Scottish Labour Health Inequalities Policy Review: SCVO response

SCVO’s policy work is driven by three strategic aims – Society, Economy and Democracy. Our response is structured around these aims: Society – ensuring that policy making reflects our changing society and the importance of empowering and supporting people, their connections and overall wellbeing. We must consider, for example, areas such as planning and transport – where and how we build houses, how those in outlying areas (rural and urban) stay connected to their communities^[i].  Ensuring we protect and enhance social capital^[ii] is just as important as a focus on economic growth. Economy – The “ties” between health inequality and how our economy operates. A wider focus on wellbeing and tackling the ineffective operation of the labour market could have positive consequences in tackling health inequalities. The likely impact of austerity and welfare reform on health inequalities cannot be underestimated. Democracy – Ensuring people have more control over their lives and the services and policies which interact with them. Building the capacity of people and communities to develop solutions to concerns and needs requires a shift of power. The key determinants of health inequalities lie in the imbalance between these three ‘spheres’ and in their interaction with our daily lives. Our essential argument is this – tackling health inequalities is so much more than “medical wellness”. It’s about people’s ability to maintain social connections; their ability to feel secure and in control of life and of the services and policies with which they might interact.

Better connected policy which reflects changing society

“Demographic change is bringing about a fundamental shift in how we all live, work and care… – rising life expectancy, shrinking family networks … huge progress in women’s workforce participation, greater incidence of disability and learning disability and advances …meaning that far more severely disabled children live into adulthood. For many families this is bringing a new mix of work, childcare and care for older and disabled loved ones – new challenges which previous generations have simply not faced." Carers UK, 2013

Policy creation that aims to tackle health inequalities must take account of the changes outlined above. Traditional transitions e.g. from child to adult life, into old age are blurring and family life is increasingly complex. Therefore, having separate, ‘compartmentalised’ approaches to policy are no longer appropriate.”^[iii] We also need to step back and consider how areas of policy which are not always directly associated with wellbeing outcomes play a key role in tackling health inequalities and how families and communities respond to changing demography and needs. This means we need to view employment, transport, housing and planning policy, and capital investment, through with a health inequality/wellbeing lens. Consider the increasing risk of isolation amongst older people and the link between loneliness and ill health; a number of commentators have suggested that this is one of the most significant policy challenges we face. ^[iv] Transport policy; how we plan housing and infrastructure developments; support for community groups to respond to local needs – all of these are often seen within separate ‘portfolios’, with multiple and sometimes unintended impact. Consider the loss of a local bus service because it might be seen as a financial ‘loss maker’ - however, the impact on older people’s isolation and health is likely to be far more costly. Older people will also undertake multiple roles - e.g. continuing with paid employment; caring for grandchildren; providing unpaid care to spouses to relatives. Yet, we had separate change funds for early years and older people. The recent IPPR “Condition of Britain” report picks up on these issues and makes links between previously unconnected policy areas. It highlights, for example, the need to consider how employment rights can be adapted to meet the increasing demand for unpaid care.  It also urges investment in community groups and organisations which capitalize on the contribution of older people and the need to help them build relationships which contribute to better health and wellbeing^[v] - therefore reducing demand for more costly crisis interventions. The third sector welcomes recent moves to consider lessons which can be learned from other countries. This was a significant part of the work carried out by the Expert Working Group on Welfare in phase 2 of its work ^[vi] and has been a key feature of the Common Weal Programme.[vii]  Examination of welfare policy in Nordic and other countries through the Third Sector Internship programme for SCVO highlighted different approaches to traditional ‘welfare’ policies such as childcare but also outlined ideas such as intergenerational living and the clever use of planning regulations to support families to involve and care for older loved ones (e.g. Australia, granny flat planning). ^[viii] Honest discussion and exploration of these approaches are vital in tackling health inequalities; we need to better connect and acknowledge the impact of our environment, housing, relationships and community connections on people’s health. More widely, as outlined by the Scottish Community Alliance, the goal in creating better policy must be to break down “silo walls” that operate within public agencies.  A focus on outcomes, including genuinely tackling health inequality outcomes, means that we need to move beyond “who does what” and where budgets lie/with whom^[ix]. These challenges are also acknowledged in the recent report by the Carnegie Trust. Part of a series called “The Enabling State”, the newest report points out that one of the key factors to successful reform of public services has to be policy outcomes which matter – not “process or input”.^[x]  Until policy and policy makers truly move into this realm, existing health inequalities will continue.  We remain unconvinced to date that plans to integrate health and social care will achieve the kinds of goals outlined by the Scottish Community Alliance – see below.

The link between our economy and health inequality

"If people at the bottom don't have the minimum necessary for a healthy life, then their health suffers... I think that people at the upper end of the income scale have no idea of what's going on down at the bottom of the scale. They don't realise how much people are really hurting." Sir Michael Marmot, health inequality expert at University College London, and author of Fair Society, Healthy Lives.

How our economy operates contributes to health inequalities in Scotland. In previous parliamentary briefings and consultation responses, SCVO has consistently argued for a changing focus for economic policy. Along with charities such as Oxfam^[xi], the Common Weal project and prominent economists^[xii], our view is that current economic approaches in Scotland and UK wide perpetuate poverty and inequality – key determinants of health and wellbeing. We find the emphasis on economic growth throughout current Scottish Government’s economic strategies to be problematic. ‘Sustainable economic growth’ as a strategy does not address the imbalances in our economy. Unfortunately, this emphasis on economic growth permeates much of the parliamentary and political discourse concerning the economy. SCVO has argued strongly that future economic strategies should focus on reducing economic inequality between regions and individuals. By moving economic strategies away from a promotion of economic growth towards a promotion of economic equality, we will create a more sustainable and prosperous economy. Employment positively impacts on a wide range of wellbeing indicators, including educational attainment, health and crime^[xiii]. Whilst there may be increases in a country’s GDP, such increases can mask large, often increasing disparities between regions or individuals. More widely, we need to see a focus on “good work” in policy, where in-work poverty and cycling between low pay and no pay are tackled. Work may be good for our collective health – bad work is not:

“The implications for population health and wellbeing of …. changes to poverty and work are generally negative. The detrimental impact of low quality, precarious and insecure work on mental health and wellbeing is especially concerning amid an economic recession which itself represents a significant risk factor for population health generally and mental health specifically. Moreover, evidence suggests that the retrenchment of social protection, outlined in the planned UK welfare reforms, will further compound these risks and lead to increased poverty rates and the exacerbation of health inequalities.”^[xiv]

The combination of austerity measures and welfare reform is especially significant for people with disabilities and for those who already face mental health challenges. When GPs and public health experts talk about a potential public health crisis arising from austerity and devastating welfare cuts, then it’s time to listen and act.^[xv] Any policy developments which seek to tackle health inequalities must take account of the damage currently being done to people and communities across Scotland. Consider for example, the challenges facing people under the age of 35, where suicide is still the biggest cause of death^[xvi]. Isolation and lack of control can affect the health and wellbeing of all age groups in our society.

Empowering, Enabling and Democratising

There needs to be a much wider argument about power balance and people having far more control over the policies and services which impact on their lives[xvii].  This is acknowledged by the Scottish Government in its’ 20:20 vision which, building on Christie’s recommendations, outlines the need to:

• shift the balance of power to, and build on the assets of, individuals and communities
• support the self-management of long-term conditions and personal action, and
• support partnership working which includes a clear role for the third sector, in Community Planning Partnerships (CPPs) and new Health and Social Care Partnerships^[xviii]

It is not at all clear that health and social care integration will achieve these ‘aims’. A focus on process and budgets risks taking attention away from the very real challenges highlighted by this inquiry. There is also a real risk that the voice of people most affected by decisions being taking in the context of health and social care integration will not be fully heard. Tackling health inequalities is not about having things “done to” people– this is a concept which the public sector often struggles with^[xix]. Much faith is placed in community planning as a way of creating more ‘connected’ policies. As the Scottish Community Alliance outlines in its recent briefing:

“Few would deny that Community Planning has had a bumpy ride since its introduction in 2003. While there has been undeniable progress in getting public agencies to work together and plan their services more effectively, the perennial problem has been the extent of its’ disconnect with communities.” ^[xx]

To truly ‘open up’ service planning, delivery and implementation; for people to have a real say in how health inequalities are tackled, there needs to be a focus on building capacity within communities to ensure that the most disadvantaged can be a central part of this - a strong point made by Voluntary Health Scotland in its briefing for this inquiry^[xxi] and by the Carnegie Trust in its work on the Enabling State^[xxii].  Building community capacity and health/social care assets is being investigated in a project being taken forward by SCVO with third sector partners in East Dunbartonshire. This national pilot will aim to build the capacity of communities and local community/voluntary organisations which play a key role in health to demonstrate their impact and to show that this approach can reduce demand on statutory health services.^[xxiii] There are wider issues at stake in relation to this issue - as outlined above, the distance between planning of services (e.g. Community Planning) and the communities they are expected to serve. There is also the wider lack of trust in politicians and political processes and the distance between policy, legislation and the people affected by those policies^[xxiv].  Public services – many which are supposed to play a key role in tackling health inequalities and support people’s wellbeing - are often out with the control of service users. This point is made as part of the Common Weal project which argues that this separation arises from e.g. the creation of ALEOs, contracting out of crucial services and so on.^[xxv]. People generally will find solutions to the challenges they are facing in their lives – sometime statutory services work against this ‘capacity’. How the state interacts with people’s lives is a critical element in assessing responses to health inequalities in Scotland.

The Third Sector as an Equal Partner

The role, contribution and resources brought to the table by the third sector must be a key element of planning to tackle health inequalities. The sector’s assets, experience and connection to communities is summarised in a briefing note on working with charities and voluntary organisations, produced by SCVO:

“They are independent, and are often well-trusted by people and communities. Because they involve communities and users they are responsive and naturally person-centred. "They largely work in ways that can be characterised as preventative – in that they seek to improve the wellbeing of people in their own homes and communities.”^[xxvi]

Third sector organisations continually need to push to be ‘at the table’; being considered as equal partners in service planning and design is a real challenge. The role of community organisations in building ‘social capital’ and people’s wider wellbeing was recognised by IPPR^[xxvii] and others. The shift to community capacity envisaged by Reshaping Care policy and within the policy intent driving the integration of health and social care must happen sooner rather than later. The value of services such as befriending, local transport, food and shopping services, carer and family support must be recognised in the drive to tackle health inequalities. These services are still not inherently valued or always supported on a long term basis.

Conclusion

Tackling health inequalities must be about more than people being medically well. It's about their connections to each other, to society and to economic wellbeing. The impact of place, work, pay, housing, access to services and supports are increasingly being recognised as key factors which contribute to health inequality. Tackling the wider determinants of health inequality requires big thinking because this requires a new approach to the economy and to a more equal distribution of wealth and power. This is acknowledged in the 2013 Equally Well review.^[xxviii] We would suggest that ‘health inequality impact assessments’ might be one way of considering the consequence of policy and investment decisions on people’s wellbeing and health at both national and local level. Going back to the Christie principles, we would like to see these driving more coherent policy making where commitments to tackle health inequalities are central to all portfolios. However Scottish Labour’s policy review develops, the changes within our society must dictate a new approach to policy making which gives people more control over their lives and the health and other services which affect them. The role of the third sector in helping people to get better/remain well, and to have the capacity to create solutions to the challenges they face on a day to day basis must also be recognized, valued and supported. Work to develop tools which help organisations (of all kinds) to look at how they might play a role in tackling health inequalities are worth disseminating further - for example, the NHS Health Scotland health inequalities action framework.^[xxix]  Whilst targeted at Community Planning partnerships, the framework might be helpful for the new health and social care partnerships. How CPPs and HSCPs link/work together is important. We would be happy to discuss our thoughts and ideas further with Scottish Labour. Regardless of the result of September’s referendum a ‘business as usual’ approach to dealing with the issues and challenges that sit at the centre of this inquiry is simply not good enough. We must use the momentum created within the constitutional debate to drive more effective and connected policy which once and for all reduces the drastic health inequalities which exist in Scotland.

Contact

Lynn Williams, Policy Officer Tel:  0141 559 5036 E mail: lynn.williams@scvo.scot Scottish Council for Voluntary Organisations, Mansfield Traquair Centre, 15 Mansfield Place, Edinburgh EH3 6BB Web: www.scvo.scot

About us

The Scottish Council for Voluntary Organisations (SCVO) is the national body representing the third sector. There are over 45,000 voluntary organisations in Scotland involving around 137,000 paid staff and approximately 1.2 million volunteers. The sector manages an income of £4.4 billion. SCVO works in partnership with the third sector in Scotland to advance our shared values and interests. We have over 1300 members who range from individuals and grassroots groups, to Scotland-wide organisations and intermediary bodies. As the only inclusive representative umbrella organisation for the sector SCVO:

• has the largest Scotland-wide membership from the sector – our 1300 members include charities, community groups, social enterprises and voluntary organisations of all shapes and sizes
• our governance and membership structures are democratic and accountable - with an elected board and policy committee from the sector, we are managed by the sector, for the sector
• brings together organisations and networks connecting across the whole of Scotland

SCVO works to support people to take voluntary action to help themselves and others, and to bring about social change. Our policy is determined by a policy committee elected by our members.[1] Further details about SCVO can be found at www.scvo.scot.

References

Scottish Voluntary Sector Statistics 2010, SCVO www.scvo.scot/evidencelibrary/Home/ReadResearchItem.aspx?f=asc&rid=1078