Equally Well: Report of the Ministerial Task Force on Health Inequalities

EXECUTIVE SUMMARY

KEY POINTS

• Health inequalities remain a significant challenge in Scotland.
• The poorest in our society die earlier and have higher rates of disease, including mental illness.
• Healthy life expectancy needs to be increased across the board to achieve the Scottish Government's overall purpose of sustainable economic growth.
• Tackling health inequalities requires action from national and local government and from other agencies including the NHS, schools, employers and Third Sector.
• Priority areas are children, particularly in the early years, "killer diseases" such as heart disease, mental health and the harm caused by drugs, alcohol and violence.
• Radical cross-cutting action is needed to address Scotland's health gap to benefit its citizens, communities and the country as a whole.

Scotland's health is improving. But there are big differences between rich and poor. In 2006, men could on average expect 67.9 years of healthy life and women 69 years. In the most deprived 15% of areas in Scotland, though, men could only expect 57.3 years of healthy life and women 59 years.

More babies born to mothers living in the most deprived fifth of areas have a low birth weight than those born to mothers living in the most affluent areas: 9% compared to 5%.

People struggling with poverty and low income have poorer mental health and wellbeing than those with higher incomes or who find it easy to manage financially.

There are large and increasing inequalities in deaths amongst young adults due to drugs, alcohol, violence and suicide.

These are just a few examples; there are many others detailed throughout this report.

The Scottish Government believes this situation is unacceptable. And what's more, it's bad for Scotland. That's why the Ministerial Task Force on health inequalities was set up to tackle the inequalities in health that will otherwise prevent Scotland from achieving the Government's overall purpose of sustainable economic growth, supported by increased healthy life expectancy.

Difference in income is not the only factor to blame for inequalities. Health may also vary according to people's age, disability, gender, race, religion or belief, sexual orientation and other individual factors. These interact with socioeconomic status and low income. While the Task Force has been primarily interested in health inequalities that result from socioeconomic circumstances, we have also considered how health and other public services respond to this range of complex factors which affect people's health.

Scientific evidence now helps explain how deprivation and other forms of chronic stress lead to poor health. Children's earliest experiences shape how their brains develop. Very young children need secure and consistent relationships with other people, or else they will not thrive, learn and adapt to their surroundings. People's responses to external stress cause premature ageing and increase risks of dying from the big killer diseases, and of dying early.

There is international agreement that reducing unfair and unjust inequalities in health needs a cross-government approach. It cannot be achieved through health policies and health care systems alone.

The Task Force's new and ambitious approach has been to take our emerging understanding of the underlying causes of health inequalities and turn it into practical and linked action across all of national and local government's key responsibilities: for making Scotland Smarter, Wealthier and Fairer, Greener, Safer and Stronger and, ultimately, Healthier.

The Ministerial members of the Task Force come from right across Government. We have worked together in a new way, in line with the Government's unified approach to its overall purpose of sustainable economic growth. Local government, NHSScotland, the Third (voluntary) Sector and the research community have also participated actively in the Task Force's work. This, too, represents a new approach in which local government and others are equal partners in developing national policy and agreeing how that can be delivered in practice.

Importantly, we have also looked at what's already happening in Scotland. There are many good services which, if rolled out across Scotland, could make a real difference.

The Task Force has discussed its thinking with a range of frontline staff and managers, a wide Third Sector audience, young people and members of the police, the business community, local authorities and NHSScotland.

Much of the change the Task Force recommends can only be generated locally, through the people in public services who work to meet their clients' needs day in and day out. They are critical in determining client pathways or routes into, through, between and eventually out of public services. The Task Force recommends how to support improvements that come from the direct experience of local staff.

• The Government should provide resources to test and promote the Task Force's approach to redesigning and refocusing public services through health inequalities learning networks. These will operate initially through a small number of test sites within community planning partnerships. Resources will be required to apply continuous improvement techniques locally, as well as to bring together all the evidence available to inform good practice, track progress and spread learning in order to influence change in public services more widely.

In order to reduce inequalities in healthy life expectancy and wellbeing generally, the Task Force has identified priorities where action is most needed:

• Children's very early years, where inequalities may first arise and influence the rest of people's lives.
• The high economic, social and health burden imposed by mental illness, and the corresponding requirement to improve mental wellbeing.
• The "big killer" diseases: cardiovascular disease and cancer. Some risk factors for these, such as smoking, are strongly linked to deprivation.
• Drug and alcohol problems and links to violence that affect younger men in particular and where inequalities are widening.

In the light of these priorities, and evidence about what causes inequalities in health, the Task Force has agreed key principles to drive our work. These include:

• Improving the whole range of circumstances and environments that offer opportunities to improve people's life circumstances and hence their health.
• Addressing the inter-generational factors that risk perpetuating Scotland's health inequalities from parent to child, particularly by supporting the best possible 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.
• Delivering health and other public services that are universal, but also targeted and tailored to meet the needs of those most at risk of poor health. We need to prevent problems arising in the future, as well as addressing them if they do.

The Task Force has reviewed what is known about effective action to reduce health inequalities and has assessed what's already happening in Scotland in the light of this evidence. Our recommendations for action run across Government and local services and that is what makes them new and different.

There is already a lot of good work underway, for example to transform the school curriculum, to improve people's chances of decent employment, to increase access to green and open spaces, particularly for children and young people in poorer communities, to intervene early in tackling youth violence and anti-social behaviour more generally and for health services to anticipate risks of ill health and support people to reduce those risks.

The Task Force's recommendations will lead to a step change over and above these developments. They involve public services working together more than they have in the past, in order to make a difference to the complex underlying reasons for inequalities in health.

The recommendations will improve health and other life outcomes for particularly vulnerable groups of people, who need a cross-government and cross-sector approach from the services they rely on. For example, the state must meet its additional responsibility to support and care for looked after children and young people and care leavers, in an effective and joined up way.

Here are our key recommendations. A full list is in Annex 4 at the end of the report.

Early years and young people

Many changes will only happen in the long term, when action to improve educational achievement and skills, employment and income bears fruit. But there will be shorter term, measurable improvements, for example in numbers of women smoking during pregnancy and children's healthy eating and physical activity levels.

Change that the Task Force recommends goes hand in hand with the early years framework being jointly developed by the Scottish Government and COSLA. Reducing health inequalities will be a key outcome for the framework when it is published in autumn 2008. There should be a continuum of services that identify need and provide support to the most vulnerable children and families across the age range.

The Task Force's key recommendations are:

• NHS Boards should improve the capacity of ante-natal services to reach higher risk groups and identify and manage risks during pregnancy.
• The Government should lead the development of support services for families with very young children at risk of poor health and other poor outcomes.
• The Government should develop a community-based integrated school health team approach, increasing the nursing staff and other professionals supporting schools.
• The Curriculum for Excellence reforms should continue their strong focus on literacy and numeracy and health and wellbeing.
• Curriculum for Excellence should provide continuity and progression through school to post-school and should aim to keep young people in learning after the age of 16.
• Physical environments that promote healthy lifestyles for children, including opportunities for play, physical activity and healthy eating, should be a priority for local authorities and other public services.

Tackling poverty and increasing employment

The Task Force's recommendations are linked to the development of the Government's framework for tackling poverty, inequality and deprivation. This is important because of the strong links between poverty and poor health. There is also a two-way link between health and employment: good quality employment helps physical health and mental health and wellbeing. And people who are currently unable to work may need help to improve their health so that they can get and keep a job.

The Task Force's key recommendations are:

• Fairer Scotland Fund resources used by community planning partnerships should contribute to health outcomes and help improve healthy life expectancy.
• The Government should help people to maximise their income and encourage them to take up means tested benefits, starting with older people and extending activity through intermediary organisations such as Registered Social Landlords and health care services.
• The Government should encourage local leadership in activating business participation in the community planning process. New agencies and current statutory partners should be involved in responding to local needs. In particular, NHS Boards should play an active part in employability partnerships across Scotland.
• To achieve the potential of business and enterprise in contributing to local community action, the outcome of improving health through work should be integrated with the remit of economic development agencies at national, sectoral and local authority levels including urban regeneration initiatives.
• NHS Boards and public sector employers should act as exemplars in increasing and supporting healthy employment for vulnerable groups.
• Public sector leaders should promote the evidence on the health benefits of employment with staff, patients and clients.

Physical environments and transport

The outcomes of these Task Force recommendations will include better opportunities, especially for children and young people, to improve health through enjoying the benefits of safe green and open spaces. Transport recommendations will make public services more accessible, as well as benefiting health through increased walking and cycling.

The Task Force's key recommendations are:

• Government action on the physical environment should include improvements to promote healthy weight and to the quality of local neighbourhoods through increased community cohesion and preventing risks to community safety.
• The Government, NHS Boards and other public sector organisations should take specific steps to encourage the use and enjoyment of green space by all.
• Delivering the Government's National Transport Strategy should include specific action likely to improve health and reduce health inequalities. For example, rolling out effective local projects that improve active travel within deprived communities.
• New Government whole-community initiatives should be measured on their impact on health and health inequalities.

Harms to health and wellbeing: alcohol, drugs and violence

The longer-term outcomes of these recommendations will be to reverse the rising inequalities in harm to health from alcohol, drugs and violence. The Government's long-term strategic approaches to both drugs and alcohol will emphasise links to poor health. Prevention is vital, especially among young people, but so is treatment and recovery for people who already have a serious drug or alcohol problem.

The Task Force's key recommendations are:

• Local authorities, Third Sector organisations and other partners should increase programmes designed to support and engage with young people who have started on the cycle of offending. More support should be provided for parents whose children begin to display violent behaviour; for counselling programmes for victims of violence and for mentoring for young people at risk of damaging, violent or anti-social behaviour.
• Local authorities and their partners should provide more positive activities for young people, including improved access to existing facilities.
• NHS drug treatment services, which will incorporate the Government's new emphasis on recovery, should link locally to other forms of support that address clients' wider problems and life circumstances.
• The Government should ensure more effective local delivery of joined up services for problem drug and alcohol users, through reform of the current Alcohol and Drug Action Team arrangements. Local resources should be more targeted to deprived groups and communities.

Health and wellbeing

Action here will make an impact on each of the priority inequalities the Task Force has highlighted, through improving people's access to health and social care services and the results those services achieve for them. This is particularly important for the most vulnerable groups of people in the population, and in primary care where the NHS has most contact with the public.

The Task Force's key recommendations are:

• Keep Well health checks in deprived areas should identify people with depression and anxiety and make sure they get treatment and support.
• The Government should create and fund new evidence-based anticipatory care programmes for other groups at high risk of health problems.
• The Government should continue to reform the funding of primary care services, to meet the needs of groups and communities most at risk of health inequalities.
• The Government should lead development of a framework for regular health assessments for people with learning disabilities in all NHS Board areas.
• Offenders who want to tackle their drug problems should be able to get access to addiction and health services within six weeks of release from prison.
• NHS Health Scotland should deliver an accessible communication, translation and interpreting strategy.

Delivering change

To make sure that the Task Force's proposals lead to real and effective action we recommend that:

• The Government should publish an implementation plan later in 2008, which gives more practical detail about how these recommendations will be turned into action and who will be responsible, at both national and local levels.

The global sums allocated by the Government to local government and for health and wellbeing include resources for programmes and services that influence the underlying causes of health inequalities, as well as dealing with the consequences for people. Within these sums, the Task Force has identified £586 million in 2008-09 as more directly targeted at addressing both causes and consequences. As a result of the Task Force's work the Government has already agreed to add a further £15 million over three years to support children and families most at risk and to back the Task Force's test sites and health inequalities learning networks.

The Task Force's local test sites will show what changes in public services can be achieved within existing resources, with a view to reducing the key health inequalities in the longer term. Test sites will also provide evidence for future spending decisions, both nationally and locally, to redesign public services and shift the emphasis from dealing with consequences of health inequalities to preventing them in the first place.

The Task Force recommends some new headline measures of health inequalities, to be reported in addition to healthy life expectancy. Measures of people's health are needed so that change can be tracked in the long-term. In the medium-term, the Scottish Government and local authorities and their community planning partners should report progress in tackling the key underlying causes of health inequalities. This must form part of the new relationship between the Scottish Government and local authorities, with their local partner organisations, as embodied in Single Outcome Agreements.

• The Government itself should review progress in implementing the Task Force's recommendations and publish their review in 2010, together with any further action that is needed.

The Task Force's recommendations are to be seen as a complete set. They will work together on the most important underlying reasons for Scotland's health inequalities. There are, however, some examples of important policy and action where the Scottish Government does not have enough powers for maximum impact. These should be pursued as part of discussions about Scotland's constitutional future.

Our recommendations have been developed as part of a new approach to policy making that shares understanding and responsibility between the Government, local authorities and other organisations which deliver services locally. Making change happen now requires all these organisations to work together. Above all, the Task Force's understanding of the reasons for health inequalities tells us that services must fit in with what their clients really need, not the other way around.

This is an ambitious and radical programme for change. But without it, Scotland will not make progress towards all of its citizens being "Equally Well".