Beyond Ambition: What does Scotland’s new Programme for Government mean for health inequalities?

Introduction

The Scottish Government’s Programme for Government (PfG) 2026-31 provides an opportunity to further embed prevention and to deliver long-term change in policy planning. Covering the full parliamentary term and supported by annual delivery plans linked to future budgets, it potentially offers a framework more aligned with the timescales over which many social and economic determinants of health operate.

As we noted in our immediate reaction, a longer-term framework could create better conditions for prevention and more joined-up action on health inequalities. But a longer timeframe does not automatically produce better outcomes.

From a health inequalities perspective, the key question is whether this Programme for Government supports sustained action on the social and economic determinants of health, including poverty, income security, employment, housing and education. These factors influence the conditions in which people are born, grow, live, work and age, and are central to both understanding why health inequalities persist and to ultimately tackling them.

A Five-Year Programme for Government: An Opportunity for Prevention?

One of the more significant aspects of the PfG is its explicit recognition that many of Scotland’s challenges require long-term action. That matters because prevention rarely operates on annual political timescales.

Improving housing conditions, reducing poverty, supporting families, helping people into good-quality employment and improving educational outcomes all require sustained effort over many years. These are also among the most important drivers of population health and health inequalities.

To be clear, although the PfG has traditionally been an annual document, its time horizon has not necessarily been limited to a year. Typically, it has combined a high-level agenda for the parliamentary term with a legislative programme for the year ahead. This is effectively what the new PfG process will do as well, albeit with less duplication and more continuity.

However, a key limitation of the PfG has been its timing in relation to the Budget. At the point when the PfG is drafted, the means of funding any new commitments remain uncertain, given that the Budget is not produced until later in the year. If annual reports can be more closely tied to the Budget, this could amount to an important shift.

The move to a five-year framework therefore has potential. If annual delivery plans and budgets genuinely align with longer-term objectives, it could provide greater consistency and stability for preventative action.

At the same time, the Programme presents prevention in a broad sense, encompassing primary, secondary and tertiary prevention. This reflects the reality that governments cannot ignore immediate needs. However, it also raises a familiar question: can Scotland successfully invest in preventing future problems while responding to current demand and fiscal pressures?

Scotland Does Not Lack Ambition

The Programme is titled Ambitious for Scotland.

Few would dispute that Scotland has developed ambitious and often evidence-informed policies over recent decades. Many of the broad priorities contained within this Programme for Government, reducing poverty, improving public services, supporting economic participation and addressing inequalities, align closely with what the evidence suggests matters.

This is why we have previously argued for greater attention to what might be termed implementation intelligence. A longer-term Programme for Government will only realise its potential if policymakers can understand the delivery context – what is working; what is not; where barriers arise; and how delivery varies across place, population groups, systems and outcomes. Equally important is effective evaluation and the ability to feed learning back into policy and practice.

A five-year Programme for Government potentially creates more space for this kind of learning-oriented approach – but only if implementation becomes a central part of how success is assessed.

Child Poverty Remains the Defining Challenge

The Scottish Government’s commitment to eradicating child poverty is not new, but its continued prominence within the Programme for Government reflects the scale of the challenge and its importance to Scotland’s future.

From a health inequalities perspective, there are few policy goals more important. Health inequalities begin early in life and are strongly shaped by the circumstances in which children grow up. Income adequacy, housing quality, family wellbeing, access to services and educational opportunities all influence health and wellbeing throughout the life course.

The PfG builds on existing efforts through a range of measures designed to support family incomes and reduce everyday costs. These include plans to increase the Scottish Child Payment to £40 per week for children under the age of one, continued expansion of free school meals, a national rollout of the £2 bus fare cap by the end of the parliamentary term, consultation on legislation to cap the price of some essential food items, and the development of a new childcare offer from nine months to the end of primary school. Together, these measures reflect an approach that combines direct income support with attempts to reduce the costs faced by families.

However, reducing child poverty at the scale required remains a substantial challenge. While social security measures can play an important role, many of the factors that drive poverty sit upstream and outside any single policy area. Sustained progress depends on a combination of adequate incomes, good-quality employment, affordable housing, accessible childcare and wider economic conditions.

The move to a five-year Programme for Government may offer an opportunity to think more strategically about these interconnected issues. However, assessing progress will require more than monitoring the delivery of individual commitments. The more important question is whether the underlying conditions that create and sustain poverty are changing, and whether improvements are being experienced by those children and families currently facing the greatest disadvantage.

This is also relevant in the context of Scotland’s child poverty targets. The interim targets were not met, and the Scottish Government is now reviewing its approach to measuring poverty. The review provides an opportunity to reflect not only on the targets themselves, but also on how progress is assessed, reported and communicated.

There is a legitimate debate about how targets should be designed and monitored. Whatever view is taken, targets can help focus attention on outcomes and provide a reference point against which progress can be assessed. More fundamentally, however, the question is whether fewer children are growing up in poverty and whether the inequalities that shape health and life chances are narrowing.

Housing: A Foundation for Health and Wellbeing

Housing features prominently within the Programme for Government’s child poverty agenda, reflecting the significant role that housing costs, quality and security play in shaping family wellbeing.

This connection matters because housing is not simply another policy area. Warm, affordable and secure housing contributes to physical health, mental wellbeing, educational attainment and life chances, while poor housing conditions and housing insecurity can exacerbate existing inequalities and create new ones. The importance of this has been highlighted in our analysis of the Scottish Government’s Housing to 2040 strategy. For families already experiencing financial hardship, housing costs can place further pressure on household budgets and increase the risk of poverty.

The Programme for Government reaffirms the Scottish Government’s commitment to deliver 110,000 affordable homes by 2032 and includes measures aimed at preventing and responding to homelessness. Notably, it commits to ending the use of unsafe and harmful temporary accommodation for children and introduces a Homelessness Prevention Fund intended to support earlier intervention.

These commitments are welcome. However, they must be considered within the context of Scotland’s ongoing housing emergency and the distinctive urban and rural needs and pressures within the housing landscape in Scotland.

Recent years have seen growing concerns around housing affordability, homelessness, temporary accommodation and the pace of affordable housing delivery. Research published by the Fraser of Allander Institute has highlighted the scale of the challenge associated with achieving Scotland’s affordable housing ambitions, suggesting that significant acceleration in delivery would be required if existing targets are to be met.

The commitment to end the use of harmful temporary accommodation for children is particularly important. Temporary accommodation can have significant impacts on children’s wellbeing, education, stability and longer-term outcomes. Yet the number of children living in temporary accommodation remains at historically high levels, illustrating the distance between the ambition set out in policy and the reality experienced by many families.

This raises a broader question about whether the overall response matches the scale of Scotland’s housing emergency. The Programme for Government contains important housing commitments but gives less attention to how these will combine to address the underlying drivers of housing insecurity and homelessness over the next five years.

The position of housing within government has also changed since the election, with responsibility now sitting within a broader Social Justice and Housing portfolio. While ministerial structures are not necessarily indicative of policy priority, the change reflects the close relationship between housing, poverty and wider inequalities. The key question is whether the new arrangements break down siloes and strengthen the government’s ability to respond to Scotland’s housing emergency and improve housing outcomes for those experiencing the greatest disadvantage.

Employment

An early promise in the PfG is to “[break] down the barriers to work, particularly for those inactive through ill-health or disability, and [to ensure] that everyone has the support required to enter and sustain well paid employment.”

Again, this is an ambitious statement, and there are a range of mechanisms that we would expect to see in order to address this goal – including addressing transport and childcare, both of which are substantial barriers to employment. We would also expect to see a discussion around employability services, apprenticeships, and working with employers to address health and work.

While the PfG touches on these items, in practice, there are some important gaps.

While transport costs are addressed, as are transport planning in city regions, transport access and frequency are not discussed. For those living in rural areas especially, a lack of reliable and sufficiently frequent transport is a significant barrier to employment. In more urban areas, safe public transport options late at night continues to be a challenge for those working in nontraditional shift patterns.

There are also questions around how expanding apprenticeships will work in practice. Beginning in 2027, all apprenticeship funding will be consolidated under the Scottish Funding Council instead of Skills Development Scotland, where it has previously sat. This move was to bring all post-school provision funding under a single organisation, which is a direct response to recommendations from 2022’s Withers Review about the complex skills landscape. Nevertheless, there have been concerns among business organisations about the choice of the SFC and implementation plans for apprenticeships moving forward.

Addressing employers is a further challenge, although a few policies may have some promise. The PfG discussed support for workers with mental health conditions and musculoskeletal conditions, although there is little in the PfG that concretely explores preventative action in employment.

Policy Blind Spots?

One question when assessing any Programme for Government is not simply what is included, but who is visible within it. And, crucially, who is not.

The PfG gives considerable attention to families, children and young people. Given the government’s commitment to eradicating child poverty, this is both understandable and necessary. However, there is a risk that other groups experience significant disadvantage and receive less attention within the overall narrative. This can compound inequalities for these groups, allowing them to fall further behind the Scottish average.

Our recent work at SHERU has highlighted young adult men as one such group (see also here, here and here).  Across a range of indicators, including poverty, insecure employment, educational outcomes, suicide, alcohol-related harms and drug-related deaths, there is evidence that some young adult men experience substantial and often overlapping forms of disadvantage such as homelessness. Yet they do not always fit neatly within established policy frameworks or become the focus of targeted policy responses.

This challenge is reflected within the Programme for Government. The document rightly recognises the importance of reducing deaths from suicide, drugs and alcohol, while also committing to improvements in mental health support. However, there is less consideration of the underlying social and economic conditions that contribute to these outcomes, including poverty, insecure work, poor-quality housing, social isolation and limited opportunities in some communities.

This is not an argument for shifting attention away from children and families. Rather, it highlights the need for a broader understanding of prevention and health inequalities across the life course. A preventative approach requires understanding not only who experiences poor outcomes, but why those outcomes occur and how disadvantage accumulates over time.

Our engagement with stakeholders has consistently highlighted concerns that young adult men can fall between policy priorities and organisational boundaries. They are often viewed through the lens of individual issues, such as employment, mental health, substance use or offending, rather than through a more holistic understanding of the social and economic circumstances that shape their lives.

From a health inequalities perspective, this matters because the harms associated with poverty and insecurity are not distributed evenly across the population. If Scotland is serious about reducing inequalities, preventative approaches must reach all groups experiencing disadvantage, including those that may be less visible within dominant policy narratives and evidence.

One of the opportunities presented by a five-year Programme for Government is the potential to take a longer-term view of these challenges. The question is whether future delivery plans, performance frameworks and reform programmes will pay sufficient attention to groups whose needs may otherwise remain hidden in plain sight.

Public Service Reform: Will Structural Change Support Prevention?

Perhaps the most significant set of proposals within the Programme for Government relate to public service reform. Alongside its commitments on child poverty, economic growth and tackling the climate emergency, the Scottish Government has signalled a willingness to pursue substantial changes to the organisation of public services, including reducing the number of territorial NHS boards, reforming local governance arrangements and bringing together a number of national public bodies.

The rationale is clear to a point. The Programme for Government argues that existing structures can be fragmented, duplicative and poorly aligned to the challenges Scotland faces today. In his accompanying speech, the First Minister argued that Scotland has “councils that are too small to be strategic and too big to be local“, signalling an appetite for reform of local governance alongside NHS restructuring.

From a health inequalities perspective, the key issue is not whether public sector structures change, but whether those changes make it easier to address the social and economic conditions that drive poor health and inequality.

The proposed reduction in the number of territorial health boards has understandably attracted attention. The government argues that larger strategic structures could reduce duplication and release more resources to frontline services. However, evidence from previous NHS reorganisations suggests that structural reform alone rarely delivers the improvements that are anticipated. Organisational change can also consume considerable time, leadership capacity and resources, while the benefits often take longer to emerge than initially expected.

The same considerations apply to local government reform. The Programme for Government places a strong emphasis on improving local governance. From a health inequalities perspective, however, the test will not be the shape of new governance arrangements but whether they improve the ability of local services and communities to work together to address poverty, housing insecurity, unemployment and other factors that drive inequalities in health.

This matters because the Programme for Government places considerable emphasis on prevention. The evidence supporting preventative approaches is strong, but our recent work in Making Prevention Real highlighted a persistent gap between commitment and implementation. Scotland has spent many years recognising the importance of prevention. The more difficult challenge has been translating that ambition into changes in funding decisions, service design and day-to-day practice.

Effective prevention requires more than structural reform. It depends on bringing together quantitative evidence, qualitative insight, professional expertise, community knowledge and lived experience to understand what is working, where barriers arise and how delivery can be improved. It also requires moving beyond siloed approaches to performance assessment and is where implementation intelligence becomes particularly important.

For this reason, reform should ultimately be judged less by the organisations it creates and more by the outcomes it enables. The important question is whether these new structures strengthen alignment and collaboration across public services, improve the use of evidence and local knowledge, and create better conditions for tackling the root causes of inequality. Without that, there is a risk that organisational reform becomes an end in itself, rather than a means of improving people’s lives.

Meeting Scotland’s Ambition

The shift to a five-year Programme for Government creates an opportunity, but it is not clear how far beyond intention it will go. Many of the priorities contained within the document align with what we know about improving health and reducing inequalities. The emphasis on prevention, child poverty, housing and public service reform reflects challenges that have long been recognised. But whether right-minded ambitions translate into meaningful change remains to be seen.

The challenge is particularly acute in the context of Scotland’s fiscal outlook. Demand for public services remains high, while significant spending pressures continue across health, social security, local government and other areas. This creates an ongoing tension between investing to prevent future problems and responding to immediate pressures.

The move to a five-year Programme for Government potentially creates greater scope for longer-term investment and planning. Whether that potential is realised will depend in part on future spending decisions. The forthcoming Scottish Budget on 3rd December 2026, together with the annual delivery plans that follow, will provide a clearer indication of how priorities are being translated into resources, implementation and action over the course of the parliamentary term.

We also note that the National Performance Framework remains under review. The sequencing here is far from ideal, with a five-year Programme created without the guidance of National Outcomes. Conversely, those outcomes, along with other aspects of the Framework, will have to be developed in a context where the Government’s agenda has already been set.

The Programme is titled Ambitious for Scotland. From a health inequalities perspective, the task ahead may be better described as Meeting Scotland’s Ambition.

If Scotland is to meet its ambitions, progress will need to be visible not only in policy documents and delivery plans, but in the opportunities, wellbeing and life chances of the people and communities who currently face the greatest disadvantage. This will require sustained investment in – and prioritisation of – the social and economic determinants of health, a stronger focus on implementation and learning across both rural and urban settings, and a willingness to judge success not by the number of commitments made, targets set or structures created, but by whether people’s lives improve.