Main Report of the National Review of Primary Care Out of Hours Services

Annex E: Report Submitted by NHS Health Scotland on Health Inequalities

Contribution from NHS Health Scotland on Health Inequalities

Introduction

We welcome the opportunity to respond to your request to contribute to the National Review of OOH Primary Care Services. This contribution addresses OOH services from the perspective of inequalities, specifically health inequalities.

This contribution is summarised here - the full contribution from NHS Health Scotland is available on the Review website.

This review, and the area of public services that the review addresses, is a crucial and rare opportunity to tackle inequalities in access, experience and outcome for people who often face the greatest challenges in their circumstances and have the greatest and most complex needs, at important times of their lives.

We realise that pressures on OOH services are substantial and rising, and that the anticipated trends of demography, public and professional expectation have hit services with full force, when resources in social care and other supporting services are less abundant, and those people and communities with fewest resources are under further strain. The NHS is a universal provider of healthcare, free at the point of need for the whole population. Its contribution to the health of the population is substantial, although it does not act alone; it is dependent on the contributions of many stakeholders, the general health of the population and determinants of health that are mainly beyond the scope of healthcare.

Key messages:

• Health and social care services and professionals have an important contribution to make to reducing health inequalities.
• Changes to out of hours primary care provision have the potential to increase or decrease health inequalities, depending on how they are implemented. Elements of the style of service more likely to decrease health inequalities are contained in key points and recommendations that follow.
• The principle of proportionate universalism should be applied to OOH developments - in other words, OOH services should be designed in the full knowledge of the needs of whole local populations, co-produced and delivered with service users in proportion to levels of need.
• Resources spent on crisis management mean that less is available elsewhere in public services to take more cost-effective, preventive measures. Helping people to access resources to prevent escalation or deterioration of their health problems should be a key feature of OOH service design.
• Barriers to access as a result of cost, geography, additional support needs, institutional settings or features of service design should be minimised as much as possible.
• There are particular risks of increasing inequalities in relation to telephone-based access; the evidence we do have suggests that uptake is likely to be influenced by a range of socio-demographic factors, including deprivation.
• There are also inequalities issues in relation to centralised primary care out of hours centres, particularly in remote and rural areas or where the reimbursement of travel costs is inconsistent.
• The evidence in relation to inequalities in access to, use of and outcomes from OOH services in Scotland is currently very limited and needs to be improved.

In particular, tackling inequalities in access to and uptake of primary care is a key focus for the NHS in reducing health inequalities. This includes ensuring equitable experience of services and targeted support for the most disadvantaged and those at particular risk of poor health outcomes. Key actions which can help to mitigate health inequalities include:

• Training to ensure that the primary care and wider public sector workforce is sensitive to the needs of all social and cultural groups, and can build on the personal assets of service users as well as being able to identify risks and areas of deficit- for example poor health literacy. Health literacy is especially important in relation to appropriateness of self-referral, concordance with treatment, and uptake of secondary and tertiary treatment services
• Linking of services for vulnerable or high-risk individuals.
• Provision of specialist outreach and targeted services for particularly high-risk individuals.
• Ensuring that services are provided in locations and ways which are likely to reduce inequalities in access (i.e. linked to public transport routes and avoiding discrimination by language and internet access).¹

These key messages from NHS Health Scotland regarding health inequalities find an echo throughout the report and in particular to people with specific needs which is addressed in the Models of Care Task Group. These messages should be seen in the light of the guiding principles set out in the Chairman's Introduction for the future development OOH services which should be seen as desirable, sustainable, equitable and affordable. They must also be taken account of in the development of a service specification for OOH services.