1. Policy approaches to health inequalities
in Scotland and England
Assessing similarities and differences in post-
devolution policy responses to health inequalities
Dr Katherine Smith
Katherine.Smith@ed.ac.uk
Global Public Health Unit, Social Policy
School of Social & Political Science
University of Edinburgh
(ESRC-MRC postdoctoral fellowship, grant number PTA-037-27-0181)

3. Current concern: The failure of policy efforts to reduce
health inequalities in England
“Has the English strategy to reduce health
inequalities failed? The importance of this question
cannot easily be overstated. The explicit and
sustained commitment of recent Labour
governments to reduce health inequalities was
historically and internationally unique […]. Their
policy initiatives built on decades of public health
research, and more often than not were based on
empirical evidence which had been collected and
summarized by leading public health experts. Labour
stayed in power for an exceptional 13 years, and in
Western democracies it is difficult to imagine a
longer window of opportunity for tackling health
inequalities. If this did not work, what will?”
(Mackenbach, 2010)

4. What do we know about post-devolution
health policy in Scotland and England?
 Most analyses focus either on healthcare policies or
on specific public health issues (e.g. health
inequalities or tobacco control).
 The story that emerges from this body of work
suggests healthcare policies have diverged
significantly (e.g. Greer 2005, Bevan 2010, Propper et
al 2009, Connolly et al 2010)…
 … whilst public health policies have remained
remarkably similar, despite clear differences in initial
intentions/rhetoric (e.g. Cairney, 2009; Smith et al
2009).

5. Is Scotland Emerging as a UK Public Health
Policy Leader?
 Interviewees across the UK are consistently
citing Scotland as a public health policy leader
in the UK, following its leadership with smoke-
free public places and minimum unit pricing
for alcohol.
 Scotland now appears to have an opportunity
to replace its tag as the ‘sick man of Europe’
with a new reputation for health policy
innovation (e.g. Smith & Hellowell, 2012).

6. Yet Policy Approaches to Health Inequalities
Remain Remarkably Consistent
Aspect of policy approach England Scotland
How were health inequalities As health gaps resulting from As health gaps resulting from
conceptualised? health deprivation. health deprivation.
Commitment to joined-up Yes. Yes.
approach?
Reference to empirical Yes. Yes.
evidence?
Targets for reducing health Yes, specific health inequalities Yes, specific health inequalities
inequalities? targets set in 2001, to be targets set in 2004, to be
achieved by 2010. achieved by 2008/2010.
How were targets articulated? To reduce health gaps (mainly To improve the health of the
between areas). most deprived groups at a
particular rate.
Where was responsibility for Local NHS bodies (PCTs). Local NHS bodies (Local
meeting health inequalities Health Boards).
targets located?

7. The absence of evidence-based policy
in both contexts:
 Senior academic researcher: ‘The research [on health
inequalities] has had absolutely no, well, it’s had very little
impact on policies,’
 Civil servant (England): ‘My impression is that after about
2001, unfortunately the sheer pace and scale of action
required of the Labour government meant that evidence
again got pushed onto the back burner […] just because
government was producing more policies than it had time to
master the evidence on.’
 Minister (Scotland): ‘I don’t think there’s very much evidence-
based policy around yet.’
Taken from Smith, 2007, 2008.

8. Comparing the evidence to policy responses for
tackling health inequalities
Idea(s) about health inequalities Are ideas are supported by Are ideas are evident in Labour’s policies?
research evidence?
Artefact and social selection No No
Access to health services and Minimally Significantly (esp. from 2004 onwards)
treatments
Contextual (place-based) ideas Minimally Significantly (through area-based
interventions)
Need to change people’s lifestyle- L-Bs are linked to HIs but Significantly (throughout the past decade
behaviours (L-Bs) are usually perceived to be but especially since 2004).
symptomatic of more
‘upstream’ causes
Material-structuralist Yes Significantly evident in policy rhetoric but
far more limited with regards to policy
actions
Psychosocial and income Significant support References to social capital are evident but
inequalities (although some criticisms) reference to income inequalities are
absent
Lifecourse approaches Yes A focus on particular social groups,
especially children, is evident but ideas
about the ‘lifecourse’ are scarce

9. 1. Policymaking bodies as institutional filters

10. How Policy Silos Shape the Relationship with
Research
Civil servant (Scotland): ‘People don’t go traipsing
through professional journals but you do have
specialists within the Department as well. So, for
example, on diet and physical activity, there is a Diet
Co-ordinator, and there is a Physical Activity
Coordinator, who are specialists in their own right…
and in addition to that, you have specialists in terms
of doctors and things like, many of whom do actually
spend a bit of time with the journals.’

11. 2. A lack of belief in alternative ways of
organising society

12. A lack of belief in an alternative way of living
Academic: ‘I think… a government that isn’t…
keen to pursue issues around… income
redistribution… you know, that’s a reasonably
popular thing to not do. Who wants to pay
more taxes? And… if taxes go up for the
richest, somehow or other everybody seems to
feel they’re being affected by it so, unless the
government is prepared to tackle that at a
media level, nobody’s going to be unhappy
with their decision… not to change taxation.’

13. 3. The lack of institutional memory within
policy

14. The Re-cycling of Ideas
Academic: ‘What’s really struck me […] is we seem to do the same bits
of work over and over again, you know? A demand will come for
something and because… I don’t keep copies of these things, I think,
‘oh, I think we’ve done that before!’ And then somebody else will dig
out… So on Monday, we’re doing a piece of work which I know we
did two years ago… But… everybody’s changed so nobody knows
that that’s what we did two years ago. […] [And] in the DH they’re
now subcontracting a lot of their work… So… somebody, some
agency will be given the job of coming up with something-or-other,
and it’s like reinventing the wheel - they’ll have no knowledge of
what the Department, or allied researchers, has already done. […]
So I think that fragmentation, which you’ve got with the normal
process of civil servants moving round is becoming intensified
because of this process of giving the work to outsiders, who don’t
even know what might have happened within the DH.’

15. 4. Politicisation of the civil service

16. Aiming to give ministers ‘what they want’
Civil servant (England): ‘If you’ve got a problem, […] the first
thing you do is to work back in the files and see what you said
last time and then to ask one another what you think we
should do and then to make a judgement about what
ministers really want, what’s feasible and what’s politically
this, that and the other.’ [My emphasis]
Former civil servant, Lord Bancroft: ‘seeing that advice which
ministers want to hear falls with a joyous note on their ears,
and advice which they need to hear falls on their ears with a
rather dismal note, [civil servants] will tend to… make their
advice what ministers want to hear rather than what they
need to hear,’ (quoted in Hennessey 1995, p130).

17. 5. Understanding the decisions health
inequalities researchers make

18. The importance of research funders:
Senior academic researcher: ‘[A]cademics are entrepreneurial,
they go where the money is and so […] if somebody says,
‘research project on X,’ you know, ‘cycling,’ we’d all start
doing sociology of cycling or something, I don’t know
[laughs].’
Senior academic: ‘[X - name of civil servant who is a personal
friend of interviewee], is still amazed that I don’t know things
like [policy] initiatives that are going on but then, can
understand when I say, you know academics - we go on a
need to know basis. […]. If there’s a call for research and
there’s some funding, well, we’re learn about that, you know -
in twenty-four hours we’ll know about that!’

19. Intentional influences on research by funders?:
Senior academic: ‘I think one of the difficulties is often
when there are bids for research funding, it’s almost
if the findings or, you know, the messages that are
required are stated from the start almost. […] When
one looks at research bids, it’s, there are strong
steers in terms of what they’re looking for, what
kinds of conclusions one’s being steered towards,
what kinds of policy messages they want…’

20. Intentional influences on research by funders:
Senior policymaker (Scotland): ‘[T]here is a kind of tension in
discussions which go on nowadays between… researchers, who
basically say, ‘give us the money - I’ve got a great programme of
research here… I can’t tell you too much about it, ‘cause the ideas
are just beginning to… So, give me the money - you can trust me
and… I’ll produce something. Don’t know what it is but, but
something will happen.’ And on the other hand, people like me and
[…] my colleagues in the MRC, who say, ‘what did we buy for the
money?’ And, ‘Well, I know you’re very interested in looking at…
health inequalities but actually, I have a problem here - I am
required to make policy in this area… at the moment, I have no hard
facts at all… and I really would like some research done… and… by
the way, I want it done within the next six months and I’ve got that
amount of money available for it. So, I want you to give me the best
answer you can within six months, given that amount of money.’
And that’s, that’s the real world.’

21. The Need to Remain Optimistic
 Most researchers I interviewed wanted to
make a difference so many described
increasingly focusing on things that they felt
could make a small difference.

22. 6. How researchers package messages to
policymakers

23. Deliberate Ambiguity:
Academic: ‘When I was at [Blank] I could have been much more… critical.
It isn’t simply that I feel the funding source wouldn’t like me to say those
things, I actually… would feel it would be a betrayal of the trust that the
people who gave me the opportunity to spend my time doing that had
in me… and I think, in a way, when I was working at [this organisation]
and they are actually funded through [government department], I
think… they would have looked at me and said, ‘how can you not have
read what is appropriate to say?’ So I think the censoring is actually self-
imposed. […] It isn’t that I think they would come the heavy on me, it’s…
there’s an unwritten understanding that I won’t rock the boat when I’m
writing in that guise. So… at an academic event, I feel I’m me, you know
[…] I can be much more pointed in the points I want to make… but… I
think when I’m writing through a funding source, which is government…
and I do out of, and maybe I shouldn’t, I do it out of a sense of loyalty
to… the people who are trusting me not to say things that would make
them feel uncomfortable… and cast into doubt the judgement that they
had in saying I was the right person to do the job.’

24. Fitting in with perceptions of policy
preferences
Academic: ‘If you have poverty and adversity of that nature,
nothing’s gonna save you. Now, they [policy makers] are not
gonna like hear that. [Pause] On the other hand, I have to
say, I think probably some people have enough clout that we
don’t need to… be too tactful. But certainly when I was less
experienced and I was putting in for money on [blanked] and
health, we did produce papers which were - how can I put it?
We weren’t coming out and saying we were absolutely sure
that [blank] causes ill-health and there’s no element of
selection. We actually found the perfect way through it,
which was to say [removed for anonymity]. Now that, I think
that’s probably true, actually, but… we were doing it, I was
doing it, I was pushing people towards it in order to be clever.’

25. References
Bevan, G. (2010), Impact of devolution of healthcare in the UK: provider challenge in
England and provider capture in Wales, Scotland and Northern Ireland? Journal of
Health Services Research and Policy, 15(2): pp.67-68.
Cairney, P. (2009), The role of ideas in policy transfer: the case of UK smoking bans
since devolution. Journal of European Public Policy 16: pp.471-88.
Connolly, S., Bevan, G. and Mays, N. (2010), Funding and Performance of Healthcare
Systems in the Four Countries of the UK Before and After Devolution. London: The
Nuffield Trust.
Greer, S. (2005), The Territorial Bases of Health Policymaking in the UK after
Devolution. Regional and Federal Studies 15: pp.501-18.
Mackenbach, J.P. (2010) Has the English strategy to reduce health inequalities failed?
Social Science & Medicine, 71:1249–53.
Propper, C., Sutton, M., Whitnall, C. and Windmeijer, F. (2009), Incentives and Targets
in Hospital Care: Evidence from a natural experiment. Working paper no. 08/205.
London: University of Bristol.
Smith, K.E., D.J. Hunter, T. Blackman, E. Elliott, A. Greene, B.E. Harrington, L. Marks, L.
McKee, and G.H. Williams (2009), Divergence or convergence? Health inequalities
and policy in a devolved Britain. Critical Social Policy 29: pp.216-242.
Smith, K.E. & Hellowell, M. (2012) Beyond Rhetorical Difference: A cohesive account of
post-devolution developments in UK health policy. Social Policy & Administration,
46(2): 178-198.