Reducing health inequalities locally

Councils can make a huge contribution to tackling health inequalities across Scotland. The interaction and relationship with the Scottish Government is pivotal to making a difference.

National recommendations for action:

Funding: Reform the resource allocation to local authorities to ensure that it is based on socioeconomic circumstances of communities.

Income: Reform Council Tax and create fairer local taxation.

Structures: Further work to reform local authority structures -balance between local and regional services and integration with wider public services, particularly the NHS and public health services.

Local recommendations for action:

1. Priorities: This is about priorities and decisions. Tackling health inequalities should be the top priority for councils. All other roles and actions of local government contribute to narrowing inequalities in health, wellbeing, and life expectancy inequalities in their populations.

2. Education and Schools: Ensures schools develop social, emotional, health and wellbeing agendas as a foundation for learning. Schools can do more to promote physical activity and improve the nutritional value of school meals. Free school meals and the provision of breakfast has long been an important public health measure. Resolve the crisis in Additional Support Needs education.

3. Physical Environment. How the environment can be improved including reducing air pollution, a major cause of death in Scotland. Councils and health boards also have a statutory duty to reduce carbon emissions as part of their climate change plans.

4. Food policy. Further action to improve healthy food in schools and other local authority settings. Wider action to improve access, affordability of healthy food. In addition to the key environmental health role in better food safety.

5. Active and Affordable Transport. An active transport plan not only reduces carbon emissions but also contributes to better health. Traffic management measures can reduce accidents that disproportionately impact on poorer areas.

6. Early years provision: This requires universal provision delivered by qualified staff, not just child minding, and can be an important setting to deliver health improvement such as toothbrushing, hand hygiene, dietary habits, and also venue to engage parents and carers.

7. Housing: Council should be building and refurbishing more social housing and supporting a fuel poverty strategy through energy efficiency standards and measures. A warm, dry house is an essential element on any health strategy.

8. Licensing: Using planning and licensing powers to address number and distribution of alcohol, gambling, and unhealthy fast food outlets.

9. Economic powers: Using economic powers support regeneration of disadvantaged communities and help people to find and stay in good quality jobs. Procurement powers should promote fair work practices, including the Scottish Living Wage.

10. Voluntary groups: Supporting community groups that help develop strong resilient communities.

11. Community development and participation: Invest in community development and build better systems to ensure genuine community participation in local policy development.

12. Leisure and culture facilities: Maintaining and developing cultural and leisure facilities that promote good health, ensuring access for all. Improve affordability and access.

13. Exemplar Employers: As employers, develop fair work practices with well designed and paid jobs. Promote healthy workplaces with first class occupational health services.

14. Care services. Social care services should be developed focusing on improving care workers pay, training, working conditions, as well as improving standards and regulations. This also means supporting collective services like day care, which tackle social isolation, particularly for older population.

No serious plan to tackle health inequalities in Scotland can ignore the pivotal role of local government.

Through their planning powers, management of transport and traffic systems, open public spaces, and leisure and cultural services, they can contribute to the quality of the built and social environment. They have powers to promote equality and wellbeing. They work in partnership with the NHS and other agencies such as the police, and voluntary & community organisations to support public health by leading community planning. In short, they make a vital contribution to weaving the social fabric of their areas and seeking to create and sustain healthy places for people to be born, grow, live, work and age.

Rising demand on the NHS and a growing funding gap means that our current health and care system is creaking at the seams. Addressing this requires a shift from the treatment of ill-health to preventing it. Above all health inequalities remain Scotland’s most urgent health issue.

As our National Commission on Health Inequalitiesⁱ highlighted, too often solutions are focused solely around the NHS. In practice many of the policy levers rest with local government and they are well placed to influence the wider determinants of health. Not least because of there close connection to communities and their role in coordinating how best to use all the available assets to promote well-being.

In this paper we make the case for health and well being to be central to the purpose of our councils – recognising that they have to be fairly funded to make meaningful interventions.

How councils contribute to a healthier Scotland

Services like refuse collection, street cleaning, dealing with fly-tipping, and environmental health directly ensure that we avoid ill health by removing the sources of disease from our communities. Living in pleasant surroundings rather than litter-strewn streets and accessing cultural facilities are also good for mental health. Sports centres, parks, and allotments offer free or inexpensive routes for people to keep fit, active and healthy no matter their age or ability. These are essential health services.

Local government also delivers direct health and care services: free personal care for the elderly, care homes support and adaption’s for people living with disabilities and chronic health conditions. These services save lives and are essential to the quality of life of many Scots. Without those lots of people would still be in hospitals, unhappy and costing a great deal more money. Housing is also a key health service. A decent safe secure affordable home is vital to both mental and physical health.

Education and the tackling the educational attainment gap is essential to addressing health inequalities. As well as teaching the subjects children need to pass exams and get jobs, schools deliver a range of health and relationships education. Schools are important settings for implementing healthy food and physical activity policies. Schools are also the gateway to a range of other agencies that can support families like educational psychologists and social workers. Ensuring that children have the best possible start and make good choices about their own lives and health will not only mean they have better lives but that we can look forward to long term savings. What the Christie Commissionⁱⁱ called preventative spending. The Childsmile – national supervised toothbrusing programme in nurseries is a case study in preventative spendⁱⁱⁱ. There is also a crisis in the inclusion and support for Additional Support Needs children in Scottish schools with a postcode lottery in how this is delivered.

The role of the councillor is recognised by NHS Health Scotland in their elected member guidance^iv. They describe the role of the councillor “as very important in terms of influencing the positive health of communities and ensuring the gap between our more affluent communities and individuals and those not so well off, isn’t widened.”. Councillors are the key advocates for their communities and for ensuring tackling health inequalities is central to the purpose and work of the local authority.

Some councillors also have a direct responsibility for the delivery of health services. Every council is represented on their health board, providing the only local democratic accountability health boards have since the decision to abandon direct elections. Others serve on Integrated Joint Boards tasked with coordinating the provision of community health services and social care. Councils also lead community-planning partnerships.

Councils also invest in community development to build local capacity to respond to local needs. Single Outcome Agreements should include clear outcome measures for reducing inequality and health inequalities, together with the commensurate resources targeted on greatest need. This should lead to the development of greater resilience enabling individuals and communities to withstand challenges such as poverty, inequality, worklessness and other factors that endanger health and wellbeing.

Lessons from elsewhere

The transfer of public health from the NHS to local government and Public Health England (PHE) has been viewed in England as a significant extension of local government powers. Public Health England has published a range of resourcesⁱ that promote good practice. Their focus is on good quality jobs, reducing social isolation and improving health literacy. While Scottish local government doesn’t have the same explicit powers, it shows the advantages of better links between public health practitioners and local authority teams. A number of local guidesⁱⁱ emphasise the role of councillors in health.

In London, there is a collective agreementⁱⁱⁱ with national partners to transform health and wellbeing outcomes, inequalities and services, through new ways of working together and with the public. The Marmot Review also includes examples^iv of how local action can tackle health inequalities.

Across Europe, local government and health work together more closely. In some cases unitary authoritie join up community health and other services. Norway, a country of similar size to Scotland does this. Although they would say that the division between acute and community services is just as challenging.

While the centralising tendencies of the Scottish Government means similar structural change is unlikely in Scotland, we can learn the lessons from elsewhere, use relevant resources and adopt best practice that can support local action. The Scottish government has set a direction for public health in Scotland.

Council Health Strategy

The starting point should be a political strategy for the council to engage with a health equality agenda. This strategy shows how the council can make positive interventions, sometimes described as ‘place-shaping’. Sir Michael Lyons in his influential report, ‘Place-shaping: a shared ambition for the future of local government’, described ‘place shaping’ as “the creative use of powers and influence to promote the general well-being of a community and its citizens”. He said that local authorities must use their ability to bring together local stakeholders and develop a vision for their area.

This should be developed in conjunction with community, voluntary groups and trade unions. Councils are the democratically elected representatives of their communities and should use that role positively to improve engagement in health issues. All policies should be measured against their contribution towards reducing health inequalities and resource allocation should be focused on disadvantaged areas.

The strategy should include a health profile that gives councils information about the health of there own residents. This should include data available about health inequalities between different groups, such as men and women, older and younger people, people from different ethnic groups, which enables councils to make interventions targeted at improving the health of groups most in need.

Councils are represented on health boards and Integrated Joint Boards, but rarely take a strategic approach to their role on these bodies. They should take their health agenda forward using these roles.

In a practical sense, councils can help health boards by refinancing health PPP schemes as set out in UNISON Scotland’s Combating Austerity toolkit. The money saved should be invested in tackling health inequalities that address the council’s health strategy.

Co-locating health and local government services is a good way of delivering seamless services, designed by staff and service users from the bottom up. Community hubs as described in the Health Inequalities Commission report and the Reid Foundation paperⁱ, show how this can be done.

Conclusion

Local government can make a huge contribution towards a healthier Scotland. Both directly through the services they deliver and in partnership with the NHS and others. They can bring the authority of local democratic accountability to a wide range of services.

When we focus on the social determinants of health, rather than the medical cause of some specific disease, we see that local government services are health services. Without local government, adults and children would die sooner, would live in worse conditions, would lead lives that made them ill more often and would experience less emotional, mental and physical well-being than they do now.

However, strengthening the role of local government won’t happen by accident. Councils need to adopt health strategies that focus relentlessly on tackling health inequalities. And the Scottish government must stop slashing council budgets to enable councils, and better distribute resources based on socioeconomic deprivation to enable them to deliver their full potential to tackling inequalities in health and wellbeing. Health inequalities will not be eliminated unless we seriously address the social determinants of health – that is where local government must play a key role.