Population Health Framework: evidence paper

Executive summary

The Population Health Framework (PHF) is a ten-year framework which sets out a long-term, collective approach to improving Scotland’s population health and reducing health inequalities. The PHF has been co-developed by the Scottish Government and COSLA, in collaboration with partners such as Public Health Scotland and Scotland's Directors of Public Health. The framework is complementary to wider reform and renewal efforts, including the Public Service Reform Strategy and the Health and Social Care Service Renewal Framework.

This report sits as a companion piece to the PHF. It draws on published evidence to provide an overview of the current status of population health in Scotland, key challenges and opportunities for improvement, and evidence-based policy approaches with the potential to enhance health and wellbeing and reduce inequalities. In doing so, the report provides the evidence base for the PHF, including its framing across key primary drivers of health, the importance of their overlap, and the rationale for the choice of initial priorities and actions outlined in the framework.

Approach

Given the broad scope of population health, the report does not aim to systematically appraise the literature, but rather presents findings from robust and reliable research and evidence that is of relevance to the PHF. It covers peer reviewed journal articles, reports from government and third sector organisations, and routinely gathered statistical and administrative data. The focus is predominantly on research conducted in Scotland, although evidence from other parts of the UK and international evidence is also considered where relevant. Research was identified through searches of databases and the websites of key organisations, as well as a series of evidence sessions held by Scottish Government analysts between March and May 2024.

Understanding population health

Health is shaped by a wide range of complex and interconnected factors. However, evidence shows that the strongest influences on health are the conditions in which people are born, grow, work, live and age. These are collectively known as the social (or wider) determinants of health, and include social, cultural, political, economic, commercial, and environmental factors. In the PHF, these are referred to as the ‘building blocks’ of health. Research shows that the social determinants have a greater impact on population health than healthcare or individual behaviours.

The PHF has been structured around four overlapping drivers of health and wellbeing:

• Social and Economic Factors – Improve the social and economic factors that support better health and reduce inequalities.
• Places and Communities – Create healthy and sustainable places by working in and with communities.
• Enabling Healthy Living – Develop supportive environments that promote health and wellbeing and reduce health harming activities.
• Equitable Health and Care – Foster a health and social care system that delivers equity, prevention and early intervention.

A fifth overarching driver considers ‘how’ the system needs to change to bring greater focus to population health and support a shift to a more prevention-based system through coordinated activities across all drivers:

• Prevention Focused System – Strengthen collective accountability for population health outcomes and inequalities.

The current status of population health in Scotland

After decades of improvement, Scotland’s health is worsening. Since around 2012, mortality improvements have stalled, death rates have risen among the most deprived communities, and health inequalities have widened. Scotland’s life expectancy is the lowest of all UK countries and remains the lowest in Western Europe.

Scotland has longstanding inequalities in income, wealth, and power, known as the ‘fundamental causes’ of health inequalities. More recently, a strong body of evidence identifies the implementation of UK Government austerity policies during the 2010s as one of the principal drivers of the changes in mortality rates in Scotland. There has also been limited progress across several key social determinants of health in recent years, such as housing, education, and employment. These factors, along with the impact of the Covid-19 pandemic, Brexit, and the cost-of-living crisis, provide further context for Scotland’s stalling health improvements.

Analyses project a 21% increase in the overall burden of disease in Scotland over the next 20 years. While such a rise would have significant implications for public health and the health and social care system, it is not inevitable. Effective policies and interventions have the potential to alter trends and improve health outcomes.

Achieving progress: opportunities and challenges

If Scotland is to improve health outcomes and create a sustainable health and social care system, there is a need to shift to a system focused on primary prevention. In the context of population health, prevention refers to actions aimed at keeping people healthy and avoiding not just poor health, but the risks of poor health, illness, injury, and early death. Primary prevention includes action that seeks to stop health problems happening in the first place by addressing the social determinants of health and improving the conditions in which people are born, grow, work, live and age. It has a high impact on population health because it proactively addresses the root causes of disease, reducing demand on healthcare systems.

Primary prevention requires coordinated action across government and sectors, engaging partners such as the NHS and public health, through to education, housing, transport, the third sector, business, and communities. This is described as taking a ‘whole system approach’. Whole systems approaches recognise that there is no single solution to address complex public health issues. Instead, they call for integrated, cross-sector collaboration, moving away from silo-based working and isolated actions.

The impacts of climate change pose significant risks to physical and mental health and wellbeing in Scotland. These risks are disproportionately affecting certain population groups and communities, exacerbating existing inequalities. However, the actions we take to adapt to our changing climate, combined with continued efforts to reduce greenhouse gas emissions, can help protect and improve population health and wellbeing while also reducing inequalities.

There is a need to take action to address the commercial determinants of health in Scotland. Most importantly, system-level action is required to reduce health harms and limit the influence of industries that negatively impact public health. This includes, for example, conflict of interest guidelines in policymaking, support for alternative business organisations such as cooperatives, and legislation to prevent corporations from interfering in public health policymaking.

Action must also be taken to address the inequalities in the access, experiences, and outcomes that people have in relation to healthcare in Scotland. This will require, for example, monitoring uptake of services across different groups and working with those experiencing barriers to design services accessible for everyone.

Improving the health of Scotland’s population: preventative policy approaches

Evidence shows that policy approaches with the potential to improve population health in Scotland include:

• Those which seek to address the fundamental causes of health inequalities, which are inequalities in income, wealth, and power between groups. This includes, for example, the creation of a Wellbeing Economy, Community Wealth Building, and the adoption of proportionate universalism in the design and implementation of policies.
• Health in All Policies, a collaborative approach which involves incorporating health considerations into decision-making across sectors, policy and service areas, to address the social determinants of health.
• The life course approach, which acknowledges that health status reflects cumulative life conditions and considers the critical stages, transitions, and settings where large differences can be made in promoting health and wellbeing.
• Place-based approaches, which recognise the interconnected impact of physical, economic, and social environments on individuals and communities, and emphasise collaborative, locally tailored interventions.
• Structural approaches to reducing health risks, such as fiscal and legislative policies that modify environments to minimise exposure to health harming products. There is limited evidence to suggest that interventions focused on individual behaviour change, such as the provision of information, services and support, have an impact on health outcomes at a population level.

Monitoring progress

As part of the PHF, a high-level aim has been set:

By 2035 we will improve Scottish life expectancy whilst reducing the life expectancy gap between the most deprived 20% of local areas and the national average.

Further details on the analytical work which informed the development of this aim can be found in the Annex – Technical note on the aim of the Population Health Framework.

We will provide updates on a regular basis offering an assessment of progress towards meeting our aim. This will include discussion of the headline life expectancy measure, along with other measures such as healthy life expectancy.

These metrics are also included in the Population Health Dashboard, which will be a crucial part of ongoing monitoring of the PHF at both national and local levels. However, the dashboard is only one tool and further investment in research and evaluation to understand the impact and contribution of actions being delivered under the PHF should be prioritised by all partners across the whole system. A collaborative approach will enhance capacity to effectively monitor progress and evaluate interventions aimed at improving Scotland’s population health outcomes.