Proportionate Universalism as a Route to Mitigating Health Inequalities? Exploring Political, Policy and Practice Uncertainties in Times of Austerity

Abstract

Abstract This chapter addresses inequalities in the United Kingdom through the lens of health inequalities. Driven by inequalities in income and power, health inequalities represent a microcosm of wider debates on inequalities. They also play a role as the more politically unacceptable face of inequalities – where other types of inequality are more blatantly argued as collateral damage of advanced neoliberalism including ‘inevitable’ austerity measures, politicians are more squeamish about discussing health inequalities in these terms. The chapter starts by depicting health inequalities in Scotland and summarises health policy analyses of the causes of, and solutions to, health inequalities. It then describes the concept of ‘proportionate’ universalism’ and sets this within the context of debates around universal versus targeted welfare provision in times of fiscal austerity. It then turns to a small empirical case-study which investigates these tensions within the Scottish National Health Service. The study asks those operating at policy and practice levels: how is proportionate universalism understood; and, is it a threat or ballast to universal welfare provision? Findings are discussed within the political context of welfare retrenchment, and in terms of meso- and micro-practices. We conclude that there are three levels at which proportionate universalism needs to be critiqued as a means of mitigating the impacts of inequalities in the social determinants of health. These are within the political arenas, at a policy and planning level and at the practice level where individual practitioners are enabled or not to practice in ways that might mitigate existing inequalities.