Purpose of the Implementation Plan
"In order to reduce health inequalities, strategies should be developed which are powerful, sustained and systematic. This requires political will, attainable objectives, effective policies and interventions, effective implementation, and evaluation and monitoring."
Eurothine Final Report, August 2007
This plan meets the first recommendation in Equally Well:
- The Government should produce a practical implementation plan by the end of 2008, setting out how the Task Force's recommendations will be turned into action and who will be responsible, at both national and local level.
Since Equally Well was published in June 2008, the Scottish Government and COSLA have discussed implementation with a wide range of groups and individuals. Details are at Annex 1. They have told us about the challenges Equally Well poses and also what they would find helpful to support them to deliver change.
Many community planning partnerships have already looked at what more they can do, to implement Equally Well locally within existing resources.
"We used the structure of our Community Planning Partnership - Inverclyde Alliance - to discuss Equally Well and allocate the recommendations. There will be a review at the next Alliance Board meeting to determine progress.
Local implementation will include work on building resilience with young people in our disadvantaged communities."
The Health and Sport Committee of the Scottish Parliament carried out an inquiry into health inequalities during 2008 and commented on monitoring progress, the importance of improving wellbeing, and various aspects of NHSScotland's response to inequalities.
The plan meets both local and national requirements by:
- Providing continuing and visible national leadership for implementation of Equally Well.
- Responding to the Health and Sport Committee's comments.
- Clarifying links between current national social policy strategies and frameworks that are relevant to the underlying causes of health inequalities.
- Being clear that progress cannot be achieved without community planning partnership leaders ensuring that priority is given locally to action on the underlying causes of health inequalities.
- Identifying in detail which organisations are responsible for acting on Equally Well recommendations both nationally and locally.
- Locating action on Equally Well within the current relationship between national and local government and the SOA process.
- Identifying remote and rural issues and demonstrating action to resolve these.
- In particular, identifying Government support for local change.
- Giving examples of how Equally Well is already being put into practice.
- Describing related policy developments that will also help to tackle health inequalities.
This plan is for:
- Scottish Government, to continue action on Equally Well and to play its part in negotiating SOAs.
- Local authorities and their community planning partners, including Health Boards and their acute services and Community Health Partnerships, and the police.
- The Third Sector.
- The private sector, which Equally Well seeks to involve more closely in local action.
- Middle managers and frontline staff in public services, who are working directly with individuals and communities affected by poor health and wellbeing.
- International audiences, to demonstrate Scotland's progress, but also to continue our commitment to learn from the best available evidence of what works in tackling inequalities in health.
- The Ministerial Task Force itself, as a baseline for its work when it reconvenes in 2010 to review progress in implementing Equally Well.
Equally Well: key principles
"I describe Equally Well as being about doing different things and about doing things differently." Professor Carol Tannahill, Director, Glasgow Centre for Population Health and Ministerial Task Force member.
The key principles set out in Equally Well to achieve change in the culture of organisations and underpin real progress in reducing health inequalities were:
- Improving the whole range of circumstances and environments that offer opportunities to improve people's life circumstances and hence their health.
- Reducing people's exposure to factors in the physical social environment that cause stress, are damaging to health and wellbeing, and lead to health inequalities.
- Addressing the inter-generational factors that risk perpetuating Scotland's health inequalities, particularly focusing on supporting the best possible start in life for all children in Scotland.
- Engaging individuals, families and communities most at risk of poor health in services and decisions relevant to their health, and promoting clear ownership of the issues by all involved.
- Delivering health and other services that are both universal and appropriately prioritised to meet the needs of those most at risk of poor health, and that seek to prevent problems arising, as well as addressing them if they do.
- Basing current and future action on the available evidence and adding to that evidence for the future, through introducing new policies and interventions in ways which allow for evaluating progress and success.
- Ensuring that the range of actions we take now will achieve both short and long-term impact and will address foreseeable future challenges.
The action in this Implementation Plan is based on these principles and on the evidence we have of what is likely to work.
The Scottish Government is developing a Community Empowerment Action Plan jointly with COSLA and the Third Sector. The plan will be launched in early 2009, and will put in place a range of support that will help to make community empowerment a core way of delivering change in Scotland over the long-term. It will provide clarity on what community is, why community empowerment is important, and how communities become empowered, taking account of views that were expressed in the dialogue on making community empowerment a reality, which took place at the end of 2007.
For some communities, empowerment will involve owning assets, and controlling budgets, or generating their own income to invest. In some cases, communities will want to take action around an injustice or to engage early with a plan for future physical development and land use, making the best of existing resources. From existing evidence, we expect to see a number of positive changes in how empowered communities work, including increased confidence and skills amongst local people; higher numbers of people volunteering in their communities; and higher levels of satisfaction with quality of life in a local neighbourhood. We know that these sorts of things can have a positive impact on a range of health outcomes.
The Scottish Government will continue to promote the benefits of community empowerment across a range of partners. It will continue to develop policy in partnership with others to help further develop culture change, and will invest in the wide ranging actions set out in the action plan.
Local authorities, particularly through their elected members, have a key role to play in promoting the benefits of community empowerment and engagement and in helping to drive the culture shift that will see community empowerment as a process which can help to deliver a range of local outcomes. Local government has a key role to play in supporting and developing the community groups which are the backbone of the community empowerment process.
Equality and diversity
In addition to planning for reductions in health inequalities, recommendation 2 of Equally Well requires action to be subject to equality impact assessment. The Government will continue to reinforce the point in all further Government policy and central and local action on Equally Well recommendations.
The Government's Mutuality, Equality and Human Rights Board has established a group to promote good relations within communities and recognise the impact of discrimination and disadvantage on health. This will support NHS Boards' action on recommendation 62 of Equally Well. The group will scope existing activity across health and other sectors, explore new approaches for the NHS in Scotland, test out ideas and disseminate effective ways of working.
Govanhill test site
Govanhill is one of West Scotland's most challenging neighbourhoods, with a significant level of health and social inequalities. It also has a comparatively large black and minority ethnic population, including a recently arrived Roma population. The test site will involve service redesign and a partnership approach that will be adopted at neighbourhood level. This will enable the implementation of an inter-related programme of social, economic and physical regeneration, in order to address the multi-faceted problems of the neighbourhood, including known priorities such as alcohol, drugs and community safety. It will actively involve the local community and Third Sector organisations and will consider the potential application of this cross-cutting approach to other areas.
NHS Health Scotland is leading the development of an accessible communication, translation and interpreting strategy and action plan for use by NHS Boards. This responds to Equally Well recommendation 64. It will provide a consistent approach to enhancing and improving communication with patients from all backgrounds.
NHS Health Scotland is working with partners in NHS Greater Glasgow and Clyde (which is already implementing its own Language and Communication Support Plan) and other Boards. The strategy and action plan will be available by spring 2009.
In addition, and in order to meet Equally Well recommendations 74 and 75 on equalities data, NHS Health Scotland will undertake a review of equalities data for health needs. This will be linked to the UK-wide requirement to review equalities data which resulted from a recent UK statistics commission assessment. The review will use outputs from the current NHSNSS Equality and Diversity Information project. It will also examine the relevance of existing HEAT targets for each equalities dimension and advise on the development of appropriate measures. The review will be carried out in 2009. Its report will set out a plan for data development and collection, with timescales and costs. Following this review, targets will be considered to support work on patient monitoring and equalities data collection. This is likely to be in 2010.
Meantime NHS Health Scotland is leading on early development of two elements which will form part of the wider plan:
- The alltheinfoplus national web-based resource for health information in a variety of languages and formats. This will be part of the "National health information and support service" led by NHS 24 which is due to be launched in April 2009.
- National contracts for interpreting and translation: proposals are being developed by procurement colleagues in NHS National Services Scotland.
Linking high-level social policies
The Scottish Government and COSLA are publishing in late 2008 frameworks on early years and tackling poverty, which relate closely to Equally Well. These three major social policy approaches link up in the following ways:
- All three have been developed jointly by central and local government.
- They are about major and intractable social problems that are interlinked and work across generations to hold back Scotland's progress: children's start in life and cycles of poverty, inequality and poor health.
- These are complex issues with often complex solutions which cannot be sorted out overnight; they require long-term, sustained approaches.
- Each framework supports the others and sets out the specific action needed to meet shared long-term health and other outcomes and aspirations. For example the importance of family support for the most vulnerable families before birth and in children's very early years.
- Commitments to rooting out inequality and promoting equality are central.
- The frameworks are vital in driving the Government's and COSLA's shared early intervention approach ie moving from crisis management to early intervention and prevention and breaking cycles of poor outcomes.
- We aim to shift the focus from providing services (doing things for or to people) to building the capacity of individuals, families and communities, and addressing the external barriers people may face to making use of the high quality, accessible public services they require.
- It is a major purpose of Government activity to support local change and development.
- Real change will happen through community planning and joined up action by the partner organisations locally.
- Often this requires small, innovative steps that will build up over time to have a big impact.
- For example, the Equally Well test sites are all about better client pathways into, through and eventually out of key public services and joining up those local services for individuals, to address the whole range of their needs.
- SOAs with Government are the way that joint local accountability for outcomes and change to meet local need is articulated.
Planning and reporting progress
In order to deliver the changes Equally Well seeks across the whole of Scotland, we need to identify:
- How long-term reductions in the key health inequalities will be monitored and reported.
- How medium-term change can be planned and managed, through community planning and the SOA process and the accountability arrangements within community planning partner organisations.
The Government has adopted the health inequality indicators and measures recommended in Equally Well, which will be used to report regularly on long-term progress across the whole of Scotland.
We will work to develop alignment between these indicators and the National Performance Framework and link reporting on health inequalities with Scotland Performs.
The Government published definitions of the high-level indicators and the current baseline position on 30 September 2008.
Headline indicators of inequalities in health outcomes
Healthy Life Expectancy (at birth)
Premature Mortality - from all causes, aged under 75 years
Mental Wellbeing - adults aged 16 years and over
Indicators of inequalities in morbidity and mortality from specific causes for specific age groups
Coronary Heart Disease (first ever hospital admission for heart attack aged under 75 years; deaths aged 45-74 years)
Cancer (incidence rate aged under 75 years; deaths aged 45-74 years)
Alcohol (first ever hospital admission aged under 75 years; deaths aged 45-74 years)
All-cause mortality aged 15-44 years (to capture large inequalities in mortality observed in this age group)
We are not attempting to define numerical targets for progress on each of the key measures of inequalities because of the complex range of factors that contribute to change. We are jointly committed, however, to delivering improvement in every one of the individual measures in the longer term. This will show we are reducing inequalities across the whole population, not just improving the position of the very worst-off people and areas.
The high level measures of health inequalities are defined at the Scotland level. Some of the measures are not currently available at more local levels.
During 2009, the Scottish Government will discuss with local organisations which subset of the national key health inequalities measures are appropriate for them and which other, related measures could be used as proxies for reporting progress towards long-term outcomes. This will help local areas to quantify the health inequalities challenges they face and provide baselines from which local targets can be set and activity focused.
Managing change in the medium term
The Government has now published (www.improvementservice.org.uk/health-improvement/ health/tools-for-soa-process) an analysis of intermediate (medium-term) health inequalities outcomes and associated indicators, where Equally Well recommends action. This analysis follows the format of the Health Improvement Performance Management package developed by NHS Health Scotland. This is already familiar to community planning audiences and sign-posted in the 2009-10 SOA guidance. The intermediate health inequalities outcomes are as follows and they are used to identify the purpose of actions in the main section of this implementation plan.
Early Years Outcomes
EY1: Reduction in child poverty
EY2: Healthier lifestyles among younger women (diet, smoking, alcohol)
EY3: Reduction in vulnerable pregnancies
EY4: Improved breastfeeding rates
EY5: Improved parent-child relationships through positive parenting approaches and skills
EY6: Children's mental wellbeing/resilience
EY7: Reduced percentage of children overweight or obese
EY8: Improved health and wellbeing of looked after children
EY9: Children's and young people's skills for life, including literacy and numeracy
EY10: School leavers in positive and sustained destinations
EY11: Children have more active lifestyles, access to greenspace and opportunities for play
Mental Wellbeing Outcomes
MW1: Reduced proportion of people living in poverty
MW2: Greater financial inclusion and better financial management by individuals
MW3: Reduction in fuel poverty levels
MW4: Healthier workplaces
MW5: Reduced sickness absence rates
MW6: Better prospects of moving into good and sustained employment
MW7: Less reported discrimination, harassment or abuse
MW8: More volunteering
MW9: Greater mental health literacy across the public and professions
MW10: Improved recovery from mental illness
MW11: Fewer suicides
MW12: Sustained or improved physical and mental wellbeing of offenders (also BK8)
MW13: Increased use of green space and more physical activity
MW14: Greater satisfaction with public services and local neighbourhoods
Alcohol, Drugs and Violence Outcomes
ADV1: Reduction in average alcohol consumption
ADV2: Reduction in alcohol-related harms
ADV3: Reduction in drug use
ADV4: Reduction in drug-related harms
ADV5: Less drug-related crime
ADV6: Reduction in domestic abuse
ADV7: Fewer offences involving violence
ADV8: Fewer adults experiencing non-domestic violence
ADV9: Violence becomes less socially acceptable
ADV10: Greater uptake of positive activities for young people
Big Killer Disease Outcomes
BK1: Reduced number of people smoking
BK2: Reduced exposure to second hand smoke
BK3: Reduction in average alcohol consumption (also ADV1)
BK4: Reduced incidence of depression and anxiety
BK5: Reduction in risk factors, eg diet and other lifestyle
BK6: Improved dental health of vulnerable groups
BK7: Improved health of people with learning disabilities
BK8: Sustained or improved physical and mental wellbeing of offenders (also MW12)
Tracking these intermediate outcomes will allow community planning partnerships and their partner organisations to set milestones for local progress in reducing health inequalities in the longer term. They will be able to identify which of the outcomes and indicators are most relevant to their local problems and the action being taken to address these. The Government hopes that SOAs will identify local plans and targets along these lines. NHS Board annual reviews will incorporate a review of progress with relevant NHS action on Equally Well recommendations.
Further development and use of evidence to connect actions to both short-term and intermediate outcomes for health inequalities is needed. Indicators of progress towards intermediate outcomes need to be assessed, to align them with linked social policy areas. We will also consider if relevant additions are required to the national and local indicator sets, and to
NHS Board HEAT targets. The Government and others will continue to work on this in 2009.
Greenspace health outcomes planning
This is a partnership action research project involving greenspace scotland, NHS Health Scotland, Scottish Natural Heritage, Glasgow City Council and the Dundee Partnership for the Environment along with local partners. The aim is to develop an evidence-informed, plausible series of links between greenspace interventions and the National Performance Framework.
The interventions in question include the development and implementation of Open Space Strategies for Dundee and Glasgow; the planning and delivery of programmes of greenspace-based health promotion (such as physical activity or health walk programmes) and specific examples of greenspace improvement. These have a strong focus on addressing the significant health inequalities in both cities.
A report will be published by April 2009 and it is expected that further work will take place in 2009-10 to look at broadening the scope of the planning tools and supporting their use in local authority and community planning partnership settings.
Working through community planning and single outcome agreements
"Co-ordinated action locally is essential if we are to make progress on reducing health inequalities. The community planning partnership arrangements (based on strong locality planning mechanisms) offer a ready-made vehicle for change and improvement, bringing together in one body senior representatives of local government, NHS, Police, Fire and Rescue, FE, DWP, Scottish Enterprise (with their access to the private sector) and the voluntary sector. Together, by pooling our efforts and resources in a planned, systematic way, we can make a difference in the vital task of improving health and reducing health inequalities. The Single Outcome Agreement, reflecting the strategy of the community planning partnership, will be an important planning and monitoring tool to improve effectiveness and to ensure accountability."
Ken Corsar, Chair, NHS Lanarkshire and Ministerial Task Force member
In the medium term, we expect to see the key local actions that will deliver reductions in health inequalities identified within community planning partnerships' SOAs with the Government. This has already started in the 2008 SOA round, as the following case studies illustrate:
Perth & Kinross SOA 2008-09
Glasgow's SOA 2008-09
Worklessness and ill-health are inextricably linked - a major issue for Glasgow, which has the highest proportion of Incapacity Benefit claimants in Scotland.
Taking forward the "work for those without" theme specifically the city has embraced the Department for Work and Pensions ( DWP) Cities Strategy by launching the Glasgow Works Partnership (part funded through the Fairer Scotland Fund), which has an initial two year contract with DWP but seeks to bring about long-term structural change in the city's employability infrastructure, ensuring that more Glasgow residents get to be part of the city's economic growth through support into employment and in work support to sustain employment.
DWP and Glasgow have agreed a range of objectives and outcomes to help reduce the level of worklessness in the city. These outcomes are reflected in a range of associated targets which are also incorporated within Glasgow's current SOA. SOA targets include raising the employment rate to 67.8% by May 2009, and reducing by 12,000 the number of residents claiming the three main workless benefits of Job Seekers' Allowance (620), Lone Parents' Income Support (2,600) and Incapacity Benefits (8,750).
Significantly NHS Greater Glasgow and Clyde plays a prominent part; partners recognise the crucial role of health in the economy, and of employment in healthy working lives. In particular, CHCPs in Glasgow have been pivotal in establishing bridging services, which offer employability-related advice and support, to which CHCP staff are encouraged to refer their clients. The aim of each of the bridging service teams is to work closely with the locally based health and social care services in order to support clients and work in a holistic way with people referred in order to help access and sustain employability opportunities.
Relevant local outcomes
Increase the number of jobs in Glasgow
Increase the proportion of better paid and more productive jobs
Increase the proportion of Glasgow residents in work
Reduce the proportion of children in poverty
Number of families receiving Child or Working Tax Credits while in work or with CTC more than the family element
Number of Key Benefit Claimants
The Government will expect coverage of health inequalities in 2009-10 SOAs, where there are relevant local issues and problems, and where local action can contribute to addressing both local and national health inequalities. There will be no separate reporting arrangements for the implementation of Equally Well.
Community planning partners are jointly responsible for shared outcomes. Each partner organisation also has its own accountability, performance management and performance reporting system.
The Government has sharpened NHSScotland's accountability for reducing inequalities in coronary heart disease, which is one of the key inequalities identified in Equally Well. A new HEAT target will be in place from April 2009 for NHS Boards to carry out targeted health checks among communities most at risk of cardiovascular disease. This will be supported with additional Keep Well resources to NHS Boards, as covered in more detail in the action section of this plan.
Community Health Partnerships
Community Health Partnerships ( CHPs) play a critical role in addressing both causes and consequences of health inequalities. They are responsible for many relevant services jointly managed by NHSScotland and local authorities. They are critical in community planning processes at both local authority and smaller-area, locality levels often addressing underlying causes of health inequalities. They are well placed to engage directly with the local community on the design and delivery of health and other services to meet local needs.
The outcomes CHPs achieve for patients and the wider community are critical to meeting Equally Well's intermediate and long-term outcomes, and in the NHSHEAT targets that contribute to these.
CHPs have sought guidance on their role in implementing Equally Well.
Some key contributions to implementing Equally Well that CHPs and their staff are expected to achieve are:
The Government and NHS Health Scotland will publish updated briefing for CHPs on improving health and reducing health inequalities by Easter 2009.
Measuring progress by CHPs
The Glasgow Centre for Population Health is developing a framework of indicators for Greater Glasgow and Clyde Community Health and Care Partnerships and Community Health Partnerships for monitoring and reviewing their actions to address health and social inequalities in order to evaluate progress. An action research approach was taken to ensure that the indicators would be relevant to the work of the CHPs and to contribute to the development of action. The indicators framework was informed by the Community Profiles and an analysis of the CHP development and service plans. The aim is for the framework to support CHPs' actions on inequalities and also to link with HEAT targets, the SOA process and organisations' internal performance management.
A final report will be available on the Glasgow Centre for Population Health website from spring 2009.
Equally Well identified significant resources already allocated to the public sector that will make a difference to the underlying causes of health inequalities; a total of £1.8 billion over the 3 years 2008-11.
Implementing recommendations in Equally Well will ensure better, more focused use of existing resources. This will be particularly important in a climate of financial constraints.
The test sites will demonstrate what change is possible within budgets locally.
In the longer term, the challenge remains of shifting resources from dealing with consequences of health inequalities to preventing poor health in the first place. The virtuous cycle: moving from action on crises to preventative and early intervention services is explored in more detail in the early years framework.
The Government's next strategic spending review will consider the need for new or re-aligned investment in future spending plans, as envisaged in Equally Well recommendation 68.
The Technical Advisory Group on Resource Allocation ( TAGRA), whose members have expertise in resource allocation and financial matters, will give technical advice on future allocation and targeting of NHS resources. Its work programme is still at an early stage. However, TAGRA will consider evidence on the effectiveness of addressing unmet need through targeted funding and will consider, with NHS Boards, whether the allocation formula could be used at sub-Board level to help them in decisions about resource distribution at more local levels.
Support for implementing Equally Well offered by NHS Health Scotland
NHS Health Scotland will support the implementation of Equally Well in the following ways:
The International Picture
Since Equally Well, WHO has published Closing the Gap in a Generation, the final report of the Commission on Social Determinants of Health. This reflects many of the same principles and practical recommendations as Equally Well. For example, the cross-government approach required, improving the circumstances in which children are born and develop, addressing inequitable conditions of daily living through a strong public sector.
The Scottish Government welcomes the WHO report. Scotland will benefit, along with the UK Government from work that Sir Michael Marmot, who led the WHO Commission, will be undertaking to identify further progress in the light of the Commission's findings. This will contribute helpfully to the Ministerial Task Force's review of progress in 2010.
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