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: Neoliberalism, Service Provision, and Health Inequalities in Scotland

Abstract

This thesis explores the impact of street-level decision-making, stigma, and symbolic powers in contributing towards the health inequalities of vulnerable individuals and groups in Scotland. There is a growing body of literature exploring the social determinants of health and the impact of living in deprivation on mortality rates. However, little is known about the relationship between people accessing services, practitioners, and health inequalities. This research focuses on the lived experiences of individuals who are either those accessing services, or service practitioners advocating for vulnerable service users.

By exploring participants’ lived experiences through a Bourdieusian lens of symbolic power and symbolic violence, this thesis will argue that service practitioners, interpreted here as street-level bureaucrats following Lipsky’s conceptualisation, function as gatekeepers to service provisions through the discretionary decisions they make. These decisions may be the consequence of stigmatisation, budgetary cutbacks, or a lack of service capacity. When decisions are made to decline or reduce service users’ access to the service provision, this may result in conditions deteriorating to the point of requiring crisis intervention. Furthermore, neoliberal attitudes in healthcare environments, driven by value-based ideologies are often at the expense of equitable access to services. These approaches focus on individual responsibility, which can marginalise vulnerable populations and undermine the wider goal of achieving universal healthcare.

By reducing early intervention and prevention, discretionary decision-making may contribute to systemic differences in health and contribute to health inequalities. Equality cannot be achieved without equitable health provision. In this thesis, I argue that habitus-related stigma, symbolic power, and bureaucracy—potentially based on neoliberal ideology—are part of the direct and indirect barriers confronted by service users when trying to access provisions. Increased early intervention and prevention methodology are required and must be driven by practitioners who have a fundamental understanding of the issues that people face when attempting to access the services they need. The study concludes with providing recommendations to expand current services, provide equitable access to provisions, improve open access to GP services, and address issues relating to neoliberal political ideology in policy and provisions to prevent further breakdowns in care.

Date of Award	2025
Original language	English
Awarding Institution	University of Dundee
Supervisor	Elaine Lee (Supervisor)