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

DELIVERING CHANGE

Key points

• Better routes or pathways into and between services and agencies are needed.
• The Third Sector has an important role to play in tackling health inequalities.
• Resources will be required to make change a reality; significant funding has been allocated.
• Staff may need new skills and to work increasingly across organisational boundaries.

PUBLIC SERVICES AND CLIENT PATHWAYS: A STEP CHANGE

The Task Force's recommendations for action cover a wide range of public services which affect people's health and health inequalities, both directly and indirectly. These include support for families, education and training, employment, housing, the physical environment, transport, leisure, policing. The ways in which these services operate and respond to people can be critical to health and wellbeing. This is especially important where people's responses to deprivation or discrimination have already made them feel out of control and unable to cope well with managing their lives.

The Task Force recognises that Third Sector services often play a particularly effective part in supporting people at risk and in disadvantaged communities. "Encouraging the building of self-confidence and self-esteem, raising aspirations and helping people to overcome barriers to services are considered as areas in which the Third Sector excels." (Third Sector consultation)

However, the refocusing and redesign that the Task Force wants to see is mainly about change across the spectrum of public services. The Task Force wants to introduce an understanding of client pathways or routes into, through, between and out of the range of services, particularly those with clients who are more disadvantaged and who rely heavily on support and intervention.

From the client's perspective, services are needed which are high quality, with well trained staff meeting clear public expectations. Services need to meet the key general principles articulated in the Government's early years framework to achieve the same outcomes for all, with more support for those who need it.

As one conclusion from the Task Force's delivery proofing consultation put it: "There should be a shift of emphasis onto those who need it most and access services less."

The Task Force recognises that these statements of good practice are not new to public services and are built in to both aspirations and delivery across the public sector. The principle of personalisation - making services relevant to each individual - is a key pillar of the public service reform agenda, for example in Changing Lives and policy priorities across health and social care.

"Personalisation enables the individual… to find the right solutions for them and to participate in the delivery of a service. From being a recipient, citizens can become actively involved in selecting and shaping the services they receive." (Changing Lives, service development change programme. 2007)

"For people to perceive that they are part of the solution and not just creators of the problem is likely to be a marker of success" (Third Sector consultation)

Personalisation can be about prevention, maintenance or intensive support - whatever is needed.

There are also widely accepted and helpful standards such as those on equality, Investors in People and the National Standards for Community Engagement.

A client pathway may be a simple one to sort out an immediate and specific need that can be met by one service alone. Or it may reflect more complex circumstances in people's lives requiring a clear route into and between several services. For example attendance at a hospital out-patient appointment might include people's experience of transport and the potential to identify further needs for family support, financial advice or lifestyle changes related to risks of ill health.

Making client pathways between services work effectively must be the responsibility of service providers working jointly, within community planning arrangements. This presents a challenge to local authorities and their local community planning partners. Meeting the challenge will contribute significantly to the national outcome target which says that: "Our public services are high quality, continually improving, efficient and responsive to local people's needs." How local agencies put this into practice is very much a local matter and effective approaches must emerge from local experience. The Task Force wants to make sure that the best evidence is available to inform local development. This includes a clear understanding of why good practice matters for health and wellbeing and how mainstream public services can help to reduce health inequalities that can be unintended consequences of the way services currently work.

The Task Force wants central support for development of new and better client pathways for public services. It wants to see a small number of local test sites (around 6), where changes to public services are planned with a particular focus on health outcomes and reducing health inequalities.

Test sites might focus on some specific client groups or communities who are most at risk. They will address complex issues such as preventing violence or substance misuse, or meeting the health and other needs of young people.

Test sites will need willing and enthusiastic community planning partners, with senior management buy-in across organisations. They will be selected to cover a mix of areas and topics and will be a vital part of implementing and delivering the changes and priorities that the Task Force recommends.

The approach within test sites must be about the whole system of mainstream services, not about services or projects individually. The purpose will be to improve interactions and relationships between services, from the client's perspective. Some of the support that should be given to the test sites includes:

• Providing existing evidence and knowledge about achieving better health outcomes and reduced health inequalities, from Scotland and further afield.
• Incorporating practice from current strategies, standards and workforce development.
• Supporting test sites to engage communities and individuals, to win their confidence and increase the chances of successful service change.
• Ensuring effective data collection and analysis. This includes promoting the sharing of information across agencies.
• Applying continuous improvement techniques, working with both frontline staff and managers to gain their commitment.
• Evaluating and assessing both the process of service change and the health and other outcomes for clients, with the focus on health inequalities.
• Identifying where wider supporting changes are required for services to achieve the maximum impact eg in initial professional education for staff.

The learning and experience from the test sites must be shared effectively, in order to influence service design elsewhere and delivery. The Task Force wants this sharing of experience to start amongst the test sites themselves. They should form health inequalities learning networks that are supported to exchange experience and share emerging understanding in new and effective ways eg Seeing is Believing-type visits, exchange of key staff, joint training across agencies, action learning and peer support. Learning will also need to be shared more widely in ways that will be likely to influence change nationally. There are existing community planning and other networks and organisations that can help with this. These include the local government Improvement Service, NHS Health Scotland, the Scottish Centre for Regeneration, the Violence Reduction Unit and the Glasgow Centre for Population Health.

New resources will be needed for the health inequalities learning networks, in particular to:

• Support the process of service redesign and transformation. This will likely be through a multi-disciplinary team led by a continuous improvement professional, and providing Scotland-wide input.
• Provide capacity on the ground to bring the relevant organisations together, promote service redesign using continuous improvement techniques and make sure evidence is available to help.
• Commission or support performance reporting, performance management and evaluation.
• Share learning amongst test sites and across Scotland in ways that will influence long-term and sustained change in public services.

Resources for service change itself will be those that are already available locally. The test sites will, however, be able to explore where in the longer term further investment may be needed. This will help to inform longer term resource plans at both local and national levels.

The Task Force's recommendation for action is, therefore:

65. 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.

WORKFORCE

The Task Force's recommendations for action will affect the roles and skills of staff working directly with clients. We also expect to see service redesign in the test sites make some new demands on both frontline staff and their managers. Historically, professionals have been trained to deliver services which focus on a particular speciality. For example, health professionals are accustomed to dealing with health issues, social carers with providing care and teachers with teaching. The effect can be that client pathways between services don't work. Disadvantaged clients may not receive the same quality of service as the rest of the population.

Our recommendations mean that staff in a whole range of public services need some new skills and may work increasingly across organisational boundaries. This may involve a key worker or at least someone in a signposting role, connecting clients with other services, as well as meeting specific needs within their own role and agency.

The Task Force is aware that current strategies such as Changing Lives and the early years framework are already addressing increasingly complex demands on workers and also trying to meet the expectations of clients about quality, flexibility and integration of services. The Task Force wants to build on work already in hand, for example to develop an early years role that can operate across several different services and a para-professional role in social services. The Task Force is also aware that some workforce change will only happen in the long term: for example through influencing organisational cultures and the value base of different professions: altering why professionals do something, not just what they know or how they operate.

In the short term, there is an increasing recognition that staff across professions and disciplines need to do their jobs in a way which is sensitive to inequalities. Some relevant education and training is already taking place, for example equality and diversity training, leadership preparation and partnership working. Much of this education tends to focus on particular practitioner groupings and is sometimes specific to policy areas and types of services. In reality, there are many common aspects where learning could be shared. The Task Force believes that some national direction is required and therefore recommends:

66. The Government should establish a short-life, cross-sector working group to enable different sectors and those working within them to recognise and share common values, knowledge and skills and develop a joint educational/training framework to support practice which is sensitive to inequalities.

The Task Force also wants to see more joined up thinking about key worker roles, based on research and what is already known about effectiveness. The Task Force recommends that:

67. The Government should use existing experience in work on Changing Lives, Working for Families and in the early years field to develop a wider concept of a key worker role and the competencies and skills required to carry it out.

Management arrangements must support services to be sensitive to inequalities and allow for corresponding changes to staff roles.

Example:the goals for an inequalities sensitive health service, as adopted in NHS Greater Glasgow and Clyde, are that it:

• knows and understands its diverse population and the nature of inequality and discrimination it experiences.
• develops and delivers meaningful engagement with those experiencing inequality and discrimination in order to design services and empower patients.
• recognises that positive behaviours for health will be more likely to be enacted if strategies for support are specifically designed to take the experience of social class, gender, race, disability, age, sexual orientation and faith into account.
• understands and removes the obstacles to accessing frontline services and health information.
• creates services that have the ability to support patients in the context of their lives and gives practitioners support to address the causes as well as the consequences of inequality and discrimination.
• recruits and retains a workforce that represents, at all levels of the organisation, the diversity of the population.
• creates a working environment which is responsive to all dimensions of health and social inequalities, and prevents discrimination and prejudice from affecting patient care and staff relations by developing the competency of and support for staff leading and implementing an inequalities sensitive health service.
• reallocates available resources and manages performance in favour of the elements of an inequalities sensitive health service.
• procures its goods and services to impact positively on health and social inequality.
• advocates for and contributes to the implementation of economic and social policy which addresses income inequality, geographic and social class inequality, gender inequality, racism, disability discrimination and homophobia, as pre-requisites for good health.