Implementation and Impact
The SLWG has brought together an extensive range of experience, expertise and evidence. This includes frontline professionals, academics, leaders of statutory, professional and third sector organisations, civil servants, and - most importantly - people with expertise derived from their own experiences of the issues being discussed. Implementation of the SLWG's recommendations will enable primary care and community-based health and wellbeing services to have the greatest possible impact on mitigating the long-standing injustice of structural health inequalities in Scotland at this time. The scope of the recommendations is therefore substantial.
To enable this work to proceed with the concerted momentum and energy it requires, the SLWG identified five foundational recommendations as priorities. These five should be prioritised as they will lay a strong bedrock on which to build the full range of ambitious and far-reaching recommendations in Annex A of this report.
The proposed five foundational recommendations to be immediately prioritised are:
1. Strengthen national leadership for health inequalities.
Options for bolstering national leadership should include consideration of a potential Health Inequalities Commissioner or similar role, and annual reporting on progress. Health inequalities are complex and multifaceted: no single department or organisation has been able to bring about sustained change on their own. Coordinated working across organisational divisions with cross-portfolio leadership and transparent accountability is a necessary prerequisite for transformative change and for the recommendations in this report to have a meaningful impact. Excess deaths and disability due to inequalities must be a national priority and require a coordinated national response.
2. Implement a national programme of multi-disciplinary postgraduate training fellowships in health inequalities.
Health and social care systems and the behaviours of frontline professionals are drivers of health inequalities. Evidence has demonstrated that postgraduate health inequalities programmes have a significant impact on, not only the awareness, attitudes and skills of professionals, but also practitioner retention and reduction of stress and burnout. The introduction of such a programme at scale will create a foundation for strengthening services where they are needed most and for building services that are informed about discrimination and trauma and are oriented to working alongside people and their communities. Primary care should also make best use of existing programmes and resources, including the National Trauma Training Programme to address a widespread lack of trauma-informed practice and care. Leaders at the frontline are faced with many competing priorities, amongst which health inequalities are often lost. Frontline workers face stress, burnout and overwhelm arising from daily encounters with trauma, discrimination and inequality. This can lead to harmful coping behaviours and systems that exclude those most in need.
3. Create an Inclusion Enhanced Servicethat invests in the management of patients who experience multiple and intersecting socio-economic inequalities.
The current distribution of health care resources in Scotland does not reflect the needs of those at greatest risk of premature death and disability. A lack of systematic data about unmet need has resulted in resource allocation formulae that do not match need. This is most clearly the case in the distribution and allocation of resources to GP practices through the GP contract. In the long term, better data will allow for more equitable resource allocation. In the immediate term however a mechanism is required that will allow investment to be targeted to the frontline and unlock the potential for other changes. A similar enhanced service exists in England.
An Inclusion Enhanced Service would help to address elements of the inverse care law by providing time for primary health care professionals to undertake co-ordinated care planning alongside people with complex and long term conditions - a key determinant of better health and wellbeing outcomes.
4. Develop a strategy to invest in wellbeing communities through local, place-based action to reduce inequalities.
Health and social care services are most be effective if they rest on a foundation of strong community networks and organisation. These encourage support from family, friends and peers; build self-confidence and belief in entitlement to services; enable access to information about health and wellbeing, including digital resources; give support to assert rights and articulate needs; and nurture skills to create and sustain health and wellbeing. Financial obstacles, discrimination and many other barriers prevent individuals and communities from realising their strengths and potential. A long term strategy, led by communities themselves with the support of locally embedded organisations, will allow community infrastructures to protect and promote physical and mental health, wellbeing and resilience, and will create an environment in which health and social care can begin to function more effectively as partners alongside the communities they serve.
5. Commission an investigation into how barriers to healthcare can themselves inadvertently contribute to excess deaths and premature disability related to socio-economic inequalities.
There is widespread experience and evidence that health and social care systems are themselves drivers of health inequalities. A thorough investigation would enquire into the mechanisms and processes by which this occurs, not only in primary care but also in mental health, addictions, hospital based services and social care.
The immediate next steps will be to establish an implementation group with clear responsibility for developing programmes of action, making the case for resources and allocating responsibilities. A reference group with wide professional representation, as well as expert reference groups of people with lived experience, should also be established to ensure scrutiny and accountability, with a public report in one year to give an account on progress that has been made.
The national recovery from the current pandemic presents both a challenge and an opportunity. Avoidable differences in people's health and exposure to death or disability based on bank balance, postcode or birthplace are injustices that should have no place in the post COVID-19 world. The recommendations in this report provide a pathway by which primary care can fulfil its duty towards shaping a fairer Scotland. For a nation to be truly modern, prosperous and progressive, it must be able to ensure that access to effective health care is available to all on an equal basis of human dignity alone.
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