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" The ultimate aim is to improve health outcomes through ensuring that health services are both appropriate & accessible and for all patients who use them "

As a public health service, the NHS in Lothian is already founded on the principles of mutuality. Therefore, the issue is not one of how to create a mutual NHS, but rather of improving and expanding it to form a service relevant to the needs of today's population. There are two areas we are already focussing attention on, these are, increasing trust and community capacity.

Why mutuality?

Mutuality describes a reciprocal relationship that exists between two inter-dependent parties and reflects the relationship between individuals, their communities, and their health systems. It helps define the rights and responsibilities of each of the partners in protecting and promoting health and providing healthcare and is at the heart of what a universal healthcare.

A mutual health service?

The drive for mutuality reflects a desire to develop health and healthcare services that are designed with people at their heart and uses an agreed framework which promotes equitable provision. A health service based on mutuality is required to meet standards of care that are defined by professionals, users, patients and public.

A mutual service is also a sustainable health system, that welcomes the active participation of the community it serves, both as co-owners of health services and co-producers of health. This engagement must recognise the diversity of local people from all backgrounds and abilities, encouraging those who choose to come to live, work and study here to engage with the various health services.

If the situation were otherwise, the solidarity of the health system, and the society it is a part of, would suffer. It is vital to maintain a society that will accept that around 83-85% of health expenditure is from the public purse: as any less than this and socio-economic and geographical inequities would increase greatly. Some European countries that do not appear to have a high proportion of public spending spent on health services have a longstanding commitment to funding being routed through voluntary sector organisations.

A mutual health service requires us to demonstrate the value we place on:

  • Building trust and engagement across all of society.
  • Our employees: as ambassadors for the health service, as people who can work with others in their home communities to build individual and neighbourhood capacity.
  • Our role as an economic force for good in the community, for example, using local suppliers and local workers, paying our bills on time; and
  • Our role as a respected and socially inclusive employer, for example, training apprentices and professional staff who are well respected by the public sector and showing the way in demonstrating that people with disabilities or long term conditions can rise to the top.

The challenge is to demonstrate that all patients and all sections of our population are able to take part and contribute to the design and delivery of services, and in the improvements in the health and wellbeing of their local communities. One of the tools for improving the delivery of health services is equity audit. Equity audit is an assessment of how fairly health services are delivered. It is used to increase the efficiency of services, and enhance the capacity of patients to make the most effective use of the services they receive. It also aims to recommend actions which are relevant and significant for patients, as well as achievable and appropriate to health service delivery.

Its ultimate aim is to improve health outcomes through ensuring that health services are both accessible and appropriate for all patients who use them. Equity audits collect information to find where inequalities in the level or quality of a service, or barriers to access exist for patients. The results enable recommendations to be made about the changes services need to make to deliver more equitable care. Information gathered includes evidence from local or national surveys and research; the experiences of patients; the views of health professionals; and analysis of statistics from Lothian health registers and databases.

This is illustrated by two examples relating to conditions that are more common in certain groups of people. Diabetes and coronary heart disease disproportionately affect people living in the least well off sections of our society. Research to date indicates that the services in Lothian are equitable in terms of the way they are delivered.

However, it is clear that factors which increase the likelihood of developing these conditions, such as smoking and being overweight, are also more common in these same groups. Therefore, it makes sense that approaches focused on prevention, such as help in giving up smoking and initiatives to support people to eat more healthily and increase their levels of physical activity, should be targeted at specific groups or within specific areas. In this way, resources are delivered where they are most needed.

People of South Asian origin have a higher risk of developing diabetes at an earlier age than other groups in the population. A culturally competent service is staffed by healthcare professionals who are aware of the different needs of different patients. It would provide, for example, the practical and expert support necessary for self-management of long-term conditions such as diabetes in a culturally appropriate way, that was tailored to the needs of individual patients. Examples include tailoring the content of dietary advice, or ensuring the availability of interpreters or language specific materials.

The equity audit programme contributes to the delivery of targets for increasing equality and diversity and for improving people's experience of care. The groundwork has been laid this year to integrate the programme more firmly within the overall strategic planning framework, and to strengthen the role of those who manage and deliver the services in making decisions on the shaping and implementation of recommendations.

In Lothian, we take a system wide approach to improving health and reducing inequalities. Previous reports have examined the burden of disease across the life course and effective forms of prevention and treatment. Over recent years, many indicators of health and life expectancy in Lothian have continued to improve. Examples include:

  • Lothian has the highest percentage in Scotland of babies that are exclusively breastfed at 6-8 weeks, 36.9%.
  • By December 2008, 95.5% of Lothian children at age 5 had completed their primary course of immunisation for measles, mumps and rubella (MMR) - well above the Scottish average of 93.1%.
  • Obvious tooth decay in our primary one children is at its lowest level since records began.
[ Figure 1 ] Immunisation uptake
MMR immunisation uptake (completed primary course by 24 months)

Immunisation uptake

[ Figure 2 ] Percentage of children recorded as exclusively breastfed at the 6-8 week review: 2004/05 to 2008/09

Percentage of children recorded as exclusively breastfed at the 6-8 week review: 2004/05 to 2008/09

Early intervention

Screening and treatment for cervical cancer benchmarks well at international level.

[ Figure 3 ] Cervical Cancer
Comparative cervical cancer mortality rates per 100,000 population1 across Health Tracker members.

Comparative cervical cancer mortality rates per 100,000 population across Health Tracker members

1 Standardised for population age and sex mix differences
Source: Health Tracker members data collection, OECD Health Indicators, National Centre for Health Outcomes Development, McKinsey Analysis.

[ Figure 4 ] Road Traffic Accidents
Age standardised1 admission rates for road traffic accidents per 100,000 in Lothian, 1998-2007.

Age standardised admission rates for road traffic accidents per 100,000 in Lothian, 1998-2007

1 Directly standardised against Standard European Population.
2007 data is provisional. Data extracted November 2008. Source: SMR01

Improvement treatment and care

Age standardised admission rates for coronary heart disease have declined as has mortality.

[ Figure 5 ] CHD death rates
Age standardised1 CHD death rates2, in Lothian, 1998-2007

CHD death rates

1Directly standardised against Standard European Population;
2Rates per 100,000. 2007 data is provisional. Data extracted November 2008. Source: GRO(S)

There are challenges however, alcohol related admissions are increasing and deprivation remains a problem. Reducing the associated avoidable rates of premature disability and death will require continuing systematic, sustainable change in policy and practice undertaken in partnership with local people.

[ Figure 6 ] Alcohol admissions
Age standardised1 alcohol related admission rates2, in Lothian, 1998-2007

Alcohol admissions

1Directly standardised against Standard European Population;
2Rates per 100,000. 2007 data is provisional. Data extracted November 2008. Source: SMR01

Trust and community capacity in NHS Lothian

Having trust in the health system requires that the organisation and the individuals within it are trustworthy. This is a pre-requisite of a mutual system. Trust is important because it facilitates collaboration and contributes towards the achievement of shared goals, such as improving the quality of care that patients experience or reducing health inequalities1. It has become increasingly clear that the public requires that the health service provides more than technically excellent care. Most of the challenges the health service faces are about relationships. On a day to day basis, therefore, trust shapes the joint working between individuals, teams and services that, together, deliver prevention and treatment. A trusted health system is an organisation that treats current and future patients, relatives, staff and contractors with dignity and respect, maintaining solidarity in difficult times.

The public places its trust in the NHS to use resources wisely in meeting its healthcare needs and it is a balancing act to create an efficient healthcare system that has the capacity to redirect resources towards areas where inequalities exist. What is needed therefore is an approach which can achieve this type of balance, whilst maintaining and increasing trust. One such approach is MESH2 (Management, Economic, Social and Human). The MESH approach seeks to build infrastructures which will build community capacity (see Box 1).

[ Box 1 ] The Components of MESH2
  • Management: management capability in financial and technical aspects, identifying community aspirations and needs, planning infrastructure development and implementation, management of service provision.
  • Economic: developing geographical access, building wider social amenities, employment support.
  • Social cohesion: unity and cohesion within communities, interaction and relationship between communities, health districts, government, voluntary sector etc.
  • Human: human aspects include deployment of professional and service personnel, leadership, skill mix.

MESH recognises that sustainable infrastructure is an essential first step in developing the capacity of a community to improve their health. Without such investment, communities may be provided with services with which they are not engaged and do not provide long term benefits. It is not hard to see where such situations have occurred in the past. Over the next two or three years we will further develop our partnerships with Local Authorities, voluntary organisations and communities to help build local capacity to work creatively with professional and wider staff groups to tackle inequalities in health and healthcare.

The World Health Organisation (WHO) report on the Social Determinants of Health3 sets health systems three tasks:

  • Improve the conditions of daily life - the circumstances in which people are born, grow, live, work, and age.
  • Tackle the inequitable distribution of power, money, and resources - the structural drivers of those conditions of daily life - globally, nationally, and locally.
  • Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

... they are the challenges for a mutual NHS in a service provider, as an employer and as an economic force in the communities of Lothian.

Key messages

  • Mutuality as a principle applied to health and healthcare is based on the best available evidence.
  • The policy framework is set by the WHO and advisory committees, especially in the context of the Millennium Development Goals.
  • Within the Scottish context, its application is intended to increase the visibility of NHS accountability and the engagement and trust of all sections of the population in the NHS.
  • Rebuilding a mutual NHS in Lothian will require us to sustain trust and further develop community capacity without sacrificing equity or efficiency.
[ Map 1 ] Scottish Index of Multiple Deprivation Quintiles 2009 - NHS Lothian Area

Scottish Index of Multiple Deprivation Quintiles 2009 - NHS Lothian Area

By Mette Tranter, HIU, 05/01/10. Reproduced by permission of Ordnance Survey on behalf of HMSO. © Crown copyright and database right 2010. All rights reserved. Ordnance Survey License number 0100022972.