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This chapter examines the issue of health inequalities in Scotland with reference to the evidence on mortality and morbidity rates, the emerging specificities of the Scottish NHS and policy options relating to the distribution of social determinants of health, including income, wealth and cultural capital, which, it is argued, continue to have a marked impact on health and longevity across the UK. In doing so, this chapter suggests that while health policy and the shape of health services matter, restructuring the NHS in Scotland with a view to improving the access of the most disadvantaged on the one hand, and resetting the priorities of health service intervention to target the principle causes of early death and chronic ill health among that population on the other, are not sufficient strategies on their own to tackle persistent health inequalities. Indeed, insofar as policy makers have sought to address health inequalities principally through an elevation of health service ‘solutions’, alongside an increased responsibilisation of individuals with regard to healthy lifestyle choices, they have failed to deliver a more socially just society in health terms. This is because such an approach neglects that significant body of evidence which suggests that tackling poverty and inequalities in income, wealth and opportunity, for example, have a far greater potential to deliver better health for the most disadvantaged; as Macintyre (2007, p 5) notes, ‘most of the major drivers of the distribution of health in the population lie outside the NHS’. As a result, the poorest and most deprived in society have seen improvements in their life expectancy over time, but not to the extent of wealthier individuals, leaving them at greater risk of premature death and escapable morbidity even in the early 21st century (Graham, 2007, 2009; Leyland et al, 2007).
This chapter focuses on the impact of recent welfare restructuring and ‘modernisation’ agendas on the non-profit sector, now increasingly responsible for the delivery of a range of welfare services, and its welfare workers. Fyfe and Milligan (2003, p 272) note that the sector is generally seen to comprise independent, self-governing bodies that do not distribute profits but are run for the benefit of others and/or the community. They are perceived to be accountable to their membership, the people they serve and represent, and their funding bodies in relation to how they spend their funds. Some rely on volunteers, some on paid workers, some on a mixture of both, and they draw on a range of resources including individual and corporate donations, state grants and contract finance, tax relief and lottery funds.
Collectively these types of organisations are commonly referred to as the ‘voluntary sector’, reflecting their traditionally voluntarist nature. More recently government policy documents have drawn on the concept of a ‘voluntary and community sector’, which hints at the government’s own neocommunitarian agenda and the place of non-profit organisations within that. Others have used the term ‘third sector’ to highlight the distinction between private, statutory and voluntary organisations and the relationship between them. However, given the recent changes in the sector and the blurring of the boundaries between different types of organisations and the roles and functions that they are now called on to perform, this chapter utilises the term ‘non-profit sector’ (Miller, 2002).
It is important to note from the outset that there is an incredible amount of diversity within the sector in terms of finances, human resources, functions, structure and organisational characteristics.
This chapter explores the experiences of British and Scottish social policy making and welfare provision since devolution. It challenges the claims of a new Scottish society and social policy by a UK-wide comparison of recent developments. The chapter also critically evaluates the Scottish Executive’s achievements in social policy, highlights the possibilities and limitations of devolution and examines the potential for a more distinctively Scottish social policy making. The following topics are included:
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New Labour and the ‘modernisation’ of governance and public services: continuities and discontinuities with the past;
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welfare partnerships and devolution as governance;
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New Labour and devolution: constitutional, procedural and financial developments;
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the distinctiveness of Scottish social policy: convergence and divergence in different social areas;
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comparison between Scottish and Welsh social policy and practice; and
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the modernisation of public services in a devolutionary context: constraints and tensions.
This chapter provides an overview of developments in social policy in Scotland since devolution. In doing so it explores the road to the 1997 Referendum (Scotland and Wales) Act and the impact of the reopening of a Scottish Parliament in 1999 with particular reference to social welfare. However, in examining recent experiences in Scottish policy and polity, this chapter seeks to move beyond a summary of both policy documents and the promises of the Scottish Executive and Scottish Parliament in order to uncover the underlying assumptions, themes and tensions that are emergent in Scottish social policy making in the devolutionary context. Here we are interested in exploring the reality of Scottish devolution rather than claims made at a rhetorical level, and in challenging common-sense claims about ‘Scottishness’, the ‘social democratic impulse’ north of the border and parochial assumptions and descriptions about ‘the Scots’ and Scotland.
This article argues that wherever non-profit organisations fulfil significant publicly funded service delivery roles, they must have an internal democratic structure conducive to ensuring that services are legitimate, accountable and of a high effectiveness and quality. Successive governments in the United Kingdom have adopted strategies that have led to increasing levels of isomorphism, with hierarchical, bureaucratic and private sector governance structures becoming the organisational archetypal norm within the sector, intensifying and strengthening the significant barriers to democratic governance that already exist. An alternative ‘assisted self-reliant complimentarity’ state–non-profit sector relationship that would be more conducive to a democratic governance archetype is advocated.
