A Chance to Change Scotland: Chance 2 Change Expert Reference Group with Lived Experience - report

Appendix 4

The Primary Care Health Inequalities Short Life Working Group

Draft Recommendations

Version shared with Chance to Change, November 2021

What is Primary Care in Scotland?

Most of the time, people look after their own health and wellbeing in whatever ways are best for them. Most people also rely on their family and community to support them. Primary health care professionals offer extra support when it is needed.

Primary care is provided by many different health care workers. These include, GPs, pharmacists, nurses, link workers, health visitors, optometrists (opticians), physiotherapists, mental health workers, dental practitioners (dentists), podiatrists (chiropodists), and many others. They work together to give people the right advice.

Primary care is delivered 24 hours a day, 7 days a week. When people need urgent care outside of standard working hours, out of hours services provide people with the help they need. When primary care professional cannot offer the correct support, specialist advice or services (such as from a hospital doctor) may be sought.

Health is caused by a wide range of different factors which are often called 'determinants of health'. These include such things as genetics, diet, exercise, wealth, employment, or being exposed to things in your environment. Health inequalities are the unjust and avoidable differences in people's health across the population and between specific population groups. These usually are caused by 'social or economic determinants' of health. People living with greater poverty, discrimination, disadvantage and prejudice with lower access to quality housing, education and employment may live shorter lives, and have fewer years spent in good health, without disability (lower healthy life expectancy).

Empower and develop the Primary Care Workforce

How to create the right conditions for better primary care. How we support the workforce and leadership.

• Put in place a national Fair Health Scotland programme to educate health care workers about health inequalities. This will involve an educational programme (called fellowships) to build a network of leaders who understand the bigger picture of poverty, racism, discrimination, injustice and privilege in providing care. Health care workers will learn the skills to plan better care with other agencies and professionals and, most importantly, with individuals and communities themselves. The programme would bring more health care workers to vulnerable communities where they are needed.
• Enhanced Service for Health Inequalities: The Scottish Government should fund GP practices to be able to offer additional services to vulnerable individuals and communities. This would be used to give better access to care, improve the patient experience, offer more support to people with additional challenges and to improve health and wellbeing. Funding would be targeted to the areas that need it the most, using the best evidence available. This would help to deliver many of the other recommendations in this document.
• People with complex health and social care needs often need care from different services and professionals. It is better if that care can be planned in a joined-up way. We should support primary health care professionals to work more together to plan and deliver care for people who have complex health and social care needs. This will require enough time and training. Joined-up care planning can bring together primary health care workers with social care, mental health, link workers, education, police, carers, housing, families and individuals themselves.
• Invest in the training and resourcing of health and social care staff for digital inclusion:

All primary care staff should understand the benefits and the limitations of digital care. They should understand the challenges people face with digital technology and how to help them. They should have the skills, confidence and equipment to make the best use of digital technology to support people. This is especially important to help people learn the skills to look after their own health, for example through online communities, peer support groups, home monitoring, YouTube instruction videos, etc.

• Make health inequalities a core part of the new GP 'Expert Medical Generalist' role:

The work of GPs is changing as more types of health care workers become involved in primary care. In the future, GPs will be more focused on supporting people with complex and difficult health care problems. This is called the Expert Medical Generalist role. GPs should understand and take into account the challenges caused by health inequalities when they work in this way.

Leadership, Structures and Systems

Tackling sources of inequalities and inequity within our systems and communities.

• Strengthen national leadership: The Scottish Government should consider options, including a new Health Inequalities Commissioner, to strengthen leadership for health inequalities in health and social care. Every means across government should be used to drive change and hold system leaders and managers accountable for tackling health inequalities.
• Create a national priority to reduce the harm caused by long term physical and mental health conditions on disability and healthy life expectancy: The NHS, the Scottish Government, and new National Care Service should make this a priority. Everyone needs to work together to use all their resources to empower individuals to stay well, supported by their families, carers and community. This priority should be built into the contract for GPs.
• Ensure that social and financial inclusion support and advice are available through primary care settings: The Scottish Government should extend its support for roles like Community Links Workers, Welfare Advisors and Mental Health Workers to make them more easy to access through primary care. These workers link people to services in their community, such a social, financial and wellbeing support, which in turn can have a positive effect on their overall health and wellbeing.
• Contracts with Health and Social Care Partnerships and GPs should have health inequalities written into them: Inequalities and equity should be included in current and future commitments and decisions about health care planning. Equality Impact Assessments should be mandatory for Health and Social Care Partnerships, in line with their statutory duties.
• Funding: any changes to how funding is used and spread out across primary care services should take account of socio-economic inequalities, rural issues, equity of access and unmet need. The Scottish Government should also commit to monitor unintended consequences or risks which a new funding model could cause.
• Transport and health: The Scottish Government should create a group which will review and take action on transport and health and should make improvements to how health and transport services interact. This should tackle inequalities and ensure that patients can access health services more easily, when they need them, and in a way that environmentally friendly.
• Recognise that people's access to digital technology can have an influence on their health: Technology can itself cause or improve health inequalities. It should be treated as a determinant of health alongside socio-economic and environmental factors. The Scottish Government and Public Health Scotland should look at ways to include access to technology and digital skills when they look at inequalities.

Empower and Enable People and Communities

Individuals and communities should have the knowledge needed to use health care and be active participants in problem-solving.

• Develop a network of expert groups of individuals with lived experience of health inequality: This would help to ensure health inequalities and people who experience them are included from the start of the policy making or planning services . This should take account of social, financial disadvantages and other characteristics related to social inequality. GP Practices should support and use these groups so that they can engage more meaningfully with their communities.
• Invest in wellbeing communities:

The Scottish Government should support the development of a more coherent and long-term approach to local action to reduce inequalities. Communities have different social and material assets . Partnerships between communities, third sector, public sector, and the NHS and social care system should prioritise and promote peer-to-peer support, shared community spaces, local groups & activities and other community infrastructure to protect and promote mental health, resilience and wellbeing. GP practices should be part of wellbeing communities.

• Pilot and implement a national programme of digital empowerment for health through community-based peer-supported learning programmes. These would, e.g., enable patients to safely use digital networks for peer support, to access health resources on-line, and to gain hands-on experience of remote appointments.
• Raise awareness of health care rights and responsibilities: People should be informed about their rights and responsibilities in relation to health care. They must be provided with information that is easy to access and understand. Information would include how to register with a GP and use health care appropriately and cover a range of other services and resources to support their use of primary care. The third sector and community organisations are important to this.

Data, Evidence and Knowledge

Make sure that information about inequalities and health is publicly available where appropriate.

• Publish high quality, accessible information on health inequality: National and local organisations should improve the collection, quality and transparency of data on inequalities. This should include how different forms of inequality can interact and impact on each other.
• Organisations should also identify and try to fill gaps in data. These bodies should also review how they publish and report on data and information about health equity and health inequalities to ensure that information is clear and is easy to find and understand so that communities and individuals gain knowledge to help them have more power over decisions which affect them.
• Develop methods for recording, assessing and reporting on unmet health needs in general practice: this is very important if the way resources are shared out is to truly reflect the needs of different communities and individuals.
• Provide communities with data and knowledge to empower them to demand or make changes that matter to them: Communities should have access to clear and relevant information that is easy to understand. This should help them to see the links between health and its social and environmental causes. It should allow communities to understand clearly the reasons why some communities in Scotland are unfairly affected by early deaths and shorter healthy life expectancy.
• Commission research into how things which can make it difficult for some people to use or find the healthcare they need may play a part in worsening healthy life expectancy related to socio-economic inequalities. This would look at: why different groups of people don't get support they need; the effect of long waiting times and delays in treatment on serious conditions; why some people are missing out on health care; what are the effects of targets for things like waiting times; and why some people harm themselves through drugs, alcohol, binge eating or even suicide because they are unable to access the care and support they need. Data on missed appointments and 'missingness' should be recorded and reported: People who provide health care need to understand which groups of people are more likely to miss appointments and which people do not use health services. This is important if care is to be safe, effective and equitable .s. Some research has already been done in Scotland to look at who does not engage with healthcare, what impact this might have on their health and what can be done to address this problem.
• More ways need to be developed to support better collaboration between professional involved in public health and staff in primary care This should help to improve the health of the overall. This would build on progress during COVID-19 to share information and understanding more effectively and routinely.
• Improve how health data in general practices is recorded in deprived communities: The Scottish Government should test the impact of providing a sample of GP practices in deprived areas with dedicated support to improve the quality and accuracy of the information they record about patients and to improve efficiency. One aim of this would be to identify practical measures to improve data about demand for healthcare.
• Work to deliver the Scottish Government's commitment to track and understand the impacts of policies to reform Primary Care should more explicitly address health inequalities.

Abbreviations used in the Report

ACEs – adverse childhood experiences

ASIST – Applied Suicide Intervention Skills Training

BMA – British Medical Association

C2C – Chance 2 Change

CHI number – Community Health Index number

CLW – Community Links Worker

COVID-19 – Coronavirus disease

EMG – Expert Medical Generalist

GP – General Practitioner

HCE Survey – Health and Care Experience Survey

HIIC course – Health Issues in the Community course

HRT – Hormone Replacement Therapy

HS - Hidradenitis Suppurativa

NCS – National Care Service

NHS – National Health Service (Scotland)

PCIPs – Primary Care Improvement Plans

SLWG – Short Life Working Group