Population Health Framework: evidence paper

3. Achieving progress: opportunities and challenges

A range of evidence has illustrated concerning shifts in the health of Scotland’s population, including stalled mortality improvements, worsening health outcomes, and widening inequalities. In a recent report, GCPH (2024) has argued that because the decline in population health is largely due to macro-level factors adversely affecting access to positive social determinants of health, changing the current trajectory will require large-scale, macro-level policies which change this adverse scenario. It is crucial that action is taken which seeks to mitigate the most immediate and severe impacts of austerity, protect the most vulnerable groups, reduce widening health inequalities, and maintain and improve the health of Scotland’s population in future. Before considering evidence-based policy approaches that have the potential to deliver on these priorities, this section considers broader evidence on where there are opportunities for achieving improvements in population health in Scotland, as well as reflecting on current and potential challenges we may face in making progress.

Key points

• 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.
• 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.
• Primary prevention requires coordinated cross-government and cross-sector action, involving 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’.
• The impacts of climate change pose significant risks to physical and mental health and wellbeing in Scotland. 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, including policies aimed at reducing health harms and limiting the influence of industries that negatively impact public health.
• Action must also be taken to address the inequalities in access, experiences, and outcomes that people have in relation to healthcare in Scotland.

3.1. Primary prevention

The case for prevention

The Marmot Review (2010) fundamentally shifted discourse on health inequalities in the UK and internationally, leading to increased policy focus on the social determinants of health (Williams and Fullagar, 2019). Yet, over the last two decades, health has worsened and inequalities have widened (Marmot et al., 2020; McCartney et al., 2022). Poor health not only presents challenges for individuals, families and communities but is also detrimental to the economy. The rate of economic inactivity (which measures how much of the population is not in work and is not ready to start work in the near future) due to long-term ill health is rising in Scotland, with ill health the leading reason for economic inactivity among those aged 16-64 (ONS, 2025; Figure 11). Economic inactivity due to long-term ill health has also been persistently higher in Scotland than the rest of the UK over the last 20 years (Randolph, 2024).

Source: ONS (2025), Annual Population Survey, Jan-Dec datasets

In 2023, the most prevalent conditions among those economically inactive due to long-term ill health were heart, blood pressure, and breathing conditions, followed by conditions connected to problems with limbs, back or neck (which likely includes musculoskeletal conditions), and mental health conditions (Scottish Government, 2024e). The proportion of inactive people reporting mental health as their main health problem has risen since 2020 (ibid.).

Economic inactivity and low levels of employment can impact a country’s productivity, prosperity and economic growth due to lower gross domestic product (GDP), reduced tax revenue, and increased spending on benefits for working age individuals (British Medical Association, 2022). This is further challenged by Scotland’s ageing population and the associated rise in age-related conditions – such as chronic conditions which affect the heart, musculoskeletal, and circulatory systems, and dementia – which place increased demand on health and social care services (Scottish Government, 2021a).

A recent report by the Scottish Fiscal Commission (SFC) (2025) considered the implications of demographic changes for public finances. The SFC outlined projections of devolved spending and funding up to 2074-75 and set out how these could affect the long-term sustainability of current Scottish Government spending. The report highlighted that, based on current trends, health and social care spending is projected to rise from around 40% of Scottish devolved public spending in 2029-30 to almost 55% in 2074-75 – a shift partly driven by the ageing population and the resulting upward pressure on health spending. This will lead to budget pressures in future, as total spending will grow faster than funding. In its baseline scenario, the SFC projects an average gap between Scottish devolved public spending and funding of 1.2%.

To explore how changes in population health could affect fiscal sustainability, the SFC also outline two alternative scenarios: a better health scenario, where life expectancy in Scotland improves over the next fifty years to match that of the rest of the UK, and a worse health scenario, where the gap between life expectancy in Scotland and the rest of the UK widens. The projections show that if population health improves relative to the rest of the UK fiscal pressure could be eased, whereas worsening health outcomes would increase these pressures. The scenarios highlight the potential for improved population health to reduce pressure on health-related spending and ease the fiscal challenges associated with demographic change (SFC, 2025).

Key to reducing demand on health and social care services and supporting long-term fiscal sustainability is greater focus on 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 (PHS, 2024a). Three levels of prevention are recognised as central to improving population health: primary, secondary, and tertiary (Figure 12).

Primary prevention

Invest in the building blocks of health to stop problems happening in the first place.

Secondary prevention

Focusing on early detection of a problem to support early intervention and treatment or reducing the level of harm.

Tertiary prevention

Minimising the consequences (harm) of a health issue through careful management.

As described in Figure 12, primary prevention aims to prevent the onset of health problems or diseases before they occur. It covers actions that seek to address the social determinants of health and improve the conditions in which people are born, grow, work, live, and age. In contrast, secondary prevention focuses on early detection of health issues and intervention to minimise the level of harm, such as by providing screening and testing services. Finally, tertiary prevention focuses on managing and mitigating the impact of existing health problems, which might include, for example, rehabilitation support for those who experienced a stroke or counselling and peer support for individuals with long-term health conditions. These are the definitions of prevention in use across the public sector in Scotland and those being used in the PHF and its implementation.

A focus on primary prevention

Secondary and tertiary prevention are crucial in helping to reduce the impact of disease and injury and improving quality of life. However, evidence shows that primary prevention has the highest impact on population health because it proactively addresses the root causes of disease, reducing demand on healthcare systems (PHS, 2019). There is now strong consensus – among academics, public health experts, and policymakers – that further investment in primary prevention is needed across the system to manage future demand, secure savings for public services, and achieve a healthier and more prosperous population (PHS, 2023b; Craig and Robinson, 2019; WHO, 2018a).

PHS (2023b) outline three ‘pillars’ of primary prevention. The first covers actions on the social determinants (or building blocks) of health, such as affordable, secure, and quality housing, stable and well-paid work, and training and education. These actions focus on improving physical and mental health and wellbeing and reducing health inequalities through coordinated efforts to improve the conditions of everyday life and reduce socioeconomic disparities.

The second pillar covers action to reduce health risk behaviours, such as smoking, alcohol consumption, physical inactivity, and poor diet. Evidence shows that action taken to reduce these risks is more effective when it targets the entire population (e.g. ‘upstream’ approaches that focus on altering environmental conditions to make healthy behaviours easier to adopt) as opposed to those that require high levels of agency (e.g. ‘downstream’ approaches that focus on individual behaviour change) (Everest et al., 2022). However, there is evidence that contemporary delivery of health policy has tended to focus more on individual choices than the upstream conditions that shape health inequalities, underplaying the importance of the structural factors and social processes that influence people’s health and their capacity to adopt healthy behaviours (Finch et al., 2023; Everest et al., 2022; PHS, 2019).

Many have pointed to the concept of ‘lifestyle drift’, whereby policies that start with the intention of addressing the social determinants of health inadvertently drift downstream to instead become targeted at individuals (Hunter et al., 2010; Williams and Fullagar, 2019), as a reason for the lack of progress in improving health and reducing inequalities. Evidence shows that while individual-level interventions have a role to play in supporting those most in need, they have limited impact in isolation (Everest et al., 2022).

The third pillar of primary prevention includes action on infectious diseases and environmental risks. Measures to reduce the risk of spread of infectious diseases include interventions such as vaccines, needle exchange, and condoms. While these may be delivered universally (e.g. childhood vaccination programmes), in some instances there is also a need to target those at greater risk of harm (PHS, 2023b). Measures to reduce environmental risks include measures to monitor, prevent, and reduce the harm from hazards such as contaminants in food or water supplies, pollution, and pests (ibid.). For example, outdoor air pollution is one of the largest environmental risks to human health. An estimated 1,800 to 2,700 deaths in Scotland are attributed to long-term exposure to outdoor air pollution each year (PHS, 2024l). Policies can be put in place to manage and improve air quality, such as regulations which set limits for outdoor air pollutants and Low Emission Zones (ibid.).

It can be challenging to make the economic case for primary preventative health interventions due to the length of time it can take for benefits to become evident. However, there is a growing body of evidence, including economic modelling, which demonstrates that prevention can deliver significant returns on investment. For example, a systematic review undertaken by Masters et al. (2017, as cited in PHS, 2023b) found the median return on investment (ROI) for prevention was £14 for every £1, with the ROI higher for investment in primary prevention. For every £1 invested in healthcare public health (secondary and tertiary prevention) the median ROI was £5, while for primary prevention interventions the ROI for £1 invested were £34 for health protection (for example vaccines and immunisation) and £46 for legislative interventions (for example the smoking ban).

These returns primarily occur over the longer-term, but shorter-term savings on primary prevention have also been documented. For instance, the smoking ban in Scotland led to reduced healthcare usage for smoking-related conditions in the years immediately following its implementation (Pell et al., 2008; Mackay et al., 2010; 2012).

As covered further in section 4.3, a strong body of evidence highlights the importance of investment in prevention in the early years in particular (Marmot, 2010; Heckman, 2013). For example, enabling children to develop their physical, cognitive, language, and socioemotional potential – particularly in the first three years of life – has been shown to yield rates of return of 7-10 per cent, meaning each year the benefits (such as better education, health, sociability, economic outcomes, and reduced crime) are worth 7-10 per cent more than the original investment (ibid.).

There is also evidence that prevention can be highly cost-effective in specific disease cases, leading to either cost savings or a low cost per quality-adjusted life year (QALY)^[17]. Modelling based on a randomised control trial of men aged 45-54 in Scotland found that primary prevention treatment with a statin could save the NHS £710,000 per 1,000 patients over five years and reduce hospital admissions by 136 per 1,000 people (McConnachie et al., 2014). At a UK level, a modelling study found that statins’ cost-effectiveness ranges from £280 to £8,350 per QALY (Mihaylova et al., 2024).

Wider societal and economic impacts of prevention which are not captured and costed within traditional health economics models are also important. As the Marmot Review (2010) demonstrated, people in good health are able to lead more fulfilling and productive lives, and participate fully in their communities, education, and work.

Prevention is also important for strengthening population resilience, which is demonstrated by recent analysis of the GBD study 2021 by Steel et al. (2025). The authors compared changes in life expectancy, causes of death, and population exposure to risk factors across the 16 founding EEA countries and four UK nations between 1990-2011, 2011-19, and 2019-21. They found that life expectancy improvements slowed after 2011 in all countries except Norway, but that the slowdown was greater in some countries than others. The extent to which life expectancy slowed during 2011-19 was largely determined by changes in mortality from cardiovascular diseases and cancers. Countries that maintained reductions in mortality from these conditions – supported by lower exposure to major risk factors such as high BMI and dietary risks, which the authors argue were likely influenced by government policies – maintained increases in life expectancy during the Covid-19 pandemic.

These findings highlight that treating high lipids or blood pressure alone is not sufficient to counteract adverse population trends, such as rising BMI and sustained exposure to dietary risks. Rather, preventative government policies which address the root causes of major attributable risks, including poor diet, physical inactivity, and the social determinants of health, are needed. By addressing these upstream factors, Steel et al. (ibid.) argue, governments can improve population health over the long-term and build resilience.

PHS (2023b) suggest that a reason for insufficient focus on primary prevention in Scotland to date may be a lack of clarity about what it means in practice for different stakeholders. Their paper seeks to present a proposed common language on prevention to support discussion and guide decision-making. Craig and Robinson (2019) also highlight two necessary preconditions for shifting towards a preventative approach to improving health and reducing health inequalities. These include making better use of the growing evidence base on the cost-effectiveness of preventative interventions and harnessing political will. This can be challenging in a complex policy environment shaped by competing interests.

3.2. Action across the whole system

The Health Foundation (2024) emphasise that the potential of investment in primary prevention will only be realised if it involves the whole system working together, from the NHS and public health, through to education, housing, transport, the third sector, communities, and national and local government. Similarly, others highlight that to deliver improvements in health there is a need to move away from silo-based working and isolated, single actions towards cross-government, cross-sector approaches that reinforce and complement each other when targeting different groups (Elwell-Sutton et al., 2019; Beech et al., 2020). For example, complex issues such as poor diet and obesity have many causes and therefore require a multifaceted and coordinated response, with consideration given to the cumulative effect of multiple, cross-cutting policy interventions (Everest et al., 2022).

Taking coordinated action in this way is described as implementing a whole system approach (WSA). This section describes the key components of a WSA and the opportunities it presents in more detail, as well as considering barriers and enablers to effective whole systems working. It then explores the specific role that community and voluntary organisations, as well as businesses, can play in driving meaningful progress.

A whole system approach

Understanding a whole system approach

A WSA recognises that there is no single solution to address complex public health issues. A coordinated and collaborative approach is needed, which entails shifting from traditional working to systems working (Public Health England (PHE), 2019; Figure 13).

Image 13 here

Source: PHE (2019)

Traditional

Silo working

Generalising

Individuals, isolated activities

Linear causes and effects

Top down control

Systems

Integrated / the whole system

Tailored to context: what matters here?

Looking at how systems work as a whole

Dynamic feedback loops

Local Authority holding the ring, stakeholders are partners

Systems ingredients

Definition of a local whole systems approach

Simple and complex systems

Local context

Shared vision and aligned actions

Prioritisation of actions

Dynamic approach

Feedback loops

Unintended consequences

Leadership at all levels

Sytstems behaviours

PHE (ibid.: p17) define a WSA as:

“An ongoing, dynamic and flexible approach that enables stakeholders to come together, share an understanding of the reality of the challenge, consider how the system is operating and where there are the greatest opportunities for change. Stakeholders agree actions and decide as a network how to work together in an integrated way to bring about sustainable change.”

An evidence review by the National Institute for Health and Care Excellence (NICE) (2010) noted that authentic WSAs draw on complexity science to explain how system features interact. They identified ten key features of a WSA:

• Identifying a system: Explicit recognition of the public health system with the interacting, self-regulating and evolving elements of a complex adaptive system. Recognition given that a wide range of bodies with no overt interest or objectives referring to public health may have a role in the system and therefore that the boundaries of the system may be broad.
• Capacity building: An explicit goal to support communities and organisations within the system.
• Creativity and innovation: Mechanisms to support and encourage local creativity and/or innovation to address public health and social problems.
• Relationships: Methods of working and specific activities to develop and maintain effective relationships within and between organisations.
• Engagement: Clear methods to enhance the ability of people, organisations and sectors to engage community members in programme development and delivery.
• Communication: Mechanisms to support communication between actors and organisations within the system.
• Embedded action and policies: Practices explicitly set out for public health and social improvement within organisations within the system.
• Robust and sustainable: Clear strategies to resource existing and new projects and staff.
• Facilitative leadership: Strong strategic support and appropriate resourcing developed at all levels.
• Monitoring and evaluation: Well-articulated methods to provide ongoing feedback into the system, to drive change to enhance effectiveness and acceptability.

NICE (2010) cautioned that some approaches labelled as whole system working are not ‘authentic’ as they reproduce rigid, hierarchical structures instead of fostering trust and relationships. They warned against mandating partnerships or relying solely on performance management to drive change.

A systematic review conducted in 2019, which built upon NICE's original work and additional international research, found that WSAs targeting obesity were associated with positive health outcomes, including reductions in BMI, increased parental and community awareness, community capacity building, nutrition and physical activity environment changes, and improved safety and wellbeing of community members (Bagnall et al., 2019). Success of a WSA was attributed to meaningful engagement of stakeholders and the community in making decisions, good governance, trust and community capacity, sufficient time to build relationships, adequate finance, and the embedding of WSAs within broader policy. However, Bagnall et al. (ibid.) also highlighted that conclusions were difficult to draw because most studies had not deliberately set out to take or evaluate a WSA.

More recent research has suggested that evidence for WSA effectiveness remains in its ‘infancy’, and that there is a need for robust longitudinal evidence to strengthen WSAs in government policy and practice (Breslin et al., 2024; Breslin et al., 2023a). Breslin et al. (2023b) highlight the paucity of evidence on factors important for successful WSA set-up and implementation in particular.

Whole system approaches in Scotland

A WSA was the approach identified to deliver the Public Health Reform programme in Scotland, a partnership between COSLA and Scottish Government (2019). This had three key components: the development of the public health priorities, the establishment of PHS, and the development of a whole system approach to public health. Whole systems working was defined as applying systems thinking and processes that enable “an ongoing, flexible approach by a broad range of stakeholders to identify and understand current and emerging public health issues where, by working together, we can deliver sustainable change and better lives for the people of Scotland” (ibid.). Nine key characteristics of a WSA for public health were also identified: System thinking; Learning culture; Collective and adaptive leadership; Purposeful engagement; Governance and resourcing; Sustainable collaborative working; Shared commitment and outcomes; Place is important; and Creativity and innovation (ibid.).

The WSA Early Adopter programme was launched by the Scottish Government in 2019, which involved developing and testing a WSA to diet and healthy weight in four ‘WSA areas’ (Dundee, East Region, North Ayrshire, and Dumfries and Galloway) with support from national partners PHS, FSS, and Obesity Action Scotland (OAS) (PHS, 2022c). These areas followed the PHE (2019) guide for implementing a WSA to healthy weight and obesity and drew on the nine core characteristics of a WSA developed by Public Health Reform. A process evaluation of the pilots demonstrated how local systems can work more effectively to address complex public heath challenges, such as by tailoring established WSA models to the local context and connecting with local strategies and structures (ibid.).

Breslin et al. (2023b) also assessed WSA implementation in two of the WSA areas, longitudinally exploring enablers and barriers. Key enablers highlighted included strong relationships between key stakeholders and the community, personal and professional investment in the process, a belief in the potential for real change, strategic support at national and local levels, sustained momentum, adequate funding, clear and accessible communication, effective engagement of the right people, and building on existing governance structures to ensure community buy-in. Meanwhile, barriers highlighted include a lack of understanding and effective publicity around WSA, WSA disengagement and reverting to old ways of working when WSA is considered ‘slow’ and ‘ineffectual’ in delivering immediate outcomes, difficulty engaging the community and stakeholders, and under-resourced leadership.

Drawing on WSA principles, PHS (2022a) have outlined a systems-based approach to physical activity in Scotland, along with guidance on how it can be applied strategically at national and local level. The approach was also informed by and adapted from the systems-based thinking underpinning Public Health Reform in Scotland (COSLA and Scottish Government, 2019) and the PHE (2019) guide. It involves seven stages, including: building the will and conditions for change; reviewing data and evidence; deep diving into the sub-systems; collating findings and emerging actions; validating findings and building consensus; and system wide action planning.

PHS (2022a) describe how a systems-based approach to physical activity moves away from short-term, solitary interventions and shifts thinking towards strategic cross-sectoral efforts that work in a complementary way to maximise limited resources and facilitate population levels of physical activity. However, they note that success depends on leadership, engagement and collaboration with and from a range of partners, including but not limited to Scottish Government, community planning partnerships, health and social care integrated joint boards, national agencies (e.g. PHS, sportscotland, and Transport Scotland), COSLA, the NHS, third sector organisations, and academia.

Community and voluntary organisations

The community and voluntary sector can play a key role in supporting population health as part of a WSA. There is a range of evidence which demonstrates how the work of community and voluntary organisations supports the social determinants of health. For example, many carry out activities that support healthy behaviours (such as cookery classes or gardening clubs), address drivers of poverty (such as skills development and employability support), and strengthen social relationships, networks and infrastructure (such as befriending services and support for communities to engage with planning regarding public spaces) (Buck et al., 2021).

However, it is not just the activities that community and voluntary organisations undertake that makes them well-placed to support the social determinants of health, but also how and where they are structured, positioned, and delivered. Evidence highlights that, because such organisations are often set up from within the communities they serve, they have a strong understanding of the issues and difficulties that may be facing the local area, as well as the solutions that will work (Locality, 2022; Daly and Allen, 2017). They can therefore draw on links with local people and families and tailor their services to meet local need and demand, such as the financial difficulties or employment barriers that are particular to their community. Such tailored support is difficult to provide through statutory services, as it relies on trust, local knowledge, and embeddedness to be successful (ibid.).

Other distinct qualities of community and voluntary organisations include their flexible structure (often attributable to the involvement of volunteers) which enables them to change and innovate to meet local needs, and that they often take a holistic, user-centred approach which focuses on the ‘whole person’ and the multiple needs they may have (Scottish Government and Scottish Third Sector Research Forum, 2011; GCPH, 2012).

Some use ‘asset-based approaches’ which aim to identify and use existing community assets, or strengths, to enable community members to have more control over their health and wellbeing (Martin-Kerry et al., 2023). Such approaches promote active participation by the community in the planning and delivery of services and the generation of community-based solutions. The core idea is that communities can drive the development process themselves by identifying and mobilising their existing, but often unrecognised, skills, knowledge, connections, and resources. Asset-based approaches shift the emphasis towards ‘health creation’, in that they positively engage the community to identify strengths that could enhance their health, rather than focusing on problems and deficits (ibid.).

Early research by GCPH (2012) explored the lived realities of asset-based working in community settings in Scotland through a range of case studies. Their work demonstrated how asset-based approaches can promote and strengthen the factors that support good health and wellbeing, protect against poor health, and build and foster communities and networks that sustain wellbeing (McLean et al., 2017). Other research has shown how assets-based approaches can strengthen social networks, empower people to access and mobilise resources, and increase their control over their own health and its social determinants (Foot and Hopkins, 2010; Cassetti et al., 2020).

There is also a range of evidence demonstrating the benefits of ‘social prescribing’. Social prescribing is a means of connecting people to non-medical sources of support or resources within their community, with referrals generally, but not exclusively, coming from professionals working in primary care settings (Buck and Ewbank, 2020). It is often used to link people to activities and services provided by community and voluntary organisations, such as arts activities, group learning, gardening, befriending, cookery, healthy eating advice, and a range of sports (ibid.). People may also be linked to statutory services such as debt counselling, housing services, and other agencies for practical and emotional support. Referrals are typically made for people with social, emotional, or practical needs and considered vulnerable or at risk, such as those living with long-term health conditions, frequent health service attendees, those in social isolation, and those with mild or long-term mental health problems (Chatterjee et al., 2017; Mossabir et al., 2015; Kilgarriff-Foster and O’Cathain, 2015).

As well as positive health and wellbeing outcomes, such as improvements in quality of life and emotional wellbeing, mental and general wellbeing, and levels of depression and anxiety (Buck and Ewbank, 2020), studies have shown that social prescribing can reduce pressure on the NHS through reduced General Practitioner (GP) appointments, hospital admissions, and A&E visits for people who have been referred, delivering significant return on investment (Polley et al., 2023).

It has been noted that further work is needed to strengthen the evidence base on social prescribing, as many studies are small scale and do not have a control group (Buck and Ewbank, 2020; Pescheny et al., 2018). There are also wider challenges with social prescribing, including insufficiency and instability of funding, low GP and patient engagement, and travel-related time and costs (Pescheny et al., 2018; Yadav et al., 2024). However, the approach shows promise for delivering action on the social determinants of health through a person-centred, supported referral pathway, while also having economic benefits (Morse et al., 2022).

GCPH (2024) emphasise the role that community and voluntary organisations can play in supporting health, pointing to the Children’s Neighbourhoods Scotland research which demonstrated the speed and agility characterising the contribution of community and voluntary organisations in Glasgow in the early stages of the Covid-19 pandemic (Bynner et al., 2020). Roy et al. (2023) also reviewed evidence on responses to the pandemic by voluntary and community-based organisations and found that they worked to adapt their practices and sustain delivery of support to some of the poorest and most vulnerable people in society quickly and effectively.

GCPH (2024) suggest that establishing a network of community-led organisations could play a vital role in delivering preventative action from within local communities. While not a substitute to structural change and national policies targeting the social determinants and fundamental causes of health inequalities, this would be an opportunity to make a short-term impact with relatively modest resourcing, especially if existing initiatives are built upon (ibid.). Importantly, however, a legislative, regulatory, and policy framework which enables the sector to collaborate effectively as part of a WSA is key. There have recently been calls for longer-term, sustainable funding arrangements for the third sector that take into consideration inflationary increases and cover full operating costs, as well as more streamlined, accessible, and proportionate funding application and reporting processes across different funding bodies (ALLIANCE, 2023; Scottish Parliament Information Centre (SPICe), 2024).

Business

Businesses can also play a key role in supporting population health as part of a WSA. In a recent report, Marmot et al. (2022) highlighted the role that businesses play in shaping the conditions in which people live and work and, as a result, their health. Firstly, as employers, businesses have a strong influence on the health and wellbeing of their workforce, with factors such as pay, benefits, maternity pay and leave, parental leave, childcare, timely provision of workplace adjustments, and efforts to target discrimination all influencing health through their impact on the social determinants (Rochford et al., 2019; Prosper, 2024). Research shows that employee-owned businesses are more likely than non-employee-owned businesses to adopt policies supporting health and wellbeing such as flexible working and mental health support, and to invest more in training and skills (Employee Ownership Association (EOA), 2023).

However, despite the potential for businesses to improve workforce health, evidence highlights challenges employers can face in enhancing work conditions. For example, the Fair Work Action Plan discusses how the ongoing impacts of Brexit, Covid-19, and the cost-of-living crisis place large economic burdens on businesses in Scotland, which impacts how readily they can apply fair work measures and support their workers appropriately (Scottish Government, 2022b).

Findings from the Fair Work Convention’s Inquiry into the hospitality industry found that some businesses were reluctant to invest in training and support for their workforce due to high levels of staff turnover, staff shortages, and increasing costs, with a feeling that any investment would be lost (Fair Work Convention, 2024). Rural and island employers in Scotland were also shown to experience added pressures, challenges, and costs unique to rural areas (such as poor transport infrastructure and recruitment challenges). Similarly, research by Serving the Future (2023) highlighted how economic challenges have compounded ongoing problems with recruitment, pay, and training, with hospitality industry employers feeling constrained by factors such as unpredictable cash flow, increasing costs, and price pressures.

In a report exploring the economic cost of ill-health in Scotland, Prosper (2024) highlights potential actions that can be taken by the Scottish Government to support businesses and other employers to address high rates of inactivity and increased absence from the workplace. Recommendations include accelerating the adoption of flexible working, improving access to mental health support, evaluating childcare costs and availability, and increasing uptake of existing programmes and resources.

The second way Marmot et al. (2022) highlight that businesses can support health is through their core activities of producing goods and providing services. The food industry is noted as a key example of this, with the potential for food producers to work with public health authorities to ensure availability of affordable, healthy foods and clear, actionable nutritional information (see section 4.5). However, it is important to note that industry objectives do not typically align with public health objectives, with businesses often prioritising profitability over health outcomes (Beech et al., 2020). As will be covered further in later sections, industries often engage in activity such as lobbying, producing favourable research, and forming close relationships with regulatory bodies to hinder the adoption of effective public health policies (Ulucanlar et al., 2023).

While there can be benefits to engaging and consulting with industry to help to ensure that policies are workable and deliverable (Beech et al., 2020), evidence demonstrates that the design of policy should be largely protected from industry involvement (Ulucanlar et al., 2023; Beech et al., 2020). Where businesses are consulted, the management of conflicts of interests is vital (Ulucanlar et al., 2023). WHO (2024d) have developed guidance on identifying, avoiding and managing conflicts of interest, with their decision-making tool offering policymakers a systematic methodology for assessing, analysing, and reaching a decision on whether to engage with private sector entities to complement or enhance efforts of the public sector in addressing the prevention and control of NCDs.

Marmot et al. (2022) also highlight that businesses can support health through their impact on the wider community. This can include developing partnerships with the public sector and community and voluntary organisations to address health needs at a local level. Businesses can act as ‘anchor institutions’, which are large organisations with assets that can be used to support their local community’s health and wellbeing and address health inequalities, through mechanisms such as procurement and buildings and land use (ibid.).

Overall, therefore, there are various ways that businesses can help to address the social determinants and support the reduction of health inequalities. However, it is important that business engagement does not undermine the directive to improve public health, and that policymaking is protected from interests that do not align with that goal. Having clear regulatory frameworks that do not put companies at a competitive disadvantage when they adopt these actions is key. A strong regulatory environment is important not only in relation to policies and legislation affecting the availability, pricing, and marketing of products, but also those relating to, for example, workplace and employment standards and environmental protections. Support for diverse business models such as worker cooperatives and social enterprises, which are more likely to support staff and communities (EOA, 2023), is also important.

3.3. More effective policy and implementation

In considering the factors that are holding back progress to reduce health inequalities in Scotland, Finch et al. (2023) highlight the ‘implementation gap’. This is a phenomenon which describes the disconnect or mismatch between policy expectations and outcomes, or policy rhetoric and practice reality (Hudson et al., 2019). Finch et al. (2023: p8) state that a “persistent and growing” implementation gap exists in Scotland, evident at different points of the policymaking continuum, which has hindered progress in reducing health inequalities.

Their research attributes this gap to factors such as short-termism planning, a centralised approach to policymaking, and a lack of coherence across policy areas. They highlight a need for policy design to take into account the wider economic and political context in which it is applied, as well as local conditions. They also discuss a need for greater evaluation of policy effectiveness and use of data and evidence in decision-making.

However, GCPH (2024) have suggested that the implementation gap perspective is based on assumptions that present challenges. These include the belief that there is a clear understanding among policymakers of what is needed to reduce health inequalities, that the necessary powers and resources are in place to address these challenges, and that policies with the potential to be effective have been fully developed. It is stated that these assumptions are problematic, in that they suggest that relevant organisations and agencies should simply continue more purposefully with doing what they are already expected to. However, they argue that the key reason that health inequalities have worsened in Scotland is sustained inequalities in income and wealth. To achieve a meaningful reduction in health inequalities, therefore, what is needed is policies that specifically aim to reduce the longstanding inequalities in income, wealth, and power.

Catalano et al. (2024) have also called for stronger action to understand the impact of policies aimed at reducing inequalities in Scotland. They highlight a lack of publicly available data of sufficient quality to assess whether policies are achieving their intended impacts, identifying two key areas where improvements could be made. First, the direct impact of policies should be measured, such as how housing policies affect housing conditions or child poverty policies reduce poverty rates; and second, broader impacts should be evaluated to understand how key policies influence broader goals like reducing health inequalities. They state that to achieve this, more investment in the necessary skills and resources to evaluate the effectiveness and value for money of public spending is required.

The Scottish Government (2024f) recently published its Evaluation Action Plan, which restates the value the Scottish Government places on evaluation and sets out ambitions for more effective and strategic use of evaluation. This includes, for example, enhanced training, exploration of options for a Centre of Expertise on Appraisal and Evaluation of Spending Programmes, and use of the UK Cabinet Office’s Evaluation Registry.

3.4. Climate change

Human activities, including the burning of fossil fuels and changes in land use and agriculture, have led to a long-term rise in the planet’s average temperature, known as climate change. WHO (2023b) has described climate change as “the single biggest health threat facing humanity”. In Scotland, the impacts of climate change are already evident, putting further stress and strain on economic, social and natural systems. These include warmer average temperatures across the year, with increased heat risk in summer months, and wetter weather, particularly in winter months (UK Health Security Agency (UKHSA), 2023). Rising sea levels, increased prevalence of extreme weather events – such as storms, flooding, heatwaves and wildfires – and water scarcity in summer months are further examples of climate impacts in Scotland (ibid.).

The effects of past emissions are also shaping present conditions, with global warming trends ‘locked in’ for at least the next 25 years. This means that a certain level of future warming is now unavoidable (Bevacqua et al., 2025). As a result, these impacts will continue and intensify in Scotland, with more frequent extreme weather events, increasing coastal erosion, and exposure to risks associated with high temperatures and heavy rainfall (ibid.).

Climate change affects physical health and wellbeing through direct and indirect pathways (PHS, 2024m; Scottish Government, 2024b; UKHSA, 2023). Direct effects include an increased risk of injuries or deaths during adverse weather events such as flooding, heat-related illnesses such as heat stroke and dehydration, and excess death from heart attacks, strokes, and lung disease due to high and low temperatures (ibid.). There is also a risk from changing patterns of food, water, and vector-borne infectious diseases (ibid.). Indirectly, climate change undermines the social determinants of health in local places. For example, flooding can displace people from their homes, result in the loss of their belongings and loss of essential utilities like water and energy, disrupt their education or work, and affect their ability to access health and care services (UKHSA, 2023).

Climate change is also a risk to mental health and wellbeing through direct pathways (e.g. traumatisation from exposure to adverse weather events such as heatwaves or floods) and indirect pathways (e.g. negative impacts on livelihoods and social networks) (Niedzwiedz et al., 2024). There is growing evidence that simply becoming more aware of climate change can affect mental health and wellbeing, a concept sometimes termed as ‘eco-distress’ or ‘eco-anxiety’ (ibid.). The mental health and wellbeing effects of climate change is an area of ongoing research, but international literature suggests that these can include heightened risk of post-traumatic stress disorder, suicide, depression, anxiety, exacerbation of existing mental health conditions, and overall poorer mental wellbeing (Lawrance et al., 2021; Cosh et al., 2024; Coffey et al., 2021). This varies in type and severity depending on the nature of the hazards.

The health risks from climate change are expected to disproportionately affect certain population groups and communities, exacerbating existing inequalities (UKHSA, 2023). Vulnerability to climate impacts is shaped by three main factors: susceptibility to health risks if exposed to a climate impact (influenced by personal characteristics like age and pre-existing medical problems or disability); likelihood of exposure to a climate impact (influenced by the geographic and socioeconomic features of a place); and the ability to prepare for, respond to, and recover from climate impacts, referred to as adaptive capacity (Sayers et al., 2022). Adaptive capacity is influenced by pre-existing structural inequalities (ibid.).

Environmental, social, economic, and personal factors will act and interact to multiply the risks to health and health inequalities from climate change. In Scotland, population ageing, current and projected future burden of disease, and widening health inequalities are likely to increase vulnerability. Those most vulnerable to health risks from climate impacts are likely to include babies, infants and children, older adults, pregnant women, people with pre-existing health conditions or disabilities, people on low incomes, and people living in deprived areas (PHS, 2024m; Sayers et al., 2022). Some communities will be more vulnerable to climate impacts due to their natural or built environment. For example, island and coastal communities will be at greater risk from coastal erosion, low-lying communities from flooding, and cities from the urban heat island effect (PHS, 2024m). Communities where lives and livelihoods are tied to the land or sea, including remote and rural farming and fishing communities, may also be vulnerable.

Climate change forms part of what the United Nations (UN) (2022) refers to as the ‘triple planetary crisis’, which also includes environmental pollution and biodiversity loss. Evidence highlights the threat the triple planetary crisis poses to both physical and mental health and wellbeing, as well as the inequalities in exposure and vulnerability across different populations (Kemarau et al., 2024; WHO, 2023b, 2024e).

While some climate change impacts are locked in, many of the anticipated health effects of climate change can still be prevented or avoided (Scottish Government, 2024g; 2024b). Moreover, the Lancet Countdown on health and climate change has stated that responding to the challenge of climate change – through what is described as ‘climate action’ – could be “the greatest global health opportunity of the 21st century” (Romanello et al., 2023). Climate action refers to actions taken by governments, society, and individuals to tackle climate change and its impacts (UN, 2015). This includes actions to reduce GHG emissions or remove GHG from the atmosphere (mitigation) as well as actions to reduce vulnerability to current climate impacts and future climate risks (adaptation) (PHS, 2024m). Urgent mitigation is needed to prevent further global warming which would lead to irreversible damage to ecosystems that support and sustain all life on Earth. Adaptation is required to protect people from climate related health risks, reduce vulnerability, and build climate resilience. If urgent climate action is not taken, the health risks from climate change will increase with progressive global warming (ibid.).

Climate action has the potential to deliver multiple positive health, social, economic, and environmental outcomes, known as ‘win-wins’ or co-benefits (PHS, 2024n; Edmonds and Green, 2023; Scottish Government, 2024b). PHS (2024n) demonstrates actions to build climate resilience that also improve the provision and quality of the places where we live and work. For example, designing and maintaining active travel infrastructure supports a reduction in car miles contributing to reduced GHG emissions. This will reduce air and noise pollution and provide more opportunities for physical activity and social interaction, improving health and reducing health inequalities. Investing in blue and green infrastructure can contribute to flood risk management while also providing spaces for people to connect in and with nature, contributing to better physical and mental health outcomes. Likewise, more energy efficient housing can reduce energy demand and GHG emissions, help alleviate fuel poverty, and improve physical and mental health and wellbeing (Scottish Government, 2017a).

A further opportunity for population health arising from climate action is around climate driven recommendations on diet. Food production accounts for over a quarter of global GHG emissions, with animal products and particularly red meat making the largest contribution to this in European countries (Sandström et al., 2018; Poore and Nemeck, 2018). The Climate Change Committee (CCC) publish recommendations for how reductions in GHG emissions may be achieved by the UK, with the 2022 recommendations to Scottish Government including taking low-cost, low-regret actions to encourage a 20% shift away from all meat by 2030, rising to 35% by 2050, and a 20% shift from dairy products by 2030 (Comrie et al., 2024).

Research commissioned by FSS showed that if those who are classed as high consumers of red and red processed meat reduced their intake to the current health-based recommended maximum of 70g or less/day, this would achieve a 16% reduction in total meat consumption, therefore supporting progress towards the CCC recommendations and health (ibid.). They showed that this could result in reductions in average BMI, cases of cardiovascular disease, and cases of type 2 diabetes over a ten-year period. While data availability did not allow the research to establish an impact on reducing colorectal cancer incidence, the researchers cite wider published literature which demonstrates this impact. However, Comrie et al. (ibid.) also highlight that if a blanket approach to reduction in meat and dairy consumption is taken as per the CCC recommendation, measures may be needed to prevent certain population subgroups from experiencing worsened low micronutrient intakes due to reduced meat and/or dairy consumption.

Where climate actions deliver multiple outcomes there may also be trade-offs. In Scotland, the Just Transition provides a policy framework to ensure that climate action is inclusive and fair, addressing existing and avoiding new injustices and inequities (Drabble et al., 2024).

3.5. The commercial determinants of health

Understanding the commercial determinants of health

As described above, businesses in Scotland have an important role to play in supporting and promoting population health as part of a WSA. This includes as employers but also in the contributions they make to local communities and to revenue for public expenditure. There are, however, commercial drivers of poor health which are referred to as the commercial determinants of health (CDoH). The CDoH have been described as one of the most dominant forces shaping human and planetary health, including health inequities within and between countries (Freudenberg et al., 2021). WHO (2023c) defines the CDoH as “the private sector activities that affect people’s health, directly or indirectly, positively or negatively”. The Lancet defines them as “systems, practices and pathways through which commercial actors drive health and equity” (Gilmore et al., 2023: p1195).

Direct harms caused by the CDoH are those resulting from consumption of health harming products, such as respiratory diseases linked to smoking or cancers linked to heavy alcohol consumption. However, research also demonstrates more indirect harms such as those relating to poor labour conditions, intergenerational poverty, rising income and wealth inequalities, and climate change (Allen, 2020; Lacy-Nichols et al., 2023a).

Freudenberg et al. (2021) highlight the importance of broadening use of the concept of the CDoH beyond a focus on the role of commercial actors in contributing to the burden of NCDs to that of other global health challenges such as infectious diseases, mental health conditions, injuries, and exposure to environmental threats. They also note that central to understanding the CDoH is the concept of power, with the CDoH also encompassing actions which allow harmful industries to maintain their powerful level of influence such as political lobbying, threatening legal action, producing favourable or biased scientific evidence, and marketing.

This activity is often described as corporate political activity (CPA), defined as corporate attempts to shape and influence public policy (Ulucanlar et al., 2023). As noted above, Ulucanlar et al. (ibid.) demonstrate how producers of health harming products consistently seek to stop governments and global organisations adopting effective public health policies through CPA, such as by opposing and lobbying against health regulatory policies like taxation and marketing restrictions. For example, Eykelenboom et al. (2019) show how industry resistance complicated the adoption and implementation of sugar-sweetened beverages taxes in countries such as Mexico, while Bødker et al. (2015) and Vallgårda et al. (2015) have shown how lobbying against the Danish tax on fat played a role in it subsequently being repealed. The CDoH therefore make it increasingly difficult for public health and other actors to protect wellbeing and reduce health inequities (McKee and Stuckler, 2018).

Young people and the commercial determinants of health

Research has also highlighted the detrimental impacts of the CDoH on children and young people, which are particularly important given that health in early life establishes trajectories for adult and population health (Modi and Hanson, 2024; Pitt et al., 2024). Modi and Hanson (2024) demonstrate that many unhealthy commodity industries specifically target children and young people, for example, through advertisements designed to promote sweet drinks, fruit flavoured vapes, and foods high in fat, salt, and sugar (‘HFSS’ foods). They are at particular risk from this marketing due to their increased susceptibility to its persuasive messages and because they experience disproportionate physical and mental impacts from their consumption (Strandgaard, 2014). Broader tactics are also used by corporations to shape social and cultural attitudes and build support among children and young people, such as funding initiatives and events that align with their interests (e.g. music festivals) (Pitt et al., 2024).

Pitt et al. (ibid.) highlight how the gambling industry in particular is using a range of novel practices and promotions to diversify and expose a new generation of consumers to its products. Gambling is a global public health issue which can have adverse impacts on the health and wellbeing of individuals, families, communities, and society, such as loss of employment, debt, and deterioration of physical and mental health (ScotPHO, 2023c). Data from the Gambling Survey for Great Britain (GSGB) showed that in 2024, over a quarter (27%) of young people aged 11-17 years spent their own money on a gambling activity (Gambling Commission, 2024).

Pitt et al. (2024) illustrate how social media platforms are exposing young people to promotions for products that they are not able to ‘legally’ consume, including gambling products. For example, young people report seeing marketing for gambling products on a range of social media platforms, including YouTube, Snapchat, and Instagram (Pitt et al., 2022). There is also a lack of regulatory compliance associated with new forms of marketing on these platforms, such as influencer promotions (Pitt et al., 2024).

Evidence highlights the importance of engaging with young people to develop understanding of the impacts of the CDoH on their health and wellbeing, the areas that young people identify as priorities for action, and the reasons some young people are more vulnerable to commercial tactics than others (Pitt et al., 2024; Soraghan et al., 2023). The NCD Alliance (2024) carried out a workshop with children and young people in Scotland on the CDoH, finding that the marketing of health-harming products, particularly in the areas of alcohol and tobacco, was a major concern. Participants expressed support for interventions that restrict commercial influences to protect their health and wellbeing.

Addressing the commercial determinants of health

Experts on the CDoH have proposed recommendations to address their negative effects. Lacy-Nicols et al. (2023b) outline three approaches to addressing the CDoH, beginning with a narrow focus on commercial actors and their commodities before widening to encompass a broader range of practices and ultimately systems. They suggest that at present, most efforts to tackle the commercial determinants of health focus on commercial actors and their commodities, especially tobacco, alcohol and foods. Initiatives at the next level – commercial practices – tend to be implemented at local or national levels of government and include, for example, mandated employee benefits (e.g. paid parental leave, unemployment benefits, and sick leave), rules on pay gaps within organisations, or regulation of tax avoidance (ibid.).

Lacy-Nichols et al. (2023b) contend that, while there is considerable evidence demonstrating the efficacy of a focus on actors and practices, these alone are inadequate. What is needed is system-level action which targets the political and economic power of the private sector. Examples of interventions at the system-level include enforcing conflict of interest guidelines in policymaking, supporting alternative business organisations such as cooperatives, and using legislation to prevent corporations interfering in public health policymaking (OAS, 2024). Lacy-Nichols et al. (2023b) argue that more attention and effort is needed at the systems level, as this has potential to fundamentally shift the way power is distributed in society to improve health equity.

Although such action may be perceived as politically challenging, there is growing evidence that the public supports policies aimed at reducing health harms and limiting the influence of industries that negatively impact public health. For example, the 2023 ASH Smokefree GB Survey found strong backing for protecting health policies from industry influence, with 75% of adults supporting this for tobacco, 70% for alcohol, and 68% for unhealthy food manufacturers (ASH, 2023).

The NCD Alliance Scotland (2024) recently set out a 10-year vision to address the CDoH centred on five key principles. These include adopting ‘a CDoH approach’, which involves holding health-harming industries to account and reducing their influence. The vision also advocates for more effective governance of the CDoH and commercial actors, as well as restrictions and action on the marketing, price, and availability of health-harming products.

Many have also highlighted a need for further research on the CDoH. This includes calls for a more consistent definition of the CDoH, well-defined metrics for quantifying their impacts, and further exploration of public views on the CDoH (Freudenberg et al., 2021; Carters-White et al., 2022). It has also been noted that, while a large body of evidence documents how tobacco, alcohol, unhealthy food, gambling, fossil fuel, and firearms industries harm health, more work is needed to explore how other sectors, particularly privatised public goods and services, shape patterns of health and disease (ibid.).

3.6. The health service

The social determinants are the most important driver of health, but the health and care system also has an important role to play. However, the NHS in Scotland is facing significant and growing pressures, many of which are driven by the country’s shifting demographic profile. As mentioned previously, Scotland’s population is ageing. The number of people aged 65 and over has increased steadily since the 1970s (ScotPHO, 2025c). Meanwhile, the number of younger people has declined, meaning Scotland’s age structure is moving towards older ages (NRS, 2025). In mid-2023, there were over one million people aged 65 and over in Scotland (20.3%) (NRS, 2024d).

The biggest change in age structure is for the oldest age groups. Over the 25 years to mid-2047, the number of people aged 75 and over is projected to increase by 341,300, while the numbers of children (aged 0 to 15) and young adults (aged 16 to 29) are projected to fall by 79,900 and 57,300 respectively (ibid.).

As well as the higher prevalence of age-related conditions noted above (e.g. increases in chronic conditions which affect the heart, musculoskeletal and circulatory systems, and dementia), the likelihood of developing two or more long-term health conditions, known as multimorbidity, also increases with increased longevity (Cezard et al., 2022). Multimorbidity has a strong association with higher risk of mortality, higher costs and use of healthcare services, and worse quality of life (Cezard et al., 2022; Barnett et al., 2012). However, while multimorbidity is most common in older people, most people with multimorbidity in Scotland are under 65 (Barnett et al., 2012), and recent research has shown that recently born cohorts are suffering from complex morbidity at an earlier age compared to earlier born cohorts at the same age (Ribe et al., 2024).

Other pressures on the healthcare system include workforce shortages in health and social care, the healthcare backlog that built up during Covid-19, and increasing costs owing to inflationary pressures (Audit Scotland, 2024). This is placing significant strain on health budgets which are already limited by weak economic growth and the number of people economically inactive due to long-term sickness (Craig and Robinson, 2019). The challenges the healthcare system is facing are evidenced by growing waiting times (Audit Scotland, 2024) and declining levels of public satisfaction in how the NHS in Scotland is run (Scottish Government, 2024h). Bell et al. (2024) state that the UK as a whole is in danger of slipping into a ‘vicious circle’ where worsening health places increasing pressure on health budgets which cannot be increased due to weak economic growth, which is in turn reinforced by deteriorating health.

Proactively shifting to a prevention-focused system is key to addressing these issues. As well as action on the social determinants of health, other key preventative measures include vaccines, immunisations, screening, and surveillance, which can reduce the burden on healthcare systems by protecting against disease and detecting problems early. Scotland has traditionally maintained high rates of childhood immunisation, with approximately 95% of children receiving most routine vaccinations by 12 months of age (PHS, 2024o). However, PHS (ibid.) has observed a downward trend in immunisation rates for infants and pre-school children over the past ten years. Data also suggest that for some adult vaccination programmes rates of uptake are lower among people in more deprived areas (PHS, 2024p).

Similarly, many screening programmes in Scotland have disproportionately low uptake among certain groups, including those living in more deprived areas, those living with a physical or learning disability, those experiencing homelessness, and those from minority ethnic groups (Scottish Government, 2023a). Addressing issues such as these is therefore crucial to alleviate pressures on the health system, derive maximum public health benefits from existing programmes, and reduce inequalities.

Craig and Robinson (2019) also highlight how the integration of health and social care services in Scotland is a policy development with potential to support a shift to prevention, helping to move towards more sustainable demands on the health and social care system. Work has been underway to integrate health and social care services since 2016, in line with the Public Bodies (Joint Working) (Scotland) Act 2014 (Scottish Government, 2019). This legislation requires councils and NHS boards to work together to form partnerships, known as integration authorities (IAs), with the aim of ensuring services are well integrated and that people receive the care they need at the right time and in the right place (Audit Scotland, 2018).

However, integration of services started slowly because of the complexity of the change and the challenging workforce and governance issues involved (Craig and Robinson, 2019). Donaldson et al. (2024) highlight evidence that integration in its current form may not achieve its stated policy goals, suggesting greater focus on place-based approaches and more comprehensive locality-empowered integrated care.

Healthcare inequalities

Evidence also indicates inequalities in the access, experiences, and outcomes that people have in relation to healthcare in Scotland. The reasons for these inequalities are multiple and complex, ranging from factors such as the availability of local services, access to transport, social connections, language, health literacy, trust in healthcare services (NHS England, 2024; Scottish Government, 2025c), and digital exclusion (NHS England, 2022), which may have been exacerbated by an increased move to digital during the Covid-19 pandemic (Scottish Government, 2020). People living in areas of high deprivation, those from minority ethnic communities, those experiencing homelessness, asylum seekers and refugees, and Gypsy, Roma and Traveller communities are at particular risk of experiencing these inequalities (NHS England, 2024).

Inequalities in access and experiences

Inequalities in access (which refers to having access to services that are timely, appropriate, easy to get to and use, and sensitive to choice and need), can lead certain groups to receive insufficient care relative to their needs, or care that is less appropriate or effective (Williams et al., 2022). For example, a recent literature review exploring access to primary care in the context of socioeconomic inequality in Scotland found that barriers can be faced at different points of engagement with primary care services (Scottish Government, 2025c). These included lower levels of health literacy, previous negative experiences of healthcare services, a lack of access to transport or financial and digital resources, and poor relationships with healthcare staff, which are impacted by time and resource constraints in deprived areas. Ensuring that services are approachable and equitably resourced, and that patients are enabled to see themselves as candidates for care, were highlighted as actions that may address some of the barriers facing those most affected by socioeconomic inequality.

Different groups can also have systematically different experiences within the services that they use, such as the quality of care they receive or whether they are treated with dignity and respect (ibid.). For example, research has explored how women and girls in Scotland experience discrimination and the impact this has on their health and health outcomes (Scottish Government, 2023b). Women who participated in the research reported experiencing discrimination at cultural, institutional and interpersonal levels. This discrimination was described as having tangible impacts on their physical and mental health through unequal access to healthcare and delays in referrals, diagnosis, and treatment. Young women faced unique challenges, with participants expressing reluctance to access healthcare due to anticipated negative treatment shaped by stereotypes.

This work contributed to the Women’s Health Plan (WHP), which aims to improve health outcomes and health services for all women and girls in Scotland and is underpinned by the recognition that women face particular health inequalities and disadvantages because they are women (Scottish Government, 2021b). For instance, the research highlighted that while women globally tend to live longer, they tend to suffer to a greater extent from a range of illnesses and generally spend fewer years in good health than men (Mobasheri, 2021), that there are significant gender data gaps in medical and public health research which contribute to health inequalities (WHO, 2019a), and that women have unique health problems that are under-researched, including gynaecological conditions like endometriosis, which can have severe impacts on their health and wellbeing (Scottish Government, 2023b).

A review commissioned by the NHS Race and Health Observatory also found evidence of women from minority ethnic backgrounds experiencing “stereotyping, disrespect, discrimination and cultural insensitivity” when using maternal and neonatal healthcare services in the UK (Kapadia et al., 2022: 49). Their review also highlighted wider ethnic inequalities in mental healthcare, digital access to healthcare, and the NHS workforce. A review by Harkins and Hoffman (2024) also found that heteronormative cultures and implicated biases in healthcare settings contribute to inequalities in both healthcare access and quality of treatment for LGBT+ individuals.

The King’s Fund have demonstrated how discrimination affects the NHS in a range of ways, including how services are designed and delivered, experiences of staff, and the health and wellbeing of the patients and communities the NHS serves (Morris and Robertson, 2024). The authors state that “the NHS cannot tackle health inequalities meaningfully without prioritising work to tackle racism and discrimination in all its forms”. Though their research focuses on England, many of the issues discussed are relevant to the Scottish context.

Kapadia et al. (2022) present recommendations to address inequalities for ethnic minority communities in healthcare, calling for enhanced data collection, monitoring, and linkage, improved access to interpreting services and translated materials, digital literacy support, and reviews of recruitment and staff development procedures to understand where the greatest barriers to ethnic minority staff’s progression. Harkins and Hoffman (2024) also present recommendations such as enhanced data monitoring and equality evidence gathering, training for staff, and public education campaigns.

Distribution of healthcare resources

A concern with regards to inequalities in healthcare access and experience in Scotland relates to what has been described as the ‘inverse care law’. This term describes an observation in some research that people who most need healthcare are less likely to receive it, particularly where healthcare is closer to market forces (Hart, 1971). Blane et al. (2024) have recently argued that this law is evident in general practice in Scotland, both in relation to the distribution of resources (fewer GPs and less funding in relation to need in more deprived areas) and within consultations (higher GP stress, lower patient enablement, and worse outcomes in practices in more deprived areas). This research was based on a review of literature, qualitative interviews with key stakeholders, and analysis of data on need, supply, and quality of general practice in Scotland. However, limitations noted include the quantity and quality of available data, the workforce data being based on a voluntary survey, and an inability to conduct needs-adjusted calculations, among others.

Based on their findings, Blane et al. (2024) make a range of recommendations for policymakers. These include ensuring that practices in more deprived areas are resourced in proportion to the needs of patients, and sustainably funding interventions working well to support patients with more complex health and social needs, such as Community Link Workers and Welfare Advisors (Voluntary Health Scotland, 2023; Scottish Government, 2021c).

Mercer et al. (2023) also explored the implications of the introduction of the Scottish General Medical Services contract in 2018 for healthcare inequalities. This contract included the formation of GP Clusters, aimed at improving quality of care locally, and an expansion of the extended multidisciplinary team (MDT) to help reduce GP workload. However, both Mercer et al. (2023) and Blane et al. (2024) suggest that the contract may not be operating optimally to address healthcare inequalities.

The Scottish Government’s Primary Care Health Inequalities Short Life Working Group, set up to explore ways to maximise primary care’s significant potential to tackle health inequalities and inequity, produced 23 recommendations for action in 2022 (Scottish Government, 2022c), with a progress report published in 2023 (Scottish Government, 2023c). One recommendation focused on increasing funding for GP practices in areas of high deprivation.

The Scottish Government’s response to this has been the Inclusion Health Action in General Practice (IHAGP) project, which provides additional funding to around 65 practices in NHS Greater Glasgow and Clyde and is highly targeted at multiple disadvantage (Scottish Government, 2024h). Practices receive payments which they use for practical actions under IHAGP themes to tackle health inequalities and healthcare inequalities: staff knowledge and understanding of health inequalities (e.g. trauma training, learning about health inequalities); proactive outreach and extended consultations for those who need them; and community engagement.

A rapid, early evaluation of IHAGP highlighted that over 7,000 extended or outreach consultations had been delivered with patients with complex health needs or those often excluded from healthcare, which improves prevention and early intervention (Scottish Government, 2024h). More than 200 staff received training on topics related to health inequality and trauma-informed practice, leading to policy changes on missed appointments and improved responses to difficult patient interactions. Other emerging outcomes included improved staff morale and reduced repeat and missed appointments. Recommendations included continued funding, stronger partnerships, better data collection, and wider sharing of best practices.

Other research also echoes the importance of working in ways that tackle inequalities for those with the most complex needs, for example through well-considered MDT working (Harris et al., 2017). However, coordinated care for those with complex needs goes beyond MDT to joint working and integrated care across primary and secondary care within the NHS, as well as beyond to the third sector and other agencies (Mitchell et al., 2015; Sampson et al., 2015).

Health and care outcomes

Evidence demonstrates the links between access to and experiences of healthcare and outcomes. ‘Missingness’ (the repeated tendency not to take up opportunities for care, such that it has a negative impact on the person and their life chances) has become an increasingly significant topic of discussion, with the evidence base reflecting on the need to tackle the issue of ‘serial missingness’ to improve outcomes for patients who may have complex social and health needs (Williamson et al., 2017). Those who do not attend appointments may do so for a range of reasons, but their past experiences of care and ability to access care can influence future attendance (Lindsay et al., 2024). Patients may not feel listened to, may feel disempowered, may not be able to access information in a suitable language, or may lack trust in clinicians due to experiences of racism or other discrimination. This can be worse where there is a lack of continuity of care, short appointments, and poor communication support (ibid.).

These experiences then go on to influence outcomes. For example, McQueenie et al. (2019) demonstrate that missed medical appointments represent a significant risk marker for all-cause mortality, particularly in patients with mental health conditions. Their research found that those with long-term mental health conditions who missed more than two appointments per year had a greater than 8-fold increase in risk of all-cause mortality compared with those who missed no appointments, highlighting the importance of interventions that focus on increasing attendance by these patients.

Serial missed appointments in general practice have also been found to be a marker for higher use of outpatient and inpatient hospital care (though not emergency department care) (Williamson et al., 2021). As noted above, continuity of care has been recommended as one way to tackle and reduce mistrust and encourage patients to attend (Lindsay et al., 2024). It has also been found to improve GP experiences of their work, and to reduce secondary care use and therefore secondary care costs (Barker et al., 2017; Sandvik et al., 2022). Positive interface working between primary and secondary care may also increase attendance and treatment compliance (Mitchell et al., 2015).

Service design and monitoring progress

PHS (2023b) highlight that to address these issues it is important that services are designed and delivered in an equitable way, given that a fundamental component of a prevention-based approach is ensuring that all groups and communities can access the treatment and care needed to stop health problems from getting worse. They discuss how NHS Scotland, with support from local public health and public involvement teams, can help to address healthcare inequalities by monitoring uptake of services across different groups and working with those experiencing barriers to design services accessible for everyone. The significance of co-design to reducing inequalities in access, experiences, and outcomes is well-documented throughout the literature (e.g. McGeown et al., 2024).

The King’s Fund recommend collecting and sharing improved and ‘thoughtful’ metrics to monitor health and healthcare inequalities (Morris and Robertson, 2024). They suggest monitoring and reporting go beyond measuring NHS activity to focus more on the NHS’ role in reducing inequalities, including the routine collection and monitoring of healthcare inequalities data (such as data on missingness), along with measuring progress, sharing learning, and ensuring accountability for improvement.