalence of disability is strongly correlated with age, increasing from 11% among children to 23% for working-age adults and 45% for adults over State Pension age across the UK.^[29] In Scotland, over half of individuals aged 75 and over reported a disability in 2017.

Common impairment types reported in the UK include mobility (48%), stamina, breathing or fatigue (36%), and mental health (34%). ³¹

Within social care, an estimated 76,605 people received support for "Physical and Sensory Disability," and 49,060 for "Learning Disability" in 2020/21. 20,590 for “Learning Disability”, 15,275 for Dementia and 14,445 for “Mental Health”. ^[30]

Disabled people are less likely to meet physical activity guidelines and report poorer mental wellbeing. In 2021, adults with long-term conditions had significantly lower wellbeing scores and were more likely to experience anxiety and depression. They also face higher levels of poverty, food insecurity, and unemployment. Children and adults with learning disabilities suffer from poorer health outcomes and shorter life expectancy, with a higher proportion of their deaths considered avoidable.

The introduction of digital service options can be an opportunity for people with disabilities to improve access to services and well-being. Disabilities are wide-ranging (sensory, physical, learning) and therefore appropriate solutions to facilitate inclusion will need to be co-designed and tested. Accessibility should be a key consideration when designing services such as the Digital Front Door.

Pregnancy and Maternity

Pregnancy can intensify financial hardship and is linked to worsening health outcomes for mothers in deprived areas.^[31] For some households, the arrival of a baby pushes them into poverty.^[32] Domestic abuse is another serious issue, with one in three pregnant women reporting some form of abuse, and pregnancy often cited as a trigger or worsening factor in abusive relationships. These intersecting challenges contribute to significant health inequalities during a critical period in family life.^[33]