Primary Care Health Inequalities Short-Life Working Group recommendations: progress report 2023

Wider Context

The work of the PCHIDG takes place in the context of wider changes both to primary care and to the factors which influence inequality in Scotland. There are several things to highlight over the course of the year which are significant for the context of the recommendations and related work.

• New publications and reports. The Health Foundation report on inequalities in Scotland published in January 2023 highlighted concerns that the health of people living in the most deprived local areas is being left behind the rest of society, and the need to address the 'implementation gap' between policy aspiration and meaningful change. The Health, Social Care and Sport Committee report in September 2022 affirmed the need for action at all levels of government to ensure that future design and delivery of public services properly recognises and addresses the needs of those experiencing disadvantage. These reports support and add urgency to the delivery of the SLWG recommendations.
• Cost of living. The impact of inflation and energy costs on the price of daily essentials such as food, clothing and heating has been significant over the year and particularly over the winter, with corresponding impact on health and inequalities. A Deep End group round table in November 2022 highlighted concerns about the physical and mental health impacts of fuel poverty, inadequate housing, food insecurity, and access to health and other services due to transport costs. Its recommendations particularly highlight the importance of the SLWG recommendations on the scale-up of embedded welfare advisors and community link workers in General Practice.
• The Scottish Government Policy Prospectus. The group noted and welcomed the continued commitment to primary care and health inequalities, renewed in the April 2023 statement, confirming the intention by 2026 to demonstrate that Scottish Government has "sustained our investment in general practice through the Primary Care Improvement Fund and invested more in practices servicing disadvantaged areas".
• The 2023/24 Programme for Government. This included a commitment to deliver targeted support to practices serving the most disadvantaged communities in NHS Greater Glasgow and Clyde and a commitment to work with local areas to ensure vital specialist services such as Community Link Workers.
• Mental Health. The SLWG report did not include specific recommendations about mental health as it was written in the context of a separate commitment to a network of 1,000 additional dedicated staff who could help grow community mental health resilience and help direct social prescribing by 2026, through the implementation of Mental Health and Wellbeing in Primary Care Services. However, as a result of The Emergency Budget Review in November 2022 funding for this programme was paused. This remains an area of concern for the group as an absence of additional mental health support directly impacts on the likely success of some of the SLWG's other recommendations to address health inequalities. This was also highlighted in the September 2023 Audit Scotland Adult mental health report.
• Primary Care Funding and Transformation. The wider context of general practice funding and workforce is important, as the SLWG was clear that change cannot be achieved through standalone projects, but by strengthening core primary care services. The Emergency Budget Review impacted on primary care funding during 2022/23, with a reduction to General Practice sustainability payments, and an in-year reduction in Primary Care Improvement Fund (PCIF) allocations. For 2023/34 those sustainability payments have come to an end, and the PCIF is maintained at £170m (plus Agenda for Change uplifts). In terms of delivery of the General Medical Services (GMS) contract, the 2020 Memorandum of Understanding (MoU) had stated that three of the MoU areas should be focussed on Vaccination Transformation Programme (VTP), Community Treatment and Care Services (CTACs) and Pharmacotherapy. The group is concerned about the continued higher prioritisation for PCIF in 2023-24 of those services, rather than mental health workers and Community Link Workers, in relation to both inequalities and the precarity of funding. Finally, general practice workforce figures were published in November 2022; analysis by deprivation shows particular challenges in the most deprived areas with a lower proportion of clinical staff, which is likely to be related to challenges with recruitment and retention.
• Community Link Workers. As core members of the multidisciplinary teams, Community Link Workers are at the forefront of work to address health inequalities across Scotland. Their work and their insights have informed the work of the PCHIDG. As well as concern about the sustainability of the funding model for Community Link Workers due to overall budget constraint and PCIF pressures, the group has noted the wider pressures on the third sector due to rising costs for third sector organisations and pressure on funding from a variety of sources as public sector budgets are constrained. This is a further challenge for link workers who connect to a wide network of local services which may have reduced capacity or have stopped completely.
• Inclusion Health Action in General Practice (IHAGP). As part of efforts to improve health outcomes for some of our most disadvantaged patients, the Scottish Government have committed up to £1,300,000 of new 'Inclusion Health Action' funding to the most deprived practices in NHS Greater Glasgow and Clyde for 2022/23 and 23/24. Current demand-led resource allocation processes do not fully take account of need and a core intent of the SLWG recommendation that IHAGP responds to is to address the 'inverse care law' which states that "the availability of good medical care tends to vary inversely with the need for it in the population served". IHAGP helps to address that gap by acting as a bridging mechanism between the Scottish Workload Formula, which currently allocates resources to general practices, and any future funding model/approach. It provides funding where there is the greatest blanket deprivation in NHS Greater Glasgow and Clyde.
• Welfare Advice and Health Partnerships (WAHPs). In line with tailored approaches to support people to access advice in accessible and trusted settings, the Scottish Government has committed £4,125,000 over three years to fund a test and learn initiative regarding Welfare Advice and Health Partnerships. WAHPs provide an integrated approach to advice, allowing GP practices to refer patients directly to a dedicated welfare rights advisor in NHS settings who can provide advice on a range of social and economic issues. This funding is currently placing welfare rights advisors in 180 GP practices across Scotland's most deprived areas, including 30 in remote and rural communities, allowing wider populations to engage with these vital services. Initial findings from WAHPs have highlighted the positive impact the initiative is having in communities. From the period between January 2022 and March 2023, the financial gain for the almost 10,000 patients accessing the service was £16.2 million, from a Scottish Government investment of £1.46 million.

The Development Group has taken account of this current context when considering where to focus efforts over the next year.