Scottish Government

4. COSLA PAPER: THE ROLE OF LOCAL GOVERNMENT

TACKLING HEALTH INEQUALITIES - THE ROLE OF LOCAL GOVERNMENT

Summary

• COSLA's submission to the Joint Ministerial Task Force on Health Inequalities addresses two main issues: how do we tackle the causes of health inequalities; and how do we respond to the consequences of health inequalities? In doing so, it makes the point that public services are currently well equipped to deal with the manifestation of health inequalities, but that we need to become more effective at dealing with the causes.

• The submission argues that the key to success in tackling the causes of health inequalities lies in effective targeted intervention during the early years of a child's development. This is best done in an holistic manner that links work on health inequalities to the development of an early years strategy.

• We need to become more adept at understanding what works in tackling the causes of health inequalities. To this end, it is suggested that knowledge sharing networks should be established to ensure that practitioners have the tools, skills and resources to make an impact on health inequalities.

• As a key provider of education, regeneration, housing, green spaces and support to the unemployed and offenders, local government is a key player in helping to tackle the consequences of health inequalities. We are committed to maintaining and improving these crucial services, thus improving the health and well-being of all members of the community, but particularly those living in disadvantage.

• It is imperative that resources are directed in a manner which supports success. There is a need for both central and local Government to consider how to fund the transition from reactive crisis management to proactive early intervention and prevention. COSLA therefore proposes a long-term twin-track approach to resourcing change: we need to invest both in our capacity to respond to crises and in our capacity to stop crises happening in the first place. We think this is an issue for both the Scottish Government and local government to consider together.

• In order to make a real impact on the health inequalities agenda, we need to obtain strategic and political buy-in. The primary vehicle for delivering change at the strategic level will be Single Outcome Agreements ( SOAs). Within SOAs, there are currently a range of indicators and outcomes that in some way relate to the health inequalities agenda. What we need to consider going forward is whether the current framework could be fine-tuned to allow for a more considered approach to tackling health inequalities.

• Council Leaders have approved the submission.

Purpose

1. The purpose of this report is to provide an input to the Joint Ministerial Task Force on the role of local government in contributing to the Health Inequalities agenda. It sets out the general policy context and explores some of the challenges attached to tackling the causes and consequences of health inequalities. It concludes by setting out a range of general principles that underpin the approach of local government to achieving a sustainable, mainstreamed and strategic approach to health inequalities.

Policy Context

2. The Scottish Government's Joint Ministerial Task Force on Health Inequalities was established with the primary aim of agreeing priorities for cross-cutting government activity that will achieve measurable outcomes in reducing health inequalities. Work to date has highlighted a number of key priorities:

• 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.

The Task Force has adopted a thematic approach to the health inequalities issue, to ensure that work is progressed across the breadth of national policy. A similar discussion has been taken forward within the local government community. From our position, we feel that in tackling health inequalities we need to give consideration to two fundamental issues:

• How do we tackle the causes of health inequalities?

• How do we respond to the consequences of health inequalities?

Tackling the Causes of Health Inequalities

3. Evidence provided to the Task Force by the Scottish Government's Chief Medical Officer suggests that a psycho-social-biological model can explain the causes of health inequalities. While poverty, smoking and poor diet impact on health inequalities, it is the physical, emotional and mental development of a child's early years that has the greatest impact. It has been established that there is a strong relationship between deprivation, chaotic social circumstances, the body's hormonal response to stress and the subsequent risk of ill health. In other words, the end result for an adult who has had to cope with a chaotic environment as a child may be an increased risk of developing heart disease, having a stroke and/or a variety of other common illnesses; he or she is also more likely to have had their schooling disrupted and to have demonstrated offending behaviour. The implication, then, is that in order to tackle health inequalities, we need to develop a sophisticated approach to early intervention and to identifying children living in chaotic circumstances.

4. For this reason, it will be important for the Scottish Government and COSLA to work together to develop the proposed Early Years Strategy. We need to become more successful at providing services to children and parents who are hardest to reach, in order to ensure that the physical, emotional and mental well-being of the child is nurtured and protected. There are four key aims which should govern this work:

• Building parenting capacity and skills pre and post birth.

• The creation of communities which support the positive development of young children.

• The delivery of integrated services which meet the needs of children and families.

• The development of a suitable workforce to support early intervention.

5. The aspirations of the early years strategy and work on health inequalities will be underpinned by reform and culture change in children's services across the public sector, in line with the Getting it Right for Every Child agenda.

6. The Early Years Strategy will provide opportunity and challenge. Opportunity is presented insofar as effective implementation will allow us to become much more effective at crisis prevention, thus having to devote less resource to crisis management. We will also become more successful at providing services to children and parents who are hardest to reach.

7. Yet, this represents a significant challenge for local government. To a large extent our statutory services are designed to manage crises when they happen - this is a necessary consequence of our statutory obligation to protect the well-being of children. Indeed, there will be occasions where the state needs to respond to negligent parents by taking the child out of the family environment and into formal care, with the local authority acting as the corporate parent. It is important that an interventionist option continues to be available to local authorities in order to protect the future well-being of children.

8. However, if we want to make an impact on health inequalities, we need to ensure that there is a more concerted effort to deliver pro-active services and that intervention is targeted at high risk families. Evidence suggests that child-focused, goal-directed, well-structured interventions have the best outcomes. This might involve developing intensive support mechanisms for high-risk families until the child reaches school age. Wrap-around provision, were it available, would undoubtedly create a service option that could help to reduce the impact of chaotic environment in the early years.

9. As part of this targeted approach, more sophisticated information sharing arrangements need to be developed between local authorities and community planning partners. It is not enough to identify a geographical area with multiple deprivation and expect service provision to reach the most vulnerable. Rather, activity has to be driven specifically at those individuals and families who experience multiple deprivation and ensure that services are tailored to their needs. This might mean an even closer working relationship between statutory services delivered by health boards, local authorities, and police authorities.

10. Yet, it has proved to be extremely difficult to target the appropriate client group, to reach those families who are furthest from the labour market, who are suspicious of statutory services and who often experience multiple social problems. A good example of this is Sure Start Scotland. It is delivered through local authorities and their community planning partners and costs around £60m per year. It funds a range of projects including family centres, parenting programmes, early entry to pre-school and a range of other support for young children with a focus on integrated multi-agency approaches. One of the major challenges faced by Sure Start has been engaging the hardest to reach and most disadvantaged members of the community. Consequently, there is evidence to suggest that the programme's impact has been quite limited, with some of the most vulnerable families actually finding themselves relatively worse off: Sure Start may have supported those with a moderate level of need, but has often failed to reach those with the greatest level of need.

11. It is evident, then, that we have an extremely challenging agenda: we are beginning to understand more clearly the causes of health inequalities, but we have a poorer understanding of what works in tackling the causes of those inequalities. It will be important for both spheres of Government to address this issue as a matter of urgency. Potential responses to the problem are expressed in more detail later in this paper.

Responding to the Consequences of Health Inequalities

12. In addition to developing intervention aimed at tackling the causes of health inequalities, we also need to consider how best we should respond to the manifestation of those inequalities. In other words, a significant proportion of the population will already have lived through the chaotic early years that give rise to vulnerabilities to ill health.

13. Most of the major drivers of the distribution of health in the population are influenced by the services and activities that councils provide or promote. The basic skills, behaviours and attitudes which are necessary to support a healthy and productive life are in part shaped by the social and civic opportunities engendered by local government activity.

Education

14. Education is often seen as a key entry point for reducing social and health inequalities. It provides literacy, numeracy, and communication skills, all of which increase people's employability and general well-being. It has the potential to combat broader social problems, to prevent children and teenagers falling into crime and violence. The Task Force has heard of the damage caused by drug and alcohol problems and the related problem of violence that affects younger men in particular. Education provides an opportunity to address these issues.

15. Within education, much of our work to date has focused on health promotion. The health promoting schools initiative has helped integrate health promotion within the curriculum and school improvement plans, to the extent that health promotion is a now mainstream part of school activity.

16. Local authorities have also made great stride towards providing pupils with healthy, nutritious school meals and other snacks. The Hungry for Success programme revolutionised school meal nutrition in Scotland. The more recent Schools (Health Improvement and Nutrition) (Scotland) Act 2007 has put school nutrition and health promotion on a more formal footing. However, it is clear that more work is needed to convince pupils of the benefits of a nutritious school meal - especially in secondary schools. This was demonstrated in the findings of a recent HMIE report Hungry for Success.

17. Education, from pre-school to adult and community learning, will remain a powerful way of influencing attitudes to health and nutrition. The challenge will be to ensure that the ongoing work fits within the early intervention agenda and genuinely tackles health inequalities. We must work to ensure that the whole community benefits from health education.

Employment and Worklessness

18. Employment provides access to health promoting resources such as housing, heating, and diet. Vibrant local economies provide diverse local employment opportunities. The reform of the enterprise network and the transfer of the Business Gateway and regeneration functions to Local Government will enable local authorities to develop more integrated business start up services to actively promote and assist in the creation of new businesses in local areas, which in turn will create job opportunities. The creation of employment in local areas particularly afflicted by deprivation will provide opportunities for disadvantaged people to acquire income and therefore other health promoting resources.

19. By taking on the regeneration function of Scottish Enterprise, councils will take the lead on enhancing the capacity of local areas to assist in retaining and attracting employment. In addition, local authorities will have the responsibility to lead on a variety of local regeneration initiatives which seek to solve both social and economic problems by regenerating areas which suffer from poverty and health inequalities.

20. Indeed, this highlights another area of local government activity: ameliorating worklessness. There is a recognition that employability services are necessary in order to provide the most vulnerable families with the skills to function autonomously in the labour market. The health of long-term unemployed people is significantly worse than it is for people in employment. However, the pathway to employment for the most disadvantaged groups remains long and arduous. Local government has been working with key partners to ensure that that pathway becomes easier to navigate. This might involve offering effective, reliable, local and affordable childcare to lone parents with a desire to enter employment; or it might mean ensuring that people with physical and learning disabilities are provided with appropriate routes into the labour marker; or it might involve the facilitation or procurement of training opportunities. Whatever services are provided, local authorities continue to recognise the value of partnership working. It is recognised that a sophisticated approach to tackling worklessness means the development of a holistic approach that combines anti-poverty measures and social opportunity. It is also about offering specific advice and resources to help people overcome financial exclusion, fuel poverty and benefits issues.

The Physical Preconditions of Health

21. The physical conditions in which individuals live have a big impact on their health. The most immediate causes of inequalities in health are specific exposures such as damp housing, hazardous neighbourhood settings (including acts of violence), or exposure to air pollution.

22. Links can be made to health inequalities in several areas of environmental policy. Access to green-space and outdoor leisure pursuits - which can contribute to well being and promote physical activity - can be a function of both income and geography. Sustainable and active methods of transport which promote both environmental and health goals are promoted by access to services and facilities such as cycle paths. Other issues which link these policy areas include air quality and the ability of different geographic areas to cope with adaptation to climate change. All of these matters are actively being addressed by local government.

23. Quality housing is also necessary for good mental and physical health. Councils are committed to the delivery of quality, affordable, accessible and sustainable housing across all tenures. The demand for affordable housing currently outstrips supply. Through the Ministerial Housing Supply Task Force, which focuses on the barriers to house building (e.g. lack of infrastructure), COSLA aims to increase the numbers of houses being built in areas experiencing specific housing pressures. Maintaining and improving housing stock reduces health inequalities by improving individuals' physical environment and reducing fuel poverty. Local authorities have set out in their Standard Delivery Plans how they will meet the 2015 Scottish Housing Quality Standard target.

24. Moreover, COSLA and the Scottish Government are working in partnership with other stakeholders to meet the challenging 2012 homelessness target. Homeless pregnant women and families with children are already identified in legislation as a priority group in need of appropriate housing. Local authorities are working hard to tackle homelessness through early intervention and prevention measures, and by offering appropriate accommodation to support homeless people.

25. In working towards its commitment to delivering quality, affordable, accessible and sustainable housing across all tenures, COSLA also recognises that an improving physical environment needs to be complemented with an improving social environment. More green spaces and a reduction in crime and anti-social behaviour are key ambitions of local government, thereby improving community safety and individuals' mental health and wellbeing.

Policy Commitments

26. As noted above, most of the major drivers of the distribution of health in the population are influenced by the services and activities that Councils provide or promote: education, social work, housing, economic regeneration and community safety all impact on the health inequalities agenda.

27. At this stage, COSLA's proposed commitment to the health inequalities agenda is based on a long-term approach aimed at achieving a sustainable, mainstreamed and strategic approach to health inequalities. To that end, we have identified the following key principles:

• Universal service provision tailored to individual need.

• Effective early intervention.

• Shared learning to help us to understand what works in tackling health inequalities.

• A strategic approach to partnership working through Single Outcome Agreements.

• A longer-term twin-track approach to resourcing change.

Universal service provision tailored to individual need

28. Some of the key services that lie at the heart of reducing health inequalities - social work, economic development, education - are areas in which local government has significant expertise. To a large extent these services are provided on a universal basis, e.g. all children receive an education. In other areas, local government services are targeted at certain sections of the community: e.g. anti-poverty measures, or social housing. With respect to health inequalities, the evidence base suggests that we have to focus on those members of the community who are most likely to become vulnerable to ill health. In other words, we need to mould universal service provision to individual need. A key implication of this is that it is not enough to identify a geographical area with multiple deprivation and expect service provision to reach the most vulnerable. Rather, activity has to be driven specifically at those individuals and families who experience multiple deprivation and ensure that services are tailored to their needs.

Effective Early Intervention

29. If we want to make an impact on health inequalities, we need to ensure that there is a more concerted effort to deliver pro-active services e.g. health promoting schools, or oral health provision at the pre-school stage. Particular emphasis should be placed on the importance of intervention during the early years, since it is during this stage of our development that our health and mortality are largely determined. This creates a hugely challenging agenda for local government. We need to become more successful at providing services to children and parents who are hardest to reach, in order to ensure that the physical, emotional and mental well-being of the child is nurtured and protected. To this end, the Early Years Strategy will be of vital importance in tackling health inequalities.

Shared learning to help us understand what works in tackling health inequalities

30. To tackle health inequalities effectively, our Community Planning Partnerships and Community Health Partnerships will need to be signed up to delivering on the health inequalities agenda. Councils will therefore need to work even more closely with partners to provide disadvantaged groups with faster access to better and more joined-up services.

31. The current evidence base suggests that child-focused, goal-directed, well-structured interventions have the best outcomes. To this end, we need to ensure that practitioners are informed by the emerging evidence base when developing services designed to tackle health inequalities. However, while we are becoming clearer about the social and biological causes of health inequalities, we know less about what effective intervention looks like. As such, there is a need to adopt a developmental approach to the problem, which allows practitioners to learn from each other.

32. Another way of expressing this may be through a continuous improvement approach, which is based on three broad principles: a holistic examination of process and results to generate best practice; a systematic consideration of the whole process in order to avoid unintended consequences elsewhere; and a learning approach that allows for the re-examination of the assumptions that underpin practice.

33. To this end, it is suggested that knowledge sharing networks should be established to ensure that practitioners have the tools, skills and resources to make an impact on health inequalities. We need to develop an evidence based approach by creating networks that help us to understand what works in tackling health inequalities. Clearly, we will need to draw upon existing structures and processes. Yet, that is not to say we cannot add value to current arrangements. Indeed, we would hope to work with the Scottish Government and other key partners to ensure that a physical resource - in the form of a team of officers - is made available to support this process. Ultimately, we want to develop a process that provides community planning partnerships with the knowledge, skills and capacities to tackle health inequalities.

A strategic approach to partnership working through Single Outcome Agreements

34. In order to make a real impact on the health inequalities agenda, we need to obtain strategic and political buy-in. The primary vehicle for delivering change at the strategic level will be Single Outcome Agreements ( SOAs). It is the longer term intention of the new outcomes framework that the whole public sector is held to account by a common set of objectives.

35. One of the benefits of addressing health inequalities in this manner is that we can also simultaneously address other challenges: if we manage to achieve measurable outcomes in reducing health inequalities, we will probably also have improved outcomes on educational attainment, poverty reduction, community safety and so on.

36.SOAs will ultimately create an environment for more effective strategic decision making at the community planning partnership level. There will be a need for the community planning partners to develop more integrated corporate plans, thereby cementing agreed priorities. This should also allow resources to be channelled to these strategic priorities.

37. Within SOAs, there are currently a range of indicators and outcomes that in some way relate to the health inequalities agenda. What we need to consider going forward is whether the current framework could be fine-tuned to allow for a more considered approach to tackling health inequalities. This is not a short-term consideration; this will need to be assessed after SOAs bed-in. Neither will it just be for councils to reflect on this: the Scottish Government must also consider the profile it wants to attach to health inequalities.

A longer-term twin-track approach to resourcing change

38. The policy commitments outlined above come with a cost. In the short-term, councils and community planning partners would be looking for some financial support to develop some of the suggested activity. In particular, we would be interested in exploring whether we could secure central funding for a continuous improvement approach to health inequalities and to evaluate the success of intervention.

39. This by itself, however, may not deliver the change we need to see. To address health inequalities it is likely that public sector resources will have to focus on early intervention and prevention, and as part of that develop a more anticipatory and proactive approach to working with disadvantaged groups. If we do not do this, we will merely be falling back on a strategy that addresses the manifestations of disadvantage rather than tackling the source of disadvantage. Consequently, nothing will change: poverty and other social inequalities will continue to place vulnerable families at risk. However, while there is a strong rationale to move service design away from reactive services, this is a high risk strategy for councils: if priority resources flow away from crisis management, the capacity to respond to vulnerable families will be reduced. The alternative is to take a long-term twin-track approach to resourcing change: we need to invest both in our capacity to respond to crises and in our capacity to stop crises happening in the first place. While recognising the limited scope for manoeuvre during the current spending cycle, it may be flagged up as a strategic priority that warrants consideration going into future spending reviews.

Conclusion

40. Health inequalities are widening and urgently need to be addressed. Emerging evidence about the causes of health inequalities allows us to alter this trend. Effective early intervention, strategic and political leadership, continuous improvement and a longer-term resourcing strategy are all important factors in tackling the problem. Local government is determined to add value to this agenda: going forward, we want to establish agreed priorities for cross-cutting government activity that will achieve measurable outcomes in reducing health inequalities.

March 2008