4. Priorities for tackling health inequalities
This section highlights some of the key points from the policy review  undertaken by NHS Health Scotland and discusses the role of CPPs.
- NHS Health Scotland's policy review suggested that there is evidence of "lifestyle drift" in tackling health inequalities, with actions focussing on mitigation of poor lifestyle choices rather than efforts to tackle the underlying causes.
- Equally Well has the potential to bring together a range of Government strategies but the monitoring of actions could be managed better.
- There needs to be a greater focus on the fundamental causes of health inequalities.
- Priority must be given to those areas that contribute most to the burden of early death if health inequalities in Scotland are to be addressed.
- Community Planning Partnerships remain key to tackling health inequalities and must be fully supported to achieve transformational change.
- Third Sector organisations are important to the success of CPPs tackling health inequalities.
4.1 What works to address health inequalities
Health inequalities: theory of causation (summary version)
It is clear that any strategy to address health inequalities requires actions operating across all three levels of determinants: fundamental, wider environmental and individual. Action to address the wider environmental causes, such as the availability of quality work, housing and education; and individual experiences, risks and lifestyles are important, but will alone not solve the problem. The fundamental - 'upstream' - causes of health inequalities such as lack of power and money also need to be addressed. For example, fiscal and employment policies such as paying a living wage to all employees covered by the Public Sector Pay Policy, or power redistribution through engaging people and communities in co-production to help design and shape the services they receive through assets based approaches. A significant problem has been where attention has been focussed and how that has been monitored.
4.2 Where to focus activity and how to maintain that focus
NHS Health Scotland's Policy Review concluded that Equally Well was bold, grounded in good evidence and had made progress in some areas. It noted that Equally Well recognised the influences of both 'upstream' economic, social and physical environments, as well as the influences of 'downstream' individual factors such as the accessibility of services, behaviours/lifestyles, and personal strengths, vulnerabilities and social networks. But there were several key factors that require attention if the strategy was to be fulfilled.
The Policy Review highlighted that actions in support of Equally Well had in many instances become focused on mitigating the effects of social inequalities, for example smoking and alcohol misuse, rather than on addressing the long term underlying causes, such as poverty and income. As such, despite its ambitions, Equally Well has primarily been delivered as a health and wellbeing initiative with limited spread into other policy areas other than early years. This is sometimes termed "lifestyle drift" and is a common feature of strategies like Equally Well. These actions are usually put in place to improve health generally, but become the focus for efforts to tackle inequalities and can deflect attention from tackling the underlying causes. Whilst these activities are important they must not be seen as a proxy for action to deliver Equally Well. There is therefore a challenge for action to remain focussed on the fundamental causes and wider environmental influences. Without action to address the unequal distribution of power, money and resources and to deliver an equitable distribution of health-enhancing environments, health inequalities will remain.
The Policy Review noted that many other strategies and actions undertaken by the Scottish Government and its partners impacted on inequalities but were not explicitly linked to Equally Well; for example the introduction of the Scottish Housing Quality Standard, the smoking ban and proposed pricing controls for alcohol. This poses a challenge when trying to monitor and reflect on all the activity that is underway to tackle inequalities, and the Task Force agreed that this should be addressed.
4.3 Supporting CPPs to deliver transformational change
The review of progress to date on Equally Well highlighted a number of delivery challenges which in the main are in the hands of CPPs. From the outset Equally Well has emphasised the impact that CPPs can make in delivering change, but they have not yet lived up to expectation. Achieving better joint working across agencies and services, as well as involving local communities and target groups, were seen as cornerstones for successful delivery on health inequalities. Equally Well highlighted the need for a significant improvement in partnership working in CPPs.
The Christie Commission was absolutely clear that a radical change in the design and delivery of public services, as well as the way in which public services work with each other and with communities, was required. The Scottish Government has agreed that this requires that:
- public services are built around people and communities, their needs, aspirations, capacities and skills, and work to build up their autonomy and resilience;
- public service organisations work together effectively to achieve outcomes;
- public service organisations prioritise prevention, reducing inequalities and promoting equality; and
- all public services constantly seek to improve performance and reduce costs, and are open, transparent and accountable.
CPPs remain critical to tackling health inequalities, since much of what needs to be done is not specifically related to health, but rather concerns the wider determinants highlighted previously, which are under the control of local authorities.
The Task Force noted that while progress has been made in some localities, it is also true that this has neither been consistent nor game-changing. Audit Scotland recently argued that CPPs have not taken full ownership of the health inequalities agenda across Scotland, that there has not been effective partnership working, and that partnerships have struggled to put in place appropriate interventions  . It is clear that tackling health inequalities should be at the core of what CPPs do.
The Task Force heard from both COSLA and the Improvement Service on how CPPs can best respond to both the recommendations of the Audit Scotland report and the ambition of all partners and stakeholders. It noted that measures already planned include strengthening duties on individual partners through a new statutory duty on all relevant partners (whether acting nationally, regionally or locally) to work together to improve outcomes for local communities through participation in CPPs.
4.4 The Third Sector and CPPs
The Task Force also heard from representatives of the Third Sector to discuss the issues that they faced and to reflect on their relationship with CPPs. A key long standing issue faced by many Third Sector organisations is their ability to obtain sustained funding for small scale work over long periods. Even when the work is recognised by the CPP as the best and preferable course of action, that is no guarantee of security, and there is a need for CPPs to provide such at an earlier point in the planning process to ensure delivery. The Task Force noted that engagement of the third sector remains inconsistent across CPPs and it was acknowledged that they needed to be more closely involved. This would be a priority to rectify in good economic times, but the current climate only heightens that need, given the key contribution the third sector can make to prevention and assets based approaches. The Third Sector representatives also raised capacity issues concerning their ability to tender for contracts and meet demand with regards reporting requirements within the wider context of a need for more co-produced approaches. It was noted that there was scope for that to be managed better both at the interface with the CPP, but also to help Third Sector organisations work more effectively together.
4.5 Giving back control - unleashing the assets in our communities
To explore and support new ways of working a series of test sites were established under Equally Well, to employ innovative ways to redesign and re-focus local public services working with communities to address health inequalities. The key learning from the test sites included:
- a requirement for commitment at senior level from across the participating organisations;
- visible efforts at co-ordination and joint working across agencies;
- working with communities;
- use of novel approaches and a willingness to accept emergent, unanticipated solutions;
Lessons from the Equally Well Test Sites
A series of test sites were established under Equally Well in 2008 to employ innovative ways to redesign and re-focus local public services working with communities to address health inequalities. The work in the test sites has been mainstreamed.
Key learning from the Test Sites:
- a requirement for commitment at senior level from across the participating organisations - and for this to be visible, active and highly permissive, in order to give encouragement to the use of novel approaches and willingness to accept emergent and unanticipated solutions.
- a requirement for blurring of boundaries between partners usually facilitated by someone who could span organisational boundaries and work both horizontally and vertically with ease to bring ideas, people and communities together.
- a requirement to understand both each other, and the challenge at hand, by tackling the barriers which stem from language and perceptions of roles and responsibilities - e.g. health inequalities being a matter of social inequality rather than purely the concern of the NHS.
- that the more communities were involved in co-creating and co-delivering, the more success was seen in the journey to desired outcomes.
- that the lived experience in communities may be very different to the professional perception of those communities. Assets can be found in the community amongst the residents, the families and individuals, but also from the range of services and groups within that community.
It was noted that the key learning points were replicated by other pilots which focussed on different health issues, and that the learning overlapped with the aspirations set out by the Christie Commission.
Link Up - Harnessing assets and improving wellbeing
Link Up (a partnership between Inspiring Scotland and ten charities) began operating in January 2012, and is funded by the Scottish Government's Cash Back for Communities Programme until July 2014. The programme operates across ten vulnerable communities. In each, a Link Up worker is employed to harness community assets in order to establish activities ( e.g. cooking, gardening, sports, cinema) in which residents are actively participating in running the activity and are helping it become a sustainable part of community life.
Impact: By September 2013, 6,300 people (often perceived to be 'hard to reach') had participated in Link Up activities with 400 volunteering. This engagement is helping to establish social networks and build social capital - significant precursors to realising the potential of a community's assets.
Link Up is also starting to gather evidence that enabling individuals to use their strengths and/or new skills for the benefit of others can lead to transformative change. For some, this benefit can begin to redefine their world view, and where they hold their community and place within it - as contributors rather than recipients. This in turn has led to higher-order outcomes: re-engagement with work; healthier lifestyles including reduced drug and alcohol misuse; reduced isolation; increased confidence; better feelings about where they live; belief in self-efficiency; and community activism.
Approach: Link Up is creating conditions where positive change is possible for some people, and is improving wellbeing by making a relatively greater part of their lives "comprehensible, manageable and meaningful". In this respect, the key features are:
- starting by asking what's good in a community and what residents can contribute rather than focusing on community deficit.
- not enforcing external agendas, but rather having residents determine activities and develop groups.
- workers have significant autonomy to develop and vary approach in accordance with the local context and aims of residents.
- flexible funding enables participant ideas to be rapidly turned into action.
- workers treat local people with respect, recognising them as valuable contributors, rather than victims/issues to be saved/resolved.
A key element of the test sites was the development of assets based approaches as there had been growing interest in understanding how such an approach might help address some of Scotland's long-standing health problems and inequalities. The Chief Medical Officer's annual report (2011)  describes the assets based approach as involving 'helping people to be in control of their lives by developing the capacities and capabilities of individuals and communities'. It highlights the 'recognition of social capital (the connections within and between social networks) and its importance as an asset', in discussing Area Based Community Development as an approach that could be applied to improve health and wellbeing.
The Christie Commission also argued that 'building personal and community capacity, resilience and autonomy' should be a key objective of future public service reform. In the Scottish Government's response to that report - Renewing Scotland's Public Services  - engaging individuals and communities in decisions about services is seen as key, if public services are to become more efficient and more effective at meeting people's needs. Arguably this can only be achieved if individuals and communities engage both with each other and with service providers - in other words - with the help of developing social capital.
The Task Force is supportive of the development of asset based approaches, and noted that programmes such as Link Up reflect that approach, and furthermore serve as a means by which social capital can be developed - resulting in a beneficial health effect.
4.6 Creating quality neighbourhoods
The Task Force also heard about the experience of Good Places, Better Health ( GPBH). GPBH was launched in 2008 as the Scottish Government's strategy on health and the environment  . Traditionally the focus within environmental health has been on toxic, infectious, allergic and physical threats. However, whilst these still demand attention, there is now a growing recognition of an additional need to shape places which are nurturing of positive health, wellbeing and resilience.
A key recommendation flowing from the GPBH experience was the proposal to develop a Scottish Neighbourhood Quality Standard. The SOA guidance published in 2012  highlighted the importance of tackling place as a key determinant of health, and this has recently been followed up by the new Architecture and Place policy statement, "Creating Places" (published in June 2013  ). It recognised that the quality of the built environment affects everyone, and that it is the purpose of architecture and urban design not only to meet our practical needs but also to improve the quality of life for the people of Scotland. To that end, the Scottish Government has committed to developing a Place Standard. The Task Force is supportive of that and sees it as an important step in providing a framework that will help reshape local environments to help promote better health. The Task Force noted that the development and implementation of the place standard should be monitored.
4.7 The life course approach - young people
One of the highest priorities for any country is to ensure the best possible start to life for every child. This was recognised and reflected in the original Equally Well report which sat alongside the Early Years Framework and Achieving our Potential. The Task Force continues to support the life course approach and noted that the age group 15-44 had been identified as a source of early deaths. There is a need to reflect on what we are doing for this age group, in order to reassure ourselves that our approach is balanced between treatment and prevention. It may be that we need to consider a framework approach that builds on the early years collaborative but is focussed on those key points in a young persons' life where there may be significant transition - such as primary to secondary school, or secondary school to work - with a focus on prevention.
4.8 Impact of Welfare Reform
The UK Government has introduced a major overhaul of the welfare benefits system. The overarching aim of this is to reduce the cost of welfare benefits. This could lead to a cut of £4.5 billion over the 5 years to 2015, around £1 billion of which relates directly to children. The Task Force heard that the consequences of these welfare reforms will manifest in both the short and longer term  . In the short term, the NHS is seeing an increase in demand on primary care from those losing benefits, as claimants seek advice and evidence for appeals. This demand can be expected to continue until the bulk of the changes have worked through the system by 2017. Claimants are also turning to other parts of the NHS for help when Primary Care cannot help them.
In the longer term, consequential demand arising from the health impact of the increased poverty caused by welfare reform and on-going austerity is expected to include:
- increased cardiovascular and respiratory illness (associated with low income, income inequalities);
- increases in obesity-related illnesses such as diabetes, arthritis and cancer arising from poorer nutrition (associated with low income, income inequalities);
- poorer mental health and general wellbeing and reductions in/disruption to health care access (associated with low income, income inequalities, housing difficulties/housing insecurity); and
- potential increases in avoidable winter mortality (associated with fuel poverty).
As welfare benefits are reserved to the UK Government, mitigating the impact of the reforms is challenging. The Scottish Government is focussed on tackling child poverty and published its Child Poverty Strategy for Scotland in March 2011. This strategy expresses the Government's commitment to tackle the long term drivers of poverty through early intervention and prevention. Guidance on mitigating activities has been developed for NHS Boards, whilst the focus is on maximising household resources and improving children's wellbeing and life chances over the longer term.
This long term approach has three underpinning principles: early intervention and prevention to break the cycle of poor outcomes; building on the assets of individuals and communities, moving away from a focus on deficits; and ensuring that children and families' needs are at the centre of service design and delivery. This is very much in line with the approach outlined originally in Equally Well and reinforced here. Collaborative action across the public and third sector is required to ensure that those with greatest need can access the appropriate support to address the impacts that benefit changes may have on public health.
Health inequalities are caused at three different levels: fundamental causes, wider environmental influences and individual experiences. Action to address the wider environmental causes and individual experiences are important, but will alone not solve the problem. The fundamental causes of health inequalities such as lack of power and money need to be addressed. This can partly be achieved by engaging people and communities in helping to design and shape the services they receive through assets based approaches, and similar. Such approaches can redistribute power within communities, share information and intelligence, build connections, and produce better outcomes.
NHS Health Scotland's policy review suggested that there is evidence of "lifestyle drift" in tackling health inequalities with actions focussing on mitigation of poor lifestyle choices rather than efforts to tackle the underlying causes. Part of the challenge to minimise such drift is better coordination of national and local government strategies. Whilst part of the focus should be on tackling the fundamental causes of inequalities, such as through the Child Poverty Strategy, there should be continued effort on coordinating approaches to tackle the wider environmental causes. Community Planning Partnerships are key to tackling health inequalities and must be fully supported to achieve the transformational change required.
The Task Force heard evidence from the Good Places, Better Health team and noted their recommendation that a Scottish Neighbourhood Quality Standard should be adopted. The Task Force were made aware that the Scottish Government had agreed to develop a place standard through its Architecture and Place policy Creating Places - A policy statement on architecture and place for Scotland (June 2013), and were supportive of this.
The number of deaths in the age group 15 to 44 years was highlighted in the latest evidence presented to the Task Force. It was agreed that in line with the Life Course approach, the Scottish Government and other agencies should reflect on actions that are currently underway that impact upon this age group, to ensure that this work is coordinated and as effective as possible in changing young people's health - which will have a positive impact on their health in later life.