Primary Care Health Inequalities Short-Life Working Group: report

The Primary Care Health Inequalities Short Life Working Group

This report and its recommendations are the product of a Short Life Working Group (SLWG) on Primary Care Health Inequalities who met over a period of twelve months. The Scottish Government established the SLWG in October 2020 as an action from the Primary & Community Health Care Mobilisation Sub Group of the Scottish Government's Mobilisation Recovery Group,^[7] in acknowledgement of the key role of primary care in relation to tackling and mitigating the impacts of inequalities.

The purpose of the group was not to conduct an academic or systematic review of the literature. Instead, it focussed on the professional expertise and insights of a wide range of stakeholders with extensive experience of delivering, planning and designing primary care across Scotland. The SLWG's terms of reference and membership (Annex C) reflected geographical areas and specialisms, with a focus on including members with the ability to implement change in their organisation or system.

The SLWG has also worked closely with an expert reference group of people, called Chance 2 Change, who have first-hand experience of the impact of health inequality as individuals and within their community.^[8] Their remit has been to identify specific service improvements and actions for primary care to help reduce health inequalities and improve health equity.

The SLWG strongly recognise that health inequalities cannot be addressed by one sector in isolation. All services provided by the NHS in Scotland, including mental health, specialist and hospital based services, need to take deliberate practical action to ensure that the health care they provide is equally accessible to all and is not discriminatory in its impact on individuals and groups. Social care also has a powerful part to play. The root causes of health inequality cannot be solved from within the health and social care system. The group's recommendations should be seen in the wider health and social care system, where there is a responsibility for all services, as well as government, the wider public sector and society at large to take effective action to ensure that individuals and communities no longer experience the injustice of health inequality.

The SLWG's focus has been to build on existing learning and evidence to identify and recommend clear actions that can be implemented and sustained with a long term impact. The SLWG's remit was intended to maximise primary care's unique potential in the patient journey to deliver meaningful improvements in health outcomes. The group took evidence from recent initiatives and programmes, such as the Govan SHIP,^[9] the Deep End Pioneer Scheme,^[10] the Community Links Worker programme (Mercer et al. 2019), and the Queen's Nursing Institute Scotland.^[11] They drew on sources, such as the Marmot reviews, the evidence gathered by the GPs at the Deep End group,^[12] and a small number of recent publications and policy papers.^[13] Their priority was to identify practical actions and programmes that could be implemented within primary and community care, yet still reflect powerful ambition for change.

The SLWG took the view that health inequalities and health inequity have complex and entrenched roots within the health service, and recognised that there can be systemic resistance to change. Mechanisms for allocating health resources are based on historical data which tend to reflect demand for health services rather than unmet need. This favours those already able to take advantage of the systems in place. At a time, however, when all services are under strain, simply changing how resources are distributed would be counter-productive if existing services were destabilised.

The unequal geographical distribution of poverty results in concentrated areas where whole communities face barriers to health care and experience poor health, high prevalence of long term conditions and premature mortality (NRS 2020). However, reliance on area-based indices of 'deprivation' such as SIMD can divert attention from individuals and households who face profound barriers despite living in less disadvantaged and even affluent areas or in rural data-zones (Scottish Government 2021e). Barriers can include institutional discrimination and stigma due to many characteristics, such as disability, ethnicity and sexual orientation, body weight,^[14] as well as poverty and social exclusion. Initiatives to address health inequity need therefore to both address the challenges experienced by geographical communities identified as experiencing 'deprivation' and the less visible but, nevertheless important, health inequity impacting on many other individuals and families throughout Scotland.

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 (Scottish Government 2018b). The Fairer Scotland Duty is additional and complementary to statutory duties under the Public Sector Equality Duty and the Human Rights Act.

The Fairer Scotland Duty

This statutory duty came into force in Scotland from April 2018. It places a legal responsibility on public bodies in Scotland to actively consider ('pay due regard' to) how they can reduce inequalities of outcome caused by socio-economic disadvantage, when making strategic decisions. This Duty is an opportunity to put tackling inequality genuinely at the heart of key decision-making. Over a million Scots are living in poverty, including one in four children; and health inequalities and educational attainment gaps are far too wide. This unfairness isn't inevitable. The purpose of the duty is to reduce poverty and inequalities of outcome, helping to realise the rights of the people who have experienced them. To fulfil their obligations under the Duty, public bodies must be able to meet what are called 'the key requirements': (1) to actively consider how they could reduce inequalities of outcome in any major strategic decision they make (2) to publish a written assessment, showing how they've done this.

As noted above, current commitments to reshaping and reforming primary care will not alone be sufficient to meet the challenges of health inequality. Additionally, as the unpredictable economic and social impacts of COVID-19 cause health needs to change and shift across our communities, primary care will also need to be able to respond flexibly as new forms of health inequality arise.

The twenty-three recommendations from the SLWG, which are included at Annex A, are built, therefore, on both a realistic understanding of the scale of the problem and a careful consideration of what might be possible in this context. They are aspirational, courageous and wide-reaching, and include a call for new, dedicated national leadership to ensure a cross-sectoral approach. However, they will only have their full impact if they become part of a much wider commitment to health inequalities and addressing the social determinants of health which sit beyond the direct remit of primary care.