What can English health policy learn from Scotland? A coherent policy approach to population health

The King’s Fund has been advocating for a stronger focus in England on population health and supporting leaders to improve population health for several years now. This has centred on integration for health, as opposed to just integration of care and services. That means coherence in policy and practice across the four key pillars of a population’s health: effort on the wider determinants (such as housing and inclusive economic growth); health behaviours; integration of care; and the role of communities themselves. In principle, this is straightforward; in practice, it isn’t.

Across The King’s Fund’s work, we have found that change is linked to three factors: having a clear vision, supported by a framework that everyone can see themselves in and that can be used as a guiding light through complexity; a shift of effort and resources towards those areas and interventions that will really improve health; and leadership that coheres contributions between and across the pillars of population health as much as within any single pillar. That’s why it’s so welcome to see the publication of the Scottish government and the Convention of Scottish Local Authorities (COSLA) framework for population health. It sets out a clear national vision and framework over the next 10 years that will drive action and change.

Image adapted by The King's Fund, based on Scotland’s Population Health Framework 2025-2035.

The framework is based on the evidence of what drives population health, and draws on The King’s Fund’s vision and framework, the Institute of Health Equity’s Fair Society, Healthy Lives (the Marmot Review) and much other evidence. Scotland’s framework condenses down to a concerted focus on and across social and economic factors, places and communities, enabling healthy living, equitable health and care, and an overall system based on prevention.

The framework sets out initial actions across these drivers and two initial evidence-based priorities – embedding prevention and improving healthy weight. There is much detail in the 38 pages (contrast this with England’s 10 Year Health Plan that comes in at a whopping 168 pages), and surrounding documentation (including an extensive evidence review), including significant areas on primary prevention, such as developing new approaches to resource allocation across health and other public service, improving whole-system accountability, and more commitment to health in all policies.

The framework will be an important guiding light over the next 10 years in recognising that what determines the Scottish population’s health and wellbeing is more than health care: that sectors and approaches need to work together to improve health (working well in their own silos is not enough), and that living a good life matters as well as length of life. The headline aim by 2035 is ‘to improve Scottish life expectancy whilst reducing the life expectancy gap between the most deprived 20% of local areas and the national average’. The annex recognises healthy life expectancy would ideally be a better aim, but because the measure is dependent on being partly constructed from surveys, and response rates are too poor, it cannot be used as such at present. It is important that over time the life expectancy aim does not inadvertently crowd out wider government action on quality of life and wellbeing. To avoid this, the Scottish Health Equity Research Unit (SHERU) has argued for clearer implementation plans and a monitoring and evaluation framework.

So, yes, more to do but Scotland does now have a population framework to help cohere the national approach to population health – this is a major step forward. Despite the now released Fit for the future: 10 Year Health Plan, England has nothing equivalent. Although there is interest and action on population health, including in many places and systems that have used or adapted The King’s Fund framework, there is nothing that people can look to that provides coherence at national level to support the delivery of the government’s stated goal, reiterated in Fit for the future, of halving the gap in healthy life expectancy between the richest and poorest regions. England would do well to draw inspiration from its neighbour.