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Improving Health in Scotland - THE CHALLENGE
A NEW FOCUSED APPROACH TO HEALTH IMPROVEMENT INITIATIVES
Improved health will require all the different policy strands, and the different action programmes for improving health, lifestyles and life circumstances to be linked and, where possible, integrated.
Improved health also requires linkages with different elements of health service provision, local authority provision and the different policy arenas of education, social justice, environment, employment and sport.
In addition, the programmes whilst all trying to improve Scotland's health must also try to close the gap between least and most affluent communities.
We know that, by supporting people at critical times in their lives and working to ensure groups of people believe that health improvement is within everyone's grasp, we can make a difference for ourselves, our families, those in our care or in our neighbourhoods. It means we can all improve health prospects, both now and in all stages of our lives.
To support this new focus and enable closer linkages and partnership working for health improvement, four major themes will be used. They will focus health improvement initiatives, build upon existing programmes and also allow greater input from others. These four themes are
Early Years, the
teenage transition, the
workplace and
community-led.
THEME 1 - THE EARLY YEARS: CREATE AN INTEGRATED PROGRAMME OF HEALTH IMPROVEMENT IN THE EARLY YEARS
Action 7 Early Years
The Executive will consult on an integrated strategy for the Early Years by spring 2003.
There is clear evidence that health throughout life is powerfully influenced by experiences in early childhood, and indeed from the time of conception (when the health of the parents is important). We also know that people often want help to solve their problems, where they have choices, remain in control and they do not understand the gaps in services. Health, local authority and voluntary sector services need to join up to provide seamless and responsive support to families to ensure the best possible start in life.
The Executive supports a range of work with families and children with the aim of improving children's physical and mental health; children's social and emotional development; children's ability to learn; and strengthening families and communities. This includes support through mainstream services (such as health visitors, learning disability services, speech and language therapy, physiotherapy, occupational therapy and pre-school provision); more targeted approaches (such as the health improvement demonstration project Starting Well, and Sure Start Scotland); and both universal and targeted childcare. NHS Health Scotland is establishing an Early Years National Learning Network to bring together and disseminate evidence and information about what works and examples of promising practice (including learning from the Starting Well demonstration project), and to support wider implementation of lessons learned. The Homelessness Taskforce in its final report, also recognised the specific needs of homeless children.
The Executive has made a commitment to defeat child poverty, a commitment shared with the UK Government. Household income is one way of measuring child poverty, but the Executive also understands child poverty in a wider sense, focusing on closing the opportunity gap and giving all children the best start in life, as well as providing appropriate and integrated services for children, in health and education and housing.
In order to secure a significant and measurable improvement in young children's health, it will be important to set out an agreed set of common goals and outcomes from this range of activity. That is what a new integrated strategy for the Early Years will be designed to achieve.
An integrated strategy for Early Years will include an enhanced focus on the following health improvement actions:
developing confident, competent, well informed and supported parents who feel secure in their role
well-nourished, well-balanced and healthy children, who are well prepared to benefit from education
pregnant women - reducing exposure to tobacco, alcohol and other drugs
increasing the proportion of mothers breastfeeding, focusing on disadvantaged groups
improving a childhood diet and oral health
improving family circumstances, coping abilities and family mental health
encouraging higher levels of physical activity
reducing accidents inside and outwith the home
promoting resilience in children and young people.
The integrated Early Years strategy will cover areas such as: increased focus on support for healthy pregnancies through primary care, family planning and maternity services; childcare provision, health visiting support for infancy and pre-school children; better integrated working between health and local authority family support services in the Early Years; and importantly, support for parenting.
Action 8 Early Years
The Executive will develop proposals for evaluation - including a baseline study of existing Early Years provision by December 2004.
It will be important to be able to measure the impact of the new integrated Early Years strategy on children and their families. We will need to track carefully the extent to which we are succeeding in delivering a change in young children's health (as well as improving outcomes in the related areas of their social and emotional development and ability to learn). The Executive will commission an outcome-focused, integrated - evaluation of the existing range of Early Years policies. This will provide base-line data against which to measure progress made under the health improvement challenge plan and related initiatives. It will also provide support to NHS Boards, local authorities and voluntary organisations in identifying measurable outcomes and targets for support to young children and their families.
Action 9 Early Years
NHS Boards, NHSScotland, local authorities, voluntary organisations individually and in Community Planning Partnerships will be expected to have clear plans of action for their areas reflecting the integrated Early Years strategy. This should be backed, where appropriate, by measurable targets.
Action 10 Early Years
Ensure that the processes, action and approaches to Early Years reach the most vulnerable families and children.
Since 1999, the Executive has been investing in supporting children through a combination of universal provision and more targeted support for vulnerable and deprived children. Universal services, such as those provided through the NHS, are delivered to all children. There are also targeted interventions such as Sure Start Scotland, support through Social Inclusion Partnerships, and childcare support in deprived areas and for lone parents to support them into further and higher education. The Executive will monitor the plans of NHS Boards and local authorities to ensure that they are reaching those who are most at risk and in need of support. This will be built into the evaluation process at actions 8 and 9 above.
Action 11 Early Years
The Scottish Executive supported by NHS Health Scotland, will work with NHSScotland, Community Planning Partnerships, local authorities, voluntary organisations and other stakeholders to implement the new integrated Early Years strategy.
THEME 2 - TEENAGE TRANSITION: A PROGRAMME TO SUPPORT YOUNG PEOPLE AS THEY MOVE FROM CHILDHOOD TO ADULTHOOD(THE TEENAGE TRANSITION)
The years from the early stages of secondary school education and adolescence to adulthood are a time of great change and a time when young people are subject to major external influences. Our intention is to create a set of circumstances where young people feel supported to the extent that they fulfil their potential, maintain self-esteem and avoid a wide range of health-damaging behaviours and other hazards. This approach will incorporate specific strands dealing with issues like smoking, drugs, sexual health, alcohol, mental health and well-being, diet and physical activity but will do much more than the sum of these individual component parts.
Schools, in partnership with the home and community, can make a difference to the health behaviours of young people.
The Standards in Scotland's Schools Act 2000 places a duty on education authorities to ensure that school education is directed to the development of the personality, talents and mental and physical abilities of the child or young person to their fullest potential. The five
National Priorities in Education have been approved by the Scottish Parliament. They address: achievement and attainment; framework for learning; inclusion and equality; values and citizenship; and learning for life.
The Scottish Health Promoting Schools Unit has been set up as a partnership initiative involving HEBS, LTScotland, COSLA and the Scottish Executive. The Unit will have a national leadership role championing, facilitating and supporting the implementation of the health promoting school concept throughout Scotland. Within health promoting schools, not only is health education integral to the curriculum but the school ethos, policies, services, extra-curricular activities and partnerships foster mental, physical and social well-being and healthy development. The concept is central to the New Community Schools initiative.
New Community Schools have the twin aims of raising attainment and improving social inclusion. A key element of this is the delivery of integrated services for pupils and their families. The health input to the initiative is crucial.
We are conscious that further approaches will be required in areas outside the school environment for this particular age group (for example the Young Scot and Youth Dialogue projects) and further action will be identified.
Action 12 Teenage Transition
The New Community Schools approach will be rolled-out to all schools in Scotland by 2007. All schools will become Health Promoting Schools by 2007.
The aim is to ensure that each young person develops personal skills, emotional intelligence and a high level of educational attainment. At the same time they need to be given the skills and the support to negotiate issues like sexuality and coping with potentially addictive substances, and are to be encouraged towards a lifestyle that optimises their physical and mental well-being. This programme proposes:
encouragement and enabling of young people to undertake regular physical activity and to eat a healthy diet
promotion of resilience and good mental health in children and young people
reduction in the levels of regretted first sexual experience, abusive relationships, sexually transmitted disease, teenage pregnancy and early parenting
reduction in young people's use of tobacco, alcohol and drugs.
This approach will be taken forward through:
the roll-out of the New Community School and Health Promoting School programme to all schools by 2007
redesign of school nursing to young people in New Community Schools but also for children with special educational needs and vulnerable children
a national strategy for sexual health to include application of emerging lessons learned from Healthy Respect in sexual health and wider aspects of young people's general health
responding to the Scottish Needs Assessment Programme review of child and adolescent mental health (to be published in 2003) assisted by the child health support group
integrated community-based information, advice and support services on all aspects of physical, sexual and emotional health for younger people.
This will require the Scottish Executive to:
implement the new Scottish Framework for Nursing in Schools, refocusing the service on identified needs and priorities
ensure further training and development of school nursing staff to meet this new challenge
undertake work to examine the role of organisations including schools, in supporting the emotional, physical and mental well-being of children and young people.
Action 13 Teenage Transition
The Scottish Executive will redesign and implement a new approach to school nursing by 2004 to ensure health improvement activity is part of the workforce programme.
While schools are a key focus for influencing experience during the teenage transition it is by no means the only one. The community environment is as important and this is addressed elsewhere in the Challenge. In addition, home environment is also important and work is proposed to examine advice and support for children and their parents/family environment.
Action 14 Teenage Transition
Learn from the experiences of 'Walk the Talk' and plan for its wider implementation throughout Scotland by summer 2004.
'Walk the Talk' is a programme that supports the development of appropriate and accessible primary care services for young people with the aim of influencing lifestyle issues such as smoking, alcohol misuse, diet and exercise and providing a sensitive environment in which sexual health issues can be explored. The third and final phase of Walk the Talk will ensure that the lessons learnt from the project become part of mainstream practice. The following elements will be central to this:
incorporating an understanding and awareness of the needs of young people into the education of health professionals
developing national and local networks of health, community education and voluntary workers to support local service development and the sharing of best practice
developing a toolkit of resources to support the involvement of young people in developing accessible services that meet their needs.
Action 15 Teenage Transition
The Scottish Executive, led by SEHD and supported by NHS Health Scotland, NHSScotland, Community Planning Partnerships, local authorities and other stakeholders will develop a programme of work to drive the step change agenda which supports Actions 13 to 14 in terms of reviewing the evidence, providing key elements of implementation and contributing to evaluation.
THEME 3 - THE WORKPLACE
The workplace setting is a major opportunity for health improvement. This plan for health improvement seeks to ensure that individuals maintain healthy lifestyles throughout adult life, are not made ill by their work, have access to programmes and services aimed at maximising their functional capacity and are able to continue to be economically active, enjoy good physical and mental health and remain independent for longer.
Action 16 The Workplace
A short-life working group representing departments and stakeholders will be established by March 2003. The working group will bring together the existing strands of work dealing with health in the workplace to promote a new and effective set of interventions which will promote healthier workplaces and influence the health of working age people.
Scotland's economic performance currently lags behind the best international standards. With an ageing population projected for the coming decades, improved business growth and performance will depend in part on our ability to improve the health of the workforce, and to maintain and increase employment rates. The promotion of good mental health in the workplace is vital and includes: support of job retention for people who develop mental health problems at work; ways of securing more and better employment opportunities for people with mental health problems or experience of mental health problems. Some key linkages are set out in
The Way Forward - Framework for Economic Development in Scotland (June 2000):
Working-age people suffer from high levels of heart disease, cancer, diabetes and respiratory disease such that, if we were able to make an impact on these diseases, it would go a long way to addressing the relatively poor life expectancy in Scotland compared with the rest of the UK and Europe
the workplace is an ideal setting not just for interventions that protect the workforce from hazards but to prevent ill health and promote good health
occupational health services and employer organisations have a key role in supporting these interventions and providing clinical assessment and care. However, occupational health services are unequally provided throughout Scottish workplaces
our infrastructure for rehabilitation, job retention and helping people return to work is less well developed than in many comparable countries. Occupational therapists, physiotherapists and employers can play a leading role in these services.
In the past, health in the workplace was primarily focused on preventing accidents and injuries. This remains important with continuing progress being maintained through UK health and safety legislation and the work of the Health and Safety Executive. More recently, progress has been made in other areas. For example, the Working Time Directive empowers employees to decline to work excessive hours, thereby protecting their physical and mental health.
Scotland is in the vanguard of occupational health policy development within the UK and already has a number of complementary programmes in place, though these are not as yet well integrated. For example:
Towards a Safer Healthier Workplace: Occupational Health and Safety Services for the staff of the NHS in Scotland (December 1999)
the development of a national occupational health service for Small and Medium-sized Enterprises (SMEs)
Scotland's Health at Work (SHAW) programme, Health Promoting Hospitals, Schools and Prisons
existing policies on breastfeeding and returning to work, adult literacy and numeracy and domestic abuse.
Other mechanisms will also be included via:
support for managers, personnel departments, unions and others who can influence workplace policies that impact on health including mental health and well-being
the legislative and organisational mechanisms that protect health and safety at work (e.g. the Health and Safety Executive health and safety legislation)
the primary care system and other aspects of the National Health Service that deal with diseases caused by an individual's occupation or work environment
NHSScotland and other public sector employers will support the work on health improvement for their own staff.
Action 17 The Workplace
The Health Improvement Directorate and Public Health Division of the Scottish Executive Health Department to co-ordinate the work programme. The development of an integrated programme of action for 'Healthy Working Lives', by October 2003 (responsibility for the different components e.g. primary care, HEBS, SHAW, occupational health, etc. will stay within existing organisations).
The objectives will include:
the implementation of Towards a Safer Healthier Workplace for the NHS staff
the development of the national occupational service for SMEs (from early 2003)
the extension of participation in SHAW to cover 40% of the Scottish workforce within 5 years
engagement of an additional 300 SMEs in the SHAW programme by 2004
near to comprehensive enablement of companies to develop their expertise in health improvement policies as an ongoing programme of work
encouragement and support for employers to develop occupational health strategies and services as an ongoing programme of work.
Action 18 The Workplace
Scottish Executive, NHS Boards and local authorities are major employers within Scotland. Both sets of organisations will be approached by spring 2003 to discuss how their joint health improvement plans will describe their role as employers and the contribution to health improvement.
Action 19 The Workplace
By July 2003 specific targets will be identified for all aspects of the above detailing targets for numbers of workplaces influences and key changes achieved by the short life working group.
THEME 4 - COMMUNITY-LED - SUPPORTING AND DEVELOPING HEALTHY COMMUNITIES
The communities we live in can have a considerable influence on our health and there is widespread recognition of the inequalities that exist between the health of the worst off and the health of the better off within Scotland's communities. Our approach will build on work already initiated that:
seeks to encourage, support and enable individuals and communities to take shared responsibility for their own health and to work together to bring about improvements. Programmes such as
Health issues in the Community5 are key to empowering the public and enabling people to become more involved in community issues
seeks to support action to address poverty, lack of physical activity and leisure facilities, poor housing and other factors that contribute to inequality.
There is a strong national commitment to engaging with and involving people and communities in all aspects of health (physical, social and mental) and health care, including health improvement. It is very important that this commitment is not lost in the complexity of organisational partnership working and that people and communities are involved and have a role in shaping the action and delivering change. Ideally, we wish to empower and support communities to be involved in developing initiatives and solutions.
Action 20 Community-Led
By mid-2004 Community Planning Partnerships as the overarching framework, together with each local NHS Board area will have agreed processes with their local authority partners to ensure that the health improving potential of community plans, Social Inclusion Partnerships, healthy living centres and other community-based initiatives are optimised.
The Executive has a multi-faceted strategy to improve health, well-being and economic productivity within communities. This strategy embraces all communities in Scotland but is particularly targeted to deprived communities. Therefore, work on this programme focuses upon Social Inclusion Partnerships, Community Planning, healthy living centres and much more. Much is already being done in this area. Historically, NHS Boards have applied resources from their planning department, public health departments and health promotion departments to partnership working in communities. More recently, jointly funded (NHS and local government) health improvement posts have been established in each local authority. Moreover, public health practitioners are employed in each (Local Healthcare Co-operative) LHCC. These posts aim to improve joint working at a local level and can already demonstrate significant success in moving local planning nearer to the communities they serve.
Community Planning Partnerships can improve life circumstances for local people through establishing shared priorities for local communities and ensuring an integrated approach to addressing them. Housing, transport, employment, recreational facilities and a wide range of public services all have an impact on the health and well-being of communities. By taking a broad multiagency view of a community we will make an impact to improve their life circumstances. Community Planning will take place at a variety of local, regional and national levels. Health improvement may, at any one time, involve one NHS Board in a number of different Community Planning Partnerships. However, the Community Planning process gives a strong opportunity to include views from the community receiving the service together with those providing the service.
In the Health Reform White Paper, we propose that NHS Boards and local authorities should work together to develop local proposals aimed at bringing together local agencies with a focus on improving the health and well-being of the community, through the Community Planning process and the development of integrated sustainable local services to address community needs. Community Planning Partnerships in different ways in different areas, provide the mechanism to improve the health and well-being of communities in ways that are identified and appropriate for that area/community.
Action 21 Community-Led
COSLA, SOLACE and NHS Health Scotland will by July 2003 have begun a programme of work to achieve the following:
lead the actions, assess, develop and disseminate the evidence-base for how Community Planning can maximise its impact on the determinants of health to deliver the health improvement agenda
introduce programmes to support the development of staff who have been jointly appointed by NHS Boards and local authorities and more senior staff with lead responsibilities for health improvement partnerships
within the context of Community Planning Partnerships support for the development of capacity and ways to promote community involvement and empowerment to deliver health improvement
specific support for the public/communities who are involved in Community Planning Partnerships to articulate their needs to improve the delivery
of services.
Action 22 Community-Led
Voluntary Health Scotland (working with Community Health Exchange) will be requested to begin, by July 2003, a parallel process of analysis and action to identify how best community-based organisations and the voluntary sector can contribute to health improvement through community-based action.
It is important that the Executive follows through with action to improve life circumstances in communities by continuing tackling low income and poverty. For example, action to reduce the proportion of unemployed, working-age people and the proportion of working-age people on low incomes will have an important impact on health.
Healthy practices remain important in the transition from education to employment, onwards into middle life responsibilities and throughout older age.
Action 23 Community-Led
NHS Health Scotland, local authorities, working with a wide range of groups including CHEX and the Community Diet Project, should identify and pursue action to enable communities to identify, learn, develop and implement health improvement issues that are important to communities.
LHCCs, given their role in Primary Care, are key organisations to respond to broad-based community-led health improvement initiatives.
Action 24 Community-Led
A plan will be developed to ensure there is a shared, accessible and relevant information system in order to identify and respond to community health and wider well-being needs by summer 2003.
The Scottish Executive Statistical Services will lead a programme to ensure all data collected, as well as being robust, are comparable and relevant to different organisations and will take account of the PHIS data sharing project.
Action 25 Community-Led
The current workforce (public health, health promotion, NHS, local government, etc.) must develop the capacity and approach health improvement in a holistic fashion. Central specialist input should only be retained where it provides added value.
Social inclusion and better mental health/well-being may develop through work in a range of projects including rehabilitation of older people, support of people with learning disabilities by occupational therapists, speech therapists in a wide range of community settings
Scottish Executive will host a meeting in spring 2003 to discuss the issue of developing workforce capacity in health improvement and public health workforce involving a multi-agency approach.
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