Detecci´ on de caracter´ısticas principales

Introduction

This section explores the overarching policy context for primary care and mental health in Scotland, and focuses particularly on policy drivers for improving health and well- being in the Scottish population.

Vision and priorities for Scotland

At the time of writing, the document that set the agenda for policy in Scotland from the governing administration was the Partnership Agreement (Scottish Parliament, 2003), a joint statement from the leaders of the Scottish Labour Party and the Scottish Liberal Democrats. The Partnership Agreement stated a set of principles for all Scottish policy as follows:

ƒ Growing Scotland's economy (themes: enterprise and lifelong learning; transport; rural)

ƒ Deliver excellent public services (themes: improving public services; health; education)

ƒ Support stronger, safer communities (themes: children and young people; justice; social justice; sports, culture and the arts)

ƒ Develop a confident, democratic Scotland (theme: governance).

Objectives based on the above principles were outlined in the spending strategy Building

a Better Scotland: Spending Proposals 2005-2008, Enterprise, Opportunity, Fairness

portfolio in a budget statement, with the most recent budget statement at the time of writing being the Draft Budget Statement 2007-2008 (Scottish Executive, 2006c).

Building a Better Scotland stated that growing the economy was the top priority for the

Scottish Executive in order to raise the quality of life for people in Scotland. Improving public services was to be achieved by increasing the levels of investment with a focus on people receiving them. Scotland's health is mentioned in the strategy as a key challenge, with priorities for health including staff contracts, re-designing services to meet the needs of patients and putting health promotion at the heart of long term plans. Efficient Government was another key objective, with a target set to achieve annual efficiency savings. Local authorities, health boards and other public bodies which make efficiency savings from within their spending allocations would be able to retain those savings and redirect them to their own frontline services. Safe, strong and sustainable communities were regarded as being essential for economic growth with housing, environment, access to support and advice and increased public participation being key arenas. The Health and Community Care section introduced for the first time in Scotland, a target to reduce health inequalities by increasing the rate of improvement for the most deprived communities by 15%. Indicators for monitoring progress on health inequalities were to be coronary heart disease, cancer, smoking, smoking during pregnancy, teenage pregnancy and suicides in young people.

Political portfolios

The Draft Budget Statement 2007-2008 (Scottish Executive, 2006c) outlined 12 areas of responsibility for nine ministerial portfolios and three specialised areas. The ministerial portfolios were: Communities; Health and Community Care; Transport; Education and Young People; Finance and Public Service Reform; Environment and Rural Development; Tourism, Culture and Sport; Enterprise and Lifelong Learning; and Justice. The other three areas of responsibility were: Scottish Executive Administration; Crown Office and Procurator Fiscal; and the Food Standards Agency. There were also four cross-cutting themes to which all portfolios had to demonstrate their contribution and these were: growing the economy, closing the opportunity gap, equality and sustainable development. The cross-cutting themes were explained in more detail in the following documents:

The Framework for Economic Development in Scotland (Scottish Executive, 2004c)

identified productivity as the critical factor in improving Scotland’s economic growth and living standards. Education, entrepreneurial skills, electronic and physical infrastructure and efficient management of resources were key elements.

Closing the Opportunity Gap (Scottish Executive, 2004a) dealt with tackling poverty and

disadvantage by increasing access to services and opportunities for all, and closing the gap between the most disadvantaged communities and the Scottish average. Key elements were employment for vulnerable and disadvantaged groups, improving children’s confidence and skills, regeneration of deprived communities and increasing the rate of improvement in people’s health status. The health inequalities targets were to be monitored under this theme.

The Equality Strategy (Scottish Executive, 2000) intended to underpin everything the

Scottish Executive does. It aimed to remove discrimination on the basis of gender, ethnicity, disability, sexual orientation, age, faith or religion. Promoting equality, tackling discrimination and addressing inequality were stated as fundamental to delivery of the four main Scottish Executive principles.

Choosing our Future: Scotland’s Sustainable Development Strategy (Scottish Executive,

2005a) aimed for a sustainable, innovative and productive economy with high levels of employment and a just society which would promote social inclusion, sustainable communities and personal well-being. Protecting and enhancing the environment and using resources efficiently were key aims.

Health and Community Care Portfolio

The main focus for the NHS within the Health and Community Care Portfolio as stated for 2007 – 2008 was to meet targets from the most recent health strategy, Delivering for

Health (Scottish Executive, 2005b), including focusing on preventative medicine,

targeting action to address inequalities in health, increasing access through improving waiting times, service re-design, a new mental health delivery plan, new hospitals and more local diagnosis and treatment. Research was described as being funded by a combination of non-commercial, commercial and internal sources. It was notable that funding from one pharmaceutical company for a new health care research initiative was at almost the same level as the non-commercial and internal sources combined (£33m versus £39m). The Draft Budget Statement 2007-2008 stated that Scottish health care research had been shown to be the most productive in the world. Consequently, health care was said to contribute to the economy by attracting substantial resources for health care research as well as by ensuring that the labour force remained healthy and available for work.

Objectives for mental health services were said to be to develop and improve their focus on promotion, prevention, protection, quality, care and recovery, and they should be

delivered in hospitals, people's own homes and in communities. The community care elements of the portfolio included investing in social care services through local authorities and the voluntary sector to promote independence where possible, support carers and to reduce inappropriate admissions and long stays in hospitals.

At the time of writing, the Scottish Executive Health Department worked through 14 area-based and 8 special NHS Boards, and provided additional funding allocations to national priorities. Approximately 80% of health spending in Scotland was allocated to the area NHS Boards to improve health and to provide integrated health and community care services (Scottish Executive, 2006c). Allocations to each NHS Board and to GP Prescribing were based on a formula recommended by the Arbuthnott Committee, which was based on four main indicators as follows:

ƒ The size of the NHS Board population

ƒ The age and sex profile of each NHS Board population

ƒ Levels of ill health and life circumstances in each NHS Board population ƒ Excess costs of delivering services in rural and remote areas.

The Arbuthnott Formula had been in use since 2001 and was reviewed in 2006 in order to take into account new information becoming available such as data on ethnicity, equity issues explored through unmet need pilot initiatives and to include other health services such as pharmacy and dentistry. The revised formula was expected to be approved in 2007 (NHS Scotland Resource Allocation Committee, 2006).

Policies and strategies for health and well-being

The White Paper driving NHS service delivery in Scotland, at the time of writing, was

Partnership for Care (Scottish Executive, 2003d), and Towards a Healthier Scotland

(Scottish Office, 1999) was the most recent White Paper for public health. In addition, key Scottish Executive Health Department strategies for primary care, mental health and improving health and well-being included:

ƒ Framework for Mental Health Services, 1997 ƒ Improving Health in Scotland: The Challenge, 2003

ƒ National Programme for Mental Health and Well-Being Action Plan 2003-2006 ƒ The Quality and Outcomes Framework for GPs (QOF), 2004

ƒ Community Planning Statutory Guidance, 2004 ƒ Delivering for Health, 2005

ƒ Community Health Partnership Statutory Guidance, 2005 ƒ Delivering for Mental Health, 2006.

NHS Boards make their own decisions about spending within a framework of standards and priorities which changes over the years. At the time of writing this was outlined in the Scottish Executive Health Department Delivery Plan Objectives and Targets within the Draft Budget Statement 2007-2008 (Scottish Executive, 2006c). Each NHS Board was to develop and agree an annual Local Delivery Plan based on these objectives, incorporating a range of linked performance measures.

The NHS in Scotland was undergoing rapid change over the lifetime of the study presented in the thesis, and a recent history of developments is discussed here in order to describe the context for the study and the direction of travel for primary care and mental health services. One of the changes was that Community Health Partnerships (CHPs) replaced Local Health Care Cooperatives (LHCCs) as the structures under which primary care and mental health were managed and organised. The other main development was that Delivering for Mental Health (Scottish Executive, 2006a) was published in the month after the data collection was completed. Delivering for Mental

Health was not included in the policy analysis carried out for the study (described in

Chapter 4) as it was published at a time that was too late to drive change within the study period. However, it was included in the review of policies in this Chapter in order to identify future directions for mental health policy in Scotland.

Development of Community Health Partnerships and integrated service delivery

Designed to Care (Scottish Executive, 1997) was the Scottish White Paper which

introduced a modernisation programme for the NHS of dismantling the internal market and working towards a system of integrated care. Primary care was to be delivered through Primary Care Trusts (PCTs) and Local Health Care Co-operatives (LHCCs). Scottish PCTs would have fewer budget holding responsibilities than their English counterparts, but provided staff such as nurses, allied health professionals and health centre management and were later (from 2002) merged with NHS Boards. LHCCs were to work in association with GPs, dentists, pharmacists and opticians who remained as independent contractors but were encouraged to be given places on boards of LHCCs. Objectives for LHCCs were described as providing services to patients, working with public health to plan for meeting the defined health needs of the LHCC population, clinical governance and to develop population-wide approaches to health improvement and disease prevention (Scottish Executive, 1997). The White Paper’s plans introduced clear moves towards working in partnership with other agencies and for integration between primary care and the acute sector, and between primary care and social care services. This also introduced an objective for primary care to begin to take a population approach to improving health as well as to deliver services to individual patients.

In a separate but linked policy process, a national collaborative group called the Joint Future Group was set up by the Scottish Office in 1999 (Joint Future Group, 2000) to support the move towards integration between health and social services, including co- located services with joint funding and joint management. The Group was initially to focus on older people but then to move onto other client groups, and reforms eventually included services for people with learning disabilities, and people with alcohol and drug problems.

A survey in 1999 found that local working between LHCCs and social work had developed substantially since the introduction of LHCCs particularly in relation to community care, although joint working between primary and secondary care was less developed (LHCC Best Practice group, 2000). Recommendations from this report influenced the objectives of the next re-structuring of LHCCs.

The process of integration and further reform in Scotland continued in the next NHS White Paper Partnership for Care (Scottish Executive, 2003d). LHCCs were to evolve into Community Health Partnerships (CHPs) but the new bodies would have statutory underpinnings instead of being voluntary groupings, and would be part of the NHS Boards. CHPs were to establish a substantive partnership with Local Authorities (social work, housing, education and regeneration were specified), patient involvement through establishing Patient Partnership Forums for patients and staff, have more devolved budgetary responsibilities and a duty to promote health improvement (Scottish Executive, 2003d). The White Paper also required health boards to work with local authorities to ensure more effective working with social care in appropriate locality arrangements, and to integrate the management of primary and acute services. CHPs were expected to play an increasingly central role in integration of services locally as they matured into their partnerships in order to improve the health of local populations as part of an ongoing programme of development and modernisation in public services (Scottish Executive, 2003d).

CHPs were the main delivery mechanism for Delivering for Health (Scottish Executive, 2005b) with contributions from local authorities and community planning. Delivering for

Health highlighted the changing health care needs in Scotland as a result of an ageing

population with an increase in emergency hospital admissions and in people living with long term conditions. It emphasised: preventive medicine; more intensive and continuous care in the community, including support for self-care and targeting of resources; the introduction of anticipatory care to identify and treat those at greatest risk; and encouragement for people to take greater control over their own health. Although

Delivering for Health was focused on health care provision, the general policy theme of

services towards an ethos of teamwork. It also recommended that the roles of health professionals should be extended including widening the circle of professionals who can prescribe.

In Delivering for Health both GPs and CHPs were expected to base their services on local needs, and the GPs Quality and Outcomes Framework (QOF) was described as the mechanism that would align GPs’ services with the needs of local communities. The QOF was developed for the new GMS contract, established by the Primary Medical

Services (Scotland) Act 2004. The aim of the QOF, established as a voluntary scheme,

was to provide financial incentives for achieving a specified level of points for a range of evidence-based indicators chosen primarily to achieve fewer hospital admissions through better management of chronic diseases (Pay Modernisation Team, 2004). The indicators and points were reviewed for the period of 2006 to 2007, to include a broader range of incentives including more mental health points; a register and needs assessment for people with learning disabilities; and a register of carers. Delivering for

Health (Scottish Executive, 2005b) also included 5 performance targets for mental

health: one to establish a register of mental health patients, one to bring long-term mental health patients in for assessment every 15 months and three relating to monitoring patients on lithium.

Improving health and well-being

Alongside the development of integrated health and social services, collaborative approaches to improving health and well-being were becoming established through formal and informal local partnerships. These became further formalised through the establishment of community planning. These approaches linked primary care into the planning structures for other public service provision, and provided the mechanism for collaborating to work towards population health improvement.

Health improvement and health inequalities

Partnership for Care gave a higher profile to health improvement and reducing health

inequalities in CHPs than had been given to the LHCCs. The CHP Statutory Guidance document (Scottish Executive, 2004d) stated that the focus for health improvement should be on:

ƒ Population health

ƒ Influencing Boards through needs assessment ƒ Working with disadvantaged communities ƒ Health promotion

ƒ Taking a wide perspective on health ƒ Working with partners

ƒ Improving well-being, life circumstances and lifestyles especially in disadvantaged communities.

These arenas reflected Scottish public health and health improvement policy documents, that is, Towards a Healthier Scotland (Scottish Office, 1999) and Improving

Health in Scotland: the Challenge (Scottish Executive, 2003e), and arguably built on

years of research and practice in public health, health education and health promotion. It also reflected that health improvement, as a step on from health promotion, was increasingly understood as a partnership activity between the health, local authority, voluntary and community sectors, rather than residing only in the health domain.

The focus in the CHP guidance for health inequalities was also stated as being to work in partnership to address the needs of the full range of community groups (Scottish Executive, 2004d). While partnership working was again reinforced as the appropriate approach to take there were no other indicators or objectives to clarify what might have been expected of CHPs in relation to addressing health inequalities. Instead, the Scottish targets for reducing health inequalities were included in Closing the Opportunity

Gap (Scottish Executive, 2004a), therefore coming under the umbrella of regeneration

policy to be delivered through the mechanism of community planning (discussed later in this section).

An annual report for health improvement was published in 2006 under the title of

Delivering a Healthy Scotland (Scottish Executive, 2006b), describing itself as providing

an update on the successes of the Scottish Executive’s cross-cutting, whole Government approach to health improvement. It identified a slightly different four cross- cutting themes for the Scottish Executive than the Draft Budget Statement 2007-2008 as discussed above, replacing equality with boosting educational achievement and used each theme as a chapter heading identifying health improvement programmes under each theme. An additional chapter included a section on health inequalities following sections on alcohol, tobacco and combined diet and physical activity. The health inequalities section described enhanced primary care services in deprived areas as the NHS contribution to a multi-agency approach to tackling health inequalities. It is argued that in using this format, the report suggested the NHS role in health inequalities to be a biomedical, behaviour change model alongside tobacco, diet and physical activity.

Equality and diversity

The Equality Strategy (Scottish Executive, 2000) represents a different but linked policy stream, where equal opportunities were to be promoted throughout the public sector and to prevent, eliminate or regulate against discrimination on the grounds of sex, marital status, race and ethnicity, disability, age, sexual orientation, social origin, beliefs or opinions. The strategy sits as a cross-cutting theme in Building a Better Scotland (Scottish Executive 2004a) but legislation has also helped to establish promotion of equality in the NHS and in society. First, the NHS Reform (Scotland) Act 2004 placed a duty on NHS Boards to promote equal opportunities. More recently, the Equality Act

2006 established a single Commission for Equality and Human Rights to prevent

discrimination on the grounds of age, religion or beliefs and sexual orientation throughout British society. The Equality Act also introduced a “gender duty” on public authorities requiring them to promote equality of opportunity between men and women, and prohibited sex discrimination in line with the Race Relations Act and the Disability

Discrimination Act.

Fair for All (Scottish Executive, 2002a) is the mechanism that the NHS in Scotland has

developed to incorporate equality into health policy formulation and implementation. It was established by the Scottish Executive Health Department in 2002 to ensure that health services became “culturally competent”, and would prevent discrimination on the basis of ethnicity. The following year, Partnership for Care (Scottish Executive, 2003d) stated that the principles of Fair for All should be extended so that health services would respond sensitively to the individual needs, background and circumstances of all people’s lives and to eliminate discrimination and promote equality of opportunity for everyone. In 2006 the Fair for All scheme was extended and now covered ethnicity, gender, disability, age, faith and sexual orientation. It sought to integrate all equalities