Primary Care Health Inequalities Short-Life Working Group: report

Recommendations of the Primary Care Health Inequalities Short Life Working Group

Health care systems that are undergirded by strong and effective primary care services achieve better health outcomes and greater health equity at lower costs than health care systems that are unbalanced towards specialist and technological health services (Starfield 2009). The Short Life Working Group's fundamental position is that a strategic national commitment to support and build primary care services and to enable sustainable, well-being communities is a necessary pre-requisite to reduce the harmful impact of health inequalities in Scotland.

The SLWG agreed the twenty-three recommendations in Annex A as the result of in-depth discussions over more than a year.

Initially, the SLWG identified nine themes to investigate how primary care and communities could be strengthened and supported to more effectively mitigate health inequalities:

• Structural Inequality
• Community Voice
• Sustainability & Leadership
• Long Term Health Conditions
• Mental Health
• Inter-sectoral Collaboration
• Digital Health Care
• Access to Health Care
• Unmet Need and Missing Communities

Small sub-groups discussed individual themes in detail to consider: existing opportunities and barriers; priority areas; levers and resources; and how to deliver the recommendations. It was considered whether some of these might be actionable directly by the SLWG, what input would be required from the Scottish Government and who would be necessary stakeholders within health, social care, the third sector and at a community or local level to ensure that the priorities would be delivered.

These thematic discussions generated ideas which fed into the development of the recommendations. The recommendations cover a range of short-term and long-term actions to tackle health inequalities and inequity head-on in primary care settings and wider communities. They are organised under four broad headings:

• Empower and Developing the Primary Care Workforce
• Leadership, Structures and Systems
• Empower and Enable People and Communities
• Data, Evidence and Knowledge

Practical steps taken so far in tandem with the work of the SLWG:

• Funding of £600k to NHS Greater Glasgow and Clyde ring-fenced for additional link worker posts.
• A national network and community of practice^[19] for community link workers.
• Welfare Advice & Health Partnerships extended and given core status
• A community led digital inclusion learning project commissioned.
• The Scottish Government commitment^[20] to create a network of 1,000 additional dedicated staff who can 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.
• Since 2007, the Scottish Government's Population Health Directorate have identified and prioritised practical actions to reduce the most significant and widening health inequalities in Scotland. This includes a report series^[21] monitoring a range of health indicators over time.
• The Scottish Government have been working with key stakeholders to provide a wider place-based approach to health improvement which will focus on how health and social care institutions can help to benefit their communities economically and socially.
• The £15 million Adult Communities Mental Health and Wellbeing Fund was announced on 15 October 2021. The Fund will focus on several areas including addressing the mental health inequalities exacerbated by the pandemic and the needs of a range of 'at risk' groups.

The SLWG formulated its recommendations against a backdrop of very significant challenges for health and social care services at this time. The NHS Recovery Plan for Scotland recognises that the COVID-19 pandemic has created a serious backlog of health care and had a significant detrimental impact on workforce wellbeing and morale in health and social care (Scottish Government 2021f). Even prior to the pandemic many believed there was an evolving crisis of workforce and skills shortages across many professions working in primary care, including nurses, pharmacists and GPs ^[22],^[23]. The Health Foundation's recent "Build Back Fairer" review for England (Marmot et al 2020b) found that the pandemic has disproportionately affected the UK's poorest areas and worsened existing health inequalities. In addition to these challenges, the climate emergency only adds to social inequity.

It will be vital that these recommendations are aligned with wider policies reshaping primary care if they are to be translated into actions and programmes of work. Alongside efforts on 'recovery' from the pandemic, there are ongoing commitments to reform primary care (including the 2018 Scottish GP General Medical Services contract^[24] and the two related Memoranda of Understanding,^{[25] [26]} the Scottish Government's Primary Care Improvement Fund, and Health and Social Care Partnerships' Primary Care Improvement Plans). In addition, the Scottish Government is also developing four new cross-cutting Care and Wellbeing Programmes; there is the ongoing redesign of urgent care; and work to design and legislate for a National Care Service. While these are being supported with additional funding commitments, there is a huge amount that needs to be done. Difficult decisions will need to be made, both centrally and locally. Core to these will be choices about the extent to which actions to address excess deaths (including drug deaths), premature disability and long-term health inequalities are prioritised alongside many other competing demands on health and social care services. This will require concerted national leadership supported by a strong and inclusive commitment from a range of partners.

Many of the recommendations therefore involve adding a specific and explicit consideration of inequalities to existing programmes of work, rather than being new or standalone initiatives. The majority of these relate directly to primary care, such as a Scottish programme of multidisciplinary postgraduate training similar to the Fairhealth programme in England,^[27] equipping and empowering multi-disciplinary teams; actions to improve the collection and use of equalities data in general practice; threading inequalities through the Scottish GP contract and Memoranda of Understanding delivery mechanisms; or a new Enhanced Service.

Other recommendations relate to the wider health and social care system, such as ensuring health and social care staff have the digital skills, understanding and resources they need; the challenging idea of an investigation into how barriers to healthcare and services contribute to premature morbidity and mortality; reviewing how transport and health services interface; or developing a better understanding of 'missingness' in health care (i.e. the needs of those marginalised populations who for complex reasons do not seek out health care or who repeatedly miss healthcare appointments) (Williamson et al. 2021).

A small number look beyond and across government policy, such as a possible new Commissioner for Health Inequalities in Scotland; investing in wellbeing communities; or recognising digital (access, literacy, confidence) as a determinant of health in its own right alongside other socio-economic factors.

We envisage the SLWG will evolve into: a development group function to formulate proposals for implementing specific recommendations; and a reference group function to provide a perspective on inequalities for wider policy developments. Both of these functions will entail significant commitment and planning with partners and consideration of different options for delivering the recommendations.

Some of the recommendations in this report will require funding in their own right, for example the postgraduate training fellowship, the establishment of an Enhanced Service for health inequalities, or the potential setting up of a Commissioner for Health Inequalities or similar. Many will require investment through existing programmes of work, in particular to develop capacity within health, social care and communities. The most important resources needed are human, to develop leadership, create better ways of working, and to enable an infrastructure of people, professionals, volunteers and communities, who are inspired to dedicate their energy, expertise and enthusiasm where it is needed most. This will only be developed gradually and will require long term vision, commitment and sustained support from the national leadership.

A key recommendation of the SLWG is that the voices of those individuals, groups or communities who have experienced health inequalities first-hand in their own lives should be foremost in all planning and policy developments which might have an impact on them. The principle of 'nothing about us without us' should hold especially true. As role modelled in the SLWG process, this should go beyond consultation to direct participation in the planning and development of policy and programmes.

The SLWG are conscious of the challenges of this ambitious portfolio. Phasing and a degree of prioritisation are certainly needed, but the scale of ambition matches the scale of the challenge.