For those working to end health inequalities in Scotland, there is deep frustration at their prevalence across the country, driven by poverty, inequality and insecurity in people’s lives. There is a clear desire among many for bolder ambition and longer-term thinking, beyond any one political or budgetary cycle, to tackle the issue and to close the gap between our rhetoric and the reality on the ground.

Nesta Scotland was commissioned by the Health Foundation in early 2022 to conduct a series of workshops and interviews with senior stakeholders from key organisations across Scotland working in and around issues relating to health inequalities. We engaged with more than 50 senior stakeholders across Scotland covering statutory bodies, public agencies, local authorities, national bodies and large and small charities.

The aim was to understand and collate expert views on what drives health inequalities, the barriers preventing us from addressing them and what action we should be taking in Scotland to end them.

What we heard clearly was a sense of frustration from many stakeholders that health inequalities remain such a persistent and widespread issue in Scotland today, driven primarily by entrenched poverty and growing inequality.

As such, there was a strong and consistent desire from those we spoke to see more radical action taken to tackle the root causes of poverty and better prevent health inequalities from arising. In addition, there was a clear ambition for Scotland to focus on longer-term, preventative outcomes when designing policies and funding public services aimed at reducing health inequalities, at both a national and local level.

We heard concerns about how centralised and risk-averse decision making in Scotland impacts negatively on trust between and across different institutions and sectors. This fed into concern about a lack of meaningful community empowerment across the country, despite many high profile initiatives at both a local and national level in this space in recent years. Competing and growing demands often leave statutory bodies, public services and voluntary organisations in Scotland with little resource to design, deliver and invest in more preventative interventions. Those we spoke to also express a clear desire to improve how we learn from ourselves and each other about what works and what doesn’t when tackling health inequalities. For many, more and better open data relating to health inequalities is the key to facilitating this.

Despite the many challenges facing those working to reduce health inequalities in Scotland, we heard plenty of reasons for optimism.

There is a strong shared desire for Scotland to reduce health inequalities and take meaningful preventative action to stop them reoccurring. We heard consistently that a gap exists between our rhetoric on dealing with health inequalities at a national level and the reality on the ground in our communities – often referred to as our implementation gap. We heard a clear desire for the Health Foundation's review to embrace its independence and take the opportunity to issue a bold rallying cry to revitalise efforts to address health inequalities across Scotland. Closing the implementation gap would allow for ambitious action and innovation on dealing with health inequalities. The will to act is there but that will needs to be empowered and translate into action.

As individuals, families and communities across the country face some of the most difficult economic circumstances in a generation, and with likely reductions in public service investment on the horizon, the need to act in a more ambitious and coherent way to tackle health inequalities has never been greater.

The Nesta Scotland team would like to thank all those who engaged with this project and gave so willingly of their time, wisdom and experience to inform this research.

Although we grappled with complex and emotive issues, it was inspiring to hear the passion and commitment from people from across Scotland who dedicate themselves to tackling health inequalities. There is a broad and passionate coalition of the willing ready to create an ambitious agenda to solve this shared problem. Now is the time for us to take bold steps – to think, plan and invest in long-term preventative action to tackle health inequalities for good.