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a voluntary health sector perspective on health inequalities in scotland

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Foreword chapter 2: Findings page 1 page 20 Health inequalities are The lived experience everybody’s business of health inequalities page 22 Executive Summary Working upstream page 2 and downstream Living in the Gap: a voluntary page 24 health sector perspective on Interventions, approaches health inequalities in Scotland and challenges

page 26 chapter 1: Introduction Further challenges page 4 and opportunities Introducing the voluntary health sector and health inequalities Case studies page 6 page 28 The extent of health inequalities Clackmannanshire and the policy landscape Healthier Lives page 8 Further policy developments page 30 and study methodology Kincardine and Deeside Befriending Case studies page 32 page 10 MS Therapy Centre Lothian Circle page 34 page 12 North Glasgow Community Fife Society for the Blind Food Initiative page 14 The March Project page 36 Includem page 16 Action on Smoking and Health chapter 3: Conclusions (Scotland) page 38 page 18 The key issues and Argyll Voluntary Action the next steps

References page 40

Acknowledgements

We are grateful to all the people who made this report possible: Lorraine Simpson of The Lines Between, for designing and conducting the study. Christine Carlin for project management and additional writing. The many voluntary health organisations who completed the online survey and the ten organisations that volunteered to be our case-studies. NHS Health Scotland for funding and other support. Finally, we would like to acknowledge all colleagues in VHS for their involvement in the project. foreword Health inequalities are everybody’s business

Tackling health inequalities and inequalities Living in the gap illustrates the activities generally is everybody’s business. Any of the sector, its views, its hopes and the given angle on the issues involved and any challenges and opportunities it faces. It productive intervention will involve public, reveals a sector that is vibrant, committed, private and voluntary sectors working with innovative and effective. At the same time, individuals, families and communities. It is it is vulnerable, too often ignored by the a complex weave, which will all too easily public sector, and sceptical of change. unravel if one set of threads is missing. It is, however, connected to the people At the same time, it is very simple to who are living in the gap; as one understand: live in Bridgeton (Glasgow) and respondent commented: your life expectancy is 62; live in Jordanhill ‘Often the individuals who are in most (10 miles away) and it’s 76. In this one need are not accessing statutory services disturbing measurement we see the gap and therefore remain in the shadows of and understand its importance. service provision.’ However, it may be everybody’s business This report might have been titled, ‘Out but individuals, sectors and communities of the shadows’, focusing as it does on will contribute different elements to the positive impact of the voluntary health the weave. sector on vulnerable and marginalised This report focuses on one set of threads – people. However, the reality is that the vast those provided by the voluntary health majority of those people continue to live in sector. In particular, the report considers the shadows, created by a gap, which we the ‘lived experience’ of health inequalities, must close through our own efforts and in hence the title, Living in the gap. partnership with others. This is perhaps where the voluntary health sector operates most effectively: alongside Lorna Hunter those who are living with the impact of Chair of the Board inequality in their day to day lives. Here, Voluntary Health Scotland more often than not, the sector’s role will March 2015 help to mitigate the impact but clearly won’t resolve it. Sometimes (and this can be seen in some of the case studies) it may help create the conditions for a generational shift, at least with individuals and families if not whole communities.

1 executive summary Living in the Gap: a voluntary health sector perspective on health inequalities in Scotland

While Scotland’s health is improving, sometimes presumed to be peripheral and as the Scottish Government has limited the gap in health outcomes between insubstantial. Living in the gap challenges powers in terms of welfare, tax and the the most and least advantaged groups that presumption and places the sector’s economy, a fact noted by the Convenor of in society is widening. We call this gap, work in the context of developing public the Scottish Parliament’s Health & Sports health inequalities. policy and firmly alongside the roles and Committee in a debate on inequalities: activities of the other sectors. A significant Living in the gap pulls together material ‘Even when we had the money, did we amount of more detailed mapping remains from a wide ranging survey of the voluntary spend it wisely? Despite significant to be done but it is clear in this report that health sector about health inequalities in investment, in-work poverty is rising, the voluntary health sector is a key Scotland and illustrates the role of the educational attainment is falling and the contributor in tackling health inequalities in sector through a series of case studies. health gap between different parts of Scotland, and that it has much more to offer. the country is widening5.’ The report shows a vibrant, diverse and committed sector, making a difference to In 2007, the Scottish Government sought people’s lives on a daily basis. The question Methodology to make progress on health inequalities posed is, ‘what difference is the voluntary by establishing a Ministerial Task Force health sector making in addressing and, A qualitative and quantitative study to identify and prioritise practical actions. more importantly, redressing health was commissioned by VHS from Three social policy frameworks were inequalities?’ Overall, the answer is ‘a The Lines Between. published over the following two years significant difference.’ Examples are given A mixed methods approach was – Equally Well, Early Years Framework of the positive interventions being made. adopted, comprising: and Achieving our Potential – all seeking Commentary is made by the sector about to address the underlying causes of barriers and frustration. Recognition is given • Context review inequalities. The role of Community to the sector’s capacity to mitigate impact • Electronic survey Planning Partnerships was put at the centre for individuals, families and communities, of driving progress across all fronts. This and its aim to work further upstream before • Workshop observations was followed by a focus on preventative inequality sets in. Finally, the report focuses spending and the establishment of the • Interviews and case studies on the key issues facing the sector in its Christie Commission, which resulted in health inequalities work and possible • Analysis and reporting the Scottish Government committing ways forward. to making a critical shift towards

prevention and placing a greater The content of the survey was informed by emphasis on the importance of ‘place’ discussion with VHS members through a in addressing inequalities. Background series of seminars and was designed to The overall health of the Scottish population produce a snapshot of activity within the This commitment was reflected in the has improved over the past 50 years1. sector. It was distributed electronically to establishment of a number of ‘Change Scotland’s former Chief Medical Officer, VHS members and partners and resulted Funds’ designed to shift the focus from Harry Burns, has stated that there is nothing in 161 responses. In addition, ten case studies mitigation of symptoms to tackling root inherently unhealthy about the Scots; were identified, interviewed and written-up, causes. The integration of health and social indeed, for most of the past 160 years, life providing detailed illustrations of the sector’s care functions under the Public Bodies expectancy has been average compared activities across Scotland and a range of issues. (Joint Working) (Scotland) Act 2014 embeds to several Western European countries2. this shift in a commitment to opening new However, against this backdrop, health Policy Context ways of collaborative working and investing. inequalities have increased dramatically, Health inequalities were described by a The Scottish Parliament’s Health & Sport with the differential in life expectancy 6 former Chief Executive of NHS Scotland Committee’s report on Health Inequalities between those in the poorest and those in as ‘probably the most complex (problem) in early 2015 reflected on the lack of impact the most affluent areas providing a stark that we face (with) no simple solution 3.’ of policies to date and the changes needed, indicator. These inequalities are the product The direction of policy over recent years including under new devolved powers, of various forces – economic, social, and reflects this, moving outward from a to make a real difference to the health historical. But they are not inevitable and health-specific focus to engaging with inequalities gap. they can be redressed. economic and social solutions. Recent The report demonstrates that the role of research suggests that, for example, Main Findings the voluntary health sector in tackling redistributive tax interventions have greater According to respondents, the third sector inequalities still appears to be insufficiently impact on reducing health inequalities than works closely with the population groups recognised or understood. Lacking the those focused on individual health that are thought to be at most risk of scale, volume and resources of the public behaviours4. Consequently, the allocation of experiencing the effects of health sector, its programmes and activities are resources is not straightforward, particularly

2 VHS Living in the gap 2015 inequalities. These groups faced key those vulnerable groups and communities health-only approach is insufficient even challenges linked with health inequality, that statutory services may struggle to in relation to health inequalities. Voluntary e.g. social isolation, barriers to accessing reach; addressing access to services issues; Health Scotland (VHS) is also aligned with services, stigma. The report illustrates a asset-building, preventative and this consensus and Living in the gap is part sector making a difference to the lives of community-based approaches; innovative, of our contribution to the plentiful people living in the health equalities gap flexible and holistic approaches; being able commentary and reflection on inequalities by supporting improvements for individuals, to get alongside those in need; commitment emerging in Scotland today. families and even communities who would to partnership. Trust was identified as a key However, in scaling up our vision, we otherwise have an even lower level of health factor, i.e. relationships with service users also need to encapsulate the detail. As and wellbeing than the general population. have a non-statutory basis and are therefore inequalities become a macro, cross-sectoral built upon trust, word of mouth and having Who does the voluntary health and organisational concern, the ways that credibility within local communities. sector work with? we deal with the day to day reality – living Challenges in the gap – is in danger of being pushed The sector supports both people with to the margins. This report provides part particular health issues – diabetes, visual A number of key challenges were identified of that detail and draws from it an impairment, etc. – and also geographical by respondents. Inevitably funding for the understanding of what we should do now – communities and communities of interest. sector was one of these with issues around to make the voluntary health sector better However, respondents emphasised that the funding cycles, funder expectations and at what it does best and more capable of work of the sector was cross cutting and unhelpful bureaucracy being to the fore. doing what it needs to do in order to reflect responsive. An example was given of Fife Beyond funding, however, the main the broader agenda of inequalities. Society for the Blind, an organisation that challenges were: being able to evidence often supports individuals in coping with We need to continue to map the activities impact; over-demand for services; lack of hearing problems, mobility issues or in of the sector but more importantly we need understanding of what the sector has to recovering from a stroke. They have to ensure that it has the tools and resources offer and a dismissiveness of its importance; responded by working with clients to build to make the greatest impact and to be able destabilisation of sector due to continual confidence and alleviate social isolation. to measure that impact. Stemming from this public sector change and reform. Most They also support unpaid carers. report will be a programme of work in which importantly, it was emphasised that only VHS, in partnership with others, will support Overall, organisations worked with more joint sector interventions could produce the these developments. than one group and respondents suggested best outcomes but that collaboration and that this reflected the flexibility of the sector partnership were too disjointed at present. in being able to respond to complex needs. Opportunities 1Health Inequalities in Scotland. Activities Audit Scotland, 2012. Respondents agreed that changes to the In terms of the key activities of the sector, way that initiatives and organisations are 2Harry Burns. Social failure, not lifestyle, has these ranged across: partnership working funded could help support improved made Scots sick. New Scientist Magazine, to improving design and delivery of outcomes in relation to health inequalities. Issue 3005, 24 January 2015 interventions; providing information about More generally, many considered that 3Scottish Parliament Health and Sport health and referral to other health services; inequality needs to be given greater priority Committee. Official Report, 22 January early intervention; advice and advocacy; across policy and across sectors. 2013. Col 3149. recovery support. Particular emphasis was given to the 4Informing investment to reduce health Respondents recognised that health importance of monitoring and evaluation of inequalities (III) in Scotland: a commentary. inequalities are manifestations of broad impact and the need for support to the third NHS Scotland 2014 social and economic issues. In their sector to develop and embed best practice. responses they identify opportunities and This report proposes that these changes 5Scottish Parliament. Official Report, challenges in working ‘upstream’ to prevent would have a positive impact on funding. Meeting of the Parliament, 20 January 2015. inequalities, acknowledging that, without a Next steps 6 joined-up approach between all levels and The Scottish Parliament. Health & Sport Committee, Report on Health Inequalities, sectors, no single intervention will provide There is a visible momentum in the Published 5th January 2015. a solution. commitment to tackle inequalities in Scotland. Public agencies like NHS Health Strengths of the sector in addressing Scotland have moved beyond health to health inequalities embrace the core economic and social Overall, the strengths of the voluntary health determinants of inequalities. Likewise, sector in addressing health inequalities are the Scottish Parliament and the Scottish highlighted including: the ability to engage Government both acknowledge that a

3 chapter 1: introduction Introducing the voluntary health sector and health inequalities

Introduction • Voluntary organisations that carry out The overall health of the Scottish population research, advocate and/or campaign on has improved over the past 50 years. 1.1 Voluntary Health Scotland (VHS) is specific health issues, conditions and Scotland’s former Chief Medical Officer, the national intermediary and network disabilities; Harry Burns, has stated that there is nothing organisation for the voluntary health sector. inherently unhealthy about the Scots; • Community-led organisations that promote VHS works with its members to strengthen indeed, for most of the past 160 years, life and support health improvement and the voice, profile and influence of the sector. expectancy has been average compared healthy living at a local level; and Estimates of the size of the sector vary and to several Western European countries. some rigorous mapping is still required. • Volunteer-led and user-led support groups However, against this backdrop, health However, this report shows a sector working, of people with shared health conditions. inequalities have increased dramatically, across geography and interest groups, to with the differential in life expectancy address the impact of health inequalities. Voluntary Health Scotland members range between those in the poorest and those in from large national charities to small, local the most affluent areas providing a stark 1.2 In April 2014 VHS commissioned service providers, and members’ interests The Lines Between to undertake a indicator. These inequalities are the product span service planning and provision, of various forces – economic, social, and quantitative and qualitative study to prevention, early intervention, self- reflect on the issue of health inequalities historical. But they are not inevitable and management, advocacy, and support they can be redressed. in Scotland, and to give the voluntary for service users and carers. health sector an opportunity to highlight 1.9 Such a dramatic difference in life its contribution to tackling health 1.6 For the purposes of this study, the expectancy is generally the result of being inequalities in Scotland. The study terms ‘voluntary sector’, ‘voluntary health affected by preventable illness, and of was made possible by a grant from organisation’ and ‘third sector’ are experiencing health problems much earlier NHS Health Scotland. interchangeable and include the range in life and for much longer than those of organisations above. 1.3 The aims of the study were to: not affected by health inequalities. Since poor health will often impact too on the • gain a better understanding from the individual’s working life, and on the lives voluntary health sector of what the lived Report Structure of their family, the overall quality of their experience of health inequalities really life often becomes poorer. This can be 1.7 This report contains three chapters: means for those individuals, families described as the ‘lived experience’ of and communities it engages with; • The remainder of this chapter describes health inequalities. The above NHS Health Scotland Policy Review stated that in • provide the voluntary health sector with the study context and methodology. 2009/10: an opportunity to highlight how it believes • Chapter 2 presents findings from the its work contributes to tackling Scotland’s study, based upon a sector-wide survey, ‘The difference in healthy life expectancy health inequalities; and observation at a series of workshops and was even more marked, at 47 years for men in the most deprived 10th compared to 70 • publicise the findings so that they can interviews with a sample of stakeholders. provide a platform for wider discussion We also present ten case studies in this years for those in the least deprived 10th, about the challenges and opportunities for chapter. a difference of 23 years.’ the voluntary health sector, the wider third • Chapter 3: Conclusions 1.10 The NHS Health Scotland website4 sector and the public sector in coming outlines key legislation and policies for together effectively to tackle health promoting equality and reducing health inequalities in Scotland. Study Context inequalities; highlighting that health 1.4 Findings from a survey, along with ten inequalities ‘are most commonly associated 1.8 Health inequalities are ‘systematic individual case studies, are presented in this with socio-economic inequalities but can differences in the health of people report. Together, the information provides also result from discrimination.’ It notes that occupying unequal positions in society’ an insight into some of the ways in which whole population approaches to improving (Graham, 20091). There are some stark the voluntary health sector interacts with health may widen health inequalities, examples of what this means in practice; people affected by health inequalities, and because marginalised groups face ‘barriers NHS Health Scotland’s Policy Review 20132 illustrates how the sector describes its work to engagement with services.’ Factors that for the Ministerial Task Force on Health in terms of addressing health inequalities may be associated with unequal health Inequalities3 found that in 2009/10: in Scotland. outcomes include low levels of income, living in social isolation, poor mental health, ‘Life expectancy at birth for men was 69 1.5 Voluntary Health Scotland uses the having learning disabilities or belonging to years for the most deprived 10th of the term ‘voluntary health sector’ to include: a minority group. population compared to 82 years for the • Voluntary sector providers of health least deprived 10th, a difference of 13 years.’ 1.11 In its work to understand and explain and social care services; health inequalities, NHS Health Scotland

4 VHS Living in the gap 2015 The Fundamental Causes of Health Inequalities. Upstream Downstream

Fundamental causes Wider Environmental Individual Effects Influences Experiences

Global forces, political priorities, societal values Economic and work Economic and work Inequalities in the distribution of leading to: Physical Physical health and well being Unequal distribution of income, power and wealth Education & Learning Education & Learning Social and cultural Social and cultural Services Services

Inequalities Health Inequalities

has developed a theory, known as the encouraging conclusions – the absolute gap • The incidence rate for cancer of the ‘Theory of Causation’ that connects the between most and least deprived areas is trachea, bronchus and lung is more than causes, influences, experiences and effects. at its lowest in the time series covered and four times higher This is illustrated in the diagram above. relative inequality has been stable since • People aged between 45–74 years are 2006 – the data indicates an ongoing 1.12 The theory of causation describes the more than twice as likely to die of cancer need to address health inequalities. first column as the ‘fundamental causes.’ • New hospital admissions for alcohol Health inequalities have their roots in the 1.15 In fact, more than 20,000 individuals related conditions are around five times political and societal forces that drive in Scotland aged under the age of 75 years more common decisions and priorities for governments die each year and there are other stark and public bodies. This results in an unfair differences when outcomes are compared distribution of power, money and resources. for people living in the most and in the How can the voluntary health This unfair distribution often leads to least deprived areas. For example: sector play a role in addressing discrimination and marginalisation of health inequalities? • Deaths by all-cause mortality are three individuals and groups. Fundamental causes times more common The voluntary health sector has a long influence the distribution ‘downstream’ of 1.16 track record of representing, engaging and ‘wider environmental influences’ e.g. • Premature mortality from coronary heart delivering interventions for those groups availability of good work, quality housing, disease is around five times more common who are most likely to be affected by health education opportunities; and access to social inequalities. Often the sector works with and cultural opportunities and to services • Low birth weight babies are more common vulnerable or marginalised individuals, those in an area. The second column on the model illustrates how the wider environment in which people live and work shapes their individual experiences, choices and decisions Health-specific issues Communities of interest e.g. discrimination, prejudice, low income, poor housing and less access to health Many organisations highlighted how A wide range of communities were services. This results in the unequal and their work related to a specific health highlighted by organisations taking part unfair distribution of health, ill health and issue as follows: in the study. These are listed below: mortality in the population. people with multiple sclerosis; children older people; people with learning and young people with cancer; people and physical disabilities; those with Who is affected by health living with (and dying from) advanced sensory impairment; Lesbian, Gay, inequalities? diseases; people with a visual or hearing Bisexual and Transgender (LGBT) 1.13 Much of the debate around health impairment; people with Fibromyalgia; communities; those living with arthritis; inequalities in Scotland focuses on the those living with chest, heart and stroke families affected by substance misuse impact of poverty. In 2012, Audit Scotland5 related health issues; people living with and parental imprisonment; women found that: or at risk of HIV and/or Hepatitis C; and young people; those affected by and individuals with ME. homelessness; individuals, couples, ‘Deprivation is a major factor in health families and children with relationship In many cases, the respondent pointed inequalities, with people in more affluent support needs; primary school pupils; out that the families of the individual areas living longer and having significantly survivors of childhood sexual abuse; concerned were also being supported better health. Health inequalities are highly those leaving care or youth justice by the voluntary organisation. localised and vary widely within individual system; women facing unintended NHS board and council areas. Children pregnancy; child loss, miscarriage in deprived areas have significantly worse & abortion; asylum seekers; people health than those in more affluent areas.’ experiencing poverty and financial 1.14 The latest statistics on health exclusion; race and equalities issues; inequalities were published in October 2014 maternal and infant health; those who (Scottish Government6). This data covers have experienced bereavement; people the fifteen year period between 1997– 2012, who smoke; those with sleep problems; combining three methods to measure and veterans aged 18–65. health inequalities: (1) a relative index of inequalities (RII), (2) identifying the absolute range in health outcomes and (3) assessing the scale of problems. Despite some

5 chapter 1: introduction The extent of health inequalities and the policy landscape

not being reached by mainstream health vulnerable communities there is clearly scope focused on – all cause mortality for ages services; or whose demands for time and to explore the extent to which their work under 75 years and from 15–44 years; and resources are placing considerable serves to mitigate the impact of inequalities on key information linked to incidences of pressures on mainstream services. on the health of individuals or prevent – heart attacks; death from coronary heart or even reverse – potential future health disease; cancer incidences and death; 1.17 In responding to this study, participants inequalities in ways statutory services cannot alcohol-related hospital admissions and were asked to highlight the key health issue achieve. However, linked to this is clearly the death; and birthweight12. or the particular community of interest key challenge of how the sector measures supported by their organisation. The 1.25 In December 2012, Audit Scotland and presents the impact of its interventions; responses are listed overleaf and give an published a report citing major differences and how its actions can be shown clearly to indication of the diverse range of issues in the health and life expectancy of different link to better health outcomes. being addressed by the voluntary sector groups of people in Scotland. The report and why it has important insights to offer stated that this was a complex problem and into what it is really like to live a life that addressing it required a range of public impacted by health inequalities. Policy framework bodies working together effectively. In their report, Audit Scotland made a number of 1.18 There is considerable recognition from The extent of health inequalities recommendations13. In their follow up the Scottish Government and NHS Scotland in Scotland Impact Report in June 2014, Audit Scotland of the role that the voluntary health sector can reported on the extent to which progress play in addressing health issues. Publications 1.21 Health inequalities have been a had been made on their recommendations14. that highlight the value of the sector’s work long-standing issue for Scotland. As one include a recent briefing paper‘Why Involve of their examples of health inequalities, the Third Sector in Health and Social Care the World Health Organisation cites the life The Health Inequalities landscape Delivery?’ (Scottish Government, 20127). expectancy at birth for men in the Calton 1.26 Some of the recent changes related The paper highlights how the third sector neighbourhood of Glasgow as 54 years, to health inequalities around policy works closely with communities and points 28 years less than that of men in Lenzie developments, structures and funding, to the often distinct features of third sector only a few kilometres away9. are listed below: service delivery which complement and 1.22 The Welfare Reform Act 2012 became enhance public sector services. The paper The Ministerial Task Force and the law on 8 March 201210. Changes to the recommended the building of an evidence three Social Frameworks welfare system started taking effect base to assist further understanding of the in 2013. The potential negative impact of 1.27 In 2007, a Ministerial Task Force on mechanisms which have allowed third sector these changes on those living with health Health Inequalities was established by organisations, acting alone and in partnership, inequalities has been highlighted by the the Scottish Government to identify and to facilitate improvements in the health of third sector and others. to prioritise practical actions, aimed at individuals and communities. reducing the most significant and widening 1.23 In 2013, the Scottish Public Health 1.19 A Growing Up in Scotland (GUS) health inequalities in Scotland. Observatory (ScotPHO) published a briefing paper onHealth Inequalities and baseline report on the impact of welfare 1.28 During 2008 and 2009, the Scottish the Early Years 2014 8 notes that ‘while reform Government and the Convention of Scottish there is much that can be achieved through (and the economic recession) on health and Local Authorities (COSLA) jointly published the health service, evidence from GUS health in equalities11. The report stated that: three linked social policy frameworks. Equally suggests that many of the actions required Well15 was the first of these frameworks and to reduce health inequalities in the early ‘Although the health impacts remain is the national policy on health inequalities. years lie outwith the remit of health services uncertain, the threats to public health are Equally Well highlighted the widening health and other service providers.’ The paper grave and all policy options to: maximise gap, stating that differences linked to income concludes that: ‘a central theme across employment (through the provision of good were not the only factor. Awareness was GUS findings has been the variation in the jobs); maximise the incomes of the poorest drawn to other factors including age, ways that formal support services are used groups (in particular those most vulnerable disability, gender, race, religion or belief and by families with different characteristics. to the benefit changes); and reduce sexual orientation – all of which interacted Mothers experiencing disadvantage are less stigmatisation of benefit recipients with socioeconomic status. likely than their more advantaged peers to should be considered.’ attend antenatal classes, parenting classes 1.29 The next two social policy frameworks and baby/toddler groups. Parents whom Measuring health inequalities were Early Years Framework and service providers and policy makers often Achieving our Potential. Each one of these most want to reach are those most reluctant 1.24 A number of key headline indicators action documents sought to address the to engage with services.’ on health inequalities are being used by underlying causes of Scotland’s health and the Scottish Government as a means of other inequalities. It was recognised that the 1.20 Given the third sector’s reach into monitoring progress over time. These are key to addressing inequalities was early

6 VHS Living in the gap 2015 intervention and so it was considered 1.35 NHS Health Scotland is the special • Reducing Reoffending Change Fund, important that resources were shifted health board responsible for health £10m. £7.5m funding came from Scottish accordingly. improvement. In their 2012–17 strategy, Government, £2m from the Robertson Trust, A Fairer Healthier Scotland19 NHS Health and £500k from the Scottish Prison Service 1.30 When it reconvened in 2010, the Scotland confirm their aim ‘to improve Ministerial Task Force concluded that there • Reshaping Care for Older People (RCOP) Scotland’s overall health record by focusing was a need for greater focus on prevention Change Fund. £230m was made available on the persistent inequalities that prevent and preventative spending. The Task Force to Health and Social Care Partnerships from health being improved for all.’ The NHS also sought to reinforce the links between the 2011–12 financial year, with a further Health Scotland Delivery Plan for 2014/1520 poor health and people’s aspirations, sense £70 million made available for the 2014–15 lists the third sector as a key partner and of control and other cultural factors rather financial year states the organisation’s intention to work than just life style choices16. with the sector to ensure the lived experience of people experiencing inequality The Integrated Care Fund The role of Community Planning is integrated into the organisation’s • Integrated Care Fund, £173.5m23 to Partnerships ‘knowledge into action’ work. succeed the RCOP Change Fund. This 1.31 Equally Well had marked a shift in new fund is accessible to local partnerships focus for health inequalities beyond the The Christie Commission to support investment in integrated services for all adults. Funding will support NHS and the policy particularly sought to 1.36 In June 2011, The Christie partnerships to focus on prevention, engage local authorities, placing Community Commission21, published its report on the early intervention and care and support Planning Partnerships (CPPs) at the centre Future Delivery of Public Services which for people with complex and multiple of the strategy. In 2010, the reconvened concluded that radical reform around the conditions, particularly in those areas where Ministerial Task Force restated the key design and delivery of public services was multi-morbidity is common in adults under role of the CPPs. required to bring about effective change, 65, as well as in older people. 1.32 In the Statement of Ambition (March including much closer partnership working, 17 embedding community participation and 2012) the Scottish Government (and What have policy initiatives local government) indicated a continuing more effective planning. achieved to date? commitment to CPPs and also to Single 1.37 In response to The Christie Outcome Agreements (SOAs) as the key Commission, the Scottish Government 1.39 There have been a considerable strategic building blocks to achieve public stated that its public service reform agenda number of policy initiatives over a period sector reform, including the reduction of would be built on four pillars: (i) a decisive of several years which have been aimed inequalities for local communities through shift towards prevention; (ii) a greater focus at reducing the health inequalities gap. delivery of high quality public services. on ‘place’ to drive better partnership, However, in January 2015, the report of 1.33 Subsequently, in its second review collaboration and effective local delivery; the Scottish Parliament’s Health and Sport of Equally Well, published in early 2014, (iii) investing in people who deliver services Committee noted the failure of successive the Ministerial Task Force confirmed its through enhanced workforce development initiatives to address effectively the health continued conviction that CPPs remain and effective leadership; and (iv) a more inequalities issue – despite this being the best vehicle, for leading progress in transparent public service culture which a stated priority of each Scottish 24 delivering Equally Well, and for engaging improves standards of performance through administration since devolution . innovation and the use of digital technology22. all partners – including the third sector. 1.40 The Health and Sport Committee has sought to widen the debate on inequalities The 2020 Vision for Health The 3 Change Funds having concluded that ‘most of the primary and Social Care 1.38 In the 2011 Spending Review the causes of health inequalities are rooted Scottish Government announced around in wider social and income inequalities.’ 1.34 In 2011, the Scottish Government set The Committee has called for the Scottish out its 2020 Vision for Health and Social £500m of public funding for 3 Change Funds aimed at supporting a transition Parliament to adopt a joined-up approach Care. In the associated Route Map, health across a raft of policy areas and has asked inequalities were identified as one of 12 across public services away from dealing with the symptoms of disadvantage and all parliamentary committees to consider priorities. Key deliverables for 2013/14 their role in addressing the issue. were: resources to be targeted on the inequality towards tackling their root causes. The funds were to be allocated over the most deprived areas and ‘Deep-end’ GP Impact of the Smith Commission practices to be rolled out more widely course of the Parliament towards innovative programmes of preventative and early across relevant areas of Scotland, with 1.41 On 27 November 2014, the Smith action across three areas: the aim of reducing hospital admissions Commission published its proposals for new and improving outcomes for the people • Early Years and Early Intervention Change powers to be transferred to the Scottish living in those areas18. Fund, £274m Parliament25. The UK Government published

7 chapter 1: introduction Further policy developments and study methodology

its draft legislation on 22 January 201526. first report28. The Ministerial Task Force Reports from VHS events including ‘A Fairer The impact on welfare reform and health determined, following this further review, Healthier Scotland: A Way Forward Together’ inequalities of the proposed legislation that a further 2 year review cycle was not held at The Gathering38 (2014), Sounding remains to be seen although the Scottish the best way to drive progress. As such, Board on ‘Third Sector Contributions to Government has indicated their concern that responsibility has now been allocated to the Narrowing Health Inequalities’39 (2013) and the draft powers give the UK government a Health and Community Care Delivery Group Symposium ‘Drawing It All Together’40 (2013) veto on key Scottish welfare policies27. which has representatives of the Scottish were also reviewed. Government, local government, NHS, the Health and social care integration third sector and other key groups29. Survey A sub-group of the delivery group – 1.42 Currently underway is the integration the inequalities action group – will be 1.50 A short survey was developed and of health and social care, a programme of responsible for undertaking research- piloted in partnership with VHS. To facilitate service reform, designed to facilitate the based work and submitting it to the effective comparison of responses across merger of adult health and social care delivery group, with recommendations what is a complex subject area, participants services (and certain other health and social on areas to be taken forward. were asked to select from a list of answers care services) currently delivered separately for each question. The options were based by health boards and local authorities in upon analysis of themes that emerged at Scotland. The integration is being taken Methodology a VHS Sounding Board event on health forward under the Public Bodies (Joint inequalities held in October 2013. An Working) (Scotland) Act 2014. Service 1.46 A mixed-methods approach was open-ended comments box per question reform, designed to facilitate the merger adopted to meet the study requirements. was provided and participants were of adult health and social care services (and This comprised: encouraged to provide additional comments. certain other health and social care services) Respondents were invited also to volunteer • Context review currently delivered separately by health to be further involved as one of the 10 boards and local authorities in Scotland. • Electronic survey follow-up case studies. The integration is being taken forward 1.51 The survey was distributed via email under the Public Bodies (Joint Working) • Workshop observations to VHS partners and members. Participants (Scotland) Act 2014. • Interviews and case studies were able to distribute the link within their own 1.43 All integration arrangements must • Analysis and reporting networks, so that responses were sought too be submitted for Scottish Government from relevant third sector organisations that approval by 1 April 2015, at which date the 1.47 Each element of the methodology do not currently hold membership of VHS. existing Community Health Partnerships is described in more detail below. Awareness of the survey was raised through also cease to exist. These new Integration a short presentation at each VHS health Joint Boards and their Health and Social Context review inequality themed event and a link to Care Partnerships will be tasked with 9 the survey was incorporated in the 1.48 Key documents were reviewed at formal health and wellbeing outcomes, VHS monthly newsletter. the outset of the study to contextualise one of which states that ‘health and social the research findings. The main areas of care services contribute to reducing health focus centred on national strategies and Survey participant profile inequalities.’ publications including: UK Welfare Reforms; 1.52 The survey, designed to produce 1.44 Third Sector Interfaces have been Guidance for NHS Boards on mitigating a snapshot of activity within the sector, 30 established in each of the 32 local actions (2013); A Fairer Healthier had extensive input from voluntary health 31 authorities – with Voluntary Action Scotland Scotland (2012); the Christie Commission organisations across Scotland, with 32 as the lead network organisation. The policy on the Future Delivery of Public Services responses from 155 voluntary organisations 33 intention is that these interfaces will play (2011); Health Inequalities in Scotland plus a further 6 from partner bodies. a key representative role in relation to the (2011); Equally Well and its subsequent new integration authorities but specific review34 (2008 and 2010); and Achieving 1.53 Profile analysis shows that: Our Potential35 (2008). Material hosted on arrangements for the third sector are subject • The survey was completed by individuals to local negotiation and decision-making. the European Portal for Action on Health representing 161 organisations (more 36 Inequalities was also referenced. than one return was submitted by 13 The Inequalities Action Group 1.49 The review encompassed: VHS outputs, organisations). Third sector organisations 37 account for the majority of responses (155 1.45 Early in 2014, the Ministerial Task Force such as Member Spotlights ; NHS Health out of 161) with the remainder (6 returns) on Health Inequalities published its second Scotland’s Health Inequalities Policy Review submitted by representatives of public review of Equally Well, concluding that no (2013); and the Report of the Scottish sector bodies, including local authorities significant narrowing of the health Parliament Health and Sport Committee’s and health boards. inequalities gap had occurred since the Inquiry into Health Inequalities (2015).

8 VHS Living in the gap 2015 • Two thirds (111) identified their service as being a ‘registered charity’, over half (89) Case studies as a ‘voluntary organisation’, 26 selected ‘other’ and a minority (10) described 1.57 Ten organisations were chosen themselves as a ‘social enterprise.’ Many from 76 that expressed interest in taking organisations (49) ticked two options part in this further aspect of the (typically both ‘registered charity’ and research. The selection process was ‘voluntary organisation’), and 9 organisations designed to ensure the case studies ticked all three options (‘registered charity’ reflected: ‘voluntary organisation’ and ‘social enterprise’). • a broad range of voluntary health sector organisation sizes, locations and • There was a broad mix of representation reach; in terms of participant reach and areas of operation. Just under a third of respondents • the opportunity to highlight different (54) operate at a national level, and a types of engagement in ‘health similar number (50) deliver within one local inequalities work’ being undertaken; and authority. A quarter (39) deliver their services • emerging survey findings. in a specific locality within a local authority area (for example, a particular postcode) 1.58 Each example illustrates a different and a minority (18) operate across multiple aspect of activity delivered by the sector local authority areas (for example, so across the ten studies a broad range ‘Edinburgh, Dundee, Tayside, West Lothian of views and experiences are presented. and Fife’). The case studies draw upon information garnered from 36 interviews undertaken Workshop observations with a range of stakeholders plus staff from each organisation, including 1.54 In 2014, VHS held the Unequal Lives managers, delivery staff and (where Unjust Deaths programme of seminars to feasible) beneficiaries. explore the causes of health inequalities and consider the impact on the health of individuals across different life stages: • Early Years • Transitions from youth to adulthood Analysis The assessment of quantitative • Vulnerable adults 1.59 data began with data cleansing to remove • Later life duplicate responses and data aggregation to allow for total counts. 1.55 There were 183 registered attendees across the four seminars. Participants worked 1.60 Analysis involved a total count and together in small groups to explore the issues percentage calculation of responses to each raised in presentations by keynote speakers. multiple-choice question and cross-counts Groups were asked to describe how their of responses made where multiple answers work ‘addresses health inequalities’ and to were possible. The data was converted discuss the strengths of and challenges into tables that rank responses in terms facing the sector. VHS published a summary of the highest to lowest frequency of report on the key themes and messages answers per question. discussed at each seminar. 1.61 The qualitative data assessment was 1.56 Notes from the events were reviewed based upon thematic analysis. This involved as part of the evidence-base for this study an initial review of the entirety of information and the researcher observed participants’ gathered; identification of key themes; discussions at three of the events. grouping, narrowing and apportioning qualitative data under themed headings; and the selection of quotes that typified responses within each category.

9 Circle A whole-family approach to supporting a group at risk of specific health harms, stigma and social exclusion. Circle supports the most disadvantaged families affected by substance use, imprisonment or where children are at risk of school exclusion. This organisation believes that its work helps to improve or prevent health inequalities, by facilitating engagement with health services and encouraging service users to address factors that contribute to poor health outcomes. Circle communicates its knowledge of the needs and experiences of this group to advocate for upstream changes that may address health inequality influences, such as service design.

10 VHS Living in the gap 2015 What is Circle, how is it funded • Linking 5th and 6th year students with ‘In West Lothian Supporting Families PSP, and who does it support? younger children who are struggling in we provide intensive support to families mainstream education who are ‘just coping.’ The aim is to Circle has two specific objectives: minimise the risk of crisis and to reduce • Placements for social work students the need for statutory interventions.’ ‘To provide help, support and protection Lone parent employability project to children, families and individuals who • Circle also works alongside several are in conditions of poverty, vulnerability • Families affected by imprisonment – schools to improve children’s educational or distress or who are otherwise in need supporting mothers and fathers in prison opportunities, prevent exclusion and by reason of their personal, social or who are returning to their families support relationship development between economic circumstances.’ families and schools. Providing information about health issues: and Influencing policy and raising awareness: Circle works with families to identify and ‘To advance education, policy and practice address unmet needs including providing Circle participates in national consultations in health and social services through the information and support to help people to related to their area of practice and study of conditions that harm children engage with health services. Actions are expertise eg the Children and Young People and families through dissemination of tailored to individual families and may (Scotland) Act 2014, and the Development knowledge gained through that study therefore vary. Examples include: supporting a of Electronic Monitoring in Scotland and the experience of service provision.’ family to register with the local GP or optician; Consultation in 2013. encouraging someone to engage with mental Circle works with parents, kinship carers, Delivering early intervention and/or health services; helping an individual to plan a children and young people. Many referrals preventative activities to improve health journey to the dentist; or building confidence come from the local Alcohol and Drugs and wellbeing, or reduce the risk of health so that an individual is more likely to Partnerships who signpost users to the problems arising. Circle highlighted that its participate in medical interventions. charity in cases where they identify children service users often face a range of barriers living in a household affected by substance ‘We supported a single mother to undergo linked to early intervention and preventative use. During 2013–14, Circle provided whole treatment for Hepatitis C that she had activities, e.g. stigma associated with family support to 672 families (comprising previously ‘put off’ for two years because substance use or imprisonment; 2,345 family members) in Edinburgh, of fears about being able to care for her discrimination from health care providers; Lanarkshire, West Lothian, East Lothian, children over the lengthy recovery. Her fear of contact with health and social Midlothian, Glasgow, North Strathclyde, support worker researched treatment services; a lack of history of engagement Fife, Forth Valley and Tayside. types and identified alternative medication with health care; and chaotic lifestyles with a shorter convalescence time-span that have negative impacts upon nutrition, and the mother engaged with this exercise and well-being. Staff highlighted How does Circle believe its treatment as a result.’ that service users typically have low work helps to improve the expectations about the long term and Gathering evidence about health may not prioritise health matters: lived experience of health and wellbeing: inequalities or prevent them? ‘An integral part of our activity is to There is ongoing consultation with the support individuals to take greater care Delivering a targeted service: communities Circle supports: of themselves and their children; to help Many service users are individuals who ‘Our research paper ‘Listening to Fathers’ families engage with health care providers have, or who are at risk of, developing identified marginalisation and a range of before crisis point; and to encourage them specific health conditions as a result unmet needs, including more training for to adopt positive health and wellbeing of substance use. Circle’s services are NHS health staff working with fathers and behaviours.’ designed to engage these groups, with additional specialist support for dads in www.circlescotland.org workstreams including: the antenatal and early years.’ • Support to all family members affected Working in partnership: by substance misuse Circle is a partner in a number of Public • Support for families with children looked Social Partnerships (PSPs). These are after by kinship carers contractual arrangements between third and public sector bodies under which the • Group work and outreach family support third sector delivers a specified service: for children under 12 years

11 Fife Society for the Blind A 150 year old charity that provides pioneering, holistic support for people in Fife who are affected by sight loss. In recent years there has been growth in the number of people affected by sight loss in Scotland, underpinned by factors such as increased life expectancy, an ageing population and the greater prevalence of health conditions that affect sight: for example, strokes or obesity. People with sight loss can experience a range of difficulties that affect health including limited physical exercise, risk of injury, low self-confidence, isolation, poverty, transport and accessibility barriers. Combined sight and hearing loss is also common. Fife Society for the Blind (FSB) focuses on two key areas of work. First, prevention: the identification and early intervention for individuals who may be affected by sight loss. Secondly, independent living support for people with sight impairment. Their range of services includes access to opticians and a specialist sight clinic, needs assessments, adapted technology, training and rehabilitation. Social inclusion is promoted through volunteering opportunities, befriending, transport assistance and fundraising activities.

12 VHS Living in the gap 2015 What is the FSB, how is it funded The lived experience of health inequalities Staff highlighted that part of their work and who does it support? can be worsened if people are unable to to mitigate health inequalities includes engage with services and resources in partnership activity with other organisations FSB provides services across Fife through place to support them. Sight loss is often to improve services. This includes a joint a team of 19 paid staff, over 100 active concurrent with other health conditions sensory project with Deaf Action, and volunteers and an annual budget of around and can have other health impacts. strategic work with the Fife Physical £900,000. There are approximately 4,750 Sight associated barriers to access Disability and Sensory Impairment Strategy individuals on FSB’s register but their reach and information may compound health Implementation Group, made up of health is wider. For example, people outwith Fife difficulties or reduce the capacity for partners from NHS Fife and the third sector. may purchase adapted equipment or self-management. FSB staff highlighted Former Prime Minster Gordon Brown MP transcription services from the charity. that services such as adapted technology, is Honorary President of FSB, and the Referrals come from a range of sources advocacy and translation help people to charity believes this contributes to its ability including GPs, hospitals, self-referrals and overcome information barriers. A recent to influence further upstream. Additionally, other third sector organisations. FSB also example includes converting guidance FSB has a service user involvement panel works in partnership with Nairn Optician, sheets about self-directed support funds to that facilitates consultation and provides a community-based service that provides facilitate greater access to support services. a gateway into local sight-loss services. a route to influence upstream factors such Staff suggested that FSB is well placed to as service design and delivery: Funds comprise Service Level Agreements respond quickly to trends and contextual ‘We were involved in a review of sensory with Fife Council and NHS Fife, legacies, developments affecting people with sight services in Fife and where possible we fundraising through events by volunteers, loss. These range from immediate, practical take part in consultations. Organisations and grants from trusts and charities. matters – such as tips for what to do when it come to us when they want to find out our snows – to new work streams including thoughts on how proposals might impact advances in technology. FSB’s innovative on people with visual impairments.’ How does the FSB believe work on adapted use of smart phones and its work helps to improve the tablets was highlighted as an effective way Service users also highlighted that FSB’s lived experience of health to sustain independent living, with many work builds capacity within families who are practical and social outcomes from greater adjusting to a loved one’s sight loss: inequalities or prevent them? use of technology: ‘At first we were all at a loss – my sight Recently, preventative activity and early ‘So much of everyday life is done on went very quickly and we have two young intervention have been prioritised as key computers or phones now – the amount children. But FSB has helped in so many areas of FSB’s activity, resulting in changes of online shopping grows year by year – ways, especially with my family; they to the design and delivery of support and so we’re looking at ways to make that taught my husband and my children how an expansion in the number of people who accessible and also keep people safe. to help me. Simple things like sighted benefit from FSB’s services. This requires It’s important to be able to do what guide training – explaining how to direct partnership working to develop relationships everyone takes for granted – or the me across a room; made a real difference- with referral agencies and raise awareness sense of exclusion is compounded.’ they feel more confident in being able among communities at risk. to help me, it’s less frustrating and I feel Another important element of the support more independent. It’s actually something There are plans to widen FSB’s reach so available from FSB is that it is holistic, as we laugh about now because at the start that more people access support when one service user’s experience demonstrates: they need it or take early steps to avoid my husband was always forgetting what preventable or further sight loss. ‘I’ve been involved with FSB for my whole to point out and I was forever bashing life. I was born blind and my parents didn’t into things!’ In addition to preventative work, FSB know what to do with a blind baby or how www.fifeblind.org.uk believe that their services are crucial in to interact; what I would respond to. They helping people affected by sight loss to taught my mum about tactile games and maintain their independence, sustain books so she could play with me… as physical and mental well-being and prevent a child I did things like mobility training, social exclusion. Their social work team cooking skills, participatory sports through provides a needs assessment for people FSB. At school I was in the young person’s who are newly registered blind, working with activity group… later I did my work individuals in their homes to develop experience here… finally they gave a tailored rehabilitation plan that identifies me the training I needed for work.’ the resources available to support recovery and improve quality of life.

13 The MARCH Project A voluntary sector organisation working with a health board, local authority and other third sector partners to address poverty and hardship issues. The partnership is currently involved in a pilot project with NHS Lothian to identify people at risk of poor health outcomes linked to poverty. The Midlothian Area Resource Coordination for Hardship (MARCH) project aims to tackle poverty and financial exclusion. One of its work streams includes a partnership with NHS Lothian’s Health Promotion Service to identify and support service users affected by poverty, particularly those with disabilities and long-term health conditions. Its work straddles two areas of the health inequalities spectrum: seeking to change upstream influences (service delivery) and working at the downstream level to support people whose health and wellbeing may be affected by low income.

14 VHS Living in the gap 2015 What is the MARCH project, ‘It has helped to strengthen the partnership ‘A shift away from the medical model of how is it funded and who between the third sector and other health simply addressing symptoms, to a more does it support? and social care providers including the preventative approach… to identify and council and NHS Lothian.’ tackle the poverty that underpins many The Midlothian Area Resource Coordination of the physical and mental health issues ‘We’re collaborating with another health board for Hardship (MARCH) project is a that our service users experience.’ over a similar project; to share learning.’ partnership between Midlothian Financial Other comments about the impact Inclusion Network, Midlothian Council and ‘Knowing how to use the 3rd sector better.’ of this work included: Changeworks. Neither a frontline delivery The MARCH project’s partnership with NHS agency nor a health care provider, the ‘Internally it has given staff a language Lothian’s Health Promotion Service is a pilot MARCH project exists to: to talk about health inequalities’… and… approach that seeks to develop capacity in ‘we can talk sensitively with service users ‘Coordinate and improve the resources the frontline teams that visit service users about how their living circumstances available for hardship in Midlothian.’ at home. These include Health Visitors, the might be affecting their health.’ Community Mental Health Team, Substance A team of 2.5 full time equivalent staff Misuse Treatment staff and the Community MARCH Project partner Changeworks is work across a range of project activity, Learning and Disability Service. These staff a national environment charity that deals often engaging with different partners are in a position to identify people living in with fuel poverty and vulnerable households. from within the Midlothian area. poverty. NHS Lothian is leading on the Many of the people identified as living in The MARCH Project commenced in workforce development aspects and hardship are referred to this service. Their September 2013 having been awarded MARCH’s role is to create resources and staff provided examples of the ways that a £200,000 grant from the Big Lottery’s referral pathways so that health staff can fuel poverty can affect physical and mental Support and Connect funding programme. signpost individuals to appropriate advice well-being, including: In April 2014 further funding was provided and support service that deal with welfare ‘Professor John Hills linked fuel poverty to via NHS Lothian from a small grant they and poverty issues. For example, it was nearly 3,000 deaths per year in the UK and were awarded by the Scottish Government suggested that health staff: there are other health effects such as lack Health and Welfare Reform Development ‘Might visit a home and notice that it is of resilience, respiratory illness, increased Fund. This enabled the MARCH Project very cold and damp, because the person risk of stroke… There are clear mental to carry out joint work with their Health cannot afford the heating. Or perhaps health impacts too: people experience Promotion Service, to help mitigate against they can’t heat their meals up because stress and depression when their home the impact of welfare reform on health they have no money for the gas cooker. Or is freezing, they won’t have visitors and inequalities in Midlothian. The Project has maybe they have nothing in the cupboard.’ become isolated… we see examples of funding to continue until the end of August children stigmatised at school when their 2015, and future funding options are The pilot is being trialed on a small scale clothes are mouldy or smell of damp; it’s currently being explored. using the ‘test of change’ approach. because their parents can’t afford the heat Because poverty is a sensitive topic, initial to dry their washing properly.’ engagement work was carried out with How do MARCH and partners staff to communicate its value and purpose. Changework’s services include advice on believe their work helps to Only those who expressed an interest in energy efficiency, switching tariffs and help improve the lived experience participation were involved in the later with understanding bills and over-charging. stages of the pilot. These staff and a small As one staff member explained: of health inequalities or number of service users took part in work ‘Often dealing with energy suppliers prevent them? to develop and test a screening tool that takes self-confidence and knowledge will be used to assess financial inclusion The MARCH project is involved in a range of rights and tariffs; many living in fuel and signs of hardship. If hardship is of activity to address the financial hardship poverty –especially the older people – identified, service users will be signposted that contributes to health inequalities. Case don’t have that. For example, if they don’t to support using the ‘crisis’ signposting study interviewees described the value of have access to the internet they can’t guide developed by the MARCH Project. the MARCH project in changing the way look things up… it’s not only extremely This contains contacts for services that that third and statutory sector partners work complicated but the price of a call to an can address needs related to money, together on health matters. For example: energy provider can be expensive, you can food, fuel, housing, health and well-being be on hold for a long time. We have the ‘Establishing that tackling financial services. One case participant described time, the skill and the patience to make hardship is linked to the preventative the approach as supporting: healthcare agenda.’ that call and advocate on their behalf.’ www.mfin.org.uk

15 ASH Scotland A national third sector organisation that seeks to reduce and prevent harm from tobacco use. As well as operating at an upstream level to tackle factors that influence smoking, they have developed partnerships with agencies that work with the groups at most risk of tobacco-related diseases, to deliver targeted, focused messages that people can engage with. There are strong associations between smoking prevalence, socioeconomic disadvantage and the rate of tobacco- attributable disease; while smoking rates have decreased across all groups, the smoking gradient between higher and lower socioeconomic classes has increased over the past 15 years. ASH Scotland’s work to reduce and prevent harm from smoking is broad ranging; including efforts to bring about changes in behaviour and influence bodies with the power to change policies or deliver targeted interventions.

16 VHS Living in the gap 2015 What is ASH Scotland, how being smoke free by 2034, there’s still a ‘There are so many things that can affect is it funded and who does need for us to make sure all the things behaviour; how many challenges you face it support? that we know about tobacco continue to in a day, how well placed you are to plan percolate through to policy and practice for the future and if you have aspirations Action on Smoking and Health (Scotland) at a local level.’ for the future… through to how many times is the national charity that tackles the harm in a day you really need a guaranteed Work streams include training for people caused by tobacco. It was established in dopamine hit. And all of that adds up to who work in the field of tobacco and health, 1973 and is an independent organisation. the day-to-day, lived experience in which such as professionals in dementia or family The majority of its work is conducted at a people smoke. So while the number of support services. ASH Scotland host and national or partnership level. A representative people who say they want to quit is pretty participate in events to foster partnership explained that: much constant across all groups, the working between the various agencies that ability to act on that desire or intention are interested in or have an influence on ‘In putting inequalities at the heart of our varies. If you simply put out the message the areas of tobacco and health. They work what we’re doing is reflecting the that ‘smoking is bad for you’ it will have undertake lobbying and advocacy work to fact that tobacco use in itself is really an an effect – but not for everyone.’ inequalities issues. When you consider that encourage the Scottish Government, health the smoking rate in the poorest communities boards and other agencies to implement An example of ASH Scotland’s efforts to is four or five times higher than in the richest polices and legislation that affect tobacco engage groups most affected by tobacco communities, and about 30–40% of all the consumption. They provide information includes a pilot project run in partnership tobacco consumed in the UK is consumed and gather evidence so that people can with a health board and a credit union called by people with mental health problems – understand and monitor smoking in ‘The Cashtray Project’. When savers set up it becomes clear that we need to tackle Scotland and view data on its impact their credit union account, the project helps tobacco use within a particular context upon health, society and the economy. them to calculate the potential savings from that is very closely matched with income not smoking, to encourage and motivate The case study interview included inequality in our society. We’ve moved past them to reduce their tobacco consumption. discussion of the unintended effect whereby the scenario when inequalities was just one ASH Scotland’s development team delivers interventions aimed at the general population part of the issue we’re tackling, to it being the training for Credit Union staff, so they result in widened health inequalities, because largely focused on inequalities.’ can discuss sensitively the benefits of lower income groups may be the least likely saving money through quitting smoking. to respond to health information campaigns Their team of 21 full time equivalent staff work Another key area of work, delivered in and are therefore ‘left behind’ in terms of across four areas; management, policy and partnership with youth organisations such unchanged behaviour. While efforts to tackle research, engagement and business. as Young Scot and Youthlink Scotland, is smoking have achieved an important supporting young people to make positive In 2013/14 ASH Scotland had a budget reduction in the overall number of smokers in choices about smoking. of around £1 million. Funding consists of Scotland, they have not sufficiently changed a range of grants from various sources, the behaviour of groups in which tobacco- The training team also works with family including core funding from the Scottish related disease is most prevalent: support services to demonstrate how far Government combined with monies from the smoke can travel through a home, even ‘We’ve seen enormous progress in terms British Heart Foundation to collate and share if the smoking takes place by a window of shifting tobacco from being right in information about smoking and tobacco or outside a particular room. All this the mainstream of society and a normal harm. Their lobbying and campaigning work activity is conducted in partnership thing that people do, to being more and is funded by Cancer Research UK and with delivery organisations. self-generated income from other sources. more towards the margins… but this shift The charity also receives funding for various has occurred differently, among different ASH Scotland is also keen to address the activities from NHS Health Scotland, the Big groups within the population. So now, issue of smoking by individuals with mental Lottery and donations. while there are many sections of society health problems, noting the prevalence of where smoking really is a very unusual tobacco use among this group. thing, in many other areas the social ‘Not only does the evidence tell us that acceptability of smoking and the smoking How does ASH Scotland believe people – especially people dealing with rate are still what they were in the whole their work helps to improve the mental health issues – feel better when population 40 years ago.’ lived experience of health they stop smoking, but you need to inequalities or prevent them? When discussing the success or failure of consider the inequality of the health harm social marketing campaigns among groups arising as a result of tobacco use among Staff acknowledge that significant progress has in society with different socioeconomic these people who are smoking when been made in Scotland in terms of changing profiles, staff talked about the complex they are at their most vulnerable.’ attitudes and behaviour, explaining that: context in which people smoke and how www.ashscotland.org.uk ‘While we have had some great successes this can make it more, or less, easy to in Scotland and have a national target of give up smoking.

17 Argyll Voluntary Action Releasing social capital to reduce isolation and exclusion in rural areas, improve mental health and support people to engage with health services and positive activities. People living in rural areas face multiple factors that can contribute to poor health outcomes including poverty, transport barriers, inaccessible services and isolation. Through facilitating volunteering, Argyll Voluntary Action (AVA) aim to avoid, prevent or reverse health inequalities in a variety of ways; through engagement in positive activities, supporting people to access services and providing an additional resource for communities most affected by health inequalities. Its work to represent partners and engage communities is also part of an effort to influence strategic decision making at an upstream level.

18 VHS Living in the gap 2015 What is AVA, how is it funded enable their views and experiences to be volunteer; this means that a broad range of and who does it support? heard. This results in a potential lack of activity is available. It includes services such representation or influence at an upstream as recycling schemes to help people afford AVA facilitates, supports and encourages level; AVA attempt to redress this imbalance equipment they need, befriending and volunteering and is based across several but note that there are resource running social events; and delivering offices in the main towns of Argyll and Bute; considerations: courses to improve skills – for example, the Lochgilphead, Campbeltown, Dunoon, ‘silver surfers’ class to improve computer ‘It might sound like an odd thing to raise in Oban and Helensburgh. In and around literacy. AVA supports community a discussion about health inequalities – but general volunteering facilitation, two key volunteering, offering practical help from the simple fact of the matter is that a half areas of work AVA focuses on relate to gardening to help around the home and hour meeting with health partners resulted groups with a particular risk of poor health learning new skills: outcomes and social exclusion: families in a six hour round trip for me. Is it worth who have experienced domestic violence spending that time, when we have limited ‘Volunteering that involves physical activity and older people. These are delivered under resources? The travel implications mean also has a positive health outcome for the programmes ‘Survive and Thrive’ and we have to think carefully about which those involved.’ meetings we attend.’ ‘Reshaping Care for Older People.’ AVA ‘Our strength and balance classes aim to has over 25 staff members and is the lead ‘Groups that we support like Grey Matters prevent falls among older people.’ organisation in the local Third Sector enable people to have a voice; outcomes Much of AVA’s work aims to empower Partnership which forms the Third Sector from GP surgeries appointment system, individuals and build community capacity; Interface. Funding is drawn from a range of changes to dropped kerbs all improve this activity has the potential to address sources including NHS Highland, Argyll & equality of access and result directly from upstream factors contributing to health Bute Council, The Scottish Government, interventions. We ensure opportunities inequalities. For example, they recently the Big Lottery Fund, Robertson Trust and to meet with professionals, decision ran a project called ‘Involving to Devolving, European Funding. makers and leaders on terms which are Influencing Change’ through which they accessible to communities; participatory sought to engage groups and individuals engagement.’ with little or no previous engagement with How does AVA believe its Staff highlighted that some of the people decision-making processes. This involved work helps to improve the living in Argyll and Bute are particularly a roadshow across remote areas. Through lived experience of health affected by a lack of joint up delivery of health support and training, the people involved inequalities or prevent them? services; volunteers provide practical services were empowered to engage with and such as driving that are used by people who influence the planning and delivery Staff highlighted that a key issue for people struggle with access to health appointments: of services. living within rural areas of Argyll & Bute relates to the difficulty of accessing ‘We know of people that require three Another area of potential upstream influence services. These barriers relate to the time, appointments with different specialists, is its role as the TSI; through this, AVA cost and distance that must be travelled. because of their complex health needs. represents local organisations in forums of On a practical and individual level the It might take them a day to travel to the influence at local, regional and national levels: distances involved can present particular hospital. But these appointments aren’t ‘When local health care plans and challenges for anyone who is experiencing coordinated – so instead of seeing three strategies are being delivered we get poor health – affecting access to health doctors in a day, they may have to make involved and facilitate representation of care and impacting upon the extent to several long trips over the course of a the third sector partners. We also engage which people go to services for diagnosis short period of time. For a seriously ill with communities and facilitate their and treatment: person that’s not helpful. One volunteer voices being heard.’ regularly undertakes a 397 mile round trip ‘We’re pushing for greater use of to accompany an older person with long Wider work with other partners also shares technology by health staff, to overcome term conditions.’ resources across the community, for the barriers to access – but there’s a lot benefit of the most vulnerable: of work to be done. Not only do health Other challenges facing some individuals staff need permission and access to the living in rural areas are issues connected to ‘Our office in Helensburgh is used as the equipment – but older people, or people mental wellbeing, such as social isolation, drop off point for donations to the food living in poverty may not have the skills or loneliness, depression and low self esteem. bank and Helensburgh and Dunoon resources needed to use these methods Staff suggested that the volunteering offices also support credit unions.’ of access.’ facilitated by AVA’s helps to combat these challenges; both for the individuals who www.argyllvoluntaryaction.org.uk On a broader level, access barriers can also volunteers and for the people they go on to affect the extent to which people are able to support. The types of voluntary activity vary participate in consultation or activities that depending on the skills and interests of the

19 chapter 2: findings The lived experience of health inequalities

2.1 This chapter presents findings on how the voluntary health sector describe the Table 2.1 Factors linked to health inequalities lived experience of health inequalities of those it supports. It also illustrates how Category Total % Count (n=147) the sector views its own contribution to ‘addressing health inequalities’, focusing Social isolation 134 91% on interventions, strengths, opportunities and challenges. Barriers to accessing services 117 80%

2.2 Summary tables illustrate the Poverty 104 71% quantitative data gathered through the survey; these are supported by additional Stigma 102 69% findings from the qualitative material, gathered through the survey comments, Behaviour (associated with increased risk of health problems) 77 52% VHS seminars and case study interviews. Other 15 10%

The lived experience of health inequalities • Social isolation was identified by almost included ‘losing contact with health services all respondents (91%) as a key factor linked when clients change their address and 2.3 Case study participants were asked for to the lived experience of health inequalities mobile number’; ‘lack of understanding their views on how health inequalities affect of the communities, families and individuals from health care providers, who want to the lives of the families or individuals they with whom they engage. Many participants deal with the medical issue not the complex support. There was frequent mention highlighted the links between social problems that relate to it’; and ‘they [those of issues such as poor mental health, isolation, poverty and/or stigma. at risk of experiencing health inequalities] including anxiety, stress, depression, and A connection between social isolation don’t have the Internet so they can’t access of loneliness. In discussion, interviewees and poor mental health was mentioned the [health] information.’ often highlighted that they believe there is a frequently, along with health-related higher prevalence of preventable or treatable • Poverty was identified by 71% of consequences including low resilience, diseases. More than one respondent respondents as a major issue underpinning isolation impeding recovery from health referred to their client groups having a health inequalities. Comments and conditions. It was suggested that social reduced life expectancy when compared examples included: ‘current welfare reform isolation can limit the ability to create and to ‘people with higher levels of income.’ is increasing risks of health inequalities due retain support networks. One participant to increasing numbers experiencing severe 2.4 A common view expressed by explained: ‘our young people are living financial hardship’; ‘parents can’t afford the participants was that much of the voluntary in the worst houses in areas of social bus fare to take their children to the GPs’; sector’s health and wellbeing interventions deprivation; they feel too frightened to go ‘many of our clients are experiencing fuel do address health inequalities; their out and too ashamed to invite people home. poverty, which affects health and wellbeing’; rationale was that interventions help to It prevents them building relationships.’ and ‘we see children with mouldy clothes narrow the gap in health outcomes by It was also pointed out that living with poor because they live in a damp, cold home… supporting improvements for individuals health may lead to or exacerbate social mould is bad for health and it makes them who would otherwise have an even lower isolation. One response noted that ‘having feel stigmatised at school.’ Some level of health and wellbeing than the cancer as a young person affects your participants suggested that financial general population. education, social life, family and friends, constraints affect the extent to which contributing to social isolation and bullying’ people can adapt to, or recover from, 2.5 The third sector works closely with the and another pointed out that ‘losing health conditions; for example, one person population groups that are thought to be confidence as a result of eyesight supported by a case study organisation at most risk of experiencing the effects of deterioration makes your world narrower said: ‘I couldn’t afford the equipment health inequalities. Survey respondents and narrower, until you no longer do the I needed to allow me to [stay] mobile.’ were asked whether or not they believe social things you used to go out and enjoy.’ key identified factors might be contributing • Stigma was highlighted as a factor that to the inequalities in health outcomes • Barriers to accessing services were impacts upon mental wellbeing, prevents experienced by the people they support. frequently identified by respondents as an engagement with health services and, in issue that contributes to unequal health some cases, was said to reduce the quality 2.6 The range of comments made in relation outcomes. In describing barriers, several of health care support received. Responses to each category suggest that many contributing factors were highlighted, such included: ‘one of the people we are respondents consider the underlying causes as chaotic lifestyles, stigma, poverty, literacy supporting with sustained drug recovery of health inequalities to be interconnected: and communication issues. Examples

20 VHS Living in the gap 2015 went to their doctor to get support for a completely unrelated health condition; they Table 2.2 Who does your organisation support? were written off because of their previous drug use’; ‘our young people often haven’t Multiple response categories Count % (n=161) benefitted from the health campaigns and interventions offered in mainstream People with a specific health issue 54 34% education because they have been excluded from school at an early age’; and A particular community, either geographical 72 45% some people being ‘reluctant to ask for help or a community of interest from statutory agencies as they are fearful of being judged and/or that their children may be taken into care.’ Table 2.3 Which of the following are the main areas of your • Comments on the link between health organisation’s work? inequalities and behaviour often focused on an individual’s poor mental health and Category Total % low self-esteem. There were references to Count (n=157) a lack of knowledge about harmful effects Health 96 60% of behaviour and individuals having limited propensity to plan for the longer term. Some Children and young people 74 46% voluntary health sector representatives explained starkly that ‘a short term outlook Social care 71 44% affects the ability to relate to health issues that might arise in the future’ and ‘as a Disabilities 70 43% result of living day to day, week to week – [they] are not planning for the years ahead.’ Volunteering 70 43% A few participants attributed the prevalence for ‘risky behaviour’ to a lack of positive Mental health 59 37% activities, suggesting that harmful behaviours such as alcohol, tobacco or Older people 58 36% drug misuse were a result of seeking a ‘dopamine hit’ as a distraction, or escape, Accommodation and housing 35 22% from unhappy circumstances. Social enterprise 26 16% 2.7 Other issues mentioned in relation to health inequalities were: lack of positive Environment 25 16% role models; increased vulnerability; learning disabilities; abuse and violence; Human rights 22 14% experiencing unresolved grief; poor parenting skills; speech, language and Intermediary 21 13% communication barriers; and political disengagement. Adult education 19 12% Local interface 16 10%

Who does the voluntary health Arts 15 9% sector support? Culture and heritage 15 9% 2.8 Table 2.2 presents two broad groupings of individuals supported by the voluntary Sports and recreation 9 6% health sector: those with specific health issues or people in a particular community. 2.9 Many case study participants pointed problems, mobility issues or in recovering or other individuals who provide care to out the challenges in categorising the from a stroke. That has led them into people who are blind or partially sighted. working with clients to build confidence; individuals they support because many of 2.10 Table 2.3 illustrates the responses to a alleviate social isolation; increase physical their clients have multiple health issues. question on ‘areas of work.’ The results here activity; and support independent living. For example, Fife Society for the Blind often provide more insight into the communities Additionally, the Society supports the family supports individuals in coping with hearing supported by the voluntary health sector,

21 chapter 2: findings Working upstream and downstream

with most organisations (135 out of 157) responding that they work across more than Table 2.4 Type of work undertaken one group. This indicates perhaps one of the unique strengths of the third sector, in Category Total % Count (n=142) that the flexibility of its approach provides a range of opportunities to engage with We work in partnership with other organisations to improve the 117 82% individuals, families and communities design and delivery of interventions for the groups we work with and to support them in coping with the challenges they face, including health We influence policy and raise awareness of the needs 100 70% inequalities. With their focus on the of the people we support individual, the family or the community, organisations in the third sector are often We refer people to other health services 99 70% called on to support their clients as they cope with a complexity of issues. We provide information about health issues 95 67%

We deliver a service targeted at addressing the needs 90 63% What work does the voluntary of a specific group health sector do? We deliver early intervention and/or preventative interventions 88 62% 2.11 Types of work undertaken by the sector to improve health and wellbeing to reduce the risk of health vary considerably, as shown in Table 2.4. problems arising Most respondents (131 out of 142) indicated that their organisation is involved in a range We gather evidence about the health and wellbeing needs 78 55% of work areas. of the people we support

We raise funds to deliver interventions to the groups 74 52% Themes in the qualitative data we work with 2.12 The majority of case study participants We provide advice or advocacy on health issues 61 43% demonstrated a keen awareness of relevant publications, funding streams (such as the We deliver health services to people who are already 52 37% Reshaping Care for Older People Change experiencing physical or mental health issues; to support Fund), contextual changes (particularly their recovery and improve their experiences the integration of health and social care services and welfare reform), Scottish Government frameworks and policies (for • The voluntary health sector’s views on How does the sector see its example, Equally Well) and Local Authority its strengths in relation to tackling health strengths in relation to tackling structures and plans (including Community inequalities health inequalities? Planning Partnerships and Single Outcome • Challenges and opportunities for 2.16 Several cross cutting themes were Agreements). the sector identified among the comments from 2.13 A clear theme running through voluntary health sector staff; each point the qualitative comments was an Addressing upstream causes is summarised below and supported by acknowledgement that health inequalities of health inequalities versus an illustrative quote or quotes. are manifestations of broad social and downstream impacts economic issues. Case study participants The ability to engage those vulnerable were asked to describe how they believed 2.14 At VHS seminars many participants groups and communities that statutory their work related to health outcomes and regarded their work as contributing to, and services may struggle to reach having an impact on, addressing health health inequalities. Themes that emerged 2.17 Many case study participants inequalities. However, many acknowledged across the survey, workshops and suggested that this is what the voluntary the challenges of demonstrating this by interviews are grouped under the following sector does best. Explanations often means of robust evaluations. categories: centred on the notion that relationships with • Participants’ thoughts on addressing 2.15 A summary of participants’ views on service users have a non-statutory basis upstream causes of health inequalities how the third sector’s work might address and are therefore built upon trust, word of versus downstream impacts upstream causes, mitigate or even reverse mouth and having credibility within local downstream impacts is provided in the communities. It was indicated that this level boxes opposite. of trust provides voluntary organisations

22 VHS Living in the gap 2015 ‘I’m sure our service hasn’t changed in How might the sector address fundamentals; but if you’d have asked upstream fundamental causes How might the sector mitigate me five years ago if we tackled health or wider environmental or undo the downstream inequalities I’d have told you no, because influences? experiences for the individual? we didn’t classify our area of work as ‘health.’ But actually, we play a key role in helping our service users to access A clear theme running through The majority of participants were more health services; we refer them, take them the qualitative comments was comfortable in explaining how their to appointments, provide information and an acknowledgement that health work contributes to improving the daily advocate on their behalf if they are having inequalities are manifestations of broad experiences and immediate health a problem, for example, finding a GP that social and economic issues. Several outcomes for people affected by health will register them. GPs in particular are participants did express the view that, inequalities. reluctant to take on people with a history of as the sector works with individuals, it substance misuse.’ (Case study interview) Participants described the provision of is unable to address these underlying direct support to individuals affected Asset-building and preventative causes or influences. However, other by health inequalities and their work approaches participants suggested their work to secure funds to deliver these might influence key stakeholders with 2.19 Respondents highlighted that they interventions. Many highlighted their the power to create those systemic or regard their approach as strengthening work to mitigate the effects of the health legislative changes, for example, the the assets of those they work with; and inequalities experienced, including by Scottish Government. The importance of responses focused on the preventative meeting needs not within the purview dedicated policy staff and participation nature of the work undertaken, particularly of statutory agencies. Examples quoted in national consultations was often among vulnerable groups. There was were providing companionship to mentioned. repeated mention of helping individuals to overcome social isolation, or supporting develop internal resources and capacity so Linked to this influencing role, a people to change harmful behaviours. that they build resilience and gain the skills frequently raised point was the sector’s The view expressed frequently was and confidence to cope with the day-to-day independence from government and that the sector reaches people who, issues they may experience: statutory bodies, which was said by for a variety of reasons, are often some to make it more of an ‘honest ‘Early intervention and support… has not engaged by or with public sector broker.’ For example, several argued for been shown to improve overall health and services. Continuity of service, flexible potentially unpopular actions – such as wellbeing outcomes for people, increase delivery structures and trust from increases in taxation – suggesting that their ability to self-manage, develop their beneficiaries were highlighted as such change would help to address self-efficacy, which results in a reduction in key strengths in terms of addressing the fundamental causes of health medical interventions.’ (Survey response) experiences and effects. inequalities. ‘We support people with increased Views on how the sector exerts vulnerability to self harm, attempted influence on the health inequalities with a position of influence. One survey suicide… alcohol and substance misuse.’ agenda largely focused on (i) participant suggested: (Survey response) contributing to changed attitudes and (ii) the way the sector works to ‘The relationships that [the] voluntary sector ‘Our focus is parents and lone parents improve service design and reach. A develops with individuals in the community with few supports in place, isolated in strong theme in these discussions was is the start of a health behaviour change.’ their community without the confidence communication, research, partnership (Survey response) to access services in their area. They have with other agencies and flexibility to poor parenting skills but are reluctant to Addressing barriers to accessing adapt to new delivery models, for ask for help from statutory agencies as health services example, Public Social Partnerships. they are fearful of being judged or/and that their children may be taken into care.’ Several participants described collecting 2.18 A key theme in discussions was the (Workshop observation) evidence, by facilitating service-user or growing awareness across public and third community engagement, to feed into sector agencies of the lived experience of ‘We put an increased emphasis on upstream decision-making processes health inequalities. There was repeated community support and capacity building and service design. The voluntary mention that encouraging or facilitating in order to help address significant health sector’s involvement in the access to health services or health challenges which include the increased commissioning of local services was information is an important part of many strains on health resources, ageing also highlighted. organisations’ work. For example, one population, increased in breakdown in manager said: support at home, etc.’ (Survey response)

23 chapter 2: findings Interventions, approaches and challenges

Provision of interventions that are on entitlements to disability welfare payments, Provision of training for partners rooted in the issues faced by specific on behalf of the Department of Work and 2.25 Linked to the notion of capacity communities Pensions]. Appeals seem to take eight building, some of the larger organisations/ months to come to fruition. Many appeals 2.20 Linked to the point above, some projects described how they engage are won and benefits backdated. However, participants suggested that because they effectively with other organisations to these people have had to survive on reduced are so rooted in their communities, they provide focused training: benefits for a period of approximately eight have a deeper understanding of their months.’ (Survey response) ‘We offer placements for social work specific needs which allows them to create students.’ (Case study interview) more detailed, nuanced support than is Freedom to test and pilot innovative possible at the higher planning level where approaches ‘We may be asked to support any organisation local authorities or health boards operate: whose service users may use tobacco 2.23 Several participants emphasised [and] provide training and support to any ‘[There are] barriers to accessing services the sector’s manoeuvrability; noting that voluntary organisations, as well as statutory due to having some of the most remote statutory agencies often have less freedom organisations, on request.’ (Survey response) and rural postcodes in Scotland. Also high in this respect because of procurement levels of stigma associated with mental rules or budget constraints: The freedom to communicate health, domestic violence and addictions, with service users ‘Our hope is that by running a successful particularly as this area is not very diverse, pilot, we can demonstrate that this model as well as being remote.’ (Survey response) 2.26 Being able to adopt engaging and is a cost effective way of supporting those personable approaches, using a range of Co-production in service design adversely affected by health inequalities, tools, was another frequently raised theme. and that the project will be rolled out Many of the service delivery models involve 2.21 It was highlighted often that the shape to other areas across Scotland.’ extensive face-to-face or telephone contact. of the intervention is more effective if it is (Survey response) Some staff use mobile phones to stay underpinned by joint thinking between the in touch with clients. Texting can be organisation and its users, and that the ‘We are a Government funded pilot. Our particularly effective with groups that sector does this well: challenge is to demonstrate the difference statutory services struggle to reach. Several our work is making to the people we support, ‘Our contribution to reducing health voluntary sector organisations use social and show how it can save the Government inequalities is made by supporting the media platforms such as Facebook, blogs and health services money in terms of involvement of service users and voluntary and Twitter to engage and communicate the preventative work we are doing.’ organisations in service delivery, review, with communities and raise awareness of (Survey response) and planning.’ (Survey response) the support they offer. Freedoms to use ‘Currently conducting a scoping project these methods is often restricted among ‘Co-production is a key aim of our on piloting Time Bank within local area.’ many statutory services: organisation.’ (Survey response) (Survey response) ‘Communication still tends to be in written Capacity to deliver support The flexible and holistic nature form e.g. leaflet with small print. Many at the point of need of service delivery people miss health messages, benefit 2.22 A number of research participants change information, etc. because of the 2.24 Several mentioned the capacity to take suggested there is often a requirement for communication method. Even if they are a ‘whole family’ approach and to straddle rapid response at a point of crisis, outwith told these messages, it is often difficult to the boundaries between statutory services, the waiting list systems operated by larger take it all in and people naturally forget such as the distinction between services for organisations or statutory delivery agencies: and misunderstand.’ (Survey response) children and adults. This type of support ‘Often the individuals who are in most need can also include assistance to family Offer an alternative (non-clinical) are not accessing statutory services and members caring for loved ones affected approach to tackling health issues therefore remain in the shadows of service by health issues: 2.27 Some voluntary health organisations provision.’ (Survey response) ‘The parents tend to have mental health feel that their ability to offer non-clinical ‘People come to us for support around a difficulties, the children have mental health, approaches helps to build improved whole range of issues which prevent them physical, sensory, learning or life threatening awareness and understanding of conditions accessing the services they need, such as difficulties.’ (Survey response) by all those involved and complements panic attacks or having a criminal record.’ medical interventions offered by the NHS: ‘Many parents of children with a disability (Survey response) need support and respite to maintain/ ‘HIV is a social issue – people tend to ‘Benefit reforms impact on genuinely ill sustain good mental health. They may also acquire HIV when they have at least two people. Highly raised anxiety and stress due be overwhelmed by the diagnosis and need other psychosocial problems such as to benefits being withdrawn after interview by help to navigate the services available to homelessness, problem drug use, mental ATOS [the agency that conducts assessments them.’ (Survey response) illness – but as much as this is known, all

24 VHS Living in the gap 2015 national strategies still prioritise clinical ‘We send out information and consultations • Big Lottery Fund outcomes. It is well established that there on health issues via our targeted e-mail lists.’ • the delivery of contracted work commissioned is no “getting to zero” [new infections and (Survey response) by NHS boards or local authorities zero deaths from HIV], without addressing ‘Took part in the local consultation on stigma; and yet addressing stigma is always • Fundraising activities; sponsored races, the Single Outcome Agreement.’ the afterthought in health strategies. In cake bakes etc. (Case study interview) fact the social elements of living with HIV, • Donations and legacies or being at higher-risk of HIV, are where ‘We attempt to work with the Scottish change is needed.’ (Survey response) Government to inform policy development.’ 2.33 The spread of funding sources (Case study interview) ‘We are interested in the social prescribing identified by respondents broadly reflects the national picture. Larger voluntary approach, where a doctor may prescribe ‘We’re carrying out a local consultation to organisations will receive just over half of an activity to assist with depression and find out what people like and dislike about their income from the public sector, whilst isolation.’ (Survey response) the area that they live in and know best. It’s for smaller organisations, this accounts for a bottom-up approach to identifying what Partnership working less than a fifth41. Comments on funding needs to change.’ (Case study interview) typically linked to one or more of the 2.28 Several participants described the way Service longevity following themes: (i) limits available; (ii) the voluntary sector organisations seek to work challenge of meeting funder(s) priorities; effectively with each other, highlighting the 2.31 This was mentioned frequently and (iii) short funding timespan, causing value of this activity in terms of extending several participants highlighted the value organisational instability; and (iv) the capacity, shared learning and reaching of having longstanding services in local resource intensive and bureaucratic nature new service users: communities that are not subject to of securing funding and, if successful, the changes that statutory services ‘We are building stronger working partnerships reporting to funders on service activity: often undergo: with local NHS teams to work together to ‘Funding is always an issue.’ (Survey response) mitigate impact of welfare reform on health ‘Third sector tend mostly to be the ones with inequalities.’ (Case study interview) the long-term relationships. This should be ‘Having one member of staff constantly utilised. Our expertise is often overlooked.’ seeking funding from a variety of sources ‘We work with many partner agencies.’ (Survey response) is very labour intensive and takes away (Survey response) the time for delivery of the actual service.’ ‘Our partners include a variety of community (Survey response) groups and organisations, statutory sector/ Challenges and opportunities ‘Financial constraints and uncertainties – government partners.’ (Survey response) for the sector would be helped by commitment to longer We are part of a virtual, multi-agency Across the study, participants reflected term funding.’ (Survey response) partnership to reduce health inequalities on barriers faced by their organisations ‘Grants tend to be time limited and this makes and tackle poverty.’ (Survey response) but equally many spoke of opportunities sustainability an issue.’ (Survey response) Tackling the ‘softer’ issues that could offer a way forward and enhance their ability to tackle health inequalities. ‘Very uneven playing field in relation to 2.29 Many voluntary sector organisations These challenges and opportunities are investment and funding.’ (Survey response) strive to engage around issues that statutory described below. agencies are not in a position to address: Evidencing value and impact ‘Don’t underestimate the effect that 2.34 Many participants identified challenges loneliness can have on health inequality and Challenges in being able to provide robust evidence the benefits of befriending as a solution.’ about the outcomes resulting from their (Case study interview) Funding interventions. Some described low confidence and a lack of capacity to ‘Health agencies refer service users to our 2.32 Almost all participants described undertake this work: organisation as an additional support.’ funding as the main challenge faced by their (Survey response) organisation, although some were sanguine; ‘There is, as yet, little understanding of the Providing a voice and articulating describing it as a ‘constant’ that could be specific context of health inequalities and the experiences of people who are overcome. Frequently mentioned funding older people. More research – including supported by the sector sources included: collaborative work – should help to inform policy, preventative work and interventions.’ • Funding from public sector bodies, for 2.30 Several participants recounted their (Survey response) efforts to contribute to local or national example, the Scottish Government policy discourse, underpinned by • Grants from charitable trusts and foundations consultation with their service users:

25 chapter 2: findings Further challenges and opportunities

‘We want to ensure we are basing our just woken up to it but we’ve been doing this our area – I identified an opportunity for work on existing and new research and for 20 years.’ (Workshop participant) them to step in and tackle an issue that is fitting in with current and emerging policy changing the way people feel about living ‘Funders always want something new – as if environment.’ (Survey response) here; reinforcing fears of violence, the sense what was successful now needs to change. of poverty and exclusion... but the request Why?’ (Survey response) Too much demand had to go through so many hoops [in the ‘Our desire would therefore be: to share Council] that I don’t know what became 2.35 Several research participants highlighted experiences and promote each other’s of it.’ (Case study interview) that their organisation struggles to meet the services, work in partnership, while avoiding demand for their services. This was often ‘reinventing the wheel’, and utilise what has Factors beyond voluntary health attributed to the high level of need within been shown to work.’ (Survey response) communities. In some cases participants sector control expressed a view that statutory agencies ‘pass Little value placed on third sector 2.41 Participants frequently made reference the buck’, using the voluntary health sector to knowledge and experience to the frustration of facing issues the deliver results they are not able to achieve; for voluntary health sector cannot address, example, due to resource deficiencies: 2.38 Some participants suggested they are with repeated mentions of factors such as: overlooked in public sector consultations, ‘Completely swamped by size of demand • Lack of employment opportunities and limited resources.’ (Survey response) others mentioned being given little feedback and not knowing the extent to which their • Welfare reform ‘They [public sector] refer onto us and participation had made a difference. This • Low incomes and the high cost of then claim they have achieved the health led some to question the value placed by fuel and food outcome; but it’s just shifted the problem policy makers on their input: elsewhere.’ (Workshop participant) • Unaffordable housing ‘It seems that the local authority is consulting With almost half our clients ‘referred’ by GPs the Third Sector Interface which has no • Widening income inequality and the and other health professionals, we strongly mandate or process in place for involving growth of zero hour contracts believe there should be more public sector individual organisations.’ (Case study interview) funding support.’ (Survey response) • Increasing demands on the NHS Hidden health inequalities • Political disengagement and exclusion Lack of awareness of ‘offer’ 2.39 A small number of participants • Lack of green space in communities 2.36 While some organisations struggled highlighted the problem where health to meet demand, conversely, other inequalities are ‘hidden’ or less visible, e.g. respondents raised concern about referral where they occur in pockets of deprivation partners’ lack of knowledge of the voluntary within more affluent areas, and suggested Opportunities health sector ‘offer’ and believed that more that it was hard to engage funders who are Many participants highlighted opportunities use could be made of their organisation: unaware of the issues: that they believed could offer a way forward ‘Raising awareness [among services users] ‘Aberdeen is seen as an economically and enhance the sector’s ability to tackle of what we offer is essential, but we can’t dynamic city and the health inequalities are health inequalities (particularly the lived do this on our own. We require others such often not recognised by those outside. It experience of health inequalities). Below, we as the NHS to raise their own awareness of is also not only in areas of deprivation but set out those most frequently mentioned. what we provide.’ (Survey response) across the city.’ (Survey response) Improve the way funding ‘Some GPs and health visitors are aware of us and others are not, even when we Lack of influence of third sector is managed have consistently tried to tell them about 2.40 Others highlighted a feeling that the 2.42 Although some respondents offered our service, which has a good track record!’ sector struggles to influence key partners quite challenging views on the nature of (Survey response) and wrestles with bureaucracy: funding, suggestions were offered on ways to improve how funding was managed and A culture of too much change ‘The balance of power in partnership working to increase access to funding: lies too much with risk averse statutory 2.37 One particularly strong theme in some of services.’ (Survey response) ‘Why don’t funders incorporate a health the workshop discussions was the frequent inequalities assessment within their criteria; changes initiated by both policy makers and ‘Difficult to influence statutory services.’ that would ensure resources were funnelled funding organisations. This included (Survey response) to the services that actively tackle health criticisms of evolution in terminology: ‘The council’s antisocial behaviour service inequalities?’ (Case study interview) ‘It’s the same thing with a new name. They’ve was about to be relocated away from ‘Outsource more services to third sector

26 VHS Living in the gap 2015 organisations; statutory agencies are often benefits of further investment in accessible confidence to learn new techniques and, ineffective and cost an awful lot more than research and evaluation services: in many cases, do not have support from voluntary sector agencies.’ (Survey response) friends or family members to help take ‘Funding to help evaluate our work to prove care of other domestic responsibilities.’ ‘We are calling for statutory bodies to be impacts and support replication would be (Workshop participant) legally required to offer funded preventative great – however it needs to be easier to services.’ (Survey response) access/apply for.’ (Survey response) Take the lead in addressing poverty ‘In terms of funding the third sector should be supported by Scottish Government Invest in community led 2.49 Several case study participants taking a longer-term view; short term approaches suggested that the sector could help to funding and that which does not support address the issues of poverty and income 2.46 An often-mentioned solution to inequality by championing the Living Wage: core costs is short-sighted. Prevention and addressing health inequalities was the early intervention makes economic sense effectiveness of locally developed, place ‘As a sector we could implement the Living and is worth investing in.’ (Survey response) based strategies: Wage and urge for it to be adopted across Scotland as a national policy. Just think Raise the priority of health ‘Invest in research into community led of how far that would go to addressing inequalities approaches and not the same old tired poverty! If I had only one wish and was research into policy led approaches.’ asked to do something to address health 2.43 Several participants suggested that (Survey response) inequalities, quickly, that would be it.’ addressing health inequalities should be ‘Support asset-based approaches to reducing (Case study interview) given a higher priority at a national level: health inequalities.’ (Survey response) ‘Solutions require strategic and structural Working together – better shifts in national spending priorities, Funds focused on more complemented by more local decision- 2.50 Another solution frequently identified making, including funding to help support radical actions by participants was partnership working community-based responses to need.’ 2.47 Linked to the notion of locally-based and developing a greater knowledge of the (Survey response) solutions, several participants urged for a service landscape: ‘We would benefit from a nationwide review more radical approach to addressing health ‘Help us link up with other service providers of need.’ (Survey response) inequalities; including the development of to build referral routes into and out of our ‘We need support in terms of being funds, policies and strategies that reflect services.’ (Survey response) regarded as equal partners in the creation the interconnected nature of the issues: of a sustainable health and social care ‘If we knew what was out there we could ‘We could view health inequalities as a system.’ (Survey response) work together.’ (Workshop participant) consequence of capitalist processes at Be clear about how we measure play in Scotland. How much money do Leadership by the sector the manufacturers of alcohol, tobacco and health inequalities unhealthy foods make? They have an interest 2.51 Many organisations suggested that the 2.44 Potential solutions offered to develop in keeping people addicted to these harmful voluntary health sector could take on more a greater awareness and understanding substances; the people most affected are the of a leadership role: communities who live in poverty. Yet it has not of health inequalities were broad ranging, ‘Further closer relationships with the likes been challenged. We were encouraged by for example: of VHS would be beneficial in terms of a minimum unit pricing but that appears to stronger, united voice.’ (Survey response) ‘Include socio-economic characteristics in have stalled.’ (Workshop participant) the data collected by the NHS. That would ‘We’d really like to highlight the value of our allow greater understanding of health Understand the complex nature work in driving the agenda at a local level; inequalities.’ (Case study interview) of the lived experience of health we’re recognised as leading the approach ‘Decide what the key indicators of health inequalities and being responsible for many of the inequalities are and get the Scottish successes brought about in our partnership. Government and health boards to report on 2.48 Some gave examples of how different That’s a big step when you consider that them’ and ‘loneliness-should be an indicator factors combine to make the lived experience a few years ago the relationship was in the Government’s national performance of health inequalities more challenging. For contractual; we were commissioned to framework.’ (Survey responses) example, one participant explained: supply the services – now we’re involved in that commissioning.’ (Case study interview) ‘[Our] clients find it difficult to engage in Provide funding support for self-management therapies because they ‘The Public Social Partnership (PSP) evaluation are worried about additional expense, have approach has shown that the third sector no access to transport, do not have the can really deliver.’ (Workshop participant) 2.45 Some responses raised the potential

27 Clackmannanshire Healthier Lives CHL is a community-based programme delivered by partners from public and third sector organisations in Clackmannanshire. The partnership aims to improve health outcomes for people facing socioeconomic exclusion, by supporting changes in behaviour. CHL is an anticipatory care project focused on preventing poor health outcomes associated with poverty, such as isolation, poor mental health, lack of information or behaviour including low levels of physical activity, poor diet, smoking and harmful or hazardous alcohol use. In recent years a key area of work has been support for older people. The intention is to prevent or mitigate the negative impacts of poverty on health and overcome imbalances that contribute to health inequalities, such as limited reach of public health campaigns and service access barriers.

28 VHS Living in the gap 2015 What is CHL, how is it funded How does CHL believe its ‘We work in local settings so we know and who does it support? work helps to improve the the health issues affecting people in our communities. The partnership enables CHL is a partnership between NHS Forth lived experience of health us to prioritise, identify the problems Valley, Clackmannanshire Council and a inequalities or prevent them? that we want to address and channel range of third sector organisations, CHL was one of the few case study the resources that are available to including Tullibody Healthy Living and participants that believes their work has the meet these needs.’ Addictions Support and Counselling – Forth potential to achieve changes at an upstream Valley (ASC). The partnership’s leadership Another aspect of CHL’s connection level. They suggested that demonstrating to addressing health inequalities is its and coordination function is delivered by third sector organisations have the skills, Signpost Recovery. asset-based approach; building community knowledge and resources to deliver resources may contribute to effecting a Since its inception in 2007–8 CHL’s funding effective health interventions may inspire change in terms of redressing imbalance in arrangements have changed in response similar approaches in other areas. It may resources/power in society. A key part of to available resources; for some time it have a strategic impact, if it informs the the programme is the delivery of activities received money from the Fairer Scotland thinking of those responsible for developing by volunteers, within local settings. Fund, however, funding has been provided polices funding work that aims to prevent, by Clackmannanshire Council for the last reverse or address health inequalities. ‘This is more sustainable, creates longer lasting change – it means with a little bit 3 years. Recently it has been successful in CHL has identified four national priority applying for funding from the Change Fund, of resource, to coordinate and advertise areas for the programme as anticipatory activity – we can achieve a lot more.’ linked to its alignment to the Reshaping care, personal health and wellbeing, Care For Older People strategy. Resources supporting re-enablement and community www.signpostrecovery.org.uk/services/ ‘in kind’ are also provided by partners; engagement. activity funded by partner agencies, for www.clacksweb.org.uk/social/chl/ example, may be listed under CHL’s ‘We’re showing that a third sector programme, to encourage awareness organisation can be at the helm of a and referrals. successful cross-sector approach to addressing health issues.’ A full range of anticipatory health services are offered, including addiction It was also highlighted that CHL’s work is assessments, physical health activities, life part of the trend towards person-centred skills support and personal development and holistic approaches to tackling health interventions for activities that contribute to issues in Scotland. They view this as part healthier lifestyles such as food preparation, of a growing awareness of the need to budgeting and planning. The programme is improve responses to public health issues: advertised widely across local health, social ‘It’s part of a longer-term approach – going care and third sector partners. beyond the traditional, medical model of People supported by CHL are referred from ‘treating the symptoms’ to an anticipatory, a wide range of sources including health preventative focus that attempts to stop and social care staff, community referrals problems building up, avoid harm or from family members or friends and reverse it, where possible.’ self-referrals. Staff roles include life skills A key element of the approach, in terms of coaches, support workers and substance its connection to health inequalities, is that misuse treatment practitioners with various CHL’s work revolves around addressing the specialisms; people receiving support may health harms that are common among be internally referred to another staff people living in poverty, over and above member if they could benefit from additional average rates among the general population skills or specific interventions. in Scotland. These include poor mental health, obesity and preventable or treatable health conditions:

29 Kincardine & Deeside Befriending A service that tackles social isolation. Social isolation was identified by all study participants as a key factor linked to the lived experience of health inequalities. Kincardine & Deeside Befriending (K&D Befriending) uses a befriending model to reduce social isolation and tackle isolation-associated health issues, such as poor mental health, health-limiting behaviours or lack of contact with health services. Although the service’s main focus is on support at the individual level, its recent participation in the Aberdeenshire Change Fund is noteworthy in terms of potential contribution to addressing health inequality influences; the Change Fund is designed to inform upstream matters such as long term service planning and resource allocation.

30 VHS Living in the gap 2015 What is K&D Befriending, element of their work; befrienders aim to ‘An evaluation of the Befriending at how is it funded and who improve health experiences, for example, Hospital pilot project showed that this by assisting clients at key points of crisis, pilot saved 25 bed days because people does it support? including recovery from an operation who were befriended felt confident to K&D Befriending is a small registered Scottish or poor health. leave the ward sooner.’ charity that facilitates befriending by 100 Staff believe the service adds value and can Staff suggested that one of the service volunteers to around 100 older people within reinforcing the positive impacts of other strengths is that befriending is not time specific areas of Aberdeenshire. Befrienders forms of health care support – befriending limited, which means that individuals can receive training and their style of delivery can take place alongside other interventions remain with their befriender for as long as is designed to be person centred, and help to achieve some of the ‘softer’ it benefits them; often receiving continuity approachable and engage people who may outcomes that statutory partners may not of support that statutory services would otherwise be reluctant to make their isolation have the resources to deliver. For example, not be able to offer or sustain. They also known or admit their need to other agencies. befrienders may support someone who is highlighted that: Clients may self refer or be signposted to the undergoing treatment, recovering from an service by social work and health services. ‘Statutory health partners can struggle illness, or is on a waiting list. They may We were told that: to reach people in the small rural provide an informal ‘top up’ of contact to communities that this voluntary sector ‘Staff, older people and their carers someone receiving support from community provider works within.’ and their referrers believe befriending mental health teams or have befriending activity helps to overcome the impact of included as part of their treatment by Another interesting element of the service loneliness and isolation on older people health services. Through positive activities, is that it offers a mechanism for releasing due to long term illness, frailty, sensory befrienders can encourage people to professional and social capital – many of and mobility problems, depression, engage with their treatment or help them the befrienders are retired people with a anxiety and dementia or lack of transport to prepare for an intervention. professional background in the field of and local services.’ health and social care. The service therefore Staff explained that befriending activity provides a means for these individuals to In 2013/14 the charity had a budget of is tailored to the needs of the individuals continue contributing their valuable skills, roughly £89,000. Three part time staff supported, providing emotional and time and energy to people who may benefit members are based across two offices. practical assistance, confidence and social from it. Funds are sourced from donations, internal stimulation. They suggested that preventing fundraising efforts and local authority and addressing poor mental health is a The presence of befriending within local contracts to deliver a limited number of key aspect of befriending, highlighting: communities can also have a positive placements. These resources are used to ripple effect: ‘The negative impacts of loneliness on recruit, train, manage and pair volunteers physical and mental wellbeing are well- ‘Reinforcing a sense of belonging, cohesion with local people who require befriending documented: loneliness exacerbates and support – both for befrienders, services. dementia, it has an adverse effect on befriendees and their wider networks. ‘A considerable amount of funding goes the cardiovascular system, is more likely Befrienders report that their own to helping older people to get out of their to lead to depression, eating and sleep awareness of health inequality and older home and to provide transport.’ disorders, and can affect the immune people’s issue has increased due to system…’ volunteering with the organisation.’ In a specific recovery-themed initiative, Enabling carers to continue delivering How does K&D Befriending the charity ran a pilot service at Kincardine support – in most cases where a carer is believe its work helps to and Glen O’Dee Community Hospital, involved, the befrienders’ service provides improve the lived experience resourced by a grant from the Change Fund. regular short periods of respite for carers. of health inequalities or During the first year 13 older people were Staff highlighted that the breaks have been prevent them? supported to maintain their independence positively evaluated and found to contribute at home after discharge and no one was to an individual’s ability to look after their The charity report that they refer clients onto readmitted to hospital. The pilot identified own health and to sustain their role as appropriate services if they identify unmet befriending’s positive return on investment a carer. health care needs and also assist people to through reduced delayed discharges and attend their appointments; for example, readmissions and supporting older people www.kdbefriending.org.uk by providing transport and accompanying to maintain their independence at home people so they are supported to access after leaving hospital: health services. Delivering services to people who are already experiencing physical or mental health issues is another

31 MS Therapy Centre Lothian A grassroots therapy centre that was established to provide accessible treatments and facilitate self-management. Many people living with Multiple Sclerosis face complex barriers – including physical, mental, economic and service access issues – that can affect their quality of life and the extent to which they are able to manage their health. This service began in response to a demand from a small group of people living with MS for more accessible treatments and greater frequency of support than could be provided by NHS Scotland. The Centre offers peer support, helps people to live with the symptoms of MS and provides assistance to facilitate self-management; including information and advice, adapted fitness classes, physiotherapy and complementary treatments.

32 VHS Living in the gap 2015 What is the MSTC, how is The holistic nature of the support and ‘Some of our younger users feel very it funded and who does activities available was highlighted as one isolated; after diagnosis they may have of the Centre’s key strengths. These vary struggled to find peers who understand it support? from specialist physiotherapy, oxygen what they are going through…or the The MSTC is based in Leith, Edinburgh and therapy, creative writing classes, adapted older users face isolation because of the was established in 1984 by a small group physical fitness classes for yoga and progression of their condition, stopping of volunteers. Now the Centre has a small Pilates and alternative treatments such as them getting out so much. Our reception team of paid staff who are supported by massages, life coaching and reiki. Staff area is busy all day; after therapies people volunteers; the centre is open for 52 hours suggested that these services complement often stay there for a chat and make across six days each week. On an annual the medical support available from the NHS, friends. It’s important to know that there basis approximately 500 service users and offer positive activities for people to is a place where people understand what access some form of support from MSTC engage in between clinical appointments. you’re going through.’ across Edinburgh, East Lothian, West They are also trying an outreach programme To address service-access barriers to Lothian, Midlothian, South Fife and the for some of the therapies for people who physical fitness that many people with Scottish Borders. are unable to travel to the Centre: MS experience, MSTC has worked in Most beneficiaries are people living with ‘The NHS model is first and foremost partnership with KICC Active Lothian to MS, but oxygen therapy treatments are also clinical i.e. addressing the physical fund and deliver adapted classes for available to other users; approximately condition of the person. That’s very yoga, Pilates and hydrotherapy, supporting 30% of the Centre’s users are being treated important, but people with MS also need people in self-managing their condition. for conditions including types of cancer, other support to help them and their loved ‘It’s so important for people with MS to arthritis, ME and autism. In addition, MSTC ones deal with the day-to-day nature of keep healthy and active. We’re all told also provides support to family members their condition. It’s important that they that; but the things that are available to who care for people living with MS. get support from people who understand the general public are simply inaccessible and have the capacity to spend a bit of to many of us. We plugged away, came Their annual budget of approximately time on them, delivered by staff who are up with a plan and found the resources £220,000 is drawn from various sources; knowledgeable, informal and friendly. At to address the gap in accessibility; by ranging from a small Service Level Agreement hospital they can end up feeling like a training tutors who can provide adapted with NHS Lothian, grants from charitable patient being treated by someone who classes local community venues.’ organisations and fundraising or donations is in a rush to see their next appointment – by volunteers, staff and service users. it can discourage questions.’ Like many of other services in the case studies, MSTC also has a service-user Linked to the above, staff suggest that consultation group. This is a forum for the nature of the MS means that the How does the MSTC believe consultation and enables people with experience will differ from individual to MS to share their views and experiences; its work helps to improve the individual. They believe that MSTC’s flexible it enables communication ‘upstream’ to lived experiences of health and varied services enable service users to influence those with the power to address inequalities or prevent them? access support that is tailored to their health inequalities or to advocate for individual needs: MSTC believe that social isolation and improved services for people living income poverty are interlinked with health ‘MS is a very difficult condition to manage. with MS. inequality issues because in the longer term, For a start there are four different types www.mstc-lothian.org.uk people living with MS are often unable to of the disease; all with very different sustain employment due to their health symptoms and forms of progression. That condition. They also face additional costs means that each individual will have to for things such as transport, equipment develop a unique strategy for living with and insurance: and managing their condition; we offer them lots of support, choice and ideas.’ ‘They may have time to fill but no means of funding social activities… it’s the most It was also highlighted that the Centre basic, and fundamental form of exclusion. enables social interaction and peer support, Before the introduction of self-directed important for a group who may experience support budgets many of the popular isolation linked to their condition: complementary treatments were unaffordable.’

33 North Glasgow Community Food Initiative Services that are rooted in the issues faced by specific communities. North Glasgow Community Food Initiative (NGCFI) works with families living in poverty and has a particular history of providing support to asylum seekers and others affected by welfare reform. At the individual level their projects are designed to improve health outcomes for people most at risk of health inequalities. The service tackles factors that underpin poor nutrition – such as access to affordable food – plus social, cultural and educational gaps that may affect healthy eating, including limited food knowledge, low skills/confidence in food preparation, inability to plan for a healthy diet and poor budgeting skills. The Initiative’s community development and empowerment work seeks to tackle upstream factors linked to health inequalities such as low levels of social capital and democratic engagement.

34 VHS Living in the gap 2015 What is NGCFI, how is it funded schemes with no supermarkets and Gathering evidence – NGCFI gathers and who does it support? residents face high transport costs. monitoring and evaluation material from They suggest this makes people reliant on all of its projects. The information is relayed The NGCFI is a registered Scottish charity expensive convenience stores, restricting to key funders, who evidence activity and and limited company operating across the quantity and quality of food that families highlight the needs of people supported deprived communities in North Glasgow. living in poverty are able to buy. As one by food initiatives. They have also Its mission is to: staff member explained: implemented a rolling programme of Local Evaluation and Planning (LEAP). ‘Engage people in practical and sustainable ‘Even Lidl, which is marketed as an food related projects that inspire health affordable supermarket, is selling 1 kg of ‘One of our volunteers told us he had and wellbeing and celebrate the diverse potatoes for 50p whereas we buy them an improved sense of self-worth from nature of communities in Glasgow.’ wholesale, add a small mark-up to help knowing that once a week he would feel cover our costs and sell them for 23p per like a customer and have some purchasing A team of 9 full time equivalent staff and kg.’ (Prices stated in November 2014) power, as opposed to someone who was 83 volunteers works with groups at risk reliant on the state for a food voucher.’ of adverse health effects resulting from The Initiative delivers a range of projects food poverty. that offer preventative and direct support NGCFI encourages activity to raise to individuals. awareness of its work and impact. It has ‘We are inclusive and support people who developed case studies and reports on experience issues such as stigma, social ‘The preventative nature of our work developments in its own newsletter and isolation, disability, poverty, low levels concerns improving nutritional outcomes through the website. of literacy or lack of information. All our and providing services that sustain beneficiaries are drawn from communities mental-well being.’ Working in partnership was described with low levels of income and many of by NGCFI as an integral aspect of activity. Staff explained that their services aim to our volunteers are disabled or asylum Referral partnerships have been established improve nutrition, health and well-being; the seekers/refugees.’ with bodies such as the Bridges activities also tackle poverty, social isolation Programme, Scottish Refugee Council and There are a significant number of and stigma. A key focus is the establishment NHS Greater Glasgow and Clyde. Staff also beneficiaries: for example, in 2013/14 of community projects to develop a circle heighted that: cookery classes were delivered to 250 of activity; growing, cooking, choosing, people and there were approximately 25 accessing and sharing fresh food. Other ‘We view local communities as key partners customers per week at each of the 10 work includes providing information about and take a “bottom up” approach to fruit and veg barras. Staff noted that: fruit and vegetables, how to cook them and involve local residents in the design and recipe ideas. Current work streams include: delivery of projects; in this way community ‘On average 3 people in each household capacity is developed.’ benefits, so there are over 750 • Fruit and vegetable barras, providing beneficiaries’ [per barra, per week].’ fresh produce at affordable prices Examples of partnership work include the many local groups involved in the Milton In 2013/2014 NGCFI had an income of Development of community gardens • Food Hub; a local regeneration project, almost £280,000. Funding consists of a and gardening sessions local churches, resident and tenant range of one to three year grants from associations and schools. Similarly, NGCFI’s various sources, including: Glasgow City • Food Hubs in Milton, Royston and cookery courses use a range of partners to Council, The Robertson Trust, Big Lottery Springburn which engage with local people. support delivery and engage beneficiaries Fund, Scottish Government Climate • Healthier eating cookery courses including nursery and primary schools, the Challenge Fund, Voluntary Action Fund, The including antenatal cookery local women’s centre, integration network, Trusthouse Charitable Foundation, SCVO, youth projects, ex-offender services and Lloyds TSB Foundation Scotland, and the • Specific food and cookery information mental health associations. Work is also Garfield Weston Foundation. All fruit and for asylum seekers underway with Pilotlight to help NGCFI to vegetables are sold on a not for profit basis. • Weight reduction courses grow, develop social enterprise options and • Nutrition workshops create a new business plan. How does NGCFI believe its • Community events and communication www.ngcfi.org.uk work helps to improve the projects lived experience of health • Healthy eating sessions in schools inequalities or prevent them? and nurseries NGCFI believes that a key issue affecting • Royal Environmental Health Institute communities in North Glasgow is the lack of Scotland (REHIS) training of affordable food; there are many housing

35 Includem Provision of support for a specific group – troubled and vulnerable young people with histories of abuse, neglect and deprivation. Troubled and vulnerable young people face many of the issues that voluntary health sector providers identified as being inextricably linked to the lived experience of health inequalities; social isolation, barriers to accessing services, poverty, stigma and behaviour associated with increased risk of health problems. Compared to their peers, troubled young people are more likely to self harm, experience poor mental health or to become young parents. They may have few positive role models or lack the educational and social capital – including skills, confidence, family and support networks – that underpin positive health outcomes and provide a foundation for adult life and parenthood. Includem’s work is designed to address these support needs and help young people make successful and healthy transitions.

36 VHS Living in the gap 2015 What is Includem, how is it dependable and caring relationship and Compared to their peers, Includem’s service funded and who does it support? work such as emotional support, education, users are more likely to become young awareness raising, structured cognitive parents. Behaviour during pregnancy can Includem is a registered Scottish sessions to drive behaviour change, affect low birth weight – a key health charity operating across Glasgow, supporting changed behaviour or facilitating inequality indicator. Ante and postnatal West Dunbartonshire, Clackmannanshire, engagement with health services, and support is part of the Includem offering Stirling, Dundee and Fife. Its focus is to: immediate crisis support. to young mums and dads; work typically focuses on positive behaviour, building ‘Deliver support to the most vulnerable and ‘The needs vary from person to person but parenting skills and developing good challenging young people in society. Our there are common issues facing most of relationships. Includem believes this can 1 to 1 support at the times of need helps them. Poverty and difficult life experiences improve early years experiences and lead to make positive changes to their attitudes, can affect physical and mental health in to better outcomes for the next generation behaviours and relationships.’ so many ways– through the cumulated of families. impact of things like exposure to violence, Nine teams totalling approximately 75 full low quality housing, bad diet, low mobility Staff discussed reasons for successes in time equivalent staff work across a range of and limited social activity.’ engaging a group that are known to be projects, often working closely with young challenging to work with. Some suggested service users’ parents and carers, where The young people supported by Includem that Includem’s flexible and responsive appropriate. Includem’s service model, often face specific hurdles that can affect service model, delivered in community used across all projects, is evaluated and their health; for example, school exclusion settings – enables effective work with evidence-based; a range of evaluation reports might result in a person missing key health young people. Others highlighted that the are available for review on Includem’s website. education campaigns; or those with a high charitable status of Includem contributes In the last year (2013/14) 556 young people level of exposure to substance misuse may to a trusting relationship between staff and were supported through 100,189 hours of find school-age drug and alcohol information services users, which encourages young contact; as a result of this work Includem not relevant to their experiences and people to be open about any issues or believes 173 families avoided breakdown and therefore ‘switch off’ from key messages. vulnerabilities and more likely to respond 106 young people were prevented from going to advice and support. The provision of into care. The 24/7 helpline received 9,984 ‘There are other logistical issues too – so ongoing transition support through the calls in that period. many of the young people we support move frequently between a range of short helpline means that young people have a In 2013/14 Includem had a budget of almost term accommodation – this can mean they route to access help at a crisis point even £3.8m. Funding consists of a range of local don’t know what health services they are if they have successful moved on or authority contracts (typically commissioned registered with, can’t track down a GP disengaged from the service. by children & families and youth justice or dentist when they need one and don’t Another area of Includem’s work is youth social work services) and one to three year have the things like identification or proof empowerment and participation; this is an grants from various sources, including The of address that you need to sign up to a area of upstream activity that may Scottish Government, The Robertson Trust, health service.’ contribute to addressing health inequality Big Lottery Fund and Police Scotland. Lack of positive role models and poor life influences such as low levels of social skills can also contribute to poor health capital and democratic engagement. Work outcomes. One young person who is underway with agencies such as Snook How does Includem believe participated in the case study explained: to co-produce material that reflects young its work helps to improve the people’s experiences. Includem uses a lived experience of health ‘My muscles have started to waste because broad range of communication platforms inequalities or prevent them? of my size – I need to lose some weight- including blogs, films and podcasts, and is and I’ve been having problems with my planning a new interactive website design Includem has developed a service model to legs… My support worker has helped me to engage service users and wider support this group which includes tailored to change things like my diet and to be audiences in its work and impact. personalised support, and a 24/7 helpline, a bit more active. It’s stuff like practicing delivered by staff who are trained to prevent my physio exercises, making sure I have www.includem.org suicide and self-harm. enough medication to last me at the weekend and over Christmas, taking the Staff explained that their work is tailored to stairs instead of the lift… She’s taught the needs of the individual; young people me a few simple things to cook instead have multiple issues that are addressed of buying ready-made – I know that’s over months of at least 3 support sessions what I need to do but it was hard. per week. While Includem is not a health She encourages me.’ service, it offers preventive and direct health activity through building a respectful,

37 chapter 3: conclusions The key issues and the next steps

Everyone’s business – promoting healthy living to groups of in tackling poverty and inequality. This people who may not use mainstream consensus stretches across civil society, Health inequalities do not stand alone; they services including the voluntary health sector. The are a part of a broader set of inequalities: issue for the sector, and perhaps for how – supporting people to access relevant economic, social, cultural, gender-based, it is regarded by the public sector, is that services. racial. As such, they cannot be addressed much of its activity is downstream, buffering solely by health strategies and interventions. These roles are evident in this report, which the impact of health inequalities by giving Equally, they cannot be addressed by a shows a voluntary health sector in Scotland individuals and families the support to cope. single sector. The public sector may have working with some of the most vulnerable Contributing to the upstream issues is the statutory duty to deliver health and and marginalised groups and individuals; and evidenced mostly around campaigning social services, address public health issues, making an impact. One of the case studies, activities where root causes are spotlighted provide social housing, deliver a benefits Includem, concludes that, over the course and long term solutions sought, and system, all of which are key to addressing of one year, its work meant that 173 families decision-makers influenced. health inequalities. The private sector also avoided breakdown and 106 young people Nevertheless, the sector does have a more has a key role, particularly as 70% of jobs in were prevented from going into care. direct upstream role. To continue with the Scotland are private sector jobs. However, Although Includem can demonstrate such example of Includem, the organisation the third sector, including the voluntary results, a key concern is expressed that provides ante natal support services in order health sector, although smaller, is a vital the voluntary health sector more generally to seek to break the cycle of poverty at the component in tackling health inequalities. needs support if it is to measure the impact earliest stages, offering a different future This is particularly true of the sector’s of its activities to that same level and with for generations following. This kind capacity to address the ‘lived experience’ of consistency. This is particularly the case of activity may become more prevalent health inequalities – the day to day reality. with smaller voluntary health organisations as upstream policies (‘early years’45, who need to have the confidence, tools The positive role already being played by the for example) bed in as mainstream and resources to adopt evaluation sector which emerges from this study can interventions. The voluntary health sector methodologies and to incorporate them be summarised as: needs to position itself in order to measure into their mainstream activities. • A shared commitment across the sector impact, overcoming issues of (small) scale, to addressing health inequalities This support could be derived from sharing and properly identifying what should be best practice across the sector and from measured and how it should be measured. • Voluntary health sector activities mitigate those parts of the public sector where the negative effects of health inequalities; measurement of impact is built in to its work. this may primarily be downstream work However, it is important to recognise that Partnership and change but it is essential in terms of the lived measurement of impact is a challenge for all experience sectors, described succinctly in a tweet from Partnership is a key theme emerging from NHS Health Scotland42 as ‘conceptually the study. Concern is expressed that the • The third sector takes a wraparound voluntary health sector is too often a junior approach – holistic, person centred, joined straightforward but execution deceptively difficult.’ Knowing and being able to show partner, with the statutory sector setting the up, responsive – and this creates significant agenda. At the same time, the survey also opportunities in responding to the needs that a particular intervention has made a difference in narrowing the inequalities gap is uncovers examples of the voluntary health of our most vulnerable individuals and sector taking the lead in local and regional communities a process that runs counter to the prevailing culture, which focuses on headlines and partnerships. This is reflected in an Audit However, it is also apparent that there is immediacy. All stakeholders – senior Scotland report into health inequalities, an untapped opportunity to harness and politicians and managers, the media, funding which found that the voluntary sector channel what the sector is doing; and to bodies and those on the front line – need to believed that the Change Funds had helped support it working alongside public and commit to clear measurement and evaluation to improve partnership working between private interventions as an underpinning principle in tackling voluntary and statutory organisations but inequalities: and to provide the funding that this was not the prevalent experience: to do so. ‘Overall… frontline staff [i.e. in the third Third sector role and impact sector] felt excluded from partnership Audit Scotland has identified the role of the third working aimed at tackling health 46 sector in addressing health inequalities as41: Upstream/downstream inequalities .’ The publication of the Christie Report43 on Audit Scotland states that ‘reducing health • providing a means of engaging effectively with communities and individuals preventative spending engendered a broad inequalities requires effective partnership political consensus that upstream work – working across a range of organisations. • delivering a range of services which may ‘It is easier to build strong children than However, there may be a lack of shared help to reduce health inequalities, including: to repair broken men’44 – was a priority understanding among local organisations

38 VHS Living in the gap 2015 about what is meant by health inequalities • Organisations are not working with voluntary health sector in tackling health and greater clarity is needed about common tools, frameworks, practice inequalities. Our ten case studies illustrate organisations’ roles and responsibilities.’ what the sector offers now and provide a • Work is needed on the sector’s ‘upstream’ Our findings reinforce this point. touchstone for thinking about the future, contribution particularly in terms of impact. The effectiveness of current systems • No clear sense of the economic and and relationships – Community Planning added value of voluntary health sector role, Partnerships, Third Sector Interfaces – i.e. the savings to the public purse is questioned by respondents. Systems Voluntary Health Scotland will: are often too remote to feel relevant to the • Public sector roles and responsibilities: • share, discuss and consult on these actual work of the sector. Equally there is lack of clarity as to who is doing what, findings and the questions they raise widely concern that major changes stemming from including Community Planning Partnerships, and with key stakeholders including the health and social care integration may be Single Outcome Agreements, health and Scottish Government, NHS Health Scotland too concerned about structure and not social care integration and other NHS bodies, MSPs and voluntary about optimising impact at the front line. health organisations The third sector and the public sector need • Partnership deficit – to work successfully to find solutions which will generate trust upstream our sector has to be more of an • determine what actions to take next, e.g. and underpin mutual progress. equal partner with public sector and not development of tools/toolkits and training dismissed as relatively informal and programme or other types of resource If sectors are working alongside each other small scale they are not necessarily working with each • work with NHS Health Scotland and other other. The integration agenda and the • Third sector’s contribution needs to be key partners to draw up an action plan, partnership structures need to focus on promoted and acknowledged identifying how to resource and implement. mutuality for the benefit of those in need. The study prompts a number of questions about what kind of actions might be needed Next Steps to move forward. These include: Language of health inequalities There may be something of a momentum • Detailed mapping of voluntary health building around approaches to health Another clear area of concern is language. sector, e.g. At policy level language can be academically inequalities and inequalities generally in derived and somewhat rarefied. As such, Scotland. In November 2014, NHS Health – The number and characteristics of it doesn’t readily facilitate dialogue across Scotland published a briefing on Health individuals supported Inequalities for the 2015 General Election sectors and reassure the front line that the – Levels and sources of funding to tackle with a range of recommendations for reality – the lived experience – of health health inequalities inequalities is fully understood by those with political parties to consider in developing 48 the decision-making powers. The 2014 Child their manifestos. In January 2015, a – Savings generated by reducing need to 49 Poverty Strategy for Scotland47 talks about Scottish Parliament debate on the subject use high tariff service reflected on why, even when money was the 3 P’s – pockets; prospects; places. • Promotion of successful and cross sector Easily remembered, this shorthand helps available, inequality increased. In the same month, the Parliament’s Health & Sport health inequality interventions and to summarise the complexity of inequalities partnerships into three interlinked components: the Committee published a report on health 50 money/resources in the pockets of those inequalities , which stressed the need to • A focus on loneliness as an exemplar living with the impact of inequality; the look beyond health solutions and which of the sector at its most effective. called for a ‘new approach.’ Following the availability of prospects in terms of jobs, There are many more issues and, in reading relationships, travel, and so on; and the publication of draft legislation on further devolution for Scotland, the Scottish this report, they will hopefully become importance of housing and community. apparent. Individual organisations will find This is the kind of conceptual approach that Council of Voluntary Organisations (SCVO) criticised the absence of ‘welfare home rule’ a set of questions relevant to them and by seems to start with the reality and which has sharing these thoughts and experiences, the capacity to break down barriers and as a missed opportunity in tackling poverty 51 the voluntary health sector will be leading create a common space for discussion. in Scotland . The Health & Social Care Alliance Scotland has published its own the way in making health inequalities report on health inequalities emphasising everyone’s business. the need for a Human Rights Based Summary of key challenges approach. • There is a lack of shared definitions, Living in the gap adds to the momentum knowledge base or language to talk about and, in doing so, provides a unique health inequalities perspective on the role and capacity of the

39 references

1Graham H. (2009) The challenge of health 20http://www.healthscotland.com/uploads/ 39http://www.vhscotland.org.uk/third-sector- inequalities. In: Graham H. Understanding documents/23629-Delivery%20Plan.pdf contributions-to-narrowing-health- health inequalities. Maidenhead: Open inequalities/ 21http://www.gov.scot/Resource/ University Press 0046/00460952.pdf 40http://www.vhscotland.org.uk/wp-content/ 2http://www.healthscotland.com/uploads/ uploads/2013/11/VHS-Symposium-Notes- 22http://www.scotland.gov.uk/Resource/ documents/23047-1.%20 28-November-2013.pdf Doc/358359/0121131.pdf HealthInequalitiesPolicyReview.pdf 41Health Inequalities in Scotland, Audit 23http://www.scottish-parliament.net/S4_ 3http://www.scotland.gov.uk/ Scotland, December 2012. http://www. HealthandSportCommittee/Inquiries/ Publications/2014/03/2561/5 audit-scotland.gov.uk/docs/health/2012/ BDG012_-_Scottish_Government_Health_ nr_121213_health_inequalities.pdf 4Health Inequalities in Scotland. and_Social_Care_Directorates.pdf Audit Scotland, 2012. 42Gerry McLaughlin @McLGerry @NHS 24http://www.scottish.parliament.uk/S4_ Health Scotland, 26 January 2015 5http://www.audit-scotland.gov.uk/docs/ HealthandSportCommittee/Reports/ health/2012/nr_121213_health_inequalities.pdf her-15-01w-rev.pdf 43Commission on the Future Delivery of Public Services, June 2011 6http://www.scotland.gov.uk/ 25https://www.smith-commission.scot Resource/0046/00461784.pdf 44Quote from Frederick Douglass. http://www. 26https://www.gov.uk/government/uploads/ goodreads.com/quotes/28899-it-is-easier-to- 7www.scotland.gov.uk/ system/uploads/attachment_data/ build-strong-children-than-to-repair resource/0038/00386355.doc file/397079/Scotland_EnduringSettlement_ acc.pdf 45http://www.healthscotland.com/topics/ 8http://growingupinscotland.org.uk/wp- stages/early-years/index.aspx content/uploads/2014/05/GUS-evidence-for- 27http://www.theguardian.com/politics/2015/ SP-Health-Sport-Comm-2014.pdf jan/22/nicola-sturgeon-smith-commission- 46Health Inequalities in Scotland. Audit scotland-first-minister-danny-alexander- Scotland 2012. http://www.healthscotland. 9http://www.who.int/social_determinants/ uk-veto com/topics/stages/early-years/index.aspx thecommission/finalreport/key_concepts/en/ 28http://www.scotland.gov.uk/ 47Child Poverty Strategy for Scotland. 10http://www.legislation.gov.uk/ukpga/2012/5/ Publications/2014/03/2561 Our Approach 2014 -2017. The Scottish contents/enacted/data.htm Government, 2014. http://www.scotland.gov. 29http://news.scotland.gov.uk/News/ 11http://www.scotpho.org.uk/downloads/ uk/Resource/0044/00445863.pdf Ministerial-Task-Force-on-Health- scotphoreports/scotpho131002_ Inequalities-a59.aspx 48Actions to reduce health inequalities: 2015 impactofwelfarereform_1.pdf UK election briefing and resources. NHS 30http://www.scotphn.net/pdf/2013_04_16_ 12http://www.scotland.gov.uk/Topics/ Health Scotland. December 2014. http://www. Final_Guidance_on_UK_Welfare_Reform.pdf Statistics/Browse/Health/ healthscotland.com/documents/24543. TrendHealthOutcome#BG 31http://www.healthscotland.com/uploads/ aspx?utm_source=website&utm_ medium=newsarticle&utm_ 13 documents/18922-CorporateStrategy.pdf http://www.audit-scotland.gov.uk/docs/ campaign=manifestobriefing health/2012/nr_121213_health_inequalities.pdf 32http://www.scotland.gov.uk/About/Review/ 49http://www.scottish.parliament.uk/ 14 publicservicescommission http://www.audit-scotland.gov.uk/docs/ parliamentarybusiness/28862. 33 health/2014/ir_140617_health_inequalities.pdf http://www.gov.scot/Publications/ aspx?r=9735&i=89206 15 2008/11/20111919/0 http://www.scotland.gov.uk/Topics/Health/ 50http://www.scottish.parliament.uk/S4_ 34 Healthy-Living/Health-Inequalities/Equally-Well http://www.scotland.gov.uk/Topics/Health/ HealthandSportCommittee/Reports/ Healthy-Living/Health-Inequalities/Equally-Well 16http://www.scotland.gov.uk/Topics/Health/ her-15-01w-rev.pdf 35 Healthy-Living/Health-Inequalities/Equally-Well http://www.scotland.gov.uk/ 51Letter to The Herald, 27/01/15 Publications/2008/11/20103815/0 17http://www.scotland.gov.uk/Topics/ Government/local-government/CP/soa 36http://www.health-inequalities.eu 18http://www.scotland.gov.uk/ 37http://www.vhscotland.org.uk/category/ Resource/0042/00423188.pdf featured-members/ 19http://www.healthscotland.com/uploads/ 38http://www.vhscotland.org.uk/connecting- documents/5792-CorporateStrategy.pdf people-a-fairer-healthier-scotland/

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