Scottish Government

9. HEALTHIER SCOTLAND

ACTION TO REDUCE HEALTH INEQUALITIES

Introduction

1. This paper sets out information to enable the Task Force to contribute to the Scottish Government's action plan on health and wellbeing, Better Health, Better Care.

Better Health, Better Care

2. The Better Health, Better Care discussion document published in August 2007 invited views, from the NHS and wider interests, on priorities for health and wellbeing in Scotland. Ministers are committed to publishing an action plan by the end of the year. This included a timetable for action for NHSScotland at national, regional and local level, as well as a series of commitments from key delivery partners.

3. Better Health, Better Care set out the themes required to deliver the Government's strategic vision for health and wellbeing:

• Improving patients' experience of care.

• Securing best value.

• Encouraging people to take responsibility for their own health and wellbeing and prevent health problems arising wherever possible.

• Focussing on tackling health inequalities.

• Providing anticipatory care and improving services for long term conditions.

• Giving children the best possible start in life.

• Ensuring continuous improvement in services.

Current health action

4. This may be identified as:

• Improving access to NHS services.

• Improving health and preventing illness.

• Contributing to improvements in the wider factors underlying health inequalities.

5. Action to improve access to NHS services currently includes:

5.1 Targeting of health care support to families with very young children through Hall 4 changes.

5.2 Increasing the number of dental students graduating in Scotland, providing the students with bursaries on the understanding that they continue practising in the NHS in Scotland after qualification, providing incentives to encourage practitioners to set up practices in Scotland and to encourage existing practitioners to extend practices. There has also been increased numbers of dental therapists being trained and in October 2008 the new Aberdeen dental school is due to open

5.3 Some targeting of resources and other specific initiatives in primary care: details at Annex A.

5.4 Keep Well programme of health checks for people aged 45-64 living in the most deprived areas and at risk of cardiovascular disease.

5.5 A number of equality and diversity activities including the Fair for All approaches. Background at Annex B.

5.6 Unmet needs pilot projects in Greater Glasgow and Clyde and Tayside. The aim of the pilots was to provide evidence as to whether supplying increased resources to Health Boards with deprived areas would lead to an improvement in access to NHS services in these areas.

6. Action to improve health and prevent illness is often shared between the NHS and other organisations. In particular, many local authorities have health improvement staff and there is joint working under community planning arrangements to produce structured joint health improvement plans. Preventive activity to reduce health inequalities includes:

6.1 Targeted improvements to children's dental health by extending the Childsmile programme and by introducing a preventative based school dental service.

Extensive tooth brushing programmes in nursery and primary schools.

6.2 Smoking cessation targeted at specific groups such as pregnant women, people with mental health problems and minority ethnic communities.

6.3 Following the smoking ban, new action to prevent young people smoking, e.g. restrictions on sales.

6.4 Strengthening community-led health initiatives through building their capacity to operate effectively and for funders and services to work better together towards shared outcomes.

6.5 In the food and health fields specifically, promoting access to and availability of healthy food in deprived communities through the umbrella body Community Food and Health Scotland.

6.6 Activities of the current National Programme for Improving Mental Health and Wellbeing.

6.7 Other targeted approaches within national and local health improvement strategies, e.g. for young people's sexual health.

6.8 Rolling out the new Healthy Start scheme, formerly the Welfare Foods programme. This now includes providing fruit and vegetables to low income families, as well as milk and vitamins.

6.9 Action to improve the health of particularly vulnerable groups of people, such as looked after children, people at risk of homelessness, prisoners and ex-offenders.

7. The NHS contributes indirectly to improvements in the wider factors determining health inequalities through:

7.1 Support for families, including 1:1 parenting and peer group support as well as structured parenting programmes such as Triple P in Glasgow.

7.2 Providing vocational rehabilitation and condition management programmes to improve people's health with a view to retaining or re-entering employment.

7.3 As a local investor in deprived communities, through employing people from marginalised groups and potentially through local purchasing of goods and services.

7.4 Investment in Patient Focus and Public Involvement in the NHS, as well as in voluntary and community sector services, all of which help to build the capacity of individuals and communities to make changes in their lives.

What is effective in reducing health inequalities?

8. Sustained and targeted support for parents in children's very early years has been shown to be effective in the medium and long term in improving health and other outcomes for children.

9. Sally Macintyre's paper for the Task Forceidentified that health promotion and social marketing aimed at the whole population have in the past widened health inequalities. To be effective, these activities need to focus much more specifically and intensively on the needs of individuals and on their wellbeing and life circumstances. There are examples of effective health improvement activities in deprived communities eg the Royston Stress Centre in Glasgow, which uses a holistic approach to smoking cessation. Statutory and regulatory approaches can also be effective, in improving the whole population's health and ensuring people most at risk of poor health outcomes are included.

10. Anticipatory care, aimed at preventable deterioration of health, has been shown to work in primary care. It is too soon to tell, however, whether the Keep Well programme will be able to engage people most at risk, support them to sustain improvement and result in better health outcomes. Introducing health checks for everyone at age 40 (a manifesto commitment) will need to be managed carefully, so as not to widen inequalities, through reaching only the better off.

11. The Fair for All approach has been effective in embedding equalities across policy and planning in NHSScotland. There are now tailored guidance, support and lead officer networks to drive programmes of work forward. Specific programmes include equality impact assessment, translation and interpretation, training and education and community engagement. Leadership has been vital in prioritising this agenda. The proposed 'single system' approach (Annex B) will assess the effectiveness of these approaches across the design, development and delivery of Cancer services across NHSScotland. Further work is needed on equality impact assessment, patient monitoring and evidencing impact.

Gaps and recommendations for further action

12.1 The NHS should make a key contribution to children's early years, through working with other agencies and communities to deliver intensive and highly targeted interventions. Critically, these activities should support families with aspects of positive parenting such as good maternal and infant nutrition. [Support should follow through in implementing the manifesto commitments on school nursing, starting with the most deprived areas]. There will be an opportunity to discuss in more detail at the Task Force's 5 December 2007 meeting on the Smarter theme.

12.2 There should be more emphasis on addressing inequalities in health through primary care. One possible route is Government funding for enhanced services over and above the main General Medical Services ( GMS) allocations. NHS Boards should be allowed to tailor enhanced services to local needs, but where approaches are found to be particularly effective, they should be scaled up and replicated more widely. Boards already have, as part of their GMS allocation, funds to invest in enhanced services, some national and mandatory but many locally developed according to local need. The Scottish Enhanced Services Programme ( SESP) currently being rolled out adds to this funding and allows Boards, with the help of Community Health Partnerships ( CHP)to select services from a national list of priority areas in order to best address local needs. Boards should ensure their use of these sources of funding reflects the need to reduce health inequalities.

12.3 Other contractual mechanisms to target available primary care resources towards areas of greater need should be maximised, avoiding duplication and inefficiency. For example, there are opportunities to further enhance the new community pharmacy contract, in particular the Public Health Service element, to address health inequality issues and provide a wider range of services such as supporting Healthy Start and providing smoking cessation support. Aspects of GMS funding which may inadvertently reinforce rather than reduce inequalities should be identified and addressed to minimise these effects.

12.4 The Keep Well programme should be maintained, with particular emphasis on engaging the hardest to reach people and finding out what works to sustain their involvement in activities reducing their risks of preventable ill health eg healthy weight management, improving mental wellbeing. The commitment to health checks for all at age 40 should be implemented in such a way that it avoids widening health inequalities.

12.5 New anticipatory care approaches should be sought, for example to reduce risks from alcohol to the health of young people, to improve the physical health of people with mental illness or a learning disability, and to support early intervention and rehabilitation for those with disabilities, multiple long term conditions and complex needs.

12.6 Effective approaches to reaching and engaging the most vulnerable groups of people in improving their health should be identified and scaled up. For example, the current multiple and complex needs projects (see Annex B), adult literacy projects in the NHS and assessments of the health of looked after children.

12.7 The Government should invest in improving the capacity of the voluntary and community sector to reduce health inequalities, most importantly, encouraging commissioners and funders and the sector to work better together, based on an understanding of shared priorities and outcomes to be achieved.

12.8 National and local action to follow the current National Programme for Improving Mental Health and Wellbeing should focus particularly on effective action to reduce inequalities in wellbeing and support recovery from mental illness. For example, improving "mental health literacy" of staff in the NHS and other key agencies involved in people's lives eg education, housing.

12.9 There should be more effective replication and scaling up of effective health improvement action, e.g. in smoking cessation. Current encouragement eg via learning networks is not sufficient to ensure that good practice happens everywhere. Techniques such as the collaborative approach and benchmarking good practice should be introduced to health improvement, to drive and manage change.

12.10 New health improvement activities, such as implementing the manifesto commitment to provide free fruit and vegetables for pregnant women and pre-school children, should focus primarily on reaching the most vulnerable groups in the population, without implying stigma or a judgmental approach.

12.11 All NHS Boards should operate pre-employment programmes to encourage the recruitment of people from hard to reach groups into the NHS, building on the current Work Foundation Study to establish the business case for such programmes. There should be more consistent action by Boards to maintain and improve the health of their own staff.

12.12NHS Boards should implement fully the recommendations of the Framework for Adult Rehabilitation, including for vocational rehabilitation. They should also adopt existing good practice amongst NHS Boards and CHPs in working with employability services to enable people to retain or return to work.

12.13NHS Boards, through CHPs in particular, need to contribute more systematically to joint activity across community planning partners, to reduce health inequalities.

12.14 There should be a systematic process for assessing the impact on health inequalities of new (and also existing) health policies and programmes, at both national and Health Board level.

12.15 Similarly, there should be more systematic assessment of the impact of other public policies and programmes, e.g. transport, planning, on health and on reducing health inequalities.

12.16 Resources targeting health inequalities and the most deprived areas should be protected at national and local levels. Resources should be scaled up where a business case can be made. There should be proper impact assessment and studies of the cost-effectiveness of current and new prevention and health improvement activity aimed at reducing inequalities.

12.17 Extension of childsmile programmes to areas not already covered and special provision for people with special needs.

Measuring success

13. Targets have been set for some time for the NHS to reduce health inequalities. These relate to improving the health of the most deprived communities by 2008 in relation to coronary heart disease, cancer, adult smoking, smoking during pregnancy, teenage pregnancy and suicides in young people.

14. These NHS targets are criticised, because achieving them does not depend only, or even mainly, on activity by the NHS. Public Health and Wellbeing Directorate and NHS Health Scotland are currently reviewing how performance is managed across the whole system of agencies involved in improving health and reducing health inequalities. This includes identifying shared priority outcomes and subsequently indicators of success appropriate to the activities of the NHS and its delivery partners. The review provides more detailed back-up to the Government's aim to identify national outcomes and strengthen public reporting on progress towards these.

Delivery and Workforce implications

15. The recommendations above for action have clear implications for deployment, roles and skills of NHS staff: GPs, nursing staff and others.

16. Recommendations also require a step change in health promotion and prevention. NHS Health Scotland and NHS Education Scotland have some programmes in place to support the public health workforce engaged in this. NHS Health Scotland is also setting up a new Directorate of Equalities and Planning by 2008 and this will help to integrate Fair for All activity into health improvement efforts to reduce inequalities.

17. Progress will be reported to the Task Force on improving workforce capacity and also on possible reform of the way the public health effort is managed, in order to make a greater impact on improving health and reducing inequalities.

18. A more concerted effort is required to make reducing health inequalities central to NHS Boards' planning and priorities. Achieving this centrality is patchy at the moment. The accountability process, including Boards' Annual Reviews, needs to focus more on whether Boards are successfully reducing inequalities in their area.

November 2007

ANNEX A PRIMARY CARE ACTIVITIES TARGETING HEALTH INEQUALITIES

Primary Medical Services

• Funding that is allocated to Boards to support the GMS contract, is calculated by a range of factors including age of population; rurality; deprivation; and gender. The Scottish Enhanced Services Programme is further weighted to reflect the age and levels of deprivation within the local community.

• GP practices are encouraged to provide the highest possible quality of services to their local community. The Quality Outcome Framework ( QOF) (focusing on clinical, organisational and patient experience targets) was introduced with the new GMS contract. The QOF rewards GP practices where quality of care is high. Recent data suggest that GPs across Scotland have achieved very high standards in all areas of the QOF, including such important areas such as mental health and coronary heart disease.

• Boards are still able to issue one off Golden Hello payments to GPs who decide to take up their first post in Scotland. The standard payment for a full time GP is £5000. Additional payments are also made to those individuals who take up this post in a remote, rural or the most deprived areas (an additional £5000 for remote and rural areas; and up to £7,500 for the most deprived areas).

• The Scottish Enhanced Services Programme for Primary and Community Care ( SESP) currently being rolled out allows Boards to select services from a national list of priority areas in order to best address local needs. These priorities include services for adults with learning disabilities and for carers, addressing unmet need for instance in hazardous and harmful drinking patterns and preventing falls, better community services for patients with diabetes and COPD, and flexible appointment systems to improve access.

NHS Dental Services

• Free NHS dental examinations for all.

• Grants available under the Scottish Dental Access Initiative for those dentists wishing to establish new or expand existing NHS dental practices in areas of high oral health need.

• The Childsmile West Programme promotes oral health from birth and targets families with young children who live in the more deprived communities across the West of Scotland.

• Those in receipt of certain DWP benefits/credits or on low income receive free NHS dental treatment and NHS optical vouchers towards the cost of glasses/contact lenses. Others may be entitled to help with the cost under the NHS Low Income Scheme.

• A deprived areas allowance for those dentists providing NHS general dental services in disadvantaged areas. There is also an enhanced capitation fee, patient registration fee, on a sliding scale depending on the area of deprivation.

• A remote areas allowance to recognise those dentists who provide NHS general dental services in sparsely populated areas.

• The Community Dental Service provides NHS dentistry to special needs patients.

Community Pharmacy

• Introduction of a new community pharmacy contract which consists of four core services provided by all community pharmacy contractors which ensures equitable access, including in areas of greater need. In particular:

• A Public Health Service through which pharmacists and their staff support self care and promote healthy life styles.

• A Minor Ailment Service which allows patients exempt from prescription charges to register with the community pharmacy of their choice and have any presenting common conditions or minor ailments, where appropriate, treated by their pharmacist on the NHS without the need for them to visit their GP.

• A Chronic Medication Service which engages community pharmacists in the management of individual patients with long term conditions through improving their understanding of their medicines and working with them to maximise the clinical outcomes from their therapy as well as promoting greater joint working between pharmacists and GPs.

• Community pharmacists currently provide a range of additional (locally negotiated) services which can include substance misuse services, smoking cessation and sexual health services such as Chlamydia testing and treatment and access to emergency hormonal contraception. Work is ongoing to standardise these services and to ensure that they are available in every NHS Board to reflect the needs of that area.

• The introduction of pharmacist prescribing is improving access to services for patients across a wide range of clinical areas. To date there are around 500 qualified pharmacist prescribers and around 100 pharmacist prescribing clinics are funded.

• NHS Boards are working to develop pharmaceutical care services plans which will identify gaps and future service provision needs.

Eyecare

• Free NHS eye examination for all, which allows patients to receive, free of charge, an appropriate health assessment of their whole visual system.

• Those in receipt of certain DWP benefits/credits or on low income receive NHS optical vouchers towards the cost of glasses/contact lenses. Others may be entitled to help with the cost under the NHS Low Income Scheme.

• Review of eyecare services in the community in Scotland the aim of which was to encourage the development of integrated eyecare services to ensure patients receive a good quality and efficient service, in a convenient setting without undue wait. This also covered a review of certification and registration of the blind and partially sighted in Scotland.

Nursing in the Community

• Development of a generic community health nurse model based on preventative and anticipatory care that identifies the needs of the most vulnerable and deprived people in our communities. Model is being tested in four NHS Boards until 2009.

• Development of a strategy for nurse and AHP prescribing which promotes the benefits of non medical prescribing to patients, e.g. better access to medicine when required.

Out of Hours Primary Care Services

• The Out of Hours Strategy Group - made up of representatives from NHS Boards, NHSQIS, NES, and NHS 24 - is developing a strategy for future sustainable models of out of hours primary care services. A key objective of this strategy is to address issues of equity that can be a particular issue for rural areas. The Group is expected to report before the end of the year and to provide guidance on how to redesign services to reflect a multi-disciplinary approach with extended role development for nursing staff and other health care professionals. The guidance is also expected to promote existing good practice in rural locations, models that are both sustainable and cost effective in the long-term, but continue to set high standards of patient care and which are measurable.

ANNEX B EQUALITY, DIVERSITY AND HEALTH INEQUALITIES

• Sources of inequality in health are broad ranging, but it is clear that a holistic description would include; life circumstances, e.g. socio-economic status; access issues, e.g. physical access, literacy, and; diversity (including the impact of prejudice and discrimination), e.g. race, sexual orientation.

• A growing raft of equalities legislation puts the responsibility firmly on institutions to demonstrate that they are tackling discrimination and promoting equity of access and opportunity for all. A major focus of recent investigations by the existing equality Commissions has been the NHS, given the very personal nature of health services. A recent formal investigation by the Disability Rights Commission for example, identified institutional barriers to essential health screening for people with learning difficulties and people with mental health problems.

• Part of SEHD's Patient Focus Public Involvement, the Fair for All agenda aims to ensure that 'whatever the individual circumstances of people's lives, including age, gender, ethnicity, disability, religion, sexual orientation, mental health, economic or other circumstances, they have access to the right health services for their needs'. Fair for All initiatives on Age, Disability, Race, Gender, Sexual Orientation & Religion / Belief have produced a range of tools and guidance to help tackle health inequalities. Such examples include: Achieving Fair, Gender Health Guidance, Good LGBT practice in the NHS and Checking for Change.

• The Multiple and Complex Needs initiative (Social Inclusion / Equality Unit) aims to improve public services for those with multiple and complex needs who may find it particularly difficult to access services and/or to maximise their own benefit from them. £4 million is being made available over two years from the Executive's Closing the Opportunity Gap Fund to a range of projects, many in the NHS, to improve the way in which they engage with service users and attract them to use their services, how they assess and deal with their particular set of service needs/problems and how they improve service outcomes for them.

• SE Patients & Quality are developing a "single system" approach which will assess all stages of the delivery of a clinical service from the policy and workforce stages in SE Health and Wellbeing to the primary, secondary and tertiary services that provide the direct patient care. This programme will start in 2007 with 'Delivering Cancer Services that are Fair for All' and will link closely with the new national Patient Experience programme.

• SE Patients & Quality have developed 'the Equality and Diversity Impact Assessment Toolkit' to assist managers within the Scottish Executive Health Directorates and Scotland's NHS Boards systematically review their policies and functions in order to meet the needs of all communities.

• The Equality & Diversity Information Project ( NHSNSS)has now been in place for 3 years and aims to collect standard routine dataset information for patients, to enable us to record progress on equalities.

• A Diversity Task Force ( DTF), chaired by a NHSCEO aims to provide the internal assurance that NHS Boards are delivering on their legal and policy requirements and reports on progress to the Chief Executive of NHSScotland.

• The National Strategy and Action Plan on Race Equality is being re-drafted at present, and will be issued for consultation in the autumn. It will then be re-drafted again in the light of the consultation and a final version should be ready for publication early in the New Year.

ACTIONS TO IMPROVE OFFENDERS' HEALTH

Purpose

1. To provide information for the Task Force on the health and other needs of prisoners.

Background

2. The Government is committed to a cross-cutting approach to reduce health inequalities, both as an important public health end in itself, and as a route towards creating a more successful country with opportunities for all of Scotland to flourish. Consideration to the health of offenders and ex-offenders has an important place in the delivery of a fairer, more equitable society.

3. The key inequalities identified for (and accepted by) the Task Force are:

• early years.

• mental illness and wellbeing.

• drugs/alcohol/violence.

• the 'big three' killers and their associated risk factors.

4. The approaches to be implemented will involve:

• Redesign of public services.

• Focus on very early years and support for families.

• Building resilience and promoting wellbeing.

• Reducing the prevalence of, and exposure to, environments (physical and social) that perpetuate health inequalities.

• Attention to delivery (includes leadership, workforce development, continuous improvement methodologies, strong partnerships).

5. Improving the health of offenders has been identified as an area in which the Task Force would like to consider specific actions. This is a population group in which the inequalities identified above are particularly prevalent - 80% being cigarette smokers; a similar % having a drug problem; two thirds reportedly having personality disorders and 70% or more having a mental health issue sufficient to require clinical support. It is also a group for which all of the approaches just mentioned are not only relevant but particularly appropriate.

6. In addition, the needs of two particular sub-groups should be highlighted. First, women prisoners, who comprise only 5% of the prison population but have exceptionally high levels of health need. Recent figures show, for example, that 98% of the women in Cornton Vale have addiction problems, 80% have mental health problems, 70% have been abused and around 50% self harm. The range of offences and sentences is wide - in February 2008 28% of current sentenced Cornton Vale inmates were in for 4 years or more, 74% in for 1 year or more, and only 28 prisoners had sentences of under 6 months. But many women do not pose a risk to the public and overwhelmingly these women are in need of protection themselves, as well as requiring treatment for mental illness, abuse and/or addictions. Many are carers, and their imprisonment may increase the vulnerability of those for whom they have a caring responsibility. In short, this is a highly vulnerable group in need of care, support and protection.

7. The second sub-group are those with learning difficulties, who comprise about a quarter of the prison population and an unknown percentage of those receiving community penalties. Their learning difficulties are often both at the root of their offending, and create a barrier to receiving effective support and service responses. Proposals for actions to support both of these sub-groups are included in the recommendations that follow.

General approach and potential benefits

8. The links between offending behaviour and poor health (addictions and mental health problems in particular) are well documented, and are recognised as being multi-factorial and multi-directional. Actions therefore need to assume no 'magic bullet' but instead recognise that there is a complex system at play. Offenders are not a homogenous group and recognition also needs to be made of the fact that in recent years a greater number of offenders have received a community sentence rather than custodial term.

9. A linked point is that neither offending behaviour nor poor health/health-related behaviour is simply an individual choice. Both reflect family circumstances, social, economic, cultural and environmental factors, and are concentrated within the same communities in Scotland. Efforts to improve health and reduce offending should include attention to these family, community and circumstantial factors as well as to individuals' motivations, lifeskills and health.

10. A related point is that investment made successfully in improving the health of offenders will bring benefits to their families and communities (who will also often have a high level of health need). Approximately 15,500 children in Scotland lose a parent to prison per year; 51% of men and women in prisons have dependent children. The health, social and educational prospects of these children are affected in turn by their parent's health. More widely, investment in continuity of care brings particular benefits to the local community from which an offender comes and to which - in most circumstance - he or she will return. Fear of crime is a major factor in undermining local residents' confidence in their community as a safe place to live. Reducing victimisation rates and perceptions of crime, and building up confidence in one's local community as a good place to live, are all further high level indicators for the Scottish Government success.

11. A great deal of work with offenders focuses on those who are furthest away from success and stability - people with compound problems and "chaotic lifestyles". We invest significant effort to improve their outcomes, and must do so if we are to ensure that economic growth - the Government's prime aim - is not divisive. A key goal for the Government is increasing active and positive participation in building the economy and work with offenders focuses on making it more likely that they will be able to contribute positively in future. That improves both solidarity and cohesion -two characteristics of economic growth that the Government wants to see

12. The health inequalities within Scotland are partly a consequence of the services currently being provided. As a minimum, we have to accept that our services are not currently effectively reducing the burdens of ill-health and vulnerability experienced by offenders, and concentrated within our poorer communities. This is not only an issue for the health services, but more widely across the public sector. It has implications for service redesign and improvement (draft Task Force report includes sections on these), and also for better "bridging" mechanisms between the more excluded members of society and mainstream services.

13. Service-redesign: It needs to be emphasised that the impacts of offending on Scottish society will not be turned around solely through criminogenic interventions. The securing of improvements to the care and wellbeing of offenders is a core strategy for the achievement of a safer, as well as a healthier, Scotland. A number of important developments are already being progressed to enhance the health impact of existing services. The prison health service is linked in to government funded initiatives on alcohol problems, Hepatitis C, the refreshed Drugs Strategy for Scotland, and strategies on sexual health, food and others. The existing six Offender Outcomes identified in the Performance Framework for Community Justice Authorities include a number that relate to improved circumstances in terms of housing and health interventions, as well as individual resilience and life skills. Proposals are currently being developed to pilot approaches to improve the condition of people with personality disorder. Furthermore, Better Health Better Care commits to reviewing NHS Scotland's approach to the health and healthcare of offenders and ex-offenders. This review is a key route to improving, and enhancing the reach, of health services for offenders. But it will be important to embed it in a wider programme of changes which secure long term improvement in the health of offenders by ensuring continuity of care through a custodial sentence and following discharge.

14. In this context the work of this Task Force will relate closely to the proposals in the emerging strategies on drugs and alcohol for vulnerable people, including offenders. Continuity of care for offenders, as the key to long term improvement, should be a key focus for us. We already fund the Throughcare Addiction Service ( TAS), which signposts those being treated for addiction problems in prison to addiction/health services available in the community, draws up a pre-release action plan and retains contact with the ex-prisoner following release. TAS does not, however, increase the volume of drug treatment services available and the time that it takes ex prisoners to access the services identified in their plans varies widely across Scotland. There is a resultant risk that the ex-prisoner will withdraw from contact with service providers or relapse into drug misuse. The situation across the health board areas has been assessed, and those with a particular problem identified.

15. Similar considerations apply to those serving community sentences in ensuring that there is ongoing access to services for those who need it at the end of the criminal justice intervention. For example, it is vital that those who successfully complete a Drug Treatment and Testing Order are able at the end of the sentence to make a seamless transition to mainstream service provision in ensuring that the offender's addiction issues continue to be addressed if the benefits gained during the order are not to be lost.

16. In relation to complementary approaches, there are some insights and positive findings emerging at a project level, for example from the Routes out of Prison project funded by the Multiple and Complex Needs pilots and the link worker pilot to support women offenders on community penalties, developed in light of the review of community penalties. Components of these projects that appear to be important include buddying/mentoring by people who have had experiences similar to those of the offenders; and the value of multi-professional outreach workers who are able to work across different sectors and act as an advocate for offenders and their families.

17. It is recommended that these emerging findings form the basis for an specific Inspiring Scotland funded programme. Particular foci for which there would be a sound basis would be a project to ensure that every women offender coming out of prison/on a community sentence was offered peer support starting during the sentence and continuing thereafter to aid integration. As noted above, women offenders have exceptionally high health needs and a high level of need for support in a non-institutional setting.

18. Another possible element of investment through the Inspiring Scotland fund would be to support Transition to Accommodation projects; providing a housing advice and assessment support service to prisoners - a model currently being developed with full stakeholder support will be available for deployment from the summer. Projects would provide better information to offenders and their families, help to increase the number of offenders leaving custody with suitable accommodation arranged, and help in the maintenance of tenancies despite custody.

19. There is, however, an almost total lack of knowledge of interventions designed to and demonstrably succeeding in narrowing the health gap between offenders and the rest of the population. Scotland is well placed to develop a programme of research that could meet health inequalities and re-offending aims simultaneously.

Gaps and Challenges

20. We have identified a number of further gaps/challenges for consideration by the Task Force:

(i) Support for offenders with learning difficulties or disabilities. The Prison Reform Trust's No One Knows programme runs to October 2008 and is building up an understanding of the experiences of people with learning difficulties and disabilities who come into contact with the criminal justice system. A number of early recommendations are already available and respond to the fact that people with learning difficulties are not identified routinely prior to arriving in custody and, once in prison, face a number of difficulties (including victimisation and exclusion from opportunities). Political leadership for action to implement these recommendations would make an important contribution to reducing the health deficit experienced by these individuals.

(ii) Support for mental health and wellbeing. The Scottish Prison Service had made considerable progress in relation to the prevention of suicide and self-harm. Most people report feeling better about themselves on leaving prison than they did on entry. However, there are a proportion of offenders (and particularly women offenders) who even seek to return to prison, as a place of safety and care. Despite current levels of over-crowding, Scottish prisons are at present relatively peaceful places and there are a proportion of offenders (particularly women offenders) who even seek to return to prison, as a place of safety and care. This has been achieved through a concerted effort to put in place positive, respectful environments and through introduction of specific mental health programmes such as mental health first aid and choose life. It is recommended that the Task Force seeks the extension of such approaches across all criminal justice settings, and includes them within its recommendations on service redesign and continuous improvement.

(iii) Work to ensure (ex-) offenders have good access to health and other public services and benefit from the same quality of service as the rest of the population. Proposals to move all health services for prisoners into the NHS will present an opportunity, and also a major challenge, in this regard. It is recommended that achievement of the HEAT targets on access be explicitly applied to care for (ex-) offenders as well as the population as a whole. In addition, it is recommended that in each community planning partnership and Community Health Partnership area, work is carried out with CJAs to ensure joint priorities and that projects are in place to supporting (ex-) offenders to use these services more effectively. This is about integrating a population group with a high level of need into mainstream services.

(iv) As highlighted earlier, the effects of imprisonment impact on offenders' families and wider social environments as well as on the offenders themselves. The SPS is developing a family and relationships policy, which aims to alleviate those wider impacts, and to support the formation and sustaining of stronger social relationships by and with offenders. The potential gains of this approach for Scotland's health are significant. The majority of people in prisons are parents and/or young people, with whom there is scope to support a new start in life not only for themselves but also for their children.

(v) The Task Force might consider flexibility to incorporate health-related programmes as part of community sentences. The report of the review of community penalties commits to allowing community service to include an element of activity other than unpaid work. This scope should be developed for women offenders as a priority, to include the development of health and care services in the community for this group. This already occurs with the 218 Centre in Glasgow for female offenders which offers both residential and day programmes with a significant focus on improving the health and well being of those being worked with. It is proposed that the lessons to be learned from the 218 approach and the opportunity presented by the more flexible approach to community service could offer a more effective route to good health, free of addictions and free of crime than that which is currently offered.

(vi) Courts in imposing a probation order are able to add additional specific conditions of the order to address a variety of issues the offender may need to address. These conditions are applied most regularly with those offenders facing serious addictions issues but a significant number are also made with those presenting with medical/psychiatric/psychological problems. However, the extent to which courts are willing to impose such conditions is often a reflection of actual or perceived levels of local service provision and the availability of more consistent treatment services which offenders might access continues to be a key issue.

(vii) There is a need to better link research on desistance/resilience with the research agenda in health (and particularly health inequalities). Much could be gained by securing a more integrated set of objectives.

MENTAL HEALTH AND WELLBEING

Definitions: Mental Wellbeing, Mental Health, Mental Illness

1. Mental wellbeing is a construct in general usage that describes the emotional, social and psychological functioning of the individual. It includes the ability to cope with life's problems and normal stresses, realise abilities, make the most of opportunities and make a contribution to the community. It can include elements such as optimism, mastery, confidence, the feeling of flow, strength of relationships, resilience, contentedness and happiness. Individual experience of mental wellbeing can be presented as occupying a position on a continuum that runs from flourishing to languishing. Mental wellbeing is being measured annually in Scotland through the Warwick Edinburgh Mental Wellbeing Scale ( WEMWBS). In Scotland in 2006, 14% of the population were classified as having good mental wellbeing, 73% average mental wellbeing and 14% poor mental wellbeing.

2. Confidence, self-esteem, positive affect (e.g. hopefulness, optimism), resilience and (mental) health literacy are individual level factors that underpin mental wellbeing and quality of life. In terms of social and environmental factors, having close and supportive friends and family, social interaction, social participation and engagement within local communities and the extent to which people are satisfied with their residential neighbourhood are all strong positive influences on mental wellbeing. Insecure and inadequate income and working conditions characterised by high demand/low control, low support and effort-reward imbalance are the most commonly cited negative influences on mental wellbeing.

3. Mental wellbeing is associated with the idea of good mental health but separate from the idea of mental illness (which is concerned with the cognitive functioning of the individual and with physical illnesses of the brain). Both people with physical and mental illnesses can have a good sense of mental wellbeing. This suggests that it is helpful to see mental wellbeing and mental illness (or its absence) as two continua for assessing an individual's experience.

4. Where people experience common mental health problems such as depression and anxiety or are subject to stress at a significantly high level, the two continua of mental wellbeing and mental health/illness intersect as the absence of mental wellbeing may also be seen as indicative of poor mental health. Depression is strongly co-related with languishing, but in time may also manifest as an acute or long term mental illness.

Links Between Mental Health and Health Outcomes

5. Those who are flourishing and in good mental health are more likely to engage in activity that promotes and protects their health. They are more likely to be socially engaged and to participate in networks that offer access to opportunities such as employment and social support. They are more likely to take responsibility for their own health outcomes. By contrast, those who are languishing are less likely to manage their own health and that of others close to them, and more likely to be disengaged, sedentary, eat poorly and abuse alcohol. They are less likely to respond positively to health improvement and mental health promotion activity. Action on health improvement needs to therefore address the underlying reasons and understand cultural and behavioural issues as to why some people do not engage positively with health improvement social marketing and promotional activity.

6. Depression is highly correlated with other chronic diseases and failure to treat depression leads to poorer general health outcomes. The current GP contract recognises this in rewarding GPs for case-finding of depression for those with CHD and cancer. Improvements in positive mental wellbeing will help reduce the prevalence of common mental health problems, such as depressions and anxiety, substance use, anti-social behaviour, as well as improving health, recovery and social outcomes in clinical populations. While the best outcomes are associated with the absence of mental illness, the presence of positive mental wellbeing brings additional benefits, especially for those with common and longer term health conditions who are limited by their condition and/or disabled.

7. There is a clear social gradient for most physical and mental health problems as well as for mental wellbeing. Poor mental and physical health is both a cause and consequence of social, economic and environmental inequalities; the uneven distribution of health problems in the population both reflects inequalities and contributes to them. Moreover, the mental and physical dimensions of health inequalities are intertwined. For example, CHD risk is directly related to the severity of depression with a 1-2-fold increase in CHD for minor depression and 3-5-fold increase for major depression. For young people, psychosocial functioning (self determination, closeness to others and school integration) is closely correlated with behaviour problems (arrests, truancy, alcohol, tobacco and marijuana use).

8. In terms of the burden of disease, mental illness (including suicide) accounts for 20% of the total burden of disease in the UK, compared with 17.2% for cardiovascular diseases and 15.5% for cancer ( WHO figures, 2006).

Current and Future Action: Part I: Depression, Anxiety and Stress

9. Commitments have been made under the Government's Delivering for Mental Health programme to increase the availability of psychological therapies and offer stepped care for those with depression, anxiety and depression and those with depression as a co-occurring condition with CHD and cancer. This builds on Scotland's work under the Doing Well by People with Depression. The commitments are supported by the HEAT target of levelling off the increase in anti-depressant prescribing and over time moving to a reduction.

10. Work is place to develop the Living Life to the Full resource (web, books, DVD, and a range of supported self-help) as a national resource and programme of work from 2008 onwards. LLTTF promotes self-help and cognitive behavioural therapy based approaches for those with depression, anxiety, suffering high levels of stress, low mood, sleep disorders and related problems. The work will focus on promoting a range of tools and resources (the work conforms to NICE guidelines and is internationally recognised as best practice) and training staff both to signpost people to it and to collaborate with individuals and groups in supporting improved self help in addressing common mental health problems in a positive and effective way.

11. The Mental Health Delivery Collaborative (which supports local service change) will focus on the implementation of stepped care approaches and embedding psychological therapies, learning from best practice experience in Clyde and elsewhere under the Doing Well by People with Depression initiative. In addition work will also focus on the contributions that Community Health Partnerships can make and through the use of community and social referrals. In each case, establishing easy to use, clear referral pathways that make systems work more easily and efficiently are key to the work.

12. Further targeting of this work on deprived areas, while recognising the often more complex issues involved that follow from multiple disadvantage is likely to produce better health and other outcomes. There are already a number of local champions for this work in deprived areas and we should them as a resource more (as well as developing more local champions). LLTTF has already been delivered through further education colleges and we can do more of that as well as examining other locations where the programme might be delivered and promoted; the work on depression, anxiety and stress and also wellbeing is well suited to inclusion within Well Centres and we will develop options for this quickly. Other programmes, such as Keep Well, should pay more attention to mental wellbeing and mental health as underpinning the response to health improvement activity.

Better Outcomes: Part II: Towards a Mentally Flourishing Scotland

13.Towards a Mentally Flourishing Scotland was published in October 2007 by the Scottish Government and focuses on Promotion, Prevention and Support in respect of mental health improvement. It is intended to support discussions with public, voluntary and third sector organisations focused on the identification of tangible, deliverable commitments for action which will form the basis of the next stage of work for the National Programme for Improving Mental Health and Wellbeing.

14. A series of national and local events are taking place to facilitate the discussions, with events being hosted by a range of mental health and non-mental health organisations. External and internal reference groups are in the process of being set up. An event will be held at the end of January 2008 to focus on how the programme can contribute to addressing health inequalities.

15. A group is being established to co-ordinate Scottish Government engagement in the process and identify how this work can make appropriate connections with work on early years, justice, social inclusion, equalities, employability, the wellbeing of children and young people and other key cross-cutting programme areas.

January 2008