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HEALTH AND SPORT COMMITTEE
AGENDA
24th Meeting, 2019 (Session 5)
Tuesday 29 October 2019
The Committee will meet at 9.45 am in the James Clerk Maxwell Room (CR4).
1. Subordinate legislation: The Committee will take evidence on the Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Amendment Order 2019 [draft] from—
Joe FitzPatrick, Minister for Public Health, Sport and Wellbeing, Claire Montgomery, Solicitor, Legal Directorate, Lynne Nicol, Head of Openness and Learning, and David Leslie, Policy Manager, Openness and Learning Unit, Scottish Government.
2. Subordinate legislation: Joe FitzPatrick, Minister for Public Health Sport and Wellbeing, to move—
S5M-19060—That the Health and Sport Committee recommends that the Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Amendment Order 2019 [draft] be approved.
3. Subordinate legislation: The Committee will consider the following negative instrument—
The National Health Service (Serious Shortage Protocols) (Miscellaneous Amendments) (Scotland) Regulations 2019 (SSI 2019/284).
4. Social prescribing of physical activity and sport inquiry: The Committee will take evidence from—
Professor Richard Davison, Professor of Exercise Physiology, University of the West of Scotland, representing the Observatory for Sport in Scotland;
Dr William Bird, General Practitioner and Chief Executive Officer, Intelligent Health;
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Kirsty McNab, Chief Executive Officer, Scottish Sports Futures;
Dr Katie Walter, General Practitioner, Cairn Medical Practice;
Flora Jackson, Health Improvement Manager, Physical Activity and Health Alliance (NHS Health Scotland);
Claire Thirwall, Health and Wellbeing Specialist, NHS Dumfries & Galloway;
Martin Hayman, Project Manager, Community Table Tennis, Table Tennis Scotland;
Kim Atkinson, Chief Executive Officer, Scottish Sports Association;
Dr Corinne Jola, Senior Lecturer in Psychology and researcher/practitioner in dance, health and wellbeing, Abertay University.
5. Petitions: The Committee will consider the following petitions—
PE01568 by Catherine Hughes on the funding, access and promotion of the NHS Centre for Integrative Care;
PE01605 by Peter Gregson on behalf of Kids not Suits, Whistleblowing in the NHS - a safer way to report mismanagement and bullying;
PE01698 by Karen Murphy, Jane Rentoul, David Wilkie, Louisa Rogers and Jennifer Jane Lee, Medical care in rural areas; and
PE01533 by Jeff Adamson on behalf of Scotland Against the Care Tax, Abolition of non-residential social care charges for older and disabled people.
6. Birmingham Commonwealth Games Bill (UK Parliament legislation): The Committee will consider the legislative consent memorandum lodged by Jeane Freeman, Cabinet Secretary for Health and Sport (LCM (S5) 25).
7. Social prescribing of physical activity and sport inquiry (in private): The Committee will consider the evidence heard earlier in the meeting.
8. Primary Care Inquiry - Phase Two (in private): The Committee will consider evidence heard on the 1 and 8 October 2019 on its Primary Care Inquiry - Phase Two.
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David Cullum Clerk to the Health and Sport Committee Room T3.40 The Scottish Parliament Edinburgh Tel: 0131 348 5210 Email: [email protected] HS/S5/19/24/A
The papers for this meeting are as follows—
Agenda item 1
Note by the Clerk HS/S5/19/24/1
Agenda item 3
Note by the Clerk HS/S5/19/24/2
Agenda item 4
PRIVATE PAPER HS/S5/19/24/3 (P)
Witness Written Submissions HS/S5/19/24/4
Agenda item 5
Note by the Clerk HS/S5/19/24/5
PRIVATE PAPER HS/S5/19/24/6 (P)
Agenda item 6
Note by Clerk HS/S5/19/24/7
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Health and Sport Committee
24th Meeting, 2019 (Session 5)
Tuesday 29 October 2019
Subordinate legislation
Overview of instruments 1. There is one affirmative instrument for consideration at today’s meeting • The Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Amendment Order 2019 2. The instrument amends Schedule A1 of the Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Order 2013 (“the 2013 Order”). It inserts the offence of wilful neglect under section 26 of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 (“the 2016 Act”) into the list of statutory offences contained in Schedule A1. 3. This offence applies to care workers who ill-treat or wilfully neglect an individual in their care. The purpose of Schedule A1 is to specify offences which do not meet the definition of “protected conviction” in Article 2A of the 2013 Order, reducing the legal protection for those convicted of an offence listed in Schedule A1 against self-disclosing and answering questions about the conviction. 4. The effect of this instrument is that a person with a conviction for the offence of wilful neglect will not be protected from being asked about, being required to disclose or being prejudiced by the conviction in those proceedings.
Background 5. Section 5 of the Rehabilitation of Offenders Act 1974 (“the 1974 Act”) provides that a conviction may become spent if a certain length of time has elapsed since the date of conviction. Once a conviction is spent, an individual becomes a “rehabilitated person” and is not normally required to disclose their spent conviction, and they generally cannot be prejudiced by its existence. 6. Section 4 of the 1974 Act permits persons not to disclose their spent convictions when asked to do so, prevents others from asking about those spent convictions and prohibits reliance on spent convictions in certain legal proceedings or to prejudice an individual in an employment context. There are exceptions and exclusions to this general approach where matters of public safety are engaged, and the 1974 Act provides the Scottish Ministers with the power to make exceptions and exclusions to the protections by order. The Scottish Ministers made the 2013 Order in exercise of this power. 7. Section 29 of the 2016 Act inserted the offence of wilful neglect into Schedule 8A of the Police Act 1997 (“the 1997 Act”) meaning that a spent conviction for the offence must be disclosed by Disclosure Scotland in a higher level state disclosure unless a sheriff orders otherwise. Higher level disclosures include
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standard and enhanced disclosures under the 1997 Act and PVG scheme records under the Protection of Vulnerable Groups (Scotland) Act 2007 (“the 2007 Act”). This order will therefore achieve consistency between the system of state disclosure under the 1997 and 2007 Acts and the system of self-disclosure under the 1974 Act. 8. The Policy Note and Guidance Notes from the instrument are attached at Annex A. 9. An electronic copy of the instrument is available at: http://www.legislation.gov.uk/sdsi/2019/9780111042854/contents
10. The Committee needs to report by 11 November 2019.
Delegated Powers and Law Reform Committee consideration
11. The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 24 September 2019. The Committee determined that it did not need to draw the attention of the Parliament to the instrument on any grounds within its remit.
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Annexe A
POLICY NOTE
The Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Amendment Order 2019
SSI 2019/XXX
1. The above instrument was made in exercise of the powers conferred by sections 4(4) and 10(1) of the Rehabilitation of Offenders Act 1974 (“the 1974 Act”). The instrument is subject to affirmative procedure. For the purposes of this note, the instrument will be called “the 2019 Amendment Order”.
This instrument amends the Rehabilitation of Offenders Act (Exclusions and Exceptions) (Scotland) Order 2013 (SSI 2013/50) (“the 2013 Order”) to reduce the level of protection an individual has against being asked about, requiring to self-disclose or being prejudiced by a spent conviction for the offence of wilful neglect under section 26 of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 (“the 2016 Act”).
Policy objectives
2. The broad purpose of the 2019 Amendment Order is to amend the 2013 Order to restrict the circumstances in which a person with a spent conviction for the offence of wilful neglect will benefit from legal protection against self-disclosing and answering questions about it (e.g. when applying for employment or in judicial proceedings).
3. The offence of wilful neglect applies to care workers who ill-treat or wilfully neglect another individual in their care. The 2016 Act provides penalties which are proportionate to the severity of the offence and the breach of trust which it entails.
4. Section 29 of the 2016 Act inserted the wilful neglect offence into the list in schedule 8A of the Police Act 1997 (“the 1997 Act”), meaning that a spent conviction for the offence must be disclosed by Disclosure Scotland in a higher level state disclosure unless a sheriff orders otherwise. Higher level disclosures encompass standard and enhanced disclosures under the 1997 Act and PVG scheme records under the Protection of Vulnerable Groups (Scotland) Act 2007 (“the 2007 Act”.)
5. The 2019 Amendment Order will thus achieve consistency between the system of state disclosure under the 1997 and 2007 Acts and the system of self-disclosure under the 1974 Act.
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General background
6. A conviction may become spent if a certain length of time has elapsed since the date of conviction, with different periods of time applying to different disposals, as laid down in section 5 of the 1974 Act.
7. Once a conviction is spent, an individual becomes a “rehabilitated person”. The 1974 Act provides that such a person is not normally required to disclose their spent conviction and that they generally cannot be prejudiced by its existence. The purpose of this approach is to appropriately allow an individual to move away from their past criminal activity so that they can contribute effectively to society while also ensuring that people with a legitimate interest, such as employers, are able to understand an individual’s background.
8. Section 4 of the 1974 Act sets out the effect of becoming a rehabilitated person. Broadly speaking, section 4 permits such persons not to disclose spent convictions when asked to do so (e.g. by a prospective employer), prevents others from asking about those spent convictions and prohibits reliance on spent convictions in certain legal proceedings or to prejudice an individuals in an employment context. However, there are certain exceptions and exclusions to this general approach when the interests of public safety are paramount.
9. The 1974 Act provides the Scottish Ministers with power to make by order exceptions and exclusions to the protections under section 4 of the 1974 Act. The Scottish Ministers made the 2013 Order in exercise of this power.
The 2013 Order
10. The effect of the 2013 Order can be described as follows:
Article 3
11. Article 3 of the 2013 Order states that the application of section 4(1) of the 1974 Act is entirely excluded in relation to a number of the types of proceedings specified in schedule 1 of the 2013 Order. What this means is that a person may be asked about any or all of their spent convictions, and that information can be taken into account, in those proceedings.
12. For certain other forms of proceedings specified in article 3 (including some of those listed in schedule 1 and Part 1 of schedule 2), the application of section 4(1) is excluded only in relation to convictions which are not “protected convictions” (see paragraph 21 below). That means that a person may be asked in those proceedings about any spent convictions which are not protected convictions, but not about protected convictions.
Article 4
13. Article 4 of the 2013 Order states that the application of section 4(2)(a) and (b) of the 1974 Act is excluded in relation to questions put in the circumstances set out in its schedule 3.
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14. Section 4(2)(a) and (b) of the 1974 Act provide protection for a rehabilitated person so they are neither required to disclose their spent conviction(s) in judicial proceedings, nor subjected to any liability or prejudice for failure to do so. The circumstances in schedule 3 include the assessment of a person’s suitability for a profession, office, employment or occupation set out in schedule 4, or to hold a licence, certificate or permit set out in paragraph 3(3) of schedule 3. Provision is made in schedule 3 for other special circumstances that arise – for example, in the context of child minding, adoption and fostering, national security, financial services and the Gambling Commission.
15. The protections in section 4(2)(a) and (b) of the 1974 Act generally continue to apply in respect of spent convictions which are “protected convictions” (see paragraph 21), even in the circumstances to which schedule 3 of the 2013 Order applies. In general, the protections also continue to apply in respect of a conviction which falls within article 4(2A) of the 2013 Order if the conviction is not included in a higher level disclosure sent in connection with the purpose for which a question is put.
16. Article 4(3) has the effect that certain questions are not covered by these special rules. In particular, the protection afforded by section 4(2)(a) and (b) of the 1974 Act does not apply in relation to questions put to assess the suitability of a person to hold firearm licences and shotgun certificates, air weapon licenses, explosives certificates and licenses granted under section 4A of the Poisons Act 1972. Further, the protection does not apply in relation to questions put by certain persons or bodies in order to assess, for the purpose of safeguarding national security, the suitability of a person of a person for any office or employment. Finally, no protection is afforded in relation to any question put to assess the suitability of a person to hold the occupation of firearms dealer or any occupation requiring the person to have a certificate certifying them to be fit to acquire or acquire and keep explosives.
Article 5
17. Article 5 of the 2013 Order states that the professions, offices, employments and occupations set out in schedule 4 are excepted from the protections in section 4(3)(b) of the 1974 Act. It also states that action taken to safeguard national security and decisions taken by persons specified in Part 1 of schedule 2 to do anything specified in that Part are also excepted from those protections.
18. The effect of this is to remove the general prohibition in section 4 of the 1974 Act against using the existence of, or the failure to disclose, certain spent convictions as a ground for dismissing or excluding a person or for prejudicing them in any way in any occupation or employment.
19. The protections in section 4(3)(b) however continue to apply to “protected convictions” (see paragraph 21). They also apply to those convictions which fall within article 5(2)(2A) of the 2013 Order which are not included in a higher level disclosure sent in connection with the profession, office, employment, occupation,
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decision or proposed decision to which the exception from the provisions of section 4(3)(b) of the 1974 Act would otherwise apply.
20. Certain occupations, actions, etc. are not covered by these special exceptions about protected convictions and higher level disclosures (e.g. action taken for the purpose of safeguarding national security or work as a registered firearms dealer), meaning that all spent convictions may be considered when making decisions in those contexts.
Protected convictions
21. The concept of a “protected conviction” is defined in article 2A of the 2013 Order (as inserted by article 2(2) of the Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Amendment Order 2015). This provides that a protected conviction is either a spent conviction which is not a conviction for an offence listed in schedule A1 or B1 of the 2013 Order or a spent conviction for an offence listed in schedule B1 of the 2013 Order, if one or more conditions in article 2A(2) relation to the conviction is satisfied. These relate to the length of time which has elapsed since the date of the conviction and the sentence imposed in respect of it.
Effect of the 2019 Amendment Order
22. The 2019 Amendment Order adds the offence of wilful neglect into the list of statutory offences in schedule A1 of the 2013 Order. This will mean that a spent conviction for this offence cannot meet the definition of “protected conviction” in article 2A of the 2013 Order, reducing the level of protection a person has against being asked about it, having to self-disclose it or being prejudiced by it.
23. In practical terms, when the Order is brought into force, the application of section 4(1) of the 1974 Act will always be excluded in relation to a spent conviction for wilful neglect in respect of any proceedings mentioned in article 3(1) of the 2013 Order. This will achieve the intention that a person with such a conviction will not be protected from being asked about, being required to disclose or being prejudiced by the conviction in those proceedings.
24. The application of section 4(2)(a) and (b) of the 1974 Act will be excluded in relation to a spent conviction for the wilful neglect offence where a question is put in circumstances to which schedule 3 of the 2013 Order applies, subject to the exception outlined at paragraph 16 above. The second exception is as set out in article 4(2)(b) of the 2013 Order, which is that:
a. at least 7 years and 6 months have passed from the date of the conviction of an under 18 year old or at least 15 years have passed from the conviction of an over 18; and b. the conviction is not included on a higher level disclosure sent in connection with the purpose for which the question is put.
25. In respect of the latter criterion, amendments made to the 1997 and 2007 Acts by the Police Act 1997 and Protection of Vulnerable Groups (Scotland) Act 2007
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Remedial Order 2018 mean that individuals with a spent conviction for an offence which features in schedule 8A of the 1997 Act - including wilful neglect - are able to apply to a sheriff to have their spent conviction removed from a higher level disclosure where the relevant timeframe at paragraph 24a. has passed.
26. After the 2019 Amendment Order comes into force, the criteria at paragraph 24a. and b. would also require to be met by a person with a spent conviction for the offence of wilful neglect in order for them to benefit from the exception in article 5(2)(b) of the 2013 Order. Article 5(2)(b) switches on the application of section 4(3)(b) of the 1974 Act in relation to any profession, office, employment or occupation specified in schedule 4 of the 2013 Order, as well as in relation to any decision or proposed decision taken by a person specified in Part 1 of schedule 2 of that Order to do or refuse to do anything specified in that Part.
Consultation
27. A consultation on the creation of an offence of wilful neglect was undertaken during the Bill stage of the 2016 Act. The Scottish Government does not consider that further consultation is required in relation to the 2019 Amendment Order, as the Bill consultation responses were clear that the commission of the offence of wilful neglect as a care worker should be treated very seriously.
Impact Assessments
28. Further Impact Assessments are not necessary, as these were undertaken during the Bill stage of the 2016 Act.
Financial Effects
29. A further Business and Regulatory Impact Assessment (BRIA) is not required, as a BRIA was undertaken during the Bill Stage of the 2016 Act.
Scottish Government Directorate of Healthcare Planning and Quality Improvement September 2019
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Health and Sport Committee 24th Meeting, 2019 (Session 5) Tuesday 8 October 2019 Subordinate Legislation Briefing Overview of instrument 1. There is one negative instrument for consideration at today’s meeting:
• The National Health Service (Serious Shortage Protocols) (Miscellaneous Amendments) (Scotland) Regulations 2019
The National Health Service (Serious Shortage Protocols) (Miscellaneous Amendments) (Scotland) Regulations 2019 (SSI 2019/284)
Background
2. The policy behind this instrument is to allow pharmacists within a community pharmacy to supply an alternative quantity, an alternative pharmaceutical form, an alternative strength, a therapeutic equivalent or a generic equivalent as indicated in the protocol – without going back to the prescriber. The Policy Note is available at Annexe A. 3. The Committee considered this instrument at its 23rd Meeting on 8 October 2019 and agreed to write to the Cabinet Secretary for Health and Sport. We received a response from the Cabinet Secretary on 22 October 2019. This is available at Annexe B. 4. An electronic copy of the instrument is available at: https://www.legislation.gov.uk/ssi/2019/284/contents/made 5. There has been no motion to annul this instrument. 6. The Committee needs to report by 6 November 2019.
Delegated Powers and Law Reform Committee consideration
7. The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 24 September 2019. The Committee determined that it did not need to draw the attention of the Parliament to this instrument on any grounds within its remit.
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Annexe A
POLICY NOTE THE NATIONAL HEALTH SERVICE (SERIOUS SHORTAGE PROTOCOLS) (MISCELLANEOUS AMENDMENTS) (SCOTLAND) REGULATIONS 2019 (SSI 2019/284)
The above instrument was made in exercise of the powers conferred by section 17E, 17N, 27, 28(1) and 105(7) of the National Health Service (Scotland) Act 1978(a). The instrument is subject to negative procedure.
This instrument amends the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, The National Health Service (General Medical Services Contract) (Scotland) Regulations 2018 and The National Health Service (Primary Medical Services Sections 17C Agreements) (Scotland) Regulations 2018 in order to extend the scope and operationalise Serious Shortage Protocols (SSPs). Where there is a serious shortage of a prescription only medicine or other drug or appliance ordered on an NHS prescription form, SSPs will allow pharmacists and dispensing doctors to supply a different product or quantity or strength in accordance with the SSP, rather than fulfilling the original prescription.
Policy Objectives Amendments to The Human Medicines Regulations 2012, which entered into force on 9th February 2019, enabled UK Ministers to issue Serious Shortage Protocols (“SSPs”) for prescription on medicines (POMs). This SSI amends The National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009 to allow community pharmacists to operate under an SSP issued by UK Ministers. Amendments also made to the English equivalent Regulations, The National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013, made provision for UK Ministers to issue SSPs in England only for all other drugs / appliances which are not POMs. This SSI allows Scottish Ministers to issue a Scottish SSP for all other drugs and appliances classed as in serious shortage. Previously, if a community pharmacy could not dispense what was on the prescription, the pharmacists needed either to refer the patient back to the prescriber or, if there was an urgent need, contact the prescriber to discuss an alternative and then get the prescription changed by the prescriber. This instrument allows pharmacists within a community pharmacy to supply in accordance with a SSP issued under the Human Medicines Regulations 2012, which may allow for the supply of an alternative quantity, an alternative pharmaceutical
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HS/S5/19/24/2 form, an alternative strength, a therapeutic equivalent or a generic equivalent as indicated in the protocol –without going back to the prescriber. This instrument also creates another type of SSP where Scotland or any part of Scotland is experiencing or may experience a serious shortage of a drug or appliance, which is not a POM. In these circumstances, the Scottish Ministers can issue a “Scottish Serious Shortage Protocol” (“Scottish SSP”) – community pharmacists will be able to supply a different drug/appliance or quantity or strength of the drug/appliance without the need to go back to the prescriber. Dispensing doctors will also be able to supply a different drug or appliance or quantity or strength of the drug or appliance where a Scottish SSP is in place. The Scottish Government and NHS Scotland have well established procedures for managing medicines shortages, and Scottish Government work collaboratively with UK Government and the Medicines and Healthcare Products Regulatory Agency in order to manage supply issues when they occur, SSPs will provide an additional tool for the purposes of managing shortages. It will be impractical for patients and a burden on NHS Primary Care services for all patients affected by a serious shortage to return to the prescriber, usually a GP, or for the pharmacist to liaise with the prescriber for each individual prescription. As an example, a delay caused by the need for a new prescription could increase the risk to patients requiring a supply of an auto-injector which would be needed should the patient experience an allergic reaction. In addition, the effective management of shortages of products may prevent products in short supply from running out completely, and so potentially significantly decreasing the risk to those patients who would otherwise be left with none of the product. Avoiding referrals back to a prescriber, where an alternative supply can be made safely and appropriately, will also enable GPs and other prescribers to focus more time on other patients care needs, including urgent care. The power to issue a SSP (POM only) is reserved to UK Government and would only be used in exceptional circumstances. “Scottish SSPs” for all other drugs and appliances than POMs may be issued by Scottish Minsters. Ministers signing off a “Scottish SSP” will be advised by the Medicines Shortage Response Group Scotland (MRSG(Sco)) which is chaired by the Chief Pharmaceutical Officer for Scotland. The MRSG(Sco) will consult with expertise in the relevant area to provide the clinical content for any protocol for a “Scottish SSP”. Each protocol will clearly set out what action can be taken by the pharmacist, under what circumstances, for which patients and during which period. The instrument does not relate to the UK’s withdrawal from the European Union. However, if withdrawal from the European Union was a contributing factor to a serious shortage of a product normally available on an NHS prescription form, a SSP may be issued by UK Ministers. For all other drugs/appliances that are not POMs, Scottish Ministers may issue a Scottish SSP should they consider a serious shortage is in place in those circumstances.
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Consultation The Scottish Government consulted with the contractors’ representative body in Scotland, Community Pharmacy Scotland, on both terms of the amendments to the 2009 Regulations and the operational guidance for pharmacists in the event of an SSP. NHS Boards were also consulted.
Impact Assessments Impact assessments have not been prepared for this instrument as there is no change in accessibility to the pharmaceutical services being delivered by community pharmacies for patients. The amendments made by these Regulations are enabling and the new arrangements will only be used when there is a recognised serious shortage. It is not possible to predict the number of serious shortages that might arise, the duration and the nature of the products that may be affected. This will be driven by intelligence gathering at the time, but expectation is that SSPs will only ever be needed in exceptional circumstances. SSPs would ensure the timely access to treatments for patients. Serious shortages of treatments in themselves present risks to patients.
Financial Effects No BRIA is considered to be required. The financial impact of medicine shortages are part of the day to day operations of the NHS in Scotland. In the event of a medicine shortage, drug costs are likely to increase as a result of more demand for less available products. SSPs will not eliminating the potential for increased costs but will endeavour to mitigate by providing alternative available product for dispensing to patients. SSPs will help in reducing the costs to the NHS in Scotland in both time and resource for new prescription forms being completed by prescribers as a result of a serious shortage.
Scottish Government Directorate for Chief Medical Officer Pharmacy and Medicines 11 September 2019
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Annexe B
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HEALTH AND SPORT COMMITTEE 24th Meeting, 2019 (Session 5) HS/S5/19/24/4 Tuesday 29 October 2019
SUBMISSION FROM Prof R.C.Richard Davison, University of the West of Scotland and Board Member, Observatory for Sport in Scotland
1. To what extent does social prescribing for physical activity and sport increase sustained participation in physical activity and sport for health and wellbeing?
Physical activity and sport are too often grouped together but are distinctly different. Physical activity is a much broader term which can cover many aspects of daily life active transport, housework, work activity, structured exercise etc. A sport participant can mean any person who directly or indirectly participates in sports as a player, contestant, team member, coach, manager, trainer or administrator. While it is recognised that the majority of physiological, psychological and social benefits arise from the physical participation of being a player, contestant or team member there are also documented psychological and social benefits for the non-physical participation of being a coach, manager, trainer or administrator. For many individuals sport participation is the primary way that they gain the majority of their physical activity over the week. However, this is not consistent across the age range as it has been shown that younger adults are more likely to gain their weekly physical activity through sport than those over 55 (van Uffelen Claire Jenkin Hans Westerbeek Stuart Biddle and Rochelle Eime, 2015). Sport is much more heavily structured usually overseen by NGB’s requires facilities and appropriately trained coaches to oversee the development of individuals taking part in that sport.
From what I understand social prescribing would involve a CLW signposting appropriate sport and physical activity opportunities as deemed appropriate. There are two significant issues I perceive with this proposal.
1. A CLW for this type of social prescribing would require a specific skillset from both prior qualifications (i.e. sport science degree) and a very specific training programme centred around exercise prescription. would need to be established to train CLW’s to complete an appropriate needs analysis and can make a considerable contribution to overall physical activity. 2. There is a distinct lack of destinations with the correct facilities and expert staff for a CLW to refer to. It is possible with the right investment that this could be created and delivered by a mix of local authority and NGB’s as well as specialist private providers.
Regardless of the system or process in place the research evidence suggests that for ‘sustained’ participation in sport or physical activity and individual needs to build sufficient ‘social or sporting capital’. There are a number of theoretical models on this topic, but none have as yet undergone robust research evaluation nor practical deployment evaluation.
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2. Who should decide whether a social prescription for physical activity is the most appropriate intervention, based on what criteria? (e.g. GP, other health professional, direct referral from Community Link Worker or self-referral)
One of the key issues in this decision-making process is the appropriate training to make the decision. There is a recognised lack of specific exercise prescription training in both GP and health professional training. While their training would enable them to recognise the potential benefit of exercise for an individual the next steps of needs analysis, personalisation, detailed prescription and monitoring are not covered in their current training.
For example, many GP’s already engage in exercise referral schemes however the effectiveness of these schemes are generally poor. This is mostly due to a poor initial evaluation of the most effective strategy for that individual and a lack of appropriate facilities and trained individuals to refer to.
One suggestion could be to have GP surgeries embedded into sport centres and equivalent facilities providing both sport and physical activity opportunities to show the direct link between health and increased activity. ‘Exercise is medicine’ and this needs to be reinforced.
3. What are the barriers to effective social prescribing to sport and physical activity and how are they being overcome?
The main barrier to an effective process is the lack of appropriate referral destinations with appropriately trained individuals.
While health inequalities and deprivation are linked with lower than average/desired sport participation and physical activity levels these issues are not unique to this group and thus a real desire to raise participation in sport and physical activity needs a much more radical population approach which is properly monitored with interventions that are properly evidenced based. There is emerging evidence that there is a group of active individuals who are becoming more active whereas the least active and non-active populations are growing. The latter group is clearly the most problematic in terms of population health trends and requires significant investment in research to develop appropriate interventions to target that group. Therefore, a major barrier is our current understanding of how to influence the
4. How should social prescribing for physical activity and sport initiatives be monitored and evaluated?
Despite extensive research findings going back more than 50 years establishing the link between physical activity levels and health and the recognition that physical activity levels are falling there has been a failure to develop successful strategies to address this significant health issue. Even today there is a lack of research evidence on successful interventions. Too often there has been significant investment in interventions that have had limited evidence base for their effectiveness followed by poor evaluation of their outcomes.
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Also, the lack of adequate population-based measurement of sport participation makes it extremely difficult to firstly determine the true extent of the problem but also determine accurately whether any interventions are actually having any effect. Two recent OSS publications (Sports For The Future: Decline, Growth, Opportunity And Challenge https://www.oss.scot/sports-for-the-future/, Sport Participation in Scotland: Trends and Future Prospects, https://www.oss.scot/spsreport2019/), using the limited evidence from the Scottish Household Survey and the Scottish Health Survey that currently exists, clearly highlight the key issues that despite many policies and interventions sport and physical activity levels are in decline and much lower than in other European countries. However, while the two aforementioned surveys are conducted to a high standard, they fail to ask the correct questions to fully evaluate the key issues in sport and physical activity. Therefore, evaluation of the effectiveness of social prescribing monitoring of numbers of individuals within a social prescribing scheme as well as properly constructed regular national surveys of both sports and physical participation as happens in other European Countries.
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HEALTH AND SPORT COMMITTEE
SOCIAL PRESCRIBING OF PHYSICAL ACTIVITY AND SPORT
SUBMISSION FROM Dr William Bird CEO Intelligent Health and a GP
We are entering the fourth revolution of healthcare. The first revolution was Public Health with drinkable water, sanitation, cleaner air and better housing and working conditions. The second is medical healthcare with the advancement of diagnostics and treatment with a focus on disease cure. The third is personalised health through dissemination of knowledge (internet) and technology such as genomics, wearables and behaviour change that is leading to precision medicine.
However, these revolutions have left three major problems unresolved. The first is unsustainable healthcare including rising costs, antibiotic resistance and the persistence of long-term conditions such as cardiovascular disease, dementia, diabetes, depression and cancers. The second problem is rising health inequalities in which the life expectancy of poorer women in the UK is now falling for the first time in recent history. In Scotland during 2015-2017 the difference in healthy life expectancy (the years of a healthy life) between the 10% most and 10% least deprived areas was 22.5 years for males and 23.0 years for females16.
The third and final problem is climate change driven by unsustainable living which is affecting the health of populations (flooding, urban heat islands) and of the planet. NHS Scotland makes up about 3.6% of the carbon footprint and 1 in 20 vehicles on the road in the UK are NHS related. However, living a low carbon lifestyle (low meat diet, active travel, improved air quality) will help reduce the incidence of many long-term conditions.
So we enter the fourth revolution in healthcare which can be categorised as People, Purpose and Place. This is based on communities rather than individuals, supporting a sustainable active lifestyle, eating local produce and using culture, art and nature to create purpose and connections to each other, leading to greater resilience and happiness. It also ensures that “place” becomes central in delivery of health. At the recent International conference in Glasgow on June 10th Aileen Campbell said:
“A place-based approach is crucial to addressing our public health priorities, helping to improve physical and mental wellbeing by empowering people to shape their local environments”1
The previous three revolutions continue but the fourth if adopted in Scotland will help combat the three of the greatest challenges we face. So what is the science behind this fourth revolution.
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Chronic stress and chronic health conditions There has been a rise in long term conditions which is not just caused by people living longer. For example, the prevalence of diabetes is rising in Scotland with 263,000 people diagnosed with type 2 diabetes in 2017 which is forecast to rise to 350,000 cases by 2025. Many long-term conditions such as diabetes, depression, anxiety, cardiovascular disease and dementia tend to cluster in areas of deprivation, which creates a gap between the life expectancy of the rich and the poor. These conditions also tend to cluster in the same person, with 23% of adults having two or more chronic conditions (ranging from 7% of those
HEALTH & RESILIENCE STRESSORS • People Strong social networks • Purpose • Autonomy CHRONIC • Place STRESS • Natural green, blue and safe environments GLUCOCORTICOIDS & CATECHOLAMINES
POOR HEALTH BEHAVIOURS
POOR SMOKING, INACTIVITY ALCOHOL, ETC. DIET
CHRONIC INFLAMMATION
CHRONIC HEALTH CONDITIONS
CARDIOVASCULAR DIABETES DEPRESSION DEMENTIA FATIGUE DISEASE
Figure 1: Highlights two pathways: health/resilience related factors (people, purpose, place) which can inhibit and relieve stress; stressors that can lead to chronic stress and poor health behaviours, both of which can lead to chronic inflammation and chronic health conditions (Adapted from Chapter 1.6, Oxford Textbook of Nature and Public Health 2018).8 under 45 years of age to 51% of those 65 years or older) with a significant deterioration of quality of life with each co-morbidity.2
Our body is designed to respond to short-term stress; if these responses are used for long term chronic stress then it causes harm and is highly damaging to the body and can result in chronic inflammation in the following ways (Figure 1):
1) Stress leads to the release of cortisol, through the Hypothalamic Pituitary Adrenal (HPA) and Ghrelin hormone both of which increase appetite leading to excess consumption of palatable and “inflammatory “food; these extra calories are stored as visceral fat, which can independently cause inflammation.5 2) Our body constantly releases catecholamines and cortisol through repeated activation of the HPA axis which switches from being anti-inflammatory to inflammatory.7
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3) Chronic stress leads to coping mechanisms such as smoking and the use of drugs and alcohol, all of which lead to chronic inflammation.6 4) We become less active to try and conserve energy. We lose our motivation and push activity further down our list of priorities. Sedentary behaviour is strongly inflammatory due to specific build-up of visceral fat, reduced anti-inflammatory Myokines from muscles, mitochondrial damage and telomere shortening. 7
Chronic inflammation is a shared pathology of cardiovascular disease, depression, anxiety, dementia, diabetes and frailty which causes damage to the body over many years.3 Chronic inflammation is directly related to deprivation and children with adverse childhood experiences will have raised inflammatory markers (such as IL-6, CRP and anti-TNF) compared to their peers. This chronic inflammation in childhood lays the foundations of long-term conditions and premature aging.4 Chronic inflammation is a disease in itself and because it has no traditional medical cure, it has to be treated by reducing chronic stress and changes in lifestyle which the third and fourth health revolutions can deliver.
Evolution of chronic stress How do we overcome and reduce chronic (toxic) stress? We evolved to be hunter gatherers and we perfected our survival techniques over 200,000 years through three main factors that are the fundamental basis of health. 1) People: We had social support from family and friends who made us feel valued and loved. 2) Purpose: We had a sense of purpose where we had defined roles, which created a sense of belonging and control over our life. 3) Place: We were outdoors and connected to nature, which we observed, understood and respected. These three “Ps” create resilience, which can reduce chronic stress, leading to reduced chronic inflammation and therefore greater health and wellbeing.
Today’s society is taking us further away from the factory settings for which we were designed. 1) People: We have a rising problem of loneliness and social isolation. 2) Purpose: A sense of powerlessness and lack of autonomy. 3) Place: A disconnection from nature and the outside world. Children spend less time outdoors than the average prisoner.
While humans may have adapted culturally to these drastic changes, these environmental changes have happened so fast that many aspects of human physiology have not yet had the chance to adapt17. Essentially, our brains and our bodies still function as if we still live like our hunter-gatherer ancestors. Because of this, it has been suggested that humans are mismatched to the environments we currently live in18, which manifests as health problems based on stress and chronic inflammation.
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The further we stray away from the context in which we evolved, the less resilience we will have, leading to worsening chronic stress, greater chronic inflammation and subsequent poorer health and wellbeing (Figure 1).
Overcoming chronic stress The early attempts of the NHS to reach out to patients and change their lifestyle were Exercise referral schemes which treated exercise deficit with exercise. This was very linear and did not address the underlying problems This in general was not shown to be sustained and NICE in England advised against commissioning more programmes.
Social Prescribing Social prescribing is an important part of treating chronic inflammation. Social prescribing uses a link worker to connect people with existing community groups with structured activities such as Health Walks, Park Runs, Zumba classes, sport etc. in addition to providing support for other aspects of their lives like navigating benefits schemes and getting job training.12 These structured interventions help to promote health and resilience (Figure 1) by directly addressing people, purpose and place and giving people new opportunities to become active, socialise, get their life back in order and feel part of the community rather than depend on new analgesia or anti-depressants.
Social prescribing is a major step forward in disrupting the medical model but there are challenges to its widespread use including funding failing to reach delivering organisations (usually voluntary, charity or social enterprise organisations) and a bias towards patients wanting to be referred in the first place into a system with a hierarchy of professionals, leaders and structures. This mean that social prescribing has limited scope to reach the many thousands who have the greatest need.
Social Movements Social movements are not new and devolve delivery and control to the community. Instead of a referral and a link worker referring a patient to an organised activity, the social movement simply connects an individual to a self-created unstructured activity. In this way, every person becomes a link worker. The mum walking her child to school, the teacher taking his class outside, the receptionist getting patients walking, the manager changing the culture of the workplace. The motivation is turned on its head. Exercise and health are now no longer the drivers but merely outcomes that are a by-product of a happier more connected life.
The fourth revolution will ensure a sustainable change that will be driven by communities connecting to each other and to their local (natural environment). The drivers of change are the positive experiences based on the values of the individual and community that increase social connections, create a sense of purpose and connect people to place (people, place and purpose). Social movements use existing social connections (families, workplace, neighbourhoods, schools etc.), as well as new connections through social media, that lead to new habits and new social norms. Instead of structured activities in the community (that often require funding and resource), the vast majority of potential new activities are informal,
Page 7 of 51 HS/S5/19/24/4 family based, local and free (Figure 2). The benefits of health and activity are hidden and, again, are simply outcomes of living a better life.
A healthy place becomes central to this fourth
Physical activity Opportunities
Structured activity Unstructured activity Active travel
Figure 2. The proportion of physical activity opportunities showing how active travel and unstructured activities have the greatest potential to promote physical activity (adapted from the Sport England Active Lives and Household survey).13
One example of an evidence-based intervention that uses the social movement model is Beat the Street (www.beatthestreet.me), which is a mass participation intervention that aims to get people more active, increase social cohesion and connect people to their local neighbourhood. It combines gamification technology and behavioural psychology to engage whole communities, particularly the least active and those in the most deprived areas. In four years, over 1 million people and 2000 schools have participated.
In Scotland over 100,000 people have engaged with Beat the Street. In Annan and Dalbeattie 38% of the entire population took part with an average of 44% of the inactive population engaged becomes active and staying active six months later with evidence of sustained change two years post-intervention.10, 11, 15 In addition to this, Beat the Street can also increase wellbeing10, active travel11, improve air quality, strengthen families and community groups and help people to connect to the very local area. The programme’s 6-week game provides opportunities for individuals to change their lifestyle by shifting extrinsic (the game itself) to intrinsic behaviour (the positive experience) to create sustained change. If we are to deliver the fourth revolution, then communities must take more control and a social movement will change a culture. Beat the Street as with any social movement where health is an outcome, the three domains of people, purpose and place are used as the end points and the physical activity is simply the means to get there:
In summary we have to move away from the medical model and embrace the third and fourth revolutions. However, personalised health which includes social prescribing on its own is unlikely to narrow the health inequalities at scale. Social prescribing needs to embrace the fourth revolution as well. This means that it is delivered in collaboration with a better place to live (accessible green space, a safe walking environment and safe open communal places, culture) and the generation of a social movement that lead to thousands of small innovations from a community that is more empowered and confident in creating a better future with
Page 8 of 51 HS/S5/19/24/4 increasing connections. Beat the Street is one innovation that shows that this can be done at scale, in the most deprived communities and with lasting impact.
References
1. http://www.healthscotland.scot/news/2019/june/experts-gather-to-discuss-place-and- public-health 2. Mujica-Mota RE, Roberts M, Abel G, Elliott M, Lyratzopoulos G, Roland M and Campbell J. Common patterns of morbidity and multi-morbidity and their impact on health-related quality of life: evidence from a national survey. Quality of Life Research 2015; 24: 909-918. 3. Soysal P, Stubbs B, Lucato P, Luchini C, Solmi M, Peluso R, et al. Inflammation and frailty in the elderly: a systematic review and meta-analysis. Ageing research reviews 2016; 31: 1- 8. 4. Baumeister D, Akhtar R, Ciufolini S, Pariante CM and Mondelli V. Childhood trauma and adulthood inflammation: a meta-analysis of peripheral C-reactive protein, interleukin-6 and tumour necrosis factor-α. Molecular psychiatry 2016; 21: 642-649. 5. Morris MJ, Beilharz JE, Maniam J, Reichelt AC and Westbrook RF. Why is obesity such a problem in the 21st century? The intersection of palatable food, cues and reward pathways, stress, and cognition. Neuroscience & Biobehavioral Reviews 2015; 58: 36-45. 6. Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet Public Health 2017; 2: e356-e366. 7. Tsatsoulis A and Fountoulakis S. The protective role of exercise on stress system dysregulation and comorbidities. Annals of the New York Academy of Sciences 2006; 1083: 196-213. 8. Bird W, Bosch M. Oxford textbook of nature and public health. 2018. 9. Pittini E, Adamo G, Gray M and Jani A. Resetting priorities in precision medicine – The role of social prescriptions. JRSM (in press). 10. Harris MA. The relationship between physical inactivity and mental wellbeing: Findings from a gamification-based community-wide physical activity intervention. Health psychology open 2018; 5(1). [Online first] 11. Harris MA and Bird W. Bright spots, physical activity investments that work: Beat the Street. Br J Sports Med 2018; [Online first] 12. Polley MJ, Fleming J, Anfilogoff T, et al. Making Sense of Social Prescribing. Report, University of Westminster, UK, August 2017. 13. Active Lives Online. [Internet]. Sport England. [cited 2019 September 7]. Available from: https://activelives.sportengland.org/. 14. Health as a social movement: The power of people in movements. [Internet]. NESTA. [cited 2019 September 7]. Available from: https://media.nesta.org.uk/documents/health_as_a_social_movement-sept.pdf. 15. Harris MA. Maintenance of behaviour change following a community-wide gamification based physical activity intervention. Preventive medicine reports 2019; 13: 37-40. 16. Healthy Life Expectancy in Scottish Areas 2015-2017 National Records of Scotland. March 2019. 17. Tybur, J. M. and Griskevicius, V. (2013) ‘Evolutionary psychology: A fresh perspective for understanding and changing problematic behavior’, Public Administration Review, 73(1), pp. 12-22. 18. Li, N. P., van Vugt, M., and Colarelli, S. M. (2018) ‘The evolutionary mismatch hypothesis: Implications for psychological science’, Current Directions in Psychological Science, 27(1), pp. 38-41.
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Intellıgent Health
Moving at Scale – From Inactive to Active
Technical analysis from Jump intelligenthealth.co.uk jump-projects.com Page 10 of 51 HS/S5/19/24/4 Beat the Street Key questions we wanted to answer Summary of key findings
Beat the Street works as a base 1 Analysis of the demographics vs national averages platform for activity in an area to see whether Beat the Street works where it is and helps build healthier more needed most (in inactive communities) resilient communities. Beat the Street participants are initially more inactive than the national average. Beat the Street With one million participants and individual programme succeeds in engaging individuals in deprived areas evidence of success, Intelligent Health commissioned Jump to collate and review impact. Jump analysed data across 10 recent Beat the Street programmes 2 Active vs inactive to compare Beat the Street against pre, post and 6 months following the game. And the national picture from Active Lives using year on compared impact against national data sets. year data to avoid seasonality Beat the Street achieves improvements in physical Summary of key findings: activity and reductions in inactivity that far exceed any movement in the national data
3 Analysis of microdata to see if the wellbeing impacts vary with demographics and socio economics Significant and The impacts The Beat Beat the Street has a greater impact on adults positive impact endure and strongest the Street from areas of high deprivation and on children on shifting inactive remain positive impact is in also reduces more generally people to active 6 months after deprived, inactive levels of (adults and children) the programme communities anxiety
2 Page 11 of 51 3 HS/S5/19/24/4 We shift adults who are inactive to being active We shift children who are inactive to being active Adults (19+) Children (under 19)
Beat the Street Active National* Active Beat the Street Active National* Active Active1 Beat the Street Inactive National* Inactive Active1 Beat the Street Inactive National* Inactive up 15% up 14% % of sample % of sample 58% at baseline 38% at baseline 80 80 (14,316/24,651) to 15% (5,782/15,400) to 73% at 6 month 52% at 6 month follow up 70 follow up 70 (822/1,125) (110/189) 60 60 14% 50 50
40 40
30 30
20 20 Inactive2 Inactive2 19% reduced 10 reduced 10 by 17% 17% by 19% 0 0 29% at baseline 37% at baseline Baseline 6 month follow up Baseline 6 month follow up (7,075/24,651) to (5,762/15,400) to 12% at 6 month follow up 1 More than 150 minutes a week 2 Less than 30 minutes a week 18% at 6 month follow up 1 More than 420 minutes a week 2 Less than 210 minutes a week * Active Lives data, Year 1 vs. Year 2 (Oct-Nov 2016 vs. Oct-Nov 2017). Year-on-year difference * Active Lives Children and Young People survey data, Year 1 (2017-2018): Autumn 2017 vs. (137/1,125) chosen as opposed to 6 months to avoid seasonality effects. (34/189) Spring 2018. 4 Page 12 of 51 5 HS/S5/19/24/4 Two big numbers show Immediately after immediate impact of finishing the game, Beat the Street: people are more active
80 161
Adults do 80 extra minutes of physical For children, the effect is activity per week after Beat the Street greater at 161 extra minutes (based on a matched sample of 5,025 adults (based on a matched sample of 869 children using regression analysis) using regression analysis) 6 Page 13 of 51 7 HS/S5/19/24/4 And this impact on physical activity endures
After the initial boost of Beat the Street, physical Adults Children activity levels drop slightly, but remain higher than at registration. Additional minutes of physical activity a week
6 months later: 200
175 Adults are active for an additional 50 minutes 150 a week compared to registration 125 (based on 837 individuals) 100
75
50 +50 +138 minutes minutes Children are active for an 25 additional 138 minutes a week 0 Beat the Street Beat the Street Beat the Street (based on 129 individuals) registration post-game 6 months later 8 Page 14 of 51 9 HS/S5/19/24/4 Positive impacts for participants in high deprivation areas Positive impacts for men and women (and boys and girls)
There is a positive improvement in There is a positive improvement physical activity post-game for all in physical activity post-game for deprivation levels Adults 6 months later Children 6 months later both genders Adults 6 months later Children 6 months later Minutes of activity Likelihood (%) to move to a higher level of physical activity However, for adults 200 While for adults the 50% the improvement changes are close for is strongest for 175 men and women individuals living in 40% 150 more deprived areas 125 The improvements for boys are 30% The same holds for 100 considerably bigger children if we look 20% at lasting impacts 75 (6 months later) 50 10% 25
0 0% High Medium Low High Medium Low Female Male Female Male deprivation deprivation deprivation deprivation deprivation deprivation
Sample sizes: Post-game: 5,025 (adults), 869 (children); Six months later: 837 (adults), 129 (children) Sample sizes: Post-game: 5,025 (adults), 869 (children); Six months later: 837 (adults), 129 (children) 10 Page 15 of 51 11 HS/S5/19/24/4 What is the impact on Biggest improvements in Beat the Street reaches the wider community? tough, inactive communities individuals in deprived areas
As well as clear evidence of shifting the population from inactive to active, Beat the Street also involves the community in volunteering:
There are about 100 team leaders in each Beat the Street programme
2019 has seen more research establishing the clear links between volunteering and benefits to wellbeing, social mixing and greater trust in and belonging to your community*
This work has also indicated that there is a greater deficit of trust and wellbeing in low socio economic 27% 100 areas and correspondingly greater benefits from volunteering in these areas
The DCMS Strategy for Sport has as one of its 5 key outcomes ‘Community Development’. As well as a significant impact on improving activity, Beat the Street benefits the community by involving them directly in delivery of the programme. The social connections and 27% of participants are from the Increases in physical activity are greatest for networks that are built through this could be what helps 30% most deprived areas in England adult participants in high deprivation areas to generate a more sustainable and enduring change (15,389/56,178) (100 minutes as opposed to 69 minutes in medium (as evidenced by the activity levels enduring for six deprivation areas and 80 in low deprivation areas – months). We will investigate this impact further in future. (*Happy Days, ABC of BAME and A Bit Rich) reference website jump-projects.com/our-work disaggregated regression analysis) 12 Page 16 of 51 13 HS/S5/19/24/4 And Beat the Street Sample sizes for physical activity Who takes part in Beat the Street? reduces levels of anxiety
The summary statistics on minutes and levels 47% of participants are 18 or younger – 25,666 out of physical activity are based on the following of 55,049 samples: 53% are 19 or older – 29,383 out of 55,049 (average Time point Registration Post 6 months age of 40.75 for the adult participants) game later Almost 70% of the adult participants are female Total sample 56,670 8,704 1,400 – 20,479 out of 29,382 -0.38 size 22% have a long term health condition Non-missing 39,752 7,650 1,314 (12,469) and 4% have a disability (1,805) physical activity data Slightly lower share of people from ethnic minority groups – this may be evened out by the sizeable Of which 24,651 6,766 1,125 proportion (4.7%) of those choosing not to disclose Adults their ethnicity
Of which 15,400 885 189 People engaged from areas of all levels of deprivation Beat the Street participants experience significantly Children
lower levels of anxiety immediately after the game Independent analysis was conducted by Jump-projects.com working with pre, post and six month on survey data of Beat the Street participants. Regression analysis was restricted to those (a -0.21 change on a scale of 0 to 10) and even more so six months later respondents who provided answers at two or more points in time, to mitigate selection bias and (a -0.38 change). Results are inconclusive on other wellbeing outcomes and child * Note that in the national data the level of to provide more confidence that the results can be attributed to participation in Beat the Street. anxiety fluctuates slightly over the months, Summary and technical write- up , data tables and caveats and limitations available on request attitudes to sport, which is surprising as most of the work in the sport, activity but wellbeing is only available in one wave from [email protected] sector tends to demonstrate positive wellbeing impacts across the board. Our of data and therefore we cannot observe * year-on-year increases (Active Lives future work will aim to understand these impacts in more detail (adult) Survey) 14 Page 17 of 51 15 Designed by cream-design.co.uk HS/S5/19/24/4
Building Active Communities
+44 (0)118 935 7371 [email protected] intelligenthealth.co.uk
Reading Enterprise Centre University of Reading Earley Gate Whiteknights Road Reading RG6 6BU @Intelligent_Hlt Intellıgent October 2019 Health Page 18 of 51 HS/S5/19/24/4
HEALTH AND SPORT COMMITTEE
SOCIAL PRESCRIBING OF PHYSICAL ACTIVITY AND SPORT
SUBMISSION FROM Scottish Sports Futures
1. To what extent does social prescribing for physical activity and sport increase sustained participation in physical activity and sport for health and wellbeing? Participation will only be sustained if the environment is right and the fundamental needs/reasons for the prescribing of participants/individuals being referred are being met. For activity to be sustained it should have the people at the heart not outcomes set by others, the change should be agreed with the individual and then whoever is facilitating the sessions work alongside the individuals to understand their needs, to support with personal development to increase confidence, self esteem and aspiration to create and achieve change themselves through regular participation. The barriers to being active regularly should be explored and these may be real or perceived, but we cannot assume to know what they are. These then need to be removed for the participation to be sustained. Organisations offering ‘wrap around’ support – pathways into regular activity after what may begin as an intensive referral- based support should be on offer and if the organisation with the original activity cannot offer this then real partnerships with local organisations who can should be sought from the outset, not as an after thought to sustainability.
2. Who should decide whether a social prescription for physical activity is the most appropriate intervention, based on what criteria? (e.g. GP, other health professional, direct referral from Community Link Worker or self-referral) The individual should decide, IF they are given all of the options to make an informed decision. There is a real need for genuine collaboration with health care staff, third sector and public bodies as together we actually have the answers to a (this) public health crisis. Regular sport and physical activity we know can change lives, to tackle poor health both physical and mental it will reduce the cost of prescriptions and being will be more able to work and lead an active healthy life. So, what are we doing about this – its all of our responsibility to make links to ensure that all agencies involved in a persons life (especially at a time of crisis or an obvious point for a referral). Obesity, mental health problems, addiction, entry into the criminal justice system, trauma, social work referral, non-engagement with school, unemployment these are all reasons to prescribe physical activity so therefore all agencies involved with an individual should be prescribing and then sharing information on progress so this can be celebrated, shared, made visible as a valid and transformational option for positive health.
3. What are the barriers to effective social prescribing to sport and physical activity and how are they being overcome? Organisations and professionals actually working together. Collaboration within the same sectors is strong and partnership working can be brilliant. However we need to look wider, every professional and sector that is working to create positive change, reduce health inequalities, create a healthier Scotland has a responsibility to work
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cross sector taking a place based approach to understand needs of communities that we serve. And together offer clear and easy routes/pathways/options into prescribing sport and physical activity. Third sector organisations continually having to prove worth is also a barrier, by constantly chasing funding and having skilled experienced practitioners doing so this impact on the amount of quality interventions that can be delivered. If an organisation can clearly demonstrate impact then there should be a regular stream of statutory funding to support this instead on constantly having to re-create the wheel. We know what works what needs to be done now is a bigger investment into sport and physical activity. All organisations offering this as a solution being accountable for working together, I like sportscotlands new strategy ‘sportforlife’ we as a third sector organisation delivering ‘Sport4Change’ for the last 20 years in Scotland can clearly see ourselves in it. Scotland is small so we need to work better together and be accountable for doing so.
4. How should social prescribing for physical activity and sport initiatives be monitored and evaluated? With the individual being prescribed. What is the change they want to see. We can create common indicators and evaluate how people feel about themselves using common templates, we can do baseline surveys to gather data from the outset – using the same measures to ensure an accurate collation. We can ensure that best practice and people willing to talk about their journeys have a platform, a voice and are involved in mentoring others being prescribed physical activity and sport.
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HEALTH AND SPORT COMMITTEE
SOCIAL PRESCRIBING OF PHYSICAL ACTIVITY AND SPORT
SUBMISSION FROM DR KATIE WALTER GP AT CAIRN MEDICAL PRACTICE, INVERNESS
I am a GP in Inverness involved in a number of projects looking at promoting physical activity from a health care setting. I have been involved from the start with Cycling UK’s WheelNess project. I have been involved with a research project with UHI which has not yet completed on attitudes of health care professionals around physical activity social prescribing. I am currently involved in Velocity’s Active People Link Workers project. This is a one year funded project looking embedding link workers into GP surgeries with the express purpose of facilitating person-centred physical activity uptake. My practice is a ParkRun promoting practice. I also sit on the Highland Green Health Partnership and the HITRANS Active Travel Advisory Group.
1. To what extent does social prescribing for physical activity and sport increase sustained participation in physical activity and sport for health and wellbeing? It would be wise for the committee to commission an overview of the evidence as this is an area of research growth and recent new evidence might be emerging: previously reviews have not highlighted that social prescribing for physical activity is very effective for sustained participation. Multiple barriers have been identified. There is currently a plethora of projects underway designed to increase sustained participation in physical activity and sport (from ParkRun internationally, Active People link workers for us very locally in Inverness) and evidence should be emerging from these. This is an opportunity to shape the key research questions which such projects could help address through their monitoring and evaluation. It is key that a good quality review is undertaken as there have been previous misguided but well intentioned large spends which lacked any evidence base and were ineffective.
2. Who should decide whether a social prescription for physical activity is the most appropriate intervention, based on what criteria? (e.g. GP, other health professional, direct referral from Community Link Worker or self-referral) Given the known effectiveness of physical activity as both primary and secondary prevention in health, across nearly all conditions both for physical and mental health, this is a matter for all health professionals. In fact, healthcare assistants might often be in a more privileged position to broach the conversation around physical activity. This is a public health issue similar to smoking: it should be everyone’s business. As with smoking cessation, that patient journey towards stopping smoking is complex, and there are lessons to be learnt.
My answer to Q2 therefore would be “none of the above, but the patient” as in a person- centred approach, it will be the patient who decides whether a physical activity “prescription” (or referral on to a link worker or a specific project) is the most appropriate intervention. But we do need to be able to have health professionals who are comfortable with the very different motivational interviewing / brief intervention skills which are needed for talking about physical activity. This is crucial. A lot of the healthcare workforce has little training or supervision in effective motivational interviewing skills.
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I have an ambivalence with the term “social prescribing” as it is a broad umbrella that maybe gathers a lot of disparate things: the most common form of “social prescribing” that I do in practice is having daily conversations about walking and cycling or taking the bus. None of these discussions feel like “social prescriptions”, and yet they are the most accessible, cheapest, most manageable changes to make for some people. From a health inequalities point of view, walking is the most accessible.
At the other end of the spectrum, I also have frequent conversations with people with complex mental or physical health needs for which it is very appropriate that it is a doctor or an advanced practitioner with a good knowledge of that patient who is able to tap in either directly to a relevant project with clear criteria, or to refer on to a link worker who holds up to date information. Projects come and go, criteria change, and it is not realistic to think that we can stay on top of these changes – link workers would be ideally suited for this.
3. What are the barriers to effective social prescribing to sport and physical activity and how are they being overcome? Again, this question needs an up to date evidence review. Known barriers from previous reviews are multiple, patient- related, healthcare professional related, and societal barriers. I will focus on those relevant to me as a health professional.
Probably the biggest barrier is the environment that we live in that is now so conducive to driving, and so off putting for cycling, and cities and towns which have now most of their services and supermarkets on the outsides, rather than near where people live, which is a barrier to walking. This is a public health issue that needs political will to reclaim from local councils and their planning department. The infrastructure we live in is vital for a healthy population and for community building: it is time to entrench that in the laws of how we build our infrastructure. I cannot recommend someone to cycle if the streets or roads near them are not safe for that. There is a key issue around social inequalities here.
I am ambivalent about self-referral as self-referral destinations abound all around us and yet patients often do not take them up. A piece of paper rarely works, but being contacted by someone can. I have been involved in a number of projects where referral is either self- referral or via email to a third sector organisation, with the patient’s consent to share their contact details. The project worker then contacts the patient directly. This is perfectly acceptable to patients and is perfectly acceptable to me as a health professional (as the governance including data governance then sits with the third sector organisation). There is a risk that many will say “you can’t do that” and yet we have evidence that this is acceptable to patients and works well. Key to this is that patients are making the decision.
I personally feel that part of empowering patients is about us as health professionals learning to have a different approach to risk with patients. We rightly worry about governance in projects, and “handing over” our patients to such projects. Sometimes rightly so, when patients have complex needs or perhaps might struggle to identify themselves whether they are suitable for such projects. But equally, getting tied up in governance can be a barrier: I know many patients who tried walking or cycling groups but whose verdict was “they treated me like a 5 year old” “they were all wearing high viz jackets”. Let’s hand back a bit of personal responsibility for risk to patients to make their own decisions. This is Realistic Medicine.
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A significant barrier is the short-term funding of a lot of great small local third sector projects meaning that they come and go and staying up to date with what local projects are still operational is impractical as a health professional. A good signposting agency such as a well resourced local third sector interface organisation or a link worker is key. ALISS has been defunct in our area for ages – no one uses it.
Probably the biggest barrier for health professionals is the very different type of consultation skills that are needed to have positive conversations with patients around self-management through physical activity. These require a person-centred approach, motivational interviewing skills, goal setting and action planning which are not skills that health professionals have been systematically been trained in. The conversations around physical activity therefore often end up being negative for the patient and negative for the health professional with little chance of behaviour change. I suspect that a lot of the evidence base showing a lack of efficacy of social prescribing for physical activity might actually relate to the type of consultations that are had. A good research question.
As an aside, the term “sport” is a barrier for many.
4. How should social prescribing for physical activity and sport initiatives be monitored and evaluated? This is perhaps the most crucial of these 4 questions as the previous 3 questions are really questions for an up to date literature review.
There are two aspects I would like to discuss:
4.1 a standardised approach to Monitor and Evaluation
There are a multitude of projects happening at the moment around physical activity and no coordinated approach around monitoring and evaluation. Many of these projects are funded on a short-term basis and gather monitoring and evaluation data to suit their funders. Interestingly, many of the projects I have been involved with are funded indirectly through Transport Scotland, though their intended benefits are not only about modal shift from cars to active travel, but also health benefits. Many of these projects have societal benefits as well.
It feels like the time is ripe to take a ground breaking, Scotland- wide, simplified and workable approach to monitoring and evaluation. If some simple core criteria could be agreed, which are relevant to the projects outcomes and not just the funders outcomes, and relevant to the key areas of research uncertainty, if a monitoring and evaluation framework and tools could be designed that are easily accessible and render evidence gathering easier for projects, thereby liberating project workers’ time, a huge body of evidence could be gathered quite rapidly.
My experience of trying to tie in projects with formal research evaluation, seeking ethics approval, is that this adds layers of delay which are unrealistic with the funding time scale of projects.
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Scotland is small enough to be develop a truly ground-breaking approach – now is the time to do so. I have had many conversations locally and nationally around this – there is an appetite for it that will need a political drive.
4.2 The opportunity to evaluate these projects through formal quantitative and qualitative research
In order to generate a realistic evidence base, it is vital that not only quantitative data but also qualitative data is gathered.
These interventions are very amenable to pragmatic randomised controlled trials comparing “usual care” to “social prescribing”. Embedding economic analysis to this is vital, including evaluation on impact on benefits, medication use, and other physical and mental health outcomes.
It is also vital that good quality qualitative data is gathered to identify further the barriers to uptake. I suspect that the quality of the conversation and the ability (or not) to be truly patient-centred is key.
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HEALTH AND SPORT COMMITTEE
SOCIAL PRESCRIBING OF PHYSICAL ACTIVITY AND SPORT
SUBMISSION FROM: A JOINT SUBMISSION FROM NHS HEALTH SCOTLAND AND THE SCOTTISH DIRECTORS OF PUBLIC HEALTH
1. To what extent does social prescribing for physical activity and sport increase sustained participation in physical activity and sport for health and wellbeing?
a. Limited but growing evidence
Whilst there is limited robust evidence available on the impact and or cost effectiveness of social prescribing programmes per se1, there is evidence of social prescribing as an early intervention approach used to achieve population health and wellbeing outcomes by tackling social and health inequalities2. Evaluations show that social prescribing can have a positive impact on physical and mental health and wellbeing and thereby reducing the demand on healthcare services3 4 5 6 7.
b. Evidence Based Physical Activity Interventions
With respect to social prescribing as a means of achieving sustained participation in physical activity for health and wellbeing, there are currently two inter-related evidence based approaches applicable to this context. NICE have produced public health guidance for both; Physical activity: brief advice for adults in primary care (PH44), (NICE; 2013)8 and Physical activity: exercise referral schemes (PH54), (NICE; 2014)9. Both approaches are person centred and include elements of health behaviour change, signposting and or formal referral and align with the principles of social prescribing.
c. NHS Health Scotland National Physical Activity Pathway
The NHS Health Scotland National Physical Activity Pathway (NPAP)10 is underpinned by NICE public health guidance PH44, as a clinical and cost effective intervention8. The NPAP is designed to enable health care professionals to integrate physical activity into existing practice. This is achieved by taking a person centred approach and utilising health behaviour change techniques, such as motivational interviewing. Using these approaches health care professionals are able to appropriately; raise the issue of physical activity with those within their care; assess a person’s physical activity levels; deliver physical activity brief advice; signpost on to local physical activity opportunities; or where further support is required, refer onto those able to provide further structured support in the form of a brief intervention, such as an Exercise Referral programme, Lifestyle Advisor or Link Worker (where such opportunities exist, as they are not universally available across Scotland).
It is estimated that one in four people would be more active if advised to do so by a health care professional11. Therefore, there is significant potential to increase physical activity levels of those in contact with health care professionals by incorporating physical activity into routine practice as advocated by the NHS Health Scotland NPAP.
d. Exercise Referral
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Exercise referral is one of the most popular interventions used by health care professionals to encourage inactive individuals who are at risk of developing, or living with, a long-term condition to become more physically active. Whilst a National Exercise Referral Scheme exists in Wales12, none of the other home countries have adopted a national approach.
Exercise referral schemes operate in various ways; typically schemes involve a partnership between multiple agencies such as local NHS health boards, general practices, community health partnerships, local authorities and leisure service providers.
A recent audit defined exercise referral as “any physical activity intervention that includes a referral by a health care professional to either a physical activity specialist or third-party physical activity/exercise service provider; to conduct an initial, individualised assessment to determine what type of physical activity to recommend for the individual's specific needs and an opportunity to participate in a tailored programme of physical activity, exercise or sport”21.
A number of factors influence the effectiveness of exercise referral schemes, including the intensity, duration and frequency of the exercise sessions, the experience and skills of those delivering the sessions9 and the proportion of those referred who initially participate in an exercise referral scheme (‘uptake’) and of these individuals how many continue to participate (‘adherence’)13. The uptake and adherence rates can be affected by the referral methods, the number of exercise sessions offered9 and the type of disease the person being referred has and the follow-up period14.
An economic analyses undertaken by NICE9 found that exercise referral schemes are less cost effective than physical activity brief advice. This was primarily due to the cost intensive nature of exercise referral compared to physical activity brief advice.
A Health Technology Assessment found that exercise referral schemes showed a small improvement in the number of people who increased their levels of physical activity15. A recent preliminary systematic review found that exercise referral schemes increased physical activity levels for people with cardiovascular, mental health and musculoskeletal disorders16. Similarly, the evaluation of the national exercise referral scheme in Wales12 concluded that exercise referral schemes can promote physical activity in the short term but only in certain populations and may be ineffective in sustaining long term outcomes. A study in Northumberland17 found that physical activity levels increased but remained below the national recommendations. A systematic review examined the effect of social prescribing on physical activity and other outcomes and found evidence of a short-term increase in physical activity when exercise referral schemes were compared with usual care, but there were no statistically significant differences18.
With this in mind, NICE9 err on the side of caution and only endorse the delivery of exercise referral for people who are sedentary or inactive and have existing health conditions or factors that put them at increased risk of ill health. In doing so, schemes are required to incorporate recommendations 7–10 of 'Behaviour change: individual approaches' NICE public health guidance (49)19. Therefore, exercise referral schemes
Page 26 of 51 HS/S5/19/24/4 should only be implemented in accordance to evidence of effectiveness as stated by NICE. e. Other forms of physical activity social prescribing
Whilst the NPAP and exercise referral models primarily focus on increasing physical activity levels to prevent, manage or alleviate multiple health conditions. Models also exist with a specific focus on single issues such as mental health, cancer, falls, pain management, stroke, diabetes or healthy weight.
In addition, other forms of physical activity social prescribing exist where physical activity is the vehicle through which co-benefits for mental health and wellbeing are achieved. These activities include health walks, modified sports such as walking football, netball or rugby and green health initiatives which, reduce social isolation, provide mechanisms of social support, reconnect people with nature, create community cohesion, develop life skills, reduce stress, and quite simply enable people to have fun. For instance, Paths for All support the development of health walks in communities across Scotland by trained leaders targeting inactive individuals or individuals living with a LTC. These have been extensively evaluated as having positive outcomes as well as having a strong social return with every £1 invested generating around £8 of benefits20. f. How to achieve sustained change
The act of social prescribing alone will not lead to sustained physical activity levels, unless the systems, culture and environment in which the programme exists are also conducive to physical activity. It is therefore important to consider aspects such as the social prescribing and physical activity knowledge of health care professionals, the process by which and the nature of the services to which someone is referred9 10 21.
Findings from the NPAP Feasibility Study22 and more recent evidence from Public Health England’s Moving Health Professional Programme23 provide mechanisms to upskill health professionals and enhance their ability to integrate physical activity into routine patient care, which in turn would lead to more people being appropriately signposted or referred to local services.
Evidence suggests that to achieve sustained participation in physical activity someone will require long term health behaviour change support. e.g. frequent follow up over a 12 month period24 25 10 26 that develops motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life27 and also that the environment in which they live is supportive of an active lifestyle8.
This reflects the need to consider social prescribing as part of a whole system approach and to utilise evidence based approaches such as the NPAP; consider the workforce development needs of health care professionals to raise the issue of physical activity; the existence of support roles such as a Link Workers or Physical Activity Counsellor to provide long term health behaviour change support and access to appropriate local community based services such as Exercise Referral, Health Walks, Green Health initiatives. As well as seeking to effect behaviour change it is important to create
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‘supportive’ environments and these include access to green space, cycle and walking pathways, as well as affordable, appropriate community facilities.
2. Who should decide whether a social prescription for physical activity is the most appropriate intervention, based on what criteria? (e.g. GP, other health professional, direct referral from Community Link Worker or self-referral)
a. Person centred
Social prescribing encompasses prevention and early intervention as well as supporting the management and promotion of self-care for people with long term conditions, all of which can help to reduce future demand on primary care services.
Adopting a person-centred approach focuses on the needs, preferences and interests of the individual. It involves a conversation shift from asking 'what's the matter with you' to 'what matters to you' and aims to support individuals to take greater control of their own health in line with the psychological principles of autonomy, motivation and self-efficacy. Those referring people onto a social prescribing scheme should be discussing it with them and deciding together if and which type of social prescribing scheme is the most appropriate to meet their needs. Therefore, physical activity may not be discussed, if not relevant to the individuals needs at the time of consultation with the link worker or equivalent support worker. Providers of social prescribing should be able to ‘co-design’ solutions for people that consider the wider determinants of their health and help people to choose activities that address these needs28.
Recognising the constraints on health and social care services, Community Link Workers (CLWs) can use evidence-based behaviour change techniques to support the individual to consider their own wellbeing and to identify interventions appropriate to their own needs. CLWS can invest time with the individual to understand their personal circumstance in a holistic manner to address any barriers. At times, it may be necessary for a GP or health professional to provide advice where an underlying medical condition is concerned. Need to know information should be included in any referral pathways between the health professional and the community link worker with the individual’s consent. b. Inclusion and exclusion criteria
A recent audit of exercise referral schemes in Scotland21 collated data on inclusion and exclusion criteria, which differed from scheme to scheme. Generally, inclusion criteria included the following; being physically ‘inactive’; having one or more long term condition; having a risk factor that could lead to a long term condition; being motivated to increase physical activity levels (stage of change). While the exclusion criteria generally consisted of; client having had a ‘recent’ acute event; presence of an unstable health condition; already regularly physically active; previous participation in the scheme and not living in the designated area for the scheme.
A similar inclusion and exclusion criteria was developed for the NPAP. Inclusion primarily focuses on those who are inactive or sedentary, have one or more stable long term condition or other factors which put them at increased risk of ill health. The exclusion criteria is minimal and restricted to those with unstable conditions and recent acute events29. This criteria was based on evidence from similar approaches9 8 25.
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Evidence shows that individuals living in the most deprived communities are 30% less likely to meet the minimum physical activity guidelines compared to those living in more affluent communities30. There is a need to ensure that interventions are targeted and remove barriers to participation. The inclusion and exclusion criteria for a social prescribing activity will depend on the nature of the activity, the target audience and the referral model applied (formal or self-referral). Referral to exercise referral should also consider the individuals needs and motivations, and it may be more applicable to ensure that the individual is able to access a more community based resource such as a local sports club or exercise class.
c. Referral model
Social prescribing is more than simply a process of referral or as a method of signposting individuals to community provision. At its best, social prescribing is a unique ‘pathway’ in which individuals meaningfully participate in the selection of the support they are offered. It involves building relationships and supporting people throughout their participation2. Effective referral is crucial to ensure both a smooth process and improved outcomes for individuals’2. This requires a workforce that is equipped with the necessary knowledge, skills, competencies and time to effectively support people making changes in their lives which result in improved health and wellbeing.
It is recognised that due to funding restrictions, some projects may have explicit referral criteria and therefore there may be some variable factors e.g. age, employment status. Where possible referral guidelines should be designed to fit the target population for the social prescribing scheme, as clear guidelines will ensure that individuals receive the most appropriate support dependent on their circumstances2.
d. Referrers
A review7 found that GPs and practice nurses were the main sources of referral onto a social prescribing scheme. However, there is growing evidence of more health professions engaging in the promotion of physical activity and social prescribing5 31 8. The recent audit of exercise referral in Scotland found that GP referrals are still prominent in most schemes but since the initial development of exercise referral schemes the range of healthcare practitioners referring into schemes has grown. Most schemes are now accepting referrals from many different healthcare professionals such as physiotherapists, practice nurses, mental health professionals, specialist nurses, occupational therapists, community nurses/health visitors/midwives and dietitians21. With this in mind the NPAP is targeted at and appropriate for delivery by a range of health care professionals32.
3. What are the barriers to effective social prescribing to sport and physical activity and how are they being overcome?
a. Physical activity knowledge of health care professionals
One of the main barriers to physical activity social prescribing is a lack of awareness of the importance of physical activity amongst health care professionals. Studies show that as little as 20% of GPs33, 59% nurses34 and 16% of physiotherapists35 are aware of the
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current UK CMO Physical Activity Guidelines36 for adults and as many as 72% of GPs do not discuss the benefits of physical activity with patients33. Therefore actions are required to increase the physical activity knowledge of health care professionals. Public Health England’s Moving Health Professional Programme23, provides an approach and mechanisms to upskill health professionals and enhance their ability to integrate physical activity into routine patient care, which in turn would lead to more people being appropriately signposted or referred to local services. This approach is reinforced in guidance on physical activity37 developed to accompany the All Our Health Framework38. However further resources are required to upscale this approach in Scotland. b. Uptake and adherence
Barriers to joining and participating in the social prescribing schemes include fear of stigma of people knowing they have a particular problem because they are participating in the scheme, patient expectations and the short-term nature of the interventions39. The Pesheny qualitative study39 also found that people were likely to uptake and adhere to the social prescribing scheme if they trusted their GP, they had supportive link workers and service providers, free services and if they could see the need and benefit of the programme i.e. improved benefits in physical and mental health39 31.
With reference to exercise referral, the reasons for not joining the intervention include; limited choice of activities and sessions not being subsidised after the initial intervention has finished5. Poor referral practices and staff training can affect the effectiveness of exercise referral schemes9.
Offering a variety of exercise and/or physical activity options including alternatives to gym-based activities and having flexible session times might overcome some of the above barriers31. Schemes may be less effective because they do not fully account for participants’ motivation and ability9. Having tailored exercise programmes to meet individual needs will help with adherence to scheme and therefore make them more effective 31 9 13.
NICE suggest in their guidelines for exercise referral schemes9 that ‘Behaviour change individual approaches’ (NICE public health guidance 49)19 should be included in the schemes. These individual approaches include recognising when people may or may not be open to change; agreeing goals to help change behaviour; tailoring interventions to individual need and monitoring progress and providing feedback. If the activities take place in accessible locations with good transport links this might also help to facilitate adherence to exercise referral schemes13 31. c. Awareness of social prescribing benefits, opportunities and processes
NHS Dumfries and Galloway Social Prescribing Framework2 emphasises that social prescribing works best where those involved have a good understanding of what it is, what it can offer and who it can benefit. Staff training, support and engagement can all help to make social prescribing feel part of everyday practice and not an additional area of work. It can also ensure that staff have a sense of ownership and a clear understanding of how they can contribute to social prescribing2.
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Studies show that health care staff may be unfamiliar with local social prescribing services and referral processes4 40. Communication and partnership working between health care professionals such as GPs, and link workers and community organisations and participants is important if social prescribing is to be effective4.
Those referring need to explain to possible participants about social prescribing and what to expect from the scheme41. Delivering feedback on participants’ progress encourages health care professionals to refer people on to social prescribing schemes4. In a small qualitative study on social prescribing in Scotland they found that health care professionals did not always trust unknown community/voluntary organisations and were concerned whether they would be accountable for referrals, which were not successful or positive for the patient. The authors of the study suggested building trust and connections between the different partners42 . A Physical Activity Signposting Consultation, conducted with health care professionals in Scotland made similar findings40.
Evidence suggests that initiatives such as social prescribing cannot be seen as ‘magic bullets’. In the context of economic austerity, such approaches may not achieve their potential unless funding is available for community organisations to continue to provide services and make and maintain their links with primary care. BJGP, 201843 6 7 43.
The need for a clear and easy referral process is identified repeatedly by NHS Health Scotland22 44 40 and NHS England45. Health care professionals expressed that multiple referral processes bespoke to each service were too time consuming and confusing. NHS England45 also suggest that social prescribing is more effective when there is an easy referral process to follow. Existing NHS referral systems such as SCI-Gateway could present a potential solution to this issue. However, it is recognised that not all practitioners have access to these systems and that there needs to be some flexibility with the referral system. Another route is through an email referral process into a specific secure mailbox2.
Recognising the range of projects that embed social prescribing, it is important that referral processes and pathways are made as easy as possible for both the referring person and the individual who is being referred2.
Health care professionals also identified not knowing what or how to signpost or refer people to local services as a barrier to social prescribing. Potential local solutions have been developed such as local activity directories or by utilising information systems such as ALISS a local information system for Scotland managed by the Health and Social Care Alliance (The Alliance) or the NHS24, Scottish Services Directory available online through NHS Inform, the public facing health interface for NHSScotland. d. Quality assurance
Concerns relating to the variability of delivery or quality of social prescribing service could be addressed by applying the principles laid out in the Quality Assurance Framework for Social Prescribing recently published by the National Social Prescribing Network in England46. Or by following frameworks such as that developed by NHS Dumfries and Galloway2.
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Further to this, NHS Health Scotland have convened an Exercise Referral Development Group, the purpose of which is to identify the core components of a quality assurance framework for exercise referral in Scotland, as a means of enhancing quality and consistency across exercise referral programmes in Scotland. The first phase of this work will be completed by March 2020.
e. Wider contextual factors
In order to maximise the uptake of non-medical solutions such as physical activity interventions, cultural expectations of patients in regards to medical interventions need to be addressed. Public awareness of self-management would be one supporting action to ensure that the public embrace the use of non-medical interventions.
Individual barriers such as confidence, self-esteem and poor mental wellbeing can all have an impact on motivation to participation. CLWs can work with individuals to address any barriers that an individual may face.
Rurality can bring further barriers in terms of the ability to access opportunities, as transport availability can be problematic. Poverty and the cost of interventions can also have an impact, as personal financial circumstances may limit accessibility to services where payment is required or where there is a real or perceived need to purchase appropriate clothing or equipment. There is a need to acknowledge the importance of ‘place’ in respect of accessing physical activity interventions as well as addressing social isolation and loneliness47. Working with communities to create the conditions that engender a sense of belonging and foster greater social connectivity is essential. Pathways should promote a range of opportunities from a simple walk through to specific sporting activities where possible. Alternative interventions, such as the use of technology e.g. apps and schemes that use pedometers to improve physical activity levels can be used within peoples own communities. The active promotion of physical activity within green space would be beneficial, as green space is easily accessible to most adults in Scotland and helps improve mental and physical health whilst promoting social connectedness and community resilience48 49.
In the current financial climate, funding and resourcing is a concern that may present barriers to implementation and sustainability of social prescribing. The current shift from health and social care delivery to communities needs to be mindful not to overburden the third sector. Health and Social Care Partnerships should consider opportunities to support community organisations and groups to ensure that resources and quality of physical activity interventions are maximised. Consideration should be given to building and growing assets within local communities, such as local sustainable solutions with low cost access and the use of volunteering. Support should be provided to local groups and clubs to allow them to access a range of training opportunities that include qualifications, as well as those that promote inclusivity (e.g. equality and diversity, mental health awareness, dementia awareness, loneliness) and health behaviour change. Reporting should be mindful of quality of outcomes rather than quantity of access, especially within delivery in rural areas.
4. How should social prescribing for physical activity and sport initiatives be monitored and evaluated?
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a. Monitoring existing schemes
Participation in physical activity and sport initiatives can improve the quality of life of individuals and communities, promote social inclusion, improve health, raise individual self-esteem, confidence, and widen horizons. Evaluation should include a range of measures that acknowledge the wider benefits to individuals that participation in physical activity can induce and not just increased physical activity levels. This will allow individuals to make the connections and value to their own needs in line with the principles of behaviour change.
The Quality Assurance Framework for Social Prescribing recently published by the National Social Prescribing Network in England46 lists a number of recommended measures of quality assurance, covering the following; data protection, safeguarding, insurance, health and safety, financial, equality, governance, pathways and procedures, skills and experience, first aid (incl. mental health first aid) and user experience.
The NHS Dumfries and Galloway Social Prescribing Framework2 highlights that, integral to any social prescribing project is the need is to ensure that it meets the objectives and outcomes that it is intended, most specifically in relation to addressing health inequalities and improving health and wellbeing outcomes. In this context the following measures are proposed:
Process measures: • No and % of individuals referred to social prescribing practice • No and % of service users who are referred to support services and types of support services • Key demographic information • No of organisations that are supported and able to receive referrals • Capacity of third sector organisations to support a social prescribing scheme including giving feedback to referrers
Output or outcome measures: • % of individuals who successfully engage with a social prescribing practice • % increase self –efficacy • % increase – loneliness • % increased physical activity levels • % increased wellbeing • Quality of life scores • Response to health questionnaires • Qualitative feedback from stakeholders on perceived impact of service on users • Self-reported improvements in health condition and well being • Clinical improvements to health • Reduction in contact/usage of health care services e.g. GP appointments • Reduction in medication • Case studies
Context and service measures:
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• Qualitative feedback regarding service quality (GPs, Practice Nurse, Health professionals, Patients, Referral partners, SP deliverers • Impact on prescribing rates • Impact on frequent attendances b. Evaluation of existing schemes such as exercise referral
A recent audit of exercise referral in Scotland21 found that while most schemes in Scotland are collecting data on age and gender of participants, other demographic data on ethnicity, disability and socio-economic status are less frequently collected. Therefore it is still unknown if or how widely schemes achieve equitable reach, or the extent to which they impact on reducing health inequalities. The audit report therefore recommended that further consideration is given to how schemes could be supported to capture this important demographic data, to determine whether they are reaching those in most need.
The audit21 also identified some common monitoring tools in use across schemes such as the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), Scottish Physical Activity Screening Questionnaire (Scot-PASQ), Physical Activity Readiness Questionnaire (PARQ), Physical Activity and Lifestyle Questionnaires, Quality of Life Scales (i.e. EQ-5D/EQ-5D-3L), General Self-Efficacy Questionnaires. As well as outcome measures for physical activity, body mass index, body composition, physical fitness, waist circumference, weight and blood pressure.
In addition exercise referral scheme also reported using the following performance indicators21: • Number referred to the scheme • Number taking up the referral • Number completing the programme • Number of activity sessions attended • Number dropping out of the scheme • Number active at specific time points • Number taking out memberships after the programme • Number follow-up contact appointments attended • Number and range of healthcare professionals referring into the scheme
Lack of staff capacity and training in evaluation is often cited as one of the challenges to undertaking high quality evaluation of exercise referral schemes
The audit therefore recommended that exercise referral professionals responsible for scheme evaluation are offered support and/or training on how to undertake high quality and robust evaluation of an exercise referral scheme21.
Evaluation support and the development of a minimum dataset for exercise referral have been identified by the NHS Health Scotland, Exercise Referral Development Group, as core components of a quality assurance framework for exercise referral and will draw on learning from the Welsh NERS scheme50 which has established a national standardised approaches to measuring physical activity and wider wellbeing benefits. A partnership approach that includes a range of stakeholders such as academia, national bodies as
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well as regional public health specialists could provide effective evaluation expertise to support this going forward, aligned to local delivery actions related to Public Health Priority 651.
NICE public health guidelines (PH54) on Exercise Referral9 recommend that exercise referral programmes should be monitored and evaluated in line with the Standard Evaluation for Physical Activity Interventions52 specifically programme description, evaluation details, demographics of individual participants, baseline data, follow-up data (also known as impact evaluation) and process evaluation.
c. Research
Given the limited amount of high quality robust systematic studies in this area, further research should be undertaken to investigate the effectiveness and cost effectiveness of social prescribing schemes6 7. These studies should use controls to show that it is the intervention which is causing the effect. Follow up with participants should be sustained over a longer period of time than in previous studies and go beyond the end of the intervention. As identified within the Audit of Exercise Referral in Scotland21, outcomes other than physical activity should be considered such as quality of life, behaviour change, physiological changes, the impact on health inequalities and health service and medication usage. It is also recommended that key outcomes are measured using objective measures rather than subjective outcome measures, where feasible. The outcome measure selected will vary depending on the reasons for referral, type of social prescription, the needs of the people participating and the resources available for evaluation5.
One study suggested that it is preferable to gather different type of evidence rather than using a single method to assess outcomes using quantitative and qualitative methods and that evaluation should include feedback from all key stakeholders such as referrers, providers and participants5.
The need to differentiate between people who adhere to the programme and how it has increased their physical activity levels was also highlighted14 i.e. measuring both outputs and outcomes45. Recording baseline data which can then be monitored at regular intervals for comparison with baseline data is recommended. Going a stage further, NHS England45 also suggest that the evaluation of social prescribing schemes should include measuring the impact on people, community groups and the health and care system.
Whilst more research is required, implementation should continue in such a way that it adds to the evidence base. The introduction of a standardised approach to monitoring and evaluation as part of a quality assurance framework would greatly enhance the design and quality of delivery of physical activity social prescribing programmes and enable comparison of effectiveness across programmes.
References:
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1 Centre for Reviews and Dissemination (University of York). (2015). Evidence to inform the commissioning of social prescribing. 2 NHS Dumfries and Galloway. (2019). Dumfries and Galloway Social Prescribing Framework. 3 Public Health England. Social prescribing: Applying All Our Health. (2019). 4 Bickerdike, L., Booth, A., Wilson, P.M., Farley, Wright, K. (2017). Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open. 5 Chatterjee, H.J., Camic, P.M., Lockyer, B. & Thomson, L.J.M. (2018). Non-clinical community interventions: a social systematised review of social prescribing schemes Arts & Health 10(2):97-123 6 Drinkwater, C., Wildman, J., Moffatt, S. (2019). Social prescribing (clinical update) BMJ 364 7 Kilgarriff-Foster, A. and O’Cathain, A. (2015). Exploring the components and impact of social prescribing. Journal of Public Mental Health 14(3):127-134. 8 National Institute for Health and Care Excellence (NICE). (2013). Physical activity: Brief advice for adults in primary care (PH44). 9 National Institute for Health and Care Excellence (NICE). (2014). Physical activity: exercise referral schemes (PH54). 10 NHS Health Scotland. (2018). NHS National Physical Activity Pathway webpages. Online at http://www.healthscotland.scot/health-topics/physical-activity/national-physical-activity- pathway 11 Public Health England. (2016). Health matters: getting every adult active every day. 12 Welsh Assembly Government. (2010). The Evaluation of the National Exercise Referral Scheme in Wales. 13 Pavey, T., Taylor, A., Hillsdon, M., Fox, K., Campbell, J. et al. (2012). Levels and predictors of exercise referral schemes uptake and adherence: a systematic review. Journal of Epidemiology of Community Health 66:737-744 14 Arsenijevic, J., Groot, W. (2017). Physical activity of prescription schemes (PARS): Do programme characteristics influence effectiveness? Results of a systematic and meta- analyses. BMJ Open. 15 Campbell, F., Holmes, M, Everson-Hock, E., Davis, S., Woods, H.B., Nana Anokye, N., Tappenden, P. and Kaltenthaler, E. (2015). Health Technology Assessment A systematic review and economic evaluation of exercise referral schemes in primary care: a short report. Vol 19 Issue 60. 16 Rowley, N., Mann, S., Steele, J., Horton, E. and Jimenez, A. (2018). The effects of exercise referral schemes in the United Kingdom in those with cardiovascular, mental health, and musculoskeletal disorders: a preliminary systematic review. BMC Public Health 18:249. 17 Hanson CL, Allin LJ, Ellis JG, et al. (2013). An evaluation of the efficacy of the exercise on referral scheme in Northumberland, UK: association with physical activity and predictors of engagement. A naturalistic observation study. BMJ Open. 18 Pavey, T.G., Taylor, A.H., Fox, K.R., Hillsdon, M., Anokye, N. et al. (2011). Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. BMJ 343. 19 National Institute for Health and Care Excellence (NICE). (2014). Behaviour change: individual approaches (PH49). 20http://www.socialvalueuk.org/app/uploads/2016/03/Glasgow_Health_Walks_assured%20a nd%20formatted.pdf 20/8/2019 21 NHS Health Scotland. (2018). An Audit of Exercise Referral in Scotland: A Snapshot of Current Practice.
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22 NHS Health Scotland.(2014). NHS Primary Care Physical Activity Pathway Feasibility Study. 23 Brannan et al. (2019). Moving healthcare professionals – a whole system approach to embed physical activity in clinical practice. BMC Medical Education volume 19, Article number: 84. 24 Bull et al. (2009). Evaluation of the Physical Activity Care Pathway. School of Sport and Exercise Sciences, Loughborough University. 25 Department of Health. (2012). Let’s Get Moving, Commissioning Guidance for a physical activity care pathway. 26 Moreton et al. (2018). Evaluation of the Macmillan Physical Activity Behaviour Change Care Pathway. MacMillan Cancer Support. 27 International Physical Literacy Association. (2017). Physical literacy definition. Online at https://www.physical-literacy.org.uk/ 28 RCGP (2019). Person-Centred Care Toolkit; developed to support GPs and primary care teams deliver person-centred care. Online at https://www.rcgp.org.uk/clinical-and- research/resources/toolkits/person-centred-care-toolkit.aspx 29 NHS Health Scotland. (2013). NHS National Physical Activity Pathway Feasibility Pilot: Practitioner Guidance. 30 https://www.gov.scot/publications/scottish-health-survey-2017-summary-key-findings/ 20/8/2019 31 Morgan, F., Battersby, Weighman, A.L., Searchfield, L., Turley, R, et al. (2016). Adherence to exercise referral schemes by participants – what do providers and commissioners need to know? A systematic review of barriers and facilitators. BMC Public Health 16:227. 32 NHS Health Scotland. (2016). Analysis of physical activity actions reported within NHS Board: Annual Health Promoting Health Service Reports. 33 Chatterjee et al. (2017). GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England. British Journal of General Practice; 67 (663). 34 Macmillan Cancer Support/ICM. (2011). Online survey of health professionals who deal with cancer. 35 Lowe et al. (2017). Physiotherapy and physical activity: a cross-sectional survey exploring physical activity promotion, knowledge of physical activity guidelines and the physical activity habits of UK physiotherapists. BMJ Open 36 Department Health. (2011). Start Active, Stay Active: A report on physical activity for health from the four home countries’ Chief Medical Officers. 37 Public Health England. (2019). Physical activity: Applying All Our Health. 38 Public Health England. (2019). Social prescribing: Applying All Our Health. 39 Pescheny, J., Randhawa, G., Pappas, Y. (2018). Patient uptake and adherence to social prescribing: a qualitative study. BJCP Open 40 NHS Health Scotland. (2017). Physical Activity Signposting Consultation Report. 41 NHS England. (2019). Social prescribing and community-based support: Summary guide. 42 White, J.M., Cornish, F. and Kerr, S. (2017). Front-line perspectives on ‘joined-up’ working relationships: a qualitative study of social prescribing in the west of Scotland. Health and Social Care in the Community. 25(1):194-203. 43 British Journal of General Practice https://bjgp.org/content/68/672/e487 2018 44 NHS Health Scotland. (2015). Social prescribing for mental health: background paper. 45 NHS England. (2019). Social prescribing and community-based support: Summary guide. 46 National Social Prescribing Network for England. (2019). Quality Assurance for Social Prescribing: A guide to support social prescribing programmes in England.
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47 Scottish Government (2018) A Connected Scotland, Our Strategy for Tackling Social Isolation and Loneliness and Building Stronger Social Connections, Edinburgh, Scottish Government 48 https://www2.gov.scot/About/Performance/scotPerforms/indicator/greenspace 20/8/2019 49 https://researchbriefings.files.parliament.uk/documents/POST-PN-0538/POST-PN- 0538.pdf 20/8/2019 50 Williams, J.W., 2018. National Exercise Referral Scheme Manager for Wales. Presentation to Exercise Referral: Learning Exchange presentations - 13 March 2019. Accessed from: http://www.healthscotland.scot/media/2418/jeannie-wyatt-williams.pdf 51 Scottish Government. (2018). Scotland’s Public Health Priorities. 52 National Obesity Observatory (NOO). (2012). Standard Evaluation Framework for Physical Activity Interventions.
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HEALTH AND SPORT COMMITTEE
SOCIAL PRESCRIBING OF PHYSICAL ACTIVITY AND SPORT
SUBMISSION FROM SCOTTISH SPORTS ASSOCIATION
The Scottish Sports Association (SSA) thanks the Health and Sport Committee for the invitation to submit to this call for views.
The Scottish Sports Association (SSA) exists to represent and support Scottish Governing Bodies (SGBs) of Sport as the independent and collective voice for SGBs. We represent their interests and currently have ~50 full members and ~18 associate members. SGBs are responsible for the governance, development and delivery of their individual sports and provide a formal structure for the over 900,000 individuals in Scotland who are members of one of Scotland’s 13,000 sports clubs. Most of these organisations are run on a not-for-profit basis and are managed by volunteers. They provide coaching, competition and participation development opportunities for their local communities and most of the 195,000 people who volunteer in sport do so within the club structure. The SSA has, as usual, compiled this submission in consultation with our members. Summary
• Through performing their core role, sports clubs make an invaluable contribution to public health • Through 13,000 sports clubs with 900,000 members, sports clubs are the largest setting through which an opportunity exists to promote health through the conduit of sport • One key barrier is the lack of awareness of the benefits of sport and physical activity and of the CMO guidelines within the healthcare profession • Public Health England states that a quarter of the population would be more active if they were advised to do so by a health care professional • A strong understanding and application of the principles of health behaviour change will be required by those developing and delivering activities if they are to be of benefit to those previously inactive • To be successful a more strategic and whole system approach is required – that sport and physical activity organisations (and the comparatively small budget associated with the sector) require support from not just the healthcare sector, but also professionals in social care, education, transport, justice, planning etc • Access to a broader range of sporting and physical activities, through a supported pathway, could encourage the retention of participants with a variety of backgrounds, experiences and motivations to continue to reap the health, wellbeing and social benefits of being active • Fully understanding an individual’s interests and motivations could help to identify the most appropriate and appealing sporting/active opportunity for an individual, which is likely to increase the participation rates in such schemes • The services which people are referred to in social prescribing are nearly always provided by the voluntary and community sector but social prescribing initiatives rarely offer any resource to help with their capacity to deliver what is required • A key factor in the success of any intervention relies upon the quality of the offering; the provision of sport/physical activities opportunities are no different. Providing such quality and diversity of opportunities requires resources
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• The ‘Sport Clubs for Health’ proposal be reviewed in relation to its applicability for Scotland and for additional resources to be released to enable this • The resourcing of social prescriptions should be considered in parallel with those for medical prescriptions – i.e. that they are provided free of charge through the NHS for as long as they are required.
1. To what extent does social prescribing for physical activity and sport increase sustained participation in physical activity and sport for health and wellbeing?
Sport and physical activity evidence The evidence which supports the contribution of sport and physical activity to improving health and wellbeing is both extensive and compelling (and is summarised in our WhySportMatters resources).
The contribution of sport and physical activity to health and wellbeing is particularly important in considering the World Health Organisation’s (WHO) definition of health:
“A state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity”.
Our members would like to highlight the following evidence which may be most relevant to this call for evidence in highlighting why sport, in addition to other forms of physical activity, plays such an important role:
• Vigorous-intensity physical activity may produce greater health benefits than moderate-intensity physical activity • High intensity levels characterise many sports disciplines • The UK Chief Medical Officers’ physical activity guidelines contain three components. While the 150 minutes of moderate intensity activity each week is the most commonly quoted, the requirement to also undertake two sessions to improve muscle strength per week is less commonly cited (the third aspect is minimising sedentary time) – and is most frequently undertaken through sporting activities • Through performing their core role, sports clubs make an invaluable contribution to public health • People who participate in sport through a club environment participate more often and for longer than those that participate within other environments • Through 13,000 sports clubs with 900,000 members, sports clubs are the largest setting through which an opportunity exists to promote health through the conduit of sport • Social prescribing to a sport through a club environment appropriate to the needs of the individual brings significant additional benefits in alignment with the WHO definition of health, as summarised in the diagram below (Kokko & Vuori 2007, from Sports Club for Health 2017):
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Social prescribing evidence Evidence supports the general premise of social prescribing as a form of early intervention for social and health inequalities in improving health and wellbeing outcomes through a positive impact on physical and mental health and wellbeing, thus resulting in a reduced reliance on NHS services.
In line with the response from our partners at SCVO: the 'Connecting communities and healthcare: Making social prescribing work for everyone' research on social prescribing published in July 2019 by The National Lottery Community Fund suggests that resources have largely gone into supporting the link worker role common in most social prescribing initiatives, but the National Lottery Community Fund’s view is that that is not enough. The services which people are referred to in social prescribing are nearly always provided by the voluntary and community sector but social prescribing initiatives rarely offer any resource to help with their capacity to deliver what is required. Social prescribing is effective if it does more than simply signposting. Other research papers suggest there is a need for better evidence to show the strength and impact of social prescribing if it is to become embedded within health services.
More specifically relating to the social prescribing of sport and physical activity, The National Institute of Health and Clinical Excellence (NICE) has produced two sets of guidance:
• Physical activity: brief advice for adults in primary care • Physical activity: exercise referral schemes
Further, Public Health England states that a quarter of the population would be more active if they were advised to do so by a health care professional.
In supporting the response of our partners at the Scottish Volunteering Forum: traditional medical prescriptions are often viewed as essential and patients are likely to follow them without question. A different approach would be required for social prescribing as activities which can benefit health and wellbeing, such as volunteering, are only likely to be beneficial if those participating in at are doing so of their own volition.
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Participation in any form of volunteering, or activity supported by volunteers, has the potential to increase confidence, forge social connections and lead to sustained behaviour change regarding physical activity. As a result it has strong links with the health and social care agenda, and is reflected in both local and national wellbeing outcomes.
In addition to the more common exercise referral programmes, there are an increasing number of sport/physical activity social prescribing options which have shown benefits for both physical and mental health while also aiding community cohesion, developing new and life skills, reducing stress and providing opportunities for social interaction and having fun. Examples of such activities include walking (including though the supported health walks offered through Paths for All, amongst others), golf, adapted or modified sports including walking football and ongoing initiatives provided for people with a disability through Scottish Disability Sport (SDS).
SDS has been working in partnership with a wide range of health professionals for many years (including ~150 referrals in the past 2 years) to support sport and physical activity referrals for individuals with a disability, demonstrating the profound health, wellbeing and social benefits which can be accessed through participating in sport and physical activity.
Sustaining participation in sport and physical activity Research has shown that a limited choice of activities can reduce the uptake of exercise referral schemes. While popular, anecdotal evidence suggests that walking health/referral groups, which are not necessarily set up to support social prescribing, often become full and unable to support further referrals due to individuals wishing to remain within the group rather than being supported towards other activities; ongoing support and exit strategies are required to help to overcome this issue. Such opportunities, in line with research on golf referrals suggests that as well as being beneficial activities in their own right, these activities may also provide a gateway to other activities should such a pathway exist.
Access to a broader range of sporting and physical activities, through a supported pathway, could encourage the retention of participants with a variety of backgrounds, experiences and motivations to continue to reap the health, wellbeing and social benefits of being active. However a strong understanding and application of the principles of health behaviour change will be required by those developing and delivering such activities, if they are to be of benefit to those previously inactive.
2. Who should decide whether a social prescription for physical activity is the most appropriate intervention, based on what criteria? (e.g. GP, other health professional, direct referral from Community Link Worker or self-referral)
Our members assume that the most successful approach to any process relating to behaviour change of any kind would be taken in consideration of and discussion with the individual/patient concerned (through a process of ‘co-designing’). Adopting a person- centred approach allows the interests, preferences, motivations, experiences and needs of the individual to be married with the expertise of health professionals to find the option which the individual is most likely to: initially attend, benefit from, enjoy, complete any specific programme/scheme/timeframe and then maintain/progress their participation either in the same activity and/or through a pathway to exploring a new activity.
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Where they exist, it may prove beneficial if Community Link Workers could assist in this co- design through behaviour change processes and taking the time to fully explore and understand individual interests and motivations as well as having access to a network of diverse, welcoming, accessible, affordable and inclusive local opportunities. Fully understanding an individual’s interests and motivations could help to identify the most appropriate and appealing sporting/active opportunity for an individual, which is likely to increase the participation rates in such schemes.
Another key factor to be explored in such discussions is the nature of the individual’s challenges, the local services available and the positive impacts of different types of sports/physical activities. A useful starting point for such discussions would be the following assessment of the positive impacts of different types of sports on key health outcomes (from Sport Clubs for Health 2017).
There are 13,000 sports clubs across Scotland – ensuring that provision is both diverse and local in communities throughout Scotland. The forthcoming connection between ALISS (A Local Information System for Scotland) and the National Services Directory via NHS Inform should provide a mechanism for more local and community activities to register on the site and for their activities to be searchable by a wide range of health practitioners and the general public.
Research by SDS in 2018 showed that 42% of respondents felt that access to more opportunities would make it easier to get involved in sport or other physical activity. However those delivering such opportunities need to have to appropriate knowledge and skills in health behaviour change to appropriately motivate and support individuals to achieve long term health behaviour change.
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3. What are the barriers to effective social prescribing to sport and physical activity and how are they being overcome?
Access for the least active Those who would reap the greatest benefits of being active, are often those that are not currently active. For the least active in society, participation in sport and physical activity may not be considered a top priority nor be seen as their most significant challenge. In such instances, an integrated approach to providing support, which may involve an appropriate aspect of sport/physical activity which may help to alleviate challenges may prove a useful starting point.
Individuals who are least active in society include those who are in long term care, have significant and often long term health issues and often who may have complex and inter- related challenges and/or dependencies. While these individuals have the most to gain from being active, they also highlight the reliance of and the role for non-sporting organisations to support and guide individuals to consider sport and physical activity and to facilitate and support an appropriate introduction to activity. Supporting the least active to become active is an excellent example of where a whole system approach is required – that sport and physical activity organisations (and the comparatively small budget associated with the sector) require support from not just the healthcare sector, but also professionals in social care, education, transport, justice, planning etc.
Knowledge and awareness of healthcare professionals One key barrier highlighted by our members is the lack of awareness of the benefits of sport and physical activity and of the CMO guidelines within the healthcare profession; research shows the following levels of awareness of the CMO guidelines:
• GPs = 20% • Nurses = 59% • Physiotherapists = 16%.
Further, 72% of GPs do not discuss the benefits of sport and physical activity with their patients. This is further exacerbated by the fact that only 4% of the population are, themselves, aware of the CMO’s guidelines.
Increased support and training for healthcare professionals may prove beneficial in helping to upskill individuals in raising sport and physical activity with their patients. Further, a requirement for all GP consultations to ask patients about their physical activity habits (in the same way they do about smoking and alcohol habits) may also prove revolutionary in enhancing awareness in both professionals and patients as well as facilitating an opening dialogue about being active.
While some feedback to date has highlighted the important role of the Community Link Workers and the opportunity they provide in this facilitation, the fact that the role is not universally available in all local areas presents a challenge to ensuring access to this support across Scotland.
It is also understood that healthcare professionals themselves have reported a key barrier to social prescribing referrals is a lack of knowledge about where or how to signpost patients to local services.
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A mechanism for healthcare professionals and sport/physical activity professionals to shape and share expertise, guidance and practice would be welcomed to optimise existing knowledge and expertise.
Access to appropriate opportunities It is assumed that the most commonly cited barriers to sport and physical activity are also relevant to the social prescribing of sport and physical activity. As such, the following factors need to be considered:
• Access to local facilities and clubs (including access to transport as required) • Affordable access to activities • Inclusive sporting/activity opportunities • Access to a diverse range of sporting/activity opportunities • Provision of a welcoming environment • Provision of supported pathways to enable people to easily engage and continue to develop within an activity/activities • Provision of flexible opportunities at a range of times • Awareness of a range of opportunities for various levels of participants, abilities, ages and motivations.
The diversity and local nature of Scotland’s 13,000 sports clubs present a significantly underutilised asset to help to improve Scotland’s health and wellbeing. ‘Sports Clubs for Health’ (2017) identifies a wide range of ways that sports clubs can further enhance the nation’s health through both:
• The direct provision of sporting/physical activities • Promoting the benefits of taking part in sport and being active.
In optimising the uptake and retention of individuals in social prescribing schemes, and as participants in sport and physical activity more generally, a diverse menu of different opportunities and a pathway promoting transitions between different activities needs to be available.
In addition to the direct provision of sporting/physical activities – the provision of environments where people can enjoy being active is also vital – including access to, and promotion of, parks/green spaces and paths for walking and cycling.
Ambiguity around referral qualifications Some of our members have reported a barrier around information they have been provided with which states that in order for a sports club/programme to have patients referred to it, the programme leader/coach requires to have undertaken a Level 3 Referral qualification. Without this qualification, they have been informed that the sports programme/club is not recognised as suitable to accept direct referrals by healthcare professionals. We understand that NHS Health Scotland is currently taking work forward to identify the core components of an exercise referral quality assurance framework and we look forward to being engaged in such discussions as this work progresses.
The vast majority of sports clubs and sporting opportunities are run by volunteers. To expect volunteers to undertake such training could prove a significant additional barrier. Clarification is sought urgently in relation to this advice.
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A strategic approach Our members would prioritise the need for a more strategic approach to be taken to both embed the social prescribing for sport and physical activity model and to ensuring the provision of a suitably diverse range of quality opportunities.
Feedback from our members to date shows that often the current approach relies upon trusted relationships between individuals, as opposed to a holistic and systematic approach. Embedding such an approach will also require suitable resources to support the delivery, as well as appropriate publicity, monitoring and evaluation.
A good example where a holistic approach and suitable publicity are required relates to the findings of the Activity Alliance, who reported that 47% of people with a disability fear losing their benefits if they are seen to be physically active.
It is vital to accept that social prescribing as a stand-alone mechanism will not result in increased and sustained participation in sport and physical activity; the supporting environment, culture and systems must all work together to ensure a holistic approach is taken.
Resourcing A key factor in the success of any intervention relies upon the quality of the offering; the provision of sport/physical activities opportunities are no different. Providing such quality and diversity of opportunities requires resources. It is also vital to understand that often supporting those that are currently inactive or who face greatest disadvantage may require a specific focus, a specialised approach and, therefore further additional resource. Many sports clubs are run by or supported by volunteers – this does not mean this resource is free, and resources will be required to enable the delivery, training, promotion and general support for clubs to engage with such opportunities.
Our members would also suggest that the ‘Sport Clubs for Health’ proposal be reviewed in relation to its applicability for Scotland and for additional resources to be released to enable this.
Our members would propose that the resourcing of social prescriptions should be considered in parallel with those for medical prescriptions – i.e. that they are provided free of charge through the NHS for as long as they are required. This is contrary to feedback received from some current social prescribing approaches, whereby the patient is expected to pay all or part of the costs of the activity.
4. How should social prescribing for physical activity and sport initiatives be monitored and evaluated?
Our members support monitoring and evaluation encapsulating the wide range of benefits of participation in sport and physical activity – including physical, mental and social health and wellbeing – and considering quality of life and perhaps the wider impact on the health and social care system.
In support of the response from our partners at SCVO: the monitoring and evaluation of social prescribing needs to be facilitated by those who are making the prescription, but it is vital that this is not overly formalised. It should be based on self-reported and qualitative
Page 46 of 51 HS/S5/19/24/4 evidence based on personal outcomes agreed with the individual. Therefore it is vital that a baseline measure is established to adequately ascertain progress made, and we would suggest that progress is self-reported at follow up medical appointments or appointments with the Community Link Worker.
Any monitoring tool needs to be proportionate, simple, effective and allow enough consistency for local and national monitoring. The availability of training and support may also be beneficial in this regard.
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HEALTH AND SPORT COMMITTEE SOCIAL PRESCRIBING OF PHYSICAL ACTIVITY AND SPORT
SUBMISSION FROM Dr Joel Rocha, Dr Rebecca Wade, Dr Corinne Jola, Dr Luis Calmeiro, Andrea Cameron, School of Applied Sciences, Abertay University
1. To what extent does social prescribing for physical activity and sport increase sustained participation in physical activity and sport for health and wellbeing? While a number of systematic reviews, including those examining a cost-benefit analysis have been conducted, it remains difficult to provide a definitive answer as to the long-term impact of the effectiveness of social prescribing and therefore this needs to be addressed. Limitations of research or exercise referral scheme reports often include relatively small sample sizes (i.e. less than 80), being less than 14 weeks duration, no follow-up, no cost analysis, no intention-to-treat analysis and reliance on just quantitative or qualitative methods instead of a mixed methods approach. Since practice clearly is ahead of the available evidence, we need to capitalise on existing practice whilst at the same time developing partnerships with research teams (e.g. within Universities and Colleges) that could contribute to a better understanding of how to implement theory-based approaches (e.g. health behaviour models) with a robust monitoring/evaluation process (e.g. impact of demand, cost-analysis, social outcomes). This process is in our opinion, important, because the extent to which social prescription is effective will depend primarily on who the target population is, on accurate evaluation of their values and needs, how the process is undertaken, what resources are available and how the evaluation/monitoring is used to improve/follow it up (i.e. there is not a one size fits all approach).
2. Who should decide whether a social prescription for physical activity is the most appropriate intervention, based on what criteria? (e.g. GP, other health professional, direct referral from Community Link Worker or self-referral) Since social prescribing relies on recognising individuals’ needs, providing them with support and connecting them with adequate services that can address such needs the decision of the suitability of such intervention should depend on the specific circumstances. We believe that with the exception of self-referral (this method would not fit within the above view of social prescription and other alternatives could be provided for those already wanting to become more active) all of the suggested examples may be appropriate as long as professionals have adequate training and time to engage in this process with the individual. Importantly, such an approach should not rely on or limit itself to imparting information (e.g., flyers) but rather expand health promotion practices to empower individuals to increase control over their own health (i.e. supporting and working in partnership with the individual). Indeed, we feel that potentially a question to who would be the primary target populations is warranted since, due to limited resources, this will also affect the way social prescribing would ultimately be undertaken. In this regard, generic criteria/guidelines to decide if social prescription for physical activity is the most appropriate intervention could be developed but they would need to depend on who the primary target population is and its application should not be reduced to a “tick box exercise” but rather a
Page 48 of 51 HS/S5/19/24/4 needs analysis undertaken by a trained professional. In terms of the primary target population, we believe that the answer that most would agree would be to target those that need it the most, however, it is important to ensure that this identification goes beyond the biomedical model of health to include broader views of health promotion (e.g., salutogenic model, health assets, social-ecological model). We recognise that in practice the desirable is often not possible but there are still important improvements that can be made to some of the current approaches. For instance, initially referral schemes sat wholly with health care professionals (most often in primary care doing the referral) that are used to the biomedical model of health and sometimes reluctant to refer patients because of essentially outsourcing a ‘treatment protocol’ to non-professionally registered individuals (i.e. they can be uncomfortable with risk). In addition, health care professionals often do not have the time to adequately engage with this process and therefore link workers can have a very important role here. Indeed, it would be good to have social prescribing coordinators that could contact/meet the initially referred individuals (e.g. from GPs) to discuss their social issues/needs, identify appropriate services and have the capacity to provide follow-up and further support when required. Some local authorities, and potentially as part of Health and Social Care Integration have adopted alternate models of prescription that in our view are moving back towards health education and therefore likely to become just an information platform. For instance, in Angus, GPs no longer do referrals to facilities (the only health service referrals are e.g. Post-cardiac rehab, pulmonary rehab) – but the Angus Alive website will be signposted if it’s thought that patients in this geographic area would benefit from a more active lifestyle. The patient then self refers to one (or more) of the Angus Alive activities (there are downloadable forms they can complete) where they can access the activities at a reduced tariff for an introductory period. NHS Tayside would recommend that new organisations looking to engage with social prescription link into Angus Alive if they want to start working with more clinical populations. Whilst we do not negate the usefulness of these type of platforms for individuals with resources and ready to engage in physical activity it is important to recognise their limitations.
3. What are the barriers to effective social prescribing to sport and physical activity and how are they being overcome? We are not culturally accustomed to social prescribing. The normal prescription is for medicine, medical intervention in response to an illness or ailment. Social prescribing of sport and activity can be preventative, pre-emptive as well as reactive. As a society we are conditioned to think in a reactive way, so a change is needed as being physically active throughout life can prevent illness and ill health (and protect against common medical conditions). Moreover there are concerns around risk, efficacy and who can deliver the screening – so capacity issues are barriers (beyond those linked to personal motivation of the individuals being given the prescription – hence why Readiness to Change is a key part of the pre-screening). In terms of overcoming these barriers, there are a host of sport and exercise graduates who could safely deliver social prescription and are a workforce that could be deployed. Specific example: The Dundee Green Health Partnership has addressed the GP referral challenge by working with third sector groups to help remove the ‘barriers’ for GPs (e.g. GPs don’t have the time to find out what is available, don’t have appropriate or up-to-date
Page 49 of 51 HS/S5/19/24/4 information, don’t know if the activity and its providers are ‘reliable’). Green Health prescriptions in Dundee are routed through a dial-up service where a trained volunteer can direct the prescription-holder to the most appropriate activity. Community Link workers could also take a similar approach but the same barrier could apply – maintaining the confidence of the prescriber by supporting and resourcing the providers is important in addressing this. A more joined-up approach to promoting activity for good health is needed. A more joined-up approach to supporting prescribers, providers and prescription-holders is needed. The first contact of a patient through the primary health care system will necessary involve a health professional (e.g., GP) who will decide on the appropriateness of physical activity. However, barriers to the prescription of physical activity by GPs are many and include lack of time and lack of skills to effectively promote behaviour change. Hence, one possible approach is to develop a protocol to (a) decrease the amount of time GPs require to assess the level of patients’ readiness to change their physical activity behaviour and (b) provide stage-matched strategies that the GP can apply. Such protocol has been tested and successfully applied by trained GPs (see, Physician-based Assessment & Counselling for Exercise, PACE project). Nevertheless, the demands for GPs are varied and resources often limited; hence, we suggest that a referral within the same health setting to a trained professional who can develop a working alliance with the client and empower him or her to change would be a desirable option. Although, social prescribing would be more effective with the involvement of trained professionals with time to engage with the process, this should be complemented with effective services made available in the community to address patients’ social needs. Otherwise what happens if existing services are not able to meet the social prescribing needs? Therefore, it is important to recognise that there is no point in identifying and referring individuals without investing in the services that will be meeting their needs.
4. How should social prescribing for physical activity and sport initiatives be monitored and evaluated? First of all, we need to clearly characterise current practices and rigorously evaluate the process, the impact and intended outcomes. In addition, we need to engage in a variety of assessments (e.g., social, educational, ecological assessments) to determine the factors (predisposing, enabling and reinforcing) that influence physical activity within specific communities. Only then can we develop theory-based interventions tailored to the individual or the community. Evaluation requires resources (funding, staff time, training and support) and it would be useful to link practitioners, GPs, scientists, and Community Link workers for evaluation, monitoring, and knowledge transfer. This closer integration would allow us to learn quickly from social prescribing interventions and be able to share evidence about what is working in different contexts. Collaborations with Universities and Colleges could be an important pathway for developing and delivering monitoring and evaluation. This would still require support, FE and HE have to show funding against time just as other organisations do, but a collaborative approach could provide added benefits; enhance the
Page 50 of 51 HS/S5/19/24/4 links between education institutions and their communities, provide applied training for the next generation of prescribers (GPs, nurses, mental health workers, link workers, social care workers, planners etc.) via student projects and/or research/consultancy, capitalise on the monitoring and evaluation expertise already present in universities and colleges and on the formal and informal channels of communication already in place within health settings enhance the impact of research/teaching. Indeed, we need to be able to recognise that changes in health outcomes may potentially go beyond the funding timeframes and therefore sustained collaborations will be vital to maintain the implemented monitoring/evaluation strategies. Specifically these strategies should focus not only on the initial processes (i.e. screening, referral, connection with community services) but also what is happening within these services and what are the perspectives of the referred individuals. Ideally it would be good to collect data at all stages and be able to track how the process worked at the individual level as this would allow us to gather knowledge of how social prescribing is working for different groups. Potentially some sort of shared database that allows all involved to input information on their part/contribution to the social prescribing process (e.g. logging an individual as being given a social prescription and keeping information about engagement, health outcomes, feedback and follow-up/support meetings) but with different levels of access to ensure compliance with Data Protection Act 2018.
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Health and Sport Committee
24th Meeting, 2019 (Session 5)
Tuesday 29 October 2019
Petitions
Note by the Clerk
Purpose
This paper provides information on four petitions that remain before the Committee. Each petition is explained with a summary, update on the current position since they were last considered and asks the Committee to determine the next steps.
Petition PE1568 Funding, access and promotion of the NHS Centre for Integrative Care
Petitioner - Catherine Hughes
Petition summary
Calling on the Scottish Parliament to urge the Scottish Government to —
1. Ensure that Scotland-wide access to the NHS Centre of Integrative Care (NHS CIC) is restored by providing national funding for a specialist national resource for chronic conditions; and
2. To uphold NHS patient choice and cease the current postcode lottery by removing barriers to patient access and prevent institutional discrimination by helping to promote the benefits of this care pathway for patients with long-term conditions.
Webpage PE1658 – Funding, access and promotion of the NHS Centre for Integrative Care
Background
3. The Public Petitions Committee took evidence from petitioner Catherine Hughes and Dr Patrick Trust, retired GP on 9 June 2015. The Committee agreed to write to NHS Greater Glasgow and Clyde in order to receive proper prognosis, as far as the board is concerned, on the financial plan and the centre for integrative care’s viability. The Committee also agreed to write to the Scottish Government to gauge their opinion on continuation of the centre for integrative care. The Scottish Health Council, NHS Highland and NHS Lothian were also contacted regarding patient referrals to the Centre for Integrative Care.
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4. In order to explain the funding and access to this service, the Committee agreed to write to the Scottish Government, NHS Highland, NHS Lanarkshire and NHS Lothian on 6 October 2015. On 8 December 2015, they also invited NHS Greater Glasgow and Clyde, NHS Highland and NHS Lanarkshire to give evidence at a future meeting.
5. On 30 June 2016, the Committee agreed to write to NHS Greater Glasgow Clyde to clarify its position and the Scottish Government to ask whether it would review its position on funding in light of the possible changes to the provision of services.
6. At its meeting on the 29 September 2016, it was highlighted that Aileen Campbell, then Minister for Public Health and Sport, confirmed in her correspondence of 26 July 2016 that designation of a centre or facility as a national resource is not a matter for the Scottish Government.
7. At its meeting on 29 September 2016, the Public Petitions Committee agreed to refer the above petition to the Health and Sport Committee under Rule 15.6.2 of Standing Orders. The Health and Sport Committee were working on their strategic plan and vision for 2016 to 2021.
8. The Health and Sport Committee agreed at its meeting on 15 November 2016 to invite the Scottish Health Council to give oral evidence on their general input and approach to consultations of the type being run in this case, as well as their involvement in classification of major service changes.
9. The petitioner also submitted written evidence in relation to this petition and Corporate Governance for our NHS Governance Inquiry in 2018. Our report, ‘The Governance of the NHS in Scotland - ensuring delivery of the best healthcare for Scotland’, concluded that, “the delivery of transformational change in the provision of health and social care can only be achieved with the support of stakeholders and the general public. This requires a fundamental change in the relationship between NHS boards, their stakeholders and the public”. The report also highlighted that, “Boards must become more open and honest about the pressures and challenges they face which will ultimately help stakeholders understand and have confidence in the decisions being taken.”1
10. The Convener of the Committee wrote to the Chief Executive for NHS Greater Glasgow and Clyde on 28 November 2018, requesting an update on the current position of the Integration Centre and if any further changes to the service are anticipated.
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11. The Committee received a response from NHS Greater Glasgow and Clyde on 18 December 2018. The letter confirmed – “The Centre for Integrative Care continues to provide a full outpatient service which has been in place for many years. There has been no reduction in outpatient provision. Over a year ago there was a redesign where a new holistic day service model was implemented. Since then, there have been two reviews of the model, one at 6 months and one at 12 months.
The reviews were supported by NHS Greater Glasgow and Clyde but were facilitated and led by both nursing, and medical clinical leads who deliver the service.
At both events there were a number of presentations delivered which identified that the new service has evaluated positively and is being well received by the patients who attend.”
12. At the Health and Sport Committee meeting on 19 February 2019, it was agreed that this petition would remain open and the Committee would bring it to the attention of relevant Cross-Party Groups who may be undertaking work in this area. The Chronic Pain CPG and Arthritis and Musculoskeletal Conditions CPG were identified as relevant groups to contact. A collective response was received from the Chronic Pain CPG on Friday 21 June 2019.
13. The Secretary for the Chronic Pain CPG, Dorothy Grace-Elder, consulted on this issue, reaching out to patients, doctors and charities for further information. Key findings include; inequality of access to services across Scotland for integrative care, waiting times and staff shortages, lack of transparency or scrutiny over decision making and the impact delays are having on the mental health and well- being of patients. Information received can be found in Annexe A.
14. The report issued to the Committee from the Cross Party Group on Chronic Pain states –
“The harm done to NHS CIC is part of the wider picture of grim shortage of staffing and funding from chronic pain, despite the condition being described as “the leading cause of disability globally and in Scotland”.
15. ‘Friends of The Centre for Integrative Care’ also provided their rationale for support on this petition. They state there is “enough evidence to demonstrate a need in current health services for this model of care and service to continue and expand”, with choice and access available for all citizens across Scotland. They are also campaigning for the “restoration of the in-patient beds at the Centre for Integrative Care, which have been essential for some patients using this service, especially for those living in rural areas”.
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16. The Cross Party Group on Chronic Pain also heard positive experiences from patients who have used the service and a GP who had referred several patients to the Centre for Integrative Care throughout his career. Further details provided in Annexe A.
17. The Scottish National Chronic Pain Management Programme (SNCPMP) is commissioned as a national service and co-located with the Centre for Integrative Care. However, the Centre for Integrative Care operates a different model and is not a nationally commissioned service. It relies on funding by NHS Greater Glasgow and Clyde and referrals from other NHS boards. The reduction in referrals from other boards has threatened its sustainability and so the petition is calling for its funding to be secured by designating it a national service.
18. In the last evidence session of the Public Petitions Committee on 29 November 2016, before Members referred the petition to the Health and Sport Committee, they raised questions around the process of applying for national service designation. This is the main aim of the petition but this avenue has not been explored in any further detail.
19. National services are commissioned by the National Services Division and applications can be made to the National Specialist Services Committee (NSSC). The NSSC has guidance on the process, including the qualifying criteria. If successful, each NHS Board contributes funding to the service.
20. Action
In light of the consideration of the petition to date, the Committee is invited to consider whether it wishes to write to the National Services Division to ask for its opinion on the suitability of the Centre for Integrative Care as a national service and whether it could be considered by the National Specialist Services Committee.
********************************************************************************************** PE01605: Whistleblowing in the NHS - a safer way to report mismanagement and bullying
Date lodged 22 March 2018 Petitioner: Peter Gregson on behalf of Kids not Suits
Petition Summary
Webpage PE01605: Whistleblowing in the NHS - a safer way to report mismanagement
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Calling on the Scottish Parliament’s to urge the Scottish Government to establish an independent national whistleblower hotline for NHS staff to replace the current helpline. It would differ in that it would investigate reports about mismanagement and malpractice, often without recourse to NHS managers.
Background
1. The Public Petitions Committee took evidence from Peter Gregson on 15 September 2016 and agreed to write to the Scottish Government, the City of Edinburgh Council, the Salford Royal NHS Foundation Trust, Public Concern at Work, NHS Boards and unions.
2. That Committee agreed to invite the Chief Executive of NHS Scotland and other relevant stakeholders including the City of Edinburgh Council, Public Concern at Work and trade unions, to provide oral evidence at a future meeting. This meeting took place on 9 February 2017.
3. The Public Petitions Committee took evidence from the Director-General Health and Social Care and Chief Executive, NHS Scotland and Director of Health Workforce and Strategic Change, Scottish Government on 2 March 2017. The Committee agreed to refer the petition to the Health and Sport Committee under Rule 15.6.2 of Standing Order.
4. On 25 April 2017, the Health and Sport Committee agreed to incorporate the petition into its inquiry on The Governance of the NHS in Scotland – ensuring the delivery of the best healthcare for Scotland and to hold an evidence session on whistleblowing at a future meeting. The Committee held this evidence session on 13 June 2017.
5. During our inquiry into Governance in the NHS, the Committee took evidence on whistleblowing from Sir Robert Francis QC, who conducted the Freedom to Speak Up review into whistleblowing in the NHS in England. He stated in his review “there are disturbing reports of what happens to those who do raise concerns. Yet failure to speak up can cost lives."
6. In the Freedom to Speak Up review, Sir Robert Francis wrote: “Whistleblowers have provided convincing evidence that they raised serious concerns which were not only rejected but were met with a response which focused on disciplinary action against them rather than any effective attempt to address the issue they raised".
7. In the NHS Governance report, the Committee raised a number of concerns regarding the need to ensure a culture of openness and transparency with mechanisms in place for staff to raise concerns in an environment where the support and guidance offered to NHS staff is both valued and trusted. The Committee also recommended that further changes should be made to the current whistleblowing system. This included the establishment of an
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investigative line for whistleblowing. Also, that NHS boards should be allowed to appoint Whistleblowing Champions that are individuals others than non- executive board directors with staff involvement in recruitment.
8. A draft Order was laid with the Parliament on 30 April 2019 and subject to the super-affirmative procedure. That means an additional stage of scrutiny whereby the Parliament considers a proposal for a statutory instrument before the instrument is formally laid.
9. The Committee consulted on the Scottish Government proposal for the role of a new Independent National Whistleblowing Officer role as set out in:
• Scottish Public Services Ombudsman (SPSO) (Healthcare Whistleblowing) Order 2019 - Proposed Draft Regulations (SG/2019/66) (112KB pdf) • Proposed Draft Explanatory Note (SG/2019/67) (271KB pdf)
10. The Committee also considered the SPSO proposals for new standards for health services handling whistleblower concerns:
• SPSO consultation on Draft Standards for NHS Services (92.7KB pdf)
11. The proposed extension would give the Ombudsman the legislative powers to:
a. Develop a set of standards for NHS services which all NHS organisations would need to follow when they receive and investigate whistleblowing concerns.
b. Investigate concerns raised by whistleblowers, as a final, independent review of these concerns, including how the health service handled the whistleblowing concerns and if it acted reasonably in making any decision.
c. Investigate how a whistleblower has been treated by their employer.
12. The Committee issued a short call for views which ran from 8 May to 22 May 2019 and held an oral evidence session on 28 May 2019.
13. Following the evidence session, the Committee published its report on 25 June 2019: Scottish Public Services Ombudsman (SPSO) (Healthcare Whistleblowing) Order 2019 – Proposed Regulations.
14. The outcome of the report stated that the Committee is content with the draft definition being consulted upon by the SPSO and subject to any minor amendments arising from consultation consider that the definition must be included within the Order. The Committee would also be content with additional powers in the Order allowing for the definition to be amended in future by subordinate legislation.
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15. Overall, the Committee were satisfied that it is appropriate the INWO should become part of the SPSO. In this way NHS staff can feel safe they will be listened to and their need to feel safe, and to have their concerns acted upon confidentially and timeously can be met. The Committee were also satisfied appropriate funding will be made available to support the role.
16. The Committee expects the final Order to be laid with the Parliament by autumn/winter 2019.
17. Action
The views of the petitioner have been considered as the draft explanatory document confirms the draft Order will “create a new route for whistleblowers in NHS settings to bring complaints about the internal handling of their whistleblowing case to the SPSO”.
The draft order contains provisions to: • allow the SPSO to investigate complaints by whistleblowers in NHS settings on the handling of their whistleblowing complaint; • enable the SPSO to question the merits of internal decisions made on whistleblowing cases in NHS settings; • clarify that the SPSO can comment upon the culture of the relevant body in relation to whistleblowing; • clarify that the SPSO can investigate and comment upon the treatment of any individual as a result of the person aggrieved raising a whistleblowing concern; and • allow the sharing of information between the SPSO and the relevant bodies (where relevant to their scrutiny or investigatory functions).
With this new approach approved, the Committee is invited to consider closing this petition on the day the final Order is approved, later this year.
*********************************************************************************************** Petition PE01698: Medical care in rural areas
Date lodged 18 July 2018
Petitioner - Karen Murphy, Jane Rentoul, David Wilkie, Louisa Rogers and Jennifer Jane Lee
Webpage PE01698: Medical care in rural areas
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Petition summary
Calling on the Scottish Parliament to urge the Scottish Government to:
1. To ensure strong rural and remote G.P representation on the remote and rural short life working group, recently established as part of the new GP contract for Scotland.
2. Adjust the Workload Allocation Formula (WAF) urgently in light of the new contract proposals to guarantee that both primary and ancillary services are, at least, as good as they are now in ALL areas so patients do not experience a rural and remote post code lottery in relation to the provision of health care.
3. Address remote practice and patient concerns raised in relation to the new G.P. contract.
Webpage PE01698 – Medical care in rural areas
Background
4. The new GP contract between the Scottish Government and the British Medical Association came into force on 1 April 2019. It aims to improve access for patients, address inequalities and improve population health, provide financial stability for GPs and reduce GP workload through the expansion of the primary care multidisciplinary team. Petitioners have raised concerns that the new formula will reduce funding for remote and rural practices. Those concerns are shared by the Rural GP Association of Scotland, which states that the workforce allocation formula “seems heavily weighted against rural communities.”
5. The Scottish Government has set up a remote and rural short-life working group, and the petitioners seek strong rural and remote GP representation on the group. In a letter to Scottish Rural Action in March this year, the Scottish Government stated that it “will ensure that its membership represents a wide range of remote and rural communities from across Scotland.”i
6. At the Public Petitions Committee meeting on 13 September 2018, the Committee agreed to write to the Scottish Government and the Rural GP Association of Scotland. It also agreed to draw the petition to the attention of the Health and Sport Committee.
7. At the Public Petitions meeting on 22 November 2018, the Committee agreed to write to the Scottish Government to address concerns raised in relation to how the workload allocation formula was calculated; the transparency of the Remote and Rural General Practice Working Group and the appropriateness of the new GP contract for rural Scotland. The Committee also agreed to write to the Scottish Rural Parliament
8. The Public Petitions Committee agreed on 4 April 2019 to invite the Cabinet Secretary for Health and Sport to give evidence and address issues raised in
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9. At its meeting on 27 June 2019, the Public Petitions Committee agreed to refer the above petition to the Health and Sport Committee under Rule 15.6.2 of Standing Orders.
10. In referring the petition, the Committee recognised the Health and Sport’s Committee’s current inquiry into Primary Care, particularly the second phase of this work which will review issues around service provision in rural areas.
11.The Public Petitions Committee is of the view that a number of issues require further scrutiny around the Scottish Workload Formula (SWF) and the role of the Technical Advisory Group on Resource Allocation in the development of the SWF. The Committee welcomes the inquiry’s focus on the new GP contract and its impact on services in remote areas.
10. Action
The Committee took oral evidence from the Rural GP Association and the Rural and Remote Patient Group for the Primary Care Inquiry on Tuesday 1st October 2019. The information provided will be incorporated into our Primary Care Report which will be published in the New Year. The Committee is therefore invited to consider any further action they wish to take on this petition.
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Petition PE01533: Abolition of non-residential social care charges for older and disabled people
Date Lodged: 01 September 2014
Petitioner – Jeff Adamson on behalf of Scotland Against the Care Tax
Webpage PE01533: Abolition of non-residential social care charges for older and disabled people
Petition summary
1. Calling on the Scottish Parliament to urge the Scottish Government to abolish all local authority charges for non-residential care services as under Part 1, Paragraph 1, Subsection (4) of the Community Care and Health (Scotland) Act 2002.
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Background
2. The petitioner contends that “non-residential social care is an equality and human rights issue” and, therefore, should be “free at the point of delivery”. Additionally, the petitioner argues that the current system is unfair, because charging procedures for these care services differ considerably between local authorities. ii
3. The Social Work (Scotland) Act 1968, Section 87 provides local authorities with the power to charge for non-residential social care services (also referred to as community care services). This does not include nursing care at home, which is an NHS service and, therefore, is provided free for people of all ages if they require it. Additionally, since the Community Care and Health (Scotland) Act 2002 and the introduction of the associated Community Care (Personal Care and Nursing Care) (Scotland) Regulations 2002, those over 65 have been entitled to free personal care. Briefly, personal care is “anything done for you that is of a personal nature” iiiand includes assistance with personal hygiene, dressing, and food preparation and eating, among other services, all of which are outlined in Schedule 1 to the 2002 Act referred to above.
4. At the Public Petitions Committee meeting on 11 November 2014, the Committee took evidence from Jeff Adamson, Ian Hood, Coordinator, Learning Disability Alliance Scotland, and Dr Pauline Nolan, Policy and Engagement Officer, Inclusion Scotland. The Committee agreed to write to the Scottish Government, NHS Scotland, COSLA, a selection of local authorities and the Equality and Human Rights Commission. The Committee also agreed to invite the Scottish Government to give evidence at a future meeting. This meeting took place on 27 January 2015.
5. At the Public Petitions meeting on 6 October 2015, the Committee agreed to write to the Scottish Government and consider the petition alongside petition PE1480, by Amanda Kopel, on behalf of the Frank Kopel Alzheimer’s awareness campaign, on Alzheimer’s and dementia awareness.
6. At the Public Petitions meeting on 30 June 2016, the Committee agreed to write to Scottish Government for an update on its review of fairness in social care charging and whether it is minded to take the action called for in both petitions, given that it has some manifesto commitments in the area.
7. Following a meeting on 29 September 2016 and subsequent correspondence, the Cabinet Secretary for Health and Sport provided a response, noting that the Scottish Government will “conduct a feasibility study into expanding free personal and nursing care to people with dementia who are under 65”. The timeframe for completing the study was summer 2017.
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8. Following the meeting on 9 November 2017, the Committee wrote to the Cabinet Secretary for Health and Sport to clarify which conditions in addition to dementia, would be covered under free personal care to people under the age of 65. The Scottish Government confirmed, “adults with any long-term condition, or those who develop dementia or other degenerative conditions under the age of 65, who are assessed as needing it will receive free personal care.”
9. At the meeting on 28 June 2018, the Committee agreed to close petition PE1480, on Alzheimer’s and dementia awareness, by Amanda Kopel, on behalf of the Frank Kopel Alzheimer’s awareness campaign, due to legislation being brought forward by the Scottish Government. Petition PE0153 remained open as further clarification was required on the funding of free personal care and how it will be implemented.
10. At the Public Petitions Committee meeting on 10 January 2019, the Cabinet Secretary for Health and Sport confirmed that the Scottish Government has “extended the provision for under-65s beyond those with a single condition—we wanted to ensure a degree of equality of approach, regardless of age”. The next stage will be to reform adult social care. Following the meeting, the Committee wrote to the Cabinet Secretary to request “further information on the costing of free personal care, how the extension of free care was to be monitored, stakeholder engagement and COSLA’s guidance on care charging”. iv
11. At the Public Petitions Committee meeting on 30 May 2019, the petitioner’s response disputed the “Scottish Government’s estimates of average weekly hours of personal and non-personal care, which, in turn, affect the numbers of those who are eligible to benefit from the extension of free personal care”.v
12. At its meeting on 12 September 2019, the Public Petitions Committee agreed to refer the above petition to the Health and Sport Committee under Rule 15.6.2 of Standing Orders.
13. During its discussion on the petition, the Committee was of the view that while the recent legislation to extend free personal care in Scotland to under-65s was a good policy intention, there are concerns that this support is not going to the right people. The Committee also discussed a number of issues that it is of the view require further scrutiny including—
• The level of cost in administering the system of free personal care; • The application of funding relating to Frank’s Law, with concerns that some of this is being used to plug funding gaps at a local authority level; • The level of service charging meaning people are choosing not to get the support they require.
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14. Action
The Health and Sport Committee will be undertaking a Social Care Capacity Inquiry in Spring 2020 which will be wide reaching and investigate closures of residential care facilities and general funding issues with both independent and council run facilities.
Full details are still to be confirmed but the Inquiry is likely to include:
• The sustainability of the current approach to social care, including care at home and residential care. • How social care would look, and be financed, in 2030. • The number of different bodies involved in organising or delivering care and support to those in need.
The Committee is therefore invited to take account of this petition as part of the inquiry.
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Annexe A
NHS Centre for Integrative Care (CIC) From Dorothy-Grace Elder, voluntary secretary, Scottish Parliament cross party group on chronic pain. (CPG)
The Group thanks the Committee warmly for their interest, which may be a lifeline for patients. I’ve consulted widely. A sample of patient, doctor and charity comments is attached.
The harm done to NHS CIC is part of the wider picture of grim shortage of staffing and funding for chronic pain, despite the condition being described as “the leading cause of disability globally and in Scotland”.
The SG “recognises chronic pain as a clinical priority”. But, at conventional services, bad waiting times and staff shortages have not been tackled properly for ten years by four successive Govt. groups. At alternative services, NHS CIC is still suffering relentless harm, despite its expertise in today’s huge issue of cutting opiate intake.
Unelected officials and appointees now dominate health, in boards and in Edinburgh. The CIC’s situation is an alarming example of how democracy for patients is ignored. There’s desperate need for elected members to intervene.
The 2015 petition by Catherine Hughes is timelier than ever. NHS CIC is Scotland’s expert centre for reducing heavy prescription drugs, including opiates. Some question areas suggested by the CPG:
What is to be done to overturn harm to NHS CIC while the Chief Medical Officer and Government are highlighting the ‘opioid crisis” -why aren’t they seeking NHS CIC expertise?
Deprived areas get 3.5 times more strong opiates than others but since Scotland -wide access was cut at NHS CIC, tackling harmful consumption in poor areas has lessened.
What is to be done about injustice to chronic pain patients overall, with four publicly funded “Improvement Groups” failing to improve waiting times and staff shortages in ten years?
What happened to the many patients cut off from NHS CIC services after officials closed CIC beds, shut two outreach clinics and banned most of Scotland from patient choice, unless people can afford it?
What’s to be done about the lack of help from so called “patient voices” like the Scottish Health Council which CIC patients encountered?
Death by cuts – and copying NHS England: how NHS CIC was harmed.
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There’s vital need for the committee to question. Patients’ views are swept aside. Patient petitioner Catherine Hughes is now ill after her remarkable 14 years of voluntary struggle.
What is to be done to stop continuing harm to NHS CIC and restore services throughout Scotland?
The CIC has high patient demand and an exemplary record in curbing or removing heavy use of prescription drugs, including opiates, although it does not ban medication. It also works on the antibiotic crisis.
Closing beds, reducing an NHS hospital to an outpatient clinic, barring most of Scotland; all this increased inequality and did most harm to the poorest areas. Patient choice is left to those who can afford private alternative treatments.
The 2018 Scottish Public Health Network report on “Health Care needs assessment of adult chronic pain services in Scotland” states:
“Prescribing of opioids in 2012 showed that, for strong opioids, patients in the most deprived areas were 3.5 times more likely than those in least deprived areas to receive them.”
“Opioid prescribing in Scotland has increased considerably”. (Morphine dispensing, for instance, rose from 280,351 items in 2010 to 440,472 items in 2014-15.)
The removal of beds in NHS CIC was aimed originally to save only about £250,000.
Increased inequality
Lack of access for most of Scotland has increased postcode discrimination and inequalities. Officials deny wishing to close the hospital – a “they would, wouldn’t they?” denial in view of years of cuts. But some staff leaving or retiring aren’t replaced. Around six doctors have gone in a few years, patients estimate. Harm began in 2005, when Glasgow officials suggested the board copy NHS England which had closed some alternative beds to save money. The Glasgow board refused in 2005. But officials began cuts, closed the hospital at weekends, closed the pharmacy and cut physiotherapy services. NHS Highland, Lothian and Lanarkshire withdrew. In 2011, Glasgow officials closed seven beds. In 2017, all beds were closed and NHS CIC became an outpatient clinic. Two outreach clinics were closed by NHS Lanarkshire officials. The CIC building was created from past public subscriptions without cost to the NHS, who pay for staffing. Opened in 1999, it is a flagship hospital with landscaped gardens.
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What happened to the many patients cut off from NHS CIC services when officials closed beds at the CIC, shut two outreach clinics and banned most of Scotland from patient choice?
Beds were removed for 350 inpatients - also around 600 day patients lost the two CIC outreach clinics in Carluke and Coatbridge on the orders of NHS Lanarkshire. (Lanarkshire has one of Europe’s worst rates of chronic pain.) Did anyone investigate what happened to sufferers barred from usual CIC help?
Why in the age of “realistic medicine” were patients for whom conventional services didn’t work offered being sent back to these services or to GPs and repeat prescriptions? They add to the existing huge waits in many areas. While only 6 boards with conventional services see all new pain patients within 18 weeks, these busy clinics also deal with thousands more return patients, who have no waiting time limit, which could be 18 months for a six monthly appointment. Huge “return” waits are a suicide risk area. These are the “conventional” services many CIC patients must return to, adding to the struggles of these services, which work well for many but now have to take on ex CIC patients with different needs.
Why is chronic pain not being helped properly, with four publicly funded “Improvement” committees failing to act on waiting times and staff shortages in conventional services in ten years?
While Government appointed groups have shown no interest in NHS CIC over the years, these groups have influence – see “ NHS CIC cut out?” further below. To explain the generally unscrutinised situation:
Four Government-funded committees have failed in their task to show improvement in chronic pain services, including the current group, the National Advisory Committee on Chronic Pain (NACCP). Three are now defunct.
The only improvement in ten years was definitely NOT through these groups but through direct intervention by the Scottish Parliament and the then health secretary, Mr Alex Neil. The elected spoke for the public.
Parties produced a unanimous vote to create the first Scottish National Residential Service for chronic pain, saving severe sufferers being sent as far as Bath in Somerset. Parliament also supported day services being tackled - helping the vast majority, but improvement hasn’t happened.
Five different reports since 2004 highlighted the priorities as: short staffing and bad waiting times, which still show no progress.
Example: The Healthcare Improvement Scotland report “Where are we now?” showed NHS Grampian had Scotland’s worst waits for chronic pain: 31 weeks in 2014. In 2018, Patient waits showed NHS Grampian reaching 42 weeks.
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But all four Govt committees did not act on repeated pleas to count the pain workforce and patient numbers and inform the public on what staffing levels should be. The current committee, NACCP, claimed to have started a workforce assessment last year. But that hasn’t been disclosed. (Such statistics can be achieved within weeks).
The Cross Party Group believes strong questions are essential for the Advisory Committee, including their civil service unit Clinical Priorities, which is on the committee. Patients really need a fresh start with new organisations. There is no public accountability or any scrutiny visible, only brief minutes. Chronic pain has hundreds of thousands of sufferers, tens of thousands eventually reach a clinic.
Is it right that a committee making recommendations which will affect sufferers is tucked away behind scenes, like a private club, always meeting behind closed doors, containing reappointments of many of the same people for years?
*The same civil service dept – Clinical Priorities – has been involved for around ten years. *Some other members were reappointed from the three failed previous groups. *The few charities – publicly funded - are largely the same for a decade. Officials are paramount, including board reps. But 11 out of 17 attending their June 5 2018 meeting were SG officials and appointees, 8 out of 15 at the August 14 meeting. The whole set up seems introverted and stagnant.
Suicide risk
Communication with the Advisory committee is not the easiest. An MSP informed the Advisory committee that a return patient had told the CPG at a meeting of her attempted suicide after 6 monthly treatment was delayed for 18 months because of staff shortages. The patient was “in screaming agony”. A & E saved her. The MSP wanted delays tackled to prevent suicide risk. But the committee’s reply was only that the patient should contact the Samaritans or similar groups. The Samaritans can’t deal with the cause: short staffing.
How NHS CIC is cut out. Why is only lip service paid to the CMO’s “realistic medicine” plans?
Why was the CIC totally ignored, even when the National Advisory Committee on chronic pain was involved with three recent official publications relevant to non-pharmaceutical treatments, the CIC speciality? How can this committee advise the Government when they live in their own bubble and use their same limited sources repeatedly? Reports to which these committees contribute are remarkably unclear on staffing or waiting times.
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Report One: “Quality prescribing for chronic pain – a guide for improvement 2018-21”.
This recommended that clinicians should “pursue non-pharmaceutical approaches wherever possible, either alone or in conjunction with medicines.” That is what NHS CIC has done for years. The report had no advice on how this can be done, perhaps because NHS CIC wasn’t shown on the 13 strong “working group” or 15 other contributors.
Only one patient representative, from a charity appointed repeatedly for around ten years, was on the working group.
Report Two: The 2018 report on “Health care needs assessment of adult chronic pain services in Scotland” by the Scottish Public Health Network, also ignored the CIC from its 11 strong project group and 14 contributors. This report also had a remarkable way of not revealing staffing numbers!
On Table 10, it gave full ticks to a board’s staffing disciplines – for clinicians, nurses, physiotherapists, etc. You can’t tell how few or many staff there are or whether working full or part time. Normal research uses WTE on number of hours worked. The Network is a member of the National Advisory Committee.
Report Three: The Scottish Access Collaborative’s (SAC) report on chronic pain (2019) also supports " non-medical models of care” but did not invite NHS CIC to be one of their 37 contributors. NACCP members and Clinical Priorities civil servants were involved with all three projects. In total, 90 people were involved with these three reports promoting reduced drug intake – but not one from NHS CIC to advise how to accomplish this.
Alternative care is being hit wherever it’s found
Patient choice is being removed quietly from Aberdeen to West Lothian. Last year, an NHS Grampian grant of around £25k to Camphill Welfare Trust in Aberdeen was removed, without consultation, they say. The Trust’s patients are similar to those of the CIC. They have 68 Grampian GPs referring patients and around 230 cases. Many can’t afford to pay - the Trust will have to increase funding work. They have case histories of patients aided to come off opioids and other drugs which they can send if you request.
Emergency Services and chronic pain
If staffed adequately, pain services are key to alleviating other NHS services, including emergency services. ISD statisticians discovered a sample of 36,877 prescription pain patients out of 47,933 had contacted “at least one” unscheduled care service – out of hours GPs, ambulance, emergency departments.
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Secretiveness and lack of transparency
There is persistent lack of openness about chronic pain issues, especially on staffing and waiting times. All four committees appear/ed extremely sensitive about these.
It’s now stated that “Scotland is the only country in the UK to publish any chronic pain waiting times”.
But “improvement” groups and Government officials opposed publication for years, although they received waiting statistics privately. Publication of new patient waits was forced by patients in 2016, through FOI. These figures showed some of Scotland’s worst waiting times beyond the 18 week maximum. A new patient becomes an uncounted return after the first visit, with no limit to waits. Next, return patient facts were sought - to show the full pressure on specialist clinics.
In 2017, the Information Services Division (ISD) decided they should seek return patient information. FOI later showed there was an immediate emailed objection from the Scottish Government’s Clinical Priorities Unit. ISD, the independent health statistics body, was told: “I don’t think we would want to start publishing this information” The project was halted.
This interference was later over- ruled by a team from the UK Statistics regulator in London who investigated in Edinburgh and supported openness in the public interest. That situation took about nine months to combat. Why do patients have to battle so hard to stop harmful internal moves?
Currently, for six months, officials still will not say which body decided to remove the new Access Collaborative from participating in a decision on £50 million of waiting times initiative money and, instead, restored the decision to health boards alone.
Specialist pain clinics were wrongly described as having only “small” numbers of patients. Will that harm clinics over a new £855 million waiting times improvement plan, competing with other parts of the NHS?
Those conducting the Scottish Access Collaborative’s workshops and writing a report were informed that only “a small number of patients” attended chronic pain clinics, an astonishing statement.
The figures from ISD are: 20,117 new patients in 2018, plus estimated thousands more return patients. Later, FOI revealed that Scottish pain clinics had over 43,000 return patients who had not been counted when it was claimed patient numbers were small. Downplaying the vital role of clinics distracts attention from bad waiting times.
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But the workshop and report organisers, DHI/GSA (Digital Health Institute/Glasgow School of Art) did accept a correction by a clinician and by the Cross party group and will state that there were 20,117 new patients last year and a similar number for years. The DHI Art School people explained they were new to chronic pain issues and had been advised earlier by officials from the Government’s Advisory Committee, including Clinical Priorities officials who were present at these sessions.
The Cross Party Group strongly opposes the Advisory Committee or Clinical Priorities being involved with the SAC’s recommendations being carried out, as is proposed.
There’s obvious need for fresh thinking, hard facts and ensuring that chronic pain gets a proper share of resources. With no official champions, it has lost out several times.
How is money used?
The SG has financed these four committees but is there any scrutiny on value for money?
£1.3 million was spent by a predecessor committee on 14 local improvement groups and a website – gone without achievements visible.
Currently, a £275,000 Government grant was awarded to Dundee University for a study involving mainly pain service “quality outcomes” in just three Scottish boards.
It is hard to rationalise how quality can be judged when the basics of staff shortage or waiting times have not been tackled. Doctors mentioned they’d need to spend time away from patients filling in more forms.
Dundee University is now handing the rest of the work to ISD, meaning more costs.
The Government grant was for the Dundee University department where three of their academics are on the Advisory Committee and some were on its predecessor committees. Was this arrangement best practice? Government grants don’t go out to tender.
£101.6 million – but pain loses out
Separately, when the Scottish Government made £101.6 million available in 2017-19 to ease waiting times for outpatients of services with the longest waits, most health boards ignored chronic pain in the first round of £51.6 million although CP has some of Scotland’s worst waits. It appears no-one spoke up for chronic pain. Health boards chose which services should get the money. But hopes rose that some new people would help with the second round.
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The new Scottish Access Collaborative wrote to the CPG in May 2018 saying the second round of funding (£50million) would be aligned with their recommendations. But by January 2019 Collaborative involvement with this funding was removed - without explanation and decisions restored to health boards. Chronic Pain got even less in the second round. FOI shows the total received over two years was a mere £372,810 out of that £101.6 million. Who advised and removed any new input by the Access Collaborative? The civil service won’t say, only that decisions were inhouse. The CPG has asked questions since January 2019 but by June still hadn’t had an answer to that £50 million question.
All of this involves the prolonged suffering of patients. In 2019, an orthopaedic surgeon, in published articles, described the Scottish health system as “cruel” for letting patients wait too long, in agony, for hip operations. Cruelty surely applies also to letting thousands of others in chronic pain wait, beyond those awaiting hip replacement.
Official bodies who were only window dressing
The Scottish Health Council (SHC) was regarded as useless by patients– the SHC even allowed one Glasgow meeting with CIC patients to be chaired by a board official promoting the cuts.
The SHC was also no help in NHS Lanarkshire, when a consultation majority of 4,800 voted for continued access by Lanarkshire patients and against closing the two CIC clinic offshoots in Carluke and Coatbridge.
The two clinics and CIC hospital access were swept aside by just nine Lanarkshire Health Board members opposing a majority of 4,800 in a consultation. The SHC regarded closure of beds in this hospital and removal of services from most of Scotland as only “minor change”. So no help. NHS Lanarkshire compiled a very weak equality & diversity statement for the Equality & Human Rights Commission’s usual paperwork on a “service change”.
NHS Lanarkshire officials failed to detail disability concerns (a “protected characteristic”) or Lanarkshire deprivation. But when the CPG asked the Commission about poor information, the Commission replied by letter, revealing that they did not check quality! Astonishing.
So Boards don’t need to worry what they submit. It’s a meaningless charade. Scottish health must get away from pretendy bodies making people believe there’s some protection, when there isn’t.
Alex Neil, the former health secretary who supported NHS CIC for years, sought restoral of beds and outreach to all Scotland – he challenged the regular mantra of boards declaring they are “patient centred”. He said: “The needs of patients must come first. I believe there is a strong case for the CIC to be funded centrally by the Scottish Government. People who benefit from
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HS/S5/19/24/5 this service from throughout Scotland should be entitled to continue to receive it.” Ends.
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Annexe B
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i The Public Petitions Committee, Official Report, 13 September 2019, Col 23 ii Scottish Parliament Information Centre Committee Briefing, October 2014 iii Care Information Scotland (2014). Care at home. Available here [Accessed 23 October 2014] iv The Public Petitions Committee, Official Report 30 May 2019, Col 8 v The Public Petitions Committee, Official Report 30 May 2019, Col 8
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Health and Sport Committee
24th Meeting, 2019 (Session 5)
Tuesday 29 October 2019
Anticipated Birmingham Commonwealth Games Bill – Legislative Consent Memorandum
Note by the Clerk
The Committee is asked to consider the attached Legislative Consent Memorandum related to the Birmingham Commonwealth Games Bill. Part 3 of the Bill relates to areas which fall within the legislative competence of the Scottish Parliament and the Committee needs to agree, or not, for those areas of devolved competence to be considered by the UK Parliament.
Members are invited to consider the attached draft.
Clerk October 2019
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Health and Sport Committee
Anticipated Birmingham Commonwealth Games Bill – Legislative Consent Memorandum Introduction
1. The Scottish Government has lodged a Legislative Consent Memorandum (LCM) in respect of the UK Government Birmingham Commonwealth Games Bill. This has been referred to the Committee for consideration.
2. The Committee is invited to consider and agree its approach to consideration of the LCM.
What is an LCM?
3. The Legislative Consent Memorandum (LCM) process is the mechanism for the Scottish Parliament to give its consent to the UK Government to legislate in the UK Parliament on matters which are within the legislative competence of the Scottish Parliament.
4. Legislative Consent Memorandums are lodged in the Scottish Parliament by the Scottish Government. They relate to Bills under consideration in the United Kingdom Parliament which contain what are known as “relevant provisions”. These provisions could:
• change the law on a “devolved matter” (an area of policy which the UK Parliament devolved to the Scottish Parliament); or • alter the “legislative competence” of the Scottish Parliament (its powers to make laws) or the “executive competence” of Scottish Ministers (their powers to govern).
5. Under an agreement commonly known as the ‘Sewel Convention’, the UK Parliament will not normally pass Bills that contain relevant provisions without first obtaining the consent of the Scottish Parliament. Committees will undertake scrutiny of the Memorandum after which the Government can lodge a Legislative Consent Motion which is taken in the Chamber.
6. The procedure for scrutiny of Legislative Consent Memorandums and Motions is set out in Chapter 9B of the Parliament’s standing orders. Where an LCM is lodged and referred by the Parliamentary Bureau to a Committee. The Committee is required to consider and report on the LCM. Background Birmingham Commonwealth Games Bill
7. The Birmingham Commonwealth Games Bill (‘The Bill’) was introduced in the House of Lords on 5 June 2019. Page 2 of 4
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8. The Bill would provide the legal basis for certain time-limited operational measures in support of the Games in primarily four areas:
• Funding – which would enable the UK government to provide financial assistance to the Birmingham Organising Committee for the 2022 Commonwealth Games Ltd
• Association with the Games – this concerns authorised and unauthorised association to the event. The provisions in this area are designed to assist in protecting commercial rights. They provide for the organising committee to be able to authorise businesses to associate with the games. They also permit the committee to act in a civil court against persons suggesting an unauthorised association between any goods or services and the games (as long as they do not fall under an exception)
• Ticket touting, advertising and trading – provisions here are aimed at prohibiting the unauthorised sale of games tickets; prohibiting the promotion of non-sponsor products, services or businesses, including as part of advertising-related ‘ambushes’ of locations or coverage during the games; and prohibiting trading at or near games locations at certain times, including providing entertainment for gain or reward or appealing for money or other property
• Transport – provisions would permit the Government to direct an individual to prepare a statutory ‘games transport plan’. This would be aimed to address transport matters relating to the games in and around Birmingham. This would also allow traffic authorities and the Government to impose short term road and pavement closures at certain times, in line with the plan. Such powers could not be used more than 21 days before the opening ceremony (27 July) of the games and more than five days after the closing ceremony (7 August).
9. The provisions within the Bill are based on precedents from previous sporting events, such as the 2012 London Olympic and Paralympic Games and the 2014 Glasgow Commonwealth Games.
10. The House of Lords Library Briefing analyses Birmingham Commonwealth Games Bill 2017-19 provides further information on the contents and purpose of the Bill.
Provisions Which Relate to Scotland
11. Part 3 of the Bill covers Touting, Advertising and Trading Offences (ticket touting offence and ancillary provisions in Clauses 9-11) which relates to matters within the legislative competence of the Scottish Parliament.
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12. Clause 9 provides that it is a criminal offence for a person to sell, offer to sell, or expose for sale a Games ticket without authorisation from the Organising Committee. Clause 9(8) provides that a person guilty of an offence under this clause is liable to a fine not exceeding £50,000 in Scotland on summary conviction. Clause 9(9) provides that any penalty imposed in Scotland will be recoverable under section 221 of the Criminal Procedure (Scotland) Act 1995.
13. Clause 10 provides that it is an offence if a UK National or person normally resident in the UK acts in a way outside the UK that if done within the UK would constitute an offence. Clause 10(4) provides that proceedings against a person in Scotland may be taken in the sheriff court in which the person apprehended is taken into custody, or in a sheriff court determined by the Lord Advocate.
Timing & suggested approach
14. Scottish Parliament Standing Orders state that an LCM should be lodged with the Scottish Parliament two working weeks after the introduction of a relevant Bill in Westminster.
15. Typically, the Committee would make its report before the last amending stage in the House – i.e. third reading in the Lords. This ensures there are no changes to the provisions. The Third Reading date was 23 October, with the Second Reading in the Commons set for the week commencing 28 October. There is no expectation the provisions affecting Scotland will be altered.
16. As the provisions relate to the 2022 Commonwealth Games in Birmingham and other locations in the West Midlands there is no requirement for separate Scottish legislation.
17. The lack of direct impact on Scottish legislation and the Bill provisions which help to ensure tickets be accessible and affordable for people living in Scotland suggests there are no obvious reasons why the Committee would require further information or to hear directly from witnesses.
Recommendation
18. The Committee is invited to consider whether it is content to agree that the relevant provisions of this Bill, so far as these matters fall within the legislative competence of the Scottish Parliament, be considered by the UK Parliament and that there is no requirement to call for further evidence. And to report to the Scottish Parliament accordingly.
Clerk Health and Sport Committee October 2019
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