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

Appendix 1: Recommendations of the Primary Care Health Inequalities SLWG with Progress to Date

The shaded boxes indicate the five foundational recommendations. (for shading please see PDF in supporting files)

1. Implement a national Fair Health Scotland programme of multi-disciplinary postgraduate training fellowships in health inequalities. This will build a leadership network in primary care to develop skills and generate additional capacity for multi-agency care planning, inter-disciplinary team working, and co-production of health with individuals and at a community level. Communities who are affected by disproportionately poorer health outcomes and high levels of excess deaths due to health inequalities should be identified to benefit from the impact of this additional capacity. The programme will build on the learning from the Deep End Pioneer Scheme and the Fair health post-CCT Trailblazer Fellowships, Govan SHIP, Lanarkshire OT and QNIS Programmes. It should develop capacity in professional practice based on deep understanding of overlapping causes and dimensions of health inequalities, including the intersectionality of protected characteristics, socio-economic determinants, place, structural racism, discrimination, impact of racism on health, and privilege.

The Scottish Government recognises the importance of all members of primary care MDTs having the skills, knowledge and confidence to work with individuals and communities affected by health inequalities, across their careers. We, therefore, take a broad view of this recommendation, as well as acknowledging its specific call for a postgraduate fellowship programme based on previous GP fellowships programmes, which also delivered benefits for GP recruitment and retention in participating practices.

NES (NHS Education for Scotland), as the lead national organisation for health workforce development and education, is key to delivery of work against this recommendation. We welcome the work which NES have undertaken in recent months to develop approaches to health inclusion education and skills across all staff groups.

There are two specifics workstreams under development/in progress, which NES are leading on.

Multi-Disciplinary Inequalities Fellowships. ('Fairhealth Fellowships')

The Scottish Government is supportive of the call for, and are awaiting a costed proposal for, new fellowships, which is being developed by NES and the PCHIDG Chair (National Strategic Lead for Primary Care at Health and Social Care Scotland). This programme would require dedicated funding for delivery and resource within NES for programme-development/management.

Health Equity Focused Training (HEFT)

We recognise the specific needs for GPs in training who specifically wish to work in areas of higher deprivation and to have opportunities to enrol in a dedicated health equity focused training scheme. We therefore welcome the work that has been taken forward by colleagues in NES and the Deep End Group over the past 18 months on a proposal for a HEFT programme in Scotland, based on learning from elsewhere in the UK and Ireland, where such schemes exist. A pilot is due to start in 2024.

Other relevant developments to note:

- The new Inclusion Health Action funding for general practices serving the most disadvantaged communities in NHS Greater Glasgow and Clyde can be used by eligible practices to support staff to increase their knowledge and understanding of health inequalities and trauma-informed care (and subsequently embed this knowledge in the way that they design and deliver their service).

- NES have been working with the Scottish Community Link Worker Network to develop national support for CLWs e.g. a Social Prescribing landing page on the TURAS learning platform. The review the Scottish Government have recently started of CLW service delivery across Scotland will explore CLWs' learning and development needs.

- We very much welcome the incorporation of health equity/inequalities onto the new General Practice Nurse pathway which NES are leading.

The Scottish Government will monitor these and other developments to ensure we have a skilled and supported workforce to help us tackle health inequity and health inequalities. The longer-term ambition, which would require cross-sectoral (including higher and further education) and cross-policy working, would be to see widening participation to health and social care courses, inclusion health embedded and prioritised across under- and post-graduate curricula, and adequate opportunity for continuing professional development (CPD) for all staff.

2. Enhanced service for Health inequalities: The Scottish Government should create an Inclusion Enhanced Service that supports the management of patients who experience multiple and intersecting socio-economic inequalities, wherever they are registered, to improve equity of access, patient experience, health literacy, and health and wellbeing outcomes. An evidence-based process for resource allocation would be needed to ensure delivery is targeted as intended. This Enhanced Service would be a key enabler to the delivery of other recommendations.

A small dedicated sub-group of the PCHIDG met twice over summer 2022 to discuss the recommendation in the context of a presumption against the creation of new enhanced services. The group further developed options and agreed that the action need not be a formal enhanced service if an alternative mechanism could deliver the aims of the recommendation. The sub-group highlighted previous health inequalities projects, in particular, the Govan SHIP project and Chance 2 Change. These discussions led to the development of 'Inclusion Health Action in General Practice (IHAGP)' and the sub-group and other stakeholders developed a range of IHAGP actions that could be undertaken within such a programme.

Following ministerial approval, in spring of 2023 funding of £300,000 was allocated to general practice in NHS Greater Glasgow and Clyde serving communities with the highest levels of poverty and disadvantage, enabling those practices to begin planning practical actions to tackle challenges they are facing in relation to addressing health inequalities within their patient populations. On 5 April 2023, the First Minister announced a further £1,000,000 of Inclusion Health Action funding for 2023/24. The Scottish Government's Policy Prospectus included a commitment to increase investment in general practices in deprived areas and IHAGP is part of the Scottish Government's Preventative and Proactive Care Programme.

IHAGP Objectives

• To prevent health outcomes worsening for people with greatest need.
• To proactively reach out to those who are 'lost' to the system, or find it difficult to navigate, and who need support to manage their health and social circumstances.

Deliverables

The 2022/23 investment will add distinct value by supporting general practices to:

- create new or enhance/increase existing patient/community participation capacity. This should have a clear focus on group working, with and for patients who experience multiple health and social inequalities.

- provide practices with support to help and enable staff (including administrative and management, clinical and link workers) to access education, knowledge resources or training on health inequality and health equity and to subsequently embed these into their practice processes and policies;

- undertake targeted and proactive action to support patients who are at high risk of physical or mental ill health due to poverty and inequality, for example through extended consultations.

Next Steps (6-month horizon)

• The Scottish Government will support, monitor and evaluate the use and impact of IHAGP over 2022 – 2024 through a dedicated Steering Group
• Resources are being developed to support the work of practices (e.g. through sharing examples of good practice and establishing learning networks).
• Participating general practices will begin to deliver their IHAGP actions.
• Participating practices will complete monitoring forms to inform SG of uptake and implementation of Inclusion Health Action by practices. This helps to ensure that the investment is being used as intended and it will provide invaluable information for the Scottish Government to use in any future development of the IHAGP or other approaches aimed at tackling health inequalities.
• The Scottish Government will separately undertake more in-depth monitoring and evaluation of the IHAGP through targeted engagement with a sample of eligible practices.
• We intend to explore how IHAGP could be extended to practices in other areas of high deprivation and incorporate lessons learned from NHS Greater Glasgow and Clyde practices this year.
• The Scottish Government will continue to explore how mechanisms for resource-allocation to general practice can better reflect deprivation and health care needs in future.

3. Empower primary health care professionals to play an expanded role in multi-agency care planning for people who have complex health and social care needs. This will require both sufficient time capacity and adequate training. Co-ordinated care planning for complex and long term conditions can bring together primary health care workers, including those working OOH in 24/7 provision, with social care, mental health, link workers, education, police, carers, housing, families and individuals themselves as appropriate. The programme of work surrounding Anticipatory Care Planning, and projects such as Govan SHIP provide models from which lessons can be learned. This recommendation would support the Expert Medical Generalist role for GPs, and the implementation and future phases of the MoU and GMS contract.

The Improving Together via GP Clusters programme provides the opportunity for GPs to come together for quality improvement. We recognise that there is more we can do to join up quality improvement across primary health care worker professions. Clusters already have a remit to address health inequalities through their intrinsic and extrinsic roles.

4. Create a national priority of reducing premature disability due to long term physical and mental health conditions: The NHS, the four new, overarching Care and Wellbeing Programmes being developed by the Scottish Government, and new National Care Service should have responsibility to deliver this priority. Primary care practitioners need to be able to work together with specialist NHS colleagues, social care, local authorities, community planning, communities and individuals most at risk, the third sector and business sectors to increasingly align resources around empowering individuals to stay well, supported by their families, carers and other assets in their community. This priority should be reflected in both core and enhanced elements of the GP contract offer, with reference to the EMG role, the delivery of realistic medicine, partnership working, and support for wellbeing in the care and management of individuals with long term conditions.

This recommendation cuts across several of the others, especially recommendations 3, 6 and 13. "A Scotland for the future: opportunities and challenges of Scotland's changing population", published in 2021, is the Scottish Government's first national population strategy. A core ambition of the Strategy, as well as raising life expectancy, is, critically, to increase the number of years that all of Scotland's people spend in good health. The Strategy describes actions within and across portfolios, and the role of our key partners, to deliver that aim.

5. Invest in the training and resourcing of health and social care staff for digital inclusion: All staff in the primary care multi-disciplinary team, for both in-hours and OOH, and including practice administration and community links/welfare workers, should understand the potential and the limitations of digital and remote care, with specific relevance to the demographic characteristics and access requirements of the communities with which they work. They should have the skills, confidence and equipment they need. This includes providing resources, capacity and support for GP and primary care teams to ensure digital access and care are intrinsic to their working practices, patient access and care delivery, and that they can maximise technology's potential to mitigate inequalities, create community and empower self-management (for example, online communities/peer support, home monitoring, YouTube instruction videos). This commitment would require NES and HIS working in partnership.

The Digital Leadership Programme previously open to Nursing, Midwifery and AHPs has been expanded and is open to other professions across health and social care. In April 2023, the Leading Digital Transformation in Health and Care postgraduate programme launched supporting our investment in digital skills and leadership. The outputs from the current Digital Maturity exercise and continued access to the online platform will inform future workforce developments across health and social care. The previously named Digitally Enabled Workforce Programme is under review and will be launched as a Digital Capabilities programme later this summer.

6. Articulate and embed inequalities as a core concern in the Expert Medical Generalist role: In parallel to other recommendations related to complexity and dedicating more GP time on patients who need it, there needs to be clearer expression of how inequalities run through the EMG alongside ways to understand whether and how this is being realised.

The opening of the GMS Contract states "A strong and thriving general practice is critical to sustaining high quality universal healthcare and realising Scotland's ambition to improve our population's health and reduce health inequalities." Reduction of health inequalities are key intrinsic and extrinsic functions of GP Clusters. This is a priority for the Scottish Government and we will work with the relevant SG areas/stakeholders to establish how this work should be taken forward.

7. Strengthen national leadership: The Scottish Government should consider options, including a new Health Inequalities Commissioner, to strengthen leadership for health inequalities in health and social care and to create momentum, overview and responsibility for measures across all public sectors to reduce inequalities in avoidable/premature mortality, healthy life expectancy, and premature disability. Existing levers, structures and systems (e.g. performance management, statutory requirements, guidance, clusters) should be used to drive change and hold system leaders and managers accountable for tackling health inequalities.

The Scottish Government continues to explore options for a response to this recommendation. The Care and Wellbeing portfolio is focussed on reducing health inequalities and, within this, the Place and Wellbeing Programme is looking specifically at strengthening a whole system approach to local action on health inequalities. This includes actions to improve joint accountability and coordinated evidence-based action by embedding health inequalities priorities within performance and planning frameworks.

8. Commit to ensuring social and financial inclusion support and advice is available through primary care settings: The Scottish Government should reaffirm its policies of promoting in primary care those roles (such as Community Links Worker, Welfare Advisor and Mental Health Worker) which provide non-clinical and social support and advice to individuals experiencing social and financial disadvantage and exclusion.

The Scottish Government remain committed to supporting Community Link Workers, whose role aligns strongly with the missions on Equality and Community in our recent Policy Prospectus. We are aware of concerns about the long-term future of CLW services in the face of ongoing pressures on health budgets and officials are reviewing the current delivery landscape to fully understand local challenges.

We continue to fund and support the Scottish Community Link Worker Network. This continues to grow and develop its membership and activity and recently held its first conference which was attended by the Minister for Social Care, Mental Wellbeing and Sport. We also continue to fund embedded Welfare Advice and Health Partnerships (WAHPs) which integrate local authority or third sector welfare rights and money advice services into NHS services.

The Scottish Government recognises the impact that debt and money worries can have on mental health and works with partners to tackle this issue. We worked with Support in Mind and the Money and Pension Service on a Money and Mental Health toolkit which was distributed to GP practices. Marketing initiatives for the general public such as 'Home Energy Scotland' and 'Money Support Scotland' provide a wide range of free and accessible resources for stakeholders, including GPs and primary care settings. This help CLWs and WAHPs to support those that need help the most.

We have also recently agreed to provide funding to the Scottish Social Prescribing Network to increase understanding and awareness of the importance of non-clinical, social support and the different forms this can take.

9. MoU and the GMS Contract Offer, should be underpinned by a commitment to address inequalities: Inequalities and equity should, formally and explicitly, run as themes through ongoing implementation of current and future commitments (including the joint December 2020 letter) in the MoU and GMS contract offer and through priority development around Mental Health and Urgent Care, maximising lessons from MDT, clusters and partnership working. Decision-making underpinning PCIPs should clearly reflect statutory requirements in relation to equalities. Equality Impact Assessments should be mandatory for Health and Social Care Partnerships, in line with Fairer Scotland Duty statutory guidance for public bodies, which includes socio-economic inequality.

Impact assessments are important drivers for data availability, accessibility and relevance. Public bodies are required by law to conduct equality impact assessments to identify and guard against potential risks of discrimination and help develop better policy. They allow us to test policies and proposals, deliver quality assurance and ensure legal compliance. Assessing the impact of policies or practice against the needs in the Public Sector Equality Duty is known as carrying out an Equality Impact Assessment (EQIA).

Since April 2018, public bodies in Scotland have been legally responsible for the 'Fairer Scotland Duty'. This requires them to identify and address barriers and inequalities of outcome that arise from socio-economic disadvantage whenever they make significant decisions, and they are publicly accountable for how they have carried out this duty. The Fairer Scotland Duty is additional and complementary to statutory duties under the Public Sector Equality Duty and the Human Rights Act. 'Long-term Monitoring of Health Inequalities' presents a range of official statistics indicators selected in order to monitor health inequalities over time. We recognise that there will be variations in the extent and quality of impact assessments across different bodies and for different initiatives and that more could be done to encourage good practice.

10. Funding allocation: any changes to how funding is allocated in primary care should explicitly consider the inclusion of socio-economic inequalities, rurality, equity of access and unmet need. The Scottish Government should also commit to monitoring unintended consequences or risks arising from a future formula or model for funding.

The Scottish Workload Formula which distributes most of general practice funding is based upon estimated workload. It is weighted for age, sex and deprivation. The previous formula included rurality as a cost factor but analysis in 2017 did not support this as a continuing factor. Scottish Government and SGPC will work together on Phase 2 of the GP contract which will be based upon the best understanding we can get of GP earnings and expenses. Inclusion of different factors within a formula depends on available data being of sufficient quality and reliability and the accessibility and quality of general practice data have been improving in recent years. The Scottish Government will monitor any unintended consequences or risks arising from any agreed future formula or model for funding.

11. Transport and health: The Scottish Government should create a group which brings together different sectors and stakeholders to review and take action on transport and health and make improvements to how health and transport services interact. This should tackle inequalities and ensure that patients can access health services more easily, when they need them, and in a way that promotes sustainability.

A Transport to Health delivery plan was drafted in early 2023 and is due to be adopted. The plan contains 16 commitments against actions for Scottish Government and other agencies. The themes include Scottish Ambulance Service Scheduled Care review, NHS delivery plans, Transport Scotland Act - NHS Board action, Regional Transport Planning and accessible travel. Work has commenced on implementing the delivery plan.

12. Recognise digital as a social determinant of health: Technology should be understood as a determinant of health inequalities and outcomes alongside other socio-economic and environmental determinants. The Scottish Government and Public Health Scotland should look at ways to incorporate digital access and skills into their analysis of inequalities.

Scotland's refreshed Digital Health and Care Strategy was published in October 2021, with a vision to improve the care and wellbeing of people in Scotland by making best use of digital technologies in the design and delivery of services to enable people of all ages and abilities to live well and safely at home. The Strategy explicitly addresses inequalities and the need to make digital services as accessible as possible. This means services which communicate with each other across our integrated health and care system, but also digital options that are available in a range of formats and recognise that people have different accessibility needs.

In 2021 we committed to taking forward a specific programme to support public engagement on inclusivity, in partnership with The Health and Social Care Alliance Scotland (the ALLIANCE) to form a Digital Citizen Panel. The Scottish Government continues to work closely with the Equalities and Inclusion Advisory Group (Digital Health and Care) and the Primary Care Health Inequalities Development Group to gather insights and advice on a range of projects. One of these was a short project by a peer-led community group, called Chance 2 Change (C2C), supporting people living with long-term conditions in a deprived area of Glasgow. The outputs from and continued access to the Digital Maturity Assessment will inform workforce developments across health and social care on an ongoing basis.

13. Develop a network of expert reference groups with lived experience to ensure these groups are included from the start of the policy making or service design process and not just at the impact assessment stage. This should take account of socio-economic disadvantage and protected characteristics and the intersections of different characteristics. Practice lists and clusters are key: as mechanisms for delivery of this recommendation and as beneficiaries from it as it would support them to engage more meaningfully with their lists/communities.

Work in progress:

• A GP advisor to SG/core PCHIDG member leads this work and has formed a working group with a broad range of community/lived experience engagement experts, including Healthcare Improvement Scotland, VHS and the ALLIANCE. They will continue to drive this work forward over the coming year.
• SG and the peer-facilitator of the Chance 2 Change Group continue to work together, including finding ways to capture and share learning from C2C.
• New Inclusion Health Action funding for general practices serving the most disadvantaged communities in NHS Greater Glasgow and Clyde can be used by eligible practices for activities and resources development for community voice engagement.
• SG Primary Care policy will, internally, continue to promote the inclusion of lived experience voices in policy-making and share their experiences with colleagues.

14. Invest in wellbeing communities: The Scottish Government should support the development of a more coherent and long-term approach to local, place-based action to reduce inequalities. Communities have different starting points in terms of social and material assets they possess. Partnerships between communities, third sector, public sector, and the NHS and social care system as 'anchor institutions', and alignment of policy across government, should prioritise supporting and promoting durable community assets that enable peer-to-peer support, shared community spaces, local groups & activities and other community infrastructure to protect and promote mental health, resilience and wellbeing. Clusters and practices, embedded in their communities, should be intrinsic to this work.

The Place and Wellbeing Programme sits within the wider Care and Wellbeing Portfolio and works with partners to understand what is needed at a national level to support local action to reduce health inequalities by harnessing the collective power of communities, and the voluntary, public and private sectors. The programme focuses on the role of communities and the NHS in influencing decisions that impact on the wider determinants of health and wellbeing such as employment, planning and social networks.

Reducing health inequalities is the golden thread that runs through our work and steers our approach. Beyond providing excellent care, our NHS and social care institutions have a vital role to play in reducing inequality in Scotland. With an initial focus on NHS Boards, we are working with the NHS in Scotland to find more ways to harness the power of its 'anchor institutions' to create job and business opportunities and build prosperity in local communities. Providing good, stable employment to people who face the most disadvantage, including opportunities to grow and progress throughout their career will help to increase incomes for families and reduce child poverty.

Objectives

The Place and Wellbeing Programme has three strategic objectives:

1. The Anchors workstream aims to support health and social care bodies to operate as effective anchor institutions as part of the wider community wealth building agenda.

2. The Communities workstream aims to empower the community and voluntary sector to act locally and complement the actions of the public sector.

3. The Enabling local change workstream is improving access to data and intelligence providing additional specialist public health resource to communities and ensuring health is engaging proactively in Community Planning Partnerships across Scotland.

Deliverables

• Scotland's health and social care bodies operating as effective and collaborative anchor institutions.
• Strengthened capacity and relationships in communities facing the most barriers to health and wellbeing.
• Coherent local partnerships involving communities, with a shared vision underpinned by public health data, intelligence and joint planning that profiles local need.

Key Action to Date

• An Anchors Delivery Group has been established to drive forward the Anchors work in three key strands: procurement, workforce, and land and assets.
• Initial discussions with NHS Lothian and NHS Fife who have both agreed in principle to be test sites to understand the enablers and barriers to the use and disposal of land for benefit of the local community and the local economy.
• Initial discussions with NHS Greater Glasgow and Clyde, NHS Lanarkshire and Scottish Ambulance Service who have both agreed in principle to be test sites to understand the enablers and barriers to more progressive procurement.
• NHS Boards have been asked to develop Anchors strategic plans by October 2023 that set out how they will progress anchor activity locally in partnership with other local anchor institutions.
• The Communities Core Group, made up of representatives from the community and voluntary sector, Healthcare Improvement Scotland, NHS Health Promotion Managers, a local authority and Scottish Government policy teams are developing a proposal for local engagement to support policy development within the Communities workstream.
• A joint position statement to the Community Planning Improvement Board from Public Health Scotland, COSLA, Scottish Directors of Public Health and Scottish Health Promotion Managers recently re-affirmed "Community Planning Partnerships and local government [as] the 'engine room' of local public health deliver".
• Work continues to progress through the Localised Working Programme at pilots in NHS Dumfries and Galloway, Tayside and Western Isles. The aim is to provide additional specialist public health resource to Community Planning Partnerships in order to improve access to good public health data, evidence, and intelligence to inform local action.

Next Steps

• Consulting on potential metrics to support NHS Boards establish a baseline to measure their contribution as anchor institutions at a local level.
• Implementing the Anchors communications strategy to update stakeholders on a regular basis, share best practice and inform them on wider policy developments.
• The Communities Core Group to finalise the local engagement approach aiming to start in the autumn.
• Mapping of grants across DG Health and Social Care to understand current funding going to local community and voluntary organisations in order to identify opportunities to improve internal processes e.g. the Self Management Fund.
• Establish an Enabling Local Change Delivery Group and review governance arrangements for the Localised Working Programme.
• Convene key system stakeholders to identify activities to strengthen health's contribution to CPPs over the next 6-12 months.
• Identify pilot sites to test the developing Population Health Dashboard.

One example of other relevant actions:

We have invested £36m in our Communities Mental Health and Wellbeing Fund for adults over two years, with approximately 3,300 grants being made to local organisations across Scotland. A further £15m is committed in 2023/24. The Fund was launched in October 2021, in recognition of the vital role that local 3rd sector organisations play in supporting mental health and wellbeing within local communities. The Fund supports grass roots community groups in building resilience and tackling social isolation, loneliness and the mental health inequalities made worse by the pandemic and, more recently, the cost crisis.

In the first two years approximately 3,300 grants were made to local organisations across Scotland to a wide range of grassroots community projects including those based around peer support, physical activity, arts and crafts activities, social interaction and befriending, with a strong emphasis on the key themes of prevention and early intervention, suicide prevention and addressing social isolation.

Year three funding will make a big difference to communities across Scotland, enabling them to build on the examples of good practice supported so far and providing them with further opportunities to re-connect, revitalise and promote good mental health and early intervention for those in distress. The purpose of the Fund is to build and develop capacity within communities to support the mental health and wellbeing of individuals.

The Fund has a focus on:

• Tackling issues such as suicide prevention, social isolation and loneliness and prevention and early intervention;
• Addressing the mental health inequalities exacerbated by the pandemic, the cost of living crisis and the needs of a range of 'at risk' groups.

15. Pilot and implement a national programme of digital empowerment for health through community-based peer-supported learning programmes to enable patients who are digitally excluded to safely use digital networks for peer support, access health resources on-line, and gain hands-on experience in using NHS remote consulting technology.

Digital Inclusion is a priority for the betterment of public health and care. It is our ambition as a government to achieve world leading levels of digital inclusion as Scotland continues its road to recovery after the pandemic. Addressing digital exclusion and the challenges faced by many without or, in some cases, no desire to access services digitally is of the utmost importance in the development of any government service. We recognise that digital is a choice, and that non-digital options must remain available. Equally, we are committed to ensuring that those who wish to access digital services are enabled and supported to do so.

In health and social care, we ensure we apply the Scottish Approach to Service Design and aim to design our products and services to include a 'non digital' route. The Connecting Scotland programme, led by the Digital Directorate, was launched in response to the pandemic to provide devices, data, and training to address digital exclusion. Some 60,000 people have benefited to date with a focus on people at a high clinical risk of COVID-19, young care leavers and families with children, socially isolated / older and disabled people, employability, and digitally excluded / low-income households.

In addition, the Digital Health and Care Directorate have invested £2m (from 2021/22 funds) with the Scottish Council for Voluntary Organisations (SCVO) for a Digital Inclusion Programme to test and implement models of digital inclusion, initially in mental health and housing. We expect to confirm successful projects in summer 2023.

The Scottish Government continues to work closely with the Equalities and Inclusion Advisory Group (Digital Health and Care) and the Primary Care Health Inequalities Development Group to gather insights and advice on a range of projects.

16. Raise awareness of health care rights and responsibilities: People who do not use primary care services or are under-represented as health services-users should be informed about their rights and responsibilities in relation to health care. They must be provided with accessible and inclusive information that they understand, through communication channels that work for them. Information would include how to register with a GP and use health care appropriately and cover a range of other services and resources to support their use of primary care. The third sector and community organisations will be key partners.

NHS Inform has a comprehensive directory covering 'care, support and rights' which provides fully accessible information on things such as registering with a GP practice and service user rights when using services. Furthermore, The Patient Rights (Scotland) Act 2011 required Scottish Ministers to publish a Charter of Patient Rights and Responsibilities, which summarises the existing rights and responsibilities of people who use NHS services and receive NHS care in Scotland. This Charter has been published in full with the most recent revised version published in Summer 2022. There is an easy read version of the Charter, as well as being available in BSL and other languages.

The Scottish Government has undertaken work with the intention of building on the work of Making It Easier – Scotland's Health Literacy Action Plan (published in 2017) in recognition of the impact of COVID on healthcare and treatment. We are working with our partner NHS Shetland on small-scale test pilots to improve health literacy knowledge and build capacity to generate improvement projects, with the intention of sharing learning with Scotland's health boards.

A specific agreement (based on the NHS Charter of Patients' Rights & Responsibilities) was put in place following engagement between Health Boards and members of the Scottish Gypsy Traveller Community. This clearly sets out what the Gypsy Traveller community should be able to expect from the NHS.

SG is also taking forward a range of work through the Gypsy Traveller Action Plan further aimed at improving awareness and understanding about the help and support they are entitled to. This includes providing funding to support the recruitment, training and ongoing support for a small number of Community Health Workers who have been recruited from the gypsy traveller community. The Health Workers provide support specifically to the gypsy traveller community, supporting community members to access appropriate services and removing existing long standing barriers that may stop them from using services (lack of awareness, distrust, prior bad experiences). The Patient Advice and Support Service (PASS) is run in conjunction with Citizens Advice Scotland. PASS provides free, confidential, independent advice and support for NHS patients in Scotland. The service is fully accessible.

17. Publish high quality, accessible information on health inequality: National and local bodies should commit to: improve data collection, quality and transparency on inequalities and how they intersect, at national and local levels for protected characteristics, deprivation and other experiences of marginalisation (e.g. homelessness), and address gaps; review how they describe, publish and report on health equity and health inequalities and mortality figures to ensure that information is accessible, easily comprehensible and transparent so that communities and individuals are empowered through knowledge.

Impact assessments are important drivers for data availability, accessibility and relevance. Public bodies are required by law to conduct equality impact assessments to identify and guard against potential risks of discrimination and help develop better policy. They allow us to test policies and proposals, deliver quality assurance and ensure legal compliance. Assessing the impact of policies or practice against the needs in the Public Sector Equality Duty is known as carrying out an Equality Impact Assessment (EQIA).

Since April 2018, public bodies in Scotland have been legally responsible for the 'Fairer Scotland Duty'. This requires them to identify and address barriers and inequalities of outcome that arise from socio-economic disadvantage whenever they make significant decisions, and they are publicly accountable for how they have carried out this duty. The Fairer Scotland Duty is additional and complementary to statutory duties under the Public Sector Equality Duty and the Human Rights Act. 'Long-term Monitoring of Health Inequalities' presents a range of official statistics indicators selected in order to monitor health inequalities over time.

As part of the Place and Wellbeing Programme, Scottish Government Health and Social Care Analysis and Public Health Scotland are currently developing a Population Health Dashboard, building on experience with the Covid Recovery Dashboard. The Dashboard will be aligned with national Care and Wellbeing Portfolio indicators and National Performance Framework outcomes, with a view to enabling local public health teams to produce relevant breakdowns geo-spatially and by population groups. The purpose, usability, accessibility and impact of their tools and resources are key concerns for Public Health Scotland.

Care and Wellbeing Dashboard will be launched by PHS on Tuesday 20 June. This will be a source of data and intelligence to support the ambitions of the Care and Wellbeing Portfolio to improve population health, address health inequalities and improve the health and care system. The dashboard covers a selection of indicators structured across the Marmot framework, looking at the social determinants of health, the conditions in which people are born, grow, live, work and age which can lead to health inequalities.

Following the release, SG analysts will work collaboratively with PHS to add content for all indicators, add further inequalities breakdowns where available, and to improve the look and feel of the dashboard to make it easier to see where progress is being made across the Marmot policy objectives.

18. Develop mechanisms for recording, assessing and reporting on unmet health needs in general practice: this would respond to an outstanding recommendation from Deloitte analysis for a revised resource allocation formula.

Crosses over with work on the barriers recommendation and wider data developments. Relevant work in progress includes:

- Scottish Government HSCA researchers are leading a workstream in response to the recommendations to investigate barriers to health care and recently shared a draft paper that aims to clarify, define and evidence the variety of ways "need" and "demand" presents in the primary care system with the workstream advisory group. The paper's rationale is that these variations need to be acknowledged to fully consider recording, assessing and reporting mechanisms.

- The Health and Care Experience Survey (successor to the GP and Local NHS Services Patient Experience Survey) asks about people's experiences of: accessing and using their GP practice and Out of Hours services; aspects of care and support provided by local authorities and other organisations; caring responsibilities and related support. The survey doesn't specifically ask about unmet need in general practice, but it collects information that could provide useful proxy measures. The survey asks whether patients can see or speak to a doctor or nurse within 2 working days when they urgently need to. It also asks about respondents to rate the arrangements for getting to speak to a doctor, nurse or the rest of the MDT. The survey has been run every two years since 2009 and questionnaire content is reviewed with each round. Space on the questionnaire is tight, but it may be possible for new questions on unmet need be developed and included in the survey.

19. Equip communities with data and knowledge to empower them to demand or make changes that matter to them: Communities should have access to clear and relevant data and analysis, delivered through inclusive communication, that explain the interconnections between health and its social determinants and the reasons for differential outcomes, across communities in Scotland, including excess deaths and the gaps in healthy life expectancy due to socio-economic factors.

The Scottish Government regularly publishes data and analysis in conjunction with our core stakeholders, such as Public Health Scotland, and is duty bound to ensure publications are accessible.

As part of the Place and Wellbeing Programme, Public Health Scotland has been working with Scottish Directors of Public Health and other key stakeholders to enhance collaboration across local and national public health teams. To take this forward, a programme of work called the 'Public Health Localised Working Programme' has been formed. The fundamental aim of this new approach is to achieve better outcomes for communities by supporting the whole system, including community planning partnerships to address inequalities and the determinants of health through local public health partnerships and teams, led locally and supported nationally. Enhanced support is intended to include: evaluation of existing policy and practice; needs assessments and profiling to better understand local populations; health impact assessments; health economics and effectiveness evidence and modelling, predictive analysis and outcome-focussed planning. A small number of pilot sites are being tested over an initial six-month period. This will ensure that national Public Health resource and capacity underpins their work in supporting Community Planning, Local Government and Health and Social Care in furthering the Place and Wellbeing programme objectives.

20. Commission an investigation into how barriers to healthcare themselves contribute to excess deaths and premature disability related to socio-economic inequalities. This should examine: barriers to access for different groups; waiting times; delayed presentations with serious conditions; "missingness" from health care; perverse incentives and behaviours created by targets; and health-damaging behaviours people adopt to self-manage or self-medicate when unable to access care and support. Data on missed appointments and 'missingness' should be recorded and reported: safe, effective and equitable health care depends on understanding of who misses appointments or does not engage with services. Work should be undertaken to build on previous data linkage analysis (‘Missingness’ in health care: Associations between hospital utilization and missed appointments in general practice. A retrospective cohort study | PLOS ONE).

SG social researchers in Health and Social Care Analysis (HSCA) are leading a workstream, which they have shaped through discussion with a wide range of stakeholders, and have established a Research Advisory Group which will meet around every 6 weeks. The aim is to compete the work in autumn 2023.

Its objectives are:

- To understand and evidence the mechanisms and processes through which barriers to primary healthcare contribute to excess deaths and premature disabilities related to socio-economic inequalities.

- To identify both gaps and trends in data and evidence, and recommend future work and action to address these.

- To consolidate evidence from across multiple primary care areas and gain a comprehensive understanding of how barriers to primary healthcare are experienced, by whom, in what parts of the system, and how they manifest in patient health outcomes.

To date, the researchers have been conducting an extensive literature review identifying existing evidence of barriers, groups affected, and impacts and recommendations. Significant work has also been undertaken to understand unmet need and the wider context of "need vs demand" in primary care. An Excel database of all literature reviewed has been created; researchers have begun to map the evidence against the patient flow in primary care; and a report on emerging themes and findings is in draft.

The current ongoing work on this recommendation centres around:

• Finalising the synthesis of existing evidence and identifying key themes and gaps.
• The mapping of evidence against patient flow through primary care, highlighting who is affected by barriers, in what part of the system, and to what impact.
• Consideration of how the barriers might be understood through lens of "need" and "demand".
• Continuing to add to the draft report and considering a clear structure for findings.

21. Mechanisms to support increased and enhanced collaborative and complementary working between public health and primary care should be developed to synergistically improve population health at macro and micro levels. This would build on momentum gained from cluster working and during COVID-19 to share intelligence and understanding more effectively and routinely.

PHS already provide analytical support to GP clusters and are currently considering how access to primary care data can be improved. We will improve outcomes by providing access to good public health data, evidence and intelligence along with the tools, resources and specialist public health capacity and the right incentives and accountability to achieve meaningful change in partnership.

22. Improve recording of health data in general practices in marginalised communities: The Scottish Government should test the impact of providing a sample of volunteer GP practices or GP clusters in deprived areas with dedicated data support to improve the quality and accuracy, the consistency and efficiency of routine data entry and coding. One aim of this would be to identify practical measures to improve and expand data on demand/expressed need.

PHS, in conjunction with NHS Scotland are currently improving the way we use information from GP patient records. These changes, which are being introduced in stages, will help to plan and improve health and care services in Scotland. PHS have recently completed a pathfinder project with Garscadden Burn medical practice, which explored 3 tests of change including ways to measure and analyse unmet need. This project identified a number of opportunities for further development, which could be scaled up beyond the project and linked to other relevant national projects.

At a national level, a considerable amount of work is underway by PHS and NSS to develop data extraction and analysis capabilities from General Practice. This includes working with a number of pilot practices on improved guidance for data entry and coding, new local dashboards to support data quality improvement and the development of a new experimental statistics publication of General Practice activity levels. This work will continue to evolve as General Practice IT systems are upgraded and data hosting solutions develop.

23. Work to deliver the Scottish Government's Monitoring and Evaluation of Primary Care Reform should more explicitly address health inequalities.

The Scottish Government is committed to ensuring that the impacts of reform on health inequalities are understood through reliable evidence. The 2019 Primary Care Outcomes Framework, which provides a structure for monitoring and evaluation of reform, included the outcome: 'Primary care better addresses health inequalities'. The primary care evaluators network are reviewing the outcomes framework to outline intermediate outcomes that will track more explicitly how primary care reform will better address health inequalities. In addition, it is considering how health inequalities can be embedded across monitoring and evaluation activities, for example:

• Recent research publications on public perceptions on ways of accessing primary care and remote appointments in primary care provide demographic breakdowns to understand how reforms are impacting different groups. The reports have been published and are available at the following links:
• Primary care - public understanding and perceptions survey: analysis report - gov.scot (www.gov.scot)
• Scottish Social Attitudes Survey 2021/22: public views of telephone and video appointments in general practice - gov.scot (www.gov.scot)
• Representatives for the health inequalities development group will sit on the national monitoring and evaluation steering group, and vice versa, to ensure collaboration. The team responsible for the monitoring and evaluation strategy are also taking forward the recommendation on how barriers to accessing primary care contribute to health inequalities.

We will publish headline results from the Health and Care Experience Survey by equalities characteristics. We will also release a report exploring variations in GP patient experience. This will use statistical modelling techniques to allow us to take into account all the available factors that have an effect on the likelihood of a patient reporting a positive or negative experience.