Tackling health inequalities means more than service reform and design

Chris Littlejohn, Deputy Director of Public Health with NHS Grampian, responds to At the frontier of Collaborative and Participatory Governance: Eight Discussions to support putting Christie into action, a report by What Works Scotland and Aberdeenshire Community Planning Partnership which reflects on the learning from their collaborative work. 

He considers some of the challenges the report raises for a public health agenda committed to tackling inequalities.

One of the first Government reports I remember learning about as a student was the Black Report. The story of its "suppression" was as intriguing as its radical challenge to the establishment to prevent and remediate health inequalities. My understanding is that many lecturers today still refer to it, almost forty years on. It is a fascinating case study in the longevity of certain reports and the impact that they can have on collective consciousness and action.

Given the impact of the Christie Report I suspect that it too will be referenced during lectures in years to come. Subsequent transformative Acts for integration and community empowerment have been huge in ambition and necessarily complex in their realisation.

When What Works Scotland was commissioned to answer the question of "how to implement Christie", many of us had high expectations. One of its final publications, At the frontier of Collaborative and Participatory Governance: Eight Discussions to support putting 'Christie' into Action, does not disappoint, distilling and refining into one document the insights the researchers  have gleaned from their engagement work during the past few years. The short answer seems to be “it’s challenging”, but the report provides much to consider and reflect upon and will be an invaluable resource for those on the sharp end of doing so.

Collaborative leadership challenges boundaries  

From my perspective as a public health practitioner, two elements of the Frontier report particularly caught my attention: the content about collaborative and participatory governance and Christie’s aspirations for a more equitable society.

If the provision of public services is in the service of human flourishing, helping everyone to realise their best potential, then all public services are in the service of health, in its widest sense. But these services are not cut off from what Edgar Cahn called 'the core economy', and participation in families, civic society and the 'third sector' also generate health and wellbeing. What Christie highlighted is that the boundaries between such services, organisations and sectors are artificial. There is more that should bind us than divide us.

Leaders who recognise this are likely to be those demonstrating the collaborative leadership recently referred to by Audit Scotland, and the courageous leadership referred to by Alliance Scotland as one of its five provocations. I have the privilege of working alongside many public and third sector colleagues who continue to show me what collaborative and courageous leadership looks like, pushing at the boundaries of established custom and expectation, seeking ways to bridge traditional organisational divides, all in pursuit of joined-up, humane and person-centred services.

Participation and health inequalities 

At the individual level, we can consider the idea that health is something we do rather than something we have. It underpins our functionings and capabilities, as Amartya Sen might say. Health being as much social as it is psychological or physical, means that participation, in all its forms, is intertwined throughout. As such, from a health perspective, participation can be seen as an end in itself, not just a means to improved decision-making, service design and service delivery (although these matter too). At the collective level, participation can be taken as a sign of societal health. High and inclusive participation rates run counter to systemic inequality and social exclusion. As such, it is important that participation is available to everyone, not just those who benefit from access to resources.


Globally we currently appear to be re-learning what happens when exclusion and inequalities are allowed to grow. One warning we should perhaps heed comes from Walter Sheidel in his book The Great Leveller, where he reveals that large economic inequalities have historically only been reversed by economic collapse or war. Mark Twain supposedly quipped, "history doesn't repeat itself, but it often rhymes", but this doesn’t seem quite so funny today.

What Works Scotland's Frontier report reminded me that Christie is about far more than service redesign. It is about the fundamental ways in which our society operates.

Given our current ecological, economic and social crises, getting Christie right matters more now than ever.

I commend the Frontier report to you and would urge that you read it and act upon it with haste.