2024 Inequality Landscape
Executive Summary
Introduction
This report picks up from the previous work commissioned by the Health Foundation as part of their independent review of health inequalities in Scotland in 2022.
Four detailed reports looked at the evidence on health and wider socioeconomic inequalities, barriers to action and public understanding:
- Health inequalities in Scotland: Public engagement research from the Diffley Partnership
- Health inequalities in Scotland: Trends in the socio-economic determinants of health in Scotland from the Fraser of Allander Institute
- Health inequalities in Scotland: Trends in deaths, health and wellbeing, health behaviours, and health services since 2000 from the MRC/CSP Social and Public Health Sciences Unit at the University of Glasgow
- Review of health inequalities in Scotland: Stakeholder engagement insight from Nesta.
The Health Foundation drew together the evidence into their report, Leave No One Behind, in early 2023. A key finding was that, since 2010, key indicators of health and living standards, such as life expectancy and average incomes and earnings, had stagnated or widened. Men and young children were also highlighted as being of particular concern. All these reports can be found on the Health Foundation website [1].
Since the 2023 report was published, we have more evidence of the impact of the pandemic and can see that people have endured steep rises in the cost of living that have affected living standards across Scotland. Public spending has been under pressure on several fronts and for the third year in a row, the Scottish Government have introduced in-year spending controls to prevent overspend on their available budget.
This report highlights a worsening situation in socioeconomic and health inequalities. The pandemic has played a role, but the roots of this decline stretch back long before this. Deteriorating life expectancy is a key indicator of the issues Scotland is facing. (Fig. 1.1).
While deaths relating to COVID-19 play a part in explaining these most recent falls, the deviation from the long run trend of faster improvement has been apparent since the early 2010s.
Measures of median incomes are also key to our understanding of average living standards. Income growth has never recovered to its pre-financial crisis trend with median incomes around 20% lower than they would have been if that trend had continued. Average incomes on average have fallen since 2019 (Fig. 1.2).
Figure 1.1 Life expectancy at birth, in years
Figure 1.2 Median weekly household incomes and the long-run growth trend pre-2010 (in 2023 £)
The links between income, living standards and health are varied and often bi-directional. As the Health Foundation write in their 2023 report:
“…almost every aspect of our lives shapes our health and how long we will live, our jobs and homes, access to education and the quality of our surroundings”
Leave No One Behind, 2023 [1]
The remaining sections delve into these wider determinants of health, exploring changes in poverty and income inequality, employment, housing and homelessness, and education. We also summarise some of the insights available in the wealth of qualitative research in Scotland, providing some sense of the lived realities behind the data.
In the penultimate section, we spotlight two key population groups for tackling inequalities: young adult men and families with young children. These were highlighted as population groups of particular concern in the Health Foundation’s 2023 report, since multiple health and socioeconomic indicators suggested significantly worsening outcomes for these two groups in Scotland’s most disadvantaged communities.
Many of the central messages of this report are well known but this does not negate their seriousness. The fact that life expectancy is falling, and health inequalities are widening, should be coalescing efforts to understand how, and where, resources can be most effective in tackling the underlying socio-economic inequalities. This is all the more important in the current bleak fiscal context; the Scottish Government is making difficult decisions around where to disinvest and these decisions have the potential to further exacerbate inequalities.
Throughout this report we make reference to another key finding of the Health Foundation’s previous work in Scotland: the gap between policy ambitions and impact on the ground. We also outline how SHERU plans to work to improve the evidence base going forward.
Trends in health inequalities
People living in deprived areas are far more likely to die prematurely (under age 75). Over the pandemic, there have been some small changes but inequalities remain broadly unchanged compared to 2019. (Fig 1.3).
Figure 1.3 Early mortality rate (under 75) (age-sex standardised rate per 100,000 population)
Cancer, circulatory system diseases, and drug and alcohol are the most common causes of early mortality, and all have wide gaps in outcomes between areas. The gap in coronary heart disease (CHD) deaths has increased over time, whereas gaps in cancer deaths have declined since 2019 (Fig. 1.4). This is due to decreases in cancer mortality across the deprivation spectrum, and increases in CHD deaths among the most deprived.
Figure 1.4 Difference between the 20% most and least deprived areas in mortality rates for cancer and coronary heart disease (CHD) (age-sex standardised rate per 100,000)
Similarly, gaps in drug misuse mortality have decreased while gaps in alcohol specific mortality rates have increased relative to the pre-pandemic period.
Mortality rates relating to drug use peaked in 2020, and while the reduction since is a positive sign, drug misuse mortality rates remain over four times higher than they were in 2000 (Fig. 1.5. See Fig 7.1 for long term trend).
Figure 1.5 Drug misuse mortality rate (age-sex standardised rate per 100,000)
Finally, alcohol mortality rates are higher than they were in 2019 for both deprived and non-deprived groups, and the gap in outcomes between these groups has widened. The most deprived areas saw a reduction in deaths in 2022 but the 2023 rate is now above the pandemic peak (Fig. 1.6).
Figure 1.6 Alcohol specific mortality rate (age-sex standardised rate per 100,000)
Life behind the data
“Nearly every day I’m picking this paper up, I’m reading aboot the life expectancy wae me and [compared to] maybe staying doon in London…They’re absolutely kicking you every way they can, like. And if you’re in a poor area, you’ll always be in a poor area… Naebody’s gonna try and help you oot it, but if you’re in an affluent area, to hell wae the rest…”
John, cited in Mackenzie et al., 2017 [2]
Qualitative research suggests there is growing public awareness of the differences in health outcomes and that this, in itself, can contribute to their sense that life in Scotland is unfair and that those in authority are not doing enough to support disadvantaged communities [2].
There are also indications that Scotland’s high drug and alcohol use rates reflect responses to a complex intersection of persistent, overwhelming poverty informing hopelessness and mental health issues, combined with easy availability and peer networks. In qualitative accounts, people often describe using alcohol and drugs to ‘escape’ from difficult circumstances, with traumatic experiences or new stressors (e.g. job loss, homelessness or relationship breakdowns) often triggering consumption.
“What made me keep doing it [using drugs]? Fear. In the fear in thinking there’s no hope for any kind of decent life […] So, I think that’s why I continued, just try to block it all out. Wasn’t caring about the consequences. I overdosed something like 28 times. Pronounced dead something like 18 times. And did it stop me doing it? Nothing stopped me doing it.”
Lee (interviewee), cited in Farmer et al., 2023 [3]
Alcohol and drugs also feature as important contextual factors when people are asked to describe how their local neighbourhood impacts on their health, with women, children and minority ethnic communities (in particular) reporting avoiding some areas as a result.
How can we improve our understanding of these trends?
The relationship between health data and income in research is primarily considered through the lens of SIMD. This is an area-based measure and not all people who have low incomes live in deprived areas, and vice versa. For example, the most recent data finds that around 30% of people in poverty live in the most deprived SIMD quintile, meaning the majority of people in poverty do not live in the most deprived SIMD quintile. SIMD therefore has some but limited value in describing how an individual’s health is tied to relative poverty. To gain a more comprehensive understanding of health inequalities, we need to use data from various sources, and linking to individual measures of living standards (e.g. poverty) would be a step forward.
Household incomes
Inequalities in household incomes are deeply connected to Scotland’s dramatic differences in health outcomes for poorer and richer groups.
The decade leading up to 2020 was marked by unprecedented stagnation in average incomes following decades of rising living standards. As shown in the introduction, we have seen average incomes start to fall in the early years of the 2020s. Changes during the pandemic and the erosion of living standards due to the cost of living crisis are part of this story but not all households have been affected equally.
The indicators in this section highlight changes in incomes over the course of the pandemic and show how trends have shifted for key population groups.
Household income has a critical role in explaining health inequalities. Poverty measures represent attempts to quantify the number of people whose income is too low to afford basic material goods and services and to participate in every day social activities.
Income and other socioeconomic inequalities, like housing and education, are closely connected. This section focuses on low income as a direct cause of poor health. Limited income makes it harder for people to adopt healthy behaviours and creates stress for households struggling to make ends meet. There are obvious outcomes from this: people may struggle to afford essentials like food or warm homes. There are also less obvious outcomes. For example, the income gap between those with low incomes and those with middle or higher incomes also leads to social isolation—a factor that negatively impacts health—because people cannot afford to participate in common societal activities, such as paid-for school trips or social events that involve paying for food or drink.
A note on data used in this section
The most reliable source of data on household incomes comes from the DWP Households Below Average Incomes dataset, a subset of the Family Resources Survey. Due to sample size, Scottish Government recommends the use of 3-year averages to assess trends in Scotland. Issues with data collection in 2020-21 means we are missing data for Scotland for this year. Therefore, any year containing 2020-21 is presented using a 2-year average and the data may be more volatile as a result.
Policy context
Addressing income poverty involves multiple policy areas, including the labour market, housing, social security, and taxation. Policy levers are divided between the UK and Scottish governments. While most social security funding comes from the UK government, some benefit powers are now devolved and spend has grown over recent years with interventions such as the Scottish Child Payment. Local authorities manage financial support schemes like the Scottish Welfare Fund under Scottish Government guidance.
There is often debate over who should be held responsible for rising or falling poverty given the complex nature of devolution. UK-wide austerity measures, especially cuts to social security, are frequently cited as beyond the Scottish Government’s control. However, the Scottish Government passed the Child Poverty (Scotland) Act 2017, fully aware of the impacts of UK austerity, and committed to mitigating these effects through initiatives like the Scottish Child Payment. Despite these efforts, they have yet to present a comprehensive plan to fully meet their statutory targets of 10% of children in relative poverty by 2030/31.
Tackling income inequality, beyond reducing poverty, is not often part of the policy discourse in Scotland. For example, there is little explicit focus on reducing income gaps between the top and middle of the income distribution. While devolved income tax powers offer this mechanism, the rationale behind a progressive income tax system is generally framed around fairness in revenue generation (i.e. those with the broadest shoulders should bear a larger share of the burden) rather than specifically aiming to decrease the income of high earners.
Definitions: Income inequality, poverty and multiple deprivation
Income inequality is the difference in income between the highest and lowest-earning households, adjusted for size, housing costs, and taxes. People are in relative poverty if their income is less than 60% of the median income and in absolute poverty if below 60% of the UK median income from 2010/11, adjusted for inflation.
Incomes can be measured before or after housing costs; this section uses before for the income measure, while poverty in Scotland is measured after.
Deprivation indices classify small areas based on factors like income deprivation, crime, and health outcomes. The Scottish Index of Multiple Deprivation ranks small areas in Scotland from most to least deprived. This report uses the worst and least deprived 20% of areas to describe inequalities where it is not possible to use individual/household measures of income.
Key trends in income inequalities
The latest data shows that, compared to pre-pandemic levels, average (median) incomes have decreased, both before and after accounting for housing costs. Falls in income were more concentrated in the middle parts of the income distribution (Fig. 2.1).
Figure 2.1 Change in incomes in Scotland compared to pre-pandemic by decile point (before housing costs)
The proportion of households in relative poverty increased slightly over the same time period, while the proportion of households in absolute poverty stayed relatively consistent (Fig. 2.2).
Figure 2.2 Average yearly proportion of the Scottish population in relative and absolute poverty (after housing costs)
This variation in relative poverty was not consistent across all groups. For example, poverty rates increased dramatically for adults under 25 during this time period (Fig. 2.3).
Figure 2.3 Average yearly proportion of non-dependent 16-24-year-olds in relative poverty (after housing costs)
Since the pre-pandemic period, poverty rates for people living in households containing one or more members who self-identify as being part of a minority ethnic community have increased and remain significantly higher than those for white ethnic groups (Fig 2.4).
Figure 2.4 Average yearly proportion of households from ethnic minority backgrounds in relative poverty (after housing costs)
Spotlight: The Scottish Child Payment
Scotland has long had lower child poverty rates compared to the rest of the UK. In 2017, it legislated to reduce poverty further to 10% by 2030/31 (Fig 2.5). The most recent data reports that 24% of children are in poverty (240,000 children).
The Scottish Child Payment (SCP) is a key part of the Scottish Government’s efforts to reduce child poverty. It provides an additional £26.70 per eligible child, per week, to families who are in receipt of employment benefits such as Universal Credit. The impact of this policy should be significant. It has been estimated that the SCP will have kept roughly 60,000 children out of poverty in 2023/24.
Unfortunately, at the moment there is no evidence of it making an impact on the official child poverty statistics. We would have expected the Scottish relative poverty line to diverge further from the rUK trend from the point of SCP rollout in 2021. This hasn’t happened and we need to understand why. Issues with data collection are thought to be part of the problem.
A number of organisations, including the Scottish Government, have collected qualitative data that indicates that families who receive the payment have benefitted from it. However, without robust quantitative data, we can’t assess its impact at scale. Even if the Scottish Child Payment was showing up in the data as expected, Scotland would still be a long way from meeting its statutory target of reducing relative child poverty to 10% by 2030/31.
Figure 2.5 Proportion of children in relative poverty (after housing costs)
How can we improve our understanding of trends?
The Households Below Average Income (HBAI) statistics are based on the Family Resources Survey (FRS), and it is now possible to link at least 95% of FRS respondents to their administrative records. By further linking this data with additional administrative sources, such as broader HMRC and DWP records, as well as exploring the feasibility of integrating Social Security Scotland and health data, we could gain a more nuanced and comprehensive understanding of poverty dynamics, including its root causes and persistence.
Such integration would enable more effective analysis of the relationships between income, earnings, welfare benefits, and poverty. Further insights could be gained by the use of longitudinal data and studies. This would help reveal whether families remain in poverty, despite receiving benefits like the Scottish Child Payment, offering valuable insights into the effectiveness of these allowances and highlighting areas where further intervention is needed.
Life behind the data
“[My family] are literally keeping me alive, like they’re feeding me and stuff. But it’s got to the point now where anything above literally staying alive is a luxury. Like everything that’s not eating is a luxury.”
Lone parent, aged 25 -34, cited in Robertson et al., 2022 [4]
Extensive qualitative data highlight how low incomes and poverty negatively impact people’s health and wellbeing in Scotland, pointing to four linked pathways that connect poverty to poor health. First, people describe not being able to afford to eat, heat their homes, or afford a decent quality home. These are material impacts that leave people hungry, cold and sometimes exposed to poor housing conditions (e.g. damp).
Second, people describe living in areas with high air pollution, traffic accidents, anti-social behaviour and crime, or fewer amenities (e.g. shops and affordable, reliable public transport links). These more structural factors can impact on physical health (e.g. air pollution causing respiratory problems) and mental health (e.g. witnessing or experiencing violence and abuse can lead to stress, trauma, fear and depression).
Third, disadvantaged communities often report experiencing stigma and discrimination. From postcode stigma to racialisation, people often feel that their postcode, name, accent and/or appearance is negatively impacting on their chances of accessing good jobs, housing and financial services. They also report financial penalties (e.g. energy companies charging low income families more via pre-payment meters than wealthier households pay by Direct Debit).
“Mine’s does what it says on the box. It goes directly to the kids whether they need a new pair of shoes or a new jacket, or…they want to do a certain activity that I wouldn’t normally be able to afford for them… It’s been absolutely fantastic. My eldest son will be joining the town’s rugby team in August, and it’s something that I wouldn’t have been able to afford beforehand ”
Mother, Dumfries and Galloway, cited in Save the Children, 2023 [5]
The fourth pathway arises from the anxiety, stress, shame and guilt that living in poverty, or in deprived areas, can cause. Qualitative accounts suggest that people (especially parents) often feel guilty about not being able to afford decent food and clothes, and ashamed of living in some areas (so much so that they may avoid inviting friends of family over). All of this can contribute to loneliness, anxiety and depression. Qualitative data also shows how poor health can exacerbate poverty, with long-term illnesses or chronic conditions leading to reduced household income (e.g. due to job loss or reduced working hours).
More optimistically, as the quotation above highlights, qualitative data provide a glimmer of hope when it comes to assessing the potential for the Scottish Child Payment to improve the experiences of low income families (though small-scale qualitative data cannot be used to assess population level impacts).
Employment
Employment is closely intertwined with health. Work can impact people’s health directly, health problems can impact the way people interact with employment, and work quality can influence people’s well being.
Leading into the 2008 financial crisis, employment earnings for workers in Scotland had seen consistent growth, followed by over a decade of stagnation. This stagnation has continued, with modest earnings growth between 2019 and 2023. Despite the upheaval of the pandemic, headline employment levels are broadly similar now compared to 2019, although as the indicators in this section show, some groups have seen vastly different outcomes.
The links between the work that people do and their health are multifaceted. There is a lot of concern about people who are not engaged in the labour market (inactivity) but we also know that quality of work, which encompasses job security, working conditions, and the level of stress associated with a job, plays a critical role in an individual’s physical and mental health. Both having a job and the quality of that job are linked to earnings, which is a significant component of household income.
Policy Context
In Scotland, employment policy levers are shared across different layers of government, and many policy areas overlap. For example, social security policy can influence people’s work decisions, the availability and affordability of childcare can determine how much parents can participate in paid work, and transport and housing will also have ramifications for where and when people can work.
Economic participation is one of the metrics within the National Performance Framework and the Scottish Government also has an explicit target on reducing the gap in employment rates between disabled and non-disabled people. The Scottish Government’s employability policy is delivered through local government via the No One Left Behind initiative. While the Scottish Government lacks devolved powers over employment legislation or the minimum wage, it seeks to promote Fair Work through public sector procurement and funds initiatives to encourage the payment of the Real Living Wage.
Key trends in employment inequalities
The gap in weekly earnings from employment between the highest and lowest-earning full-time workers has varied marginally but remains wide (Fig. 3.1).
Figure 3.1 Average weekly employment earnings (in 2023 £)
The number of people economically inactive in Scotland is only marginally higher than pre-pandemic. The reasons why people are inactive, however, have changed since 2019, with more people claiming inactivity due to long-term illnesses or disability, largely connected to mental health (Fig. 3.2).
Figure 3.2 Proportion of inactive people by reason for inactivity in Scotland *
* 2020 data is omitted due to sample size issues
Rates of inactivity are always higher for younger age groups, reflecting numbers in higher education. The proportion of young people not participating in work or education was higher than pre-pandemic in 2022, but declined by 2023 (Fig. 3.3).
Figure 3.3 Proportions of those aged between 16 and 19 that are not participating in education, employment or training
There are relatively few robust and regularly updated measures of job quality and problems with the ONS Labour Force Survey have led to further issues with the data. Underemployment, which measures whether people want to work more hours, has stayed fairly stagnant since recovering from its mid-pandemic peak (Fig. 3.4).
Figure 3.4 Proportion of workers who are underemployed in Scotland
Spotlight: The disability employment gap
The Scottish Government has a goal of reducing the gap in employment levels between disabled and non-disabled adults from 37.4 to 18.7 percentage points between 2016 and 2038 (Fig. 3.5).
Bridging this gap is important, given that people with disabilities are more likely to live in poverty. An important qualifier is that paid work is not right or possible for all disabled people, and adequate financial support is crucial for those who will remain outside paid work. The definition of disability comes from the UK 2011 Equality Act and includes people with a long-term limiting health condition.
As of 2023, this gap is now at 29.9 percentage points, which is well ahead of schedule, but not, as far as we can tell, due to the impact on government policy.
Analysis of the data shows that the progress is not due to more disabled people moving into work. Instead, the number of people already in work identifying a disability has increased (Fig. 3.6). This trend follows a similar one seen across the UK, and a general trend in increased disability prevalence and reporting worldwide [6].
Figure 3.5 Proportion of working age adults in employment by disabled status*
Figure 3.6 Percentage point change in disability prevalence and in the disabled employment gap since 2016*
How can we improve our understanding of trends?
The ability to integrate health and employment data can provide a holistic view of the relationship between job conditions and health outcomes. Linked data allows for better control of confounding variables, ensuring that observed relationships between employment and health are not due to other underlying factors.
To be able to connect such data effectively, there needs to be improved coverage and definitional consistency around health conditions within official labour market data for Scotland. The Office for National Statistics (ONS) has delayed the full implementation of the Transformed Labour Force Survey (TLFS), the replacement for the Labour Force Survey (LFS). The aim of the TLFS is to improve labour market statistics through survey redevelopment and increasing the use of administrative and other data sources. This work is in response to declining response rates in social surveys and should hopefully provide greater reliability around estimates, particularly for smaller groups in the labour market.
Life behind the data
“I’ve watched my son who is now twenty-two…I’ve watched him over a period of time having to go onto websites, having to apply for jobs, no’ getting any word back, no’ even getting notified whether he’s getting an interview, or whether he’s successful, or unsuccessful. You just watch the… sorta esteem just drain oot them.”
Alex, cited in Mackenzie et al., 2017 [2]
Meaningful work can have a positive impact on people’s mental wellbeing, while unemployment, and shifting between poor quality, insecure work and unemployment, negatively impacts people’s mental health and sense of hope for the future.
This can rapidly create a negative feedback loop in which people experience worse mental health as a result of unemployment, and then struggle with applying for jobs as a result.
People who lived through Scotland’s de-industrialisation, in the 1970s and 1980s, often recall how (despite hazardous working conditions) large, local employers contributed to a sense of community, while trade union representation and ratepayers associations helped improve working and living conditions and strengthen community ties, and also served as an important political voice for working class communities.
“During my period in the power station in Lochaber, British Aluminium Works, I was a very strong trade union man… We had disputes with management and we always resolved them, because there was never any danger of us going too far, which I don’t think management at the time appreciated, because it wasn’t a job, it was a community.”
Alexander Walker, former Electrical TU shop steward who worked at the Lochaber power station 1964-2001 (oral history participant), cited in McIvor, 2017 [7]
In the subsequent years, some areas in Scotland have struggled to develop new, meaningful employment opportunities, creating a situation in which people describe feeling that they lack purpose in life, and experiencing a sense of hopelessness about the future [2]. Although trade union membership is slightly higher in Scotland compared to England, the big picture trend is of a decline in trade union membership from 39% of employees in Scotland in 1995 to only 28.8% by 2023 [8]. This represents an important decline in the capacity of unions to ensure workers’ voices are adequately represented in Scottish policy discussions and heard by key decision-makers, alongside the voices of employers [9].
Housing and homelessness
While some aspects of housing availability and affordability have improved, differences in outcomes between the wealthiest and poorest households in Scotland have widened.
Issues with housing affordability and quality in Scotland are longstanding and, despite the efforts of different levels of government, remain a long way from being solved. This is perhaps best exemplified by the Scottish Government recently declaring a ‘housing emergency’ in Scotland due to concerns over the availability and affordability of homes, particularly for those on low incomes.
Poor housing conditions can lead to respiratory issues, while inadequate income to heat a home properly can further exacerbate health problems. Housing affordability affects disposable income, limiting the ability to spend on other necessities. Additionally, insecure housing tenure can be challenging for families seeking stability and, in extreme cases, can lead to homelessness. Research has shown a strong relationship between homelessness and poor health outcomes, including higher mortality rates, increased emergency room visits, and more prescriptions, particularly for mental health and substance use issues. Homelessness is often closely connected to health crises, and repeated episodes can worsen these health problems.
Since 2019, fuel poverty and fuel insecurity has increased, even while relative poverty among most renters and homeowners has decreased. Homelessness applications have risen, and the resulting health impacts are worrying: more people are citing safety and health issues, and deaths among people experiencing homelessness have increased.
Policy Context
Housing policy is fully devolved to the Scottish Government. One significant area of activity in recent years is the Affordable Housing Supply Programme, with a target of delivering 110,000 additional affordable homes by 2032, with 70% for social rent. Inflation and budget cuts have raised concerns about meeting these targets. [10]
Scottish local authorities deliver housing policy, and also have a statutory duty to find permanent accommodation for those threatened with or experiencing unintentional homelessness [10]. Interventions to prevent homelessness are generally preferred as a policy strategy, since this avoids the harms caused by homelessness can be more cost-effective, but preventative measures are not yet widespread [12, 13].
The 2024 Housing Bill includes a new requirement for a range of public bodies to be more proactive, but concerns have consistently been raised as to whether there will be sufficient resources to implement preventative policies [14].
Key trends in housing inequalities and homelessness
Poverty rates are significantly higher in the rented sector, but with evidence of a reduction since in the latest data (Fig. 4.1). This may be due to changes in government policy. See ‘Spotlight’ section for discussion of whether the private sector rent cap can explain this trend. Social rents were also held down during this time.
Figure 4.1 Proportion of population in relative poverty by tenure
There is little evidence to help us understand whether the decrease in poverty in these tenures has translated into better socioeconomic outcomes or whether savings have been outweighed by higher costs elsewhere. For example, food insecurity rose for all types of tenants between 2019/20 and 2022/23, but rose most dramatically for private tenants (Fig. 4.2).
Figure 4.2 Proportion of people who are food insecure by tenure
Scotland built more affordable housing in 2022/23 than at any point pre-2000. Many of these homes were in the social rented sector. However, the list of people on the waiting list for social housing has continued to grow (Fig. 4.3).
Figure 4.3 Number of new affordable houses built in Scotland
There are limited updates on housing quality. No data was collected during the pandemic, and 2023 shows little change compared with 2019. One exception is fuel poverty which rose between 2019 and 2022 (there was no data available for 2020 and 2021) (Fig. 4.4). Fuel poverty depends on income and the energy efficiency of housing. People who rent their homes are more likely to be fuel poor than those who own their homes.
Figure 4.4 Proportion of people in fuel poverty
The number of new homelessness applications increased in 2022/23 compared to 2018/19, although fewer households had experienced rough sleeping in the three months prior to their application. The reason for the fall during the pandemic can largely be attributed to emergency legislation, including a temporary ban on evictions and home repossessions (Fig. 4.5). The Scottish Government largely attributes the overall rise in homelessness to a lack of housing availability and the cost-of-living crisis [15].
Figure 4.5 Number of homelessness applications and applications citing rough sleeping
The reasons why people become homeless changed over the course of the pandemic. In 2022/23, a higher overall proportion and total number of people cited abuse, violence (both domestic or non-domestic), or harassment as a reason for leaving accommodation compared to 2018/19, but this trend was at its highest in 2020/21 and 2021/22 (Fig. 4.6).
Figure 4.6 Proportion of homelessness applications citing violence, abuse, or harassment
Furthermore, significantly more people now cite physical or mental health reasons for failing to maintain accommodation in 2022/23 compared to 2018/19 (Fig. 4.7).
Figure 4.7 Number of homelessness applications citing mental health, physical health, or a drug or alcohol dependency.
Since 2019, deaths among people experiencing homelessness have increased and plateaued. During the pandemic, the Scottish Government and local authorities provided self-contained accommodation for those sleeping rough or in shared housing. It is challenging to assess how this affected health outcomes due to the policy’s short duration and the coinciding pandemic, which likely increased mortality rates (Fig. 4.8).
Figure 4.8 Number of estimated and identified deaths among people experiencing homelessness*
* The estimated rate is an attempt to correct for underreporting. See NRS Homelessness Deaths for more information.
Spotlight: Private sector rents
Analysis of data on housing costs (primarily made up of rental costs) in the private rented sector shows that costs have been falling in recent years. According to the data from the Households Below Average Income (HBAI) data published by DWP, this has only happened in Scotland and not in other parts of the UK (Fig. 4.9).
Figure 4.9 Weekly housing costs in private rented sector (£)
ONS data showed that rents in Scotland have been rising at broadly the same rate as other UK countries since 20211. These data are primarily based on new tenancy data whereas the HBAI data captures people on existing tenancies too. This data is available more frequently, and often makes the headlines, but only gives part of the story.
Scotland introduced legislation in the latter half of 2022, which froze in-tenancy rents until March 2023 and then capped them until March 2024. The downwards trend in rents in Scotland predates the introduction of the rent cap, a trend which continues during 2022-23, with the rent cap in place for the latter part of that period.
Currently, there is no other data source that captures in-tenancy rents, making it difficult to assess the reliability of the observed trend without additional evidence for corroboration. To understand what has happened to rents since 2023, we will need to wait for the next HBAI update in March 2025. It won’t be until March 2026 that we have data to analyse any effects after the rent cap ended.
How can we improve our understanding of trends?
Integrating detailed housing data (e.g., dampness, overcrowding, heating) with health and social services data could help assess poor housing’s impact on health outcomes like respiratory illnesses and mental health. Better information on the employment status of individuals and the relationship to housing stability, including analysis of housing affordability is required to reveal the extent to which financial stress related to housing affects health.
Examining housing disparities, including pollutant exposure and healthcare access, could help to highlight the long-term impacts of housing location. Longitudinal studies and more routine data linkage can help with this, allowing for identification of high-risk groups and enhancing the evidence base to inform the design of targeted interventions, such as housing upgrades, health services and/or social support for specific populations.
Life behind the data
“Two months without a cooker, countless weeks where the boiler would break down and I wouldn’t have hot water and I wouldn’t have any gas for cooking […] so aye, that was really kinda detrimental to health. I lost a bit of weight through it as well and my mental health suffered as well, ‘cause it was as if they didn’t care. So I was going to work depressed, coming back depressed, looking at the depressing house.”
Research participant, cited in Garnham, 2021 [16]
Studies that use qualitative methods find a strong relationship between people’s housing experiences and their mental wellbeing. This can include overall housing quality, relationships with landlords, and neighbourhood dynamics. People frequently describe how important it is for their mental wellbeing to have a place to live that feels safe, secure and like ‘home’.
Housing quality, unsurprisingly, can have dramatic impacts on people’s quality of life. For instance, people often respond to fuel poverty by heating single rooms, which can contribute to overcrowding and interpersonal stress. Furthermore, there is a compounding problem where households may experience both food insecurity and fuel poverty, deepening the potential gap in health outcomes between poorer and wealthier households.
Other issues people in Scotland addressed include harassment, anti-social behaviour, or undesirable drug and alcohol use. People in Scotland also often describe feeling that they are discriminated against in other areas, such as employment and financial services, due to living in particular housing ‘schemes’ or neighbourhoods. For people living in rented accommodation, relationships with landlords can make a substantial difference to their experience: if people have responsive landlords who appear to care about them, this can positively impact on their mental wellbeing, while unresponsive or uncaring landlords can contribute to stress and insecurity. When people feel ashamed of their housing, they may avoid inviting people in, contributing to social isolation.
“I tried to kill myself about 5 times. It [homelessness] kicked your self-esteem to death.”
40 year old male (interviewee), cited in Paudyal et al., 2020 [17]
Homelessness brings many further problems and is often intertwined with health and addiction crises. Repeated episodes of homelessness exacerbate these health challenges. However, the depth of stigma and discrimination faced by people experiencing homelessness can not be understated. People experiencing homelessness often cite the difficulty of accessing basic services, such as healthcare, bathrooms, and of keeping clean in general. All of this negatively impacts on people’s mental wellbeing. Faced with the stress of homelessness, many participants in qualitative studies describe turning to drugs or alcohol as a ‘coping’ mechanism or as a way of temporarily ‘escaping.’
Education
By and large, educational attainment and qualification trends have returned to pre-pandemic levels, for better or worse, with large gaps between deprived and non-deprived areas.
Education outcomes experienced some large shocks during the pandemic. The poverty-related attainment gap in primary students meeting grade level expectations increased, reversing some narrowing of the gap in the years leading up to the pandemic. Conversely, the poverty-related attainment gap at secondary school narrowed during the pandemic. Trends have generally now returned to pre-pandemic levels.
The relationship between education and health outcomes is complicated and often unclear. Many health outcomes are worse for people with lower levels of education, but there is no clear evidence that having a better education can affect health in adulthood. There is evidence, however, that experiences at school can provide the foundation for secure living standards in adulthood, both in terms of academic qualifications achieved but through other skills and capacities that are developed during this time [18].
Policy context
School education is fully devolved to Scotland, funded through the Scottish budget and delivered by local authorities who have statutory duties to provide school places. Education policy is set by the Scottish Government and there have been a number of new initiatives in recent years, alongside the implementation of Curriculum for Excellence (CfE). Education Scotland is the public body charged with supporting the improvement of education in Scotland.
In the last few years, there has been an OECD review on the implementation of the Curriculum for Excellence and an independent review of assessment practices and the Scottish Qualification Authority. Both had recommendations for improvement that are being considered by the Scottish Government [19].
In recognition of the wide gap in attainment across the income gradient, the Scottish Government has put in place funded initiatives under the banner of the Scottish Attainment Challenge, such as Pupil Equity Funding (which is paid directly to schools, rather than to local authorities). Since 2023, a new Strategic Equity Fund has been paid to local authorities based on the proportion of children in poverty in the area [20].
Key trends in education inequalities
During the pandemic there was a widening in educational inequalities at primary level, as measured by the difference in attainment by the Scottish index of multiple deprivation. The gap has now retuned to broadly the same level as it was pre-pandemic (Fig. 5.1).
Figure 5.1 Proportion of P1 and P7 students meeting grade level expectations in reading*
*2019/20 data is unavailable as the data collection was cancelled.
At secondary school level, the latest exam results published by the Scottish Qualifications Authority (SQA) showed that the attainment gap between pupils from the most and least deprived parts of Scotland has widened. After reductions during academic years impacted by the Covid-19 pandemic, the poverty related attainment gaps at National 5, Higher and Advanced Higher are all now wider than they were pre-pandemic (Fig 5.2).
Figure 5.2 Proportion of candidates attaining grade A-C at SCQF Level 6 (Higher)
Post school, the gap in higher education participation amongst 16-19 year olds has been fairly persistent across the period of the pandemic. Although there has been some narrowing in 2024, this remains stubbornly high (Fig 5.3).
Figure 5.3 Proportion of people aged 16-19 participating in higher education
Rates of attendance at school have been falling in recent years across all pupils. Moreover, pupils from the most deprived areas continue to experience lower attendance rates compared to those from the least deprived areas. Sickness absence rates are also higher in more deprived areas (Fig. 5.4).
Figure 5.4 Proportion of half days of possible attendance recorded as absent in school by students’ deprivation quintile, 2022/23
Spotlight: Mental health and educational attainment
Educational attainment mediates the relationship between early-life conditions (such as low birth weight) and later health outcomes, emphasising the role of education in health equity.
In Scotland, there is limited data that looks at health outcomes by education. Instead, most health statistics use the SIMD, which is primarily based on income, but includes some measure of educational deprivation. This may be because health and educational attainment do not have a clear relationship with each other: while people who have achieved better education generally have better health outcomes in the UK, studies have found mixed results in trying to understand whether or not this relationship is causal [18].
Regardless of the mechanisms behind this relationship, there is a clear inequity in outcomes, with people with low or no qualifications having higher-than-average rates of depression, even when factoring income and employment status (Fig. 5.5, 5.6).
Figure 5.5 Proportion of individuals earning the lowest 20% of incomes who have at least one depression symptom, by highest education level
Figure 5.6 Proportion of individuals without qualifications with one or more depression symptoms by employment status
How can we improve our understanding of trends?
Understanding how the pandemic affected children already facing socio-economic disadvantages is crucial for finding the right solutions. The new Health and Wellbeing Census, which analysed 2021/22 data from 16 local authorities who shared their data with the Scottish Government, found a 10 percentage point gap in perceived good or excellent health between pupils from the 20% most and least deprived areas. The survey covered a full range of topics encompassing all aspects of wellbeing including mental and physical health, sexual health, and substance misuse. Expanding this analysis to all 32 local authorities and exploring the linkage to broader education (e.g. attainment) and health data could offer deeper insights into the socio-economic factors influencing young people’s health and well-being in Scotland.
The use of children’s data requires careful consideration, particularly ensuring informed consent is obtained for research. Currently, pupil data is not systematically considered alongside socioeconomic or health indicators, except through area-based measures like SIMD.
Life behind the data
“My teacher [in college] was a bit racist… like maybe because I’m from a different country or maybe because I’m Arab I don’t know… but she was treating me really bad. And you don’t eat and you’re over-thinking”
Female student, cited in Tinner and Alonso Curbelo, 2024 [21]
Qualitative research suggests young people in Scotland often see education as a means of achieving positive life goals, such as a decent job and income security which, in turn, enable people to buy a home. However, some pupils from poorer backgrounds, or who have a minority ethnic identity, often describe feeling discriminated against and judged in the school system, which can impact young people’s mental wellbeing as well as their qualifications. The policy approach to grading during the COVID-19 pandemic (when exams were paused) cited as an example of how inequalities can be institutionalised and feel impossible to escape.
Research with teachers in Scotland suggests there is a great deal of awareness of the multiple ways in which social and material life circumstances can constrain children’s ability to engage with education. While this is potentially positive, it also informs a widespread expectation that more affluent pupils will fare better with educational attainment, which to some extent reflects young people’s anxiety that teachers ‘judge’ them according to their background.
“It was just quite frustrating that it was, like, all of these people that were going to fail and stuff like that when all of the grades came out but they got predicted higher because, like, maybe the area they were in. Like, I remember seeing people online that was like, they went to a good school but they were performing badly, but because they went to a good school, their grades got picked up massively. It was just really frustrating because there was…I felt, like, helpless, like, ’cause there was nothing I could do about it, and it just kind of got, like, taken away from me.”
18 year old male group participant, discussing the Scottish approach to grading during the COVID-19 pandemic, cited in Fergie et al, in press [22]
Qualitative research with parents tends to focus on specific groups of parents, such as single parents and parents of children with additional support needs or disabilities. The findings suggest that these groups were particularly badly hit by the closure of schools and support services during the COVID-19, and are concerned about the long-term impacts on their children, including in terms of educational attainment.
Populations of concern
In Leave No One Behind, the Health Foundation highlighted children and young adult men as particular populations of concern due to significant and persistent health inequalities.
Children are more likely to live in relative poverty than adults, and children are overrepresented in deprived areas compared to non-deprived areas. Inequalities in health outcomes start from birth: poorer children have lower rates of healthy weight from birth through primary school, and higher rates of developmental issues as toddlers. The socioeconomic impacts on children can follow them through their lives, affecting low-income children as they become adults and parents themselves.
Meanwhile, younger adult men (under 45) are of concern due to the extreme difference in health outcomes they face compared to Scottish women, and men in other parts of the UK. Suicide, drugs, and alcohol are the leading causes of death among men between age 15-44, with men from deprived areas experiencing significantly worse outcomes compared to men from non-deprived areas [23, 24].
Policy Context
Policy around children in their early years is a key focus of Scottish Government in many areas, including public health. Various cross-policy considerations are geared to step in once a mother is pregnant and are a critical part of the infrastructure to tackle health inequalities. The Child Poverty (Scotland) Act and work to identify priority families most at risk of poverty mentions children under the age of 1, and policies such as the Best Start Grant are geared to provide some additional income support.
UK Government also has a role in the living standards of young children. For example, the UK Government’s two child limit was introduced for third (or subsequent) children born from 2017, and an increasing number of families with young children have seen a reduction in support through the social security system [25]. The Scottish Government is among those calling for the two-child limit to end, but so far has chosen not to explicitly mitigate the policy with its own resources beyond what is provided through the Scottish Child Payment.
There is far less of an explicit policy focus on younger adult men despite evidence of some quite sizeable socioeconomic inequalities. While there are policy focuses in areas which are relevant, such as housing, employment, and education, there is no central strategy for this group. Whilst the high figures of drug related mortality in recent years have led to action taken by the government, this has largely focused on crisis interventions rather than preventative actions to ensure future generations do not suffer the same outcomes.
Families with young children: a data snapshot
Families with 3 or more children have significantly higher rates of poverty than families with fewer children, with the gap in poverty increasing from around 2019 (Fig. 6.1). The increase is likely to be related to the two child limit on UK means-tested benefits which came into effect for 3rd and subsequent children born from 2017 onwards.
Figure 6.1 Proportion of households in relative poverty by number of children
A disproportionate number of children born in Scotland are born in areas of high deprivation. Around 25% (56,000) of all children were born in the most deprived SIMD quintile in 2022/23, compared to 16% (39,000) in the least deprived (Fig. 6.2).
Figure 6.2 Proportion of total live singleton births by area deprivation
Children born in deprived areas are more likely to be born at a low birthweight, and health problems continue throughout their lives. While there was some improvement in low birthweight across the pandemic, these gaps have widened, and low birthweight proportions are now higher than they were pre-pandemic (Fig. 6.3).
Figure 6.3 Proportion of live singleton births at a low birthweight (under 2,500g) by area deprivation
Children living in deprived areas are also likely to have developmental concerns at 27-30 months, with gaps widening on average (Fig. 6.4).
Figure 6.4 Proportion of children who have developmental concerns at 27-30 months
Younger adult men: a data snapshot
Average mortality rates linked to alcohol misuse, drug misuse and suicide have followed different trends over the past two decades. The largest recent trend has been the significant rise in drug related mortality, which has fallen from its peak but remains high (Fig. 7.1).
Figure 7.1 Average mortality rates for men from alcohol, drug, and suicide (age-standardised mortality rate per 100,000)
There are large gaps in health outcomes for men living in deprived areas compared to men living in non-deprived areas, and compared to the population as a whole (Fig. 7.2). There is small variation year to year in the gap between the least and most deprived areas, but overall the gaps remain wide.
Figure 7.2 Alcohol, drug, and suicide mortality rate and deprivation (age-standardised mortality rate per 100,000 people), 2022
Younger adult men are more likely to be unemployed than other age groups, and men are less likely to be participating in work, education and training aged 16-19 than women (Fig. 7.3). Rates of educational attainment are also lower.
Figure 7.3 Proportions of those aged between 16 and 19 that are not participating in education, employment or training
Men also make up a significant proportion of homelessness applications (56% in 2022-23), with 42% more homelessness applications for single men compared to single women (Fig. 7.4).