Better Health, Better Care: Action Plan

SECTION TWO: HELPING PEOPLE TO SUSTAIN AND IMPROVE THEIR HEALTH, PARTICULARLY IN DISADVANTAGED COMMUNITIES

2.1 IMPROVING SCOTLAND'S HEALTH

This section sets out actions to:

• Increase healthy life expectancy in Scotland
• Break the link between early life adversity and adult disease
• Reduce health inequalities, particularly in the most deprived communities
• Reduce smoking, excessive alcohol consumption and other risk factors to a healthier life

Introduction

Building a Health Service: Fit for the Future (2005) identified the main challenges to health and wellbeing as an ageing population, persistent health inequalities, a continuing shift in the pattern of disease towards long term conditions and growing numbers of people with multiple conditions and complex needs. Better Health, Better Care provides us with an opportunity to refresh our understanding of these challenges and reflect new insights that have emerged over the past few years.

The Scottish Population

Overall, Scotland's population is projected to rise from 5.12 million in 2006 to a high of 5.37 million in 2031. This represents an increase over the medium term of around 5%, driven largely by immigration. Over the longer term however, our population will start to decline, falling below 5 million by 2076.

Changes to the age profile of the population continue to present us with a particular challenge. The number of younger people is projected to decline, whilst the number of people of pensionable age is projected to rise by around 31%, from 0.98 million in 2006 to 1.29 million in 2031. ¹ The number of people aged 75 and over is projected to increase by around 81% from 0.38 million in 2006 to 0.69 million in 2031. These are the "baby boomers" of the post-war period.

In itself, an ageing population tends to increase the demand for healthcare, although its effects are being offset to a significant extent by the fact that our older citizens are on average healthier than they have ever been. The main impact of the age profile is therefore on the type of demand we face, since older people have a higher incidence of chronic disease and on average a greater number of long term conditions.

Long Term Conditions

The increasing number of people with long term conditions presents a major challenge for health and social care services and for society. According to Scottish Household Survey estimates, in 2005/06, 23.6% of adults aged 16 or over reported some form of long-term illness, health problem or disability. By the age of 65 nearly two-thirds of people have developed at least one long term condition, whilst 27% of people aged between 75-84 have two or more such conditions. ²

Someone living in a deprived area is more than twice as likely to have a long term illness compared with someone in an affluent area, and people living with a long term condition are likely to be more disadvantaged across a range of social indicators such as employment, educational qualifications, home ownership and income. The impact of deprivation can also be seen in terms of mental health and wellbeing, with a recent Scottish survey reporting higher levels of mental wellbeing being associated with those on higher incomes.

Figure 1:
All-cause standardised mortality ratios ( SMRs) in council areas.
Men aged 0-64 Scotland 2000-02.
Source: Medical Research Council ³

Health Inequalities

Although people in Scotland are living longer than ever before, our life expectancy remains lower than that in most other Western European countries. Variations in life expectancy have increased consistently over the past 10 years. Men living in Scotland's least deprived areas now have a life expectancy of 10.7 years longer than men living in the most deprived areas, whilst for women, the life expectancy gap is 6.8 years. Figure 1 uses standardised mortality ratios ⁴ to show that the excess of 'premature mortality' in men is largely concentrated in the Clydeside conurbation and in Dundee city. A similar pattern can be found in premature female mortality, although the differences in mortality levels are not quite as large.

Between 1981 and 2001, there was a 62% fall in deaths amongst men from Ischaemic Heart Disease ( IHD) and significant reductions in deaths due to lung cancer, cerebrovascular disease, chronic respiratory disease and accidents. Female mortality under the age of 65 declined by 33%, reflecting significant falls for IHD, breast cancer, cerebrovascular disease, accidents, chronic lower respiratory disease and for suicide. However, at the same time, we have seen a substantial increase in the number of deaths amongst both men and women under the age of 65 from chronic liver disease and increases amongst men in this age group from suicides (up 43%) and deaths linked to mental and behavioural disorders due to the use of drugs and alcohol. These increases are far more pronounced amongst people living in deprived areas and are having a major impact upon overall levels of inequality in mortality between social classes. They suggest a need for a sharper focus on inequalities within efforts to tackle alcohol and drug misuse and improve mental health and wellbeing across Scotland.

Scotland's Opportunity

The new Scottish Government moved quickly to streamline the Cabinet, creating new opportunities for cross-cutting working, in which every portfolio is challenged to contribute to health and wellbeing wherever, whenever and however they can.

The mutual benefits of working together across Government include:

• Education and Lifelong Learning: Shared actions to provide children with the best possible start in life, develop life skills, resilience and confidence, adopt a rights based approach to children's services, improve the way the curriculum addresses health and wellbeing and supports a whole school approach
• Finance and Sustainable Growth: working with local authorities to achieve shared outcomes, improving employment opportunities and opportunities to promote health in the workplace, developing local transport solutions and enhancing the role of the voluntary and community sector in the design and delivery of health-related services
• Rural Affairs and Environment: Shared approaches to the provision of sustainable models of service in remote and rural areas and ensuring the long term environmental sustainability of NHS services
• Justice: Action to improve community safety, health services in Scottish prisons and tackling drug misuse.

By creating Scotland's first ever Minister for Public Health and expanding the health and wellbeing portfolio to include key determinants of health - such as sport and physical activity, housing, homelessness, poverty, social and financial inclusion and regeneration - we have laid the groundwork for a more radical and inclusive approach to achieving shared objectives. These include our goals to tackle poverty and disadvantage and to regenerate our most deprived communities, which are central to reducing health inequalities and meeting our aspirations for health improvement. In particular, it has provided us with the opportunity to make an impact on health and health inequalities, the key driver of these policies.

Key commitments include:

• increasing the supply of good quality sustainable housing, as we work with local government and other housing providers towards a Scotland where everyone will have a secure, warm house at a cost they can afford. A total investment of £1.47 billion has been identified within the draft Scottish budget to support this ambition
• launching a wide-ranging consultation on the future of housing in Scotland to consider how best to free up the supply of housing to buy and to rent, in order to create sustainable, mixed communities and provide a fair deal for first-time buyers, tenants and taxpayers
• preventing and tackling homelessness by ensuring everyone who needs it is able to access appropriate accommodation, advice or support
• ensuring that NHS Boards continue to make progress in achieving Health and Homelessness Standards
• establishing a new fund amounting to £145 million a year within the local government settlement to be deployed by Community Planning Partnerships, to tackle poverty and deprivation and to help more people overcome barriers and get back into work
• supporting a range of large-scale regeneration projects and working with local government and Community Planning Partnerships to target regeneration activities on tackling poverty in our most deprived communities
• working with Community Planning partners towards the eradication of child poverty
• building on work with Community Planning partners on suicide prevention and the delivery of local suicide prevention action plans
• taking the opportunities offered by the Commonwealth Games in 2014 to develop sustainable and accessible community facilities and encourage wider participation in sport and physical activity.

2.2 AN ENABLING HEALTH SERVICE

Introduction

NHSScotland is uniquely placed to provide services and support which build people's capacity to improve their health and wellbeing. This is an enabling role: to help create the conditions in which people have the confidence, motivation and ability to make healthy choices and to provide professional support and advice when required. This has been recognised more clearly in the HEAT targets for 2008/09, which provide a clearer specification of the distinct contribution that NHSScotland will make towards the Scottish Government's strategic objectives and the national outcomes required to achieve a Healthier Scotland.

Mental Health and Wellbeing

Scotland is recognised internationally for some of its work in mental health legislation, services, improvement activities and supporting population mental health. There is, however, more to do to enhance, support and improve people's mental wellbeing so that they are able to flourish and have the confidence and capability to make healthy choices for their lives. We wish to build a country in which we understand that there is no health without good mental health and know how to support and improve our own and others' mental health and wellbeing. Our discussion document, Towards a Mentally Flourishing Scotland, offers an opportunity to shape our future agenda for promoting and improving mental health and wellbeing, preventing mental health problems, mental illness, co-morbity and suicide and support improvements in the quality of life, social inclusion, health, equality and recovery of people who experience mental health problems or mental illness.

Further work is required to address the stigma, prejudice and discrimination that still exists around mental health problems and illness. Part of this approach will involve ensuring that key workers (social workers, teachers, healthcare staff, community workers, employment support staff and other key public services staff) are mental health and mental wellbeing literate, through, for example the roll out of the Mental Health First Aid Programme. This will enable mental health awareness to become an embedded part of their work and practice. Mental health and wellbeing literacy should also include a recovery-oriented approach, so that people with a mental illness are enabled to lead and direct their own wellbeing and recovery.

We are committed to delivering better outcomes for those people who suffer from depression by matching appropriate therapies to the specific needs of individuals. New quality standards will form the basis for the way in which everyone who enters the service is managed and treated. We will assess delivery, and support clinicians and service planners to tackle any inequalities in delivering care. Whilst antidepressants will offer the most appropriate help for some, for many others, particularly those with mild to moderate depression, anxiety and stress, a range of other interventions may be more appropriate and effective. We are therefore targeting NHS Boards to reduce the annual rate of increase of defined daily dose, per capita, of antidepressants to zero by 2009/10 and once achieved, deliver a 10% reduction in future years.

Smoking

We have helped people to quit smoking through the successful ban on smoking in public places and by increasing the minimum age for purchasing tobacco from 16 to 18 years. Our continuing commitment to the anti-smoking agenda will be demonstrated through the publication of a new smoking prevention Action Plan in 2008, supported by an additional £3 million per annum. Building on the key messages from our expert report Towards a Future Without Tobacco (2006) and the subsequent widespread consultation, the new Action Plan will set out national and local actions and focus on reducing the availability, affordability and attractiveness of tobacco products. We will continue to develop a network of smoking cessation services across Scotland, supported by continued investment of £11 million per annum, with NHS Boards being targeted to support 8% of its smoking population to quit successfully by the end of 2010/11.

Alcohol

The negative effects of excessive alcohol consumption continue to dominate the debate on health improvement in our country. Although many people drink sensibly, alcohol is responsible for significant levels of harm to individuals' health, to families and to our communities. Scotland's liver cirrhosis rates are now 2.5 times higher than in England and it is estimated that one Scot dies every six hours as a direct result of alcohol.

In Spring 2008, we will publish a strategy to tackle alcohol misuse, which will set out a series of long term outcomes for cross-Government action to tackle alcohol problems and help change the drinking culture in Scotland. The draft Scottish budget provides an additional £85.3 million over three years to reduce alcohol-related harm - the single largest investment ever in this area. We will drive forward a significant expansion of brief interventions to identify early and nip in the bud health harms from harmful and hazardous drinking. We will also significantly increase access to follow up treatment and support for those who need it, and increase the number of alcohol nurses in acute and primary care settings.

Drug Misuse

We are working closely with Justice Ministers and others on a new National Drugs Strategy to be published in Spring 2008. An action plan will be published alongside the strategy which will summarise the key actions with timelines. The strategy will be based on five themes: better treatment to promote recovery; better drugs education and information; more choices and chances for young people; better outcomes for children affected by family substance misuse; and better enforcement. In 2007/08, the Scottish Government provided £23.7 million to NHS Boards for drug treatment and rehabilitation services and we are working in partnership to ensure that the right structures are in place to support local delivery. The draft Scottish Budget includes a total of £94.3 million for NHS Boards to support drug treatment and rehabilitation services in the period 2008/11.

Diet, Physical Activity and Healthy Weight

In common with other countries we face a significant challenge from rising levels of obesity. This is influenced by a number of factors including diet and physical activity, but critically also psychological, cultural, environmental and global factors that require to be met by a long term and evidence-based approach. Rising levels of obesity bring with them increasing risks of a range of chronic diseases, particularly type 2 diabetes, stroke, coronary heart disease and cancer.

We have identified an additional £11.5 million in the draft Scottish Budget over the next three years to help people, particularly children, tackle obesity through diet and physical activity programmes. Our priorities are:

• Publication of a detailed Food and Health Delivery Plan during 2008 that will set out how we can encourage a healthier national diet in Scotland. This will complement the development of a national food policy for Scotland, that will include healthier food as one of its objectives.
• Work with NHS Boards to ensure consistent weight management strategies across Scotland, with whole community approaches to reducing childhood obesity, including a commitment to the development of sustainable transport solutions.
• Longer term work with our partners to address environmental influences on obesity in line with the best available evidence of effectiveness. This includes developing sustainable places that provide practical, safe and pleasant opportunities to significantly increase walking and cycling trips both for leisure and transport purposes.

Scotland's physical activity strategy Let's make Scotland more active (2003) continues to provide the primary driver for physical activity policy for the Scottish Government and our delivery partners. The Strategy sets a target that 50% of adults and 80% of children should be meeting the recommended levels of physical activity by 2022. This will be a challenge given 2005 data which suggest that 33% of women (16-74), 44% of men (16-74), 74% of boys (2-15) and 63% (2-15) of girls are meeting the target currently, but we aim to double our previous financial investment in this strategy. We also intend that the 2014 Commonwealth Games will act as an inspiration to Scots of all ages to think afresh about their participation in sport and other physical activity.

Sexual Health

Scotland's sexual health is poor. There are rising levels of sexually transmitted infections, particularly in young people under 25 and Scotland has, by Western European standards, high levels of unintended teenage pregnancies, particularly in areas of high deprivation.

Respect and Responsibility, Scotland's national Sexual Health Strategy, was launched in January 2005 with the aim of reducing the number of unintended teenage pregnancies and the number of sexually transmitted infections throughout Scotland. We remain committed to this strategy which will positively influence the cultural and social factors that impact on sexual health. We will support its implementation with annual funding of £5.2 million until 2010/11, to enable NHS Boards and their partners to increase testing and diagnosis, improve education, information and advice and provide local, easily accessible services to patients. The draft Scottish Budget identified £1 million over two years to increase the availability of independent sexual health information in urban as well as rural settings.

Health Protection

The Scottish Government has already introduced to the Scottish Parliament legislation to modernise the law relating to public health to make it fit for purpose in dealing with emerging threats to public health such as SARS and pandemic flu. The Public Health Bill clarifies the roles and responsibilities of the different agencies involved in responding to threats, outbreaks and incidents, and brings Scotland into line with the requirements of the new International Health Regulations.

Levels of childhood immunisation in Scotland are already high, and we have committed to make available a new vaccine capable of preventing most forms of cervical cancer to all girls aged around 12-13 years, from Autumn 2008. In addition, a catch up campaign will make the vaccine available to all girls under 18 years at the time of introduction. Our draft budget commits to fully funding the implementation of the Hepatitis C Action Plan - including providing testing and treatment services to the significant numbers of people in Scotland with undiagnosed Hepatitis C. We have also announced expenditure of over £100 million over the next three years to increase Scotland's resilience against a flu pandemic, by more than doubling our stockpile of antiviral drugs, antibiotics, face masks and respirators.

Public Health

We need to strengthen the engagement of Scotland's public health community in decisions about how and where to invest NHSScotland's resources to improve health and prevent disease. We will therefore review and clarify the role and expected contribution of Directors of Public Health in ensuring that the major service and financial strategies of NHS Boards meet these objectives, in line with NHS Boards' corporate responsibilities for protecting and improving public health. We will also ensure that Community Health Partnerships are able to call upon adequate professional public health support and advice and ensure that decisions about service change and investment across NHSScotland are more routinely informed by health impact assessment. To support this activity, we will facilitate the development of regional managed public health networks, supported by action to refocus and clarify the roles of special health boards in relation to public health. These networks will be responsible for providing leadership and professional development opportunities for staff working in public health and developing capability and capacity in public health across NHSScotland to ensure that major finance and service plans take full account of their potential impact on the health of the local population.

Social Marketing

Public information remains an important feature of our integrated approach to health improvement and we are working in partnership with NHS Health Scotland,
NHS 24, Food Standards Agency (Scotland), and local NHS Boards to develop a more
co-ordinated approach to the design and delivery of health improvement campaigns. This will focus on the priority health improvement areas in a targeted, coherent and joined-up way across all key partners and seek to empower and enable people to make changes in their lives.

We will:

• Address stigma, prejudice and discrimination around mental health
• Enhance the mental health literacy of key workers such as teachers, social workers, community staff, employment support officers and health care staff
• Publish a new smoking prevention Action Plan in 2008 supported by additional funding of £3 million per annum and continued investment in a network of cessation services
• Expand significantly access to treatment and support for those with alcohol problems as part of a new strategy for tackling alcohol misuse to be published in Spring 2008 and supported by additional investment of £85.3 million over three years
• Support drug treatment services and work with partners to introduce a new drugs strategy and delivery framework in 2008
• Improve Scotland's diet through a Food and Health Delivery Plan and the development of a national food policy for Scotland
• Tackle obesity by delivering consistent weight management strategies across Scotland
• Work with partners to address the environmental influences on obesity including the greater provision of opportunities for safe walking and cycling
• Implement Scotland's sexual health strategy and increase the availability of independent sexual health information
• Modernise health protection in Scotland by taking forward a new Public Health Bill in the Scottish Parliament during 2008
• Introduce an immunisation programme to combat cervical cancer available to all girls aged 12-13 years from Autumn 2008 and introduce a "catch up" campaign for girls aged up to 18 years at the time of introduction
• Enhance treatment and testing services for Hepatitis C
• Commit more than £100 million over three years to increase Scotland's resilience to a flu pandemic
• Review and clarify the role of Scotland's public health community to ensure that major financial and service strategies improve health and prevent disease
• Develop a coherent, integrated approach to social marketing covering key health promoting messages

2.3 THE BEST POSSIBLE START

Introduction

By getting it right in the early years and supporting good health choices and behaviours amongst children and young people, we can set them on a trajectory where they can sustain good health throughout their lives. Making the best possible start is therefore at the forefront of the future health agenda.

Setting a New Direction for Early Years Policy

The Scottish Government has announced its intention to work with local government and other partners to develop a long term early years strategy by Autumn 2008. This will establish a framework within which we will work together to deliver effective early years support for children and young people, taking a preventative approach and allowing any problems to be identified and tackled earlier and more effectively. This will provide an opportunity for action to give children the best possible start through integrated, cross-Government approaches which build parenting and family capacity, create supportive environments and develop professionals and ways of working that enable us to meet the individual needs of children and their families.

Getting it Right for Every Child

Getting It Right For Every Child is a national programme that is changing the way adults and organisations think and act to help all children, young people and their families grow, develop and reach their full potential. Getting It Right For Every Child is about universal services being pro-active in assessing and addressing the child's needs and providing, or arranging for the provision of, appropriate support for the child at an early stage. It puts children's needs, experience and wishes at the heart of the process. Parents, carers and those with a relevant interest who can contribute are engaged in assessment and planning as far as this is appropriate in each case.

Getting It Right For Every Child promotes the streamlining of assessment and decision making processes so that children and families do not experience duplication or confusing systems. It brings support to the child rather than the child or family having to navigate the maze of separate agency services. Given the impact of parenting and parental stresses on the quality of care and interaction with children, this needs to be effective at a family level and bring about a culture shift within children's services so that they focus on the overall needs of the child. Our main challenge is to re-engineer services so that they work together more effectively, by assessing and making changes to the cultures, systems and practices in NHSScotland and its partner organisations. In addition, we will work with adult services to help shift their outlook so that they focus more intently on the needs of children within the family unit.

Our Most Vulnerable Children

We need to ensure a particular focus throughout early years and childhood on children who we know to be the most vulnerable in terms of health and wellbeing. These include disabled children, children who offend, children in homeless families, who are looked after or accommodated, who live in substance misusing households, are at risk in situations of domestic abuse and violence or live with parents who have mental health problems or learning disabilities. In many instances, these risk factors overlap and are strongly associated with poverty and deprivation. The new early years strategy will have a particular focus on improving outcomes for such groups and we will be working to ensure there is a continuum of care for vulnerable children and young people that supports them well beyond their early years.

Health for all Children (Hall 4) is a surveillance, assessment and need identification programme which provides NHS Boards with the foundation for working with young children, and the means of access to more intensive support for those with greater needs. We are working with NHS Quality Improvement Scotland to ensure its successful implementation and to support new ways of offering support through inter agency working.

We will work to ensure that our new strategies on drugs, alcohol and smoking prevention support the broader early years strategy and include approaches to protect children from the effects of substance misuse. This will, for example, include a commitment that NHS Boards will identify a lead maternity care professional to help mothers stop drinking or smoking during pregnancy. In addition, we will implement the recommendations of Looked After Children and Young People: We Can and Must Do Better to improve the emotional, mental and physical health of these children and ensure that NHS Boards provide the support that the children require, including access to primary care and dentistry. As part of this commitment, NHS Education for Scotland has been commissioned to develop a competency framework to support the training and development of specialist nurses for looked after and accommodated children's nurses.

Pre-Conception

Many women and teenage girls experience unintended or unwanted pregnancies. While pregnancy and parenthood are positive choices for some young people, for others unintended pregnancies and parenthood are associated with negative social and psychological consequences such as incomplete education, poverty, social isolation and low self-esteem. The Sexual Health Strategy, Respect and Responsibility, which contains a key aim to reduce the number of unintended pregnancies, recognises that ensuring success depends on involving parents, carers, young people and partners as well as key clinical services.

We need to ensure good clinical services and easy access to information throughout Scotland and that this is done in a context of promoting a positive and respectful approach to sexuality and sexual relationships.

Antenatal Care

NHSScotland's antenatal services mean that it is uniquely placed to develop early relationships with Scottish families and to identify risks and offer a preventative approach to health care. We need to strengthen antenatal care so that we get better engagement with families who are at higher risk of poor outcomes, paying particular attention to the needs of teenage mothers who have traditionally started antenatal support later and had less of an engagement with elements of the service such as antenatal classes.

Maternity Care

The Maternity Services Action Group is currently reviewing and updating the national maternity policy set out in The Framework for Maternity Services (2001) and the subsequent Expert Group on Acute Maternity Services (2002). We remain committed to the provision of women and family-centred services within a network of care, with the bulk of that care being offered as locally as possible by clinically competent professionals. The Keeping Childbirth Natural and Dynamic ( KCND) programme is a 3-5 year programme which aims to provide evidence based care, reduce unnecessary intervention, ensure informed choice for women and introduce multi-professional antenatal, intrapartum and postnatal care pathways which will enable the service to better identify and support vulnerable women and families.

Supporting Parenting

Most of a child's needs in their earliest years are met by their parents, families and wider social networks. Children who live in families where parental capacity is high and which have strong family and social networks often go on to enjoy better outcomes later in life. Whilst most, if not all, parents require and value a degree of support as they begin parenting, some require additional help to build the resilience to support the development of their children. The early years strategy is putting a particular emphasis on building parental capacity and health services such as home visiting and community nursing will be a strong focus of this work.

One of the key areas where parents influence child health during pregnancy and the early years is infant nutrition. Our new Food and Health Delivery Plan which will be published in 2008 will therefore include actions to help promote nutrition in women of childbearing age and pregnant women and support breastfeeding and healthy weaning in infants. This includes the provision of free fruit and vegetables for pregnant women and pre-school children. NHS Boards will be targeted specifically to increase the proportion of newborn children who are exclusively breastfed at 6-8 weeks to 33.3% in 2010/11 and we will appoint an Infant Nutrition Co-ordinator to promote good infant nutrition at a national level.

Oral Health

Standards of oral health in children have a strong relationship with deprivation and can be a sign of wider issues related to the quality of care and support a child is receiving. There is clear evidence that young children with decay in their baby teeth are very likely to have problems with their adult teeth and that tooth decay can be prevented by establishing good habits in terms of diet and oral care at an early age. That is why we have introduced a new target for NHS Boards to ensure that 80% of all children aged 3-5 years are registered with an NHS dentist by 2010/11.

In December 2007, a new Schools-based preventative dental service was launched in NHS Fife. It will roll out to Tayside and Ayrshire and Arran in early 2008 and later to other NHS Board areas. Under the umbrella of the Childsmile programme, this will see fluoride varnish being applied to children's teeth during their first year at school and, in the second year, supplementing this with the application of fissure sealants as appropriate. Further support will be provided by expanding the current Childsmile programme aimed at very young children to the island NHS Boards and one other rural Community Health Partnership and a scheme in rural parts of Grampian which better integrates school and community based dental services in order to improve continuity of care.

Evidence Based Interventions

We will look at the evidence on what can be done to improve the wellbeing of children in deprived areas in the light of recent data published by UNICEF and studies linking child wellbeing with income inequality. Our first step will be to publish a review of available evidence, followed by a programme of work with NHS Boards to implement those evidence based interventions that will mitigate the effects of inequality on wellbeing. We will adopt a similar approach to early interventions, publishing a review of the current evidence on the effects that these might have on health outcomes and working subsequently with NHS Boards to begin putting new programmes in place by Summer 2009.

Integrated Children's Services Plans

Integrated Children's Services Plans have a vital role in ensuring that local authorities, NHS Boards and other relevant agencies and organisations come together to plan services and support for children and families, including the most vulnerable, in each local authority area in a co-ordinated way. They bring together a number of core statutory and other planning requirements for children and young people into a single plan. These include the relevant child health plans.

All local partners and relevant organisations are involved in preparing the plan, including, amongst others, the local authority education, social work and housing departments, NHS Boards, police, children's reporter services and voluntary organisations. The planning process determines local needs for services and support; how local agencies and organisations will work together to deliver and develop services in response to these needs; the most effective use of staff and other resources; and how services will be monitored and evaluated in terms of the outcomes for children, young people and their families. A shared local ownership of the Integrated Children's Service Plans and the planning process will ensure the best possible outcomes for children and families.

Child Centred Approaches

We want to see a child centred approach to the planning and delivery of children's services. This includes the rights of children to be heard and heeded as well as the right to privacy and confidentiality, health, education and safety.

Figure 2: Influences on Health from Conception to Adulthood

Schools

Health-promoting schools have developed in the context of community planning and Integrated Children's Services in recognition of the role that schools can play in promoting and sustaining the health of children and the wider community. The place of health promotion in schools and the importance of sound nutritional guidance to ensure accessible high quality food and drink within schools has now been enshrined in legislation with the passing of the Schools (Health Promotion and Nutrition) (Scotland) Act 2007. The Act places a duty on Scottish Ministers and local authorities to endeavour to ensure that schools are health promoting. The Act goes on to state that a school is 'health promoting if it provides on its own or in conjunction with health boards, parents or any other person, activities, an environment and facilities, which promote the physical, social, mental and emotional well-being of pupils'. Consequently, health promotion will permeate every aspect of school life.

We have already increased provision of free healthy school lunches to all Primary 1-3 pupils in our trial scheme in five Scottish Local Authority areas. In 2009/10, provided the evaluation of the trials is positive, legislation will be introduced to allow extension of the nutritious free school meals to all pupils in P1 to P3. Assuming the legislation is passed, local authorities will provide free school meals to all P1 to P3 pupils from August 2010. Subject to necessary legislation being passed, entitlement to free school meals will be extended to all primary and secondary pupils of families in receipt of both maximum child tax credit and maximum working tax credit from August 2009.

Through the Curriculum for Excellence children will have opportunities to take part in physical activities and learn about health and wellbeing and all teachers will have the responsibility of promoting aspects of health and wellbeing from age 3-18. Our Active Schools initiative aims to promote healthy, active and well-motivated communities providing new opportunities to get involved in active pursuits. When combined with the benefits of the Reaching Higher sport strategy and attracting the 2014 Commonwealth Games to Glasgow, our young people will have increasing opportunities in sports.

There are further opportunities to provide more effective health care in schools through a range of agencies and health care professionals such as midwives, mental health nurses and Allied Health Professionals. We shall continue to work with our partners to carry out our duties to implement the Education (Additional Support for Learning) (Scotland) Act 2004 and to ensure that children with additional support needs receive appropriate support from health care staff. Healthcare support for schools and teachers will therefore be increased, starting in those areas with the highest concentrations of vulnerable children. Care will be delivered in partnerships involving children, families and teachers and using a multidisciplinary approach. This will be part of a continuum of care for children, young people and their families as they move through the school years, ensuring that transitions are as smooth as possible, and that those most vulnerable receive the services they require.
Figure 2 sets out the influences on health from conception to adulthood and their possible impact on an individual's potential.

Child and Young People's Mental Health

The Scottish Government is committed to improving the mental health and wellbeing of children
wide-ranging programme of improvement across all aspects of care, services and support. We will implement the Mental Health of Children and Young People Framework for Promotion, Prevention and Care by 2015. We will also:

• reduce the number of admissions of children and young people to adult beds by 50% by 2009
• increase dedicated inpatient beds nationally from the current 44 to 56 beds by 2010
• provide mental health training for all those working with, or caring for, looked after or accommodated children and young people by 2008
• ensure that a named mental health link person is available to every school by 2008 to better inform all concerned and help identify needs at the earliest point
• provide training for child psychotherapy through NHS Education for Scotland.

Specialist Children's Services

Delivering a Healthy Future: Action Framework for Children and Young People's Health in Scotland (2007) sets out a 10-year Action Plan to assist hospital and community-based health services to respond to the challenges of improving and maintaining children's health in the 21st century. In line with this framework, we will publish in 2008, a National Delivery Plan for specialist children's services. Managed Clinical Networks for children's services will define and develop services for children at a national, regional and local level and we are committed to developing new hospitals in Glasgow and Edinburgh by 2012 and sustaining four major children's hospitals across Scotland in Glasgow, Edinburgh, Aberdeen and Dundee.

We will:

• Work in partnership with local government and others to develop a long term early years strategy by Autumn 2008
• Work within the framework of Getting it Right for Every Child to change cultures, systems and practices in NHSScotland and its partner organisations
• Ensure the widespread implementation of Health for All Children, supported by NHS Quality Improvement Scotland, to enable intensive support for those with greatest needs
• Continue work to protect children from the effects of drugs, alcohol and smoking
• Implement the recommendations of Looked After Children and Young People: We Can and Must Do Better
• Develop a competency framework through NHS Education for Scotland to support the development of specialist nurses for looked after children
• Strengthen antenatal care to better engage with parents with higher needs, in particular teenage mothers
• Develop actions to promote infant nutrition within the new Food and Health Delivery Plan
• Target NHS Boards to improve breastfeeding rates and appoint an Infant Nutrition Co-ordinator at national level
• Roll out the new schools based preventative dental service
• Publish reviews of current evidence on early interventions, particularly those that will mitigate the effects of inequality on wellbeing and develop a programme of work that will implement them across NHS Boards
• Extend entitlement to free school meals, subject to legislation being passed
• Increase healthcare support for schools and teachers starting in those areas with the highest concentrations of vulnerable children
• Implement the Mental Health of Children and Young People Framework for Promotion, Prevention and Care by 2015
• Publish a National Delivery Plan for Specialist Children's Services in 2008
• Sustain four major children's hospitals across Scotland, including new hospitals in Glasgow and Edinburgh by 2012

2.4 TACKLING HEALTH INEQUALITIES

Introduction

Poor mental and physical health is both a cause and consequence of social, economic and environmental inequalities. Risk factors include individual behaviours such as smoking, alcohol misuse, diet and inactivity and also aspects of the wider social, economic and physical environments that shape such behaviours, including educational achievement, income / relative poverty, the work environment and unemployment. Inequalities can also cross the generations, with children born and brought up in disadvantaged families being more likely to experience poorer health in later life.

Ministerial Task Force

A Ministerial Task Force on Health Inequalities led by the Minister for Public Health has been established to identify and prioritise practical actions to reduce the most significant and widening health inequalities. Our national discussion provided an opportunity to inform the work of that Task Force and there was an enthusiastic response from all concerned. The key message was that effective action requires us to work across Government and in conjunction with our partners in the public, private and voluntary sectors in order to tackle both the causes and consequences of health inequalities. The outcomes agreed with local authorities provide a real opportunity to make significant progress with this shared agenda.

The Task Force will report to Cabinet in May 2008 with proposals that will:

• reduce factors in the physical and social environments in Scotland that act to perpetuate health inequalities
• build the resilience and capacity of individuals and communities to improve their health
• enhance the contribution that public services can make to reducing inequalities.

The Task Force has adopted some key principles to drive its work. These are:

• 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 and 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 a good 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 Task Force is setting priorities which include:

• an emphasis on supporting families and children in the very early years
• enhancing mental health, wellbeing and resilience
• the importance of education and skills, income and employment status as factors underlying inequalities in health
• a multi-agency approach in which public, private and third sectors work together, with strong Government leadership.

Delivering reductions in health inequalities will require a continuous improvement approach, with clear definition and performance management of outcomes. All Government policies will need to be assessed for their impact on health and demonstrate how they are contributing to reducing health inequalities and we will support this by the development and application of a systematic process for such assessments.

Staff and services need to engage the individuals and communities they work with if they are to build the resilience and capacity that are necessary for change. Community planning partnerships will be vital to local delivery and ensuring that resources are allocated on the basis of need.

Early Years

Our approach to providing children with the best possible start, described in the previous section, lies at the heart of the approach being considered by the Ministerial Task Force. This underpins our commitment to extending the entitlement to free school meals and introducing free fruit, vegetables, milk and vitamins for low income families.

Within the context of universal service provision, there is a clear need to increase the intensity of the support provided for particularly vulnerable children and families and work more effectively with partners as part of the forthcoming early years' strategy to address their needs in a holistic way. As detailed previously, NHSScotland will work with partners to identify our most vulnerable children and take action to scale up and replicate those interventions that we know can make a difference, such as smoking cessation services for pregnant women and programmes that encourage parents to play with their babies and promote wellbeing from an early age.

Abolition of Prescription Charges

Prescription charges are a tax on ill health. The Scottish Government is therefore committed to abolishing these charges and ensuring that those who require medication, particularly those suffering from long term conditions, are not deterred by cost. The charges will therefore be reduced significantly over the next 3 financial years, beginning in April 2008 and abolished completely by April 2011. Removal of this barrier to good health will support people to make choices which are good for their health and wellbeing. The draft Scottish Budget identifies £97 million to support these changes.

During this time the cost of prescription pre-payment certificates will also reduce significantly. This will benefit those with long term conditions, particularly those who require regular or large numbers of prescriptions.

Primary Care

The Ministerial Task Force has identified the need to place more emphasis on tackling health inequalities through primary care. This requires the allocation of resources to better reflect the additional workload required to meet the needs of people in disadvantaged areas. The new Scottish Enhanced Services Programme for Primary and Community Care reflects the Scottish Index of Multiple Deprivation and will therefore weight resources more significantly towards such areas than previous methods of resource allocation.

We will also look specifically at those areas of the GP contract that we believe do not adequately reflect the additional needs of GP practices in disadvantaged communities. In particular we will engage with the professions on future changes to the Minimum Practice Income Guarantee and Quality Outcomes Framework for GPs to ensure that the distribution of existing and future resources better reflects the balance of workload that is required to help us tackle health inequalities in Scotland.

The new community pharmacy contract also offers opportunities to better target resources towards areas of greatest need. This is particularly true of the Public Health Service which could be used to improve access to smoking cessation or sexual health services or to promote the benefits of the Healthy Start and Keep Well programmes.

Anticipatory Care

The Task Force has already made it clear that it wants to see a more widespread application of anticipatory care approaches across Scotland. Working with partners within Community Health Partnerships, we need to pilot, assess and roll out if successful, a range of new approaches to tackle health care priorities such as reducing the risks of alcohol to the health of young people, improving the physical health of people with mental illness or a learning disability and supporting early intervention and rehabilitation for those with disabilities, multiple long term conditions and complex needs.

The Scottish Government will continue to support the Keep Well programme, so that it has the time to prove that it can reduce health inequalities in cardiovascular disease by the year 2010 by increasing the rate of health improvement among high risk groups, aged 45-64, living in the most deprived communities. This programme complements the commitment to extend screening and health checks, including the development of the "Life Begins" programme.

Keep Well NHS Lanarkshire Keep WellNHS Lanarkshire is a primary care based anticipatory care programme providing health checks to individuals aged 45-64 years living in Airdrie, Wishaw and Coatbridge. Through a dedicated focus on better engagement between the NHS and service users, over 5,000 have been encouraged by letter, phone call or home visit to attend their Keep Well Health Check. This diverse one-stop assessment that identifies clinical, lifestyle and socio-economic needs has prompted access to a range of services across partner agencies, ranging from drug treatments for previously undiagnosed long-term conditions to joining of local weight management groups and smoking cessation classes.

Targeting Support

Where appropriate, we will take specific action to focus on the needs of particular groups. This will include, for example, action in partnership with Defence Medical Services Department and the charity Combat Stress to meet the mental health needs of serving and former armed forces personnel.

Effective approaches to reaching and engaging with the most vulnerable groups of people to improve their physical and mental health need to be identified and scaled up. This might include actions to support people in institutional settings, such as care homes or secure care, groups such as homeless people who may not otherwise be reached by traditional approaches or people who experience discrimination in whatever form. We will use proven approaches to continuous improvement to enhance the rate at which we identify and implement good practice across Scotland, with a particular focus on the supporting NHS Boards to deliver against the targets for tackling health inequalities that are included within the HEAT performance management framework.

Prisons and Offender Health Care

Offenders and ex-offenders tend to have poorer physical and mental health, lower standards of dental health, greater prevalence of substance misuse and higher rates of conditions such as Hepatitis C. Within a wide ranging strategy to tackle health inequalities, it therefore makes sense for NHSScotland to review its approach to the health and health care of offenders and ex-offenders and to consider what more can be done in prisons and custody settings to ensure continuity of care during the transition between prison and the community. Subject to the normal controls around patient confidentiality and consent, this requires us to improve the exchange of information between healthcare professionals working inside and outside of Scotland's prisons.

Employability

The workplace provides an ideal opportunity for the primary prevention of ill health and the promotion of health and wellbeing. We are determined to re-energise Scotland's healthy working lives agenda, working in partnership with employers, unions, local authorities and other stakeholders such as HSE Scotland. We will support employers to ensure safe and health promoting environments and ensure that all NHS Boards adopt existing good practice in working with community planning partners and employability services to enable people to retain or return to work. The Ministerial Task Force on Health Inequalities is clear that all NHS Boards should commit to implement fully the recommendations of the Framework for Adult Rehabilitation which includes actions to improve vocational rehabilitation. A clear plan for action should be agreed by the end of 2008, which describes the unique contribution that NHS Boards can make at local level to help people return to work as part of local Workforce Plus partnerships.

Third Sector

The Scottish Government is committed to improving the capacity of the third sector to reduce health inequalities. We are continuing to implement the recommendations of the 2006 report of the community-led task group, by supporting commissioners and funders on the one hand and community-led services on the other, to work better together in achieving shared outcomes. Throughout the national discussion we heard from people working in, or benefiting from, third sector organisations and initiatives, who were concerned about their ability to provide or receive these services over the longer term. We will therefore establish a national review of the way in which NHSScotland supports these organisations to explore ways in which we can enhance the sustainability of programmes that demonstrate a clear benefit for patients and their carers.

Health Promoting Health Service

Given the proportionately greater use of acute services by patients from deprived communities, health promotion in acute care settings offers a major opportunity to improve health and reduce health inequalities. We will therefore build on existing good practice by identifying some simple but effective actions that can be taken to improve the health of patients, staff and visitors. This includes screening accident and emergency patients for harmful or hazardous drinking and encouraging them to cut down, promoting breastfeeding and providing healthier food and drinks. There is unique opportunity to develop this agenda in partnership with staff organisations, building, for example on the success of Nutrition Now, the Royal College of Nursing's clinical campaign, developed in conjunction with patient groups to raise standards of nutrition and hydration in hospitals.

A Corporate Citizen

NHSScotland has a huge opportunity to act as a force for change in shaping and influencing healthy environments far beyond hospital settings. It is a major employer and investor, has a huge influence on the built environment and, through its approaches to issues such as travel, energy consumption and waste disposal can make a significant contribution to the Scottish Government's objective of securing sustainable economic growth. Innovative employment and investment schemes in particular can act as a major source of regeneration in some of our more deprived areas. By offering pre-employment training and first destination work opportunities, particularly for those on benefits, NHS Boards can directly support individuals to improve their prosperity and their prospects for better health and wellbeing. Within the next 12 months we therefore expect NHS Boards to participate in a network of pre-employment services for people on benefits who require support to return to work.

NHS Lothian Health Care Academy NHS Lothian is part of the consortium behind the Edinburgh City Jobs Strategy. This aims to increase the rate and speed of disadvantaged groups moving into sustained employment within the city. The Health Care Academy is a six week pre-employment course that helps prepare people for a clinical position and a career in the NHS. The course runs three days a week and includes two clinical placements, practice interviews and training on issues such as basic life support, communication and confidence building. In the past two years, 79 people have been trained through the Academy. 64% achieved permanent employment in the NHS, voluntary or social care sectors whilst a further 7% went on to Higher or Further education.

We will:

• Publish cross-Government proposals from the Ministerial Task Force on Health Inequalities in May 2008 to tackle Scotland's most significant and widening health inequalities
• Phase out prescription charges and abolish them completely by 2011
• Work with partners to reform the GP contract to ensure that it adequately reflects the needs of GPs working to improve patient services in deprived areas
• Extend the use of the Community Pharmacy Public Health Service to improve access to support and advice in deprived areas
• Pilot, assess and roll out new approaches to anticipatory care
• Support the roll out of the Keep Well programme to reduce inequalities in cardiovascular disease
• Introduce a programme of "Life Begins" health checks
• Work with partners to meet the mental health needs of serving and former armed forces personnel
• Strengthen our ability to assess and replicate proven approaches to tackling health inequalities in both physical and mental health across Scotland
• Review NHSScotland's approach to the health and healthcare of offenders and ex-offenders
• Ensure that all NHS Boards implement the Framework for Adult Rehabilitation, and work with partners to support people in returning to work
• Improve the capacity of the third sector to reduce health inequalities
• Roll out simple but effective health promoting interventions within acute care settings
• Work with staff groups to support and encourage NHSScotland's staff and their families to make healthy choices
• Support NHS Boards to participate in a network of pre-employment services for people on benefits who require support to return to work
• Implement a systematic process for assessing the impact on health and health inequalities of health and work with partners to extend this approach to all Government programmes

"improvement can only be achieved through shared ambition and effective joint working"

NHS BOARD