Scottish Government

11. CONSULTATION

TACKLING HEALTH INEQUALITIES AND POVERTY - CONSULTATION WITH SCOTLAND'S THIRD SECTOR

Summary

Established in October 2007, The Ministerial Task Force on Health Inequalities undertook to agree priorities for cross-cutting government action to reduce health inequalities in Scotland, through a cross-cutting, cross-sectoral approach.

The Task Force priorities of supporting children's early years, enhancing mental health and wellbeing, increasing education and learning opportunities and employability, all through a multi-sector approach will contribute to current Government economic and health strategies. The Task Force is due to report in June 2008.

Voluntary Health Scotland ( VHS) was asked by the Government Public Health and Wellbeing Directorate to scope the views of the third sector on current Government approaches to combating poverty and health inequalities, identify actions that should be taken by the different sectors and provide examples of effective third sector initiatives.

In a two-phase approach, VHS conducted an online survey of third sector organisations, using their 123 responses to facilitate a ministerial roundtable discussion.

Third sector participants were broadly in support of Government priorities for tackling poverty and its effects on health, adding other issues and groups with whom the sector works best as meriting policies and action. While supporting the need for early intervention, participants gave equal weight to addressing the structural causes of poverty.

Participants emphasised their strengths in working with many marginalised groups, complementing Government approaches to reducing the impact of poverty on the early years. These included skills in supporting individuals and groups to lift themselves out of poverty through raising self-esteem and confidence alongside structural measures to remove barriers to income enhancement and employment.

Despite some reservations about the success of recent 'closing the gap' initiatives, respondents believed that targeting extra efforts at the poorest groups were essential, citing many examples of their own successful initiatives.

Recommendations for action included making explicit the urgency of explaining and tackling poverty in Scotland, establishing the primary importance of partnership working, making better use of new planning structure to do this, aligning resources more closely through joint budgeting and shared outcomes, thus maximising returns on investment. Finally, performance management of programmes which allow the added value brought by the third sector to the alleviation of poverty and reducing health inequalities was seen as essential.

Introduction

Living longer healthier lives and combating the significant inequalities in society are key Government objectives for a better Scotland. Reducing inequalities in health is therefore crucial to this purpose. The Ministerial Task Force on Health Inequalities was set up in October 2007, with the aim of:

• Agreeing priorities for cross-cutting government activity that will achieve measurable outcomes in reducing health inequalities.

• Identifying practical measures to reduce the most significant and widening health inequalities.

• Ensuring key sectors and organisations that are involved in delivering action on health inequalities work alongside the Task Force in order to build commitment and support.

The specific objectives of the Task Force are:

• To reduce factors in the physical and social environments in Scotland that perpetuate health inequalities.

• To build the resilience and capacity of individuals, families and communities to improve their health.

• To enhance the contribution that public services make to reducing health inequalities.

And its priorities are:

• Maintaining an emphasis on supporting families and children in the very early years.

• Enhancing mental health, wellbeing and resilience.

• Strengthening the importance of education and skills, income and employment status as factors which can combat inequalities in health.

• Taking a multi-agency approach in which public, private and third sectors work together, with strong Government leadership.

The Task Force is due to report in June 2008.

The Task Force priorities are made explicit in the Better Health, Better Care: Action Plan (December 2007), in which there is commitment to:

• Increase healthy life expectancy in Scotland.

• Break the link between early life adversity and adult disease.

• Reduce health inequalities, particularly in the most deprived communities.

• Reduce smoking, excessive alcohol consumption and other risk factors which compromise a healthier life.

The Ministerial Task Force has also been informed by the Government's approach to tackling poverty through the development of a new delivery framework for reducing income inequality - Taking forward the Government Economic Strategy: a discussion paper on tackling poverty, inequality and deprivation in Scotland (January 2008). In this, the Government sets out its fresh approach for delivering sustainable economic growth through adherence to the Government's three 'golden rules' of Solidarity, Cohesion and Sustainability. Within the Purpose Targets, the objective of ensuring that greater equity underpins the delivery of sustainable economic growth is reflected in the Solidarity Target:

• To increase overall income and the proportion of income earned by the lowest three income deciles as a group by 2017

• this is predicted to have a positive effect on tackling poverty and contribute to the achievement of the UK-wide target to eradicate child poverty by 2020.

The framework for reducing income inequality will be focused on delivery of the Solidarity target, but to achieve this it will also be important to attain the Cohesion target:

• To narrow the gap in participation between Scotland's best and worst performing regions by 2017

• narrowing the gap in economic activity between Scotland's best and worst performing regions is key to promoting equity and tackling the challenges of multiple deprivation.

These objectives are considered to be the conditions of economic and therefore societal sustainability in Scotland.

Against this background, the Government is developing its strategic approach to improving health, combating health inequalities and tackling poverty through the involvement of all sectors, identifying effective approaches and initiatives that will shape ongoing action. The role of the voluntary or third sector is seen as increasingly important in strategic approaches to addressing these issues and in identifying through its stakeholders the approaches which work best.

The consultation

As part of the strategic approach to tackling poverty and its impact on health inequalities, Voluntary Health Scotland was asked by the Government Public Health and Wellbeing Directorate to ascertain the views of a selected range of stakeholders in third sector networks on current Government approaches to combating poverty and health inequalities and what kind of additional efforts which should be made by the different sectors. Respondents were also asked to provide examples of effective initiatives from within the third sector.

The consultation consisted of two phases. The first phase took the form of an on-line enquiry, which was carried out in February 2008 through the use of an on-line enquiry tool, Survey Monkey. The link to the enquiry is: http://www.surveymonkey.com/s.aspx?sm=4tXdngZ8o_2fztPIpxLRiRdg_3d_3d

The enquiry yielded 123 responses in just over two weeks. The resultant material was analysed by Rock Solid Social Research and used as the basis for the second phase, a roundtable discussion event for an invited third sector audience held on 17th March, at which the Minister for Public Health, the Director for Public Health and Wellbeing and the Deputy Director for Social Inclusion were present.

Phase One - on-line enquiry

Analysis of the on-line phase of the consultation is presented below.

Findings

1 Supporting government priorities for tackling poverty and health inequalities

Government priorities for tackling poverty and addressing health inequalities identified thus far are: protecting and supporting the early years; improving mental health and wellbeing; maximising income; improving employment opportunities; creating opportunities for and take-up of education, learning and skills development

When asked if they agreed with these priorities as key areas for action on poverty and health inequalities, respondents were almost unanimously in support. However, they added a number of other areas for action which were felt to be crucial. Most salient of these were fuel poverty, homelessness and environmental conditions affecting elderly people. Respondents also prioritised working with marginalised groups which included young people and young adults in transition - those leaving care and leaving home, those becoming unemployed or affected by family break up - as directly meriting policies and action.

One respondent said: "Fuel poverty has clear links to health inequalities. While the Scottish Government recognises the impact of damp homes on health, the promotion of affordable warmth must be prioritised and supported by Health Boards" (environmental charity); and another added: "I would like to see work supporting the elderly population as many of them live in poverty and isolation, this contributing to poor quality of life and ill-health" (community food project).

And: "Young people leaving school and leaving care having to manage their lives as they try to get into the job market are among the most vulnerable." (youth support agency)

Specific approaches were highlighted: improving access to existing services; supporting the acquisition of financial skills and eating well on a low income; structural action on the benefits and taxation system (although this is a reserved issue, it was felt that the Scottish Government was in a good position to influence Westminster on this); and increasing learning and recreational opportunities for young people.

2 Prioritising prevention and early intervention

Respondents were asked to rank three preventive measures and early interventions according to their effectiveness in breaking the cycle of disadvantage and its effects on health inequalities. The measures and interventions were: a) increasing educational opportunities; b) enhancing skills development; and c) improving employability. All were considered important, although there was a slight weighting towards improving early learning opportunities - seen as a prerequisite for improving skills and employability.

Additional themes which featured strongly were providing as much support as possible to families and interventions to improve mental health, wellbeing and self-confidence. While most of these preventive measures and early interventions focused on working directly with individuals, families and communities, there was still strong support for addressing what were seen as the real root causes of poverty - structural inequalities - "These [above] interventions address the effects of the structural organisation of institutions, systems and decision-making - we would include better provision of good standard housing, affordable good quality food, more opportunities for leisure and recreation and participation in local decision making." (community health projects network)

3 Alleviating the impact of poverty on health

Turning to the impact which poverty has on ill-health, respondents were asked which of a number of measures for lessening the impact of poverty on health they most favoured. The measures were: a) targeting support for young mothers prior to the birth of their baby; b) targeting direct support towards lone parents; c) increasing childcare opportunities for lone parents; and d) providing general support for families with very young children.

Again, these measures were seen as of almost equal importance, re-emphasising the principle of acting early to prevent children from growing up with the damaging effects of living in poverty. It was also felt that there must be continuity of support, which invariably requires co-ordinated interventions at different times - it was of little use putting in extra resources to support lone parents with under fives if that support did not continue in the school context. Providing parenting programmes and engaging absent fathers in the lives of their children were given priority, too.

Respondents came out strongly in support of intervening to reduce the impact of poverty on the lives of other vulnerable groups, in particular young people requiring more chances and more choices in life, homeless people, carers and those with addiction to drugs - "While working with families with young children is very important, we must remember that there are many other vulnerable groups of individuals with multiple needs", one respondent said.

4 Determining the best policy avenue for poverty reduction

The Task Force is interested in hearing where the emphasis should be put in relation to poverty reduction - enhancing the internal capacity of individuals to lift themselves out of poverty, or removing external barriers to income enhancement, such as improving access to education and employment. This is a long debated issue, and the superficial impression was that respondents leaned towards enhancing internal capacity (58%) over removing external barriers (41%). However, within these categories, very few favoured a one-line approach and most respondents qualified their position by saying clearly that both approaches were necessary and mutually reinforcing. One respondent quoted evidence from the Poverty Alliance and studies by the Joseph Rowntree Foundation which suggested that: " People's capacity and resourcefulness are automatically increased when barriers to income enhancement are removed. " And a housing charity added: "People need to feel they can succeed and then they will be able to work through the barriers."

Respondents listed a number of ways in which internal capacity could be enhanced and external barriers removed. These included increasing self-confidence and self-esteem, raising aspirations, pursuing educational and learning opportunities (seen as enhancing internal capacity), as well as removing benefits disincentives, providing affordable child care and improving educational opportunities, transport and housing (seen as removing external barriers).

Encouraging the building of self-confidence and self-esteem, raising aspirations and helping people to overcome barriers to services are considered as areas in which the third sector excels.

5 Closing the gap or lifting the poorest out of poverty?

Research shows that unequal societies, where the gap is greatest between rich and poor, experience the worst health inequalities. ²⁴ We also know that improving overall economic performance does not necessarily make the poor less poor and for some years, Scottish government policy has put more emphasis on closing the gap than on lessening absolute poverty. Respondents to this enquiry, however, appeared to be marginally more in favour of lifting the poorest sections of the community out of poverty (54%) than of closing the gap (46%). As before, however, the two approaches were not seen as mutually exclusive.

Those who preferred closing the gap as the primary approach adhered to ethical principles of solidarity, egalitarianism and fairness in support of this approach - "The wealth of rich people is as much the issue as the poverty of poor people - inequalities are unhealthy in themselves" (national support group); and "Inequality and the perception of inequality is corrosive to good communities and the commitment of individuals to the social good." (local community health initiative).

A number of those in favour of lifting the poorest out of poverty cited the evidence for the perceived ineffectiveness of many "closing the gap" initiatives. One national support group for older people said: "Closing the gap means there is potential for more people to enter into poverty"; and another respondent said: "Closing the gap might just uplift the central section and leave the top and bottom sections in very much the same position as they are now." (local community health project).

Respondents mentioned specific groups of vulnerable people on whom targeted efforts to reduce poverty should be concentrated - groups who are potentially at risk as well as those already living in or on the margins of poverty. These included lone parents, BME groups, refugees and asylum seekers, homeless people and, increasingly, low-paid workers and low-income home owners.

6 Prioritising Government action on tackling the root causes of poverty and alleviating its effects on health

Respondents were asked to rank those actions already identified as top priorities for action by the Task Force. The actions are: a) concentrating on support for the early years; b) enhancing opportunities for increasing education and learning; c) increasing employment opportunities; and d) providing interventions to improve mental health and wellbeing.

All four priorities were seen as of more or less equal importance, and interlinked. One national support group for lone parents pointed out: " Contradictions in government policy should be addressed: lone parents are to be pressurised into employment; part-time work leaves them vulnerable to low pay and consequent poverty, but full-time work leaves their children with little parental time."

Some respondents felt that it was insufficient to promote educational, learning and employment opportunities without ensuring that people had suitable conditions in which to pursue these opportunities - cramped space in a damp unheated house was a deterrent to learning, as was lack of affordable child care facilities at a training centre, or an unwelcoming reception by front-line public sector workers for clients living in poverty. Others felt that there was an over-emphasis on the early years and on getting lone parents back to work and stressed the importance of maximising benefits take-up by vulnerable groups - including young people, those with special needs or who were homeless, those with mental health needs and older people. Many implied that without approaches to improving mental health and wellbeing - approaches in which the third sector has long experience - promoting learning and employment take-up was likely to be of limited value.

Finally, a number of people pointed out that while reform of the fiscal and benefits systems was an issue reserved to the Westminster Parliament, the Scottish Government was in a good position to advise Westminster of the directions which needed to be taken, from experience of the current Scottish situation.

7 Determining the best contributions of other bodies and sectors to the alleviation of poverty

Respondents were asked to identify ways in which other bodies and other sectors could best make a difference to addressing the root causes of poverty and alleviating its effects on health. There was consensus here that long-term strategic planning across all sectors was absolutely essential. Moreover, strategic planning without some measure of joint budgeting and development action was of limited value - in short, the focus must be on "agreeing cross-sector priorities and budgets being allocated to actions rather than organisations" (anonymous).

Additionally, partnership working on the ground could reduce red tape and thereby improve access to benefits and services for vulnerable groups by signposting people to services, providing co-ordinated information and creating single assessments of need.

The private sector was seen as having a major contribution to make on the ground, both as employers and investors in local communities and the public sector should be making more use of these opportunities. Private sector employers were considered to have a responsibility for providing living wages, training and career development, flexible working conditions, fair recruitment practices and maintenance of equality and diversity in the workplace, as well as support for vulnerable workers, including those affected by mental ill-health.

As investors, private sector companies had many means at their disposal for alleviating community poverty - providing socially-just bank lending, social housing, fair pricing of healthy foods, leisure opportunities, employee volunteering openings and sponsorship of health-promoting services.

As a national lobbying group put it, "long-term commitment to economic activity in deprived areas, rather than focusing on profit and shareholder values over a short time; involving members of local communities in meaningful way…is key to making a difference".

8 Determining the best partnership opportunities for the Third Sector

The added value brought by the third sector to anti-poverty work and tackling health inequalities is already well known. Across Scotland, many hundreds of voluntary organisations, support groups and community development projects are working effectively in close partnership with the statutory sector.

Identifying the most positive opportunities for third sector partnerships with other sectors, the majority of respondents focused mainly on the need to open up the field at strategic planning levels. Participation in community planning and in relation to health, the Joint Health Improvement Plan, as well as in high-level working groups and in joint funding bids were all seen as key opportunities. The new Concordat and with it, requirement for local authorities to establish Single Outcome Agreements was seen as an additional route to strategic partnership working with the third sector.

At operational level, many pointed out that the third sector was uniquely placed to address the root causes of poverty in communities, in partnership with statutory agencies, and to respond sensitively to the immediate needs of the most vulnerable - "the third sector is able to engage individuals labelled as 'hard to reach' and this should be taken up and harnessed by other sectors. Joined up approaches to service users would avoid a multitude of access points …" (environmental charity).

But respondents acknowledged the weaknesses of their own sector and the current difficulties it was facing, which were detracting from its effectiveness: " The third sector is very disparate; it needs improved knowledge and understanding of the issues generally and of the opportunities that can open up via social enterprise, improved co-ordination and effective impact at strategic and delivery levels. The danger of large scale procurement is that instead of closeness to the community it relies on efficiency via scale …" (local network body).

And: "More mechanisms are needed to bring about greater understanding between the sectors in identifying what's better for sectors to take forward individually and what's better for sectors to collaborate on, clarifying the actual benefits which are brought about for people experiencing poverty when sectors collaborate." (community health network).

Respondents did acknowledge the responsibilities which the third sector itself needed to take on for pointing out the value of its own approaches: "Third sector organisations could do more to present better their ideas and ways of working. The focus on engaging with other sectors should be on the benefits to their business rather than preaching about their responsibilities." (national lobby group)

9 Bringing Third Sector skills to the alleviation of poverty and its effects on health

Respondents were asked to rank key areas to which third sector skills could make most difference. The areas for intervention were: a) measures to support children's early years; b) enhancing opportunities for increasing learning and skills development; c) increasing employment opportunities; and d) providing interventions to enhance mental health and wellbeing. Increasing employment opportunities through informal learning and formal training support to individuals, combined with enhancing mental health and wellbeing, were the most highly ranked of these areas, and again, respondents felt that the third sector was well placed in terms of the skills of its workforce to work in this context.

Many respondents emphasised that it was by means of providing extensive support for improving mental health and wellbeing that the third sector supported individuals in increasing their self-confidence and therefore their employability. The third sector was extensively seen as excelling in crisis intervention, helping people to get back on their feet and become better at taking charge of their own lives, which led eventually and in many cases, to their being able to enter or re-enter the job market.

Throughout this enquiry generally, it seemed that respondents saw Government as already providing a great deal of support for the early years and believed that third sector skills were best deployed in working with communities and with particular groups of vulnerable young people and adults in building self-worth and confidence. People said: "Reaching out and involving the most excluded members of our communities, feeding back experiences of those most disadvantaged to influence strategy and services…" (campaign group), and "Supporting the participation of people experiencing poverty in engaging with public sector bodies." (community health network).

10 Identifying the strengths of individual Third Sector organisations

Respondents were asked to describe the particular strengths of their own organisation in tackling the effects of poverty on ill-health. By and large, the strengths of respondent organisations mirrored those of the third sector in general.

Third sector added value attributes identified within respondents' accounts of the key strengths of their own organisation included skills in partnership working, crisis intervention and rapid response ability and providing sustained support for individuals and groups - in other words, being there for the long term.

The third sector is uniquely placed to respond rapidly and sensitively to individual need. It quickly gains trust with those who can be wary of statutory services, provides early intervention, can alleviate crisis and signposts people to statutory services. Often it is third sector organisations which provide the links between individuals or groups and a range of services in different sectors. They support and work with the most excluded and vulnerable people whom statutory services often find hard to reach and address individual and community deficit in self-esteem and confidence, encouraging positive mental health and wellbeing and making people more able to take charge of their own lives.

The sector offers volunteering opportunities and work placements, thereby increasing chances of employment, and promotes participation by individuals and communities in civic society.

All these attributes can bring much to partnership working with the statutory sector, can ease the pressure on public services and have the power to address and alleviate poverty and its effects on health.

11 Highlighting Third Sector work in alleviating poverty and addressing health inequalities

Many respondents to this enquiry provided vivid accounts of ways in which their work was responding directly to poverty in this unique "third sector way". Snapshots of some of these are featured here.

"We work closely with primary care staff, encouraging them to refer people who might benefit from learning. In this way we have been able to meet some very socially isolated people who spend most of their day simply coping with the challenges of poverty and deprivation. Getting involved in learning starts to reduce social isolation, improve self-worth and open up alternative futures." (health and literacy project).

"Our energy professionals work with the public, private and third sectors. We help them to develop policies and programmes for identifying and tackling the effects of cold damp homes on service users. We use a range of approaches suitable for the group involved - giving affordable warmth advice by telephone, offering support in people's homes, running group work sessions. Referrals to and from associated organisations enable amore holistic service, helping people get out of fuel debt and create warmer healthier homes …" (Third Sector energy advice agency).

"We run a fruit and veg co-op in the nursery where mums can pre-order, pay and pick up their order when they pick up their children. We have also a breakfast club for mums - mums rarely eat in the morning and this does not provide a good role model for their children." (food co-operative).

"Our volunteering towards employment project supports people volunteering in the NHS and with other partners. Our volunteers may have had mental health problems, addictions etc., and they are now better equipped for re-employment because of he skills they have developed as volunteers." (volunteer centre).

12 Aligning resources across sectors to alleviate poverty and its effects on health

Respondents were asked for their views on and experience of ways in which resource-alignment can best be achieved in the interests of preventing and alleviating poverty and its effects on health.

Respondents put the strongest emphasis on effective partnerships. They listed key 'quality' features of good partnership working at both planning and operational levels. Essential to the process is mutual respect and a shared vision of what needs to be achieved, jointly developed strategies and service planning, equitable allocation of resources, effective communication between all partners, shared intelligence (including the vital dimension of engaging constantly with service users and local communities), joint workforce learning and skills development and mechanisms for signposting users to services across all sectors. In effect, respondents were identifying the key principles of The Scottish Compact and where these exist, of local compact agreements for joint working.

In relation to the relief of poverty and its effects on health, early intervention was seen as "spending money now to save money later". If needs are anticipated at an early stage and jointly managed resources put in, the need for expensive single-agency intervention can be avoided at a later stage. Examples of this include working with vulnerable older people to minimise fuel poverty and maximise household warmth, thus saving crisis-driven hospital admissions; encouraging young mothers to feed their families on a low budget, thus minimising the damaging development of poverty-related poor nutritional status and its effects on their children's learning and wellbeing.

Resource sharing was another valued strategy. One respondent said: "Where resources are tight, there should be scope for a group of organisations to employ staff on a shared basis to carry out targeted work. In our experience service users are initially reluctant to go outwith the [third] sector because of fears of discrimination but a single specialist post can be shared between three or four agencies." (addiction support service).

Better use of "social prescribing" was seen as another means of effective resource-sharing - "If cross-referral between from healthcare services and the many local third sector organisations were better organised, people could be supported in the community, often preventing illness arising from poverty and deprivation and avoiding the need for more costly health care…" (volunteer centre).

Financial incentives for partnership working were highlighted - a condition of funding being granted should be that there must be cross-sectoral working: "Working partnerships between the statutory services and voluntary organisations need to be backed by government with financial incentives, otherwise the inclusion of the sector in partnerships is not meaningful." (mental health campaign group).

Funding should be allocated to specific objectives but restrictions on the eligibility for support of particular groups affected by poverty were seen to put unnecessary restrictions on what could be achieved at a community level through cross-sectoral local initiatives. In other words, the desired outcome - an overall increase in take-up of local employment opportunities, for example - should allow for the third sector to partner statutory services at all stages of the process, bringing its own unique strengths to the outcome.

13 Identifying other factors which can lessen the impact of poverty on health

Respondents were asked for their views on what other factors could make a significant difference in alleviating the impact of poverty on health. By far the greatest emphasis was put on a reiteration of the necessity for cross-sectoral working - by sharing resources, developing skills jointly and increasing employer input. A respondent described this in more detail: "Definitely encouraging more willingness to work across sectoral boundaries. Staff in our project all have a background in adult education but are based in NHS premises. Primary care staff who work according to a psycho-social model of health value our input and value having our project as an additional resource for people who are their patients." (health and literacy project).

The second main focus was put on building evidence of what works and feeding this into government policy and staff training, ensuring that funding is sufficiently stable to promote and embed best practice.

Workable approaches included "Having a 'skills bank' of tools, approaches and strategies which can successfully be used in tackling inequalities; having local 'champions' to promote services" (smoking cessation organisation); and:

"Ensuring that successful local anti-poverty initiatives are sustained with long-term funding; ensuring that evidence is collected from these initiatives and shared across all sectors; building capacity in 'poverty awareness raising with managers and staff of public sector organisations." (community health network).

In the performance management of health improvement systems and interventions, there must be a joint determining of what outcomes translate into improvement and what intermediate stages must be gone through to achieve this improvement. The third sector need to articulate more clearly exactly what it can contribute to this process and partnerships encouraged to let third sector skills shine through where these are best positioned to make a difference. As one community food initiative said: "Not everyone needing to make dietary changes is able to aspire to full-time employment - what is needed are indicators of the increase in self-confidence and self-esteem which clients can achieve with third sector support. "

National intermediary bodies Voluntary Health Scotland and CHEX are currently working with NHS Health Scotland to build third sector capacity for building evidence of its own effectiveness.

Phase Two - Roundtable Discussion

The material derived from the on-line enquiry was used as basis for the roundtable discussion held on 17 March 2008. The Minister for Public Health, the Director of Health Improvement and the Deputy Director for Social Inclusion took part in the discussion.

The Minister for Public Health, Ms Shona Robison MSP, opened the discussion with an overview of the Government's position on tackling health inequalities and the key issues that had emerged thus far from the deliberations of the Task Force.

Ms Robison emphasised that the strength of the Task Force on Health Inequalities lay in bringing together ministers from across all government directorates and key external partners, including COSLA, to address the extent of health inequalities and identify the scope for action. In the course of its work, The Task Force had agreed key concepts and ways of working. These state that:

• Action must be cross-governmental

• Work is needed to raise awareness across all sections of society of the implications of poverty and inequalities for Scotland's health and future

• Priority must be given to moving forward practical action rather than on further analysis of the problem

• Community Planning Partnerships ( CPPs) could be the best context for action, but their capacity and ability to reach those most excluded requires to be strengthened

• Actions must be evidenced-based and applied in creative ways

• The key starting point for action must be families, engaging with their needs even before the birth of children

• Clear service pathways must be developed to meet anticipatory need, obviating inappropriate crisis intervention

• To make best use of the substantial investment in local government and health, service re-design must be prioritised

• Better use must be made of the skills of people on the ground, in particular frontline workers

• The measurable achievements of third sector work in partnership with other sectors must be built into models for action, using third sector skills in building trust with people most affected by health inequalities

• There must be recognition that action must be sustained over a time period much longer than four years, requiring cross-party support by the body politic for long-term success

Following reflections by Ms Robison on the progress achieved by the Task Force, input was provided by the Deputy Director for Social Inclusion, Mike Palmer, on the current Government Economic Strategy's approach to tackling poverty, inequality and deprivation in Scotland.

Participants were reminded of the clear role laid out for the third sector in tackling health inequalities in both Better Health, Better Care and the Government Economic Strategy, as follows:

- We will improve the capacity of the third sector to reduce health inequalities by:

• Supporting commissioners, funders and community-led services to achieve shared outcomes; and

• Reviewing the way in which NHS Scotland supports third sector organisations to explore ways of enhancing the sustainability of programmes that demonstrate a clear benefit for patients and carers.

And:

- The third sector should be regarded as a full partner in the [economic strategy] process …

The roundtable discussion was framed around identification of the characteristics of interventions most likely to be effective in reducing health inequalities. These characteristics emerged from the analysis of the data yielded by the on-line enquiry.

To open the discussion, an overview of the main features and findings of the on-line enquiry was provided by Rock Solid Social Research. The full presentation is contained in Appendix 1 to this Report.

In small groups, participants were then asked to address three issues and tasks.

1 Identifying characteristics of successful interventions

In the on-line enquiry, Third Sector respondents identified a number of essential characteristics or defining features of interventions that are effective in reducing health inequalities. These are:

• Ensuring cross-sectoral, inter-agency delivery

• Working where people are at

• Ensuring a comprehensive approach

• Ensuring responses that are sensitive to ethnicity and culture

• Tailoring services to meet expressed individual and community need

• Working at the interface between supplier and recipient, using the strengths of both

• Working with (extended) families as a unit

• Investing in people's futures

• Maximising individual and collective participation and empowerment

• Embedding sustainable support for long-lasting outcomes

Participants were asked to comment on these and they added further characteristics of success.

1.1 Considerable work needs to be done in communicating effectively Scottish and UK government policies and strategies for poverty reduction; participants noted that significant numbers of people - often those already disadvantaged - still do not have internet access. The use of a variety of media and communication methods is an ingredient of success.

1.2 At the same time, further work is needed to understand and explain to an audience beyond Government the underlying economic causes of inequalities and how these impact on people's health. For people to perceive that they are part of the solution and not just creators of the problem is likely to be marker of success.

1.3 Working with frontline health professionals and local government workers to change their perceptions of and attitudes to health inequalities can increase solidarity and reduce stigma.

1.4 Success breeds success - maximising the visibility of initiatives and celebrating achievements are likely to be precursors of success.

1.5 Ensuring a careful balance between individual and societal responsibility is likely to ensure sustainable results - focusing on mutuality and co-production.

1.6 Successful interventions are likely to feature ongoing analysis of the changing picture of individual and community need - building in action research can help this process.

1.7 Setting jointly-owned and realistic targets supported by sustainable funding are likely to gain "early wins", in which all parties can have a stake.

1.8 Establishing joint posts or ones that link with other local services can maximise resources and lead to jointly owned improvement.

Participants in the roundtable discussion identified many or most of these defining features of success as ones that had led to successful practice by their own organisations.

2 Taking forward and embedding successful interventions in strategy and practice

Participants were asked to say how the successful features identified could be taken forward in strategy and embedded in practice. They advocated a number of key ways of working.

2.1 Establishing a shared vision of a healthier, fairer Scotland and setting up a strategic and practice-based approach common to all sectors and agencies has real potential for the alleviation of poverty.

2.2 Using social marketing approaches in ongoing strategies to explain absolute and relative poverty and how these impact on health inequalities in Scotland today is key to establishing a shared vision.

2.3 Working with all frontline workers and those who are in face-to-face contact with individuals and communities is likely to de-stigmatise poverty and reduce the blame culture.

2.4 Maximising the partnership approach to strategy and practice at all levels is the main predictor of success.

2.5 Engaging with third sector infrastructure locally, e.g. local councils of voluntary service CVSs) and community health projects networks is likely to result in wider, more strategic engagement with the third sector.

2.6 Encouraging people to access under-used services through well-used services, e.g. benefits take-up advice in health centres, health screening information in post offices can maximise the one-stop shop approach.

2.7 Relating to the above, developing the one-stop shop approach and extending local income maximisation initiatives, e.g. credit union and food-co-operative provision offers individuals and families greater resources for self-reliance

2.8 Promoting measurement of the effectiveness of interventions through Social Return on Investment and social capital increase is to be advocated.

2.9 Establishing identification of savings made to the NHS and other statutory services must be a part of measuring effectiveness.

Participants in the roundtable discussion believed that embedding these key ways of working in strategy and practice were crucial to the success of interventions.

3 Third Sector recommendations to the ministerial Task Force

Finally, participants in the roundtable discussion were asked to identify key recommendations for action at policy and practice levels. Their recommendations were clustered under four main headings.

3.1 Communicating the urgency of poverty and health inequalities

Throughout the whole consultation process, respondents from the third sector expressed the view that the meaning of poverty and its impact on the health of people in Scotland required clear explanation at all levels, using as many different means of communication as possible. Accustomed as they now are to raw depictions of absolute poverty throughout the world, many people in Scotland are unaware of the devastating impact of relative poverty in communities close to where they live.

Key Recommendations for improving communication about poverty and health inequalities in Scotland today are therefore:

3.1.1 To create a greater awareness of the definitions of absolute and relative poverty and what these mean for Scotland's health today

3.1.2 To encourage social marketing methods for information dissemination and to include the general public, communities, the third sector and a broad range of statutory sector workers within the target audiences

3.1.3 To use the above approaches to de-stigmatise poverty and inculcate a philosophy of a fairer sharing of Scotland's resources

3.2 Adopting a partnership approach to tackling poverty and health inequalities

In both the online enquiry and the roundtable discussion, respondents from the third sector repeatedly stated the absolute primacy of working together. This reinforces the concept of the "mutual NHS" laid out in Better Health, Better Care.

Key Recommendations for taking a partnership approach to tackling poverty and health inequalities in Scotland today are therefore:

3.2.1 To promote the value of Scotland's people as the greatest resource in the alleviation of poverty and co-production as the means of enhancing personal and societal resources

3.2.2 To maximise returns when planning interventions by using partnership approaches rather than setting up single-sector interventions

3.2.3 To commit meaningful resources to the third sector role in partnership and co-production of health, embedding the principles of the Scottish Compact for partnership working

3.3 Maximising returns on investment for health

Third sector respondents to the online enquiry and at the roundtable discussion stressed the importance of establishing a shared vision and desired outcomes from the start and of moving towards these coherently in shared programmes.

Key Recommendations for maximising returns on investment for health are therefore:

3.3.1 To establish from the beginning a shared vision of desired outcomes and use to best advantage the strengths of public sector, private sector and third sector contributions

3.3.2 To ensure that the scale of investment matches the problem and ensure that initiatives are sustainably funded for long enough to make a measurable difference, while still allowing for intermediate indicators of success

3.3.3 To balance resource allocation between addressing general need and targeting the most disadvantaged individuals and communities

3.3.4 To balance approaches which focus on individual income maximisation, e.g. better benefits take-up with those which improve structural opportunities, e.g. childcare, learning and skills opportunities

3.4 Establishing evidence of effectiveness in order to replicate successful interventions

Third sector respondents to both the online enquiry and at the roundtable discussion had much to say on evidence and were keen to see established effectiveness measures that allow the strength of third sector working to "shine through".

They believed that in the performance management of health improvement systems and interventions, there must be a joint determining of end outcomes and an identification of the unique added value brought by the third sector to intermediate outcomes. At the same time, respondents acknowledged that the third sector needs to do more work on establishing measures of added value and translating these into "added health".

Key Recommendations for establishing evidence of effectiveness to replicate successful interventions are therefore:

3.4.1 To introduce the concept of "public value" in the setting of outcomes

3.4.2 To include in outcome measures an identification of cost savings made, e.g. where community-based partnership interventions can reduce impact on NHS services

3.4.3 To make better use of social return on investment and social capital as measures of effectiveness

3.4.4 To measure the value of co-production and partnership in the interests of establishing mutuality within the NHS

3.4.5 To promote evidence of success more effectively across Scotland and incentivise replication of workable initiatives

Conclusions to the Consultation

At the end of the two phases of this consultation on the views of third sector organisations in Scotland on current Government approaches to combating poverty and health inequalities and on the additional efforts which require to be made by all sectors, Voluntary Health Scotland has been able to reach a number of conclusions on the value of the exercise. These are:

1. Third Sector organisations across Scotland valued the opportunity to be included in the deliberations of the ministerial Task Force on Health Inequalities. While their experience is diverse, there was considerable consistency in their priorities for strategy and action.

2. The realities of poverty and inequalities in Scotland today and their effects on health need to be better explained to the public and to the workforce across all sectors in order to reduce stigma and increase fairness and solidarity. Imaginative communication methods need to be used.

3. There is room for the Scottish Government to influence Westminster thinking on new approaches to combating the underlying causes of poverty and inequality, based on the Scottish experience.

4. Those participating in the consultation supported and broadly agreed with current Scottish Government priorities for action. However, they identified other additional areas where poverty can be at its most corrosive, areas in which third sector action can make a real difference.

5. It is expected that Government take the main responsibility for supporting families and children in the very early years, making best use of statutory obligations in this area and partnered by the third sector in critical areas.

6. Improving mental health, enhancing self-esteem and confidence in both individuals and communities are pre-requisites for approaches focusing on employment and employability - best use must be made of third sector skills in meeting these needs.

7. Partnership working at all stages is the single best predictor of success. The third sector must be included as strategic thinking partner, as well as partner in delivery. Better use needs to be made of planning and partnership opportunities, including those newly created through changes in local government relationships with national Government with the advent of the Concordat and Single Outcome Agreements.

8. More creative use needs to be made of the private sector in partnership working.

9. There is an ongoing need for better evidence of "what works best in partnership" and of the value of partnership working itself. Recent thinking on shared outcomes and the value of investment in the public good must be incorporated into evidence. Indicators need to be established which allow the unique added value of the third sector to shine through.

The on-line enquiry phase of this consultation was organised by Phil McAndrew and Helen Tyrrell of Voluntary Health Scotland

The analysis of the on-line data and the facilitation of the roundtable discussion were carried out by Marion Lacey of Rock Solid Social Research

The report was written by Helen Tyrrell

15 April 2008

'DELIVERY PROOFING EVENT'

Scottish Health Service Centre
Crewe Road, Edinburgh

Wednesday 19 March 2008: 10:30 - 15:00

1.0 Introduction

The Scottish Government hosted a 'delivery proofing' event in Edinburgh to enable an invited audience to consider the emerging conclusions of the Ministerial Task Force on Health Inequalities.

The event was attended by over 40 participants drawn from a range of sectors and settings (a full participant list is included in Appendix 1.)

The aims of the event were:

• to check that the Task Force's emerging conclusions are practical and can be delivered by organisations working directly with individuals, families and communities.

• to seek to refine and improve on these conclusions where necessary to make them more realistic and deliverable.

• to examine both barriers to and opportunities in implementation, including possible early and visible successes.

The event opened with Ministerial addresses from both Shona Robison, MSP, Minister for Public Health and Jim Mather, MSP, Minister for Enterprise, Energy and Tourism, during which the key areas within which the Task Force is likely to make its recommendations were outlined. Participants were then asked to contribute to discussions on two of the following themes:

• Redesigning public services

• Preventing future problems

• Wellbeing and resilience

• Skills and capacity of the workforce

• Violence reduction

A summary of points from discussions on each of these themes is outlined below.

2.0 Redesigning public services

Facilitator: John Howie, Health Scotland.

Note taker: Helen Hassell, Health Scotland

Participants were asked to consider the following questions:

• How can we make public services more accessible to people who need them most?

• How can they best work with people's complex needs where more than one organisation is involved?

• How can we redesign and transform the services we have, rather than working through separate projects and time limited funding?

The discussion that followed can be grouped into four areas:

2.1 Redesign cycle

Participants felt that complementary planning systems are required which are needs led, embrace community development approaches and are not restricted as a consequence of annual planning cycles and non-negotiable deliverables and associated spends. In addition more flexible working across financial years (through increased ability to 'carry forward') would support this.

Comments received in relation to the '4 stages of redesign' were provided as follows:

2.1.1 Evidence of Need to Redesign

• The system for design needs to change overall and include more focus on planning. (Planning)

• Effective and participative methodologies with all service user/citizen groups and providers to identify needs and preferred local solutions

• The involvement of service users to inform service redesign and improve access is essential. (Service Planning)

• Effective data collection is a priority

• Sufficient time and resources to ensure the accurate and impartial analysis of results, priorities identified and recommended solutions is essential

• The importance of the health impact assessment process as a vehicle for promoting wider responsibility across a range of organisations was emphasised.

• It is important to have a longer term view of impact assessment. (Planning)

• Political drivers can come above patient need, e.g. GP extended hours. There needs to be consideration of the opportunity cost of what is not done. (Planning/Evidence)

• A sound evidence base is important to inform design. (Planning)

2.1.2 Planning for Redesign

• The compartmentalisation of policy streams and a tendency to 'set in stone' too early can make it difficult to translate original intensions into action on the ground. (Planning)

• If populations (e.g. learning disabilities) do not fall within the remit of central targets such as HEAT, it can be difficult for frontline staff to ensure that issues relevant for these populations are considered and acted upon at a local level. (Planning)

• Action plans need teeth. (Planning)

• Engagement with communities and individuals to win their confidence is key. (Planning/Communication)

• There are tight budgets and increasing public expectations - a debate is needed. (Planning)

• There is a need to ensure that targeted approaches do not further discriminate against populations not deemed to be in greatest need, e.g. rural (Planning)

• The use of community planning needs to enable delivery and not be tokenistic. (Planning)

• Community development approaches can work well but are not happening across the board. (Planning)

• Health and social care agendas don't always dovetail. (Planning/Delivery Processes)

• Services need to be clear on their key aims, objectives and client group, and raise awareness of this. There needs to be a starting point to build on. (Planning)

• Staff 'buy in' to redesign is essential to effect change. (Planning)

• Funding constraints for councils could result in areas of most need getting least funding. Services which impact upon health, e.g. housing, are not always given a high priority. (Resource Allocation/Planning)

• It is important to build on what already works well and not redesign everything. (Planning/Review/Evidence)

• It may not always be about redesign but a 'change of focus', guidance would support this.

• Community Planning Partnerships are a good mechanism to support redesign. (Planning)

2.1.3 Delivering Redesigned Services - Resources and Capacity

• The joint assessment process is a good system but the practicalities of delivery are problematic. Central policy and guidance would support development of local systems without duplication of effort. Information sharing across agencies and consent issues also need to be addressed and there needs to be technology to support this.

• The voluntary sector funding mechanism often focuses on specific groups/agenda but most individuals needs cut cross different groups/topics. (Funding Mechanisms)

• Short term pilot funding is welcome however can cause problems in terms of sustainability if alternative/extended funding is not released. This is particularly frustrating when services showing evidence of effective practice cannot be continued.

• Legislation, e.g. DDA has enabled change. (Legislation)

2.1.4 Monitoring and Review of Redesigned Services

• There was view that reducing the inspection regime which is seen in some quarters as a large burden, would be beneficial but monitoring and evaluation was still seen as important. (Governance)

• Action plans and strategies are not always translated on the ground, e.g. Fair for All. (Scrutiny)

• Clarity about where the accountability lies would be helpful. (Governance)

• Information gathered from services needs to be reviewed and used to inform change. (Service Planning/Evaluation/Dissemination)

• There has been extensive redesign of mental health services but there is no knowledge as to whether services have improved for service users as a result of this. (Governance)

• Services are sometimes redesigned to 'tick boxes' not designed around service user needs. This can be the result of bureaucracy and there is a need to simplify things and free up time but ensure accountability. (Governance)

To ensure effective and efficient redesign a robust, enabling and complimentary planning environment at both national and local in essential.

2.2 Access

• The importance of equity of access to services was emphasised as was the design of services to ensure this happens. Positive discrimination in allocation of resources to focus on populations who need it most, e.g. geographic areas, learning disabilities, homelessness etc. needs to be considered.

• Many people who need services do not know where to get them. (Access)

• Co-location of services would be helpful as could information sharing across organisations. (Access)

• Choice for all, not just those who are better informed is an essential value. (Access)

• Services are stretched due to lack of resources and it can be difficult to develop good relationships with service users due to lack of time during contacts. (Capacity/Access)

• Pressures and different priorities mean it is difficult to invest time in working across different organisations. (Capacity)

• There should be a shift of emphasis onto those who need it most and access services less, rather than traditional approach of treating ill people. (Access)

2.3 Workforce Development

• There is an assumption that an increase in knowledge will automatically result in positive change, but this does not always happen. (Workforce Development)

• Education of commissioners around target setting is needed. (Workforce Development)

• Importance of cultural values as the basis of how we plan and deliver services. (Workforce Development)

2.4 Leadership

• Effective leadership at all levels across the system is essential if public services are to work towards the same set of goals.

3.0 Preventing future problems

Facilitator: Ann Kerr, Health Scotland. Note taker: Cara Letsch, Health Scotland

Participants were asked to consider the following questions:

• How can public services prevent problems arising that are likely to lead to poor health later on?

• What can services do to focus on supporting families in children's very early years?

• What about other kinds of preventive action, e.g. to improve people's physical and social environments?

3.1 Preventing problems

• In addressing the first of these questions the group felt that the inequalities gap should be tackled by focussing on those most at risk. Services should not merely aim to narrow the inequalities gap, but should also be about preventing the gaps from emerging in the first place.

3.2 A focus on early years

• There was general agreement that 'early years' was the period from pre-conception to 3 years and that, within this, services should target groups that have been identified as vulnerable. Moreover, support needs to be sustained, so that individuals do not become at risk again when services cease, noting that families can move in and out of vulnerability.

• The need to focus on vulnerable young people who were likely to become parents, such as Looked After and Accommodated children and young people ( LAACYP), was recognised, however the idea of preparation for parenthood being taught in schools met with some resistance.

• It is suggested that support during pregnancy should include ways to develop and maintain the aspirations of young women (and their partners), such as pathways to employment. A key short term measure of the success of this intervention would be delaying another pregnancy.

• Families where drug use is a problem were also seen as a priority group. Key areas for action were access to treatment and sustaining support beyond quitting. (See also notes on partnership)

• NB Care with language is required. Interventions should be at the appropriate time, this generally means early, but there is a risk of confusion between early intervention and intervening in the early years.

3.3 Cultural change

• The group identified that without cultural change, intervention strategies will be ineffective. Fostering an aspirational culture is fundamental. This links to Dr Harry Burns' observation of a sense of helplessness in areas of deprivation with poor health outcomes

• To highlight cross-cultural differences, a member of the group provided the example of young women in the Netherlands whose sexual health outcomes were greatly improved because they, in contrast to the Scottish target group, had "aspirations" or the drive to make differences in their lives, which supported better health outcomes.

• Devolution and the change in government may provide an opportunity to strengthen Scottish culture and build aspirations

3.4 Capitalising and building upon existing strengths

• The universal, non stigmatising nature of education and health services is important in enabling trust. Although there are problems with engagement, access and inclusion, the importance of continuous therapeutic relationships is a key strength. The roles of HVs and school nurses were particularly noted. However potential threats to these services, such as the changes in GP regulation, Community Nursing Review should be recognised.

• It was noted that poverty alone should be regarded by health professionals as a risk factor, and that the evidence suggests that siting GP practices/primary care services in areas of deprivation has an impact on health outcomes.

3.5 Strengthening partnerships and making connections

• The importance of local partnerships and the practicalities of implementing good partnership working on the ground was a key theme throughout the workshops. Although recognised in policy, in practice they can depend on working relationship and support to embed partnership working is required.

• Partnerships are enabled/strengthened by the creation of joint workers, joint teams, joint training, improving professional networks, good referral systems, communication networks, information sharing, co-location, and local mapping.

• Barriers to collaborative working include: adaptability of systems (particularly ITC), inflexible reporting and accountability. If there are high level shared outcomes and SOAs then these must translate into funding arrangements on the ground.

• Better services do not necessarily need more financial resources. What is needed is for all sectors to think more broadly and flexibly about their role. Signing up to shared outcomes is a major step forward and requires both clarity and flexibility in terms or roles and responsibilities if they are to be achieved.

• Examples were given of services for vulnerable groups where "wraparound" services were developed that were responsive to the needs. These were often led by a keyworker, but set up on a multi-agency basis and in the best examples service users were equal partners in the design and delivery of the services.

• There are "trigger points", such as the first ante natal visit and referral to Children's Panel which can help identify vulnerable individuals for referral to other support services.

• Examples of good practice include: Highland GIRFEC Pathfinder, Tayside project, Lothian schools, and Glasgow Housing.

• NB examples of good practice were mentioned throughout the workshops, and individuals were happy to be contacted. Participants felt that use of these in the Task Force report could be valuable

3.6 Workforce issues

• In order to enable good referral and support from a range of services, the general workforce need to work in ways that support multi-agency working, focussing on the client needs, rather than professional/sectoral needs.

• The worker at the first point of contact needs to appreciate the influence of early years intervention on health in later years. It was recognised that developing these skills and knowledge across the general workforce in contact with families with young children was a tall order.

• The need for good assessment leading to intensive, multi-agency support for the most vulnerable groups, with skilled key workers was recognised.

3.7 Environment

• The need for improved home safety, opportunities for play, outdoor play and physical activity were all noted.

• Threats to the housing stock, and the cost of accessing PFI premises were noted as barriers.

3.8 Key Groups

3.8.1 Families and drug use

• As well as the key issue for children affected by drug use, the wider issues of the parent's health, local 'drug economies' and the criminal justice system all resonate negatively in communities, making this group a priority for early intervention.

3.8.2 LAACYP

• This group as a whole have poor outcomes in life, not just in their health. They are particularly likely to become young and unsupported parents, creating future risk.

3.8.3 Young pregnant women

• Evidence supports ensuring early access to good antenatal care and continuing support improves the life chances for themselves and their baby. Delaying future pregnancy is an early indicator of effectiveness.

3.9 Short-term recommendations:

The group felt that the following areas could usefully be the focus for immediate attention:

• Review implementation of GIRFEC and integrated assessment.

• Identify common key trigger points that bring pregnant women, their families and young children to any service. This has the potential to develop good referral systems or protocols and ensure the appropriate multi-agency support.

4.0 Wellbeing and resilience

Facilitator: Laurence Gruer, Health Scotland.

Note taker: Katie Hetherington, Health Scotland

Participants were asked to address the following questions:

• How can public services foster in their clients the qualities of resilience, coping, adaptability and a sense of control over their lives?

• How can services involve clients and local communities in service design and in decisions that affect them?

It was agreed that the focus for today's event would be essentially inequalities in socio-economic status, rather than those relating to for instance gender, ethnicity, disability, sexuality. etc. (although the importance of these in relation to health inequalities was acknowledged).

There was a consensus that wellbeing and resilience have an important bearing on health and thus, by their variable extent across individuals, families and communities, contribute to health inequalities.

The discussions mainly concentrated on how services and other factors can influence wellbeing and resilience and have greater positive impact.

4.1 Accessible, personalised and timely services

• As well as generally ensuring that people know about the full range of services available to them, services should be tailored to individual circumstances and made available at the right time. One example from a school perspective was the importance of a rapid response once the need for support and services to children and their families is identified (linked to early intervention below).

• There was a need for a cultural shift in how some services are provided to improve the experience of people when they access services, e.g. to avoid multiple discrimination and stigmatisation for some people once they access services.

• Broad-brush approaches will not tackle health inequalities as those isolated and excluded will remain so and this may lead to the inequalities gap widening.

4.2 Early intervention

• The importance of early intervention was recognised. The role of services and activities in helping build resilience and giving people (at all stages in their lives) opportunities that may prevent crisis situations and poor outcomes for them at a later stage, was seen as crucial.

• The voluntary sector play an important part but are vulnerable to funding cuts by local authorities on what can be seen as 'non-essential' services but may lead to negative impacts for people later on.

4.3 Building communities and societal values

• Equipping individuals to become self-sufficient and take ownership can help give a sense of empowerment and motivation to change.

• There was recognition that a lack of a sense of belonging to a community contributed to health inequalities. There was also a view that individuals need to feel valued by society and that people need to have hope in their lives. In some cases getting into work can provide this but for some people such as refugees and asylum seekers work is not an option and when it is, often skills are not recognised.

• Working with children and young people to help towards achievable aspirations and goals was discussed.

4.4 Partnership working

• Building shared agendas across services so people's needs are not treated in isolation was seen as important. Government and policy can play a part in this by setting expectations about partnership working and incentives for it to work. Some partnerships could be explored further, for instance with GPs. Multi-agency working around schools can provide children and families with support tailored to their specific needs.

4.5 The role of key workers

• Key workers were seen as important in building relationships with clients and ensuring that they receive the right services at the right time.

4.6 Involving users in service design

• This is important but the view was expressed that currently it is being heavily driven by central government leading to a 'tick box' exercise and may not be very meaningful in practice. Are we consulting with the right people? What about those we are not talking to? Are some people over-consulted?

4.7 Wealth distribution

• Several participants felt there was a need for core political decisions to be made about wealth distribution in the country and the allocation of resources to our public services if we are to make a difference to Scotland's health inequalities.

5.0 Skills and capacities of the workforce

Facilitator: Shirley Fraser, Health Scotland

Note takers: Emma Witney, Health Scotland and Alun Ellis, Scottish Government

Participants were asked to focus on the following questions:

• What qualities and ways of working are needed amongst staff to prevent clients' problems emerging, rather than react to crisis?

• What support do frontline staff need from their own managers and from their organisation more generally?

• What would help staff to work better with staff of other organisations with whom they are likely to share clients?

The discussions on skills and capacities of the workforce was wide ranging and many issues identified in other groups, such as the need for appropriate structures and systems to promote interagency working, appeared here too. The theme of skills and capacity building is one that will be of growing importance as the recommendations of the Task Force become more detailed and concrete and implementation considerations come to the fore. The points raised can be grouped under three headings.

5.1 Ensuring individual skills and knowledge

• Creating appropriate levels of competence, autonomy and accountability within the workforce was seen as important. Participants felt that trusting professional judgement and engendering appropriate skills was the key to achieving this. If this were in place then the need for referral to specialist services could be reduced.

• Defined roles/responsibilities and accountability needs to be combined with a learning culture where there is permission to admit when things are not going to plan and then learning from mistakes.

• Specialised staff could be seen as counterproductive to delivering holistic care - is there a need to have a generalised work force that can deliver and refer to a number of services?

• Staff need to be given the knowledge and tools to refer and signpost individuals to other services which they cannot deliver. Partnership working will lead to increased staff knowledge of other services. This can help with referral to services.

5.2 Creating supportive service structures and networking opportunities

• Shared short- and long-term outcomes at national and local level were seen as important and useful in providing the context for developing structures and systems to promote joint working.

• Should systems be implemented that allow for individual/patient information to be shared across service including GPs, police, schools, health workers?

• By encouraging staff who deliver services to 'buy in' to the service they will, in turn, deliver a better level of service

• Mechanisms to provide continuous feedback to staff/organisations in terms of the impact of their work on people's lives/behaviours were seen as desirable. The need for expectations to be realistic and achievable was also emphasised.

• Clarity about values and goals was seen as central to developing closer collaboration between voluntary and statutory agencies. Equal status within partnerships (e.g. CPPs) was also see as important together with a commitment to appropriate accountability and performance management systems. The importance of being realistic about what can be achieved with limited resources was also emphasised.

• Co-location was identified as a useful mechanism for promoting joint working and better information sharing. Work on specific areas of focus such as safer neighbourhoods, requires a clear consensus on priorities and goals.

• Shared and more effective IT systems can also be useful for identifying needs (particularly of at risk groups).

• Greater sharing of evaluated practice at national and local level would be useful.

• In areas where the workforce is predominantly female it is essential to ensure that there are sufficient resources to provide maternity leave cover. Plea for no more re-organisation in the near future as it disrupts effective partnership working.

• Staff and services may need to prioritise the care they provide and who they provide it to due to resource implications. Prioritisation may be aided by an evidence base for 'what is most effective'.

5.3 Influencing wider cultural and attitudinal values

• Implement policies that tackle long standing cultural values, e.g. acceptability of alcohol and drugs/going to work with a hangover

• Avoid blame culture around areas of deprivation through providing real tangible alternatives to risk taking behaviour (and providing staff with skills and knowledge to follow through on implementation)

6.0 Violence reduction

Facilitator: John Carnochan, Strathclyde Police

Note taker: Karyn McCluskey, Strathclyde Police

Participants were asked to address the following questions:

• How can public services contribute locally to reducing violence in the community?

• How can local services be coordinated more effectively to prevent violence?

• Do existing information sharing arrangements support or inhibit coordinated service deliver?

• Given the group most at risk of poor life outcomes in relation to health, education and violence is young males, what can be done to reduce the risk and/or increase protection?

At the outset participants felt that the topic of 'violence' immediately seemed to indicate it as a police issue and therefore the people who attended were in the main police officers. It is perhaps pertinent to note that the concordat provides the potential for developing action plans to tackle violence based on a local analysis of the problem. This opportunity will enable all CPP partners, including local communities to see 'violence reduction' as 'their business'.

A number of issues were seen as important by the group:

• Information Sharing - came across as one of the biggest inhibitors to progress in delivery of services at an appropriate time and to the right people. Despite huge effort it seems that the legislation confuses us and inhibits us. Where there is good information sharing, it seems to be more about personal relationships as opposed to the goal of good service delivery.

• Comprehensive analysis also came out as a key inhibitor - although it was recognised that this is improving, with the sharing of police and health data in the public health profiles.

• Early years and parenting came out as the strongest theme and the connectedness of good intervention to the outcomes of children was recognised across our two groups. Holistically approaching the needs of the child through family, housing, education etc. was seen as key - integrated case management needed to work better to achieve this.

• Mental health, wellbeing and resilience are critical to reducing violence in the long term. It was highlighted that males are our most at risk group - behind girls educationally, more at risk of becoming a victim or offender, have the worst health. Added to this the decline of the nuclear family is in decline and there is an absence of male role models as fathers, bread winners, or present in the community or media in positive roles. The result of this is that young males are creating their own social constructs of what it is to be male in 21st century Scotland; this is resulting in violence, binge drinking, risky behaviour and lack of aspiration or goals. The role of mentoring by males came up in our groups as a positive step.

• The tackling of alcohol also came through as critical in delivering 'Violence Reduction' and the consultation on alcohol is anticipated as being a way forward for Scotland.

• Communities - it was mooted that an emphasis on communities taking responsibility for their own issues was fundamental to 'Violence Reduction', instead of relying on Police mainly to deal with issues such as failures in parenting and setting boundaries. Good signposting to services to deal with own issues was required - such as Teen triple P, services for dealing with anger and violence (of which there are very few at present) both self help and programmes in the community.

• Early identification of violence and aggression problems in primary schools seem to be thwarted by a lack of interventions such as SNAP (Stop Now And Pause) which works with parents and children to address problems and deliver better outcomes.

• Tolerance - there is a high tolerance level of violence in areas of highest deprivation and normalisation of violence. Tackling this tolerance is one of our greatest challenges both within communities and organisations who perhaps don't see violence as an issue they can do much about. Through the new concordat we believe that we need to deliver a framework/plan for local authorities to tackle the issue based on the analysis of the problem in their area. Violence is such a complex issue that clear guidance and a 'what work' framework is key.

APPENDIX 1 - PARTICIPANTS

Mrs Linda Allan, NHS Greater Glasgow & Clyde
Ms Martha Baillie, Waverley Care
Mrs Sue Barnard, Shared Care Scotland
Mr David Brownlee, Citizens Advice Scotland
Mrs Rosalind Bryson, Sensing Change Project - RCA Trust
Mr Graham Cairns, Strathclyde Police
Mrs Lynette Cousens, Lothian and Borders Police
Dr Andrew Cowie, Scottish General Practice Committee
Mr Ian Davidson, Argyll & Bute Council
Mr Chris Denmark, Action Team on Alcohol and Drugs in Edinburgh
Mr Steven Duncan, Lothian and Borders Police
Mrs Moira Dutton, Trinity Academy
Mr Mike Finlayson, Forth Sector
Mrs Yvonne Gallacher OBE, Money Advice Scotland
Ms Liz Gladstone, North Lanarkshire Council
Mrs Vivien Goodbrand, Falkirk Council
Ms Pauline Graham, Social Firms Scotland
Ms Carrie Ho, Project Empower Glasgow West CHCP
Ms Shona Honeyman, Glasgow City Council
Ms Jane Kellock, West Lothian CHCP
Ms Isobel Kelly, North Ayrshire Council
Ms Heather Knox, West of Scotland Regional Planning
Mrs Valerie Lawrie, City of Edinburgh Council
Ms Marion Logan, STRADA
Mrs Elizabeth Lumsden, RoSPA
Mr Andrew Macdonald, East Ayrshire Council
Miss Sandie Mackay, North Lanarkshire Council
Mr Robert Madden, Renfrewshire Council
Dr Rajan Madhok, Royal College of Physicians and Surgeons
Dr Zelda Mathewson, NHS Tayside
Ms Catherine McDerment, NHS Lothian
Mr Gilbert McGill, Mamillan/ DAGCAS Cancer Benefits Team
Ms Agnes McGowan, NHSGreater Glasgow & Clyde
Ms Linda Middlemist, West Lothian CHCP
Mrs Maxine Moy, NHS Fife
Ms Suzanne Munday, Coalition of Carers in Scotland ( COCIS)
Mrs Maureen O'Neill Craig, NHS Greater Glasgow & Clyde
Dr Euan Paterson, RCGP (Scotland)
Mrs Dawn Redpath, Working for Families Fund, Dumfries & Galloway
Mr Laurie Russell, The Wise Group (on behalf of SECC)
Mr Dave Simmers, Community Food Initiatives North East
Mrs Petra Staats, SUSTRANS
Mrs Mary Stewart, Fife Carers Centre
Mr Nigel Walker, East Dunbartonshire Citizens Advice Bureau
Mr Graham Watt, University of Glasgow
Mrs Helen Weir, West Dunbartonshire Council - Addiction Services
Mr Andrew White, Comhairle nan Eilean Siar (Western Isles Council)

APPENDIX 2: PROGRAMME

Scottish Health Service Centre
Crewe Road, Edinburgh

Wednesday 19 March 2008

APPENDIX 3:

Ministerial Task Force on Health Inequalities - Summary of Progress up to December 2007

The Task Force has met 4 times between October and December 2007. It has agreed its remit, which includes cross-Government activity to achieve both short and long-term outcomes, and the need to use existing evidence and have a clear and measurable impact through its recommendations.

The Task Force will draw on the Better Health, Better Care consultation. It has also agreed how to involve and communicate with external interests, including organisations that will be critical to putting its recommendations into practice. Further consultation and involvement will be carefully targeted, in order to secure commitment and buy-in.

The Task Force is considering factors that influence people's health, from individual characteristics, through people's lifestyles and behaviours, to wider influences such as education, employment, living conditions and other environmental influences. The focus is, however, on health outcomes. The most significant inequalities have been agreed as:

• Children's very early years, where inequalities first arise and may influence the rest of people's lives.

• The high economic, social and health burden imposed by mental illness, and the corresponding requirement to improve mental wellbeing.

• The "Big Killers" including cardio-vascular disease and cancer. Risk factors for these, such as smoking, are strongly linked to deprivation.

• Drug and alcohol problems and links to violence that affect younger men in particular and where inequalities are widening.

Scientific evidence is emerging of how deprivation and other forms of chronic stress lead to poor health, starting at the very early stages of life. The Task Force is basing its principles and approach on this evidence. It has set out key principles to drive its work, which include building the resilience and capacity of individuals, families and communities to improve their health and to reduce factors in the physical and social environments in Scotland that would otherwise perpetuate inequalities in health.

The Task Force's principles have been published in the Government's Better Health, Better Care action plan, December 2007. The action plan states the high priority that the Government attaches to reducing health inequalities. This is reflected in the Spending Review 2007 which prioritises spending on relevant current and new activities.

Professor Sally Macintyre has advised the Task Force about action that works in tackling inequalities in health. This includes structural changes in the environment, legislative and regulatory controls, maximising income and reducing price barriers, improving accessibility of services, prioritising disadvantaged groups, offering intensive support where people need it and starting young. The Task Force will test its recommendations for actions against this evidence.

Some NHS Chief Executives presented information to the Task Force in November, to enable it to contribute to the Better Health, Better Care action plan. As a result, the Task Force is on record in the action plan as identifying critical activity to: support particularly vulnerable children and families, realign resources and effort in primary care, extend anticipatory care approaches to preventing ill health, reach and engage with the most vulnerable groups of people to improve their physical and mental health more effectively, ensure that health is not a barrier to retaining or entering work, and improve the capacity of the third sector to reduce inequalities in health. The NHS itself plays a critical role as an employer, investor in local communities and as a community planning partner. More detailed delivery programmes are now being worked up to turn these recommendations into specific action.

The fourth meeting of the Task Force considered tackling health inequalities through action in children's early years and with young people. The Task Force's conclusions will feed into the Government's early years strategy due in 2008. This will also be taken into account in the More Choices, More Chances element of development and delivery of the new Curriculum for Excellence during 2008.

Key points for the early years strategy include the need for holistic support for children and families at risk of poor health and other outcomes, in all aspects of their lives and for sustained periods. Redesign of existing services is required, working through mainstream planning and delivery systems and joining up services effectively across statutory agencies. It should be possible to test out promising approaches from other countries quickly, to find out how to make these work in a Scottish context. A number of workforce factors will be critical, for example encouraging professions to work across organisation boundaries, fostering the key worker approach for more complex families and boosting the confidence and skills of staff to deal with issues such as sexual health and prevention of early pregnancy. The Task Force emphasised the importance of literacy and numeracy, which are vital for people's subsequent capacity to manage and improve their own health, as well as for other aspects of their lives.

The remaining Task Force meetings will address themes from the Government's Safer and Stronger, Wealthier and Fairer and Greener objectives. They will look at health inequalities that depend on gender, ethnicity, disability etc. as well as on socio-economic status. Finally, the Task Force will look at delivering and managing implementation of its recommendations, making sure that the impact of these can be measured and evaluated.

YOUNG SCOT

EXECUTIVE SUMMARY

This report outlines the process used in a video consultation group set up to allow young people aged 14-25 to create video diaries which addressed the questions of inequalities in health. These videos have been edited and were presented to the Ministerial Task Force on Health Inequalities on 16 April 2008 by two of the young people from the group. All edited and unedited video content was uploaded to a microsite for access by all young people in Scotland. The video consultation was cross-linked and promoted through relevant sites and publications to encourage young people to contribute.

Introduction

Young Scot is the national youth information agency for Scotland, providing young people aged 11-26 years with a mixture of ideas, information and incentives to:

• Allow young people to make informed decisions and choices about their lives.

• Turn their ideas into action.

• Take advantage of the opportunities available in Scotland and throughout the rest of Europe.

• Have the confidence and knowledge to become active citizens in their communities.

Young Scot achieves these aims through the provision of an integrated youth information package, offering young people access to information and services through a variety of media, including books, magazines and web-enabled services, including www.youngscot.org - the national youth information portal.

There are currently over 340,000 Young Scot members, with young people offered the opportunity to join via our partnership local authority network Dialogue Youth.

Figures show that people living in the poorer areas of Scotland have worse health and die younger than those that live in well-off areas. There are a number of factors that could contribute to this, such as lack of education and good quality affordable food, each of which furthers the health inequalities of Scotland as a nation.

The Government's focus on the needs of people in poorer areas has led to the set up of a Ministerial Task Force on Health Inequalities, which focuses on practical actions for change, working across the Government and with partners in the public, private, and voluntary sectors to tackle the causes, and the effects of health inequalities.

Young Scot, in partnership with local authority, statutory and voluntary sector providers, has significant experience in developing consultation processes and investigatory initiatives as part of a menu of connections enabling young people to be involved in, for example, community planning structures, national decision making processes and changing services.

The Scottish Government approached Young Scot to gather the views of a representative group of young people in Scotland aged 14-25 on the topic of health inequalities. Young Scot decided to use cutting-edge new media consultation methods to engage the group and allow them to present their views in an innovative manner.

Outcomes

The outcomes set out for the video consultation were:

• The collation of a representative group of young people's views on the inequalities of health and their reasons behind them.

• Empowerment of the young people through full involvement in each step of the consultation process, from diary creation to presentation to the Ministerial Taskforce.

• Young people provided with the opportunity to express their views to policy makers.

• Ministers provided with the opportunity to hear directly from young people on the issues that affect them.

• The creation of an ongoing resource which can continue to provide views on the topic.

• Testing of video technology as a consultation method, with a view to future use of this method in local and national engagement with young people.

Methodology

The consultation used digital video technology and a web interface designed to encourage visitors to the site to leave their comments on both the videos and on the topic overall. The pilot of the video consultation began in March 2008 and ran until early April 2008.

Young Scot worked with a representative group of six young people to create the video consultation. This group of young people consisted of three young people from Young Scot's Health Panel, set up to inform Young Scot and NHS Health Scotland of health issues of importance to young people aged 14-26, and to ensure young people have the opportunity to work with Young Scot and Health Scotland to improve the health information available to young people through Young Scot's information products and services. The rest of the group was made up of a volunteer who works with the Scottish Inter Faith Council, and two asylum seekers from Glasgow, who volunteer with Positive Action in Housing.

Each young person was supplied with a video camera and additional equipment such as a tripod and clip microphone. Training was provided by Young Scot for each member of the group, focusing on how to use the equipment and next steps for carrying out the consultation. This training was conducted by the Young Scot Senior Development Manager (Online), responsible for overseeing the digital media work for the organisation.

Once they completed the training, the young people were tasked with answering a series of questions through a self-filmed video diary or blog. These questions were drawn up and approved by the Scottish Government, and covered a number of themes, including 'Friends', 'Family', 'Education and Employment' and 'Smoking, Drugs and Alcohol' (see Appendix 1 for a full list of the themes and questions provided to the young people). The young people filmed themselves giving their views and answers on the themes, and were encouraged to gather the views of others in their lives, including other friends and family.

The young volunteers had two weeks to record their footage, before the videos were returned to Young Scot. During this period 12 hours worth of video footage was recorded by the young people. The videos were then edited by Young Scot, using video editing software, to provide a presentation overview of the answers provided by the young people. Young Scot then worked with two volunteers from the group to assist in preparing them to present the finished video consultation to the Ministerial Task Force on Health Inequalities on 16th April 2008. The young people who presented were Fiona Beaton (17), a member of the Young Scot Health Panel and Haroon Ahmed (19), a volunteer who works with the Scottish Inter Faith Council.

On the day, the edited video consultation was shown, with the young volunteers outlining the process carried out for the consultation, their personal views, and answering questions posed by the Task Force.

Alongside delivering the presentation to the Ministerial Task Force, both the presentation and the unedited versions of each of the video diaries were uploaded to a new online microsite for all young people to access and provide feedback on.

The microsite features the overall presentation on the homepage, and is broken down into each individual theme, and the video blogs from each of the young people on each theme are available for everyone to watch. Along with links to further information on the topic of health inequalities, each theme subsection has a feedback form to allow visitors to leave their comments on the subject, thus continuing the dialogue on health inequalities. The interface design was structured around the concept of user-generated content. This means that the user is encouraged to contribute to the content of the page by giving their views on the site itself, rather than the content being completely authored by a programmer or behind the scenes content management system.

The online microsite is supported by further Young Scot information services, including the Health information channel on www.youngscot.org, information factsheets from the Young Scot InfoLine website, and the Young Scot InfoLine, a free and confidential information enquiry service for young people.

Young Scot Health Information Channel - http://www.youngscot.org/channels/feelinggood/

Young Scot InfoLine website - http://www.youngscot.org/infoline/

Young Scot InfoLine phone line - 0808 801 0338

A short URL (web address) was also created for the online microsite at http://www.youngscot.org/healthvideoblogs which will be used to promote the consultation and its findings. The video consultation will be promoted and cross-linked through representative websites and publications to encourage debate and wider engagement from young people across the country.

Summary of Findings

There were a variety of opinions expressed on each theme outlined for the video blogs. The key views which came from the consultation were:

• There is no room for health inequalities in Scotland as a modern nation.

• Services can be daunting for young people and need to be made more youth friendly.

• Alcohol is too readily available and inexpensive, causing health inequalities and also making communities less safe in the evenings.

• More should be done to make healthy food cheaper.

• More should be done to provide healthy recreation for young people, with current problems often stemming from transport issues.

• Wealth is one of the key reasons behind health inequalities.

• Young people should be involved in the continuing process of tackling health inequalities and improving services.

• Providing qualified health information for young people is one of the key elements of tackling health inequalities.

To hear all the views expressed by the group of young volunteers, visit the online microsite at http://www.youngscot.org/healthvideoblogs

Next Steps

Young Scot was delighted to work with the Health Inequalities Task Force and Scottish Government on this project. The video consultation has proven in this instance to be a successful method of using modern technology to engage young people and gather their views, along with providing an ongoing dialogue with them through the feedback from the online microsite. It provides an accessible and interactive option which compliments other methods, such as depth interviews and focus groups.

Contact

For more information about any aspect of this work, please contact:

Martin Dewar, Senior Development Manager (Online), Young Scot

Tel: 0131 313 2488

Mobile: 07884 016083

Email: martind@youngscot.org

APPENDIX 1

Ministerial Task Force on Health Inequalities - Young Scot Video Blog Consultation Briefing for Participants

Themes and Things to Think About

Family

• How important is your family life to your health and wellbeing?

Friends

• How important are your friends to your health and wellbeing?

Community

• How does your local community contribute to your health and wellbeing?

Education and Employment

• What does your school/college/university do to help your health and wellbeing?

• Are there any other people that contribute to your health and wellbeing, e.g. youth workers?

• What are your educational goals?

• What skills and opportunities will you require to achieve these goals? Are there any barriers to achieving these?

• What are your career aspirations?

• Will anything prevent you from achieving these goals?

Violence and Safety

• How safe do you feel going out in your local community (during the day/at night?)

• Do you feel you have access to good services for recreation?

Discrimination

• How have you been treated by the public services you have used?

• Have you ever felt/experienced discrimination because of your age?

Smoking, Drugs and Alcohol

• Do you or your friends smoke?

• Do you or your friends regularly consume alcohol or drugs? (would the young people involved in the consultation be willing to answer this on camera)

• If you do drink/take drugs, what is the reason for this?

Public and Private Services

• What services do you regularly use? How would you rate them?

• Are you unable to access any services that you would like to use? What prevents you from accessing these?

• Are there any services that are not available to you but you feel would make a positive difference to you/your community?

• What difference do you and your friends think you could make in delivering/planning services?

Finance

• Does cost hinder your ability to access certain services? How would you make services cheaper?