A Comparative Study on the Influence of Healthcare Decentralisation on Equity in Scotland and Sardinia

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1-06-2020 Francesco Filigheddu - s2066262 Dr Ir. A.A.H.E. (Ellen) van Reuler International Relations and Organisations The Welfare State in International Perspective Bachelor Thesis Wordcount: 8300

It is right to do so: A comparative study on the influence of healthcare decentralisation on equity in Scotland and Sardinia

Table of Content 1 Introduction ...... 3

2 Literature Review ...... 4

2.1 Healthcare Equity ...... 4

2.1.1 Healthcare Equality ...... 4

2.1.2 Healthcare Equity: Theories and Origins ...... 5

2.1.3 Geographical and Local Inequities...... 6

2.2 Decentralisation ...... 7

2.2.1 Decentralisation: General Framework ...... 7

2.2.2 Healthcare Decentralisation ...... 8

2.2.3 Decentralisation and Equity: A Contested Relationship? ...... 9

2.3 Why a different approach is needed ...... 10

3 Methodology ...... 11

3.1 Theoretical Expectations ...... 11

3.2 Conceptualisation ...... 12

3.2.1 Healthcare Decentralisation ...... 12

3.2.2 Healthcare Equity ...... 12

3.3 Research Design ...... 13

3.4 Case Selection ...... 14

3.5 Operationalisation ...... 15

4 Results ...... 16

4.1 Sardinia ...... 16

4.1.1 1978 - 1992 ...... 16

4.1.2 1992 - 2017 ...... 17

4.2 Scotland...... 19

4.2.1 1978 - 1999 ...... 19

4.2.2 1999 - 2019 ...... 20

5 Interpretation ...... 22

5.1 Contingent Factors ...... 22

5.2 The Role of Institutions...... 23

5.3 Ideology and Partisanship ...... 24

6 Conclusion ...... 25

6.1 Main Pitfalls ...... 25

6.2 Implications ...... 26

6.2.1 Academic implications ...... 26

6.2.2 Societal Implications ...... 26

7 References ...... 27

7.1 Primary Sources ...... 27

7.1.1 Sardinia ...... 27

7.1.2 Scotland ...... 29

7.2 References ...... 32

7.3 List of Abbreviations ...... 41

8 Appendix I ...... 42

8.1 Sardinia and Italy ...... 42

8.2 Scotland and The United Kingdom ...... 43

9 Appendix II ...... 44

9.1 Sardinia ...... 44

9.1.1 Before Decentralisation (1981-1992) ...... 44

9.1.2 After Decentralisation (1992-2018) ...... 51

9.2 Scotland...... 66

9.2.1 Before Decentralisation (1978-1999) ...... 66

9.2.2 After Decentralisation (1999-2018) ...... 81

1 Introduction It is not controversial to say that everyone deserves to live a healthy and fulfilling life. The right to health, that is, “the enjoyment of the highest attainable standard of health” (WHO, 2006 [1946], p. 1) is officially recognised in the preamble of the Constitution of the World Health Organisation (WHO), as well as in numerous international declarations and agreements (Backman et al., 2008). Nonetheless, important inequities persist worldwide, undermining the enjoyment of this right (Marmot et al., 2008). Inequities are known to be reinforced by geographic and socioeconomic disparities (Nuti & Seghieri, 2014). Nowadays, about one billion people still live in slums or underdeveloped communities (Marmot et al., 2008). Since the emergence of the new public management (NPM) paradigm in the early 1980s, governments with different healthcare systems have tried to reduce the problem (Simonet, 2011). Healthcare decentralisation is seen as one of the most effective measures (Paris, Devaux & Wei, 2010). Accordingly, several scholars have tried to determine whether healthcare decentralisation increases equity. Most of these studies are limited in that they only focus on the healthcare sector itself, without acknowledging the complex web of the determinants of health. Equity, however, cannot be solely measured through quantitative and financial indicators, but it also comprises a more sophisticated, normative side. This dimension is inherently political and discursive, and greatly impacts implementation (Plamondon et al., 2019). Such nuances have been largely ignored in the literature. Therefore, this thesis will contribute to mending this gap by analysing the relationship between decentralisation and healthcare equity discourses in two rural, decentralised regions, namely, Scotland and Sardinia. It will adopt an in-depth exploratory, qualitative design. The research question guiding the project is the following: RQ: What is the influence of decentralisation on discourses about healthcare equity? This thesis is divided into four sections. Firstly, the main academic debates on equity and decentralisation are reviewed. Subsequently, the main components of the theoretical framework are introduced and theoretical expectations are drawn from them. Then, the main variables are conceptualised and operationalised. The methodology and selected cases are also discussed and justified, and the results of the analysis are presented and compared. Finally, the main pitfalls and implications of the study are discussed.

2 Literature Review The following literature review provides an overview of the main debates concerning equity and healthcare decentralisation. First, the difference between health equality and equity is debated. This thesis will focus on the latter concept, as it allows for more conceptual subtlety. Accordingly, the origin of the term and its relationship with geographical and socioeconomic factors are discussed. In the second part of this section, the notion of decentralizing the healthcare sector to achieve equity is introduced. Finally, a brief selection of the empirical studies testing the correlation is reviewed.

2.1 Healthcare Equity 2.1.1 Healthcare Equality It is commonly understood that the right to health implies the attainment of an equal and equitable healthcare system (Marmot et al., 2008). What this entails is often left unspecified. Braveman (2016) observes how the words “healthcare equality” and “healthcare equity” are regularly used interchangeably, both in academic and non-academic settings. However, many argue that the two terms ought to be seen as conceptually distinct rather than overlapping (Macinko & Starfield, 2002). Whitehead’s (1991) seminal reflection on these concepts paved the way for more contemporary definitions (e.g. Braveman, 2016). Whiteman argued that healthcare equality refers to systematic, observable disparities between the healthcare systems of two or more regions. Healthcare equality can also refer to differences in health conditions among groups in general. These might be caused by several factors. For instance, geographical and socioeconomic disparities, such as large income inequalities and limited healthcare investments, are likely to be correlated with poorer healthcare quality (e.g. Franzini & Giannoni, 2010). From a methodological perspective, healthcare inequalities are generally measured econometrically (e.g. Cantarero, 2005; Costa-Font & Rico, 2006; Booysen, 2003). As an empirical concept, health inequality per se does not imply undesirability, i.e. the term does not presuppose any normative judgement on the value thereof. It is for this reason that Kawachi, Subramanian, and Almeida-Filho (2002) contend that healthcare equality mainly serves as a descriptive concept, and thus has relatively limited analytical capacity.

2.1.2 Healthcare Equity: Theories and Origins On the other hand, most scholars associate healthcare inequity with the idea that systematic healthcare inequalities are unfair, unjust, and ought to be eliminated (Whitehead, 1991). Healthcare equity is a normative idea in that it is essentially connected with concerns for social justice, fairness, human rights, and more holistic reflections on how society should be governed (Braveman & Gruskin, 2002; Starfield, 2006). Before introducing the origins and contemporary interpretations of the term, it is necessary to stress the subjective nature of any discussion of healthcare equity. Insofar as different theories of justice conceptualise fairness differently, the meaning of equity will vary accordingly. However, these differences have not prevented the emergence of a common school of thought on what the term generally entails. Most scholars trace the philosophical origin of healthcare equity to Rawls’s (2009 [1971]) highly-influential theory of distributive justice (Oswald, 2015). The implications are manifold. Reflecting on how to ensure that everyone has a fair chance of achieving their potential, Daniels (2001) contends that healthcare has special moral importance in that it helps individuals fulfil their duties by protecting equality of opportunity. In other words, by guaranteeing that everyone has the same fair chance of living a healthy life, the healthcare sector plays an essential role in promoting social justice (Braveman et al., 2011). Nevertheless, as Rawls originally argued not all inequalities ought to be considered inequitable, that is, unfair and unjust. One’s imprudent life choices, for example, may lead to health disparities. Similarly, genetic and biological variations among individuals, such as differences in life expectancy among genders, do create significant health inequalities (Kawachi, 1999) This would not mean, however, that such inequalities should be considered inequities. Only the disparities that are originated from preventable injustice ought to be categorised as inequitable (Whitehead, 1991). Therefore, avoidability is the essential feature that renders health inequalities unfair, and thus inequitable. Large differences in access to healthcare, a shortage of facilities, ethnic disparities, and deteriorating environmental conditions have been identified as some of the factors that make healthcare systems comparatively unequitable, thus hindering individuals’ right to health (e.g. Schulz & Northridge, 2004; Zsembik & Fennell, 2005). Several theories have been developed in this regard. Kawachi, Subramanian, and Almeida-Filho (2002) mention poverty and deprivation as the main sources of inequity. It has been observed that people at the lower end of the

socioeconomic gradient systematically show worse health conditions than those at the opposite side of the spectrum. This, in turn, aggravates the pressure on the healthcare system: poorer people need its services more often, provided that they can access it (Arcaya, Arcaya & Subramanian, 2015). Another fundamental determinant of health inequity is the absence of universal health coverage, which can significantly limit access to healthcare (de Andrade et al., 2015). However, even when universal coverage is guaranteed socioeconomic disparities might persist. Furthermore, in addition to these material explanations psychosocial theories have demonstrated how worse socioeconomic conditions are linked to lower levels of mental and physical health, thus accentuating inequities among groups (e.g. Ball et al., 2017; Gallo, 2009). In general, socioeconomic and health inequities are known to be significantly correlated: disadvantaged, poorer groups see their right to health constantly threatened. However, not only socioeconomic factors but also geographical variables can generate health inequities.

2.1.3 Geographical and Local Inequities Geographical variables include, for instance, the extent to which regions are connected and how isolated communities are. Disparities are globally widespread and significantly undermine the efficient functioning of healthcare services. One can argue that not only might there be inequities within social groups, but also more generally between the healthcare services across different areas and regions. Due to their geographical nature, such inequities can be found at any level, including between national constituencies, districts, cities, and even neighbourhoods (Marmot et al., 2008). Some observers have theorised the existence of a chronic “inverse care law” concerning healthcare supply and delivery: those areas that need the most, tend to receive the least (Mohapatra, 2017; Zere et al., 2007). Numerous scholars attempted to explain the emergence of geographic inequities with the aim of eliminating them. They did so by focusing on different factors. Marmot et al. recommended that “the strengthening of public finance to improve social determinants of health will entail the building of national capacity for progressive taxation and the assessment of potential for new national and global public finance mechanisms; fair allocation between geographical regions and ethnic groups is also necessary” (2008, p. 1666). Costa-Font and Gil’s (2009) study of the Spanish healthcare confirmed that income inequality between regions is again one of the main determinants of healthcare inequities. They did not find, however, that

differences in financing systems (i.e. progressive or regressive) were associated with healthcare inequities. Other scholars have found that the degree of ruralness of areas is positively correlated with health inequities (Erwin et al., 2010). The more social groups are segregated and disperse, the more difficult it is for them to access healthcare services. Delivery is also significantly more complicated in regions with poor infrastructure. The negative consequences of ruralness are especially visible in developing countries. For example, Balarajan, Selvaraj and Subramanian (2011) observed that healthcare supply in India is significantly impaired in rural areas as opposed to the more urbanised regions. Empirically, they found that government hospitals in rural areas had on average less than half of the beds that urban hospitals have. However, geographical disparities are not only found in Global South countries, but they can be observed in numerous OECD countries such as Italy (Iammarino, Rodriguez-Pose & Storper 2019; Mangano, 2010) and the United Kingdom (Asaria et al., 2016). It can be inferred that disparities emerge independently of the specific variety of healthcare system adopted (see Wendt, Frisina & Rothgang, 2009), even in universal national healthcare systems. For instance, Norman and Boyle (2014) observed large mortality inequalities between England and Wales, which were generated by different levels of deprivation; at the same time. Overall, it has been observed that healthcare policies that are designed for urban areas might not translate as intended to less densely-populated and accessible areas (Smith et al., 2013). Therefore, governments and international organisations alike searched for ways to identify geographical inequities and subsequently eliminate them. These reforms were informed by the emergence of the new public management paradigm and often were aimed at reducing costs and increase efficiency (Simonet, 2010). Measures included redistributing economic resources to disadvantaged regions and creating institutions that would monitor the development of a more efficient infrastructure (Iammarino, Rodríguez-Pose & Storper, 2019). The most commonly adopted and systematic policy, however, was decentralisation.

2.2 Decentralisation 2.2.1 Decentralisation: General Framework From a general perspective, decentralisation refers to the practice of transferring certain competencies from a higher level of government to a lower one (Pollitt, 2005). Although the term is often used to indicate a transfer of power from the central government to one or more of

its regional constituents, decentralisation per se does not imply this specific meaning. Rondinelli’s (1981) seminal work, albeit dated, is conventionally considered as the core theoretical framework for understanding decentralisation practices (Sumah, Baatiema & Abimbola, 2016). Rondinelli identified several kinds of decentralisation such as delegation, deconcentration and devolution, with the latter being the most impactful. In the case of the United Kingdom, for instance, the education, housing, and transport domains are now competences of her sub-national units (Scotland, Wales, and Northern Ireland) (MacKinnon, 2015). It is also worth mentioning that decentralisation need not exclusively be a political process because it is often conceived as an administrative and financial process as well (Oates, 1999; Saltman & Bankauskaite, 2006).

2.2.2 Healthcare Decentralisation In respect to the healthcare sector, all of the above-mentioned processes can be observed at the same time. One can argue that the healthcare sector is to different degrees one of most decentralised welfare domains in the OECD area as well as in a majority of developing countries (Simonet, 2010). Following Rondinelli’s (1981) suggestions, the rationale behind healthcare decentralisation lies in the idea that healthcare inequalities generated by geographical disparities between regions are inequitable and thus ought to be eliminated. Historically speaking, the 1978 Alma Ata conference on Primary Health Care had established the principle that decentralisation would improve resource allocation as well as accountability, and since then numerous countries sought to apply it (Kawonga, Maceira & Nunn, 2005). Recent, notable experiments in healthcare decentralisation include for instance the creation of a Great Manchester area in the United Kingdom where health and social care are devolved (Walshe et al., 2018). However, whether decentralisation has effectively reduced inequities, especially in rural regions, remains a contested issue. A plethora of longitudinal and cross-sectional exploratory studies have been conducted in numerous and diverse areas, including Western Europe (Simonet, 2010), China (Zhou et al., 2013), Oceania ( Leeder, 2003; Mohammed & Ashton, 2016), several African regions (Abimbola et al., 2015; Asante & Zwi, 2009; Zere et al., 2007; Zon et al., 2017), and Central and South-East Asia (Jacobs & Camargo, 2020; Langran, 2011; Madon, Krishna, & Michael, 2010). Evidence tends to be contradictory and can vary widely across areas, not least because of the abundance of different conceptualisations of healthcare equity (Braveman, 2006;

Lane, Sarkies, & Haines, 2017). In what follows, a brief, selected review of this body of literature will be provided.

2.2.3 Decentralisation and Equity: A Contested Relationship? To begin with, Jimenez and Smith (2005) found that fiscal decentralisation in Canada substantially helped provinces’ efforts to reduce infant mortality. As they argue, however, only employing fiscal indicators for assessing the effects of decentralisation leads to a partial picture of the real situation. Using once again mostly financial indicators, Costa-Font and Rico (2006) observed that the devolution of healthcare competencies to Spanish provinces did not generate more inter-regional inequalities. Nonetheless, they also note that comparisons with other countries are made difficult by the absence of universal, widespread decentralisation models. Regarding the Italian healthcare system, Mangano (2010) depicted a complex scenario where decentralisation led the already wealthier regions to invest more in healthcare, with no significant changes as for the other regions. He also found institutional and regional healthcare arrangements to significantly vary, thus making it difficult to provide a clear picture of whether decentralisation had positive effects on equity. Similar findings, namely, that decentralisation might lead to lower levels of income redistribution and more inequities, were also presented by Ferrario and Zanardi (2009), and Giannoni and Hitiris (2002). Not all scholars have adopted quantitative methods, but some conducted in-depth interviews with policymakers and healthcare workers (see e.g. Abimbola et al., 2015; Jacobs & Camargo, 2020). These studies indicate that the effects of decentralisation may significantly vary depending on a variety of circumstantial cultural and political factors, such as corruption and accountability. Others focused on implementation from an abstract meta-theoretical perspective, that is, the extent to which studies on decentralisation aligned to the general goal of promoting good equity practices (Plamondon et al., 2019). It is complicated to derive a systematic theory from these investigations, mostly due to the idiosyncratic natures of the decentralisation processes analysed. That healthcare decentralisation is an ill-defined term and that can have varied effects on equity depending on which aspect thereof are analysed is also suggested by Greener et al.’s (2009) study of decentralisation of the British National Health Care System (NHS). Perhaps crucially, the authors emphasise the importance of local peculiarities when

studying healthcare decentralisation: outcomes might be highly dependent on the political and institutional characteristics of the regional entities in which it is applied. An equivalent conclusion is reached in Sumah, Baatiema, and Abimbola (2016)’s extensive review of the effects of decentralisation on equity in seven countries. These authors argue that it is not possible to provide univocal answers to the question of whether decentralisation positively affects equity; they find that decentralisation might not necessarily reduce inequities in healthcare access and financing, as opposed to Costa-Font and Turati’s (2018) later study. They also suggest that pre-existing historical inequalities might explain why even after decentralisation inequities are not eliminated.

2.3 Why a different approach is needed Overall, what one can derive from the abovementioned studies is that contingencies and path-dependency play an important mediating role vis-à-vis the effectiveness of decentralisation as an intervention to reduce inequities. It does not follow, however, that outcomes are pre- determined. Different regional institutions might implement decentralisation in different ways: some might invest more financial resources in healthcare infrastructure, while others might focus on the management of healthcare personnel. Such decisions might have a significant impact on equity, given that certain areas, especially the rural ones, have special health needs (Marmot, 2008). Unfortunately, few studies analyse the discursive development of these decisions. It is not clear, for instance, whether the framings of equity change after decentralisation is introduced. This is the fundamental gap that this thesis aims to fill: if one is to fully understand the effects of decentralisation on equity, a nuanced approach that goes beyond the quantitative analysis of inequalities indexes is required. Following Sumah, Baatiema, and Abimbola (2016) one can also argue that comparisons between cases might help discern the effects of the contingent variations of institutional arrangements. The next section addresses these theoretical and methodological issues.

3 Methodology 3.1 Theoretical Expectations To the author’s knowledge, no overarching theoretical framework on the discursive relationship between decentralisation and equity exists: it is not possible to test a specific theory on a new set of cases. Instead, this thesis will adopt an exploratory approach. One can still elaborate some theoretical expectations on whether and how discourses around equity change after decentralisation; it is possible to do so by extrapolating some of the major findings from the aforementioned literature. Since it is not clear in which ways discourses are affected by decentralisation, the following expectations ought to be considered tentative and not definitive. Hence, their main purpose is to provide a general idea of the main discursive strands that could be found in the analysis. To begin with, one of the main expectations is that pre-existing socioeconomic inequities affect the way equity is framed. Countries where decentralisation is entrenched are more likely to tackle equity successfully, especially from a financial point of view (Mosca, 2006). An example of this is provided by Finland, where healthcare decentralisation has historically helped rural, sparsely-populated areas to retain more resources to satisfy their health needs (Koivusalo, 1999). To generalise, poorer, geographically disadvantaged regions might decide to specifically target such inequities through healthcare decentralisation (Sumah, Baatiema, and Abimbola, 2016). In other words, after decentralisation one is expected to observe the development of discourses concerning the elimination of socioeconomic inequities. The effect might be strengthened by the concomitance of two factors. First, democratic accountability is expected to improve health outcomes (Wigley & Akkoyunlu-Wigley, 2011). This variable is of uttermost importance in regions where corruption and mismanagement of healthcare resources are widespread (e.g. Jacobs & Camargo, 2020; Madon et al., 2010), but it is also important in already-established democracies. Some scholars emphasise that healthcare equity can only be fully achieved when a multitude of socioeconomic factors are taken into considerations, such as whether food security is present (Ottersen, 2014). It is then expected that health equity will be consistently framed in terms of democratic accountability (Oickle & Clement, 2019). Second, as Andrews and Martin (2010) suggested ideological and political interests play a fundamental role in framing discourses around healthcare. It is more likely to see measures that

promote healthcare equity in those regions ruled by parties that reflect a general, active commitment to the issue. An interesting example of this dynamic is provided by Wales, where after devolution the parties that controlled the regional parliament pushed for equity policies that would directly contrast the pro-austerity measures enacted in the previous years by the central government in London (Greer, 2016). The following paragraphs further specify the dimensions and variables that will be explored in the thesis.

3.2 Conceptualisation In this subsection, the main variables of the study will be conceptualised. As formulated in the research question (p. 1), these are healthcare decentralisation and discourses on equity.

3.2.1 Healthcare Decentralisation As mentioned in the literature review (p. 6), decentralisation conventionally refers to “the notion of authority being spread out from a smaller to a larger number of actors” (Pollitt, 2005, p. 3). Decentralisation can be also conceptualised as a state, as a process, or both (Bankauskaite & Saltman, 2007). Regarding the decentralisation of the healthcare sector, two analytical approaches are possible. First, a degreeist approach, i.e., studying the extent to which the sector is decentralised. Second, a longitudinal approach, that is, how decentralisation affects the sector’s functioning over time. This thesis will adopt the latter approach: it will consider healthcare decentralisation as a dynamic process that occurs over a prolonged timeframe. (Byrkjeflot & Neby, 2008).

3.2.2 Healthcare Equity Equity in the healthcare sector can be conceptualised in several, oft-contrasting ways (Braveman, 2006). Braveman et al.’s (2018) definition is perhaps one of the most comprehensive: Health equity means that everyone has a fair and just opportunity to be as healthy as possible. Achieving this requires removing obstacles to health, such as poverty and discrimination and their consequences, which include powerlessness and lack of access to good jobs with fair pay; quality education, housing, and health care; and safe environments (Braveman et al., 2018, p. 2).

Relatedly, another fundamental aspect to be conceptualised is the difference between horizontal equity and vertical equity (Sumah, Baatiema & Abimbola, 2016). The former means that equity is framed so that “there are no differences in health services where health needs are equal” (Starfield, 2001, p. 546). Horizontal equity is thus associated with a uniform healthcare supply across all areas. On the other hand, vertical equity refers to the practice whereby “enhanced health services are provided where greater health needs are present” (Starfield, 2001, p. 546). Vertical equity will be framed in terms of specific, targeted interventions aimed at certain disadvantaged groups or areas; the aim is to provide equal health outcomes. Concerning the binomial “discourses about equity”, different conceptualisations are possible. From an academic standpoint, discourse is generally taken to mean the way explicit (written) and non-explicit (non-written) language are integrated to convey specific meanings (Gee, 2014). Thus, discourses around healthcare equity do not only include the written policies and measures taken to improve it but also every circumstantial meaning related to the term. Discourses might include, but are by no means limited to, how financial resources are allocated to equity programs (Lane et al., 2017), how policies developed for different welfare domains can foster healthcare equity (Davison, Ndumbe-Eyoh, & Clement, 2015), and conversely, how healthcare equity can promote equity in other welfare domains (Plamondon et al., 2019).

3.3 Research Design As mentioned before (p. 7), studies on the effect of healthcare decentralisation on equity are carried out through numerous designs. Scholars tend to agree on the idea that comparative designs allow one to identify patterns and recurrent themes (e.g. Mosca, 2006). At the same time, some scholars emphasise the need for taking into account the contingent factors that inform country-specific decentralisation policies and regional healthcare practices (Sumah, Baatiema, and Abimbola, 2016). Since the effectiveness of policy implementation depends on how goals are framed, discourses around equity acquire crucial importance. To the author’s knowledge, few studies have engaged with primary sources, such as policy documents, health plans and alike. To mend this gap, the following research design will be implemented. First, discourse analysis will be performed on the policy documents and health plans of two decentralised regions to understand how discourses around equity are framed before and after decentralisation is introduced. More specifically, discourse analysis does not only entail

observing the recurrence of specific terms such as equity but also interpreting the context and meanings around them (Wodak & Meyer, 2009). Results will be then discussed and compared to investigate whether similar patterns and recurrences can be found in the two regions.

3.4 Case Selection To study the development of discourses around equity after healthcare decentralisation, two cases were selected. Some general criteria behind the choice included whether they had an established pattern of decentralisation with a clear historical beginning (Byrkjeflot & Neby, 2008), as well as whether it was possible to obtain enough documentation in a language the author could read. Possible cases included Sicily, Wales, Veneto, or Northern Ireland. Eventually, Scotland (United Kingdom) and the Autonomous Region of Sardinia (Italy) were selected due to the author’s familiarity with both cases. Overall, these two cases can be considered typical or representative for the following reasons (Seawright & Gerring, 2008, p. 299). Firstly, both regions belong to countries that possess a universal healthcare system and have devolved their national healthcare competencies to their subnational units, albeit to different degrees. Secondly, in both regions a significant portion of the population lives in rural areas (Pacione, 2004; Cois, 2020). Ruralness has important implications on the socioeconomic features of both cases. For instance, 45% of the Sardinian municipalities suffer from major socioeconomic deprivations due to ruralness (ATS Sardegna, 2018). It is known that decentralisation is especially aimed at disadvantaged and sparsely populated areas such as rural regions (Zhou et al, 2013). Therefore, it is expected that by analysing the typical cases of Scotland and Sardinia one can better understand how discourses on equity develop after decentralisation. The sources of this study will be a selection of major legal documents and health plans (see Appendix II). These were accessed online via the Sardinian Region website (RS, 2020), the National Archives (TNA, 2020), and Government of Scotland website (SG, 2020). Sources mostly consist of major documents such as health plans and primary legislation. When necessary, discourse analysis was supplemented with sources such as governmental responses to parliamentary committees, deliberations, and secondary literature. The research timeframe, 1978-2019, was selected for the following reasons. First, the Italian National Healthcare Service was established in 1978, while regional governments

(including Sardinia) had been formally established eight years before. At the same time, the Scottish National Healthcare Services, which was formed in 1948, underwent a fundamental reform in 1978. Therefore, the starting year of 1978 was chosen to match data for both regions. Furthermore, healthcare decentralisation will be considered to have taken place, respectively, in 1992 for Italy and 1999 for the United Kingdom (see France et al., 2005; Greener et al., 2009). A brief timeline of the major developments of both the Italian and British healthcare systems is provided in Appendix I.

3.5 Operationalisation

Given the exploratory nature of the present study, it might be difficult to provide a precise list of discursive terms that are expected to convey the meaning of equity. The endeavour is complicated by the fact that there is no exact linguistic match between Italian and English regarding the word “equity”. Italian tends not to differentiate between “uguaglianza” and “inequità”, both of which can be translated either with inequality or inequity. To ensure systematic results, a flexible approach will be adopted whereby larger semantic blocks consisting of multiple contextual cues will be treated as distinct discursive framing tools. The sole presence of words such as “disadvantage” or “equity” will be deemed as not sufficient to fully convey discourses around equity. Instead, a broader, more contextual approach will be used to determine whether specific semantic blocks refer to horizontal, vertical equity, or other related concepts. A sample of the relevant indicators for horizontal and vertical equity is outlined in Table 1. The results of the analysis are presented in the next section. Table 1: Indicators for horizontal and vertical equity

Category Italian English Horizontal equity Uniforme/uniformità, Comprehensive, uniform armonizzare, omogeneità, planning, homogenous, joint adeguamento, centrale, planning, all Regions, organico, complessivo Esigenze territoriali, modello Local needs, individual needs, Vertical equity diffuso, rurale, iniziative locali, delegation of responsibilities, priorità, interventi specifici, targeted interventions, emarginazione di gruppo, disadvantaged communities, autonomia, peculiarità, rural communities universalismo selettivo

4 Results The next section is structured as follows. To begin with, the findings for Sardinia will be presented. The first subsection concerns the period before decentralisation (1978-1992), whereas the second covers the post-decentralisation phase (1992-2018). Subsequently, the findings for Scotland will be presented according to similar criteria: first, before devolution (1978-1999), then, after devolution (1999-2018). The complete rendition of the analysis is included in Appendix II.

4.1 Sardinia

4.1.1 1978 - 1992 The pre-decentralisation period in Sardinia is characterised by the attempt to locally implement the 1978 National Healthcare reform, which had established a universal, Beveridgean system. In this regard, the 1981 reform (RS, 1981, art. 2) highlighted the presence of notable demographic and geomorphological disparities between the healthcare of Sardinia and other regions: “[the goal of the healthcare system is to] plan, reorganise, and coordinate the integration of social and health services with the aim of gradually eliminate the existing disparities [squilibri] […]” (RS, 1981, art. 2). This reform did not elaborate, however, on the determinants of such health inequities. Some of the priorities that emerge in the documents, such as promoting democratic accountability and the active involvement of citizens (RS, 1981, art. 21; 1992) quickly lost importance in the following years, mainly due to negative healthcare politicisation (see France et al., 2005). This is indicated by the progressive marginalisation of terms such as partecipazione dei cittadini (citizens’ participation), which played a fundamental role in the early documents (RS, 1981). On the other hand, integrating social care with healthcare remained a recurrent goal. However, the focus at that time was still on creating a uniform care model to be applied homogeneously across all areas: “The unitary management of health protection will be provided uniformly across the entire territory of the region” (RS, 1981, art. 2). On a more practical level, the goal was to promote horizontal equity by providing an integrated infrastructure model that covered both social care and healthcare (RS, 1985). This would be later extended to any Sardinian and non-Sardinian citizens (RS, 1991). The scope of integration, however, remained limited in that the relative 1988 reform (RS, 1988) strictly

addressed socioeconomic and psychological inequities, as opposed to later, broader plans. This might be partially explained by the structure of regional competencies, that is, by the fact that healthcare was still treated as a distinctive legislative domain. National health plans are also prioritised: “The dispositions of the Regional Health Plans can be applied insofar as they are not in contrast with the relative dispositions in the National Health Plan” (RS, 1985, art. 8). On the other hand, in the following years the institutional boundaries between welfare competencies started to blur more. This can be inferred by the progressive disappearance of formulations such as “organic and comprehensive response” (RS, 1988, art. 3), or “uniform model” (RS, 1981, art. 27), which univocally referred to the healthcare and social sectors only. During this period, equity is mainly framed in terms of equity of access: “The following principles must be guaranteed: a) equality, when same needs are present, in terms of the quality of delivery and social care interventions […]” (RS, 1988, art. 4). Measures to reduce the inequities that arose from the peculiar geographical disadvantages of Sardinia included the possibility for citizens to be reimbursed when accessing healthcare services in other regions, including transportation and living costs (RS, 1991). Another intervention was allocating additional subsidies for research concerning specific Sardinian diseases, such for instance Beta Thalassemia (RS, 1990). Tangentially, these measures were also intended to tackle social exclusion and inter- and intra-group inequities. Nonetheless, no systematic health plan nor comprehensive attempt to tackle such issues was put in place until decentralisation was introduced.

4.1.2 1992 - 2017 The 1992 National Healthcare reform represented a significant effort to decentralise the whole system. It was translated to Sardinia three years later (RS, 1995). The 1995 provisions mainly contained financial measures designed to eliminate the budget deficits that the local healthcare units had accumulated in the previous years. However, their long-term consequences were significant, as indicated by the goal to “decentralise the [Local Health Units’] functions in the territory” (RS, 1995, art. 16). This reform still retained a commitment to horizontal equity: “…the Region shall pursue the objectives of promoting, securing, and rehabilitating the physical and mental health of citizens, under uniform conditions across the entire regional territory” (RS, 1995, art. 1). Yet, it also marked a significant shift towards a different approach. This is

suggested by the increasing importance of terms such as “economic-financial autonomy” (RS, 1995, art. 30). A later revision of the integrated healthcare-social care system (RS, 2005a) introduced the notion of selective universalism: “[The Region shall follow the principle of] a) selective universalism, to ensure equality of access to the integrated system [eguaglianza delle persone nell’accesso al sistema integrato] and to the services, following priority criteria based on the evaluation of need” (RS, 2005a, art. 2). Equity of access both for Sardinians and non-Sardinians remained the main objective (RS, 2006a), but the necessity of helping local communities, both through financial means and collaborative projects, was recognised more systematically. Some deliberations were put in place which would grant more power to local healthcare units, especially in rural areas: “[The Region shall promote] the activation of Health Districts as organisational and functional units that are closer to the citizens, with real [reale] autonomy” (RS, 2005b). Another reform (RS, 2006b) framed equity in terms of a healthy lifestyle and recommended that the Regional Health Plans would “illustrate the health needs of the population living in the territory [of the Region] with particular regard to the social and territorial inequalities [diseguaglianze] concerning health” (RS, 2006b, art. 12). Local peculiarities started to refer not only to Sardinia as a whole but also to single territories that were deemed to require special attention, called areas of prioritised intervention [aree prioritarie di intervento]. Subsequently, the 2007 Health plan (NS, 2007a) represented the first systematic attempt to identify the key determinants of health inequities, which now included environmental differences as a major form of disparity between rural and urban areas. The shift towards vertical equity and micro-level targeted interventions is also evident in the 2007 deliberations (NS, 2007b) and 2014 primary health care reform (NS, 2014). Interestingly, the latter reintroduced centralisation measures to rationalise the system and decrease the number of autonomous healthcare units. Nonetheless, it was still framed as an effort to promote equity of access, and interestingly, social justice [giustizia sociale]. The similar 2016 reform (NS, 2016) used formulations that had not been employed since the 1981 reform such as “homogeneity and harmonisation of the management processes across the entire regional territory” (RS, 2016, art. 2). Two years later a new health plan (ATS, 2018) synthesized the older concerns for horizontal equity with the newer ones for vertical equity by hinting at the necessity of acknowledging newly-emerging social and health challenges (called new poverty [nuove povertà]), including the

environment. The Region intended to tackle these through the further integration of healthcare with other welfare domains, but did not systematically plan in this regard. To summarise, decentralisation in Sardinia coincided with a shift from the early attempt to create a uniform and harmonious healthcare system across the entire region to more targeted interventions aimed at specific areas and social groups. Discourses regarding the integration of social care with healthcare have remained important throughout the whole period and have progressively taken into account more factors and health determinants. Overall, one can interpret such discursive changes as a general move towards vertical equity.

4.2 Scotland

4.2.1 1978 - 1999 As for Scotland, one can observe two very distinct pre-decentralisation discursive phases. The first covers Thatcher and Major’s Conservative governments; the other starts in 1997 and coincides with the years immediately preceding devolution. The key difference in terms of how equity is framed is that in the former it mainly refers to financial equity, whereas in the latter to vertical equity. Firstly, the 1978 Health reform prioritised health improvements for Scottish citizens (TNA, 1978, art. 1), while a few years later the need of coordination between local Health Boards was reinstated (TNA, 1983, art. 13). The 1980 Black Report on health inequities described numerous socioeconomic disparities that undermined the functioning of the NHS (Black et al., 1980). In the following decade, however, Conservative governments focused on incentivising competition and economic efficiency. Control of expenditure, as delineated in the Griffiths’s Report (1983) became the central priority, while no systematic attempt to reduce inequities was made. The same trend can be observed in documents such as Enthoven’s (1985) Report and the Cumberledge Report (1986). Concretely, the prominence of financial concerns is signalled by the institution of NHS Trusts and other cost-efficiency measures, such as GP fundholding practices (TNA, 1990; 1992). Equity, and especially equity of access was framed as largely dependent on the financial resources available. No special provisions for the disadvantaged areas of Scotland were to be formulated during this first phase. When the Labour party rose to power in 1997, however, priorities drastically changed. First, numerous reports were released which emphasised the distinctive health needs of Scotland (TNA, 1997a). Not only did the government start to elaborate on the recommendations advanced

in the 1980 Black Report (TNA, 1998, par. 33), but they also acknowledge the need to integrate the notion of socioeconomic deprivation into their health plans. The measures introduced in 1990 were kept but reframed in terms of giving more autonomy to local communities and promoting interregional financial equity (TNA, 1997b, par. 4). Furthermore, the first Blair government paved the way for the devolution of health competencies to the soon-to-be established Scottish parliament, a policy that was intended to incentivise a cohesive response to health inequities across all regions. Therefore, concerns for horizontal equity were now supplemented by the goal of prioritising certain social groups and areas, thus promoting vertical equity. Since devolution was yet to be fully implemented, however, discourses around equity tended to be still influenced by the idea that Westminster could coordinate all interventions. Such a perspective would also rapidly change in the following years.

4.2.2 1999 - 2019 The process of devolution entailed a significant reform of the Scottish institutional setting. With the 1998 Scotland Act the only exclusive competencies Westminster kept were benefits and social security, defence, employment, equal opportunities, foreign policy, immigration, and trade and industry. The new Scottish Parliament acquired a large degree of autonomy and thus the government could adopt autonomous, innovative discourses around healthcare equity. Firstly, the 2004 Health Reform (SG, 2004, art. 1) dissolved the 1990 NHS Trusts and repealed most of the associated cost-efficiency provisions on the grounds that they would undermine an equitable service for all (see also SG, 2007, p. 34). The integration of the healthcare sector with other welfare practices at the local level became a key priority, as well as vertical equity. The overarching goal was to raise the NHS standards to higher European levels (SG, 2018, p. 5). A major difference with the pre-devolution period is that now the integration of services sought to include all domains of welfare, including education, justice, and environment (SG, 2007, p. 19). Equity of access started to be framed in terms of targeted interventions that would eliminate disparities caused by an increasingly long list of variables, including “gender, ethnicity, geographic location or socio-economic status” (SG, 2010, p. 23). The impact of rurality on health outcomes is particularly emphasised as a justification for extensive investments towards disadvantaged communities. This is demonstrated by telling passages such as “We will do this, not just because it is a legal requirement. It is right to do so and we believe that it will

lead to services that are equitable and fair for all the communities we serve” (SG, 2010, p. 24). Healthcare equity ceased to be a separate function of health outcomes and socioeconomic indicators; it was now framed more as a holistic aggregate of personal and socioeconomic wellbeing factors that are highly dependent on the levels of relative community deprivation (SG, 2018, p. 2). Hence, the Scottish government promoted the idea that although healthcare is a distinct institutional competency, boundaries between welfare domains should be overcome to promote an integrated, systematic answer to health inequities (SG, 2016, par. 11). In sum, discourses around healthcare equity in Scotland significantly changed with devolution. They shifted from prioritising horizontal and financial equity to making vertical equity as the central priority. Moreover, healthcare equity became increasingly associated with welfare at large, hence the focus on the systematic integration of competencies and policy domains.

5 Interpretation In this section, results will be interpreted and compared. Overall, the analysis showed that healthcare decentralisation coincided with a significant discursive shift. In both Sardinia and Scotland, vertical equity became the central priority of health plans and legislative acts alike. The shift appears to have been more drastic and abrupt in Scotland, whereas the Sardinian governments followed a more gradual path. The following explanations for why this might be the case are not intended to be comprehensive, but they demonstrate the importance of political factors when studying healthcare decentralisation and equity.

5.1 Contingent Factors

Firstly, some of the similarities and differences between Scotland and Sardinia can be ascribed to contingent and historical factors, as expected by Sumah, Baatiema & Abimbola (2016). For one, the expectation that geographical disparities and ruralness would a major role in the framing of health inequities was met. Both regions’ post-decentralisation priorities seem to have been partly informed by some of the World Health Organisation guidelines, especially the 1996 report on public health (WHO, 1996). Policy translation (Stone, 2012) might have played a role in shifting the regions’ priorities towards vertical equity in that the World Health Organisation explicitly suggested to prioritise targeted interventions. Timing might have played an important role as well. Discourses about the idea that democratic accountability improves healthcare equity (Oickle & Clement, 2019) were only observed in the case of Sardinia, and even then, they tended to quickly lose their importance in the 1990s. The reason might be that the 1992 National Health Reform made clear that the previous healthcare management system needed to be de-politicised, partly due to the increasing number of scandals that eventually led to the collapse of the First Italian Republic (France, Taroni & Donatini, 2005). More in general, it seems that the correlation between healthcare decentralisation and democratic accountability might be more relevant for developing countries than for regions with already-established democracies such as Scotland and Sardinia (cf. Madon, Krishna & Michael, 2010).

5.2 The Role of Institutions

One of the reasons why discourses have shifted more quickly and more forcefully in Scotland than in Sardinia might be related to their institutional setting. In the case of Sardinia, national health plans remained the main yardstick even after 1992. Although regions obtained more powers concerning the financial distribution of resources, the institutional distribution of competences did not significantly change. The regions are still largely unable to legislate, for instance, on education or housing policies. This is notwithstanding the fact that Sardinia, being an island, has been historically granted a larger degree of autonomy than most Italian regions (Hepburn, 2010). On the other hand, with decentralisation Scotland acquired a larger set of competences and elaborate a more systematic and integrated approach. Institutional differences might be associated with how decentralisation was implemented. Costa-Font and Perdikis (2018) identified different varieties of healthcare decentralisation, namely, a federacy and a systems model. Whereas the former is “typically one based on the transfer of governmental responsibilities only to certain specific territories while the bulk of the country remains centrally managed” (Costa-Font & Perdikis, 2018, p. 1), the latter is conceptualised as a “model where all territorial units are held responsible for a specific policy domain, e.g., health care policy” (Costa-Font & Perdikis, 2018, p. 2). The federacy model tendentially arises out of historical rights, while the systems model can be established regardless of demand s for self-governance. This is important in that a federacy model is likelier to push for autonomous and regionally distinct discourses, whereas in a systems model discourses are less likely to differ across regions. Costa-Font and Perdikis argue that The United Kingdom is an archetypical case of a federacy model, whereas Italy can be considered an example of a systems model, similar to Spain. Since decentralisation was designed to be uniform across all regions, Sardinia did not gain any special legislative powers which would help her to elaborate a more systematic response to the issue of healthcare equity. On the contrary, devolution in the United Kingdom was asymmetrical, leading regions to have “distinctive institutional forms and modi operandi” (Jeffery, 2009, p. 289). Perhaps the most evident institutional difference between the decentralisation processes of Sardinia and Scotland is that the former it was solidly grounded on a rigid, fixed constitutional setting, whereas the latter had indigenous and much more destabilising roots, as argued by Tierney (2009). To assess the historical impact of decentralisation in Italy and the United

Kingdom is beyond the scope of this thesis. However, what one can discern from the extensive literature on the topic is that decentralisation did not undermine the unitary core of the Italian constitution, nor did it introduce political federalism, whereas in the case of Scotland it led to much stronger autonomy (Bilancia, 2005). One might argue that this is the reason why Scotland was able to promote discourses that overcame the fixed institutional boundaries that the Sardinian administration was limited to.

5.3 Ideology and Partisanship

Lastly, ideological differences and partisanship might have also had a significant impact on the development of discourses about equity. Marks, Hooghe, and Schakel (2008) contended that strong regional identity and unique ethnocultural norms are positively correlated with regional authority. Hepburn (2009a) explains how Sardinian parties never managed to create a strong, autonomous national identity as the Scottish National Party (SNP) did, notwithstanding the constant presence of strong secessionist sentiments (Sorens, 2005). Sardinian regional governments have always consisted of coalitions including numerous parties with different ideologies, ranging from Eurocommunism and socialism to liberalism and conservatism (Hepburn, 2009b). The high number of veto players and the alternation between ideologically opposed coalitions (see Appendix I) might explain while discursive shifts have been more gradual in Sardinia. This is significantly different from Scotland, where after-devolution politics has been dominated by the centre-left Labour Party and the green-left-wing SNP. As Greer suggested (2010), the Scottish government adopted evident, unsympathetic stances towards the priorities set by the previous, Conservative national administrations. This signalled by the strong will to not focus anymore on financial concerns and horizontal equity. The same dynamics took place in Wales, but again, due to asymmetrical devolution the Welsh response was more limited (Greer, 2009). One might argue that conflicts between national and regional priorities intensify when ideologically opposed administrations have to coexist at the same time, especially in a majoritarian political system such as the United Kingdom (Mitchell & van der Zwet, 2010).

6 Conclusion The objective of this thesis was to explore the impact of healthcare decentralisation on discourses about healthcare equity. To this aim, discourse analysis was performed on major policy documents from two rural regions, namely, Scotland and Sardinia. It was found that discourses around equity did substantially change over the period investigated. Before decentralisation, they centred around uniform interventions, financial concerns, and horizontal equity. After decentralisation, healthcare equity began to be systematically framed in terms of vertical equity, that is, targeted interventions aimed at specific, disadvantaged groups. Furthermore, a key finding is that the two regions’ discourses concerning the integration of healthcare with other welfare domains (e.g. social care) started to converge after decentralisation, albeit to different degrees. Differences and similarities were explained in terms of contingent, institutional, and ideological factors. Due to space constraints, interpretation was necessarily inexhaustive. In the following, the thesis’s main pitfalls and implications will be presented.

6.1 Main Pitfalls

As for the main limitations, a reflection on discourse analysis as a heuristic method is in order. One must acknowledge that since the outcomes of discourse analysis depend on the researcher’s interpretation of both texts and subtexts, i.e. of circumstantial content, results will be neither fully generalisable nor fully replicable (Breeze, 2011). Concerns for validity and reliability do not necessarily compromise one’s attempts at obtaining a more detailed, in-depth picture of the ways specific concepts can be politically framed. Having said that, the present study only analysed major legal documents and political statements, such as health plans and legal frameworks. Numerous pre-decentralisation documents are still not openly accessible but should be considered. More diverse sources could be used as well, such as parliamentary debates and interviews with policy-makers. These would allow obtaining a more precise picture of the priorities and interests that led politicians and experts alike to reframe healthcare equity over time. Second, this thesis failed to explain whether decentralisation was caused the discursive shift towards vertical equity, or whether the opposite was true. It may be possible to obtain a clearer answer by analysing the national, international, and transnational contexts wherein

decentralisation policies originated. Doing so would allow determining whether concerns for vertical equity developed autonomously or not.

6.2 Implications

6.2.1 Academic implications Research on healthcare decentralisation and equity could further implement discourse analysis and apply it to different cases, especially considering that Sardinia and Scotland might be only considered representative of the OECD area. Discourse analysis should also be integrated with a more detailed exploration of institutional and historical settings. Such analysis should include at least the mechanisms whereby competencies are shared and transferred between different welfare domains, and the extent to which health plans are inter-correlated. Moving beyond methodological nationalism (Wimmer & Glick Schiller, 2002) might help understand whether discursive shifts were also influenced by policy translation processes at the international or transnational level (Stone, 2012). In general, this thesis can be seen as a starting point for more research on the political framing of decentralisation (see e.g. Cheney, 2013). Possible questions might include: to what extent are discourses influenced by ideological partisanship? How does the distribution of institutional competencies affect discourses? Such investigations could be also carried out through quantitative and mixed designs.

6.2.2 Societal Implications Third, this thesis suggested that decentralisation policies might be associated with more attention given to marginalised groups, at least from a discursive perspective. In general, legislators might want to consider loosening welfare boundaries, as Scotland did, as a way to incentivise systematic, integrated answers to healthcare inequities. Moreover, they might also want to assess the effects of geographical disparities on welfare. In general, shifting competencies to the local level might constitute an effective tool to pay more attention to areas and groups with special needs. Even without full devolution, legislators should consider consulting and collaborating more closely with different subsections of civil society as a way to ease policy translation.

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7.3 List of Abbreviations

ATS Sardegna = Azienda per la Tutela della Salute Sardegna [Agency for the Protection of

Health Sardinia]

TNA = The National Archives (TNA)

NHS = National Healthcare Service

RS = Regione Sardegna [Region of Sardinia]

SG = Scottish Government

8 Appendix I The following is a brief timeline (1978-2019) of the most important developments in the healthcare sectors of Sardinia (Italy) and Scotland (United Kingdom). Major political events are also included for reference.

8.1 Sardinia and Italy

1978: The Italian National Healthcare System (Sistema Sanitario Nazionale, SSN) is founded 1979: The Christian Democratic Party (DC) wins the Italian general elections and forms a coalition government with the Socialist Party (PSI), the Social Democratic Party (PSDI), the Republican Party (PRI), and the Liberal Party (PLI). The resulting (extremely unstable) majority, called the Pentapartito (Five Parties) will rule until 1994 (minus the PLI). The DC also wins the Sardinian regional elections, but no stable majority emerges 1981: The 1978 SSN reform is implemented in Sardinia (RS, 1981) 1984: The secessionist/green Sardinian Action Party (Psd’az) wins the regional elections along with the Communist Party (PCI) and the Socialist Party (PSI). 1989: The DC wins the Sardinian regional elections 1992: The SSN is reformed following New Public Management principles; decentralisation 1993: The Italian First Republic collapses after a series of corruption scandals (Tangentopoli); the old national parties either disband or quickly get absorbed by new coalitions 1994: Silvio Berlusconi’s center-right coalition wins the first general elections of the Italian Second Republic; a center-left/green coalitions wins the Sardinian regional elections 1995: The 1992 SSN reform is implemented in Sardinia (RS, 1995) 1999: The 1992 SSN reform is extensively amended to eliminate some of its most radical provisions; Forza Italia (FI), Silvio Berlusconi’s center-wing party, wins the Sardinian regional elections 2001: a constitutional reform formalises the Italian regions’ competencies in a more systematic way 2004: A very fragmented center-left/green coalition wins the Sardinian regional elections 2007: a new Sardinian regional health plan is approved 2009: The People of Freedom (PdL), Silvio Berlusconi’s center-right coalition, wins the Sardinian regional elections 2014: A center-left/green coalition wins the Sardinian regional elections 2019: The Psd’az, now a populist right-wing party, wins the Sardinian regional elections along with Matteo Salvini’s Northern League and Silvio Berlusconi’s FI

8.2 Scotland and The United Kingdom

1978: The Conservative Party wins the general elections; Margaret Thatcher becomes the Prime Minister until 1990; 1980: the Black Report on health disparities is published 1983: the Griffiths Report recommends to reform the NHS with the aim of privatising parts of it and introducing more competition 1984: The NHS is restructured; district health authorities (DHAs) replace the area health authorities (AHAs) 1986: The Primary Health Care Green paper seeks to increase patients’ choices 1989: the Working for Patients white paper attempts to introduce an internal market to the NHS 1990: The Community Care Act establishes NHS Trusts and GP fund-holding practices 1992: The Conservative Party wins the general elections; The Health of the Nation report establishes a disease-based structure of intervention; the Private Finance Initiative is introduced 1996: Three white papers are released: Choice and opportunity, Primary care: delivering the future, and The NHS: a service with ambitions; priorities do not significantly change 1997: The Labour Party wins the general elections and rules until 2010; the Designed to Care Scottish white paper sets out the NHS priorities for the next years 1998: Scotland Act: a Scottish parliament is created and competencies are devolved; decentralisation 1999: The Labour Party wins the Scottish general elections 2003: The Labour Party wins the Scottish general elections 2004: The 2004 Scotland Act eliminates the NHS Trusts in Scotland 2007: The Scottish National Party (SNP) wins the Scottish general elections; the Better Health, Better Care action plan is released, further promoting the integration of healthcare with social care 2008: the A Mutual NHS programme establishes the principle of mutuality between patients and the NHS 2010: The Conservative Party wins the general elections and forms a coalition with the Liberal Democrats; the Healthcare Quality Strategy is approved in Scotland 2011: The SNP wins the Scottish general elections; prescription charges are eliminated in Scotland 2014: The Scottish Independence Referendum fails; the Public Bodies (Joint Working)(Scotland) Act 2014 further integrates healthcare and social care 2015: The Conservative Party wins the general elections 2016: Brexit Referendum; the SNP wins the Scottish general elections 2017: The Conservative Party wins the snap elections, but has to form a minority government with the Democratic Unionist Party (DUP) 2019: The Conservative Party wins the general elections

9 Appendix II 9.1 Sardinia

9.1.1 Before Decentralisation (1981-1992) Document Text Interpretation

Regione Art. 2 Sardegna [La Regione realizza nel proprio territorio il Servizio sanitario Coordination (1981) nazionale, assumendo quale indirizzo fondamentale la between social care programmazione, la riorganizzazione, l'integrazione ed il and health care to coordinamento dei servizi sociali e sanitari in funzione della tackle territorial progressiva eliminazione degli squilibri esistenti nelle condizioni socio-sanitarie del territorio e con l'obiettivo di pervenire alla tutela inequities globale della salute, attraverso i momenti della prevenzione, della cura e della riabilitazione, nel pieno rispetto della persona e della dignità umana. Democratic La Regione assume altresì come obiettivo prioritario l'effettiva participation as a partecipazione dei cittadini alla realizzazione del Servizio sanitario tool to fulfill the nazionale, in modo da assicurare la rispondenza dei servizi e degli population’s needs interventi alle reali esigenze di salute e di benessere della popolazione.

Alla gestione unitaria della tutela della salute si provvede in modo Uniformity of uniforme sull'intero territorio regionale mediante le Unità sanitarie healthcare. No locali di cui alla legge 23 dicembre 1978, n. 833, i cui rispettivi ambiti special provisions territoriali sono delimitati dalla Tabella A allegata alla presente legge. recognised for specific groups L'Unità sanitaria locale coordina ed integra i propri servizi con quelli Coordination and sociali esistenti nel territorio, secondo le norme e le modalità di cui al integration between successivo art. 40. healthcare and social services Art. 21. Democratic Le Unità sanitarie locali, anche con riferimento alla legge 8 aprile 1976, n. 278, ed alle leggi regionali, devono assicurare tramite participation regolamento la più ampia partecipazione dei cittadini, delle Local social care formazioni sociali esistenti sul territorio, degli operatori e dei seen as fundamental rappresentanti degli interessi originari ai sensi della legge 12 febbraio component of 1968, n. 132, a tutte le fasi della programmazione dell'attività delle healthcare Unità sanitarie locali e alla gestione sociale dei servizi sanitari, Participatory nonché al controllo della loro funzionalità e rispondenza alle finalità management of del servizio sanitario ed agli obiettivi della programmazione. Al healthcare riguardo dovranno essere assicurate forme idonee di partecipazione Democratic alle rappresentanze sociali degli operatori socio-sanitari, dei Consigli representation of di quartiere, degli organismi democratici della scuola, costituendo Consigli socio-sanitari consultivi rappresentanti degli organismi sopra healthcare workers; indicati, nonché delle forze sociali e degli utenti al fine di formulare deep integration of proposte su piani e programmi zonali, sui bilanci preventivi e sui conti the healthcare sector consuntivi with the other domains; specific L'articolazione in distretti avviene a cura del consiglio comunale, local programs consiglio della comunità montana, assemblea della associazione dei comuni, previa consultazione dei Comuni compresi nell'Unità

sanitaria locale ed il loro ambito territoriale deve essere determinato Criteria to determine sulla base dei seguenti criteri (30) : 1) demografico: la popolazione di healthcare units ciascun distretto deve essere compresa tra 5.000 e 30.000 abitanti. È boundaries: 1) consentito un numero di abitanti maggiore o minore in relazione demographic all'indice di concentrazione della popolazione sul territorio; 2) criteria, 2) geomorfologico: ogni distretto deve comprendere una porzione di territorio tale da consentire, in relazione alla viabilità, alle geomorphological caratteristiche dei luoghi e degli insediamenti abitativi, ottimali factors (i.e. condizioni e tempi di accesso alle strutture esistenti. ruralness) The focus is on Art. 26 ensuring equity of Gli enti locali sono tenuti ad esprimere il proprio parere su tutti gli atti access regardless of sottoposti alla loro consultazione da parte delle Unità sanitarie locali, socioeconomic entro il termine perentorio di trenta giorni dalla relativa richiesta. factors, e.g. Medesimo obbligo sussiste per i pareri richiesti dalla Regione o da ruralness una Unità sanitaria locale alle altre Unità sanitarie locali Other local entities

Art. 27 participate in La Regione, al fine della programmazione sanitaria e della gestione determining the del sistema informativo sanitario, facente parte integrante del servizio health needs informativo regionale, provvede a determinare ed individuare l'insieme delle informazioni necessarie per il perseguimento degli Uniform models obiettivi predetti, predisponendo modelli uniformi per l'acquisizione e across all territories l'elaborazione dei dati.

Art. 30 L'organizzazione dei presidi, uffici e servizi dell'Unità sanitaria locale deve rispondere ai seguenti criteri: a) assicurare la massima economia e flessibilità di gestione nell'ambito della funzionalità ottimale dei vari servizi; b) attuare l'integrazione tra i servizi e presidi sanitari e quelli sociali, Integration of prevedendo le modalità di impiego del personale al fine di garantire social care with l'unitarietà degli interventi e di privilegiare il momento preventivo- healthcare sociale nelle attività dirette alla tutela del benessere psico-fisico della popolazione; Domiciliary care to g) assicurare, ove sia necessario, l'erogazione delle prestazioni, anche a domicilio dell'utente, in ogni parte del territorio, ricorrendo, quando ensure territorial opportuno, alla mobilità del personale all'interno dell'Unità sanitaria equity locale;

Art. 40 Fino all'emanazione della legge regionale di riordinamento e riforma Social care degli interventi in materia di assistenza sociale, le Province, i Comuni competencies e i loro Consorzi coordineranno le attività che in tale materia ad essi delegated to the competono ai sensi della normativa vigente, con l'intervento sanitario municipalities promosso dalle Unità sanitarie locali. A tale fine gli enti di cui al primo comma dovranno svolgere, sui propri programmi di assistenza sociale, le opportune consultazioni con le Unità sanitarie locali Integration of social care with healthcare. Cooperation between domains

Regione Art 2. Equity as a function Sardegna La Regione, conformemente alle finalità ed ai princìpi della L. 23 of an equitable (1985) dicembre 1978, n. 833, e secondo quanto sancito dall'art. 1 della L.R. distribution of health 16 marzo 1981, n. 13, esercita le funzioni di programmazione infrastructure and an perseguendo i seguenti obiettivi: - la tutela globale ed integrata della homogeneous salute dei cittadini sardi attraverso i momenti della prevenzione, della cura e della riabilitazione; - l'equilibrata distribuzione sul territorio quality of service regionale delle strutture, dei servizi e dei presidi, al fine di realizzare The “real” needs of l'omogeneità delle prestazioni; - il rafforzamento quantitativo- the population qualitativo dei servizi sanitari di base adeguandoli ai bisogni reali implies della popolazione; - il coordinamento e l'integrazione dei servizi dishomogeneity; sociali e sanitari con il Piano di sviluppo della Regione. Integration between social care and Art. 5 healthcare La Regione uniforma la sua potestà regolamentare, di indirizzo e di coordinamento, nonché i suoi conseguenti atti e provvedimenti, al The Regional Piano sanitario regionale che ha efficacia di indirizzo, di prescrizione e di vincolo per tutte le attività in esso previste per lo specifico settore government has the sanitario. Ai contenuti e agli indirizzi del piano i comuni e le Unità role to uniform sanitarie locali dovranno uniformare i loro programmi di attività local healthcare nell'esercizio delle funzioni di cui sono titolari; alla medesima programs osservanza sono impegnate le province e le Comunità montane per gli atti ed i provvedimenti di loro competenza nel settore sanitario.

Art. 8 Harmonisation of Su proposta della Giunta regionale, il Consiglio regionale provvede ad local practices adeguare e ad armonizzare le norme della presente legge a quelle della Priority of the legge di Piano sanitario nazionale; nelle more di tale adeguamento le disposizioni del Piano sanitario regionale sono applicabili in quanto National Health non in contrasto con le corrispondenti disposizioni del Piano sanitario Plan. This implies nazionale. somewhat limited leeway for regional targeted interventions Regione Art. 3 The reorganisation Sardegna 2. L'organizzazione dei servizi socio-assistenziali è rivolta in of social care (1988) particolare alla realizzazione dei seguenti obiettivi: services as a way to a) prevenire e concorrere a rimuovere le cause di ordine economico, tackle sociale e psicologico che possono provocare situazioni di bisogno e di socioeconomic and emarginazione nella vita sociale e produttiva; d) favorire, in accordo con gli organismi competenti, l'integrazione psychological dei servizi socio-assistenziali con i servizi sanitari, educativi, culturali inequities e scolastici, nonché con tutti gli altri servizi che operano nel territorio, al fine di assicurare una risposta organica e complessiva ai bisogni Integration of della popolazione; healthcare with e) promuovere ed assicurare un ordinato sviluppo sociale stimolando e social care sostenendo le iniziative favorevoli che nascono all'interno delle stesse Uniform, comunità territoriali homogenous answer; but Art. 4 some recognition for Nell'esercizio delle funzioni socio-assistenziali deve essere garantito il rispetto dei seguenti principi: local initiatives a) uguaglianza, a parità di bisogno, della qualità dei servizi e degli interventi socio-assistenziali Equity as a function of quality and access

Art. 5 1. I servizi e gli interventi socio-assistenziali sono destinati, nel rispetto delle norme statali e regionali vigenti, a tutti i cittadini italiani residenti nel territorio della Regione, senza distinzioni di carattere Equity of access giuridico, economico, sociale, ideologico e religioso. 2. Hanno altresì extended to all diritto di usufruire degli interventi socio- assistenziali gli stranieri e gli apolidi residenti nel territorio regionale, nel rispetto delle norme citizens, including statali ed internazionali vigenti. 3. Gli interventi socio-assistenziali si foreigners, with no estendono inoltre alle persone occasionalmente presenti o distinctions temporaneamente nel territorio regionale, che si trovino in situazioni di bisogno tali a richiedere interventi non differibili e non Regional healthcare tempestivamente attuabili dai competenti servizi delle altre Regioni o extend to those who dello Stato estero di appartenenza. 4. Sono fatte salve le norme statali cannot access vigenti in materia di domicilio di soccorso healthcare in their respective countries Art. 9 1. La Regione, nell'ambito del riordino del sistema socio- assistenziale, svolge le funzioni di programmazione, indirizzo, coordinamento e controllo. Coordinated 2. In particolare: management of g) favorisce e promuove la costituzione di associazioni fra più social care and Comuni per la gestione congiunta degli interventi socio-assistenziali; health care; municipalities are Art. 10 encouraged to work 3. Al fine di assicurare la maggiore corrispondenza alle esigenze di together programmazione e di gestione dei servizi socio-assistenziali, gli ambiti territoriali di cui al primo comma del presente articolo, possono essere modificati, contestualmente a quelli delle Unità sanitarie locali e nel rispetto delle disposizioni legislative dettate dal The boundaries of D.P.R. 19 giugno 1979, n. 348, con deliberazione del Consiglio the social care regionale. districts depend on 4. Le amministrazioni comunali, singole o associate, coordinano ed those of the relative integrano i propri servizi socio-assistenziali con quelli sanitari health care units esistenti nel territorio e con gli altri servizi di sviluppo e di intervento Integration of sociale] social services with health care plus Art. 13 other unspecified 1. All'interno di ciascuno degli ambiti territoriali delimitati ai sensi del welfare domains. It precedente art. 10, allo scopo di favorire il riassetto territoriale delle amministrazioni locali e di consentire lo svolgimento delle funzioni ad is implied that esse spettanti in modo efficiente e coordinato, nonché l'effettuazione healthcare promotes di interventi che interessino congiuntamente la popolazione ed il local development. territorio di più Comuni, questi ultimi hanno la facoltà di dare vita a forme di collaborazione ed intese, da realizzarsi sulla base delle Targeted indicazioni e con le modalità indicate dal piano regionale socio- interventions assistenziale di cui al successivo art. 20] involving several territories; Art. 22 Uniformity 1. La Regione, ai fini di programmazione e di gestione degli interventi socio-assistenziali, provvede alla rilevazione ed all'elaborazione di dati sull'attività dei servizi socio-assistenziali, di dati demografici, economici e sociali. 2. Le informazioni raccolte sono messe a disposizione della The Region has the collettività e, in particolare, dei soggetti istituzionali titolari delle role to investigate on funzioni socio-assistenziali, di associazioni e fondazioni private, di local socioeconomic

associazioni di volontariato e di altri soggetti sociali operanti nel conditions settore. 3. La Regione periodicamente provvede, anche sulla base delle esigenze presentate dagli enti territoriali, ad effettuare studi e ricerche sulle cause economiche, sociali e psicologiche che possono aver Recognition of determinato situazioni di bisogno e di emarginazione sociale anche al fine di individuare e definire più efficaci modalità di intervento. social exclusion as a factor fostering Art. 25 inequities 1. Allo scopo di prevenire e rimuovere fenomeni e situazioni di emarginazione di singoli e di gruppi, la Regione e gli Enti locali promuovono, nel rispetto degli ambiti di competenza indicati dalla presente legge, l'istituzione dei servizi e strutture di aggregazione Local social and sociale, incentivando, favorendo e realizzando di propria iniziativa healthcare interventi di tipo educativo, culturale, ricreativo, sportivo o di tempo initiatives as a tool libero] to tackle inter- and

Art. 27 intra-group L'ubicazione dei centri [di aggregazione sociale] deve essere tale da inequities assicurare l'integrazione con la rete delle strutture e dei servizi culturali e socio- sanitari del territorio e favorire la partecipazione alla vita di relazione. Integration of social and health Art. 39 care with the cultural 1. I centri di pronto intervento assicurano, in attesa della domain individuazione degli interventi più adeguati, il soddisfacimento temporaneo dei bisogni di alloggio, nutrimento e di altri bisogni First aid centers as primari a favore di minori o di soggetti non autosufficienti che abbiano lasciato la famiglia o non possano comunque ricevere in essa places to fulfill adeguata assistenza. 2. I centri accolgono gli utenti secondo le urgent indicazioni del piano regionale socio assistenziale, senza limitazioni socioeconomic di età, sesso o condizioni personali needs, with no distinctions made between users

Regione Al fine di perseguire e potenziare la prevenzione e la cura della B- Sardegna Thalassemia, la Regione Autonoma della Sardegna - ai sensi Scientific research (1990) dell'articolo 5, lettera a) della legge costituzionale 26 febbraio 1948, as a tool to promote n. 3, e ad integrazione degli interventi statali di cui all'articolo 8 e interregional equity seguenti del D.P.R. 11 febbraio 1961, n. 249, e successive by tackling regional, modificazioni - assicura un adeguato sostegno finanziario per la promozione della ricerca scientifica nel campo della patologia specific diseases molecolare e genetica ed in quello della terapia genico-somatica. Regione Art. 3 Sardegna 1. L'assistenza indiretta consiste nel rimborso totale o parziale delle Reimbursement of (1991) spese sanitarie sostenute per prestazioni sanitarie di diagnosi, cura e health-related riabilitazione fatta eccezione per le spese di comfort alberghiero non expenditures as a comprese nella retta di degenza. way to tackle 2. Nel caso di ricorso a strutture sanitarie ubicate al di fuori del territorio regionale sono inoltre concessi contributi per le spese di interregional viaggio e di soggiorno. disparities 3. I contributi di cui al comma precedente sono concessi anche quando la prestazione sanitaria è erogata in forma diretta, purché sia stata preventivamente autorizzata con le modalità previste dagli articoli 10 e 20 della presente legge.

The Region covers Art. 9 all travel and Per le prestazioni sanitarie fruite al di fuori del territorio regionale la transportation Regione concede, a valere su fondi propri, il rimborso delle spese di expenditures; note viaggio o di trasporto dell'assistito. how these

Art. 14 reimbursements are I benefici previsti dai successivi articoli 16, 17 e 19 possono essere framed as “benefits”, concessi per le prestazioni di diagnosi, cura e riabilitazione the same term that individuate con le procedure previste dal D.M. 3 novembre 1989 del would be used for Ministero della Sanità , che non sono ottenibili adeguatamente e socio-assistencial tempestivamente presso i presidi ed i servizi pubblici o convenzionati welfare programs dal servizio sanitario nazionale. Such measures are only intended for 2. La prestazione è considerata non erogabile tempestivamente urgent needs, not as quando le strutture pubbliche o convenzionate richiedono un periodo a systematic tool to di attesa incompatibile con l'esigenza di assicurare con immediatezza la prestazione stessa, o quando il periodo di attesa comprometterebbe confront regional lo stato di salute dell'assistito o precluderebbe la possibilità disparities dell'intervento o delle cure. It is also implied here that not all 3. La prestazione è considerata non ottenibile adeguatamente quando technological tools essa necessita di professionalità o procedure tecniche e curative, od will be always attrezzature non presenti nelle strutture pubbliche o convenzionate. available to fulfill health needs Art. 16 1. Ad integrazione dell'assistenza diretta a favore dei cittadini di Stati membri della CEE prevista dall'articolo 22 del Regolamento CEE n. 1408 del 1971 sono previste le seguenti forme di concorso pubblico Interestingly, no nella spesa: distinction is made a) rimborso delle spese sanitarie sostenute per prestazioni sanitarie between services fruite in strutture private non convenzionate con l'istituzione estera; offered by private b) rimborso delle spese di viaggio del paziente e dell'eventuale and public accompagnatore sostenute su mezzi pubblici in classe economica; healthcare; both are c) rimborso delle spese di trasporto del paziente dell'eventuale reimbursed by the accompagnatore; region d) rimborso delle spese per prestazioni a carattere libero- professionale, anche rese in costanza di ricovero.

2. I rimborsi previsti dal comma precedente sono a carico delle Unità The Regions only sanitarie locali nella misura dell'80 per cento per le spese di cui alle reimburses the sum lettere a), b) e c) e nella misura del 40 per cento per le spese di cui alla that cannot be paid lettera d). by the local 3. La Regione provvede con fondi propri al rimborso della quota healthcare units residua.

Art. 17 Non-Sardinian or 1. Al fine di garantire la parità di trattamento ai cittadini di paesi non-Italian citizens extra-CEE, che in base a disposizioni di legge o ad accordi can make use of the internazionali sono equiparati ai fini dell'assistenza sanitaria, ai cittadini italiani, la presente legge garantisce il rimborso delle spese service; equity of sanitarie sostenute per prestazioni rese in strutture pubbliche o treatment convenzionate dall'istituzione estera per le quali l'utente non è legittimato a fruire dell'assistenza diretta ai sensi della legislazione CEE, nei limiti della vigente legislazione nazionale.

Regione Art. 1 Sardegna 1. La Regione autonoma della Sardegna promuove l'istituzione di (1992) servizi socio-assistenziali a favore delle persone affette da disturbi Further norms for psichici residenti nel territorio regionale in armonia con la legge the integration of regionale 25 gennaio 1988, n. 4. social care with 2. In attuazione dell'articolo 16 della legge regionale 25 gennaio 1988, n. 4, la presente legge detta norme per il coordinamento tra i servizi healthcare sanitari ed i servizi socio-assistenziali, nel quadro delle competenze che la medesima legge assegna ai Comuni ed alle Aziende USL e nel rispetto delle disposizioni di cui all'articolo 30 della legge 27 dicembre 1983, n. 730 e al D.P.C.M. 8 agosto 1985 (3) .

Art. 2 1. Nel quadro delle procedure di programmazione previste dal Titolo It is acknowledged III della legge regionale 25 gennaio 1988, n. 4, i Comuni singoli, here the importance associati o consorziati predispongono ed attuano a favore dei soggetti of socioeconomic affetti da disturbi psichici o da ritardo mentale: a) interventi di assistenza economica, ai sensi dell'articolo 34 della factors in improving legge regionale 25 gennaio 1988, n. 4, e degli articoli 1, 2, 3 e 4 del the quality of mental D.P.G.R. 14 febbraio 1989, n. 12, e successive integrazioni e health care modificazioni; d) gli interventi di assistenza domiciliare, ai sensi dell'articolo 35 della legge regionale 25 gennaio 1988, n. 4; e) servizi di trasporto finalizzati all'accesso ai servizi nel territorio; f) forme di inserimento lavorativo, o in aziende pubbliche e private, o Equity as a function mediante la costituzione di cooperative di lavoro e laboratori protetti, of job employment secondo le disposizioni di cui all'articolo 30 della legge regionale 25 and social inclusion gennaio 1988, n. 4, e agli articoli 7 e 16 della legge regionale 24 ottobre 1988, n. 33; of disadvantaged g) attività di aggregazione culturale, ricreativa, sportiva, di tempo individuals libero, secondo le indicazioni degli articoli 25 e 27 della legge regionale 25 gennaio 1988, n. 4

Art. 4 1. L'équipe del Servizio della tutela della salute mentale e dei disabili The quality of the psichici o Servizio della tutela materno-infantile consultori familiari service depends on neuropsichiatria infantile, tutela della salute degli anziani, local infrastructure. riabilitazione dei disabili fisici dell'Azienda USL competente per It is implied here territorio, integrata dall'operatore del servizio socio-assistenziale del Comune, determina la tipologia dell'intervento a favore del soggetto that were the quality affetto da disturbi psichici o da ritardo mentale, previa attenta of the local valutazione dei servizi e delle risorse presenti ed attivabili nel infrastructure territorio. Contestualmente stabilisce la cadenza temporale delle insufficient, its relative verifiche . functions would be 2. Nel caso in cui nell'Unità Sanitaria Locale non sia attivato il assumed by the Servizio della tutela della salute mentale e dei disabili psichici, le closest healthcare funzioni di cui al comma precedente sono esercitate dall'omonima unit → territorial struttura dell'Azienda USL viciniore . equity 3. Nel caso in cui nell'Azienda USL non sia attivato il Servizio della tutela materno-infantile consultori familiari neuropsichiatria infantile, tutela della salute degli anziani, riabilitazione dei disabili fisici, le funzioni sono svolte dall'omonimo servizio dell'Unità Sanitaria Locale Cooperation viciniore . between 4. Per l'attuazione di specifiche forme d'intervento che richiedono municipalities to l'integrazione tra l'area assistenziale e l'area sanitaria, i Comuni e le ensure the quality of

Azienda USL stipulano apposite convenzioni ai sensi dell'articolo 16 the service della legge regionale 25 gennaio 1988, n. 4, e dell'articolo 14, terzo comma, del D.P.G.R. 14 febbraio 1989, n. 12.

Art. 6 Targeted 1. L'Amministrazione regionale è autorizzata ad erogare un sussidio economico a favore delle persone residenti in Sardegna che siano interventions aimed affette da disturbi mentali aventi carattere invalidante e che si trovino at specific, in stato di bisogno economico secondo le norme della presente legge. disadvantaged groups 9.1.2 After Decentralisation (1992-2018)

Regione Art. 1 Sardegna 1. Ai sensi dell'articolo 1, lettere c) e d), della legge 23 ottobre 1992, (1995) n. 421, e dell'articolo 3 del decreto legislativo 30 dicembre 1992, n. 502, come modificato dal decreto legislativo 7 dicembre 1993, n. 517, Uniformity is la Regione persegue gli obbiettivi della promozione, del restated, but more mantenimento e del recupero della salute fisica e psichica del cittadino, in condizioni di uniformità sul territorio regionale, autonomy is given attraverso apposite aziende denominate Unità sanitarie locali, aventi to local healthcare personalità giuridica di diritto pubblico, dotate di autonomia units organizzativa, amministrativa, tecnica, patrimoniale, contabile e di Compared with RS gestione. (1981), the criteria behind the 4. Gli ambiti territoriali delle aziende-U.S.L. possono essere formulation of modificati - in relazione sia a particolari condizioni geomorfologiche healthcare units e demografiche, sia alla dislocazione nel territorio delle strutture e dei boundaries are less servizi sanitari - con il Pianosanitario regionale, tenendo conto delle precise but include proposte formulate dalla Conferenza dell'azienda-U.S.L. in sede di determinazione delle linee di indirizzo del programma sanitario the conditions of dell'azienda stessa ai sensi dell'articolo 43, comma 4. local health infrastructure Art. 16 Equity as a function 1. Al fine di assicurare una risposta coordinata e continuativa al of the coordinated bisogno socio-sanitario delle comunità locali, l'azienda-U.S.L. efforts by the local, decentra le proprie funzioni nel territorio articolando l'organizzazione decentralised centrale in distretti, salvo quanto disposto dal comma 8. healthcare units

7. Per ciascun distretto è istituita nel bilancio dell'azienda-U.S.L. una Financial equity contabilità separata. Il distretto è dotato di autonomia finanziaria nei limiti e secondo le modalità stabilite dalla legge regionale sulla gestione patrimoniale ed economico-finanziaria dell'azienda-U.S.L. di cui all'articolo 64, comma 1.

Art. 17 1. Il distretto esercita le funzioni di interesse locale concernenti The new l'osservazione l'analisi epidemiologica, l'assistenza sanitaria di base, decentralised, health l'assistenza farmaceutica, l'igiene e la medicina preventiva, la districts have to profilassi delle malattie infettive, la medicina scolastica, la medicina

sportiva, la medicina legale, l'assistenza specialistica territoriale, la coordinate with the medicina riabilitativa, l'assistenza psichiatrica e psico-sociale municipalities to territoriale, la medicina veterinaria, l'assistenza infermieristica integrate social care ambulatoriale e domiciliare. Esso, inoltre, esercita le funzioni socio- with health care assistenziali di interesse locale di competenza dell'azienda-U.S.L. ai sensi dell'articolo 14 della legge regionale 25 gennaio 1988, n. 4, ricercando il coordinamento e l'integrazione con le attività socio- assistenziali del Comune. Financial Art. 24 autonomy 1. L'azienda-U.S.L. ha un proprio patrimonio; destinato al raggiungimento delle finalità istituzionali, costituito da: a) i beni mobili ed immobili di proprietà dell'azienda-U.S.L. ai sensi del successivo comma 3 e dell'articolo 25; b) i beni mobili ed immobili acquistati a titolo di donazione, eredità, legato. Financial autonomy; it is Art. 30 1. Gli ospedali che non sono costituiti in azienda sono strutture perhaps implied by dell'azienda-U.S.L. nel cui ambito territoriale ricadono. 2. I presidi “economic ospedalieri delle aziende-U.S.L. hanno autonomia economico- autonomy” the idea finanziaria con contabilità separata all'interno del bilancio of promoting local dell'azienda. initiatives

Art. 39 1. La Regione esercita le funzioni di programmazione sanitaria ad essa attribuite ai sensi della legge n. 833 del 1978 e successive modificazioni ed integrazioni, in armonia con i contenuti e gli obbiettivi del Piano sanitario nazionale ed in coerenza con il programma pluriennale regionale. Coordination between territories 2. Ai sensi dell'articolo 2, comma 7, della legge 8 giugno 1990, n. 142, le Province ed i Comuni partecipano alla programmazione sanitaria regionale con le modalità indicate dall'articolo 43, commi 4 e 5 della presente legge, ai fini della determinazione del fabbisogno Universities sanitario dei rispettivi ambiti territoriali. contribute to 3. Ai sensi dell'articolo 6, comma 1, del decreto legislativo n. 502 del drafting health plans 1992 e successive modificazioni, le Università contribuiscono along with the local all'elaborazione dei Piano sanitario regionale con particolare riguardo healthcare units alla determinazione dell'apporto delle Facoltà di Medicina alle attività assistenziali del servizio sanitario ed alla dislocazione e tipologia delle strutture sanitarie, con le modalità previste dall'articolo 41, comma 3 della presente legge. 4. Le aziende-U.S.L. e le aziende ospedaliere concorrono all'elaborazione del Piano sanitario regionale attraverso le proposte contenute nel proprio programma sanitario

Art. 40 Once again, the 1. Il Piano sanitario regionale individua gli obbiettivi fondamentali di National Health prevenzione, cura e riabilitazione del servizio sanitario regionale, Plan retains its nonché i criteri e gli indirizzi generali per la loro attuazione, in coerenza con l'entità delle risorse ad esso destinate e nel rispetto del privileged role Piano sanitario nazionale. Il Piano si articola in azioni programmatiche e progetti obbiettivo - così come definiti dall'articolo The LEAs 2, commi 3 e 5, della legge 23 ottobre 1985, n. 595 - e contiene, in (Minimum Levels of particolare: health assistance)

e) i livelli minimi di assistenza sanitaria garantiti in condizione di ensure uniformity uniformità sul territorio regionale e gli eventuali, ulteriori livelli; across all territories; h) i criteri generali concernenti il bacino di utenza, la localizzazione, Healthcare as a more gli standard strutturali e di personale dei distretti sanitari; humane service; it n) gli indirizzi generali per l'integrazione dei servizi sanitari e dei is unclear how this is servizi socio-assistenziali; q) gli indicatori concernenti l'attività diretta alla personalizzazione ed achieved in practice all'umanizzazione dell'assistenza sanitaria, nonché lo stato di attuazione della legge regionale 3 febbraio 1993, n. 9 The Regional Health Art. 43 Plan is adapted to 2. Il programma sanitario dell'azienda-U.S.L. individua le attività e le the local realities; it iniziative più idonee alla realizzazione a livello locale degli obbiettivi is acknowledged, in del Piano sanitario regionale, sulla base dello stato di salute della very broad terms, popolazione e delle condizioni strutturali, organizzative e funzionali that certain areas dei servizi. In particolare esso contiene: a) l'individuazione delle aree might need targeted d'intervento sanitario ritenute d'interesse prioritario; b) l'indicazione, per ciascuna iniziativa, della dotazione qualitativa e interventions quantitativa di personale, delle dotazioni tecnologiche e strumentali e delle opere di edilizia sanitaria ritenute necessarie; c) l'indicazione, per ciascuna iniziativa, dei costi presumibili, distinti in spese di parte corrente e spese in conto capitale. 3. Il programma sanitario contiene, inoltre, le proposte di adeguamento del Piano sanitario regionale ritenute necessarie per Such targeted l'attuazione delle iniziative dell'azienda-U.S.L., con particolare interventions also riferimento a: include measures a) l'entità del finanziamento a favore dell'azienda-U.S.L.; designed to improve b) le priorità qualitative e quantitative nel riordino delle piante organiche; health infrastructure c) la realizzazione di opere di edilizia sanitaria; at the local level d) l'adeguamento e lo sviluppo delle dotazioni tecnologiche e strumentali. The financial Art. 45 distribution of 2. Le quote capitarie di finanziamento sono determinate tenendo resources now also conto: depends on the a) della popolazione residente in ciascuna azienda-U.S.L.; quality of health b) della spesa per le prestazioni sanitarie ai sensi dell'articolo 8, infrastructure; commi 5 e 6, del decreto legislativo n. 502 del 1992 e successive modificazioni, regolarmente contabilizzata; disadvantaged c) della consistenza e dello stato di conservazione delle strutture territories obtain immobiliari, degli impianti tecnologici e delle dotazioni strumentali; more resources to d) delle risultanze dei controlli di gestione. compensate their lack of technological Art. 47 instruments; the 1. Le risorse in conto capitale derivanti dal fondo sanitario nazionale e main goal is re- le risorse aggiuntive stanziate dalla Regione sono ripartite tra le equilibrium aziende-U.S.L. e le aziende ospedaliere con gli atti di programmazione di cui all'articolo 40 ed in coerenza con gli obbiettivi in essi stabiliti, tenuto conto: a) della consistenza e dello stato di conservazione degli immobili, degli impianti tecnologici e delle dotazioni strumentali; b) della necessità del riequilibro territoriale nella dislocazione delle strutture, degli impianti tecnologici e delle dotazioni strumentali

Regione Art. 1 A new integrated Sardegna 2. La presente legge disciplina il sistema integrato dei servizi alla system is created to (2005a) persona, di seguito denominato "sistema integrato", comprendente coordinate all l'insieme delle attività di programmazione, realizzazione e valutazione welfare programs; dei servizi e delle prestazioni volte a favorire il benessere delle not how healthcare persone e delle famiglie che si trovino in situazioni di bisogno sociale, esclusi gli interventi predisposti dal sistema sanitario, previdenziale e policies are distinct, di amministrazione della giustizia. but they nonetheless 3. Il sistema integrato promuove i diritti di cittadinanza, la coesione e belong to the l'inclusione sociale delle persone e delle famiglie, le pari opportunità, integrated system; attraverso la realizzazione di azioni di prevenzione, riduzione ed the main goal is to eliminazione delle condizioni di bisogno e disagio individuale e reduce familiare derivanti da inadeguatezza di reddito, difficoltà sociali e socioeconomic condizioni di non autonomia. inequities

Art. 2 1. Nella disciplina e nella realizzazione del sistema integrato, la Regione e gli enti locali, nell'esercizio delle rispettive competenze e Principles: equity of nel rispetto delle competenze attribuite allo Stato dalla Costituzione, access, solidarity, assumono i seguenti principi di indirizzo: selective a) l'universalismo selettivo, a garanzia della eguaglianza delle persone universalism, nell'accesso al sistema integrato e nella fruizione dei servizi, sulla democratic base di criteri di priorità fondati sulla valutazione del bisogno; accountability; b) la solidarietà sociale ed istituzionale come elemento fondamentale some groups might per assicurare la realizzazione sostenibile e qualificata del sistema be prioritised; the integrato su tutto il territorio regionale; new integrated d) la concertazione istituzionale e sociale e la partecipazione attiva dei system includes all cittadini come criteri generali di sviluppo dei processi decisionali, finalizzate ad assicurare la partecipazione democratica e la the past provisions trasparenza dell'azione pubblica; plus new concepts, e) l'integrazione delle politiche e degli interventi sociali con le altre such as that of politiche e gli interventi posti in essere per assicurare una risposta subsidiarity; the organica ed integrata ai bisogni che le persone incontrano nel corso term is not della vita; explained, but it can f) la sussidiarietà, nelle due accezioni orizzontale e verticale, come be interpreted to criterio generale di realizzazione del sistema integrato, in cui la mean that valorizzazione delle autonomie e delle pluralità sia finalizzata a municipalities and garantire i diritti di cittadinanza e l'accesso ai servizi su tutto il local healthcare territorio regionale; g) l'assicurazione alle persone ed alle famiglie dell'accesso al sistema units must integrato, la non discriminazione e i diritti di cittadinanza; h) la coordinate to centralità delle comunità locali, intese come sistema di relazioni tra promote intra persone, famiglie, istituzioni e organizzazioni sociali, ognuno per le regional equity; proprie competenze e responsabilità. Focus on the local communities Art. 3 1. In conformità a quanto disposto dall'articolo 6 dello Statuto speciale per la Sardegna ed in attuazione del decreto legislativo 31 marzo 1998, n. 112, alle funzioni di programmazione, promozione, organizzazione e finanziamento del sistema integrato concorrono i comuni, le province e la Regione, cui spetta altresì, sulla base delle rispettive competenze, garantire l'equità, l'efficienza, l'efficacia e la Equity along with qualità del sistema. efficiency and 2. La Regione e gli enti locali promuovono la partecipazione degli effectiveness; altri soggetti pubblici, dei sindacati e del terzo settore, ovvero delle probably equity of

organizzazioni di volontariato, degli organismi non lucrativi di utilità access, due to the sociale, degli organismi della cooperazione, delle associazioni e degli participation of local enti di promozione sociale, culturale e sportiva, delle fondazioni, degli municipalities in the enti di patronato, degli enti riconosciuti, delle confessioni religiose healthcare process con le quali lo Stato ha stipulato patti, accordi o intese operanti nel settore, alla programmazione, realizzazione e valutazione del sistema integrato. 3. La Regione e gli enti locali valorizzano e sostengono iniziative di mutuo aiuto e di solidarietà sociale promosse dai cittadini e dalle Local initiatives; formazioni sociali che perseguono le finalità di cui alla presente legge. once again, solidarity appears to Art. 4 be a relevant term 1. Hanno diritto ad accedere ai servizi ed alle prestazioni di cui alla presente legge: a) i cittadini italiani; b) i cittadini europei, in conformità a quanto disposto dai trattati Universal access to comunitari; c) i cittadini extracomunitari residenti ai sensi dell'articolo 41 del the integrated decreto legislativo 25 luglio 1998, n. 286; system; the d) gli apolidi ed i rifugiati residenti, nel rispetto delle normative statali formulation is very ed internazionali vigenti; similar, if not more e) i cittadini stranieri di cui all'articolo 18 del decreto legislativo n. precise, than that 286 del 1998; found in RS (1991) f) i minori comunque presenti sul territorio regionale; g) i cittadini sardi emigrati e le loro famiglie, ai sensi e nei limiti di quanto previsto dalla legge regionale 15 gennaio 1991, n. 7. Equity in the form of the extension of 2. Gli interventi di cui alla presente legge si estendono alle persone occasionalmente presenti o temporaneamente dimoranti nel territorio the services to those regionale, che si trovino in situazioni di bisogno tali da richiedere who cannot make interventi non differibili e non tempestivamente attuabili dai servizi use of them in their territorialmente competenti o dagli stati esteri di appartenenza. respective countries

4. Accedono prioritariamente al sistema integrato i soggetti in Vertical equity: condizioni di povertà o con limitato reddito, con incapacità totale o some groups are parziale di provvedere alle proprie esigenze per inabilità di ordine prioritised fisico e psichico, con difficoltà di inserimento nella vita sociale attiva e nel mercato del lavoro, nonché i soggetti sottoposti a provvedimenti dell'autorità giudiziaria per i quali siano necessari interventi assistenziali.

Art. 8 1. La Regione esercita le funzioni di programmazione, indirizzo, The whole system is verifica e valutazione del sistema integrato, garantendo l'attuazione su integrated; this tutto il territorio regionale dei livelli essenziali di assistenza, implies that these l'integrazione con la programmazione sanitaria ed il coordinamento policies take into con le politiche educative, formative, del lavoro, della casa, account of the dell'ambiente e dello sviluppo socio-economico. impact of socioeconomic 2. In particolare spettano alla Regione le seguenti funzioni: i) promozione di iniziative di formazione e aggiornamento per factors on healthcare professionisti ed operatori sociali appartenenti ad enti pubblici ed ai soggetti privati che partecipano alla realizzazione del sistema Coordination integrato, in raccordo e su proposta di aziende sanitarie locali e between comuni; municipalities and

the healthcare sector, Art. 16 not only in the 1. Al fine di costruire un sistema di responsabilità condivisa e di drafting on new favorire l'integrazione degli interventi sociali, socio-sanitari e sanitari policies but also in a livello di ambito, i comuni associati e l'azienda sanitaria locale their competente: a) realizzano in forma congiunta la programmazione di ambito di cui implementation; all'articolo 21; healthcare and social b) stipulano appositi accordi e convenzioni con i quali è disciplinata la care goals seem to realizzazione dei livelli essenziali socio-sanitari di assistenza di cui be conflated into a all'articolo 3-septies del decreto legislativo 30 dicembre 1992, n. 502, single category e successive modifiche e integrazioni.

Art. 17 This formulation of 1. La Regione e gli enti locali adottano il metodo della criteria is similar, programmazione degli interventi e delle risorse, del lavoro per but not perfectly progetti, della verifica dei risultati in termini di efficacia, appropriatezza, efficienza e soddisfazione degli utenti. identical to that 2. La Regione e gli enti locali, nell'esercizio delle rispettive funzioni, found in article 2; provvedono alla programmazione degli interventi e delle risorse note the absence of secondo i seguenti principi: equity from the list; a) integrazione con la programmazione sanitaria, coordinamento con which is replaced by le politiche attive del lavoro, della formazione e dell'istruzione, con le a non-defined politiche abitative e di gestione urbanistica e territoriale; “appropriateness”; a b) concertazione e cooperazione tra enti locali, azienda sanitaria new term, locale e Regione; “concertazione”, is c) concertazione e cooperazione tra i soggetti pubblici e i soggetti introduced, but it sociali solidali che partecipano con proprie risorse alla realizzazione del sistema integrato; seems to be d) individuazione delle priorità regionali e locali sulla base dei functionally bisogni, tenendo conto dell'esigenza di garantire equità sul territorio identical to regionale e promozione delle risorse locali. coordination 3. Gli enti locali, ai rispettivi livelli, applicano il metodo della Vertical equity; concertazione, anche tramite l'istituzione di organismi di certain territories are consultazione stabili di cui fanno parte gli attori sociali e professionali prioritised attraverso le proprie organizzazioni di rappresentanza.

Art. 19 Socioeconomic 1. Per la realizzazione degli obiettivi di cui alla presente legge, la Regione provvede, sentiti gli organismi di consultazione, alla measures are predisposizione del Piano regionale dei servizi alla persona integrato integrated with con il Piano dei servizi sanitari. healthcare policies Regione L’Assessore dell’Igiene Sanità e Assistenza Sociale riferisce che il Notwithstanding the Sardegna Servizio Sanitario Regionale è caratterizzato sotto il profilo establishment of the (2005b) organizzativo e funzionale, sia a livello regionale sia aziendale, da integrated system, notevoli carenze che condizionano l’erogazione appropriata ed major disparities equilibrata dei livelli essenziali di assistenza sull’intero territorio remain regionale e determinano un costante incremento dei costi di gestione del sistema.

- il potenziamento dell’assistenza sul territorio, nelle sue diverse Equity in terms of funzioni – di prevenzione e di erogazione dell’assistenza - attraverso more autonomy and la concreta attivazione dei Distretti quali unità organizzative e more resources to be funzionali più vicine al cittadino, dotate di reale autonomia; lo given to local sviluppo di forme di assistenza alternative al ricovero, in particolare a healthcare units, as

domicilio del paziente, sarà la linea di intervento da privilegiare in well as a more assoluto su tutto il territorio regionale, anche in ragione delle efficient integration benefiche ricadute sull’intero sistema di offerta e sulla sua capacità di between social care risposta ai bisogni dei più deboli. In questo contesto si porrà and healthcare particolare attenzione al potenziamento e alla riqualificazione It is implied here dell’assistenza specialistica, all’integrazione ospedale e territorio e al governo delle liste d’attesa al fine di garantire alla popolazione del that healthcare territorio di riferimento la continuità assistenziale; supply might be undermined by the poor coordination between healthcare layers Regione L’Assessore dell’Igiene e Sanità e dell’Assistenza Sociale riferisce la Equity of access in Sardegna necessità che, anche per l’anno 2006, sia approvato un programma per terms of services (2006a) assicurare le prestazioni sanitarie, in regime di ricovero presso le offered to non- strutture sanitarie pubbliche della Regione Sardegna, a favore di European citizens cittadini non appartenenti all’Unione Europea, che necessitano di cure Universality is once di particolare specializzazione. again prioritised L’obiettivo principale del programma è di supportare l’azione delle istituzioni pubbliche e private, con sede nella Regione Sardegna, che svolgono attività di cooperazione internazionale o di assistenza umanitaria, in maniera da rendere più incisiva la loro azione di aiuto e sostegno alle realtà in cui tali istituzioni si trovano ad operare. Regione Art. 1 Principles of Sardegna 2. I principi di sistema del SSR sono: Regional Healthcare: (2006b) a) la centralità della persona, titolare del diritto alla salute; universality and b) l'universalità e l'equità nell'accesso alle prestazioni e ai servizi equity of access sanitari; c) la globalità della copertura assistenziale.

4. La Regione promuove la qualità e l'appropriatezza dei servizi e delle prestazioni resi dalle aziende e dagli altri soggetti di cui al Humanisation, as in comma 3, vigilando in particolare affinché essi siano improntati ai RS (1995); supply principi della personalizzazione e dell'umanizzazione del trattamento must conform to e affinché ogni persona che entra in contatto con il SSR sia accolta individual needs, but secondo i suoi bisogni e le sue esigenze assistenziali. Sono posti a no specific priorities carico del SSR le tipologie di assistenza, i servizi e le prestazioni are mentioned sanitarie che presentano, per specifiche condizioni cliniche o di rischio, evidenze scientifiche di un significativo beneficio in termini di salute, a livello individuale o collettivo, a fronte delle risorse impiegate. First mention of 5. Il SSR valorizza le responsabilità individuali e collettive nella healthy lifestyles; promozione di stili di vita idonei alla tutela della salute e favorisce la interestingly, this is partecipazione degli utenti, singoli o associati, alla valutazione dei not associated with servizi sanitari, secondo quanto previsto negli atti aziendali di cui socioeconomic all'articolo 9. factors

Art. 4 1. È compito della Regione: Integration of a) impartire direttive alle aziende sanitarie per l'attuazione di interventi di comunicazione, educazione e promozione della salute in healthcare with collaborazione con il sistema scolastico, gli ordini professionali, social care l'università e con le organizzazioni di volontariato, di promozione

sociale e della cooperazione sociale, nonché per la partecipazione alla verifica della qualità dei servizi e delle prestazioni erogate e alla verifica dei risultati; The Regional Health Art. 12 Plan makes Il piano regionale dei servizi sanitari: a) illustra le condizioni di salute della popolazione presente sul socioeconomic and territorio con particolare riguardo alle disuguaglianze sociali e intraregional territoriali nei confronti della salute; equity as the first b) indica le aree prioritarie di intervento ai fini del raggiungimento di priorities obiettivi di salute, anche attraverso la predisposizione di progetti obiettivo; c) individua gli strumenti finalizzati ad orientare il SSR verso il miglioramento della qualità dell'assistenza

Art. 16 Uniformity is now 3. La Regione persegue l'unitarietà, l'uniformità ed il coordinamento delle funzioni del servizio sanitario regionale, promuove mentioned later and l'integrazione e la cooperazione fra le aziende sanitarie e favorisce il paired with coordinamento a livello regionale delle politiche del personale e delle coordination (see politiche finalizzate all'acquisto, anche attraverso aziende capofila, di RS, 1981) beni e servizi e allo sviluppo dell'innovazione tecnologica e del sistema informativo sanitario regionale. A tal fine è istituito presso l'Assessorato regionale competente in materia di sanità un coordinamento presieduto dall'Assessore regionale e composto dal direttore generale della sanità e dai direttori generali delle aziende sanitarie. Il coordinamento, in relazione ai temi specifici di valenza territoriale, prevede la partecipazione dei direttori delle aree socio- sanitarie locali The integration of Art. 17 healthcare with 3. I distretti socio-sanitari costituiscono l'articolazione territoriale social care occurs at dell'area socio-sanitaria locale e il luogo proprio dell'integrazione tra the local level; assistenza sanitaria e assistenza sociale; essi sono dotati di autonomia autonomy is tecnico-gestionale, nell'ambito delle funzioni individuate dall'atto emphasised aziendale, economico-finanziaria, nell'ambito delle risorse assegnate, e di contabilità separata all'interno del bilancio aziendale. In sede di verifica del raggiungimento degli obiettivi dell'attività del direttore generale dell'ATS, definiti ai sensi dell'articolo 16, la Giunta regionale assegna specifico rilievo alla funzionalità operativa dei distretti Uniformity of supply is now 5. Il distretto territoriale, diretto da un responsabile nominato ai sensi framed as a function del comma 3 dell'articolo 3-sexies del decreto legislativo n. 502 del of local 1992, e successive modifiche e integrazioni, articola l'organizzazione peculiarities, dei propri servizi tenendo conto della realtà del territorio ed assicura: instead of a a) il governo unitario globale della domanda di salute espressa dalla homogeneous, comunità locale; regional supply → b) la presa in carico del bisogno del cittadino, individuando i livelli appropriati di erogazione dei servizi; vertical equity; the c) la gestione integrata, sanitaria e sociale, dei servizi, anche same applies to the collaborando alla predisposizione e realizzazione del PLUS; services supplied by d) l'appropriato svolgimento dei percorsi assistenziali attivati dai the integrated medici di medicina generale, dai pediatri di libera scelta e dai servizi system direttamente gestiti,per le competenze loro attribuite dalla programmazione regionale e locale;

e) la promozione, anche in collaborazione con il dipartimento di prevenzione, di iniziative di educazione sanitaria nonché di informazione agli utenti; f) la fruizione, attraverso i punti unici di accesso, dei servizi territoriali sanitari e sociosanitari, assicurando l'integrazione con i servizi sociali e con i servizi ospedalieri; Financing of Art. 26 Regional healthcare 1. Il finanziamento del servizio sanitario regionale è assicurato dal now takes into Fondo sanitario regionale, costituito in sede di bilancio di previsione account of local alla luce del fabbisogno determinato a livello nazionale, dall'eventuale peculiarities, finanziamento di livelli assistenziali integrativi e aggiuntivi rispetto a including insularity; quelli essenziali, dal finanziamento dei maggiori oneri derivanti da note how it is fattori epidemiologici, dalla morfologia del territorio e dall'insularità, acknowledged the nonché dalle somme necessarie al finanziamento aggiuntivo per la copertura dello squilibrio di bilancio corrente. In presenza di costi need to prioritise sensibilmente superiori ai ricavi, la Giunta regionale dispone un piano certain areas → di riorganizzazione, riqualificazione e rafforzamento del servizio vertical equity sanitario regionale idoneo a garantire la sostenibilità del servizio stesso, della durata massima di un triennio. Nel computo dei ricavi, ai fini della predisposizione del piano di riorganizzazione, non si tiene conto delle somme necessarie al finanziamento aggiuntivo per la Compare with RS copertura dello squilibrio di bilancio corrente (1981; 1995); a new

list of contingent 2. Nella definizione dei criteri per il finanziamento delle ASL si tiene conto dei seguenti fattori: variables is added; a) popolazione residente, sulla base delle caratteristiche demografiche the goal is to achieve e territoriali rilevanti ai fini dei bisogni di assistenza; financial equity by b) fabbisogni e costi standard, come definiti a livello nazionale, con le emphasising that eventuali specificazioni idonee a tenere conto delle peculiarità Sardinia might need regionali; special resources c) variabili di contesto, con particolare riferimento alle caratteristiche infrastrutturali del territorio, alla variabilità demografica stagionale, ai fenomeni di spopolamento, all'articolazione delle prestazioni erogate tra quelle a produzione diretta aziendale e quelle acquistate da terzi soggetti erogatori, pubblici e privati; d) obiettivi assistenziali e funzioni assegnate alle ASL dalla programmazione regionale. Regione Centrale è l'idea dello sviluppo delle attività territoriali che può The focus shift from Sardegna avvenire soltanto in presenza di adeguate risorse: obiettivo strategico the centrality of (2007a) del Piano è permettere ai cittadini di trovare risposta ai propri bisogni hospitals to that of di salute non solo nell'ospedale, ma soprattutto nel territorio di the smaller, local appartenenza, luogo nel quale si realizza concretamente l'integrazione healthcare units fra il sistema dei servizi sociali e quello dei servizi sanitari.

Il Piano 2006-2008 si propone di contrastare alcune patologie che Vertical equity: colpiscono con particolare rilevanza la popolazione sarda e rispetto Sardinians are more alle quali il sistema dei servizi deve consolidare le proprie capacità di susceptible to certain intervento, in termini di prevenzione (primaria e/o secondaria), di diseases, and diagnosi e di cura. Sono prese in considerazione le patologie che per targeted frequenza e/o situazione attuale dei servizi appaiono cruciali per una interventions are più adeguata tutela della salute della popolazione sarda. Esse sono: il implemented diabete mellito, le malattie rare, la sclerosi multipla, le talassemie. First time the Il Piano promuove un'attenta valutazione del legame fra salute e correlation between

ambiente. È noto, infatti, che il benessere delle persone è direttamente health and collegato all'ambiente fisico nel quale gli individui vivono e lavorano. environment is Il contesto ambientale è quindi uno dei pre-requisiti fondamentali per mentioned in a il miglioramento dei livelli di salute della popolazione. A sua volta la major document; it salute è una risorsa significativa per lo sviluppo sociale ed economico is also associated della collettività. Salute, ambiente e sviluppo sono pertanto fortemente correlati e richiedono un'efficace azione strategica per la with socioeconomic crescita della Sardegna. Nello specifico, la regione Sardegna è factors to caratterizzata da una situazione sanitaria e ambientale piuttosto demonstrate how diversificata. Sotto il profilo sanitario, si registrano aree con tassi di Sardinia might need longevità del tutto eccezionali (verosimilmente sintomo di una buona targeted qualità della vita e di un ambiente sufficientemente protetto) e territori interventions in this con elevata incidenza di importanti patologie (rispetto alle quali regard devono essere attentamente valutati gli specifici fattori di rischio); sotto il profilo ambientale coesistono aree naturali per lo più incontaminate (nelle quali il suolo, l'aria, l'acqua e gli alimenti sono di fatto preservati dalla maggior parte degli inquinanti) e zone ad elevato rischio di contaminazione (per la presenza di inquinanti chimici, di sorgenti di campi elettromagnetici, di discariche abusive, di inquinanti atmosferici, di amianto, ecc.). This paragraph Obiettivo strategico del Piano sanitario 2006-2008 è la highlights the goals riorganizzazione della rete ospedaliera, allo scopo di adeguarla alla of the Regional reali esigenze dei cittadini, garantendo appropriatezza e qualità dei Healthcare; first of percorsi diagnostico-terapeutici, superando ingiustificate carenze ed all, the link between evitando inutili duplicazioni. La parziale trasformazione di alcuni socioeconomic piccoli ospedali in strutture a bassa intensità assistenziale potrà factors and health is consentire il miglioramento della qualità dell'assistenza nonché la salvaguardia dei livelli di occupazione; la riqualificazione degli reinstated; then, it is ospedali delle zone interne sarà delineata tenuto conto del ruolo che acknowledged that a tali strutture possono svolgere anche in termini di coesione sociale, di uniform response to mantenimento delle persone in difficoltà nel proprio ambiente di vita Sardinia’s problems e di contrasto delle tendenze allo spopolamento. Nel complesso, must be provided l'intera offerta ospedaliera dovrà essere programmata sviluppando un across the whole sistema a rete che risponda in modo coordinato alla domanda della territory; at the same popolazione sarda. Il modello a rete "hub and spoke", che prevede la time, the differences creazione di strutture assistenziali con differenti gradi di complessità, between Sardinia rappresenta un modello da sviluppare al fine di favorire una risposta and the rest of the appropriata ed efficiente su tutto il territorio regionale. In tale ottica, il ridisegno della rete ospedaliera comporta interventi per la regions are razionalizzazione e la riqualificazione dell'offerta di posti letto e lo emphasised; a mix sviluppo del sistema a rete. In particolare è necessario tenere conto of horizontal and delle peculiarità dell'offerta ospedaliera legate alle condizioni di vertical equity can insularità della Regione Sardegna, che rendono assai difficile la be thus be observed mobilità extraregionale, ovviamente molto più agevole nel resto del territorio nazionale. E' pertanto indispensabile programmare un'offerta sanitaria ospedaliera regionale di qualità, indirizzata alla richiesta sanitaria con i tassi epidemiologici più elevati. Note the reference to equity contained in La Sanità pubblica è l'insieme degli "sforzi organizzati della società per sviluppare politiche per la salute pubblica, la prevenzione delle the WHO malattie, la promozione della salute e per favorire l'equità sociale guidelines nell'ambito di uno sviluppo sostenibile" (OMS 1996). In Sardegna la situazione della prevenzione è gravemente carente. Decentralisation is seen as a way to

All'interno della Sardegna, il tasso di ospedalizzazione varia in modo tackle the historical significativo nelle diverse aziende sanitarie; la variabilità è in parte socio economic riconducibile ai tradizionali fattori legati alla demografia e alla rete inequities found in dei servizi. the island

Si tratta cioè di sviluppare una rete di servizi in grado di garantire risposte adeguate sotto il profilo clinico e organizzativo, che sia espressione di un'assistenza che supera la centralità dell'assistenza ospedaliera a favore di quella sul territorio, favorendo – quando Note, however, that possibile - il mantenimento del paziente al proprio domicilio. the need of uniform measures is In carenza di un piano sanitario regionale la rete dei presidi, pubblici e reinstated privati, che erogano assistenza ospedaliera si è altresì sviluppata in modo non organico ed equilibrato sul territorio. In particolare la distribuzione dei posti letto tra le varie specialità presenta lacune ed esuberi non solo a livello regionale, ma soprattutto nelle singole aree Once again, the territoriali. deficiencies of the La gradualità nell'adeguamento della rete ospedaliera risponde healthcare all'esigenza di prevedere cambiamenti sostenibili dal punto di vista infrastructure are sanitario, economico e strutturale. In particolare, tenuto conto della ascribed to necessità di pervenire ad una consistente riduzione dei posti letto Sardinia’s ordinari per acuti, il presente Piano ne propone un contenimento nei socioeconomic and limiti previsti dagli standard nazionali, aumentati del 5% come ipotizzabile nel caso in cui la deroga contenuta nell'Intesa Stato- geomorphological regioni del 23.3.2005 possa essere valida per la Sardegna (pur con features → vertical motivazioni differenti da quelle legate al territorio, cui può fare equity riferimento la Sardegna). Ciò in considerazione delle peculiarità dell'Isola, caratterizzata da una elevata dispersione della popolazione, una specifica conformazione geomorfologia del territorio, una rete viaria particolarmente difficile, oltre alla più nota insularità (circostanze in grado di giustificare una maggiore diffusione, sul Thus being said, territorio, dell'offerta ospedaliera di alcune specialità cliniche). horizontal equity La modalità di produzione ed erogazione dell'assistenza ospedaliera within the regional secondo il principio delle reti integrate prevede la concentrazione territory is della casistica più complessa in un numero limitato di centri (hub), prioritised, with che trattano volumi di attività tali da garantire la qualità dell'assistenza special attention ed il trattamento della restante casistica in centri periferici (spoke) la dedicated to rural cui attività è fortemente integrata con quella dei centri (hub). Il areas sistema, ove adeguatamente sviluppato, è in grado di garantire a tutta la popolazione equità di accesso a prestazioni di qualità uniforme su tutto il territorio regionale. La rete ospedaliera organizzata e sviluppata secondo il modello dell'hub and spoke garantisce minima congestione, forte specializzazione, massima efficienza tecnica attraverso la concentrazione della casistica e la tempestività di invio dalla periferia. Equity as equity of access; the Assicurare un giusto equilibrio tra domanda e offerta di servizi formulation is very sanitari rappresenta uno degli elementi portanti di una similar to RS programmazione finalizzata a far sì che le risorse disponibili siano (2005a) impiegate in relazione ai bisogni della popolazione secondo criteri di efficacia, efficienza, appropriatezza ed equità nell'accesso. Si tratta di mettere in essere interventi di programmazione e di regolazione capaci, da un lato, di orientare il sistema sanitario ad erogare

prestazioni che garantiscano i migliori risultati delle cure, la qualità e l'economicità dei servizi prestati, l'aderenza delle procedure cliniche alle più accreditate evidenze scientifiche, la gestione in sicurezza dei pazienti seguiti, dall'altro di evitare che si verifichino sia situazioni di sottoutilizzo dei servizi per difficoltà di accesso sia di sovrautilizzo per una domanda indotta dall'offerta. Regione L’Assessore dell’Igiene, Sanità e dell’Assistenza Sociale riferisce che Sardegna l’art. 26 della L.R. 10/2006, al comma 2 dispone che “la Giunta (2007b) regionale individua ogni anno, sentita la Commissione consiliare competente in materia di sanità, i criteri per il riparto annuale del Fondo sanitario regionale tra le Asl tenuto conto dei livelli essenziali di assistenza e sulla base di: a) popolazione residente, tenuto conto delle caratteristiche demografiche rilevanti ai fini dei bisogni di assistenza; b) variabili di contesto, con particolare riferimento alle caratteristiche infrastrutturali del territorio, alla variabilità demografica stagionale e ai fenomeni di spopolamento; c) fabbisogno di assistenza tenuto conto della domanda di prestazioni e della rete dei servizi e presidi; d) obiettivi assistenziali e funzioni di coordinamento assegnati alle Asl dalla programmazione regionale”.

2. La definizione dei criteri di riparto per singolo livello o sottolivello di assistenza deve essere coerente con il dettato del citato articolo 26 della l.r. 10/2006. Al riguardo vengono presi in considerazione i criteri di seguito specificati: a) “popolazione residente, tenuto conto delle caratteristiche demografiche rilevanti ai fini dei bisogni di assistenza” (comma 2, art. 26, L.R. 10/2006): il criterio, regolarmente utilizzato a livello nazionale e regionale, fa riferimento alla popolazione residente, Vertical equity for opportunamente pesata per tener conto del diverso bisogno di specific groups assistenza in base ai consumi di prestazioni sanitarie per età e based on the genere. Si prevede di utilizzare il sistema di pesi adottato a livello National Health Plan nazionale (per il riparto fra regioni e province autonome, di cui all’allegato 1) con riferimento all’assistenza farmaceutica, alla specialistica ambulatoriale e all’assistenza ospedaliera. Le fasce di età sono inoltre utilizzate per l’allocazione delle risorse destinate alla medicina generale (popolazione con più di 14 anni), alla pediatria di libera scelta (popolazione 0-14) e all’assistenza agli anziani (popolazione con più di 65 anni); Specification of the b) “variabili di contesto, con particolare riferimento alle caratteristiche criteria found in RS infrastrutturali del territorio, alla variabilità demografica stagionale e (2006b); ai fenomeni di spopolamento” (comma 2, art. 26, l.r. 10/2006): per le interestingly, variabili di contesto si prevede di utilizzare la dispersione della tourism makes it popolazione sul territorio, le presenza turistiche rilevate dalle necessary to adopt Amministrazioni Provinciali, nonché i costi della rete dei servizi targeted ospedalieri (di cui al punto precedente) per tener conto dei maggiori oneri connessi alla gestione di servizi ampiamente distribuiti sul interventions to territorio; guaranteed equity of access

Regione Art. 1 Sardegna 1. La Regione, con la presente legge, avvia il processo di riforma del Horizontal equity (2014) sistema sanitario regionale mediante disposizioni urgenti finalizzate a: obtained through a) garantire la tutela della salute come diritto fondamentale centralisation, as dell'individuo e interesse della collettività; opposed to the b) riorganizzare il sistema sanitario regionale mediante il previous attempts to

rafforzamento delle attività territoriali e la razionalizzazione della rete delegate more ospedaliera; powers to the c) adeguare l'assetto istituzionale e organizzativo, prevedendo una smaller healthcare riduzione del numero delle aziende sanitarie locali, rispetto all'attuale, units in coerenza con le norme di riordino del sistema degli enti locali; d) garantire il miglioramento della qualità e dell'adeguatezza dei servizi sanitari e socio-sanitari in ogni territorio, attraverso il rafforzamento di quelli esistenti, l'efficientamento delle strutture organizzative, garantendo forme di partecipazione democratica e mantenendo l'autonomia dei territori periferici nelle politiche socio- sanitarie;

Art. 2 1. Al fine di favorire la razionalizzazione della spesa e potenziare i Centralisation processi di pianificazione e aggregazione della domanda pubblica di framed as a tool to beni e servizi sanitari, la Giunta regionale, con specifico promote social provvedimento, sentito il parere della Commissione consiliare competente in materia di sanità, individua le modalità di justice but also accentramento della committenza delle aziende sanitarie, mediante competitiveness; no linee di indirizzo per la razionalizzazione della spesa sanitaria explicit reference is regionale da conseguire attraverso il governo e la standardizzazione made to equity della relativa domanda, secondo le previsioni di cui all'articolo 1, comma 455, della legge 27 dicembre 2006, n. 296 (legge finanziaria 2007), e successive modifiche ed integrazioni, e all'articolo 9 del decreto legge 24 aprile 2014, n. 66, convertito con legge 23 giugno 2014, n. 89 (Conversione in legge con modificazioni, del decreto legge 24 aprile 2014, n. 66, recante misure urgenti per la competitività e la giustizia sociale. Deleghe al Governo per il completamento della revisione della struttura di bilancio dello Stato, per il riordino della disciplina per la gestione del bilancio ed il potenziamento della funzione del bilancio di cassa, nonché per l'adozione di un testo unico in materia di contabilità di Stato e di tesoreria).

Art. 7 Measures regarding 1. La Regione, con l'obiettivo di qualificare l'assistenza territoriale al the integration of servizio della persona, di integrare i processi di cura e di garantire la healthcare with continuità assistenziale, individua nella Casa della salute la struttura social care remain che raccoglie in un unico spazio l'offerta extraospedaliera del servizio comparatively sanitario, integrata con il servizio sociale, in grado di rispondere alla domanda di assistenza di persone e famiglie con bisogni complessi. similar to those 2. Le Case della salute operano per conseguire i seguenti obiettivi: found in the a) appropriatezza delle prestazioni attraverso percorsi diagnostico- previous documents terapeutici e assistenziali, presa in carico globale e orientamento di pazienti e famiglie; b) riconoscibilità e accessibilità dei servizi; c) unitarietà e integrazione dei servizi sanitari e sociali; d) semplificazione nell'accesso ai servizi integrati. Regione Art. 2 Sardegna 1. L'ATS, sulla base degli atti di indirizzo deliberati dalla Giunta (2016) regionale e delle direttive dell'Assessorato competente in materia di The formulation of sanità, svolge le funzioni di: the new, centralised a) programmazione aziendale e gestione complessiva dell'erogazione healthcare system is dei servizi sanitari e socio-sanitari; b) omogeneizzazione e armonizzazione dei processi gestionali nel very similar to that territorio regionale in coordinamento con l'attività delle altre aziende found in RS (1981), including the

sanitarie; reference to c) accentramento, per quanto di competenza di tutte le aziende homogeneity and sanitarie della Sardegna, dei processi di aggregazione della domanda harmonisation; no di beni e servizi e di approvvigionamento degli stessi; special references to equity are made in this document ATS La demografia è una disciplina indispensabile per individuare come le Notwithstanding the Sardegna variazioni della popolazione possano essere influenzate dal contesto new centralisation (2018) socio economico e dalle sue modalità di organizzazione e efforts, the most funzionamento in un processo di interazione continuo. Diventa recent Regional determinante l’esigenza di pensare alla demografia come strumento di Health Plan expand programmazione per prevedere i bisogni, per monitorare il divenire e quindi determinare l’azione di governo allo scopo di dare risposte on Regione immediate: dai servizi, alla casa, alla sanità. In particolare, gli studi di Sardegna (2007a) “demografia” investono vari aspetti, del tutto o in parte correlati fra and identifies the loro: la bassissima fecondità, l’invecchiamento demografico, new social l’intensificazione delle correnti migratorie ed il conseguente aumento challenges as the delle collettività straniere nelle città. Quindi hanno per oggetto main factors mutamenti dei livelli di natalità e di mortalità, l’aumento delle influencing migrazioni, cambiano la prospettiva dalla quale si devono affrontare i healthcare priorities problemi e l’organizzazione all’interno dei territori e del sistema sociale. Le previsioni demografiche rappresentano un importante strumento analitico e programmatico, in particolare in periodi come questo in cui si rivela crescente l’attenzione verso sistemi territoriali che non Sardinia’s local rientrano nelle aggregazioni amministrative canoniche, comunque peculiarities are ricchi di peculiarità e sufficientemente omogenei sotto il profilo emphasised, along economico, sociale e geografico. Proprio per questo motivo essi with the need risultano destinatari di misure politiche mirate e specifiche, per le quali è utile disporre di possibili scenari futuri.

Non si può inoltre non considerare che la Sardegna vive il triste “New poverty”; the primato nazionale nell’ambito delle nuove povertà, con una netta rapidly-changing crescita della fascia di persone che vivono in condizioni di marginalità sociale, generalmente escluse dai processi di solidarietà della società socioeconomic civile, in parte perché la loro stessa esistenza è per lo più ignorata, in context are said to parte perché le caratteristiche della povertà estrema connotano le influence the persone in termini di diversità, rendendo così più difficile la loro development of accettazione e integrazione sociale. Poiché le condizioni sociali healthcare goals hanno un peso determinante sulla salute dei cittadini, il risultato atteso è comunque quello della creazione di una fetta di popolazione in condizioni di salute precaria, particolarmente fragile, afflitta in modo particolare da disturbi mentali e dipendenze patologiche che accentuano il divario sociale e la mancanza di prospettive di The link between cambiamento della propria situazione, di potere sui diritti di cittadinanza, di autonomia individuale, di identità personale. Peraltro poverty and è ormai assodato che l’appartenenza a determinati classi sociali mortality is svantaggiate porta, non solo ad un aumento della morbilità e mortalità emphasised, as well con conseguente maggior ricorso ai servizi sanitari, ma che, a parità di as the disparities condizioni socioeconomiche, vi siano ripercussioni differenti legate al between rural and contesto nel quale la persona è inserita; esistono differenze importanti urban areas infatti tra chi risiede in ambito cittadino rispetto ai piccoli Comuni, e tra essi si rilevano notevoli differenze di salute delle popolazioni residenti nei Comuni situati sulle coste rispetto a quelli posti all’interno dell’isola, ovvero se abbiano caratteristiche rurali oppure di

montagna. “Socio-sanitary E’ evidente che la problematica sopra rappresentata sia da ritenersi a crisis”; note how the tutti gli effetti una vera e propria emergenza sociosanitaria, per la terms are used quale gli interventi di Prevenzione, sia primaria sia secondaria, together rappresentano uno strumento fondamentale nel contenimento del suo sviluppo.

La distribuzione territoriale dei posti letto mostra una forte Strong inequities polarizzazione con una concentrazione maggiore (ASSL di Sassari e between local and ASSL di Cagliari) in corrispondenza delle aree più popolate dove urban areas operano anche le due Aziende Ospedaliero-Universitarie (AOU di Cagliari e AOU di Sassari) e l’Azienda Ospedaliera Brotzu (AOB, Cagliari). Una dotazione inferiore di posti letto si registra nei territori delle ASSL Medio-Campidano e Olbia-Tempio. The proposed Senza alcun dubbio, la necessità di una maggiore integrazione sociosanitaria è alla base di tutti i processi di riequilibrio dei sistemi solution seems to be sanitari che sono in atto nelle varie realtà del nostro Paese. Questo similar to that put perché si fa sempre più strada, tra i decisori e tra gli operatori sanitari, forward in RS la convinzione che i diversi servizi rivolti ai cittadini in ambito sociale (2005a), that is, e sanitario debbano essere sempre più interconnessi, con l‘obiettivo di more integration costruire una rete di assistenza e di cura che risponda ai bisogni del between healthcare cittadino, riducendo al minimo gli sprechi. Si tratta, come è ovvio, di and social care; at un processo che richiede tempi e modalità graduali, ma che è senza the same time, the dubbio rivolto a cambiare la funzione stessa della struttura role of local ospedaliera, così come è stata per lungo tempo intesa. L‘ospedale, healthcare units in non costituisce più la sola risposta alla domanda di salute dei cittadini, una risposta, spesso inappropriata e inutilmente dispendiosa, ma advancing targeted diventa il luogo dove concentrare i grandi interventi, gli eventi acuti, interventions is spostando sul territorio la prevenzione, la cura delle patologie reinstated and croniche, l‘assistenza a disabili e non autosufficienti. amplified → vertical equity

9.2 Scotland

9.2.1 Before Decentralisation (1978-1999)

Document Text Interpretation

The Art. 1 Compare with RS National (1) It shall continue to be the duty of the Secretary of State to promote (1981). Here, in Scotland a comprehensive and integrated health service designed to “improvement…” Archives secure— (a) improvement in the physical and mental health of the (1978) precedes prevention, people of Scotland, and, (b) the prevention, diagnosis and treatment of diagnosis etc. illness, and for that purpose to provide or secure the effective provision of services in accordance with the provisions of this Act.

Art. 1A [2005] This Act has been 1) It is the duty of the Scottish Ministers to promote the improvement amended several of the physical and mental health of the people of Scotland. times; this addition (2) The Scottish Ministers may do anything which they consider grants a new is likely to assist in discharging that duty including, in particular— financial tool to (a) giving financial assistance to any person, (b) entering into promote health; note arrangements or agreements with any person, (c) co-operating with, or that the focus in on facilitating or co-ordinating the activities of, any person. individuals, not

Art. 2 groups (1) The Secretary of State [ F2 (a)] shall by order constitute in accordance with Part I of Schedule 1 boards for such areas as he may by order determine, for the purpose of exercising [ F3 such of his functions [ F4 relating to the The borders of the health service] as he may so determine], and for the purpose of Health Boards are making arrangements on his behalf for the provision of the services not fixed and may mentioned in Part II; and those boards shall [ F5 , without prejudice to change on the basis subsection (1B),] be called Health Boards [ F6 and] F6 of specific local (b) subject to subsections (1A) and (1C), may by order constitute needs. Compared to boards, either for the whole of Scotland or for such parts of Scotland as he may so determine, for the purpose of exercising such of his RS (1981, art. 21), functions [ F4 relating to the health service] as he may so determine; no specific criteria and those boards shall, without prejudice to subsection (1B), be called are mentioned. Special Health Boards. (3) The Secretary of State may by order vary the area of any Health Board, whether or not the variation involves the constitution of a new Board, or the termination of the functions of an existing Board; and, before making such an order, the Secretary of State shall consult with such bodies and organisations as appear to him to be concerned. The same duties under article 2 are Art. 2a [ 2005] (1) It is the duty of every Health Board and Special Health Board and also repeated of [ F15 HIS and] the Agency to promote the improvement of the verbatim vis-à-vis physical and mental health of the people of Scotland. (2) A Health the single Health Board, a Special Health Board [ F16 the Agency or HIS] may do Boards. The goals of anything which they consider is likely to assist in discharging that this addition, which duty including, in particular— can be interpreted as (a) giving financial assistance to any person, vertical equity, are (b) entering into arrangements or agreements with any person, further explained in

(c) co-operating with, or facilitating or co-ordinating the activities of, SG (2007). any person. Whereas in RS Art. 2B (1981) the focus of (1) It is the duty of every body to which this section applies to take consultation (i.e. action with a view to securing, as respects health services for which it is responsible, that persons to whom those services are being or may accountability) was be provided are involved in, and consulted on— (a) the planning and on the development, and (b) decisions to be made by the body significantly municipalities, here affecting the operation, of those services. individuals come first Art. 2CB [2010-2013] This later (1) Where it is the function of a Health Board to provide or to secure amendment the provision of a service, the Health Board may secure the provision broadened the of that service outside Scotland. Health Boards’ (2) For the purposes of securing the provision of any service referred territorial scope; to in subsection (1), a Health Board may make such arrangements for the provision of the service as they think fit (and may in particular compare with RS make contractual arrangements with any person). (1991) No specific mention Art. 2D [2004] of equal (1) Health Boards, Special Health Boards [ F28 , the Agency and opportunities are (as respects its health service functions only) HIS] must found in the RS discharge their functions in a manner that encourages equal documents. opportunities and in particular the observance of the equal According to the Act opportunity requirements. mentioned here, they (2) In this section “ equal opportunities ” and “ equal opportunity are defined as “ the requirements ” have the same meaning as in Section L2 (equal opportunities) of Part II of Schedule 5 to the Scotland Act 1998 (c. prevention, 46). ] elimination or regulation of discrimination between persons on grounds of sex or marital status, on racial grounds, or on grounds of disability, age, sexual orientation, language or social origin, or of other personal attributes, including beliefs or opinions, such as religious beliefs or political opinions” The Art. 12H [1999] These later National (1) It shall be the duty of each Health Board, Special Health Board amendments were and NHS trust and of the Agency to put and keep in place evidently introduced Archives arrangements for the purpose of monitoring and improving the quality (1983) to a) improve the of health care which it provides to individuals. overall quality of the

Art. 12J [2004] service, and, most (1) In exercising their functions in relation to the planning and crucially, b) to

provision of services which it is their function to provide, or secure promote the the provision of, under or by virtue of this Act, Health Boards shall integration of social co-operate with one another, and with Special Health Boards and the care with health Agency, with a view to securing and advancing the health of the care. It can be people of Scotland. surmised that the (2) In pursuance of subsection (1) a Health Board may— (a) undertake to provide, or secure the provision of, services as later Scottish respects the area of another Health Board, and the other Health Board legislators were not may enter into arrangements with the first Health Board for that satisfied with the purpose, original formulation, (b) undertake with one or more other Health Boards to provide, or which did not secure the provision of, services jointly as respects their areas. mention the (3) A Health Board undertaking to provide, or secure the provision of, additional services under subsection (2) may— opportunities for (a) enter into arrangements with another Health Board, a Special health boards to Health Board or the Agency in relation to the provision of such promote territorial services, (b) do anything in relation to the provision of such services which equity through they could do for the purpose of providing, or securing the provision collaborations and of, such services as respects their area. other. (4) This section is without prejudice to any other power which a Health Board may have.

Art. 13 In exercising their respective functions, Health Boards, [ F113 HIS Interestingly, a (as respects its health service functions only),][ F114 NHS trusts,] similar formulation local authorities [ F115 , integration joint boards] and education can be already found authorities shall co-operate with one another in order to secure and advance the health of the people of Scotland. in RS (1981).

Art. 13A A key difference in (1) The duty under section 13, in relation to persons to whom coordination this section applies, includes— measures between (a) joint planning of— Scotland and (i) services for those persons; and Sardinia is that in (ii) the development of those services, [ F117 by Health Boards and the former social such of the authorities as mentioned in that section [ F118 care was not (yet) (including HIS)] as may be concerned] included within (b) such consultation with voluntary organisations providing services similar to those mentioned in paragraph these provisions; but ( a ) as might be expected to contribute substantially to the joint see how related planning of the services mentioned in that paragraph; concerns about [ F119 (c) the publication, at such times and in such manner as the equity were already bodies who have made joint plans under paragraph ( present in NA a ) consider appropriate, of those joint plans. ] (1997a) (2) This section applies to— (a) disabled persons within the meaning of the Disabled Persons Once again, the (Services, Consultation and Representation) Act 1986; formulation is (b) persons aged 65 or more; and ambiguous and (c) such other categories of persons as the Secretary of State may by order specify.] suggests some leeway Art. 16A Power to make payments towards expenditure on community services. (1) A Health Board may, if they think fit, make payments in Note how the

accordance with this section to any [ F141 local authority] towards integration of social expenditure incurred or to be incurred by them in connection with the care and healthcare performance of the following functions— is only implied and (a) any function [ F142 under any of the enactments mentioned in not made explicit as section 5(1B) of the Social Work (Scotland )Act 1968 (power of in later formulations, Secretary of State to issue directions to local authorities in respect of their functions under certain enactments), other than section 3 of the as well as in RS Disabled Persons (Employment)Act 1958]; (1981, Art. 30)

See NA (1990); Art. 87A-C [repealed in 1999] these articles established the NHSS Trusts The Art. 12E The measures National (1) Each NHS trust shall have an originating capital debt of an amount concerning the specified in an order made by the Secretary of State with the consent establishment of Archives of the Treasury, being an amount representing, subject to subsection (1990) NHSS Trusts are (2), the excess of the valuation of the assets which, on or in identical for England connection with the establishment of the trust, are or are to be transferred to it (whether before, on or after its operational date) over and Wales (see the the amounts of the liabilities which are or are to be so transferred. previous articles in the same Act); these Art. 12F decentralisation (1) Every NHS trust shall ensure that its revenue is not less than measures did not sufficient, taking one financial year with another, to meet promote financial outgoings properly chargeable to revenue account. equity in that little (2) It shall be the duty of every NHS trust to achieve such financial autonomy was given objectives as may from time to time be set by the Secretary of State to Scottish Trusts in with the consent of the Treasury and as are applicable to it; and any respect of other such objectives may be made applicable to NHS trusts generally, or to a particular NHS trust or to NHS trusts of a particular description. regions.

Art. 87B (1) In respect of each financial year, every Health Board shall be The effects of fund- liable to pay to the members of each recognised fund-holding practice holding practice on in relation to which it is the relevant Health Board a sum determined equity will be briefly in such manner and by reference to such factors as the Secretary of mentioned in NA State may direct (in this section referred to as an “allotted sum”). (1997b). It can be argued in general Art. 87D that these measures, (1) Subject to subsection (2), for each financial year every Health Board shall, by notice in writing given to each practice in relation to as well as those the members of which it is the relevant Health Board, specify an included in art. 87D, amount of money (in this Act referred to as an “indicative amount”) severely limited the representing the basic price of the drugs, medicines and listed ability of single appliances which, in the opinion of the Board, it is reasonable to Health Boards to expect will be supplied in that year pursuant to orders given by or on address behalf of the members of that practice. vertical/horizontal (4) The members of a practice shall seek to secure that, except with inequities. Compare the consent of the relevant Health Board or for good cause, the orders with the subtle for drugs, medicines and listed appliances given by them or on their criticisms thereof in behalf are such that the basic price of the items supplied pursuant to those orders in any financial year does not exceed the indicative NA (1997a; 2007), amount notified to the practice for that year under subsection (1). etc.

The .1 The Government welcomes the Committee's recognition that the Here the National NHS reforms are now securely in place and that the real question to establishment of be addressed is how well they are working. Since the former NHS Trusts is Archives Committee began its inquiry evidence has been mounting of the (1992) associated with beneficial effects of the new health service: horizontal equity. — an average 600,000 more patients treated per year; — the successful elimination in all Regions of people waiting over The focus largely two years for hospital treatment and a reduction of over half in the remains on the number of one to two year waiters; greater patient choice; financial side, — delegation of responsibility to where the services are provided; however (“greater — better value for money. patient choice”).

1.7 We agree that the remit which the Committee has identified for Note how equity of itself is appropriate to the new-style NHS. The Government remains access is here firmly committed to the principle of a comprehensive health service connected with the available to all, largely free at the point of delivery and financed “resources mainly from general taxation. The aim is to deliver the best possible health services for the resources available both to improve the health available”. Such of individuals and as a basis for improving the wider health of the formulation almost natiom The Government believes the success of the NHS Reforms disappears in later will become more and more evident as time goes on and looks documents, nor is to forward to co-operating with the Committee in assessing be found in the RS improvements in the coming years. documents. The 2. The Government will ensure that the NHS remains true to its National historic ideals, free at the point of use, funded through general taxation and available to all on the basis of need. This Government Archives were elected with a clear mandate for change - a mandate to change (1997a) the NHS for the better. We will deliver the commitments which won Vertical equity, as us the support of the Scottish people, and do so in ways which recognise the distinctive needs of Scotland. These have been long in special measures reflected in the structure and organisation of our health services, and for the local we shall build on them. To d o so is entirely in keeping with the communities traditions of the past, but also acknowledges that the creation of a Scottish Parliament is intended to ensure that in the future Scottish solutions are found to suit Scottish circumstances. Here interregional 5. Our vision is to build on the strengths we have in the NHS in inequities are Scotland and to tackle some of the existing shortcomings which are of mostly framed in concern to patients and NHS staff alike. We want an NHS concentrated on improving health and reducing health inequalities. terms of specific Scotland is at, or close to the bottom of, the international health diseases that affect league table in the key areas of coronary heart disease and cancer, and Scotland more than people in other European nations enjoy a significantly longer life other regions; see expectancy than the people of Scotland. While the NHS must continue NS (1990); to target these key areas, real improvements in public health will only moreover, be effected by tackling the variations in health status between social groups and between different parts of Scotland. We will publish a differences between Green Paper aimed at establishing a collaborative approach between social groups are the NHS and the agencies whose decisions on housing, recognised → unemployment and poverty directly affect Scotland's health. targeted interventions 8. To deliver this vision, the Government have concluded that a partnership approach based on co-operation, not competition, is the Compare with NA way ahead for Scotland's Health Service. A market-style NHS has (1990; 1992) failed patients; it set doctor against doctor, and developed two-tierism

allied to bureaucracy, although to a lesser extent in Scotland than elsewhere. We will retain the benefits of devolved management and retain distinctive roles for Health Boards and Trusts in a patient- focused service built on partnership. Our approach will bring people together to meet the needs of patients by developing 4 main partnerships: a partnership between the Government and the people of Scotland, reflected in the Government's pledge to continue with annual real increases in NHS funding; a partnership between patients and the professionals who care for them, by giving both a bigger say in the design and management of the NHS in Scotland; a partnership between different parts of the NHS in Scotland to Integration of promote the integration of care and provide patients with a seamless social care and service; healthcare a partnership between the NHS in Scotland and other organisations whose work can help improve health and the quality of services to patients. 9. There have always been differences in the way the NHS is organised in the different parts of the UK to take account of different Vertical equity: the needs. But sometimes, changes have been made in Scotland to reflect difference between changes in England rather than in response to specifically Scottish English and Scottish needs. The NHS will continue to provide a common service needs is reaffirmed. throughout the United Kingdom, but the advent of the Scottish Note how analogous Parliament will mean a Scottish NHS more finely tuned and more formulations are not rapidly responsive to Scottish needs. found in the RS documents. 10. The NHS in Scotland will be one of the main responsibilities of the Scottish Parliament. It will be for the Scottish Parliament to decide the details of its relationship with health bodies, including funding Targeted arrangements. Devolution provides an opportunity to build on the interventions. Note strengths of the NHS in Scotland, as well as on the Scottish tradition how the concept of of community responsibility for those needing care. For example, insularity acquires a services can be organised to take account of the range of differing different yet needs, from those of major cities to those of remote and island homologous communities. The new system outlined in this White Paper lays the meaning than NS foundations for the work of the Scottish Parliament in improving the (2006b, art. 26). health of the Scottish people now and for future generations.

36. Services need to be responsive not just to the needs of individual This principle might patients but also to the preferences of the public at large. To redesign imply horizontal services from the perspective of patients - and to reflect this in all equity, but the aspects of health service planning - requires finding out what patients formulation is and communities want; and consulting them over proposals for ambiguous change.

49. A start has already been made. The Priorities and Planning Horizontal equity, Guidance issued in August 1997 set out the framework for planning according to which the Government wish the National Health Service in Scotland principles that are to adopt. A number of further changes are in train on the management of human resources and financial services, designed to achieve greater still established at consistency in service organisation across the country. These the national level (as proposals, which have come forward from the NHS, are intended to opposed to SG, achieve greater efficiency in the organisation of these important 2007, and so forth) support services, as well as to eliminate waste and duplication. Later

in the White Paper we set out further proposals intended to ensure that wherever people work within the NHS in Scotland they are treated fairly and equitably in accordance with principles established at national level.

57. The Shields Report, published in March 1996, set out the main roles and responsibilities of Health Boards in the context of the internal market. With the abolition of the internal market, some of the detail of the Shields Report requires reconsideration. But the Government retain the view that the principal role of Health Boards remains the protection and improvement of the health of their resident populations. In more detail, Boards should focus on: health protection health improvement and health promotion needs assessment service development resource allocation resource utilisation performance management of Trusts' implementation of Health Improvement Programmes and to do so with the underlying aim of promoting equity.

102. The Government have already announced a review of the Equity here arrangements for distributing resources to Health Boards for hospital presumably refers to and community health services (HCHS) and Family Health Services equity of access, but (FHS) to ensure the distribution reflects local population needs and also financial operates as fairly as possible. The review is wide ranging and covers equity; the not only the distribution of Health Board general allocations (which currently enable Boards to secure health services for their resident underlying principle population) but also how funds for FHS, including the drugs bill, are is horizontal equity distributed. The review will, therefore, examine the methods for allocating the resources available to the NHS in Scotland including both primary and secondary care. We will move towards a distribution of funds in the future which is more objective and needs based with the aim of promoting equitable access to health care. This will ensure equal access to resources for people with equal needs. It will also seek to incorporate a range of allocations for special purposes which are currently issued separately.

104. At the moment Health Boards are given annual allocations to Interregional meet the cost of HCHS based on the weighted capitation formula, equity. The new commonly known as the SHARE (Scottish Health Authorities allocation of Revenue Equalisation) formula, which was introduced in the 1970s. resources implies Most parts of Scotland now get their fair share of resources based on vertical equity, a the existing formula. The Review of the SHARE formula will principle that was inevitably lead to a need to redistribute funds and this will, as in the largely absent in the past, be done on the basis of an equitable redistribution over the previous documents coming years with the key aim of avoiding turbulence.

112. In future, a formula will be used to allocate this capital to Health Board areas on the basis of need. Health Boards will then allocate capital to Trusts before the start of the financial year. The role of Health Boards is strategic rather than becoming involved in the detail. Individual investments by Trusts of a significant size must be cleared by the Health Board to ensure consistency with the Health

Improvement Programme.

2. The necessary first steps in the preparation of Health Improvement Programmes are open discussions between Health Boards and Trusts Again, horizontal to share and agree all relevant information in the light of existing equity. The service strategies including financial baselines. Having agreed the baseline information, these discussions will identify the mutually formulation is still supportive objectives and action to be taken by each organisation over partially influenced the coming years to improve the health of the population. The extent by the financial to which the Programmes serve the greater good of the population and concerns found in secure health gain is a key criterion by which Boards and Trusts will NA (1990; 1992) be held accountable. The principal agenda for Trusts is the The framing of implementation of relevant Health Improvement Programmes. health inequalities Collaboration and co-operation will help to improve quality. remains ambiguous, 4. Each Health Improvement Programme should set out: if not more holistic proposals to protect the public health, including emergency planning; than that found in proposals to promote health; the previous proposals to analyse and tackle health inequalities; paragraphs service changes and developments, including those involving primary care; a rolling programme for the implementation of evidence-based clinical guidelines and clinically effective practice, to be monitored through clinical audit; resource assumptions including locally generated efficiencies; human resource strategies; how efficiency in the use of existing assets will be maximised; proposed capital investments; and changes in the National Health Service's estate; and Information Management and Technology strategies.

The In Scotland we have a Health Service of which we can be very proud. National Over many years we have developed a distinctively Scottish approach to meet the health care needs of the Scottish people. We have done so Archives by building on the founding principles of the NHS as they have (1997b) applied throughout the UK for almost 50 years. We have established a service which is: - universal in its reach, available to everyone wherever they live Equity of access is - high quality, applying the highest professional standards and prioritised employing techniques based on the latest knowledge - available on the basis of clinical need, regardless of the ability to pay, and - patient-centred through its increasing focus on the experiences and needs of individual patients. The Government's reforms set out in Working for Patients are complete. We now have a structure targeted on better patient care which will serve our nation well into the 21st century. The direct management of health care services has largely passed from the Health Boards to the 47 NHS Trusts, and the internal market for health services is now the means by which standards are improved and services made more responsive to patients' wishes. In March 1996, the Shields Report set out the Roles and Responsibilities of Health Boards and described the key role they now play as Note how the new

commissioners of health care, working in close co-operation with government did not general practitioners including GP fundholders, to give strategic completely dismiss direction to local health services. The creation of Trusts and GP the measures found fundholders has allowed major devolution of decision-making and has in NA (1990); they demonstrated the benefits which can flow when those in closest did not mention, contact with patients have a proper say in the way services are organised and delivered. These substantial changes have been put in however, place while the Scottish Health Service has continued to deliver an improvements to expanded range of higher quality service. financial equity as in NA (1992) 3 The Government believes that the Scottish Health Service should continue to share in a growing economy. Its commitment to real terms The formulation is increases in Health Service spending year by year is reflected in the still similar to NA Public Expenditure settlement for 1997-98. The Government looks to (1992); quality the Scottish Health Service to respond, as in the past, by striving for implies financial the highest standards of quality and by extracting maximum value gains from all of its resources.

4 Decisions on competing needs will remain difficult, but this has been the case since the NHS was founded. The Government does not Here the opposition accept that it should prescribe the range of treatments which the to NA (1990) Scottish Health Service should or should not provide. No list of becomes clearer; treatments could ever accommodate the range and complexity of cases differences in health which confront clinicians daily. There would be a real risk that outcomes between decisions would be taken out of the hands of clinicians and placed in Scotland and other the hands of others who lack the necessary experience or expertise. regions are implied, 5 The health of Scottish people is improving, and the Scottish Health as in NA (1997a) Service continues to deliver high quality services to increasing numbers of patients. 6 Over the 10 year period to 1995 the number of deaths from coronary heart disease, cerebrovascular disease (strokes), accidents, respiratory disease, and cancer have all declined. Annex 1 presents details of these trends, which reflect the dedication and skill of those working in the Scottish Health Service and associated agencies. More attention to the 13 When the need to seek help arises, people want easy access to local level; compare services. For most, the contact will be the family doctor and his or her this with RS (1995) clinical team, who will be able to meet the majority of their needs. For those who need specialist services, speedy access is equally important. Provision of optimal access requires a co-ordinated effort: - to ensure patients have access to care locally whenever possible; - to organise effective services which meet emergency needs, especially outside normal working hours; - to minimise the time taken to admit patients who require urgent hospital treatment; - to reduce the length of time which doctors and their patients wait to receive the results of diagnostic tests; and - to ensure that waiting times for out-patient and in-patient The integration of treatment continue to shorten. 15 The Government's goal is to produce an integrated, high-quality social care with service which is sensitive to the needs of patients. This does not mean healthcare delineates imposing uniform service patterns or management solutions across vertical equity. Scotland. Indeed, flexibility in the way services are provided is Note how essential because: the needs of individuals vary; the needs of geographical

communities vary. Some population groups suffer more illness than differences are others, and some face particular difficulty in gaining access to mentioned to justify services. Services in rural and remote areas may need to organise targeted differently from those provided in urban or suburban areas; and interventions services may be at different stages of development across Scotland, and priorities for change will vary accordingly.

57 The Chief Scientist Office of The Scottish Office Department of Health is responsible for funding research which is relevant to the health needs of the Scottish population. Reflecting this approach, four Research priorities specific research initiatives have been launched in recent months to shift towards a more stimulate additional work on: integrated plan - Mental Health - focusing particularly on community care; - Nutrition - developing themes in the Diet Action Plan by targeting approaches which will affect dietary habits, obesity and effective weight management; - Cardiovascular and Cerebrovascular Disease - focusing on research to underpin disease prevention and improve rehabilitation; - Primary Care - stimulating the further development of research by those working in Primary Care, and encouraging A call for financial innovative practice. equity. Note how 94 As responsibility for some aspects of care moves from the Health the transfer is Service to local authorities as a result of Care in the Community, somehow Government policy in Scotland recognises the need for resources to asystematic, transfer as well, and formal arrangements were introduced in 1992. A compared to the measure of the joint understanding among local partners which has fixed provisions in been achieved is the significant recurring resources that are now transferring each year from the Health Service mainly to local RS (1995, Art. 47) authorities. £80 million is expected to transfer in 1996/97. Health Board General Managers remain directly accountable for all sums transferred under these arrangements, and are required to ensure that the funds are used for the purpose agreed and at the level of spend negotiated. A more forceful formulation of the 95 The Government now judges that it would be desirable to move previous articles; further to break down the organisational boundaries between health integration is one of and social care, as these can be confusing to patients and can hinder the top priorities the co-ordinated provision of care. Either the GP or the Social Work Department can be the key to the services needed, and in consequence there can be confusion and uncertainty about who to turn to in particular cases. This is especially so in more complex cases where the need for assistance is greatest. This confusion is not confined to the public. It occurs amongst those responsible for providing the services. It follows that one of the main ways of making the system more responsive to public needs is to help to remove some of the confusion about existing organisational arrangements.

The Poverty, unemployment, poor housing can blight lives and destroy The first priority National health. Brave attempts to tackle ill-health have often foundered on the becomes tackling rocks of real lives, poor prospects and counter-pressures. This Paper is socioeconomic Archives about planning for health, through personal and community efforts. (1998) inequities Our challenge to institutions comes through health impact assessment, health improvement programmes, healthy eating, help in the planning

of community development to secure health gains. The challenge to people is to look after the health interests of themselves, friends and family. Here, environmental Good health is more than the absence of disease. It has to do with the factors are way we live, the quality of our life and our environment. That is what public health - and this Green Paper - is all about. Overall the health mentioned earlier of Scotland is improving. The drive to act for our own health has had than in RS (2007a) some impact. Many fewer adults smoke, and we are now less likely to die from heart disease or cancer in middle age. But the improvement has neither matched progress by similar countries nor reached all Scots equally. Smoking, poor diet, too little exercise and misuse of alcohol and drugs stand in the way of better health: their roots lie A difference partly in poverty, unemployment, poor housing and poor between this environment. Ill-health is not a problem for patients or health services formulation and RS alone, but impacts on family and community life, and on local (1988, art. 25) is the services. Care for our own health throughout life is a strong theme in this Green Paper. But broader changes in how people live - which inclusion of they are not in a position to control - are as important. True public education, and health policies are embedded in action to improve our quality of life general welfare and protect our environment, to tackle social exclusion, in improving policies to tackle housing and educational achievement, in addressing poverty and health inequities; unemployment and in the re-structuring of the National Health this will become a Service as a public health organisation with health improvement as its leitmotif of later main aim. It is the business of Government - all of Government - and documents all those who are in a position to influence and contribute to our quality of life. Note the connection

Making an impact on public health means acting on the life between social care, circumstances that underlie poor health, including a worthwhile job, a health priorities, and decent home, a good education and a clean environment. It also inequities. The includes personal investment in healthy lifestyles, backed by sound formulation is much policies and, more rarely, regulation. And we must target the places more explicit than where people are, including schools, workplace and community that found in the RS settings, and the Health Service. Success will require strong documents partnerships between health professionals and other local bodies within a national framework. (paragraph 95) So our proposed priorities are improving life circumstances, such as tackling deprivation and encouraging individuals to adopt healthier lifestyles by not smoking, by eating for health, taking greater physical exercise, and avoiding alcohol and drug misuse. (paragraph 81) We propose, for Scotlands main illness priorities, coronary heart disease and stroke, cancer, mental health, sexual health (including teenage pregnancies and HIV/AIDS), dental and oral health, and accidents. (paragraph 46) For each of these priorities, tackling inequalities will be our first challenge. The notion of 2. The 20th century has seen dramatic improvements in Scotlands healthy lifestyle is health as once common diseases like polio were conquered. As the not to be found in century ends, there are positive trends. Men and women live longer than at any time in the past; premature deaths from the two main killer RS documents until diseases -coronary heart disease and cancer - are decreasing; and the RS (2006b). oral health of adults is improving. But deep-seated problems remain. Moreover, here the Lifestyles that lead to poor health are common. Smoking, especially connection between among young people, is unacceptably high. Many of us do not eat a health inequities

balanced diet. Too few of us take adequate exercise. The dental health and socioeconomic of children is poor. Alcohol misuse remains a serious problem. Drug factors is more misuse continues to grow. What is more, the progress that has been precise. Note also made is relatively modest in relation to advances in other developed the mention of Western nations and our position in the international health league is gender and the unenviable. Overall progress, nationally, also masks increasing health inequalities between social classes and wealthy and poor areas. Health concept of inequalities also reflect gender and ethnicity. Environmental and deprivation social conditions in many areas of Scotland still fall below standards acceptable in a modern society and, where deprivation exists, health is much poorer. Again, along with 3. A fresh approach is necessary - a public health strategy which socioeconomic addresses the root causes of our health problems. Improving lifestyles factors, must continue to be rigorously tackled, but within a framework which environmental recognises, and focuses on, the underlying social, economic and inequities are seen environmental circumstances which influence health. A worthwhile to play an important job, a decent home, a clean environment, are all key health determinants. A good education increases self esteem and enhances role employment prospects. The Governments policies are geared to creating a climate in which these basic social rights are brought within the reach of all. The need is to ensure that each strand of policy, and every new initiative, is taken forward within a coherent framework, so that health gain is maximised. Above all, we need to attack the inequalities which scar our health record. 4. True public health policies are imbedded in action to improve our Decentralisation as quality of life and protect our environment, in improving housing and a way to promote educational achievement, as well as in addressing poverty and uniform answers unemployment and in the restructuring of the National Health Service as a public health organisation with health improvement as its main (i.e.. Horizontal aim. Collaboration, involving all partners with an interest in health, is equity) the key. A Scottish Parliament, with its wide-ranging powers, will facilitate the cohesive approach to health improvement we have hitherto lacked. This Green Paper offers suggestions on how coordination can be improved. It is not concerned with the structures of the National Health Service as such, though clearly the location and delivery of health services are vital to good health and health professionals have a crucial contribution to make to health improvement, as discussed in the Governments White Paper Designed Vertical equity to Care: Renewing the NHS in Scotland, published in December 1997.

6. Tackling Scotlands health problems is not just about confronting major diseases and illness. It is also about recognising and attacking the health inequalities which have increasingly seen the more affluent enjoy much better health than people who are less well off. Coronary Heart Disease, Cancer and Stroke 7. The two most common causes of death in Scotland are coronary heart disease (CHD) and cancer, each of which accounted for approximately a quarter of all deaths in 1996. In the same year, among people aged under 65, cancer was responsible for almost one third of deaths, and CHD for just under a fifth. Stroke is the third largest killer, and the three diseases are increasingly referred to as Scotlands Big 3 in attempting to place them firmly on the public agenda. It is no surprise that cardiovascular disease (including CHD and stroke) and cancer have been identified Note the as major priorities for the NHS in Scotland. comparisons made

with other countries. 12. Mental health, alongside cardiovascular disease (coronary heart Despite the lack of disease and stroke) and cancer, is a top priority for the NHS in evidence, tackling Scotland. Although there is no evidence to suggest that mental illness interregional occurs more frequently in Scotland than in other industrialised inequities remains a countries, it is one of the most common forms of ill-health. In any year, about one-quarter of the population will experience some mental priority distress. Most of these will see their general practitioner at some point, but only a half will receive treatment explicitly for mental health problems. Ninety per cent of those treated suffer from depression or anxiety. Only 1 in 10 people with a mental health The mention of this problem will be referred to the specialist mental illness services. pivotal document Therefore, the general practitioner and his primary care team are the indicates that main providers of care. At least 1 in 10 of the 16 million consultations tackling with GPs each year involves a mental health problem. socioeconomic inequities has 33. In 1980, the Black Report drew attention to the contribution of socio-economic inequalities (as indicated by social class) to become one the most inequalities in health experience within the UK. More affluent people important priorities of both sexes and at all ages experienced less illness and premature death than the disadvantaged groups. A class gradient was observed for most causes of death, including stillbirth, accidents, cancers, respiratory disease and cardiovascular disease. Available data indicated a similar pattern with regard to chronic illness. Possible The formulation is explanations for the relationship between health and inequality were much more considered, based on artefact, natural and social selection, culture or systematic than that behaviour and economic and socio-structural factors. The report stated in RS (2007a); note that there was no single or simple explanation, but stressed the importance of material conditions of life. also the inclusion of 34. Further studies have confirmed the findings of the Black Report. ethnicity and gender These show not only that disadvantaged groups, whether in urban or rural environments or determined by ethnicity or gender, experience more chronic incapacitating illness at an earlier age, but also that socio-economic determinants of adult health, with particular regard to CHD, may date from very early life, including before birth. Avoidability as a 44. Scotland carries a greater burden of ill-health than other developed criterion for defining countries, with the problem being greatest among low income groups. health inequities, as The quest to lighten that burden starts with agreement on which conditions and illnesses to tackle most urgently, including action on per WHO guidelines the underlying inequalities. 45. Priorities should satisfy a number of criteria. They should: - be major causes of premature death or avoidable ill-health - offer significant scope for reducing overall health inequalities; - be open to effective prevention and/or positive health promotion; and - be amenable to measurement and monitoring.

53. Areas of multiple deprivation pose a particular threat to health. The combined problems of low incomes, unemployment, poor housing, a degraded environment, and high levels of crime impose an additional burden of ill-health on many families. Each of these problems can, in isolation, affect our risk of poor health, but this Targeted combination of social ills can place extreme stress on communities, interventions,

families and individuals. vertical equity

54. Regeneration of these areas is required to transform the housing stock, improve the environment, provide training and employment, tackle crime, bring new amenities, and build a sustainable community Interestingly, the infrastructure. The Government are determined to take action to regenerate our most deprived urban communities. At the same time, formulation is very the Government recognise that disadvantage can also be found in rural similar to RS (1988, areas, where local solutions can address inequalities on similar art. 25) concerted lines.

56. The Government are concerned about the impact of social exclusion on health. There are growing numbers of people who lack the means - material and otherwise - to participate in mainstream economic, social, cultural and political life in Scotland. Long-term Compared to RS unemployment, poor housing, homelessness, poverty and low (1981), the notion of educational achievement can all contribute to ill-health. Some health problems may also contribute to social exclusion. Some people may geographical face stigma and prejudice as a consequence of a particular health reachability (= problem, such as mental illness or HIV/AIDS. Some may face equity of access) is practical barriers to opportunity through disability. And high levels of not emphasised in long-term illness can suppress economic activity and employment in these documents; many communities. instead, geographical 57. An important aspect of peoples life circumstances is the extent to disparities are which a wide range of services and facilities is easily reachable, generally framed in affordable and user-friendly. Health services, including health centres, terms of health visitors, and pharmacies, are not only about treating illness: they promote and support health. Adequate shopping facilities are also socioeconomic important so that people, especially in deprived and remote inequities communities, can have easy access to purchase the foods which are necessary for a balanced diet. So are safe and accessible places for The goal of taking exercise. A good transport system brings such provision within promoting social the reach of all, while reducing pollution and accidents. cohesion through reducing inequalities 81. The effects of life circumstances and lifestyle on health are readily is formulated more apparent, well documented and have been accepted by the explicitly than in RS Government. Tackling them is important in health terms, and, more (2005a) broadly, in support of social cohesion and community safety. We propose that the priorities should be: - Life circumstances, such as deprivation - Smoking - Eating for health - Physical activity - Alcohol and drug misuse In identifying a range of priorities, an overarching objective must be to reduce inequalities. Again, note the 96. Health regeneration calls for personal investment in our own abundance of health: improved living conditions; and supporting infrastructure and services. Mental and physical well-being will improve, as we rebuild concurrent factors in deprived communities access to the opportunities people elsewhere take for granted. There is no quick fix. Changing habits acquired The notion of through many generations will need a cultural shift which will not be uniqueness vs. non- achieved at the touch of a switch. But we can ease and quicken uniqueness is largely

change. The right mix of measures - economic, social, environmental absent from the RS and behavioural - will deliver not just better health but many other documents social gains.

97. Scotlands problems are pressing but not unique. We need to learn from other countries that have overcome similar problems and now have better health. Views are welcome on actions taken elsewhere, which have led to health improvement, and which can be made to work in Scotland. Decentralisation as 101. The Government have a particular responsibility to ensure that a tool to promote all their policies are brought together in a coherent way so that the vertical equity potential for health gain is achieved. It must also set the tone for economic and social prosperity, leading to job creation, better This new education, a cleaner environment and so on. The Scottish Office, with formulation is its wide-ranging economic, social and environmental remit, is well broader than the placed to promote this integrated approach to health. Devolution will enhance its capacity to marshall and target its policies and resources general of in a way which best reflects Scotlands health needs. cooperation found, for instance, in NA 154. Local authorities wield a significant influence on health right (1978) or RS (1981) across the range of their functions. Maximising their potential to improve health must be fundamental to any strategy. Environmental health, housing, economic and community development, social work, education, police, transport, planning, sports, leisure and recreational facilities can all contribute substantially to a prosperous, safer community, in which good physical and mental health can flourish. They also have the lead role in area regeneration. As in the case of national policy development, it is important that strategies and Observe how these policies at local level should take health considerations into account. targeted interventions are 158. The prime aim of the NHS in Scotland is to improve the health of translated into policy the people of Scotland. This has been a consistent theme of the annual (TNA, 1978, art. Priorities and Planning Guidance issued to the Service, and it applies 12J, 13A etc.) to every part of the NHS and to every aspect of its work. 159. Health Boards have responsibility for protecting and improving the health of their resident populations. In this role, they work in partnership with other parts of the NHS, with local authorities and with other local organisations. With their wide expertise and knowledge of local health needs, Boards are ideally placed to help Vertical equity as a other organisations to target services, funds and personnel where there top priority is greatest need. Boards have an important role as leaders of local health alliances to improve health and in ensuring that health is high on the agenda of other partnerships in which they are involved.

170. Nowhere is all this more important than in areas of deprivation. Reducing health inequalities by effective frontline delivery of the full range of health services - including health promotion - in areas of deprivation is a key priority for the next few years. The Government have already taken steps to broaden the range of potential contracts for GPs, in particular under the Primary Care Act Pilots, offering new salaried options which can be used to bridge current gaps in practice provision. Building on this, the Government are considering a mapping exercise to identify systematically areas disadvantaged in terms of service provision so that new initiatives can be focused there.

9.2.2 After Decentralisation (1999-2018)

Scottish Art. 1 Government (1) In the National Health Service (Scotland) Act 1978 (c. 29) TNA (1990), which (2004) (referred to in this Act as “the 1978 Act”), section 12A and Schedule established the 7A (establishment, functions, dissolution etc. of National Health NHSS trusts, is Service trusts) are repealed. largely repealed

Art. 7 After section 2A of the 1978 Act (inserted by section 9(2)) insert— “2B “2B Duty to encourage public involvement Note how this (1) It is the duty of every body to which this section applies to take provision could action with a view to securing, as respects health services for which it already be found in is responsible, that persons to whom those services are being or may TNA (1981, art. 2), be provided are involved in, and consulted on— but not as a duty (a) the planning and development, and (b) decisions to be made by the body significantly affecting the operation, of those services. (2) This section applies to— (a) Health Boards, (b) Special Health Boards, and (c) the Agency.

Art. 9 (1) After section 1 of the 1978 Act insert— “1A “1A Duty of the Again, the goal of Scottish Ministers to promote health improvement health promotion - (1) It is the duty of the Scottish Ministers to promote used not to be the improvement of the physical and mental health of the framed as a duty people of Scotland. - (2) The Scottish Ministers may do anything which they consider is likely to assist in discharging that duty including, in particular— (a) giving financial assistance to any person, (b) entering into arrangements or agreements with any person, (c) co-operating with, or facilitating or co-ordinating the activities of, any person. (2) After section 2 of that Act insert— “2A “2A Duty of Health Board, Special Health Board and the Agency to promote health improvement - (1) It is the duty of every Health Board and Special Health Board and of the Agency to promote the improvement of the physical and mental health of the people of Scotland. - (2) A Health Board, a Special Health Board or the Agency may do anything which they consider is likely to assist in discharging that duty including, in particular— (a) giving financial assistance to any person, (b) entering into arrangements or agreements with any person, Scottish Our Action Plan also sets out a range of measures to improve the Vertical equity, Government quality of our National Health Service. It gives effect to our territorial equity; (2007) commitments to local care whenever possible, embedded in note how it has communities and tailored to people’s needs. It gives effect to our become the first commitment to care that is even quicker, even safer and even more priority efficient and effective than ever before. It recognises the excellent

progress made by NHS staff over the last few years, and in the first months of this new Government. In the spirit of continuous improvement, our Action Plan seeks to accelerate that progress. Our model of improvement is built around the existing strengths of Note how the NHSScotland – a collaborative, integrated approach built on our framing implies a traditional values. We will therefore retain our unified Board structure and ensure that NHSScotland remains firmly in the public reversal of TNA sector – a public service delivered in partnership with the public. Our (1990); integration Action Plan brings together our commitments to public participation, and cooperation are improving patient experience, patient rights and enhanced local now valued over democracy and expresses them in terms of a more mutual approach to financial concerns healthcare. The Scottish people are more than consumers of NHS services. They share ownership of the NHS and that gives them rights and responsibilities which we discussed with the thousands of people who participated in our consultation and which we begin to set out in this Action Plan. This commitment

A mutual NHS enshrines our values of co-operation and collaboration indicates a sort of in the very fabric of the organisation. We believe that co-operation convergence with and collaboration both across NHSScotland and between the values found in NHSScotland and its partners, is a more effective means of driving the later RS change than internal competition. Our national discussion has documents (2007a-) confirmed our belief that a public service, particularly one which supports people at some of the most emotionally testing times of their lives, should look to drive and sustain change on the basis of patients’ needs and the expertise of our staff, rather than a reliance on market forces. The values of co-operation and collaboration must be assertive rather than passive values. The challenge of implementation, is to create the structures and processes that support them in making a real difference to our services. Compare this with The new Scottish Government moved quickly to streamline the TNA (1997a). Cabinet, creating new opportunities for cross-cutting working, in Decentralisation which every portfolio is challenged to contribute to health and shifted competencies wellbeing wherever, whenever and however they can. The mutual in a much more benefits of working together across Government include: dramatic ways than - Education and Lifelong Learning: Shared actions to provide in Sardinia, thus children with the best possible start in life, develop life skills, allowing the Scottish resilience and confidence, adopt a rights based approach to children’s services, improve the way the curriculum government to blend addresses health and wellbeing and supports a whole school welfare domains approach with the goal of - Finance and Sustainable Growth: working with local improving health authorities to achieve shared outcomes, improving outcomes employment opportunities and opportunities to promote health in the workplace, developing local transport solutions and enhancing the role of the voluntary and community sector in the design and delivery of health-related services - Rural Affairs and Environment: Shared approaches to the provision of sustainable models of service in remote and rural areas and ensuring the long term environmental sustainability of NHS services The inclusion of the - Justice: Action to improve community safety, health key determinants services of health marks a in Scottish prisons and tackling drug misuse. significant shift from

By creating Scotland’s first ever Minister for Public Health and the RS documents, expanding the health and wellbeing portfolio to include key where competencies determinants of health – such as sport and physical activity, housing, are still fixed and homelessness, poverty, social and financial inclusion and regeneration only social care can – we have laid the groundwork for a more radical and inclusive be fully integrated approach to achieving shared objectives. These include our goals to tackle poverty and disadvantage and to regenerate our most deprived with healthcare communities, which are central to reducing health inequalities and meeting our aspirations for health improvement. In particular, it has provided us with the opportunity to make an impact on health and health inequalities, the key driver of these policies. Key commitments include: - increasing the supply of good quality sustainable housing, as we work with local government and other housing providers All of these goals towards a Scotland where everyone will have a secure, warm are much more house at a cost they can afford. A total investment of £1.47 systematic than billion has been identified within the draft Scottish budget to support this ambition those in RS (2007a) - launching a wide-ranging consultation on the future of housing in Scotland to consider how best to free up the supply of housing to buy and to rent, in order to create sustainable, mixed communities and provide a fair deal for first-time buyers, tenants and taxpayers - preventing and tackling homelessness by ensuring everyone who needs it is able to access appropriate accommodation, advice or support - establishing a new fund amounting to £145 million a year within the local government settlement to be deployed by Community Planning Partnerships, to tackle poverty and deprivation and to help more people overcome barriers and get back into work - supporting a range of large-scale regeneration projects and Note the now- working with local government and Community Planning constant mention of Partnerships to target regeneration activities on tackling environmental poverty in our most deprived communities factors

Poor mental and physical health is both a cause and consequence of social, economic and environmental inequalities. Risk factors include individual behaviours such as smoking, alcohol misuse, diet and inactivity and also aspects of the wider social, economic and physical environments that shape such behaviours, including educational achievement, income / relative poverty, the work environment and unemployment. Inequalities can also cross the generations, with The framing of these children born and brought up in disadvantaged families being more goals, universal yet likely to experience poorer health in later life. prioritised, is reminiscent of the The Task Force has adopted some key principles to drive its work. concept of selective These are: universalism found - improving the whole range of circumstances and in RS (2005a, Art. 2) environments that offer opportunities to improve people’s life circumstances and hence their health - reducing people’s exposure to factors in the physical and social environment that cause stress, are damaging to health and wellbeing, and lead to health inequalities - addressing the inter-generational factors that risk

perpetuating Scotland’s health inequalities, particularly focusing on supporting a good start in life for all children in Scotland - engaging individuals, families and communities most at risk of poor health in services and decisions relevant to their health, and promoting clear ownership of the issues by all involved Vertical equity - delivering health and other services that are both universal and appropriately prioritised to meet the needs of those most at risk of poor health, and that seek to prevent problems arising, as well as addressing them if they do

The Ministerial Task Force has identified the need to place more emphasis on tackling health inequalities through primary care. This requires the allocation of resources to better reflect the additional workload required to meet the needs of people in disadvantaged areas. The new Scottish Enhanced Services Programme for Primary and Community Care reflects the Scottish Index of Multiple Deprivation and will therefore weight resources more significantly towards such areas than previous methods of resource allocation. We will also look specifically at those areas of the GP contract that we believe do not adequately reflect the additional needs of GP practices in disadvantaged communities. In particular we will engage with the Note, once again, the professions on future changes to the Minimum Practice Income opposition to the Guarantee and Quality Outcomes Framework for GPs to ensure that previous the distribution of existing and future resources better reflects the governments’ balance of workload that is required to help us tackle health policies inequalities in Scotland.

Prescription charges are a tax on ill health. The Scottish Government is therefore committed to abolishing these charges and ensuring that those who require medication particularly those suffering from long term conditions, are not deterred by cost. The charges will therefore be reduced significantly over the next 3 financial years, beginning in Vertical equity April 2008 and abolished completely by April 2011. Removal of this barrier to good health will support people to make choices which are good for their health and wellbeing. The draft Scottish Budget identifies £97 million to support these changes.

Where appropriate, we will take specific action to focus on the needs of particular groups. This will include, for example, action in partnership with Defence Medical Services Department and the charity Combat Stress to meet the mental health needs of serving and former armed forces personnel. Effective approaches to reaching and engaging with the most vulnerable groups of people to improve their physical and mental health need to be identified and scaled up. This might include actions to support people in institutional settings, such as care homes or secure care, groups such as homeless people who may not otherwise be reached by traditional approaches or people who experience discrimination in whatever form. We will use proven Note how approaches to continuous improvement to enhance the rate at which uniformity is we identify and implement good practice across Scotland, with a deemed not to be particular focus on the supporting NHS Boards to deliver against the enough anymore; targets for tackling health inequalities that are included within the compare with the

HEAT performance management framework. opposite case, RS (1981, art. 2) It is important that we understand and respond to the needs of the different groups and communities we serve. It is not enough to provide a uniform service and expect that patients and the public will be able to take advantage of that service equally. A lot has been achieved in NHSScotland already but it is critical that every part of the service considers whether the services it provides, and the way in which they are provided, support equity. Remote and Rural Health Care Building a Health Service: Fit for the Future recognised that a one size fits all approach can not meet the challenges of providing health care in remote and rural areas and established a national steering group to develop a framework for the provision of services in those areas. A further group was established to develop specific training for doctors working in remote and rural areas. Both groups have now reported and we will issue guidance on how we expect their recommendations to be implemented early in 2008. The proposed framework presents a model for sustainable remote and rural services which maximises the contribution of each member of the health and social care team, and encourages further integration of services. Primary care teams are recognised as the bedrock of the health care Vertical equity; system. Recommendations are made to extend, as far as is possible, also note the brief the range of diagnostic tests and specialist support available to those mention of human teams to prevent unnecessary onward referral and travel for patients. rights. Compare The potential to upskill members of those teams to provide more local with the (undefined) services - for example through the development of GPs with special concept of interests - is also recognised. humanisation in RS

Fair for All Our Fair for All agenda seeks to understand the needs of (2006b, art. 1) different communities, eliminate discrimination in the NHS, reduce inequality, protect human rights and build good relations by breaking New priorities down barriers that may be preventing people from accessing the care include and services that they need. It aims to address inequalities by religion/personal recognising and valuing diversity, promoting a patient focused beliefs approach and involving people in the design and delivery of health care. A vast amount has been achieved already, with guidance now being available to help staff understand and meet their responsibilities under the Disability Discrimination Act, support NHSScotland in implementing the Gender Equality Duty, assess progress in achieving race equality outcomes and provide information and good practice General commitment examples of LGBT people using NHS services. Guidance on to equity = fair religion/belief and issues relating to age are due to be launched equality shortly. A new Directorate of Equalities and Planning is being created in NHS Health Scotland to bring together this work and to be the focus of support, advice and expertise to NHSScotland in addressing diversity and reaching excluded communities. We are committed to continuing and further developing our Fair for All approach across NHSScotland. We will therefore ensure that we equality impact assess this action plan throughout its implementation. We will do this, not just because it is a legal requirement. It is right to do so and we believe that it will lead to services that are equitable and fair for all the communities we serve.

Scottish In order to capture patients’ assessment of their relationship with the Government healthcare professional supporting them, in such a way that it can be (2010) used to inform improvement, a measurement technique known as the Consultation and Relational Empathy (CARE) measure has been developed in Scotland. The CARE measure has been well validated with doctors, both with GPs in primary care and consultants in secondary care. We will pursue the introduction of the use of the Equity framed in CARE measure in all clinical appraisals and with other healthcare terms of equitable professionals. We will be able to use these measures to highlight outcomes; see below action needed to ensure equity in terms of health outcomes and experience. Other tools to support staff, patients and carers in achieving the mutually beneficial partnerships we want will be developed, where appropriate, including outcomes approaches such as Talking Points.

The Quality Ambitions In order to be recognised as having world- leading healthcare services, we need to set out a clear set of ambitions with related measurable and achievable objectives (interventions) on which we can report progress. Better Health, Better Care was based on the Institute of Medicine’s six dimensions of quality. These six dimensions will remain central to our approach to systems-based healthcare quality improvement: - Person-centred: providing care that is responsive to individual personal preferences, needs and values and assuring that patient values guide all clinical decisions; - Safe: avoiding injuries to patients from healthcare that is intended to help them; - Effective: providing services based on scientific knowledge; - Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy; Horizontal equity, - Equitable: providing care that does not vary in quality but with targeted because of personal characteristics such as gender, ethnicity, interventions geographic location or socio-economic status; and included → - Timely: reducing waits and sometimes harmful delays for both those who receive care and those who give care.

Our Commitment to Equality NHSScotland is committed to Vertical equity understanding the needs of different communities, eliminating

discrimination, reducing inequality, protecting human rights and building good relations by breaking down barriers that may be preventing people from accessing the care and services that they need, as well as meeting the legal duties in relation to age, race, disability Again, uniformity and gender. It aims to address inequalities by recognising and valuing loses its importance; diversity, promoting a person-centred approach and involving people diversity (= vertical in the design and delivery of healthcare. There are strong linkages equity) gains between some of the key actions required and being taken forward to relevance address health inequalities in Scotland, and proposed drivers of our quality strategy. In particular the person-centred and clinical effective drivers (specifically through long-term conditions) have the potential to address the health problems of many of those who carry a disproportionate burden of ill-health in our communities. Each of the aligned and integrated national programmes, intiatives and interventions pursued in support of achieving the three Quality Ambitions will require to be fully assessed in terms of their impact on equalities through a Health Inequalities Impact Assessment (HIIA),

which includes mandatory Equalities Impact Assessment (EQIA). Through this we will ensure that the Quality Strategy optimises its impact on reducing inequality across Scotland.

Scottish 6. This plan will help our health and social care system evolve, Government building on the excellence of NHS Scotland, recognising the critical (2016) role that services beyond the health sector must play and is ultimately fit for the challenges facing us. What that will look like for individuals is described in more detail in Appendix 1. We must prioritise the actions which will have the greatest impact on delivery. We will focus on three areas, often referred to as the ‘triple aim’: - we will improve the quality of care for people by targeting investment at improving services, which will be organised and delivered to provide the best, most effective support for all (‘better care’); - we will improve everyone’s health and wellbeing by promoting and supporting healthier lives from the earliest A broad years, reducing health inequalities and adopting an approach conceptualisation of based on anticipation, prevention and self-management equity; it can be (‘better health’); and interpreted as - we will increase the value from, and financial sustainability of, care by making the most effective use of the resources vertical equity available to us and the most efficient and consistent delivery, inasmuch as it ensuring that the balance of resource is spent where it entails targeted achieves the most and focusing on prevention and early interventions intervention (‘better value’).

10. To improve the health of Scotland, we need a fundamental move away from a ‘fix and treat’ approach to our health and care to one based on anticipation, prevention and self-management. The key causes of preventable ill health should be tackled at an early stage. Note the similarities There must be a more comprehensive, cross-sector approach to create a culture in which healthy behaviours are the norm, starting from the with the original earliest years and persisting throughout our lives. The approach must Beveridgean acknowledge the equal importance of physical and mental health as conception of the well as the need to address the underlying conditions that affect welfare state health. Integration of all 11.This can only be done by health and other key public sector welfare domains services (such as social care and education) working together becomes systematic systematically. All services must be sensitive to individual health and and not limited care needs, with a clear focus on early intervention. Moreover, it will anymore to social not just be what services can provide, but what individuals themselves want and what those around them – not least families and carers – can care provide with support. Services need to be designed around how best to support individuals, families and their communities and promote and maintain health and healthy living.

21. Optimising and joining up balanced health and care services, whether provided by NHS Scotland, local government or the third Compare with RS and independent sectors, is critical to realising our ambitions. (2007a) Integration of health and social care has been introduced to change the way key services are delivered, with greater emphasis on supporting people in their own homes and communities and less inappropriate use of hospitals and care homes. The people most affected by these

developments, and for whom the greatest improvements can be achieved, are older people, people who have multiple, often complex care needs, and people at the end of their lives. Too often, older people, in particular, are admitted to institutional care for long periods when a package of assessment, treatment, rehabilitation and support in the community – and help for their carers – could better serve their needs. Scottish In a vibrant, modern Scotland it should be possible for everyone to be Government as healthy as they can be. It should be the case that the social, (2018) economic and physical environments we live in help create health and wellbeing, and that local communities and public services make it possible for individuals to take positive decisions about their own health and feel supported to do so. Unfortunately, for too many people in Scotland and in too many places, this is not the case. As a nation, our overall health is unacceptably poor in comparison to other Western European countries, and many people living in our most Vertical equity deprived communities still experience poorer health than those living in our wealthier areas.

We want Scotland to be a place where everybody thrives. We want to reset how Scotland thinks about wellbeing and health. Wellbeing cannot be created and sustained by the NHS alone. High quality and equitable healthcare and health protection services are vital in improving and maintaining health, addressing health inequalities and protecting us from communicable and environmental threats. But it’s not primarily in our hospitals or our GP surgeries that health is first created. It is in our homes and our communities, in the places we live and through the lives we lead. These are the places where we must work to make it easier for people to be healthy, and the efforts of Systematic society as a whole must increasingly turn towards supporting this sort integration of ‘wellbeing creation’.

These public health priorities represent an important milestone. They represent agreement between the Scottish Government and Local Government about the importance of focusing our efforts to improve the health of the population. The priorities connect strongly to, and will help accelerate, our wider work and include local strategic planning and partnership activity; the refreshed National Performance Framework and related National Outcomes; our Digital Health and Care Strategy, and forthcoming public health policies to be published in the coming weeks and months, and our efforts towards sustainable economic growth. This document also sets out how we will work Compare with RS together and with other parts of the system to achieve this change (our (1981, art. 1) reform principles). And these priorities are not just for our public health professionals. This document is intended to be a foundation for the whole system, for public services, third sector, community organisations and others, to work better together to improve Scotland’s health, and to empower people and communities. It is a starting point for new preventative approaches, and a new awareness around wellbeing, that will develop and strengthen in the coming years. Vertical equity as a Our ultimate aim is to improve the health of the population and to way to tackle local reduce the unacceptable variation in life expectancy that exists across disparities Scotland. Tackling the health inequalities that prevent good health

runs through all that we do, and this is reflected in our reform principles. In taking that work forward we are committed to a shared vision for a modern, inclusive Scotland where everyone is able to live with human dignity. We will ensure our approach to improving the health of the population is fully consistent with Scotland’s commitment to equality and human rights, including the duty we have to meet international obligations and to work in ways that eliminate discrimination, advance equality of opportunity and foster good relations between people who share a protected characteristic and those who do not.

While life expectancy is increasing overall, there are significant Note how these differences in the life expectancy and health of people across factors are more Scotland, depending on factors such as where they live, their age and specific than the list gender, and their ethnic group. People living in less affluent areas of in ATS (2018) Scotland have a shorter life expectancy than those living in wealthier areas. (Figure 2 opposite). Healthy life expectancy – the number of years we can expect to live in good health – also varies significantly across Scotland. At the population level, there are marked differences between the most and least deprived areas in terms of how long Systematic people can expect to live in good health. This can be a difference of integration between up to 28 years for men and 25 years for women. These differences are welfare and strongly influenced by the social conditions in Scotland, the healthcare circumstances into which people are born, the places where they live, their education, the work they undertake, and the extent to which good social networks exist.

The impact of these variations in health within Scotland, at the same time as the population is ageing, is wide-reaching. More people in Scotland are now living with one or more complex health conditions. They require more health and social care and that requirement will increase as they age. Fewer people are able to work and remain in work as a result of health problems or because of the requirement to care for loved-ones who are unwell. There are human costs in terms of life expectancy and years lived in poor health, but this also limits our ambition to build a thriving and prosperous Scotland where our Interregional people achieve their full potential. For our public services, responding disparities effectively to this burden of poor health and inequality will become unsustainable. None of this is acceptable. Despite tremendous progress in life expectancy it is not acceptable that our health is poorer than other parts of Europe, and it is not acceptable that people in Scotland are not able to thrive. Note the holistic We want to change the places and environments where people live so formulation, much that all places support people to be healthy and create wellbeing. more systematic Whether it is physical improvements to help us move from place to than ATS (2018) place with ease; empowering communities to make decisions that directly affect them; improving local access to green spaces; or shifting the commercial environment towards the availability of healthier options. The evidence is strong that improvements to our environment have a positive and lasting impact on the public’s health. Creating safe places that nurture health has long been central to the public health agenda. From the early days of public health this has included access to safe water and sanitation, ensuring accessible health services and improving our environmental health through food

safety and improvements to the quality of the air we breathe. We now The equation need the other parts of the system that have a role to play in the shape welfare → of communities and places to be increasingly thinking about the health impacts of decisions and activities. Planning, construction, healthcare is social housing and transport policy all lie outside the remit of the emphasised health service, but all materially impact our health. The extent to which long term considerations of health are taken into account and balanced against other priorities when making decisions about the places in which we live varies – but there is consensus for closer collaboration between those who design and build places, those who live in them and those with an interest in improving the public’s health. For example, the Scottish Government’s 2017-18 Programme for Government includes a commitment around planning systems and the food environment in our schools, and councils are working with partners, including local communities, to tackle fuel poverty, reduce violence, prevent accidents and co-design environments that support more active travel. Equity in terms of avoidability; note The health-related harms of relative poverty are complex, but can be the the connection reduced and are preventable. To do so, we must reverse the growing with equality of gaps in income and wealth in Scotland. Scotland’s Economic opportunities, not Strategy (SES) places Inclusive Growth as a core priority. This is outcomes defined as ‘growth that combines increased prosperity with greater equity; that creates opportunities for all and distributes the dividends of increased prosperity fairly’. We must share power and create opportunities for all people, families, communities and groups to be involved in decisions that affect them. We must prevent the unfair treatment, exclusion and isolation of both people and groups and the accompanying stigma they feel. The NHS, Scottish Government and Local Government also have a role as the employers of over 500,000 employees in Scotland – almost two out of every ten people. While those working in public services have a strong tradition of speaking Systematic effort to out on inequality and poverty, public funds – and health resources in tackle particular – are overwhelmingly targeted toward treating the socioeconomic consequences of that person’s life in poverty, rather than on tackling the determinants of poverty at a population level. If we are serious inequities about reforming public health, this balance will need to be challenged at a local and national level. We cannot simply keep focusing our time and effort on patching up the impact of such inequalities; we must venture further upstream and fix them at source. The role of local communities is Local partnerships, including the third sector and communities reinstated themselves, are best-placed to understand and tackle the inequalities that still exist in Scotland, and which often become most visible when working at the neighbourhood level. By targeting anti-poverty measures to those in most need, councils are working with partners to improve food security by providing out-of-term time meals for children, take action on fuel poverty and ensure people have access to affordable housing.