Accountability and control are important for improving outcomes, creating better services, involving service users in decisions, and ensuring financial sustainability.

The health and social care integration agenda in Scotland has created organisations called “Integration Joint Boards” - which are new partnerships between NHS Scotland and local authorities with joint responsibility for providing services and planning health and social care. There is concern that this impacts on accountability. Local authorities used to be wholly responsible for adult social care - meaning decision-makers were elected and their decisions were subject to scrutiny. While a small number of councillors sit on boards, their structure means decisions are a step further removed from the people that their choices impact, their operations are less transparent and they are less open to scrutiny.

Scottish Labour promised a National Care Service, which would have empowered local government. Instead, the SNP have branded their plans as a National Care Service but have failed to empower communities or councils – instead it has been outsourced to KPMG to work out how to deliver it.

Privatisation in the NHS both in Scotland and across the UK is a concern – whether it is the Westminster Government pushing outsourced services or the SNP in Holyrood calling on private hospitals and other healthcare firms to take charge of 1,500 procedures. As well as creating a damaging profit incentive, this risks staff pay and conditions and reduces accountability to patients and communities. The Co-operative Party believes that wherever possible public services like health and social care should be truly public – delivered in-house. However, when services or goods, whether it’s PPE manufacture, food and energy supply, or specialists or local clinical services, cannot be provided by the public sector, there should be a role for community and co-operative provision – rather than distant private sector providers. But many barriers exist to communities and co-operatives who want to play a role.

The nursing staffing shortage in Scotland is at a record high – to the point that the military was called on to plug staffing gaps in Scottish NHS services in 2021. Understaffing puts more pressure on staff and puts patients at risk. In care, the story is not much different, with a recent report from Audit Scotland warning that social care faces huge challenges and care workers reporting that they do not feel valued by society, that they need greater autonomy and that they are in desperate need of a pay rise.

Scotland is home to shocking health inequalities. There is a systematic relationship between deprivation and life expectancy. In a poorer area such as Drumchapel, a man’s life expectancy can be more than 10 years shorter than in the neighbouring areas like Eastwood and Bearsden. Deprivation has an even bigger effect on healthy life expectancy with men in the least deprived areas spending 23 extra years in good health compared to those in the most deprived areas. Covid has exacerbated this – lower income jobs are less likely to be ones that could be done from home during the worst periods of the pandemic, and issues such as inadequate housing and overcrowding allowed the virus to run rampant through more deprived neighbourhoods. This exposed too many racial and gender inequalities which have also widened. Many also experience barriers to accessing services – because of language, real or anticipated discrimination, or a lack of understanding of a complicated health system. This is often reported to be the case, for example, for asylum seekers and refugees, and Gypsy, Roma and Traveller communities. Studies show that this can especially be the case for disabled people who face barriers such as long waiting lists, long distances to access services, and difficulties accessing transport – which has only been exacerbated by the pandemic. The availability of services is also unequal - more deprived areas tend to have fewer GPs per head for example – as is the experience of them. According to Stonewall, 13% of LGBT respondents reported experiencing unequal treatment because they were LGBT, with this number rising to 32% for people who are transgender and 19% for Black, Asian and minority ethnic LGBT people. And outcomes are often, as a result, unequal. The data on maternity deaths in the UK, for example, show black women are four times more likely to die during pregnancy in the UK than white women. For Asian women, they are twice as likely to die. Another shocking example from a recent study shows that the UK has the largest female health gap among G20 countries and the 12th largest globally. In Scotland, there are also extreme geographical inequalities. The campaigning by groups such as Keep Mum, in Moray, and the Caithness Health Action Team has highlighted the challenges pregnant women face in the Highlands and Islands where women can be sent 200 miles away from home simply to access the appropriate maternity care. A lack of obstetricians and paediatricians means NHS Caithness says they cannot safely offer a full maternity service.

Given the strong correlation between socioeconomic factors and health, there is clearly a public health argument for tackling inequality and growing fairer more sustainable local economies. Whether it is access to good quality, affordable food or decent workplace conditions, the co-operative movement has long been part of this work. Community Wealth Building, too, looks at health and local economic outcomes and their relationship. In Cleveland, Ohio, the original Community Wealth Building work was led by the Cleveland Clinic who used the power of their procurement to invest in employee ownership and reinvestment of local wealth. There are also innovative examples of co-operatives who are using social prescribing to improve outcomes.