There is no silver bullet, but lots of transformational ideas to address health inequalities, writes Ian Welsh.
As a nation we are collectively healthier than we have ever been and that fact is important as we recalibrate our collaborative efforts in health and social care in the new world of health and social care integration.
- Advances in medical science have significantly improved the quality of the healthcare we receive.
- A series of initiatives (such as the smoking ban and five a day campaigns) have had resulted in short term public health improvements, mainly for those in more affluent areas.
- We have embraced practices such as self management which recognise that, above all, people need to be in the driving seat to decide what is right for managing their condition and creating a vision of just how life can be better for people living with long term conditions, their families and carers.
- These factors and more have led to a steep improvement in the life expectancy of the Scottish population in the last 30 years.
However, at the same time, Scotland’s health inequalities remain particularly difficult to budge, resistant to successive waves of investment in entrenched communities.
A recent Audit Scotland report, for example, found that men in areas of multiple deprivation died a full eleven years earlier than their counterparts in Scotland’s most affluent areas. Glasgow has the lowest life expectancy in Scotland for men and women, while men in the Borders and women on Orkney are expected to live longest. Even more stark is the difference in healthy life expectancy which stands at 59 for men and 62 for women.
These variations highlight our current inability to eradicate a source of national shame, but they also represent a significant human rights injustice which we as a society have yet to address.
The development work this year on human rights in health and social care ( a workstream of the Human Rights Action Plan) jointly led by the ALLIANCE and Health Scotland, will add some impetus to calls for reductions in health inequalities and the overarching mission in Health Scotland’s A Fairer Healthier Scotland drive over the next five years will ensure a continuing focus on the evidence behind the issue.
It is important to see all this, moreover, in the context of the Scottish Government’s Equally Well programme, launched in 2008, the report of its Ministerial Taskforce for Health Inequalities, and a range of pilot sites operating across Scotland with the aim of improving the reach and impact of mainstream local services.
The challenge for all of us operating in our respective spheres of influence is to translate evidence into multi-faceted action across disciplines, budgets and communities in the interests of the service user.
The accepted theory on health inequalities is that where you live, your education, your housing, your employment and your income determines the length, and quality, of your life. It is, ipso facto, clear that coordinated across-the-board action is required to drill down on the challenges associated with persistent health inequalities.
Equally, while deep seated problems are never susceptible to silver bullet interventions we will all need to recognize and acknowledge that collective action is required to shape a healthier future for Scotland. That collective action needs to be driven in local contexts and the British Academy’s recent report “If you could do one thing…”(this link will take you away from our website) identified numerous local actions that could reduce health inequalities.
A series of initiatives are required to tackle the upstream causes of health inequalities, relating to wealth, poverty, job availability and housing supplies, as well as to ensuring that health and social care services themselves reverse the inverse care law and direct their resources more effectively towards tackling unequal outcomes. That is why locality planning cannot be undertaken in the new Health and Social Care Partnerships without an underpinning commitment to the reduction of health inequalities.
Neither, however, can the impact of social connectivity, meaning and purpose be underplayed. The kind of response that these factors need in the future will be different from our remedies of the past. Approaches are required that build confidence, a sense of purpose and social support networks within communities across Scotland.
The Scottish self-management agenda, for instance, places a greater emphasis on such approaches, supporting disabled people and people who live with long term conditions to make well informed decisions about their lives and to live well, supported by peers and communities. The ALLIANCE Self Management Fund in Scotland was highlighted, for example, in a 2013 Carnegie UK report as being a leading initiative in public sector reform. This is just one of a series of initiatives focussed on unpicking the existing assets within communities experiencing long term disadvantage.
General Practitioners are at the front line in this fight but GPs signposting to sources of support to live well remains an area of often untapped potential.
Our Scottish Government funded Links Worker Programme, delivered in partnership with the RCGP, SAMH and the Deep End, aims to do just that.
Building that stronger connection with GP practices, and their teams, in primary care settings and linking it to local community development will be an important outcome for the new Health and Social Care Partnerships.
Because working within general practices which serve some of the most socio-economically deprived areas of Scotland to identify local community solutions and match them to the needs of the individuals will improve the social capital of all!
The ALISS (A Local Information System for Scotland) programme exists to make such data more openly available to raise awareness and share information about local community assets. In truth, this level of intervention is as overdue as it is welcome and emphasises the need to nurture and utilise the strengths of resources which are already available across the country. Such links and access must be proactively built in order to support people living in poor circumstances. Most crucially, ALISS works by harnessing community capacity and local ownership, not by delivering a centralised, or top-down solution.
There can now be no doubt that the forthcoming integration of health and social care must be grasped as an opportunity to develop more connected approaches locally. Integration and inequalities are not separate agendas and community planning must recognise this in future plans.
Localities, with good data about local needs and strong local voices, must be the real engine behind genuine change.
Looking to the immediate future, the Ministerial Task Force on Health Inequalities will issue what is expected to be its final report later this month. I expect this to further reinforce the importance of social capital, coproduction, asset-based approaches and of partnership, particularly with the third sector. The Health and Sport Committee will also be examining key aspects of health inequalities, including early years and access to services. Meanwhile, as mentioned, we are embarking on the first year of Scotland’s National Action Plan for Human Rights which focus heavily on health, reinforcing people’s right to health, and to the determinants of good health. The ALLIANCE will again be putting health inequalities to the centre of our national conference in May.
All of this is welcome and again puts health inequalities into sharp relief but the time has come for us to move beyond policy and begin to make a practical difference. In order for this to happen, eradication of health inequalities should be a major policy-into-practice aspiration for the Scottish Government before and beyond the Referendum and it should have the highest possible cross-sectoral profile within Government.
I was delighted recently to hear the new head of health and social care in Scotland, Paul Gray, make a strong personal commitment to delivering on health inequalities. He was very clear that we must succeed, not only because the health service will be unsustainable if we don’t, but even more pressingly because people in Scotland are suffering now and suffering severely and that is not acceptable.