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

ACTION AND RECOMMENDATIONS

Recommendations for change

The Task Force's recommendations for change in policy, practice and delivery follow in the rest of this report. These start with children's early years and the role of education in determining later health. They include throughout the need to build individual, family and community wellbeing and resilience. The report addresses critical underlying causes of health inequalities such as poverty and lack of employment as well as exposure to physical and social environments that perpetuate poor health and create inequalities. There are links between all of these themes.

The Task Force has examined and discussed the range of key policy responsibilities, corresponding to the Government's five strategic objectives for a Smarter, Wealthier and Fairer, Greener, Safer and Stronger and Healthier Scotland. Each of the following sections looks at one area in more detail, summarising:

• Why this matters for health inequalities.
• What works.
• What's already happening in Scotland.
• What the Task Force recommends.

Volume 2 of this report, available on the Government's web pages, incorporates the discussion papers that the Task Force has commissioned. These provide a more detailed account of the evidence-base and the approach that the Task Force has taken.

Making it happen

This agenda is for the whole of public services and their partners in other sectors. It requires significant refocusing of public services. As COSLA said in their discussion paper for the Task Force: "To address health inequalities it is likely that public sector resources will have to focus on early interventions and prevention, and as part of that develop a more anticipatory and proactive approach to working with disadvantaged groups. If we do not do this, we will merely be falling back on a strategy that addresses the manifestations of disadvantage rather than tackling the source of disadvantage. Consequently, nothing will change: poverty and other social inequalities will continue to place vulnerable families at risk."

The Scottish Government and COSLA are working in partnership to tackle health inequalities. As a key provider of social support, education, regeneration, housing, and green spaces, local government will continue to make an important contribution in tackling health inequalities. Local government is committed to maintaining and improving these crucial services, thus improving the health and wellbeing of all members of the community, but particularly those living in disadvantage.

Delivering action and change on this scale will only be possible with strong leadership and effective community planning partnerships. Local joint planning and working will require the right contribution from each agency involved. Accountability will operate through the Single Outcome Agreement process, acknowledging where arrangements differ across sectors, eg NHSScotland, Third Sector organisations. Staff who have the right skills and who are supported to operate in new ways will be critical. The Task Force will recommend new ways of managing change that take into account the plethora of existing initiatives and developments, but go beyond these to embody a more fundamental understanding of what is required to reduce inequalities in health and wellbeing.

SMARTER SCOTLAND: EARLY YEARS AND YOUNG PEOPLE

"Early intervention is a hallmark of this Government's approach to improving the lives of Scots and delivering the better Scotland that we all want to see. The early years of a child's life are a key opportunity to build resilience and reduce the impact of inequalities on health outcomes."
Adam Ingram, Minister for Children and Early Years

"We have a once in a generation opportunity, with the transformation in the education system under Curriculum for Excellence, to make a lasting difference to our children's health, wellbeing and life chances. By placing the child at the centre, personalising learning and support, we can tackle underlying poverty and deprivation and take a holistic approach to health and wellbeing for all our children and young people."
Maureen Watt, Minister for Schools and Skills

Key points:

• Children's circumstances in the earliest years of life are critical to future health inequalities.
• Action is needed to end the cycle of health inequalities which passes from parent to child.
• A range of services is needed to support and help children and families.
• Vulnerable groups such as looked after children or those who live in a house where alcohol or drugs are misused require particular help.
• Children should be encouraged to enjoy learning and to stay in education beyond the age of 16.

Why this matters

The earliest years of children's lives are critical to their future development. Scientific evidence tells us how future health and wellbeing are determined by the ways children's brains develop. Inequalities experienced by parents and their own lifestyles such as drug and alcohol use can harm their children. Support for families that improves children's mental and physical health and life prospects is needed. This must continue through an education system that develops in young people the qualities of resilience and adaptability, together with aspirations and the capacity to go on learning and developing throughout their lives.

Educational achievement is critically affected by children's home circumstances and influences out of school. A major challenge for Scottish education is to reduce the achievement gap that widens up to around age 15. Children from poorer communities and families are more likely to underachieve. As the OECD Review of Quality and Equity of Schooling in Scotland (2007) found: "Family cultural capital, lifestyle and aspirations influence student outcomes through the nature of the cognitive and cultural demands of the curriculum, teacher values, the programme emphasis in schools and peer effects."

Young people told us the same in Young Scot's consultation for the Task Force:

• Family and friends matter a lot to their health and wellbeing.
• They want to learn more at school about a healthy life.
• But they also need the right choices and chances outwith school: advice on health just for young people, safe places to go and chances to take exercise that they can afford.

What works?

Effective action in the early years to address future inequalities in health, and linked aspects of people's lives, includes:

• High quality ante-natal care that identifies and addresses risks early.
• Improving maternal nutrition during pregnancy.
• Improving the quality of interaction between parents or carers and children in the very early years, for example through high quality home visiting services and parenting programmes.
• Targeted interventions and programmes for children at particularly high risk.
• High quality centre-based pre-school provision and school education.
• Alleviating poverty in families with young children.
• Reducing environmental hazards.

Example:The Nurse Family Partnership Home Visiting Programme targets low-income first time parents and their children. It was set up by Professor David Olds at the University of Colorado, and aims, by an intensive programme of home visits by highly trained nurses, to improve pregnancy outcomes, improve child health and development and importantly improve families' economic self sufficiency by helping parents to see and plan their own future, including continuing their education and finding jobs.

The HMIE report Missing Out has identified characteristics of schools achieving good all round outcomes for their pupils:

• Teaching that provides the highest quality learning experiences.
• Leadership and a shared mission.
• Partnerships including those with parents and families.
• Ethos of ambition/achievement.

What's already happening in Scotland?

The Government and COSLA have recently published a joint policy statement on early years and early intervention (March 2008). This provides the strategic context for the Task Force's work on early years and is an important step on the way to delivering a comprehensive early years framework in the autumn. It marks a shift away from crisis intervention and towards identifying and addressing risks early in life that lead to poor health and other inequalities.

The Task Force supports the statement in the Foreword that: "the biggest gains … will come from supporting parents - to help them help themselves - and by creating communities which are positive places to grow up".

The policy statement sets out four principles of early intervention which are the same as those behind the Task Force's work.

• Our ambitions are universal … to have the same outcomes for all and for all to have the same opportunities.
• We take action to identify those at risk of not achieving these outcomes or having these opportunities and take action to prevent that risk materialising.
• We make sustained and effective interventions in cases where these risks have materialised.
• We shift the focus from service provision as the vehicle for delivery of outcomes to building the capacity of individuals, families and communities … and addressing the external barriers they may face … making use of high quality, accessible public services as required.

Most services for children and families are delivered through the universal health and education systems. There are also some highly targeted services, such as children and families social work, drug rehabilitation and services for looked after children that focus on families in greatest need. Sure Start Scotland provides a mix of universal and highly targeted services for families.

Example:Special Needs in Pregnancy, Inverclyde. The special needs in pregnancy service ( SNIPS) helps pregnant women in Inverclyde to access a range of services. Multi disciplinary assessments are done. The service has two midwives, two family support workers, a homemaker, senior social worker, health visitor, senior nurse from Inverclyde drug services and a community drug team worker. Advice is also available from a consultant psychiatrist. There is strong emphasis on prevention. Women with a range of issues and difficulties are therefore encouraged to use the service. Women who are misusing drugs or alcohol get a response, which is characterised by joint working and early intervention.

The Government will now provide £19 million over three years to improve diet and other healthy living activities for pregnant women and children up to age 5, especially those in deprived groups and communities.

NHS Boards have already been given a target to increase the proportion of new-born children exclusively breastfed at 6-8 weeks from 26.6% in 2006-07 to 33.3% in 2010-11. In order to achieve this they will need to increase breastfeeding rates in deprived areas and among disadvantaged groups.

The Government's Getting It Right For Every Child ( GIRFEC) approach is about identifying children's needs at any age and bringing together the agencies that should be involved in their lives.

Within the GIRFEC approach, the reform of Scottish education from age 3 to 18 under Curriculum for Excellence will provide more choices and more chances for all children and young people.

The Additional Support for Learning Act (2004) supports early intervention and a personalised approach to additional support needs, in order to address inequality and promote positive outcomes for children and young people.

The Schools (Health Promotion and Nutrition) (Scotland) 2007 Act places a duty on local authorities to ensure that schools are health promoting. This links with the developments in Curriculum for Excellence.

Example:Pitfour Primary School, Mintlaw, Aberdeenshire. This school is in a village that contains a large housing estate with significant social challenges within its catchment area. The school is aiming to become an accredited health promoting school, involving the parents and other partners from the wider community. They have held evening events on healthy eating and behaviour, bullying and discipline. To encourage positive behaviour by all children a booklet Promoting Positive Behaviour has been issued to all pupils. It is filled in every day and goes home at the end of the week for parents/carers to sign.

Home-school link workers support vulnerable families to engage with education services and there are other initiatives to increase parental and community involvement in school education.

Looked After Children and Young People: We Can and Must Do Better, aims to improve educational and other outcomes for looked after children, who have particularly poor education and other life prospects. "Young people leaving school and leaving care, having to manage their lives as they try to get into the job market, are among the most vulnerable." (Third Sector consultation)

Example:Edinburgh City Council - Corporate Parenting Action. The Reading Champion project run by Edinburgh City Council is a very practical example of corporate parenting in action. The project aims to improve the mental health and wellbeing of looked after children by encouraging reading activities. Reading to or with children is a bonding activity carers can use. Engaging in reading helps relaxation. It helps develop relationships with caregivers and therefore improves mental health and wellbeing. This project also creates opportunities for children to interact with adults and build essential literacy skills to assist in later life.

Example:Children's Learning and Supported Play ( CHLASP) - East Ayrshire Council. CHLASP is a multi-agency response to addressing the needs of children who are homeless. It is widely recognised that children who experience homelessness are more likely to encounter physical, mental and emotional ill health. Schooling and opportunities for play and social development are also subsequently affected. CHLASP supports children's access to:

• Transport to school or nursery of origin to ensure stability and consistency in children's education and care.
• Transport to health and dental appointments.
• Funding and support to access out of school care and after school activities to provide social and play opportunities in a safe, stimulating environment.
• Cooking skill training for Tenancy Support Workers who deliver cookery classes within homelessness hostels and individually in furnished accommodation.
• Direct referral to Working for Families to support pre-employment skills development for parents/carers.

Outwith school, there are opportunities for young people to play sport, be physically active and enjoy the outdoor world. But these opportunities are not yet available equally to all, nor to young people in some of the most deprived communities, whose life chances are poorest.

Example:Young Scot is the national youth information charity for Scotland. It provides young people between the ages of 11 and 26 with a mixture of information, ideas and incentives to help them become confident and active citizens. One of these services, the Young Scot card, is carried by over 340,000 young people in Scotland. Promoting healthy and positive active lifestyles is a key element of the card, and there is money off at places such as Virgin Active, Walkabout Scotland, Historic Scotland and Scottish Youth Hostel Association. In many local authority areas the Young Scot card is used by young people to access local authority leisure services.

Task Force recommendations

Many of these are for the long term, and will lead to reduced inequalities in aspects of children's future lives, such as income, employment, and the health they enjoy. In some cases, though, we shall see shorter term improvements, for example in numbers of women smoking during pregnancy and children's healthy eating and physical activity levels.

The policy statement on early years and early intervention sets out a number of tasks that will seek to improve outcomes for children and families, with a particular emphasis on reducing inequalities. These are closely aligned with the Government's Better Health, Better Care action plan (December 2007) which put the best possible start for children at the forefront of the Government's health agenda.

As well as supporting the wider agenda that these policy documents have established, the Task Force has identified a number of specific recommendations where we believe there is an urgent need to test new approaches in Scotland across the age range.

3. Reducing health inequalities should be a key outcome for the early years framework being developed jointly by the Government and COSLA. This reflects the joint development across Government and other agencies of policy that links understanding of influences in the early years of life on future health.

4. NHS Boards should improve the capacity of ante-natal services to reach higher risk groups and identify and manage risks during pregnancy. This will include, rolling out and evaluating a 3-5 year programme to better identify and support vulnerable women and families, through a number of professionals providing effective care.

5. The Government should arrange a Scottish survey of the incidence of Foetal Alcohol Syndrome. This is caused by the mother's harmful drinking during pregnancy and leads to physical and psychological damage to children, unless there is early intervention and treatment.

6. NHS Boards should improve breastfeeding rates in deprived areas and among disadvantaged groups. The Government's new infant nutrition co-ordinator will concentrate efforts on reaching these groups.

7. The Government should lead the development of holistic support services for families with very young children at risk of poor health and other poor outcomes. This should test how the Nurse Family Partnership approach can work in Scotland. Testing will need to examine how best to target the families most in need, engage them effectively and work alongside them to build up their own capacity. It must ensure fidelity with the strong evidence-based Nurse Family Partnership approach.

8. There should be a range of services that identify need and provide support to the most vulnerable children and families. As part of that, the Government should develop a community-based integrated school health team approach, targeting children at risk and increasing the nursing staff and other professionals supporting schools.

9. The Government should continue to improve support for children at risk in households where alcohol or drugs are misused.

10. Curriculum for Excellence should continue its strong focus on literacy and numeracy, with every teacher taking responsibility for delivery across the curriculum.

11. Curriculum for Excellence should take a holistic approach to health and wellbeing outcomes, including active and healthy lifestyles, supported by the new school health team approach. This should cover learning in mental, emotional, social and physical health to promote resilience, confident, independent thinking and positive attitudes.

12. The ethos within which Curriculum for Excellence is implemented should place the child at the centre of the process, so that learning starts from the child's perspective, with different abilities and backgrounds taken into account.

13. Curriculum for Excellence should provide continuity and progression through school to post-school, aimed at keeping young people in learning after the
age of 16.

14. 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. The Government should support the Third Sector to increase opportunities for play, through investing in an Inspiring Scotland theme, subject to current discussions.

15. Each NHS Board should assess the physical, mental and emotional health needs of looked after children and young people and act on these assessments, with local partner agencies. Boards should ensure that health services are more accessible to looked after children and to those in the transition from care to independence.

WEALTHIER AND FAIRER SCOTLAND: TACKLING POVERTY AND INCREASING EMPLOYMENT

"There is a clear relationship between income inequality and health inequality. Ill health is both a cause and a symptom of poverty. It is critical that the solutions we develop target root causes in all their complexity. Action on inequality must be seen as an investment in the future of our country. Taken with our commitment to tackle income inequality through our Solidarity Target, this report offers genuine opportunity to make real progress at last on Scotland's appalling record of health inequalities."
Stewart Maxwell, Minister for Communities and Sport

"Together with their Government, councils, health services and their local business communities, Unions and the Third Sector, Scotland's people hold the answers to their own problems. Centrally-led, target-driven initiatives have not worked to address the deep-rooted and complex issues of health inequality in Scotland's most vulnerable communities for the past three decades, and there is no reason to suppose they will start to work now.

Excellent examples abound - from Raploch in Stirling to the Bronx in New York City.

The task of Government, therefore, is to activate Scotland's most vulnerable communities, to facilitate and support local people, schools, voluntary agencies, councils, businesses and other players to develop local leadership, and local ideas and programmes to address local issues.

As Enterprise Minister for Scotland, I shall be delighted to commit myself to help make this happen."
Jim Mather, Minister for Enterprise, Energy and Tourism

Key Points:

• Poverty is a key factor in poor health and health inequalities.
• Employment is important to individual and community health and wellbeing, both physical and mental, as well as to the economy.
• Workplaces should be health-promoting and public sector employers should set a good example.

Why this matters

The links between poverty and poor health are central to the Task Force's thinking. Tackling poverty and deprivation will improve health and contribute directly to delivering the Government's overall purpose of sustainable economic growth.

Poverty influences poor health and inequalities in a number of ways. It affects the environment in which children are born and is likely to increase stress on both parents and children which will set patterns for children's future development and life chances. People on low incomes and those living in the most deprived areas are most likely to rate their general health as poor and to be more susceptible to mental illness. Poverty drives much of the inequality in death rates from the big killer diseases. Poverty also worsens the outcomes for individuals with chronic disease: increasing chances of losing employment and shortening life expectancy. Socioeconomic disadvantage underlies the increasing inequalities in the harm caused by drugs, alcohol and violence, particularly among younger adults.

There is strong evidence that work is generally good for physical and mental health and wellbeing and that worklessness is associated with poorer physical and mental health and wellbeing.

A key aspect of the Government economic strategy is to increase the numbers of those participating in the labour market, meeting the target to narrow the gap in participation between Scotland's best and worst performing regions by 2017.

A variety of motivating factors drive employers to adopt safe and healthy working practices, including their statutory duties under the Health and Safety at Work Act. However, the case for workplace health and wellbeing policies to support increased, sustainable employment particularly of vulnerable working age people is less well understood. This is typically viewed as a "health" not a "business" issue. Understanding of the case for good quality work, its impact on reducing health inequalities and therefore its contribution to sustainable economic growth, needs to move beyond the healthcare profession into business and local communities. Laudable attempts to join up local services can only go so far: communities need to be activated to help themselves, tapping into support from relevant local partners and government agencies. This will require local leadership to define common goals and influence community planning. Ministers stand ready to help pump prime this process and help communities engage with each other and with other stakeholders.

What works

Action at a whole population level is one of the most effective ways of tackling health inequalities linked to poverty. This includes, in particular, tax and benefit measures aimed at stopping and reversing trends in income inequalities. Child poverty needs to be addressed through redistributive benefit and tax measures. These remain under the control of the UK Government.

Within Scotland, increasing and improving employment opportunities is a significant means of tackling the root causes of poverty and poor health.

Investing in workplace health and wellbeing also makes sound commercial sense. Evidence shows that immediate benefits include reduced sickness absence, staff turnover and injuries, and increased employee satisfaction, productivity and company profile. Bottom line benefits include reduced staff costs, recruitment costs, legal costs/claims, insurance premiums, health care costs and management time. Studies have shown that every £1 invested can yield as much as £84.

What's already happening in Scotland

The Scottish Government is currently consulting on a framework for tackling poverty, inequality and deprivation to be produced later in 2008. This is within the context of the Government's economic strategy. The Government's discussion paper (January 2008) seeks to build on action tackling poverty in three main ways:

• Prevention of poverty and tackling the root causes.
• Helping to lift people out of poverty.
• Alleviating the impact of poverty on people's lives.

Current action to tackle the root causes of poverty includes the Government's Fairer Scotland Fund (£145m per year for the three years from 2008-09). This is a new fund to be used by community planning partnerships, with a strong emphasis on interventions at an early stage. It aims to help people towards and into employment and also addressing the problems faced by those for whom work is not a realistic option. It is a catalyst, to encourage local agencies to use their mainstream budgets and services to get better outcomes of all kinds for the most deprived people in their area.

Financial inclusion or helping people get access to financial products and services can also help reduce poverty. There are a number of public services which help people deal with debt and manage on a low income. These approaches have a positive impact on mental and physical health related to debt and managing on a low income.

The Scottish and UK Governments have had a range of measures addressing fuel poverty in place for some time. Scottish Government funding is concentrated on the Central Heating Programme which targets older people who do not have a functional central heating system. However, the Scottish Government's review of the programme in its current form shows the programme is not a very effective way of tackling fuel poverty. The Scottish Government has reconvened the Scottish Fuel Poverty Forum with all the key stakeholders and a remit to report to Ministers in the autumn with recommendations on how to use current resources to tackle fuel poverty more effectively.

There are some good examples of corporate responsibility among Scotland's employers, both in increasing employment opportunities for vulnerable people and in promoting healthy workplaces to prevent sickness absence and new cases of incapacity. The benefits do, however, need to be much more systematically spread. Evidence of what works should also inform action both inside and outside government.

Example:Nairn's Oatcakes, a medium-sized independent oatcake and biscuit manufacturer based in Craigmillar, Edinburgh, is making good strides in helping to address many of the employability issues faced by one of Scotland's most deprived communities.

Working in partnership with Haven Products and Jobcentre Plus, the company identifies potential candidates for employment with a learning disability, provides them with work experience and offers training and then a permanent job. It also actively employs and supports members of the community with learning disabilities.

Together with Castlebrae Community High School, Nairn's participates in a series of pupil awareness sessions about the "World of Work". The company has run the Nairn's Challenge to develop a new biscuit with first year pupils in each of the last 12 years. The company also supports the breakfast club, CV preparation advice, mock interviews and work experience for Castlebrae pupils to aid their transition into employment.

Nairn's also tries to ensure that its workforce is as healthy as possible through the Healthy Working Lives award scheme. The company promotes smoking cessation information, provides healthy eating and physical activity advice and offers annual health checks with an occupational health nurse. They also offer a free fruit bowl and subsidised membership of a health club to all staff.

The UK Government's welfare reform arrangements are aiming to encourage more people who can do so to enter employment.

Professor Carol Black's recent review of the health of the working age population has made further recommendations about health, work and wellbeing, including early intervention, GP involvement and expert condition management to prevent health problems escalating.

In Scotland, the Workforce Plus employability framework is delivered through local Workforce Plus partnerships. Healthcare professionals are now becoming more involved in local strategies and the NHS is developing the provision of vocational rehabilitation across Scotland. A pilot project in Dundee is providing faster rehabilitation for employees with work-related health conditions.

A framework for supported employment across Scotland is currently being developed between COSLA and the Scottish Government.

The Scottish Government has signed a Local Employer Partnership with Jobcentre Plus ( JCP). NHS Boards are also setting an example to other employers through pre-employment services for people who require support to move from benefits into sustained and good quality work.

GPs are being engaged through dialogue with the Royal College of General Practitioners ( RCGP) and through joint events with JCP to promote employability in the primary care sector. The Scottish Government is working with JCP to extend the pilots that have successfully placed employability advisers in GP surgeries.

The Scottish Centre for Healthy Working Lives is a centre of excellence, promoting the health and wellbeing of the working age population of Scotland. The Centre's activities include the Healthy Working Lives Award and the provision of occupational health services, especially to small and medium sized enterprises ( SMEs).

The Scottish Action Plan on Health and Safety (March 2007) includes action to improve business access to health and safety advice and expanding occupational health support. Action is also underway to increase workers' involvement in managing health and safety as evidence shows this improves performance.

The Scottish Government and the Scottish Trades Union Congress issued a joint communiqué in January 2008 on action to reduce health inequalities through improving employment opportunities and enhancing health and wellbeing in the workplace.

Task Force recommendations

These recommendations will influence the development of the Government's framework for tackling poverty, inequality and deprivation and help ensure that the link between poverty and poor health is broken. Recommendations on employment will extend responsibility for making sure that people benefit from being in work that is good for their health:

16. Fairer Scotland Fund resources deployed by community planning partnerships should contribute to health outcomes and improving healthy life expectancy.

17. Universal public services should build on examples of effective financial inclusion activity, to engage people at risk of poverty with the financial advice and services they need. Removing the stress caused by debt will improve people's health and wellbeing.

18. 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 healthcare services. Extra resources acquired by clients tend to be directed towards spending on fuel, food, education, recreation and transport, with resulting improvements in general health, living standards and economic benefits for the local community.

19. Any future Government action on fuel poverty should consider explicitly whether improvements in health and reductions in health inequalities can be expected as a result.

20. 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.

21. 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.

22. NHS Boards and public sector employers should act as exemplars in increasing and supporting healthy employment for vulnerable groups.

23. Public sector leaders should promote the evidence on the health benefits of employment with staff, patients and clients.

24. Professional bodies in the field of occupational and public health should be consulted on incorporating the evidence on the health benefits of employment into professional development and practice.

25. The Scottish Centre for Healthy Working Lives should refine the Healthy Working Lives Award scheme to make it more flexible and accessible to smaller businesses.

26. Public sector organisations should increase the use of community benefits clauses in their contracting processes.

GREENER SCOTLAND: PHYSICAL ENVIRONMENTS AND TRANSPORT

"The places where we live, work and play, can do so much for our health. What each of us can do matters, not only in terms of the benefits to the environment but also in terms of our own personal wellbeing. I believe that by delivering a Greener Scotland we will also contribute towards a Healthier and Fairer Scotland."
Mike Russell, Minister for Environment

Key points

• Physical environments have an impact on people's mental and physical health and wellbeing.
• Play and recreation areas for children and young people should have high priority.
• Transport and planning policies should include actions to improve health inequalities.

Why this matters

People's physical environment can have a really positive impact on their health and wellbeing. But poor quality surroundings can have the opposite effect.

Health inequalities would be much wider today if it were not for a number of policies that have improved the environment. These include neighbourhood regeneration, housing improvements and controls such as clean air acts. The Task Force wishes to reduce still further people's exposure to factors in their physical and social environments that cause stress, damage health and wellbeing, and lead to health inequalities.

What works?

There is evidence of links between environmental factors and health inequalities. For example, people living in more deprived communities are at greater risk of many of the chronic health conditions associated with obesity; those who report the highest levels of local environmental "bads" are also more likely to suffer from anxiety, depression and poor general health.

Children who have better access to safe green and open places are more likely to be physically active and less likely to be overweight than those living in neighbourhoods with reduced access to such facilities. Access to green space is also associated with greater life expectancy in older people.

Recent briefing by the Glasgow Centre for Population Health on how transport could reduce health inequalities concluded that: "Transport strategies have a vital role to play in improving social inclusion and accessibility through investment in good public transport systems and instituting measures that encourage walking and cycling."

The interactions between individual health and physical and social environment characteristics are complex, however. There is disappointingly little evidence for specific effective action that would achieve measureable reductions in health inequalities in Scotland. In line with the Task Force's thinking about the impact of stress on people's health, it may be more important to ensure that people concerned are fully involved in decisions and policies which affect their lives.

What's already happening in Scotland?

The Government recognises the importance of green space and is committed to the provision of an environment which contributes towards well designed, sustainable places with access to amenities and services. The importance of quality of the environment, nature and green space in promoting mental health and wellbeing is recognised.

Example:The Forestry Commission Scotland's Woods In and Around Towns initiative enhances the contribution of woodland to the quality of life in Scotland's urban and post-industrial areas such as Easterhouse and Castlemilk in Glasgow. Community woodlands are developed by involving local people and also by restoring mineral and derelict sites to woodland. Woods in highly-populated areas provide recreational facilities, contribute to people's wellbeing, benefit the environment and stimulate new economic activity.

Volunteering, and environmental volunteering in particular, can help to improve people's mental and physical health and to engage with some of the disadvantaged groups and individuals mentioned in this report, such as young people, offenders and those experiencing mental health problems.

The high incidence of litter and fly-tipping across many areas of Scotland blights the landscape and depresses the spirit. While long-term change in behaviours leading to a more responsible attitude towards our local environments is the ultimate answer, measures need to be taken now to deter the practice and challenge offenders. The Government intends to hold a national summit on the issue later this year and in the meantime encourages the greater imposition of existing penalties.

Scottish Planning Policy 11: Open Space and Physical Activity ( SPP 11) sets out national policy on planning for open space and facilities for sport and recreation. It requires all Scottish local authorities to prepare an open space audit and strategy for their area to help safeguard existing valued open space and identify priorities for future investment. There is a presumption against development on open spaces which are valued and functional, or which are capable of being brought into functional use to meet a need identified in the open space strategy. SPP 11 recognises the health benefits of open space and physical activity, and states that it is particularly important to ensure that disadvantaged communities have accessible open space of good quality. The Scottish Government will shortly be issuing an updated Planning Advice Note 65: Planning and Open Space in support of the new SPP 11.

Scotland's planning system is undergoing significant modernisation. The Planning etc (Scotland) Act 2006 introduced substantial changes and work is underway to implement the provisions of the Planning Act. One key aim of the reforms is to deliver a more inclusive planning system, enabling local people to be more involved in the decisions that shape the development of their communities. The reforms focus on improving involvement during the preparation of development plans, and encouraging greater public participation in the early stages when applications are being considered.

The Government's National Transport and Physical Activity Strategies aim to increase the proportion of short journeys made on foot and on bikes, to improve individual health and also to reduce carbon emissions and improve air quality. There are a number of small scale transport projects that work well in deprived communities. For example, Tri-Cycling runs after school bike clubs in Craigmillar, Edinburgh and the Bike Station in Edinburgh has a small project that teaches young people in deprived areas how to build their own bikes.

The Kerbcraft child pedestrian skills training programme has enhanced pedestrian skills in 5-7 year olds, especially in deprived areas.

The Government is planning a number of whole community developments and demonstration projects. One example is the Smarter Choices, Smarter Places sustainable travel demonstration towns, recently announced in partnership with COSLA. These projects will focus on active travel, building in health outcomes from the outset. Other developments will include a focus on promoting healthy weight and support the creation of sustainable places as beacons of good practice in planning and building.

Long-term Scottish research studies are examining the impact of better quality social housing and neighbourhood transformation (for example through mixed-tenure housing developments) on people's health and other aspects of their lives. For example, the Go Well project in Glasgow is investigating the effects on individuals, families and communities of neighbourhood transformation and of people's moves within or beyond the city, over a 10 year period from 2006.

Task Force recommendations

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

27. Government action on the physical environment should include: evidence-based environmental improvements to promote healthy weight, and improving the quality of local neighbourhoods through providing more environmental "goods" to foster better physical and mental health, improve community cohesion and prevent risks to community safety.

28. The Government and local agencies and partnerships should apply the "precautionary principle" across policy development affecting greenspace in environment, education and health. It should increase the priority given to the creation, retention and promotion of high quality green spaces as essential for health improvement, especially in communities at risk of poor health.

29. The Government, NHS Boards and other public sector organisations should take specific steps to encourage the use and enjoyment of green space by all, with a view to improving health. Public sector organisations should provide materials, resources and training and evaluation of specific initiatives eg the prescription of "green space use" by GPs and clinical practitioners.

30. Local authorities and others should foster greater public responsibility for maintaining local environments.

31. Children's play areas and recreation areas for young people generally should have high priority in both planning and subsequent maintenance by the responsible authorities.

32. The National Transport Strategy delivery plan, currently being worked up by the Government, should include specific actions likely to improve health and reduce health inequalities. For example, rolling out effective local projects that improve active travel and increase walking and cycling by deprived communities.

33. Health inequalities should be addressed specifically in the Government's first formal review of the National Transport Strategy, which will report in 2010.

34. The Government should take forward action targeting children from disadvantaged areas who are at greater risk of injury in road accidents and to encourage local authorities to follow existing good practice in this area.

35. New Government whole-community initiatives should be measured on their impact on health and health inequalities.

SAFER AND STRONGER SCOTLAND: HARMS TO HEALTH AND WELLBEING: ALCOHOL, DRUGS AND VIOLENCE

"Prevention, education and recovery are the keys to reducing health inequalities caused by the linked problems of violence and alcohol and drug misuse."
Fergus Ewing, Minister for Community Safety

Key points

• Violence, alcohol and drug misuse are often linked and are major factors in health inequalities.
• More effective drug and alcohol treatment are needed, as are better ways of tackling problems at an earlier stage.
• Domestic abuse is a significant problem and affects women and children in particular.

Why this matters

The Task Force is making it a priority to halt the increasing inequalities in death rates, in particular among younger men, caused by problems with alcohol, drugs and violence.

The Task Force heard that violence is a significant problem in Scotland, accounting for 26% of all crime and 40% of the prison population. Violence is often linked with use of alcohol and drugs. Recorded violence is also significantly linked to deprivation. The death rate from assault in the most deprived communities is nearly four times that of the Scottish average and over 10 times that in the least deprived communities.

"Young males are creating their own social constructs of what it is to be male in 21st century Scotland; this is resulting in violence, binge drinking, risky behaviour and lack of aspiration or goals."

Detective Chief Superintendent John Carnochan, Head of the Violence Reduction Unit.

Example:David was born in one of the most deprived areas of Scotland to a mother who used drugs, drank and smoked throughout the pregnancy. He was brought up in an extended family none of whom have ever worked; three "uncles" have convictions for serious violence. Before he was nine David moved or was rehoused eight times, four times due to domestic abuse. David is one of the smallest boys in his year when he starts high school, in an area with high crime levels. He is soon truanting, involved in gang activity and identified as "outwith parental control"; he is known to various agencies including the police and social work. At fourteen, after a series of exclusions, he has left mainstream education. He drinks, takes drugs and abuses solvents. His family resist offers of help. At fifteen he commits three assaults, theft, breach of the peace, robbery, steals two cars, commits various road traffic offences and is charged with attempted murder. While awaiting action to be taken for these offences, David visits the nearby city centre. David has been drinking and is carrying a knife. David bumps into complete stranger John and stabs him once in the upper torso. John dies fifteen minutes later. David is sentenced to 7 years for culpable homicide.

Domestic abuse is a significant problem in Scotland affecting between one in three and one in five women over their lifetime. 87% of victims of domestic abuse are female. Children living in homes where abuse occurs are often witness to this and can be hurt themselves, either by trying to intervene to protect their mother or being physically abused by the perpetrator.

The experience of domestic abuse is a strong risk factor for poor health for both women and children. It is associated with higher levels of depression, anxiety, suicidal thoughts, and drug and alcohol abuse, whilst the array of physical health problems include gynaecological disorders, adverse pregnancy outcomes, chronic pain, irritable bowel syndrome and injuries.

What works?

We know that alcohol misuse underlies many of the worst symptoms of inequality especially violence. The Task Force heard evidence that regulatory, structural or fiscal interventions affecting the whole population (such as increasing the price of alcohol) can be effective in reducing health inequalities due to alcohol-related harm. Information-based approaches (such as health information campaigns) tend not to influence the most disadvantaged groups and individuals, who often find it harder to change behaviour.

In addition, there is strong evidence that screening and brief interventions help people who are drinking at levels which put them at increased risk, but who are not alcohol dependant. Where people are identified a short, simple advice session has been shown to be effective in helping them to reduce consumption over the medium term. Although there has been little analysis of the effectiveness of brief interventions across different socioeconomic groups, it is thought that these are equally successful across the whole population.

People with drug and alcohol problems need treatment services which are linked with services in housing, training or education to support them to recover from their addiction and to sustain that recovery.

However, we need to look wider than just substance misuse. The Task Force endorses the World Health Organization's ( WHO) public health approach to violence which is to work across agencies and focus on prevention, rather than reaction. In the shorter term, innovative approaches to enforcement by the police, local authorities and other criminal justice partners may help. For example, the police, prosecutors and judiciary have worked together on knife crime to establish a much firmer regime built on the foundation of tougher legislation. This has included doubling the maximum sentence for carrying a knife. The long-term solution, however, depends on us looking much earlier to those interventions that are effective in stopping violent behaviour developing in the first place.

What's already happening in Scotland?

The Government is publishing in Summer 2008 a consultation paper on a long-term strategic approach to tackling alcohol-related harm. This will include a mixture of whole population and targeted measures. The final strategy will be cross-Government and will bring all elements of public alcohol policy into a coherent framework.

NHS action is already being focused towards reducing alcohol-related harm, through increased alcohol screening and brief interventions, with efforts being targeted towards A&E Departments, primary care and ante-natal care, and amongst deprived communities. In particular, an alcohol services demonstration project, including alcohol screening and brief interventions, will be piloted within the Scottish Prison Service over a three year period.

Example:the Coal Industry Social Welfare Organisation is being funded to tackle alcohol misuse, smoking and associated health issues in some of the most disadvantaged communities in traditional coal field areas in central Scotland. The project will enable local communities to develop their own networks of support via "buddy systems" and similar mechanisms, so that the objectives of smoking cessation and moderation of alcohol consumption become embedded in the local culture as core values.

The Government is also publishing a new drugs strategy in Summer 2008. A key priority of the strategy is to see more people recover from problem drug use to live longer and healthier lives. The strategy includes action and reform at both national and local levels. It highlights the major contribution of work to tackle drugs in reducing health inequalities, and vice versa.

Example:the Lothian and Edinburgh Abstinence Programme ( LEAP) is a three month day programme for people with substance misuse problems. LEAP works closely with the City of Edinburgh Council and other local agencies to deliver a recovery-orientated programme in the community with a focus on abstinence. Patients follow an intensive programme which includes medication and also therapeutic care to address the underlying issues of drug misuse. The programme links up with vocational training and education providers to help equip clients with skills and qualifications to move on with their lives once the programme has finished. Supported housing is provided where required. There is an emphasis on self-help and aftercare.

The Violence Reduction Unit ( VRU) with Government support, has been the national centre of expertise on violence reduction in Scotland since April 2006. The VRU launched a comprehensive 10 year action plan in December 2007. This follows the WHO approach to prevention, which can be divided roughly in terms of age groups:

• Primary prevention - preventing violence or other anti-social behaviour from occurring in the first place. Focused on children from pre-birth through to high school age and their parents.
• Secondary prevention - preventing the escalation of violence and anti-social behaviour towards serious criminality. Focussed on children of high school age and including diversion and positive opportunities for young people through to more formal youth justice measures.
• Tertiary prevention - preventing violent offenders reoffending, typically adults within the criminal justice system.

The evidence presented to the Task Force confirms there is a lack of current effective interventions aimed at vulnerable young men in all three categories. There are difficulties in engaging with them and influencing the complex mix of individual behaviours and underlying causes.

Example:Streetbase, aimed at 10 to 18 year old vulnerable males in Lanarkshire, involves street workers who actively engage and develop relationships with young people on the streets who are misusing alcohol or at risk of doing so. Streetbase provides one-to-one counselling on alcohol-related problems for the person concerned and the partners, children, friends and employers. The initiative encourages alternative activities including gorge walking, quad biking and football and has impressive outcomes including reducing alcohol consumption and anti-social behaviour and enhancing community relationships.

To tackle domestic abuse and other forms of violence against women, a cross-Government approach has been adopted, reflecting the need for concerted action across sectors and agencies. The key elements of this approach include prevention through social marketing campaigns and materials in schools, support services for women and children affected by abuse, and challenging perpetrators through the justice system. We shall learn more about what helps children and young people through domestic abuse pathfinder projects within the Government's Getting It Right for Every Child ( GIRFEC) approach.

Task Force recommendations

The fundamental causes of violence and drug and alcohol misuse are the same as the causes of other health inequalities: poverty, poor educational attainment and lack of opportunities for young people. The longer term outcomes of the recommendations that follow will be to reverse the rising inequalities in harm to health from alcohol, drugs and violence. Early intervention is key in tackling youth violence and anti-social behaviour more generally. Diversion including providing alternative activities is an effective method of early intervention. But while prevention as a whole is vital, so are treatment and recovery.

36. Local authorities, Third Sector organisations and other partners should increase programmes designed to support and engage with those young people who have started on the cycle of offending but not yet escalated to serious violence. For example, more support should be provided for parents whose children begin to display violent behaviour; counselling programmes for victims of violence and mentoring programmes for young people at risk of damaging, violent or anti-social behaviour; appropriate use of campus officers in schools with an extended peripatetic role; increased availability of anger management and cognitive behaviour programmes both in the community and in prison; targeted action to provide routes out of gangs and gang intervention schemes.

37. Local authorities and their partners should provide more positive activities for young people including improved access to existing facilities. The Government will continue to develop its Cash Back for Communities programme to ensure that more "choices and chances" are available to young people to divert them from a life of crime or anti-social behaviour.

38. NHS drug treatment services, which will incorporate the new emphasis on recovery, should be required to link locally to other forms of support that address clients' wider problems and life circumstances.

39. 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 ( ADAT) arrangements. The resources that member agencies contribute to ADAT activities should be more targeted to deprived groups and communities.

40. Strong leadership for joint working addressing the underlying causes of violence at local level is required through, for example, greater NHS involvement in local community safety partnerships and police participation in relevant health and education forums. Such partnerships should be built on effective cross-agency information sharing to ensure risk is identified early and managed effectively.

41. The Government should support improved data collection, analysis and sharing by all agencies, to ensure that the true level of violence and opportunities for joint solutions are identified. The National Injury Surveillance Model currently being trialled by NHS Lanarkshire should be evaluated and then rolled out, in order that hospital injury data can be shared across agencies, to ensure more effective enforcement and prevention action. Better data generally will help to develop strategies for individuals and communities where violence is an issue.

42. NHS Boards should ensure that all women attending key NHS services are asked routinely if they are or have been a victim of domestic abuse. This will improve detection of abuse and afford women and children the opportunity to access support and services. Enquiries should be targeted at areas where women who are experiencing abuse may be disproportionately represented, mental health, addiction, maternity, sexual and reproductive health, primary and community health services, and A&E departments.

43. NHS Boards and community health partnerships, with other local organisations, should ensure a swift and effective response to the needs of women and children experiencing abuse.

HEALTHIER SCOTLAND: HEALTH AND WELLBEING

"Health services need to be part of strong local partnerships dedicated to reducing health inequalities."
Shona Robison, Minister for Public Health

Key points:

• Health services are important in tackling health inequalities but must act in partnership with other agencies.
• Children's health, "killer" diseases such as cardiovascular disease and mental health and wellbeing are priority areas for addressing inequalities in healthy life expectancy.
• More needs to be done to help vulnerable people access health services.
• Anticipatory care, particularly targeting deprived communities, should help reduce inequalities.

Why this matters

The Task Force believes that health services make an important contribution to reducing health inequalities, especially in giving children the best start in life and anticipating and preventing health problems that people experience later. The Government's action plan Better Health, Better Care (December 2007) says NHSScotland should:

• Treat the consequences of health inequalities and minimise their impact.
• Address risks for individuals, including their health-related behaviours such as smoking, which is a major cause of health inequalities.
• Provide a universal gateway to the more targeted support that some people need; for example support to families in children's early years.
• Play a corporate role in the spectrum of services locally. For example, NHS Boards support schools in delivering health and wellbeing aspects of the curriculum. NHS Boards are also significant local investors through employing people from their community and local purchasing of goods and services.

Local authorities have the power to promote and improve the wellbeing of people in their area, and are key partners locally with health services.

Mental illness and mental wellbeing are specific priorities for the Task Force. People with mental illness are more likely to die earlier from suicide, or illnesses such as cardiovascular disease ( CVD) and tend to have generally poorer health through conditions such as diabetes.

Mental wellbeing is associated with good mental health, but is not necessarily the same as absence of mental illness. Much of the Task Force's work is based on the importance of factors such as resilience, hopefulness and optimism that create mental wellbeing and quality of life. These allow people to deal effectively with life's problems and normal stresses, to make the most of their abilities and the opportunities available and to play a positive part in their community.

People whose wellbeing is good are more likely to look after their own health. However, depression is closely associated with poor physical health, for example increasing significantly the risks of CVD.

Example:the Royston Stress Centre provides evidence-based smoking cessation interventions as part of a wider stress management programme. The focus of the centre's work is helping people to acquire and improve personal coping skills through the development of self awareness and to develop new strategies and solutions for dealing with stress. The centre provides a range of one-to-one therapeutic support including therapeutic massage, acupuncture, reiki, relaxation, counselling and group work to adults suffering from the full range of stress-related problems.

There are a number of disadvantaged groups of people whose health is particularly at risk. Health and other services must respond to their specific needs and give them the same quality of service as everyone else.

Example:the Disability Rights Commission (2006) found that people with learning disabilities and mental health problems are much more likely than other citizens to have significant health risks and major health problems. For people with learning disabilities, these include obesity and respiratory disease. For people with mental health problems, problems include obesity, smoking, heart disease, high blood pressure, respiratory disease, diabetes and stroke. However, these groups were less likely to receive some of the standard, evidence-based checks and treatments than other patients, for example cholesterol checks and statins (cholesterol-lowering drugs), measurement of body mass index, blood pressure checks, and cervical and breast cancer screening.

Health services need to respond to inequality and diversity in a range of ways. These include making services more culturally sensitive and accessible, for example through translation and interpreting, and by providing a different level or type of service where needed, such as addressing South Asian people's higher risk of developing diabetes.

Improving the health and wellbeing of offenders will make inroads into the Task Force priority to reduce inequalities associated with violence and alcohol and drug problems. For example around 80% of the prison population have a drug problem; 66% have personality disorders and 70% a mental health problem that requires clinical support.

Women prisoners, who comprise only 5% of the prison population, have exceptionally high levels of health need. For example 98% of the women in Cornton Vale have addiction problems, 80% have mental health problems, 70% have been abused and around 50% self harm.

People with a learning disability make up around 25% of the prison population. Their learning disability is often at the root of their offending and also creates a barrier to getting effective support from services available.

What works?

Anticipating preventable ill-health has been shown to work in primary care, through evidence-based checks and early action for people with either risk factors or early signs of disease.

Psychological therapies can help people with depression and anxiety.

The physical health of those with mental illness can be improved through action on smoking and regular medical reviews and interventions on lifestyle, physical activity and diet.

Promoting access to employment, recreation and social engagement are important in reducing the number of people who develop mental illness and in addressing inequalities in mental health.

Equalities legislation requires organisations to demonstrate that they are tackling discrimination and promoting equity of access and opportunity for all. Within the NHS, the Fair for All agenda aims to ensure that "whatever the individual circumstances of people's lives, including age, gender, ethnicity, disability, religion, sexual orientation, mental health, economic or other circumstances, they have access to the right health services for their needs". Fair for All initiatives have produced a range of tools and guidance to help NHS Boards tackle health inequalities. It is too early, however, to see improved health outcomes or changes in patient experience as a result.

What's already happening in Scotland?

Children and young people

The NHS as a universal service is critical in providing ante-natal care, support for families with young children and school health services. These are already targeted to some extent on families most at risk of poor health.

Example:Childsmile School, the school dental service is targeted at the 20% most deprived areas in Scotland. The school-based service provides a range of preventative care interventions for children in primary 1 and 2 to reduce the risk of dental decay, running in 44 schools in NHS Fife and NHS Tayside.

Primary care

NHS action to reduce health inequalities starts with primary care, where more than 90% of patient contacts take place.

The Government is reviewing how GPs are remunerated, via the GMS ( GP) contract, to reflect the additional needs of practices in disadvantaged communities and using the Scottish Enhanced Services Programme ( SESP) to provide funding to address local needs. The allocation of resources to NHS Boards for the SESP and to practices through the GMS contract reflects the greater needs of more deprived populations.

Keep Well health checks are operating in the most deprived communities to identify and support people at risk of cardiovascular disease and diabetes, to reduce their risk. The Well North programme starts similar checks in 2008 for more than 45,000 people in the Highlands, Grampian and Island communities.

There is also a range of improvements in NHS dental services, community pharmacy and eye care to improve access and services for deprived groups and communities.

The Government is phasing out prescription charges, to ensure that people are not deterred by cost from getting the medication they need. This will be of particular benefit to those who have long-term conditions.

Mental health and wellbeing

The Government's Delivering for Mental Health Programme is improving care and treatment for people. It covers not only those with severe and enduring illnesses such as schizophrenia, bi-polar disorder and dementia, but also those with a wider range of conditions such as depression, anxiety and stress.

The Government-funded See Me campaign has gone some way to reduce the stigma associated with mental illness and improve people's prospects of recovery. NHS Health Scotland and the National Programme for Improving Mental Health and Wellbeing have also been effective in improving general understanding, for example through mental health literacy training for a wide range of people, not just health professionals.

The Quality and Outcome Framework ( QOF) of the GMS contract includes two indicators for depression. We are supporting GPs in implementing these indicators firstly to ensure that new patients presenting with depression have a formal assessment using a standardised tool and matched therapy appropriate to level of need. Secondly, treatment models are being developed for those with CVD and/or diabetes, who are identified as having depression and anxiety under the QOF.

Patients with severe and enduring mental illness should, where possible and appropriate, have a physical health assessment every year. This is also supported by an indicator in the Mental Health area of the QOF.

Example:Living Life to the Full is a project which builds on work done in Glasgow and Clyde which used existing experience of introducing self-help materials for cognitive behaviour therapy ( CBT) into the NHS. The Government will be funding the piloting of this approach in three NHS Board areas over the next three years. Targeting people with mild to moderate depression, the programme will offer multiple ways of accessing CBT self-help. Interventions will be provided in a variety of ways, such as one-to-one self-help clinics; using written workbooks or a CD Rom, telephone, group sessions, college courses or using website delivery. The project aims to meet the needs of individuals but also to increase capacity in the NHS to support delivery of CBT and a wide range of other interventions. This work will be evaluated.

Eleven NHS Boards are now taking advantage of enhanced service provision funding to provide health checks for people with learning disabilities.

Vulnerable groups: access to services

Some targeted action seeks to address the particular needs of disadvantaged groups of people. This includes the Government's multiple and complex needs initiative, which has an emphasis on changing staff awareness, attitudes and behaviour. The NHS projects being funded are focusing on factors such as engaging clients, building up trust and finding time and appropriate ways to assess clients' needs fully.

Example:The Prison Leavers Project - Women Centred Space in NHS Lothian is about improving the health outcomes for women leaving Cornton Vale. It provides a "safe place" for women returning to the community or women involved in the criminal justice process to engage in formal and informal learning and to gain support from each other and workers both in the Centre and from other agencies. The activities are centred on providing education and support in the form of courses and educational events. Women using the service are involved in design of the space, planning the programme and management of the project.

The health care needs of people who are homeless or at risk of homelessness have been recognised in comprehensive health and homelessness standards. The Government monitors progress in meeting these standards through the NHS Board annual review process.

Example:NHS Forth Valley seconded a community psychiatric nurse in July 2006, to work in the Falkirk Council housing support team, to provide dedicated support to homeless people. In a 16 month period, 105 homeless people of all ages have been referred to the service. Outcomes for them which the service has helped achieve have included: a more settled housing situation; registration with a local GP; accessing mental health and substance use services; accessing community support and supported accommodation; and improvement in general mental wellbeing.

The Scottish Prison Service ( SPS) is already following Government initiatives on alcohol problems, Hepatitis C, drugs, sexual health and healthy food. Continuity of care during the transition between prison and the community is vital. A feasibility study in relation to the transfer of prison medical services to the NHS is currently being considered by the Government.

The SPS also has a number of initiatives in place to improve mental health and wellbeing, support for family relationships and aspects of healthy living.

Example:The Scottish Prison Service is using Scotland's Mental Health First Aid training course for staff and prisoners and is training staff as trainers to deliver the course throughout the service.

Local authorities play a major role in providing services to people in need. They are key partners in shifting the balance of health and social care, to meet the needs of older people, vulnerable groups in the community and those with long-term conditions.

For many people, social care services are critical in sustaining and improving their health. The health of unpaid carers can likewise be improved by supporting them in their caring role. In developing these services, key themes are personalisation, following the recommendations of Changing Lives and shifting the balance of care into the community.

One important way (though not the only one) of providing more personalised services is self-directed support. Local authorities and NHS Boards are able to offer self-directed support which allows disabled people and others to purchase their own social care. Self-directed support improves people's lives and builds their capacity to take care of their own health. Take up is low, however.

Survivor Scotland is a national strategy which provides support for survivors of childhood sexual abuse. If survivors receive the self-care and preventative services they require, they are less likely to present later with serious physical and mental illness. Greater public and professional awareness of the issues surrounding abuse is required, however, as are more specialist abuse services and cost effective therapeutic interventions.

Task Force recommendations

These will make an impact on each of the priority inequalities the Task Force has highlighted, through improving the service people get from health and social care services, especially those in particularly vulnerable groups and at some important life stages. We have already said above what the NHS can do for children and families who need the most support. Outcomes from the action here will include better health for people who use social care services and a better experience of services for people with specific and complex needs.

Children and young people

44. Local agencies should provide high quality, consistent information to young people in a whole range of settings, including easily accessible drop-in services, staffed by health professionals and youth workers. These will support young people to make better decisions about things that affect their health significantly, for example sexual health matters.

Primary care

45. Keep Well health checks in deprived areas should identify people with depression and anxiety and make sure they get treatment and support.

46. The Government commitment to health checks for all at age 40 should be implemented in ways that build on the Keep Well programme.

47. The Government should create and fund new evidence-based anticipatory care programmes for other groups at high risk of health problems.

48. The Government should continue to reform the funding of primary care. Service developments through the Scottish Enhanced Services Programme should address the needs of groups and communities most at risk of poor health.

Mental health and wellbeing

49. NHS Board interventions to address depression, stress and anxiety should be increasingly targeted in deprived communities, ensuring that approaches and materials used are appropriate.

50. The next phase of Government-led work, following the National Programme for Improving Mental Health and Wellbeing should apply evidence of what works, in particular for those in disadvantaged groups and areas whose future health is most at risk.

Smoking

51. It should be a key priority within the Government's smoking strategy that NHS Boards and their local partners act to prevent young people in deprived communities from smoking, and to provide more effective support to smokers in those communities to quit.

Vulnerable groups: access to services

52. NHS Boards should target health promotion and health improvement action better for people with learning disabilities and others who may need support with access to information, in line with statutory disability requirements.

53. The Government should lead development of a framework for regular health assessments for people with learning disabilities in all NHS Board areas.

54. Each NHS Board should have a designated senior post responsible for ensuring that people with learning disabilities receive fair and equitable treatment from health services.

55. The Government should roll out a programme for improving the dental health of vulnerable groups, addressing the needs of, for example, older people, prisoners and homeless people.

56. NHS Boards and local authorities should work together to maximise the potential of self-directed support which allows disabled people and others to choose and purchase their own social care. Action should include publicising self-directed support, ensuring there are user-led support organisations locally and combining health and social care budgets.

57. Offenders and ex-offenders should have access to the health and other public services they need and benefit from the same quality of service as the rest of the population. Women offenders' health needs should have priority. This will require joint action by community health partnerships and community justice authorities.

58. Criminal justice agencies and NHS Boards should work together to ensure that offenders who have engaged with the Throughcare Addiction Service are assessed for and able to access addiction and health services within six weeks of release from prison.

59. Criminal justice services should work with other public and Third Sector organisations and user groups to respond to studies led by the Prison Reform Trust that aim to improve the experience and wellbeing of people with learning disabilities who are in trouble with the law.

60. Scottish Prison Service approaches to promoting positive mental health and wellbeing should be extended across all criminal justice settings.

61. The Scottish Prison Service should offer family and relationships support from the date of entry to prison. 51% of men and women in prison had dependent children and approximately 15,500 children in Scotland lose a parent to prison every year. The health, social and educational prospects of these children are affected in turn by their parent's health and wellbeing.

NHS wider role

62. NHS Boards should take opportunities to play a leadership role in promoting good relations within communities, recognising the impact of discrimination and disadvantage on health. An example of a leadership approach is in NHS Highland, where health service staff are working with community partners to develop a web-based alert/notify/monitor system for hate crimes, linked to anti-racism and anti-discrimination activities.

63. All contractors and providers commissioned by the NHS should be explicitly required to monitor their services in accordance with public sector equality duties, ensuring that their analysis uses qualitative and quantitative data to monitor the needs of different groups.

64. NHS Health Scotland should deliver an accessible communication, translation and interpreting strategy and action plan, with clear outcome measures.