Working Together for a Healthier Scotland

Chapter 5 - Roles, Responsibilities and Action

96. Health regeneration calls for personal investment in our own health: improved living conditions; and supporting infrastructure and services. Mental and physical well-being will improve, as we rebuild in deprived communities access to the opportunities people elsewhere take for granted. There is no quick fix. Changing habits acquired through many generations will need a cultural shift which will not be achieved at the touch of a switch. But we can ease and quicken change. The right mix of measures - economic, social, environmental and behavioural - will deliver not just better health but many other social gains.

97. Scotland’s problems are pressing but not unique. We need to learn from other countries that have overcome similar problems and now have better health.

Views are welcome on actions taken elsewhere, which have led to health improvement, and which can be made to work in Scotland.

98. Health measures need to be coherent, with each agency aware of its joint and separate roles, and each potential health setting ‘wired up’ for health improvement, in a structured way. This chapter sets out our proposals for co-ordinated action to realise maximum health gain.

THE PUBLIC

99. Any strategy for health improvement must have at its heart the recognition that it is "the public’s health" and the public’s own responsibility. Countless steps can help shape our own future health, and combine to shape the nation’s health. But we can also influence and affect others - the move to smoking-free settings and reductions in drinking and driving are examples of how change takes off, as more and more Scots subscribe.

100. As individuals with responsibilities, we have a right to expect healthy choices to be made easier choices, particularly in communities where access and choice are constrained by poverty. And we have a right to protection from industrial wastes and pollution, to a clean environment and safe clean water. The public should have the chance to help identify the key health issues affecting them and the action needed to promote health. Central government, working with other public and private sector bodies, have a responsibility to support healthy choices with accurate and credible information, strong leadership and the creation of a strategic framework within which the NHS, local authorities and other partners can work to deliver improved health.

CENTRAL GOVERNMENT

Policy Co-ordination

101. The Government have a particular responsibility to ensure that all their policies are brought together in a coherent way so that the potential for health gain is achieved. It must also set the tone for economic and social prosperity, leading to job creation, better education, a cleaner environment and so on. The Scottish Office, with its wide-ranging economic, social and environmental remit, is well placed to promote this integrated approach to health. Devolution will enhance its capacity to marshall and target its policies and resources in a way which best reflects Scotland’s health needs.

102. Health will be a key consideration in policy formulation across the spectrum of Scottish Office responsibilities and Scottish Office Ministers will ensure that health considerations are given due prominence in developing and taking forward initiatives within their respective portfolios. The Scottish Office Minister for Health, in collaboration with his Ministerial colleagues, will drive and oversee the work of the interdepartmental group of senior officials which will ensure co-ordination across The Scottish Office to improve Scotland’s health.

103. The Government propose that this task should be facilitated by means of health impact assessments, which will identify and evaluate the health implications of relevant new central government policies and initiatives. The Public Health Policy Unit in The Scottish Office Department of Health will have the responsibility for this work within The Scottish Office. The emphasis will be on identifying a small number of significant policies which clearly affect health and on considering how best health gain can be maximised or, conversely, adverse effects on health avoided.

Views are invited on the proposal that health impact assessments should be carried out on evolving national policies. What guidance would be helpful both to identify the policy areas which would benefit most from such an approach and to assist in the undertaking of such assessments?

Strengthening Communities

104. In seeking to foster community cohesion and reduce social exclusion it is important that community-based approaches to promoting health across a broad front are put on a sustainable footing, with local action underpinned and enabled by policy and strategy at higher levels.

105. Community involvement is a key component of our area regeneration policy. Sustainable regeneration requires community support, involvement and ownership. The local community is a full partner in all our regeneration partnerships. The New Life Partnerships all have community support structures to facilitate community participation in the partnership process, and there is much valuable experience which can be learnt from them.

106. The Government are looking at new ways of meeting the needs of communities. With COSLA, we have established a working group on community planning, to consider how to develop the role of local authorities in working together with other bodies to plan for and meet the needs of their communities. The group will also identify best practice in existing council partnerships in planning, providing for, and promoting the economic, social and environmental well-being of the communities they serve.

107. The Government are committed to tackling social exclusion. In Scotland, this will be taken forward at central Government level by Lord Sewel and The Scottish Office Social Exclusion Network. The Government are keen to take on board views about how best social exclusion is to be tackled and a consultation exercise is being undertaken.

108. In addition, the Government suggest setting up an expert working group, chaired by The Scottish Office Minister for Health, charged with drawing up a strategic framework for concerted action to promote health at community levels with a particular focus on, but not limited to, deprived communities. This would include any necessary national structures or mechanisms for stimulating and supporting local action. The working group would critically appraise available evidence on links between community factors and health and on the effectiveness of various approaches to strengthening communities, taking account of the emerging findings from the enquiry under Sir Donald Acheson, the work to tackle social exclusion and ongoing activities in community planning, community development and area regeneration. As part of its work, the working group could identify large-scale ground-breaking projects at community level, which, in a concerted way, focus on pressing and stubborn local problems, for example, coronary heart disease.

Views would be welcomed on this proposal and specifically on the composition of any such working group.

Other Action on Life Circumstances

109. The Government will also drive forward its policies for revitalising Scotland’s economy and environment, creating the climate in which good health can flourish. These include:

Employment

• through the continued deployment of the energies and powers of the Enterprise Networks in Scotland to create employment, provide training and improve the environment, and with the availability of direct help for industrial development, such as the Regional Selective Assistance Scheme, much can be done to reduce unemployment, attack the problems of social exclusion and promote economic activity.
• the introduction of the National Minimum Wage to encourage industry to compete on the quality of goods and services they produce rather than solely on low costs based on low rates of pay. With an adequate income, people will be able to afford to choose a more healthy lifestyle.
• increasing the ability of young people to get into work as a result of the impact of the Government’s New Deal initiative. The New Deal for 18-24 year olds was launched in the Tayside Pathfinder area on 5 January 1998 and arrangements for implementing the programme in the rest of Scotland from the beginning of April are well advanced. The New Deal for those aged 25 and over is due to commence in June. The New Deal for lone parents, currently being piloted in the Clyde Valley, will be expanded nationwide from October. The New Deal for people with a disability or long-term illness has recently been launched and bids have been invited to help deliver the programme’s aims.

Environment

110. A clean environment is a key health determinant. We will continue to take action to improve the quality of our environment. Sustainable development is the main element of the Government’s manifesto commitment to place the environment at the heart of policy making. It requires the pursuit of economic growth and social progress, which respects the environment. Our sustainable development strategy is, therefore, a key contributor to the drive to improve public health in Scotland.

111. Action will be taken to improve the environment in which we live and work. Key areas include:

• the Government have set local authorities four key priorities for housing investment. These are: housing in the worst physical condition (below the tolerable standard); condensation and dampness; homelessness; and care in the community. Already we have made available an additional £15.5 million of new money in this financial year, and over £50 million extra for 1998-99. All of our housing priorities have a direct relevance to health. We attach importance to improving energy efficiency and extra resources are being provided this year and next to improve the energy efficiency of housing stock. The Rough Sleepers Initiative, with a budget of £16 million over the 3 years to 1999-2000, supports partnership projects at local level to help those sleeping rough.
• transport is influential on health in a number of ways. Access to health services, shopping centres and recreational facilities is made easier. This is particularly important for isolated rural and deprived communities. Pollution, too, can be addressed by policies which reduce the need to travel and dependency on cars, especially in urban centres; and greater provision for cyclists and pedestrians contributes both to a cleaner, safer environment and to improved health through increased physical activity. The Government intend to publish in Spring 1998 a White Paper on Integrated Transport in Scotland, which will take account of the health dimension in these key policy areas. In addition, the Government have set up a National Transport Forum for Scotland. This brings together the major transport operators, decision-makers and influences to provide advice to Ministers and encourage greater co-ordination between the various forms of transport. Health and environmental interests are represented on the Forum.
• air quality is high on our agenda. The Report by the Committee on the Medical Effects of Air Pollutants: Quantification of the Effects of Air Pollution on Health in the United Kingdom, confirmed the links between air pollution and effects on health. The Report concluded that each year significant numbers of vulnerable people are admitted to hospital or have their deaths hastened because of the effects of air pollution.
• The Government’s National Air Quality Strategy was implemented in December 1997. It establishes health-based standards and objectives for 8 individual pollutants to be met by 2005. The Strategy sets out a new system of local air quality management under Part IV of the Environment Act 1995. Local authorities now have a duty to assess and review their air quality and to identify pollution hot-spots where national policies alone will not deliver the statutory targets. In these cases, local authorities must declare an Air Quality Management Area and develop an Action Plan to tackle the problem. In addition, the Government announced last July an accelerated review of the Strategy in order to consider the scientific basis of the objectives set in the Strategy, and the range of policy options which will help deliver them. The review findings will be announced later in 1998. Last November, the Government launched a new system for informing the public about air quality. This followed extensive consultation to take account both of the concerns that the existing system was misleading in terms of the descriptions of effects on health, and also to ensure consistency with the standards in the Strategy.
• good quality water from both public and private supplies is essential to good health. Although risks from drinking water are small compared with other "life" hazards, it is important that this basic requirement for health is adequately protected. The Government are urging Scottish water authorities to accelerate their investment both in treatment works and in pipes under the ground. The Government are determined that Scottish water should always meet the very highest standards.
• during the last 20 years, the UK water industry has made steady progress in the understanding of lead in drinking water and has moved towards compliance with a lead standard more stringent than elsewhere in Europe. The replacement of all lead communication pipes by water authorities is likely to become mandatory following the introduction of a tighter standard for lead in the revised EU Drinking Water Directive. The Directive excludes the replacement of lead plumbing in domestic properties. However, in recognition of the work involved, the EU have allowed water authorities 15 years to meet the new standard.
• a safe and healthy working environment is an important determinant of the health of the workforce. The Health and Safety Commission and Executive are working on a national occupational health strategy and expect to issue a consultation paper during 1998. This strategy will complement and contribute to the strategy for a healthier Scotland.

112. Many of these environmental factors are raised in the National Environmental Health Action Plan, published in July 1996 and drawn up under the auspices of the World Health Organisation. The Government intend to review the Plan ahead of the next WHO Ministerial Conference on Environment and Health to be held in London in 1999.

Area Regeneration

113. Area regeneration has a key contribution to make to improving health. It tackles the social, economic and environmental problems of multiple deprivation. And it embodies the concerted approach the Government seek to foster.

114. Area regeneration policy is based upon a long-term, strategic approach. It is founded on a partnership approach with all key local and national agencies working together, in conjunction with the local community. This has been developed within the four pilot ‘New Life for Urban Scotland’ Partnerships (Castlemilk, Ferguslie Park, Wester Hailes and Whitfield) and is now being developed within the Programme for Partnership framework. The New Life Partnerships have achieved a high impact in relation to housing, crime, education and employment. In recent years, the Partnerships have begun to tackle health issues more directly by drawing up health strategies, and seeking to tackle lifestyle factors such as smoking.

115. Programme for Partnership now supports twelve Priority Partnership Areas (PPAs) with a 10- year lifespan. Eleven Regeneration Programme areas have also been designated. Health Boards are members of the Partnerships in each area. Each Partnership is required to establish baseline data on health indicators, and to set targets for health gain. This will allow us to monitor the impact of the regeneration process on health in some of our most deprived communities.

116. Regeneration partnerships offer significant opportunities for health gain. There are opportunities for the new PPAs to make use of their block Urban Programme allocations to develop innovative but appropriate local solutions to health issues, and if necessary to fund pilot or developmental work. The PPAs have access to large sums of Urban Programme Funding (ranging in 1998/99 from £760,000 to £3.4m.)

117. The PPAs, existing Urban Partnerships, and Regeneration Programme areas offer scope for the development of work to tackle health inequalities. Partnership areas could bring ‘added value’ to initiatives being developed on a nation-wide basis. For example, a ‘healthy living centre’ developed within a PPA might achieve increased impact as a consequence of additional investment in complementary local services. Health Boards, which have become active in Partnership areas, have discovered that the Partnership process facilitates consultation with local agencies and the local community on service development. There are significant opportunities within Partnership areas to develop innovative approaches to health and health promotion which recognise the circumstances of local people, and to monitor their impact and outcome. For example, Argyll and Clyde Health Board are running a pilot service in the Inverclyde Partnership, through the secondment of a Health Implementation Officer into the Partnership team. The outcomes of this work will be reported to The Scottish Office as part of their formal management agreement. If successful, this pilot could be considered as a model for future reporting arrangements. But there is scope for other models to be tried.

Views are invited on how health improvement can be further integrated into the work of the PPAs and Partnerships.

Healthy Living Centres

118. The Government’s White Paper on the National Lottery, The People’s Lottery, set out our plans for a core network of healthy living centres, funded from Lottery proceeds. This initiative has great potential to improve health. It will be of particular value in deprived communities, and under the criteria we are assembling, preference will be given to projects which target areas and groups with the worst health. Projects may be small or large and there is no set blueprint. There will be scope to be bold and imaginative in utilising what will be substantial sums of money from the New Opportunities Fund to improve our health. Any initiative which has the prospect of improving health in the community will be within bounds.

The Scottish Prison Service

119. The Scottish Prison Service (SPS) is responsible for the primary healthcare of prisoners. Prisoners are more likely to be disadvantaged across the range of factors which determine health. The Government recognise fully the pivotal role which prisons can play in improving the health of the prison population both within the prison setting and beyond. The time in prison offers the opportunity to look not only at direct offending behaviour but also at the associated factors which may have contributed to crime, including drugs, and the ability to function independently in society on return to the community.

120. The Government will, therefore, expect the SPS to help offenders address their offending behaviour, to provide appropriate education, training and counselling opportunities and to continue to work with APEX and other organisations to seek to increase the employment prospects for prisoners on release. In addition, the SPS will continue to ensure that healthcare provided in prisons is in line with Government policies on health and best practice in the community. Within this context, it will work within the WHO healthy prisons initiative. In pursuit of this, Inverness Prison, in collaboration with Highland Health Board, is developing a "healthy prison" project concentrating on the issues of alcohol, diet and co-ordination of care on release. A study has also been put in hand under the Scottish Needs Assessment Programme to review the opportunities for health promotion in prisons in key areas such as coronary heart disease, diet, smoking and exercise.

Lifestyle Topics

Smoking

121. To combat smoking and make inroads into the associated toll of ill-health and premature death, the Government will publish a separate White Paper on tobacco, setting out its overall control strategy, with proposals for action at all levels - international to the individual. That White Paper will consider the steps to be taken forward towards a ban on tobacco advertising alongside a range of comprehensive and integrated supporting measures.

The Government’s smoking strategy will shortly be set out in a White Paper. Views are invited meantime on how best to develop strategies for those most at risk from tobacco: young people and those living on low income.

Alcohol Misuse

122. A strategic review of alcohol issues will start with an evaluation of the structure for tackling alcohol misuse in Scotland. A recent national alcohol symposium has identified areas where action might best be targeted. These include greater involvement of young people themselves in prevention and promotion; learning and teaching about good practice; changing perceptions about excessive drinking; and improved co-operation and co-ordination. Because alcohol is so widely and pleasurably used, the general public is largely ignorant of the cost of alcohol misuse to society. A change in attitudes to underage and heavy drinking is essential.

The Government, in developing an alcohol policy for Scotland, would welcome views on key areas for action. Specific proposals are invited on how best to bring about a change in the culture and to reduce excessive drinking, learning from successful approaches with drink driving.

Drug Misuse

123. Realism about the scale of the challenge ahead and the timescale for results is essential, but the Government believe that we can hit hard on serious harm to health from illicit drugs and the drugs trade, with the right mix of policies and support. In shaping the future attack on drug misuse we will build on those parts of the existing strategy that work best. Much of this work has been supported by all the main political parties in Scotland for many years. A good example is the Drugs Task Force report of 1994 - Drugs In Scotland: Meeting the Challenge, a robust framework for the current action against drug misuse, which has commanded a great deal of support in the field. Drugs Action Teams, an innovation from the Task Force report, have had an important leading role.

124. Another significant element in the fight against drug misuse in Scotland in recent times has been the Scotland Against Drugs Campaign. Our Manifesto for Scotland said that we would step up and refocus the Campaign initiatives at the community level. On taking office we moved quickly to affirm the continuation of the previous Government’s financial support for the Campaign, while indicating that we would look carefully at what should happen after March 1998, in the context of the best way forward for wider consideration of drugs prevention initiatives in Scotland.

125. Some important foundations for future work have been laid. The management of drug misuse has been strengthened through new national objectives, issuing guidance on drug misuse services and introducing a new information strategy. Improving research will be our next target. Understanding is needed of the jigsaw of separate components of the problem and what the effects of environment, personal factors and drug availablity are.

126. Drug misuse cannot be dealt with in isolation. Not all drug misuse problems are caused by social disadvantage: it occurs across all levels of society. But its hardest impact is in deprived areas, in terms of health and community safety.

127. There are complex issues in targeting misuse in areas that are trying to dispel a poor image and make new economic starts. But the infrastructure available through the Partnerships that have now been established in many of Scotland’s most deprived areas offers considerable scope for action on drug misuse.

128. Government, agencies and individual drug workers can do a great deal, but young people, parents, the media, business and individuals representing their communities also need to be engaged. Dynamic alliances to complement existing activities by statutory and voluntary agencies are particularly important for drug misuse, because of its volatile nature, links to crime and widespread lack of knowledge among adults in general and parents in particular.

Views are invited on how to broaden the scope for action in tackling drug misuse, so that both health and community safety issues can be addressed, particularly in areas of high use. How can the interest and support of the wider community, including business and the media, best be captured and made use of? How can community organisations best work with the agencies who specialise in drug misuse? What should be the outcomes sought, and how can they be measured?

Views are also sought on how far preventive work, aimed at young people, should target tobacco, alcohol and illegal drugs together, separately, or largely through broader lifestyle approaches and the wider health determinants.