Primary Care Health Inequalities Short-Life Working Group: report

Annex A: Recommendations of the Primary Care Health Inequalities Short Life Working Group

These 23 recommendations of the Primary Care Health Inequalities Short-Life Working Group reflect the scale of the task and the ambition of our vision. All of us involved in primary care have a collective responsibility to make change. Principle responsibility for some recommendations will clearly lie with specific organisations and this will be made more explicit, in 2022, as the successor to the SLWG focuses on how they ideas could be turned into actions. The SLWG are, however, clear that these recommendations, under four broad themes, have relevance to all health and care bodies, leaders, staff and service users in Scotland.

As noted in the main report, we have identified five 'foundational' recommendations as priorities which will provide a bedrock to build on.

Theme: Empower and Develop the Primary Care Workforce

Creating the right conditions; sustaining the workforce and leadership.

• Implement a national programme of multi-disciplinary postgraduate training fellowships in health inequalities. This foundational recommendation 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 Fairhealth Trailblazer post-CCT Fellowships, Govan SHIP, Lanarkshire OT and Queen's Nursing Institute in Scotland 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 should create an Enhanced Service for Health inequalities: This foundational recommendation would support 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.
• 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 General Medical Services GP contract.
• 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.
• 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.

Theme: Leadership, Structures and Systems

Tackling sources of inequalities and inequity within our systems and communities.

• Strengthen national leadership: For this foundational recommendation the Scottish Government should consider options, including the potential creation of 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.
• 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.
• Commit to ensuring social and financial inclusion support and advice are available through primary care: 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 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 multi-disciplinary, clusters and partnership working. Decision-making underpinning primary care improvement plans 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.
• 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.
• Transport and health: The Scottish Government should create a group which brings together different sectors and stakeholders to review and take action on transport andhealth 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.
• Recognise digital as a social determinant of health: Technology should be understood and recognised 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.

Theme: Empower and Enable People and Communities

Individuals and communities should have the knowledge needed to use health care and be active participants in problem-solving.

• 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
• Invest in wellbeing communities: For this foundational recommendation 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.
• 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.
• 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.

Theme: Data, Evidence and Knowledge

Securing intelligence on health equity and inequalities to enhance transparency and improve understanding and recognition.

• 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.
• Develop mechanisms for recording, assessing and reporting on unmet health needs in general practice: this would respond to observations in a report for the Scottish Government that an alternative allocation model would be needed to address some sources of inequalities, but evidence for this was lacking.^[29]
• 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.
• Commission an investigation into how barriers to healthcare themselves contribute to excess deaths and premature disability related to socio-economic inequalities. This foundational recommendation is for work to 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 negative behaviours/coping strategies people may resort 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 (e).^[30]
• 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.
• 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.
• Monitoring and evaluation of primary care reform should more explicitly address health inequalities. It is essential to track and understand the impacts of reform on inequity and inequality.