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6. WEALTHIER AND FAIRER SCOTLAND

ANTI-POVERTY ACTION TO REDUCE HEALTH INEQUALITIES

Introduction

1. There is a clear, consistent relationship between the distribution of poverty and that of adverse health outcomes. This paper will briefly review trends in poverty; discuss the relevance of poverty to the specific health inequalities that are priorities for the Task Force; and identify anti-poverty action with the greatest potential for addressing these health inequalities, both at individual level and in regeneration of our most deprived communities.

Poverty is defined in a variety of ways (see technical annex). By regeneration of communities, we mean not only physical regeneration, but a wider set of actions intended to increase economic activity and employment, improve business confidence, deliver better educational outcomes, enhance skills, achieve greater levels of community safety and improve environmental quality.

2. Tackling poverty, inequality and deprivation will support delivery of the Purpose of the Government's Economic Strategy:

To focus the Government and public services on creating a more successful country, with opportunities for all of Scotland to flourish, through increasing sustainable economic growth.

The Government Economic Strategy ( GES) has, of course, set out how we will deliver on that Purpose. The GES's focus is on maximising Scotland's richest resource - its people - and on making Scotland a wealthier and a fairer place. The GES is clear, therefore, that delivering sustainable economic growth must also involve delivering on the Government's three "Golden Rules" of Solidarity, Cohesion and Sustainability.

The Solidarity Golden Rule is the primary focus for the Government's efforts to tackle poverty, inequality and deprivation; it involves providing the opportunities, and incentives, for all to contribute to Scotland's sustainable economic growth.

As outlined in the GES, the Solidarity Golden Rule is backed up by the following time-bound, national target:

Solidarity: to increase the overall income and the proportion of income earned by the three lowest income deciles as a group by 2017.

Work to achieve the Solidarity target will also support the related Cohesion Golden Rule, which gives priority to achieving more balanced growth across Scotland's regions, ensuring that all Scotland's communities have a fair chance to succeed.

The following Purpose target is also of particular relevance to the Task Force:

To match average European ( EU15) population growth over the period from 2007 to 2017, supported by increased healthy life expectancy in Scotland over this period.

3. Although clearly relevant to the anti-poverty and regeneration policy context, actions (e.g. early years interventions) that have been fully addressed elsewhere in this report will receive only a brief reference in this paper. Enterprise and employment themes will be addressed elsewhere.

Trends in poverty within Scotland (1996-2006)

4. Targeted approaches by previous administrations to addressing social and economic exclusion have successfully lifted some sections of the population out of poverty, but the twin challenges of persistent poverty and increasing income inequality across the entire population remain. Although there has been an overall (10%) decline in the number and proportion of individuals who live in poverty within Scotland over the past decade (annex), this decline has not affected population subgroups equally (Table 1).

Table 1: % population sub-groups in relative poverty (before housing costs), 1996-2006

The greatest reduction has been amongst children and pensioners. However, 880,000 people (18 per cent of the population) still remain in relative poverty. The risk of poverty is highest among families with no-one in employment, but a sizeable and growing proportion (38%) of those in poverty live in families where at least one individual is in work. This reflects the fact that over 500,000 Scottish employees are low paid (paid less than 60% of the median full-time hourly wage).

The impact of poverty on health inequalities

5. Health inequalities associated with poverty are increasing. In Scotland, our healthiest communities are moving along a diverging path from those with the worst health and wellbeing; life expectancy continues to rise in the most advantaged areas of the country whilst, at best, remaining unchanged - or falling - in Scotland's poorest communities.

6. There is strong evidence to suggest that poverty is a powerful driver of the most significant health inequalities.

7. Early years: intrauterine growth retardation and low birth weight are much more prevalent among lower socio-economic groups, and a poor start in life results in long term, damage in the structure and function of the developing child. These early biological effects interact with subsequent adverse environmental and behavioural influences to amplify health risks in later life. Strains on families resulting from low household income also influence family functioning, children's emotional development and their subsequent relationships outside the immediate family, behaviour and potential to learn at school.

8. Risk factors for the "big killers": cardiovascular disease and cancer, e.g. smoking: these conditions (jointly responsible for 55% of all deaths in Scotland in 2006) are driven by cumulative life circumstances from the early years onwards. They underpin much of the overall variability in death rates between socioeconomic groups in adulthood. Socioeconomic disadvantage also worsens individuals' outcomes after the onset of chronic disease, including shortened survival and increased likelihood of labour market exclusion.

9. Mental wellbeing and mental illness: in 2006, a national survey of the Scottish population classified 14% as having good mental wellbeing, 73% average and 14% poor. 28% said that they had personally experienced a mental health problem. People on lower incomes and those who lived in more deprived areas were most likely to rate their general health as poor and to be more susceptible to mental illhealth. Those with a low income and resident in a deprived area are known to be at heightened risk of dying by suicide, with the gap between suicide rates in the highest and lowest social classes increasing as socio-economic deprivation worsens.

10. Drugs, alcohol and violence: alcohol and drug use are important drivers of health inequalities in younger people. Detailed analysis of death records between 1981 and 2001 concluded that this was largely explained by socioeconomic disadvantage and was mediated through increasing death rates from suicide, chronic liver disease and mental and behavioural disorders due to the use of drugs and alcohol.

What Anti-Poverty Action is Effective in Reducing Health Inequalities?

11. Actions at a (whole population) regulatory or structural level that seek to improve health and wellbeing are likely to be among the most powerful levers for tackling health differentials associated with income inequality.

12. Evidence presented to the UK Acheson Inquiry into Inequalities in Health in 1997 suggested two legitimate policy responses relevant to the influence of poverty on health inequalities. The first is to accept that widening income inequalities are an inevitable aspect of improved productivity, economic growth and national prosperity, although these positive changes should ultimately lead to an improved health profile for the majority of the population. The second is to implement a fiscal programme aimed at fundamentally arresting and reversing the trend in income inequalities, in the hope that would lead to reduced health inequalities also.

The first of these approaches is out of line with the Government's overarching Purpose. As indicated above, this makes clear that increasing sustainable economic growth should go hand in hand with a fairer sharing out of Scotland's wealth. This recognises that all of Scotland's people are potential assets to be released for the benefit of everyone, and greater social equity will provide the opportunities - and incentives - for all to contribute to Scotland's sustainable economic growth.

Although the second approach is not mainly within the devolved powers currently available to the Scottish Government the Government's anti-poverty discussion (see below) is examining whether devolved powers might be enlarged to embrace key areas related to tackling poverty such as tax/benefits arrangements and welfare to work policy.

Devolved policies can play an important role in tackling the root causes of poverty, through impact on people's life circumstances. These are addressed in the remainder of this paper.

Recommendations for Action

13. Levers are available to the Scottish Government under the current devolution settlement to tackle poverty in 3 broad ways:

• Prevention of poverty and tackling the root causes

• Helping to lift people out of poverty

• Alleviating the impact of poverty on people's lives

These are the subject of Taking Forward the Government Economic Strategy: A Discussion Paper on Tackling Poverty, Inequality and Deprivation in Scotland published by the Scottish Government on 31 January 2008 (available from the Scottish Government website.) This paper is the basis for a national discussion which will lead to the production of a framework for tackling poverty, inequality and deprivation later this year.

14. Tackling the root causes of poverty

14.1 Early Years Influences

Recommendations for reducing health inequalities in the early years of childhood were fully outlined in the Early Years paper and will therefore not be reproduced here. However, it is important that reserved policies address child poverty through redistributive child benefit and tax measures. Some key levers under devolved control include enablers such as changes in employer attitudes and practices, and affordable and accessible childcare, which is often a real barrier to employment.

14.2 Fairer Scotland Fund

The Fairer Scotland Fund ( FSF) is a new fund to be deployed by community planning partnerships worth £145m per year over the next three years. The FSF amalgamates seven previous funding streams and their monitoring regimes. It will support Local Authorities, their Community Planning Partners ( CPPs) and the Third Sector to work together to tackle challenges around poverty, deprivation and employability in their communities. It will focus on the causes of poverty, rather than solely addressing the symptoms, with a strong emphasis on interventions at a sufficiently early stage for vulnerable individuals, families and disadvantaged communities. The FSF will make a major contribution to tackling health inequalities by seeking to lift people out of poverty by helping them towards and into employment, as well as addressing the requirements of those with multiple and complex needs and addressing the challenges faced by those for whom work is not a readily available or straightforward option.

The FSF should promote more effective, outcome-focused, collaboration between local partners at CPP level, with health and wellbeing outcomes at the forefront. Importantly, the FSF will not be expected to 'sort' disadvantage on its own; it will act as the catalyst for galvanising mainstream resources and budgets towards lasting change. Commitment from NHS Boards to the community planning fora and the use of NHS skills and resources will be vital.

The performance management framework supporting the FSF operates within the new framework of national and local outcomes and indicators. Specific outcomes to be delivered will be included in the Single Outcome Agreement ( SOA) between each Local Authority and Scottish Government. CPPs will work in partnership to achieve agreed outcomes relevant to local needs, through investment of FSF and mainstream resources. There is a clear emphasis on achieving key health outcomes, and on delivering on the Government's targets relating to healthy life expectancy and Solidarity in particular.

15. Helping to lift people out of poverty

15.1 Multiple and Complex Needs Initiative

Many public service providers find it difficult to deal with clients who have multiple, or a complex combination of, problems. These clients are often excluded from accessing the services they require and will often be living in poverty.

The Scottish Government's Multiple and Complex Needs Initiative, being run by the Scottish Government's Social Inclusion Division, aims to improve public services for people who may not have benefited from recent improvements to service delivery because they find it difficult to access services and/or to get what they need from them. Pilot projects are exploring ways in which different services can 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 therefore how they can improve service outcomes for them. Of the 14 projects, eight are working with people who have multiple and complex needs as a consequence of health issues such as sensory impairment, HIV/ AIDS, mental health issues in minority ethnic communities and offenders.

An evaluation of the projects is being undertaken to identify what does and doesn't work, and the key lessons learnt will be disseminated to a broad range of service providers. The insights gained, for example in terms of holistic approaches, shifts in staff culture and working across traditional organisational and professional boundaries, will support the Task Force's approach to redesign of public services and provide good practice examples.

15.2 Maximising the Potential of Social Enterprise

Social enterprise is a business model which offers the prospect of greater equity of economic power and a more sustainable society by combining market efficiency with social and environmental aims. Social enterprises have potential for addressing health inequalities directly, through initiatives such as community food initiatives, community transport schemes, housing associations, and leisure trusts. They can provide crucial services and support for vulnerable communities and also employment opportunities. The Scottish Budget allocated a £93.6m transformational package for the Third Sector as a whole. A Scottish Investment Fund (£30m over three years) will support enterprise in the third sector through strategic investment in individual organisations supported by integral business support and management development. It will be helpful if specific criteria for investment include reducing health inequalities.

15.3 Maximising the Potential of Public Sector Organisations in Financial Inclusion

The NHS as a universal service can help connect with vulnerable people to provide information, advice and referral on appropriate financial products and services. These, in turn, can contribute to reducing poverty and alleviating the impact on mental and physical health related to debt and managing life on a low income.

Individuals who are most deprived and most in need tend to gravitate away from financial services and many access them only when their needs are acute, rather than being engaged at an early stage. Innovative models of good practice with wider potential for replication include the following:

• The Financial Services Authority is collaborating with the Royal College of Midwives to distribute its free "Parent's Guide to Money". The guide was developed with help from parents and health professionals. It tells parents what they need to know about all aspects of finance and helps them to benefit from financial support and to make sound financial decisions.

• The Perth Citizens Advice Bureau has successfully piloted outreach services in a pharmacy in Blairgowrie. This has helped provide advice - particularly on benefits - to those who are sick, long-term ill or disabled.

• North Lanarkshire Council and the Scottish Association for Mental Health have collaborated on a project to reduce the impact of financial exclusion experienced by unemployed people with mental health problems. The focus has been on key issues of accessibility to advice services, the health impacts of increasing money advice and income maximisation and the role that improved welfare benefits advice can have in promoting employability.

• Renfrewshire Council have supported a financial inclusion advisor to work with Cancer and Palliative Care patients. The service provides home visiting, surgery and hospice based advice and assistance on benefit reviews, applications and representation, as well as money and debt management advice. By supporting patients and their families it is hoped that the impact of ill health and job loss will be minimised. The success of this approach has been recognised with Macmillan Cancer Support funding provided to expand the project.

• Citizens Advice Bureaux are working in 11 GP practices across Edinburgh to provide money and welfare rights advice to vulnerable patients.

Local Community Health Partnerships ( CHPs), can play a key role in maximising beneficial joint working between the NHS and financial inclusion services through engaging with people at risk of poverty and linking them in with appropriate financial inclusion activity.

15.4 Early Intervention on Poverty to Promote Mental Wellbeing and Prevent/Minimise the Health Impacts of Alcohol and Drugs Misuse

As noted above, there are strong correlations between poverty and the incidence both of mental health issues, and health issues related to alcohol and drugs misuse. It is suggested therefore that the work being taken forward on Towards a Mentally Flourishing Scotland and on strategic approaches to tackling alcohol should link closely with the anti-poverty discussions being undertaken by the Government, with a view to identifying 'upstream' anti-poverty interventions that can contribute to the promotion of mental wellbeing and reduce the negative health impacts of alcohol and drugs misuse.

16. Alleviating the impact of poverty on people's lives

Scottish Government policies in a number of areas can help to improve the quality of life of people currently living in poverty, working in tandem with UK Government fiscal policies. Current Scottish action includes freezing/phasing out of Council Tax, free school meals, free prescriptions, free personal care and concessionary travel for disabled and older people.

16.1 Promoting Benefit Take-up

Although take-up of means-tested benefits has reached a plateau, some £4 billion a year still goes unclaimed across the UK. There remains a need for high quality welfare rights services, with careful consideration of their range and accessibility. For example, locating advice services in primary care can help to reach older and disabled people. The extra resources acquired by clients tend to be directed towards extra spending on fuel, food, education, recreation and transport, with resultant improvements in general health, living standards, reduction in social exclusion and local economic benefits.

Scottish Government has been exploring with DWP, its agencies, HM Revenue & Customs and a range of other bodies, what role we might play in helping people maximise their benefits and tax credits. Pilot benefits take-up campaigns directed at older people and a longer term initiative designed to maximise benefit take-up across a range of eligible people is now being planned by a broad partnership involving UK and Scottish Governments and NHSScotland. An important part of this work will be to examine increase benefits and tax credits in order to help improve the health and wellbeing of claimants.

Local projects could also be scaled up. In a scheme in Glasgow, members of the West of Scotland Seniors Forum operate a freephone information "hotline" operated by older volunteers who have undertaken intensive training programmes and provide advice to other older people on keeping warm in the winter and accessing the help available. The volunteers also provide practical assistance to people who are having heating or insulation fitted: for instance, taking someone out for the day while work is being carried out. Although there is no clear evidence about the health gain to be secured from alleviation of fuel poverty (see below) promising and practical initiatives such as this one could be replicated elsewhere and their impact on health evaluated.

16.2 Tackling Fuel Poverty

Fuel poverty - not being able to heat a home to an acceptable standard at a reasonable cost - is caused by a combination of three factors; low household income, high fuel costs and poor energy efficiency in the home (in terms of ineffective insulation and inefficient central heating and often poor housing design). Progress in reducing fuel poverty was made between 1996 and 2002 as fuel prices fell but this has subsequently reversed, in parallel with the steep increases in gas and electricity prices which occurred from 2003 onwards. As the Scottish Government only has control of the energy efficiency element of fuel poverty, it is very difficult to act effectively when fuel prices rise or when incomes do not rise sufficiently to offset the price rises. However the Scottish Government has been able to successfully raise the energy efficiency of the housing stock over time, though still more progress is required on this front.

A range of measures aimed at addressing fuel poverty has been in place for some time, The bulk of Scottish Government funding is concentrated on the Central Heating Programme ( CHP) which is available very widely across the pensioner population of Scotland, depending on whether pensioners require their first central heating system or a replacement system for one that has broken down. Such is its popularity (even without widespread publicity) this programme currently has a 5-6 month waiting list (broadly around the historical average) and a priority scheme has recently been introduced to help those without heating or hot water. The CHP in particular has been running since 2001 and now only 3% of Scottish pensioner households have no form of central heating. It is therefore somewhat surprising that fuel poverty has risen so steeply in recent years.

Evaluation of these initiatives, which have themselves changed in character and scope over time, has been somewhat limited to date. There are inevitably lessons to be learnt from existing programmes - where these have worked and where they have failed - helping to improve their effectiveness and inform the development of future schemes. This is why the Scottish Government has announced an internal review of fuel poverty programmes, the main findings of which will be shared with stakeholders in early 2008.

The benefits of installing central heating in particular were assessed in a recent University of Edinburgh study but it stopped short of saying that the wider availability of central heating was bringing identifiable health benefits across Scotland. As there is no clear evidence about the health gain to be secured from alleviation of fuel poverty and in particular central heating, it is imperative that programmes are accompanied by a well designed health impact assessment.

February 2008

TECHNICAL ANNEX: POVERTY IN SCOTLAND

Poverty is defined and measured in different ways. At its simplest, poverty can be defined as low income. However, although low income is a major component of poverty, it is usually found in association with a broader set of closely connected factors associated with social disadvantage, including unemployment, poor skills, poor housing and fractured personal and family relationships.

Poverty can be considered in absolute or relative terms. Absolute poverty refers to a set standard which does not change over time. Relative poverty is defined as having a household income less than 60% of the current UK median after adjustment for household composition.

For a single person, to be poor is to live on less than £145 per week, before housing costs. The equivalent figure for a couple is £217, or for a couple with two children aged 5 and 14, £332 per week.

There are 880,000 individuals living in relative poverty before housing costs in Scotland. This represents 18% of the population.

The number of people in poverty in Scotland has fallen by 10% in the last 10 years. The reduction has been greatest amongst children and pensioners. However last year the number of working age adults in poverty rose by 10,000.

Chart 1: Number of people in poverty, Scotland 1995-96 - 2005-06

Source: Family Resources Survey, Households Below average Income datasets.

ENTERPRISE AND EMPLOYMENT ACTION

Introduction

1. This paper will, firstly, consider how health inequalities are influenced by employment and wider macroeconomic conditions; and, secondly, identify relevant policy actions with the greatest potential for addressing Scotland's growing health inequalities.

2. The Government Economic Strategy ( GES) provides the route map for this Government to deliver on its overarching Purpose, increasing sustainable economic growth (Figure 1).

Figure 1: Key components of Scotland's Government Economic Strategy

3. One of the key components of economic growth is increased labour market participation. Despite improvement in labour market participation compared with our historic position, Scotland still lags behind the strong regional economies in the South East of the UK. Over 600,000 people in Scotland are classified as economically inactive; latest figures show that 285,000 people of working age (representing 9% of the working age population) are Incapacity Benefit claimants. Increased growth is dependent on the creation of more employment opportunities in Scotland and on ensuring that more of our working age population become economically productive.

4. The GES is, however, targeted at making Scotland wealthier and fairer. Therefore, delivering on sustainable economic growth must also involve delivering on our three Golden Rules of Solidarity, Cohesion and Sustainability. The Solidarity Golden Rule is directly relevant to increasing employment opportunities in Scotland; it involves providing the opportunities, and incentives, for all to contribute to Scotland's sustainable economic growth. Moreover, the related Cohesion Golden Rule, involves putting greater priority on achieving more balanced growth across Scotland. As indicated in Paper 15, the Solidarity and Cohesion Golden Rules are underpinned by the following time-bound, national targets:

Solidarity Golden Rule: to increase the overall income and the proportion of income earned by the three lowest income deciles as a group by 2017.

Cohesion Golden Rule: to narrow the gap in participation between Scotland's best and worst performing regions by 2017.

5. As shown in Figure 1, population growth is one of the three key drivers of increased GDP growth. Accordingly, Scotland's GES recognised that this will be achieved by a combination of changes, including inward migration and increased healthy life expectancy. It therefore defines the following population growth target:

To match average European ( EU15) population growth over the period from 2007 to 2017, supported by increased healthy life expectancy in Scotland over this period.

The influence of employment and macroeconomic conditions on health inequalities

6. Being in employment has powerful health enhancing ppotential, because:

• Employment is generally the most important means of obtaining adequate economic resources, essential for material wellbeing and full participation in today's society.

• Work meets important psychological and social needs in societies where employment is the norm.

• Work is central to individual identity, social roles and social status.

• Employment, education and income are the principal drivers of the steep socio-economic gradients observed in mortality, physical and mental health outcomes.

7. In their 2006 systematic review, Waddell & Burton concluded that, on balance, being in "good work" is generally better for health and wellbeing than unemployment. It identified the following workplace characteristics through which people gain benefits from employment:

• Safety

• Fair pay

• Job security

• Personal fulfilment and development, balancing effort and reward

• Good communication

• Control over pace of work and key decisions that affect the workplace

• Task discretion, minimising requirement for monotonous and repetitive work

• Skill levels allow employees to cope with periods of intense pressure

• Accommodating, supportive and non-discriminatory

• Social capital is supported through informal friendship networks or formal associations, enhancing resilience

8. Economic growth can provide both benefits and risks to health.

Potential benefits include:

• Increased consumption of goods and services

• Reduced unemployment and poverty

• Greater wellbeing, although wellbeing may not increase above a certain level of income

• Improved public services

Potential harmful consequences include:

• Problems from increased consumption, including obesity and alcohol related harm.

• Environmental consequences of growth, such as increased urbanisation, loss of green space, decreased biodiversity and pollution.

• Increased working hours, poor work-life balance and mental health problems.

• Increased income inequality.

• Increase in crime and social exclusion, due to polarisation and inequality.

As indicated above, the focus of the GES is to promote the benefits of economic growth, and, through the achievement of the Golden Rules, to negate the potentially harmful social and other consequences of that growth. Evidence shows that comparable independent nations, particularly Denmark, Finland and Norway, have achieved higher than average economic growth whilst retaining considerably greater social equity than Scotland.

9. With respect to the key health inequalities identified by the Task Force, the following points should be noted:

• Early years: Two-thirds of all low-paid employees in Scotland are women. If affordable childcare is unavailable, this exacerbates household poverty and other adverse environmental influences in the early years.

• Cardiovascular disease and cancer: In combination with other factors that show social clustering in time and place (including educational attainment, income, the social environment, individual behaviour and prevailing economic circumstances), worklessness is an important contributor to cardiovascular health inequalities. Job insecurity and short term work represent part of the continuum of adverse employment circumstances, with growing evidence that these new patterns of employment also exert an adverse impact on cardiovascular risk factors.

• Mental wellbeing and mental illness: Worklessness and poor working conditions are strongly associated with poor mental health, with some evidence that this is a major causal pathway underpinning the cardiovascular mortality effects discussed above. The Labour Force Survey 2005-06 estimated that 10.5 million working days were lost from work in the UK due to stress, depression or anxiety (43% of all days lost).

• Drugs, alcohol and violence: People from the most deprived areas in Scotland are three times more likely to be admitted to hospital with an alcohol-related diagnosis than people from the most affluent areas and men from the most deprived areas are seven times more likely to die from an alcohol-related condition than men from the most affluent areas. There are inevitably consequences for people's productivity and ability to sustain employment.

What types of economic and employment policies can reduce health inequalities?

10. As discussed at an early stage in the Task Force's work, actions at a regulatory or structural level have potential to reduce health inequalities as well as interventions at an individual level.

With respect to this policy area, two reserved matters might be raised as part of the National Conversation; these are Health and Safety legislation and the UK's current "Welfare to Work" arrangements. Given the substantial overlaps between the regulatory aspects of Health and Safety and devolved responsibilities for workplace health and wellbeing, devolution of Health and Safety legislation could improve efficiencies, synergise health promotion and health and safety functions and achieve better prioritisation of the Scottish Government's strategic objectives. Devolution of aspects of 'Welfare to Work' policy could potentially create a more seamless set of employability arrangements to move workless people towards and into the labour market.

11. The Scottish Government's existing powers can be used to reduce health inequalities. Action within these powers can broadly be categorised as follows:

• Policy action at individual level.

• Policy action directed towards workplaces and employers.

• Policy action at the wider economic level.

12. Action at individual level principally concerns a range of employability initiatives. By "employability" we mean the combination of factors and processes which enable people to progress towards or get into employment, to stay in employment and to move on in the workplace. Evaluations of employability initiatives suggest that the following factors are important determinants of effectiveness:

• holistic, client-centred, customised provision of training and support.

• based on assessment of local demographics, social environment and market demand.

• build on existing service provision.

• credible with employers and potential clients.

13. Action directed towards workplaces and employers seeks to ensure that work is sustainable, is not counterproductive to physical or mental health and wellbeing and offers the possibility of progression to pay levels that protect people from poverty. It also offers opportunities to actively promote healthy lifestyle choices, by offering, for example, healthy food choices, physical activity opportunities and smoking cessation services.

14. Health inequalities are fundamentally shaped by the wider economic environment, thus policy actions at this level are very powerful levers for achieving more equitable health distribution. Relevant "upstream" action includes balanced development and integration of both the enterprise and health agendas, building supportive business environments and systematic investment in learning and skills.

Recommendations for policy action

15. Policy action at individual level

A wide range of employability interventions seeks to move people closer to, or into, work. What is suitable for an individual will be determined by the reason for their being out of work, the nature and degree of any incapacity, their skill level, and the length of time they have been out of work.

Workforce Plus is Scotland's employability framework, with delivery of national targets to reduce economic inactivity in seven local authorities. Action is delivered via local Workforce Plus partnerships and the approach is now being replicated more widely.

a) Improving services that get people into employment

NHS Boards need to work proactively with community planning partners and local Workforce Plus partnerships to enable people to retain or return to work.

Working for Families helps parents and carers to access employment, training or education by providing additional support, in particular, with affordable childcare. The approach operated over the last four years across 21 Local Authorities; decisions around its future mainstreaming will be made by Community Planning Partnerships based on local needs. However, given the positive outcomes achieved to date, it is expected that many aspects of Working for Families will continue, with potential for new areas to adopt it, using resources identified within the Fairer Scotland Fund.

b) Stronger focus on people with specific problems/out of work longer

Workforce Plus acknowledges the need to deliver person-centred services that meet the needs of individuals, whilst offering greater support to some specific groups. Accordingly, well designed interventions use person-centred approaches to initial engagement, including outreach work, to engage with those who are furthest from the labour market. Workforce Plus also has a particular focus on helping clients with learning disabilities and mental health problems; it has appointed a learning disabilities co-ordinator to help Community Planning Partnerships progress their work on employability in the context of learning disability. It has also commissioned the Scottish Development Centre for Mental Health to support Workforce Plus partnerships, locally and nationally, in achieving the objectives of Workforce Plus for people experiencing mental illness.

The Welfare Benefits system is currently a reserved competency and any changes to the existing eligibility criteria and its assessment system would require negotiation at UK level.

c) Achieving a more effective NHS contribution

It is essential that senior management in Health Boards and CHPs understand the important link between health and work in order to develop health services that reflect this. One of the key learning points from a "Working for a Healthier Scotland" conference in November was the need to secure "buy in" at a strategic level that employability is a major part of the jigsaw to improved health and wellbeing.

Healthcare professionals, particularly GPs and others in Primary Care, are well placed to work with patients who would benefit from being supported either directly into employment or, more commonly, into services that will help those at a distance from work to progress towards employability. However, employability is a complex field and it is clear that much more needs to be done to help healthcare professionals understand more easily where they can refer patients in their journey towards improved employability and enable their patients to access employability services appropriate to each person's individual circumstances, such as additional therapy, rehabilitation, skills and training. Achieving these aims in a systematic way will require work with NHS Boards, Community Health Partnerships ( CHPs), the Royal Colleges and associated training providers to develop an understanding of the beneficial links between work and health and enable health professionals to access appropriate services for their patients.

The Condition Management approach is currently used by health professionals as part of the Jobcentre Plus Pathways to Work programme. Early engagement through general medical practices can be successful, providing that local support services are part of the engagement and wider delivery system. An employability adviser in a Paisley general practice setting engages with the practice healthcare team, providing simplified routes to Jobcentre Plus and its associated services. This has achieved improved health for patients and successfully changed cultures within the practice in relation to employment.

d) Supported employment schemes

Supported employment is a widely recognised method of assisting disadvantaged individuals into the labour market by providing a range of client-focussed interventions to support clients and employers. The Scottish Union of Supported Employment ( SUSE) has set out a blueprint outlining roles and responsibilities of different organisations in promoting and delivering supported employment, from early engagement to finding work and aftercare support, citing quality standards as a crucial element.

16. Policy action directed towards workplaces and employers

a) Increase awareness of business benefits derived from investing in workplace health

Evidence from around the world shows that investing in workplace health and wellbeing makes good business sense. Employers who have invested in making the workplace more pleasant, have given employees more power over how they do their work and have engaged with their workforce on measures that promote health and wellbeing have reported a significant return in workforce loyalty, a better image in the community, reduced sickness absence, improved morale and increased productivity.

b) Use effective approaches to influencing employers more consistently

Evidence is emerging on the motivating factors that drive businesses to adopt healthy working policies in the workplace. However, workplace health promotion currently tends to be the preserve of more enlightened businesses, who take a holistic rather than purely financially-based view of the benefits. More employers need to be convinced of the strong business case underpinning healthy workplace strategies to encourage their widespread adoption, particularly in small and medium sized enterprises ( SMEs). Further case studies are needed on the range of business benefits, as well as encouraging existing Healthy Working Lives award winners to be champions and mentors. These activities need to become more systematic through the existing business support infrastructure.

c) Specific action on improving mental health in the workplace

The economic consequences of lost working days in the UK due to stress, depression or anxiety are profound, accounting for over 40% of all days lost. However, a recent survey of 500 UK companies found that 80% had no policy to deal with stress or mental ill health in the workplace and only 3% believed they had an effective policy. Only 37% of employers indicated that they would consider employing someone with a mental health problem.

Specific areas of activity to address mental health issues include:

• Risk assessment for work-related stress using the Health and Safety Executive ( HSE) guidance "Tackling Stress: the Management Standards Approach".

• Raise awareness of those groups who may be particularly subject to bullying and harassment in the workplace through good equal opportunities policies, anti-discriminatory practices and clear routes for reporting problems.

• Eradicate stigma and discrimination against people with mental health problems, especially amongst employers.

• Training resources for employers and managers on tackling stress in the workplace and managing people with mental health difficulties.

• Support rehabilitation and provision of psychological therapies.

d) Implementation of Scottish Action Plan on Health and Safety

The Action Plan, published in March 2007, contains non-legislative measures to achieve some broad outcomes which contribute to reducing health inequalities through safe and healthy work. These include:

• Expansion of business access to health and safety advice and occupational health support via a range of complementary routes.

• Increased worker involvement in health and safety.

• A role for Scottish Government as "standard-bearer" for the health and safety performance of Scotland's public sector.

Delivery is being coordinated in partnership with a range of organisations who make up Scotland's "health and safety system".

e) Extend availability of vocational health and rehabilitation services

Health and safety legislation requires management of workplace risks which could cause ill health or exacerbate existing conditions. However, evidence shows that occupational health is not well understood, especially by small businesses, and that occupational health provision and adoption of rehabilitation policy is very low. In response to this, the SCHWL is developing an "intelligent customer" function to give practical advice on the type of occupational health services appropriate to individual businesses. This is likely to include referral to NHS and other specialist services where appropriate.

In particular, better coverage of SMEs is needed, where organisations do not have their own occupational health provision. Potential solutions include bringing together occupational health advice and provision for SMEs in a local area contract and encouraging larger employers to extend their provision down their supply chains.

The NHS is frequently the first contact point for those with conditions that may compromise their ability to gain or maintain employment. There is a need for improved, rapid access to relevant treatments in order to support a return to work as quickly a possible.

17. Action at the wider economic level

Several specific actions within the five channels of the GES Strategic Priorities have powerful potential to influence health inequalities in Scotland. These include; enterprise support to geographical areas facing multiple deprivation; improved planning systems that balance development of good quality, health promoting and sustainable places with the requirements for economic growth; support to businesses employing people from deprived communities; and ensuring that the supply of education and skills in Scotland can respond to employer demand.

a) Improved integration of spatial planning and health agendas

The GES outlines a set of actions that will create a more streamlined approach to planning and development across urban and rural Scotland. This will ensure that planning systems optimise the requirements for economic growth in ways that support the health promoting potential and sustainability of geographical communities.

b) Improved integration of enterprise and health agendas

Workplace health is typically viewed as an issue belonging to "health" not "business" - the SCHWL, for instance, operates under the NHS. The fact that the community of professionals working towards a "healthy workforce" are drawn almost exclusively from the health community limits the potential progress of initiatives to address health inequalities in the workplace.

Business Gateway will be in a position to influence employers' attitudes and behaviours towards the health of their workforce, and that of potential recruits.

c) Learning and skills

Scotland's Skills Strategy (2007) aspires to a Smarter Scotland that engages more effectively with a globally competitive economy, based on high value jobs. It seeks to promote progressive and innovative business leadership, entrepreneurship and innovation, where small businesses are encouraged to grow, with strong, coherent support for businesses of all sizes. The Strategy also contains a strong equity dimension that seek to ensure that all people in Scotland can realise their aspirations and achieve their potential.

d) Investment in Urban Regeneration Corporations and major infrastructure projects

The Scottish Government is investing a total of £87 million in Urban Regeneration Companies ( URCs) over the SR 07 period, which is expected to lever over £500 million of private sector investment. The Government are keen to see URCs bridging the gap between physical, economic and social regeneration and, as such, have encouraged them to take a holistic approach to the regeneration of their areas, recognising that although much of their investment will be in place transformation, many of the outputs and outcomes needed if an area is to be regenerated will relate to areas such as employability, educational attainment, community safety and health.

As a result, the URCs have an important coordination role to ensure that their respective work programmes are complemented by interventions aimed at achieving outcomes in these areas, many of which will be the responsibility of local partners. The URC network are also developing approaches around the use of community benefit clauses in procurement to ensure that opportunities for people in the most deprived communities are maximised. The extent to which this is achieved will be captured in the monitoring and evaluation framework that is being developed to monitor the impact of the URCs' activity.

e) Maximising the contribution of public sector organisations

Thirteen NHS Boards are involved in pre-employment activity, with each Board having developed clear, structured and well supported pathways for people from marginalised groups to access employment opportunities. A draft business case and a "gold standard" template detailing success factors for successful implementation, continuation and mainstreaming of pre-employment activity has been developed. These resources will help Boards to build the case for widening their recruitment pool as part of standard employment practice.

Social and environmental requirements can be included in public contracts if they comply with the requirements of EC Treaty Principles (including equal treatment, transparency and proportionality) and procurement rules. The Community Benefits in Procurement ( CBIP) programme has enabled piloting of the methodology for including targeted recruitment and training opportunities in public sector contracts in a manner that is consistent with procurement legislation. It has identified key lessons for the public sector to facilitate the inclusion of the community benefit clauses in future contracts.

Conclusions

This paper has identified specific policy actions at individual, organisational and the wider economic environmental levels that all have the potential to increase or decrease existing health inequalities. Understanding the net effect of these actions on health inequalities is complex and will necessitate use of health impact assessment and evaluation approaches alongside adoption of new policy actions.

February 2008

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