SHERU Response: Population Health Framework

The Scottish Government and COSLA have co-produced a new Population Health Framework, which sets out their long-term collective approach to improving Scotland’s health and reducing health inequalities for the next decade. Public Health Scotland, working alongside Directors of Public Health in Scotland, played a key role in developing the framework, including by contributing to a linked evidence review.

SHERU was one of many organisations that contributed to consultation work in late 2024, with an expectation that the new framework would be published in early 2025. While later than expected, the new framework was finally published on the 17th June 2025. Pitched as a means of strengthening cross-government and cross-sector collaboration, the Population Health Framework places a strong and welcome emphasis on primary prevention.

The underpinning evidence paper, which cites work by SHERU, the Fraser of Allander Institute and the Health Foundation, is broad and thorough. Anyone reading it would be left with no doubt that a socioeconomic gradient lies behind Scotland’s long-standing health inequalities. That is, those from lower income households and more deprived places have much poorer health and shorter lives than their better off counterparts. This review positions upstream interventions to improve living standards (i.e. ‘primary prevention’) as a key route to better health, and emphasises the necessity of a cross-government approach:

‘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’.’                            

Evidence Review, p9

The evidence paper references Scottish burden of disease burden projections, and was published on the same day as updates of long-term service demand projections, both of which underline the importance of prioritising prevention. The new framework reflects this evidence in multiple strong statements, with ‘embedding prevention in our systems’ the first ‘initial priority’ set out. Prevention is also strategically placed as a cross-cutting approach to health across actions to improve social and economic factors, places and communities, and to enable healthy lives and equitable health and care.

This framing of prevention is important, and we’re pleased to see it given due prominence. While prevention was mentioned in the framework’s predecessor, Public Health Priorities for Scotland, the Population Health Framework provides a stronger and more consistent focus on primary prevention and preventative investment.

However, as with anything in life, actions speak louder than words.

We were surprised and disappointed to see that, across the multiple actions listed in the Population Health Framework, few relate to upstream primary prevention. During the consultative stages of development, SHERU had strongly emphasised the need for clear and specific actions relating to primary prevention and called for plans to monitor and evaluate these actions. Without this, it is hard to imagine that the new Framework will help achieve the much-needed shift towards primary prevention that the Christie review, published 14 years ago, called for.

We are also disappointed at the missed opportunity to signal a step change in a cross-government approach. Despite the clear acknowledgement that key drivers for health sit outside health policy, the majority of actions sit firmly within the health and social care portfolio. It is particularly concerning that the only firm commitment under ‘preventative investment’ is developing a tool for health and social care to help prioritise prevention and investment. Moving money around within the health and social care budget is not going to lead to a culture shift in terms of prevention. To be genuinely transformational, this needs to be cross government, and decisions on budget allocations need to be more joined up to outcomes, with less emphasis on the Ministerial portfolios that budgets are currently siloed within.

A key example of the limitations is housing, where commitments around action are limited. The evidence paper mentions housing as an important determinant of health multiple times, and states that there has been “limited progress across several key social determinants of health in recent years, such as housing, education, and employment”. Indeed, a national housing emergency has already been declared. We would therefore have expected the Population Health Framework to set out clear and specific actions to help address this. Instead, the following list of actions on housing are vague, process-oriented, and largely a summary of existing commitments:

·         ‘Supporting the contribution of better housing to health

·         Sustaining national and local cross-government collaboration to address inequalities and maximise health outcomes in response to the housing emergency

·         Progressing the Housing (Scotland) Bill

·         Progressing joint actions agreed by Scottish Government and COSLA on improving temporary accommodation and affordable housing.’ Scotland’s

Population Health Framework, p27

Phrases like “supporting the contribution of better housing to health” and “sustaining collaboration” suggest a continuation of current efforts rather than a transformative approach. Similarly, referencing the broad progression of the Housing (Scotland) Bill and joint actions with COSLA lacks specificity around how these high-level policies are expected to directly and measurably improve the housing conditions that drive health inequalities. In short, none of these actions demonstrate the targeted, outcome-focused interventions that the evidence demands to address housing as a major determinant of health.

Without clearer cross-government leadership linked to concrete implementation plans, the framework is ultimately risks failure. It is a plan that says it wants to transform the population’s health by tackling upstream issues, but only appears able to commit to downstream changes. It lacks any semblance of being a cross-government strategy, and exemplifies perfectly the criticism that the Scottish Government operates in policy silos.

The closest we get to a cross-government action is ‘developing and implementing a ‘health lens’ to impact assessment’. What this means is unclear in practice. This is important given a recent systematic review of evidence on efforts to achieve ‘Health in All Policies’ (HiAP) reports ‘a disappointing gap between HiAP expectations and policy outcomes’. There have been many previous attempts to use Health Impact Assessments (or versions of it) to achieve a cross-government approach in Scotland (the Scottish Health Impact Assessment Network has existed since 2001), with limited evidence of impact at the national level, so it will need clear and sustained leadership to be effective. It is good to see a commitment to, ‘ensuring that national level impact assessments include health considerations that are rigorously evaluated during policy development’ but to be effective, such approaches need buy in on the shared outcomes that can be delivered across policy teams and, ideally, a pooling of resources to make sure it can happen. This buy-in clearly isn’t evident within this framework, so it would be helpful to see rapid follow up on this commitment which sets out the necessary leadership and cross-government mechanisms to enable the health lens approach to succeed.

Many of the broader actions sit at the local level. Given that the framework was co-produced with COSLA, and since many of the actions set out do need to be delivered locally, this makes sense. The mechanisms to enable cross-service working at the local level are more obvious, and there are commitments to use Community Planning Partnerships and existing processes such as Local Development Plans to embed health and wellbeing. The Collaboration with Health Equity Scotland (CHES) is also mentioned. Yet, while joined up implementation at the local level is crucial, many of the key policy levers that shape the social determinants of health lie at the national level. Without a clear and coordinated cross-government approach nationally, it is unrealistic to expect local actors to deliver the scale of change required.

What else was missing?

Given the extent of ‘deaths of despair’ in Scotland (deaths from drugs, alcohol and suicide), it was surprising to see that suicide was absent from the framework. And given the intersection between health and justice challenges and systems in Scotland, it was concerning to see only a passing reference to justice and no mention of health in prisons. The health-justice intersection is particularly impacting men from lower socio-economic backgrounds in Scotland – the same group who are most at risk for ‘deaths of despair’. Understanding the way in which socioeconomic factors shape both health and justice outcomes and the various ways in which health and justice systems interact for the most marginalised communities in Scotland should be a core part of a whole of government approach to tackling health inequalities.

The role of ‘lived and living’ experience has the potential to play a critical role in overcoming policy silos when considering where to prioritise action and how best to design effective implementation. It was therefore good to see the Framework mention lived and living experience as important for work around drugs and alcohol, and to see plans to work directly with children and young people in an accompanying Child Rights and Wellbeing Impact Assessment. However, if participation is to go beyond listening, to help realise the Framework’s ambition to improve population health and reduce health inequalities, plans to engage with the communities facing the sharpest inequalities need to be far more cross-cutting. People’s day-to-day lives do not reflect the silos of the policymaking system and it would have been good to see clearer plans for community engagement to help ensure preventative efforts mirror and support the needs and experiences of Scotland’s population.

Next Steps

Scotland’s Population Health Framework brings a much-needed focus to preventative approaches to tackling health inequalities, and the underpinning evidence review is thorough. However, to be effective, this needs to be rapidly followed by an implementation plan that makes clearer how the actions and commitments within the framework are to be realised, along with a clear indication of fiscal resources that are required, what has been already set aside, and what will need to be found in the Scottish Budget. An implementation plan should also set out who is accountable for ensuring that the actions are carried out, and, given key policy levers are at the national level, this needs to ensure that accountability reaches up to the Scottish Government.

We would also like to see clearer commitments to realising a whole of government approach, with appropriate resources, and actions to address key issues that are not covered by the new framework (notably suicide and the health-justice intersection) and more cross-cutting plans for public engagement.

As we understand it, a monitoring and evaluation strategy will soon follow (there are workshops already set up for this purpose, which we will be participating in). While this is good news, monitoring and evaluation ideally need to be part of policy design, alongside implementation planning, rather than something that is considered later. This would ensure, for example, that actions are not only achievable but also measurable.

Whilst it is difficult not to see this framework as a missed opportunity, there has been significant time and energy contributed from officials and stakeholders over the last year. Ultimately, the way that the Scottish Government is structured—and the absence of mechanisms to support whole-of-government approaches across all levels and policy areas—remains a fundamental barrier to delivering the change in approach that the evidence review makes clear is required. This isn’t inevitable, but it is disappointing that, for an issue as vital as the population’s health, a more collective approach could not be achieved. It’s interesting that the new Public Service Reform strategy, released by the Scottish Government 2 days after the PHF, echoes much of the change that is needed and sets out an intention to change this, including clearer leadership, more accountability and budget processes that enable preventative spend. Delivering the aims of the Population Health Framework could offer a powerful early test of whether this reform agenda can deliver real change in practice.