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Health in Scotland 2001

CANCER

The Size of the Problem

As highlighted in last year's report Health in Scotland 2000, cancer has now overtaken coronary heart disease as the commonest cause of death in Scotland. In 1997 over 25,000 cases of cancer were diagnosed in Scotland and in 2000 almost 15,000 people died of the disease. Lung cancer is the commonest cause of cancer death in both sexes, followed by colorectal cancer in men and breast cancer in women.

Cancer and Deprivation

For many cancers, incidence and mortality are higher and survival is lower in people from more deprived areas. Looking at the incidence and mortality from all cancers combined gives an indication of the extent of the inequalities. Cancer incidence is 14% higher in those from the most deprived areas of Scotland and mortality from cancer 40% higher.

The year 2000 target for cancer was to reduce mortality from cancer in people under 65 by 15% between 1986 and 2000. This has been met. A new target to reduce mortality in people aged under 75 by 20% between 1995 and 2010 has now been set. There has, however, been little evidence of any impact on inequalities in mortality from cancer. Figure 2.3 shows the trends in death rates from cancer since 1991. People from all deprivation groups have seen a decline in rates, but the gap between those in the most deprived and least deprived areas remains. In fact, the ratio of death rates between the most and least deprived has increased slightly over
the period.

Fig. 2.3 Trends in death rates from cancer by deprivation quintile

Prevention of Cancer

The risk of developing cancer can be reduced through healthier lifestyles. Prevention is a priority and the key messages are:

• Do not smoke

• Eat more fruit and vegetables

• Take regular exercise

• Moderate alcohol consumption

• Avoid over-exposure to sunlight.

Strategic Direction

2001 saw the publication of two major reports that will drive the development of cancer services over the next several years.

• Cancer Scenarios: an aid to planning cancer services in Scotland in the next decade

• Cancer in Scotland: action for change.

Cancer Scenarios: an aid to planning cancer services in the next decade

Cancer scenarios, published in April 2001, analysed trends in incidence and likely impact of developments in treatment of the major cancer sites over the next 10 years. These projections will underpin planning processes and inform the investment decisions which must be taken.

Cancer in Scotland: action for change

In July 2001, the Executive published its cancer plan Cancer in Scotland: action for change, which considered the whole patient journey from prevention through to palliative care and made a series of detailed recommendations. The strategy proposed the reconfiguration of the Scottish Cancer Group and the establishment of three Regional Cancer Advisory Groups in the North, West and South-east. The major function of these groups is to bring together all those concerned with cancer care, working in Managed Clinical Networks in order to "draw up realistic and effective workforce, equipment and chemotherapy spending investment plans in agreement with NHS Boards".

Implementation

Scottish Cancer Group

Following publication of Cancer in Scotland, the Scottish Cancer Group was restructured under the chairmanship of Dr Anna Gregor, newly appointed Lead Cancer Clinician for Scotland. The new group has a greatly strengthened representation from the voluntary sector and patients, as well as representation from the three Regional Advisory Groups, clinical disciplines and management. The remit of the Group includes advising on the implementation of Cancer in Scotland, bringing forward annual investment plans for cancer services and monitoring improvements in services, ensuring good practice and learning across Scotland. In the latter function, the Group works with the Clinical Standards Board for Scotland (CSBS) to advise on key aspects of services which should be monitored at national level. The Group will report annually to the Chief Medical Officer.

Capital Investment in Key Area of the Patient's Journey

The first task of the restructured Group was to collate and co-ordinate the investment plans for the first of 3 years additional investment totalling 40 million. The emphasis in the first year was on capital investment to build capacity in key areas of the patient journey. The Minister for Health and Community Care announced in November 2001 investment totalling 10.75 million, of which 6.78 million was for capital equipment including a wide range of imaging and pharmacy equipment. In addition, new consultant posts in medical, clinical and paediatric oncology, radiology, pathology, surgery and palliative care were created and recruitment is underway. Other key posts were funded including pharmacists, radiographers (both therapeutic and diagnostic), clinical nurse specialists (including chemotherapy and palliative care), speech and language therapists and a bereavement counsellor. The second year's plans are currently in preparation. Full details of the allocations for the first year are available on www.scotland.gov.uk and www.show.scot.nhs.uk.

Research to Strengthen Cancer Services

The Scottish Cancer Group is committed to promoting a central role for research in the provision and development of cancer services in Scotland and specifically strengthen support for clinical trials. A joint consultation exercise/workshop on research infrastructure for clinical trials was held in early 2002. This will bring together clinicians working in research, research nurses, academic researchers and the voluntary sector research organisations to build on the foundations created by the Chief Scientist Office and CRAG over the past 10 years, through the contribution of the Scottish Cancer Therapy Network.

The Scottish Cancer Group will work through a number of task-specific subgroups. The Referral Guidelines subgroup, were charged with preparing guidelines for urgent referral from primary to secondary care in the spring of 2002. These guidelines were published in May this year and are available on the Cancer in Scotland website ( www.show.scot.nhs.uk/sehd/cancerinscotland ). Other subgroups will cover patient information, chemotherapy, quality improvement and information management and technology.

Managed Clinical Networks

Managed Clinical Networks bring together everyone involved in the care of a specific cancer to agree care protocols across the area covered by the Network and audit the outcomes of treatment. The Scottish Cancer Plan stipulates that Managed Clinical Networks for all cancers should be in place by 2002. They will provide the mechanism through which redesign of services (for example for lung cancer and colorectal cancer) will be pursued in order to ensure the speediest possible journey for patients and optimal use of resources. Networks will be brought together within their Regional Cancer Advisory Group and with other regional networks to ensure sharing of best practice and a consistency of approach to cancer services across Scotland.

A national networks workshop was held in August 2001 sponsored by the Scottish Cancer Group. This provided an opportunity for clinicians and other network members to consider the benefits for patients of successful networks as well as the challenges faced in network development. Although held soon after the publication of Cancer in Scotland, the momentum for change was clear, and SCG will continue to facilitate a series of National Network meetings to share innovations and best practice.

Cancer Open Forum

A Cancer Open Forum was organised by the Scottish Cancer Group to engage with all in Scotland who have an interest in the implementation of the cancer strategy. The Open Forum, held in October 2001, attracted 350 delegates from around Scotland including staff from NHSScotland from the primary, secondary and tertiary care settings, the voluntary sector and patient representatives and demonstrated areas of good practice and work ongoing across Scotland.

Clinical Standards Board for Scotland

Standards of care for the four most common cancers:

• breast

• lung

• colorectal

• gynaecological

were amongst the earliest priorities for CSBS. A series of standards were agreed through a rigorous process that included patients, professional and lay carers involved in the whole process of care. During the summer and autumn 2001, CSBS completed a round of visits to all Trusts to assess the extent of compliance with these agreed standards and their reports are expected to be published in the early spring 2002. These will provide an invaluable baseline against which to judge the improvements that are expected from overall implementation of Cancer in Scotland and the additional investments being made. Indeed many of the planned investments are focused on improvements in cancer services aimed at meeting CSBS standards. The process of standard setting and auditing, targeted investment and repeat audit will lead to identifiable improvements in cancer services and, importantly, in the experience of care by cancer patients.

Beatson Oncology Centre

During 2001, an action plan to address the longstanding difficulties facing the Beatson Oncology Centre (BOC) in Glasgow was announced by Greater Glasgow NHS Board. The Minister for Health and Community Care appointed a new clinical director (Dr Adam Bryson) to provide impetus and focus to the delivery of the Action Plan. An Expert Review Group (chaired by Professor Bernard Cummings from Toronto) spent 2 weeks in January 2002 meeting all parties, and reported to the NHS Board. Recruitment of a range of staff (including replacement and additional consultant oncologists) is under way, and the business case for moving the BOC from the Western Infirmary site to Gartnavel Hospital (with additional radiotherapy capacity and new in-patient facilities) is expected to be approved shortly.

Cancer and Older People

Cancer is commoner in later life with around one-third of all cancers diagnosed in people over 75 although they form only 7% of the population. EGHOP emphasised that older patients may not always receive cancer treatment that might benefit them. EGHOP recommended that older people with cancer should have access to the service developments that will follow from implementation of Cancer in Scotland: action for change.

The Size of the Problem

Mental health problems are one of the commonest causes of ill health in Scotland. The lifetime risk of any mental disorder is 1:3. Depending on the criteria used, between 15%-20% of individuals will have had a mental health problem in the preceding 12 months. For women the rate is higher, for men lower. Many facets of social exclusion contribute to the prevalence of mental health problems - isolation, a history of abuse, homelessness, discrimination and communication problems. Continuing problems, such as being a long-term carer, marital conflict and a chronic physical illness also contribute. All these also increase the likelihood of substance misuse - drugs or alcohol - which in turn make mental health problems more likely.

Mental Health and Deprivation

Suicide is an important cause of premature death, especially among young men. Through the 1990s suicide rates in young men have steadily increased. There is a strong association between suicides and deprivation, with twice as many suicides occurring in those from the most deprived areas of Scotland. Over the 1990s the rates have increased by nearly 40% in young men from the most deprived areas of Scotland. While many factors are at work in causing this trend, it is important to take measures to improve prospects and promising futures for young, particularly unskilled men and support them at difficult times.

The steady rise in suicide rates in young men through the 1990s in Scotland, which contributes to a 250% rise over the last 2 decades, is sad evidence of social and environmental pressure - mental ill health contributes to a quarter of all suicides, with substance misuse adding at least that again. Any circumstance of social adversity doubles the rate of mental ill health among children and young people to 1:5. Mental health problems spill over into the older years.

Evidence comes from UK surveys, with the samples including people from Scotland, published during 2001 by the Office for National Statistics. Also the Confidential Enquiry into Suicide and Homicide by People with Mental Illness Report Safety First (2001) included a 3 year sample from Scotland for the first time.

Strategic Direction

The policy statement "Renewing Mental Health Law", which was published in October 2001, set out the Executive's response to the Millan Committee's comprehensive review of the Mental Health (Scotland) Act 1986, and provides the framework for new mental health legislation, which is to be introduced in the Scottish Parliament in 2002.

Policy and strategy development have followed the line set in the January 2000 Ministerial Summit, reflected in Our National Health (December 2000) emphasising the need for comprehensive mental health services. The 1997 Framework for Mental Health Services in Scotland again was confirmed as setting the philosophy and direction for service development. It was acknowledged that the management of anxiety and depression in the community, and support for positive mental health (as opposed to illness treatment) services should be emphasised.

It is quite clear what the social circumstances and skills are which an individual requires to maintain positive mental health.

• First, a person needs to be able to identify, describe and be willing to communicate
  inner feelings.

• Second, an individual needs to have some valued role in life, whether as an employee or as a member of a local community or social group.

• Third, comes a circle of supportive friends who can provide a sense of being valued.

The skills required include being able to solve problems, to be able to cope with feelings without seeking quick fixes such as alcohol or drug use and being able to empathise with how other people are feeling. This much is known; implementation is discussed below.

Implementation of Policy

Activity during 2001 falls under five headings:

• The Mental Health and Wellbeing Sub-group

• Quality Development

• Positive Mental Health

• Refreshing the Framework

• Shifting the Balance of Care to the Community.

The Mental Health and Wellbeing Sub-group

This Group was set up after the Ministerial Summit to "support, influence, and help advance the further strategic development of mental health services in Scotland". It finished its first round of visits to NHS Board areas, and partner agencies, in spring 2001. The outcome of visits are published in full on its website ( http://www.show.scot.nhs.uk/mhwbsg ). While the Framework and other guidance material remains in force, for its second round the Group has given prominence to the issues flagged up in Our National Health. A written report after each visit goes to Ministers and to local partners and now a score sheet will be used to contribute to the new Performance Accountability Framework.

Quality Development

Three Scottish Needs Assessment Programme (SNAP) Working Groups have worked throughout 2001:

• on child and adolescent mental health

• liaison psychiatry and psychology (the psychological influences on physical health) and

• autistic spectrum disorder.

Reports from all three will become available during 2002. SIGN has guidelines on postnatal depression, alcohol problems in primary care and generalised anxiety disorders in preparation.

The Scottish Health Advisory Service is now using a standard template to structure its inspections. During 2001 the Clinical Standards Board Schizophrenia Standards were used by all Scottish Trusts to conduct an internal audit of compliance with five of the 13 standards. Visits for the purpose of external accreditation were made by groups of professionals and lay people (including users of services and carers). There are indications of good individual professional practice, within a very narrow scope. The wider dimensions, of patient information, of support for carers, of psychological and occupational intervention and measures to reduce social isolation, are relatively neglected. There is little audit taking place to draw this to the attention of service providers and the components of local services often do not link well together. Clearly there is a considerable re-engineering and information management/sharing task ahead.

With support from the Clinical Effectiveness Programme for Scotland work on outcomes
for people with schizophrenia, a young persons integrated care pathway for behavioural
disorder and anxiety problems and an approach to medically unexplained symptoms has been carried forward.

The Framework

In the past year, a template for the provision of psychological interventions at all levels of care, from voluntary agencies to the most specialist of therapies, was prepared, widely consulted upon, and launched. This was complemented by a pilot project, in four Trusts, supported by the Mental Health and Wellbeing Development Fund, to examine best practice in the provision of efficient and effective psychological interventions. Absent from the original Framework document was a template for eating disorders and this deficiency has now been remedied.

Changing the Balance

There is a tension between the needs of people with severe and enduring mental health problems, and the needs of those in the community with usually - but not always - less severe disorders, such as depression and anxiety. Dealing with the latter group falls to primary care services. People with depression and anxiety are generally extremely heavy consulters and there are great benefits for their peace of mind and well-being - mental health promotion - if they can be assessed and managed adequately. Many such people have wider difficulties in their lives and help means giving assistance to change circumstances and increasing a person's ability to cope. The increase in prescription of the newer oral anti-depressant drugs in the last decade, although alarming to some, is probably evidence that general practitioners recognise depressive disorder better and patients are willing to take the newer drugs with fewer side effects. However, coping abilities and changing circumstances are not enhanced by medication (although an individual's ability to start to deal with issues may be). For these reasons, psychological treatment has to become more available to people seen by their general practitioner. Such interventions need to be available locally, of good quality, provided by people with the necessary skills, working in the right practice framework.

Psychological Interventions

There is now a strong evidence base for a number of psychological interventions "talking treatments". Such interventions can meet the needs of the majority of people with anxiety and depression found in the community, many of whom are reluctant to accept pharmacological intervention. Such interventions are also relevant to the management of alcohol problems and drug misuse, as well as many people found in general hospitals whose physical condition is complicated by mental health problems. A psychological intervention is the treatment of choice for women with postnatal depression. Many professionals can provide a psychological intervention, with the correct training, practice framework and continuing supervision. Workforce planning mechanisms are being used to ensure that a supply of people with the appropriate skills will become available to meet the growing need.

The Size of the Problem

Diabetes is one of the most significant health challenges facing modern society. Diabetes is the fourth-leading cause of death in the UK. It is a serious and progressive chronic disease with potentially devastating consequences for health. The complications of diabetes include a higher risk of:

• heart disease

• stroke

• kidney damage (diabetic nephropathy) that can lead to renal failure

• eye disease (diabetic retinopathy) that can lead to blindness

• peripheral vascular disease and foot ulceration that can lead to amputation.

It is estimated that around 3% of the Scottish population (about 150,000 people) have been diagnosed with diabetes, with many thousands more who are as yet undiagnosed or are at serious risk of developing diabetes in the future. Some commentators have suggested that the prevalence will double over the next 10-15 years.

Scottish Diabetes Survey

NHSScotland is making concerted efforts to improve the quality of diabetes data available both for patient care and for population-based planning and audit. This is being achieved by the development of regional clinical information systems and an annual national survey. The first Scottish Diabetes Survey was undertaken and reported in 2001. It is believed that Scotland is the only country in the world to achieve such a national picture.

The 2001 report included data from all 15 NHS boards. A total of 105,777 patients were reported, a prevalence of 2.07%. The difference between this and the estimated rate (of about 3%) is largely explained by the different stages of development of the regional registers. The Survey will be repeated in September 2002.

See Figure 2.4.

Fig. 2.4 Number of people with diabetes in Scotland. Scottish Diabetes Survey 2001 and future projections

The percentages used in the figure above (and taken from the Scottish Diabetes Survey 2001) are based on data provided by the Registrar General for Scotland for a Scottish population of 5,119,200, the mid-year estimate at 30 June 1999.

There are two main types of diabetes:

• type 1 (an autoimmune condition usually occurring in people under 30)

• type 2, which is strongly linked to obesity, poor diet and lack of physical exercise and which usually develops in people over 40.

About 85-90% of people with diabetes have type 2 diabetes. Diabetes is also more prevalent among ethnic minority groups - communities of Asian and African-Caribbean origin have a prevalence of diabetes between three and four times higher than those of European origin.

Rising Incidence of Diabetes

• There is an increasing incidence of both type 1 and type 2 diabetes, but particularly type 2. The pronounced rise in type 2 diabetes is attributed to a combination of:

• better detection of the disease in its early stages

• changes to lifestyle, namely poor diet and lack of exercise leading to increasing levels
  of obesity.

Diabetes and Deprivation

Type 2 diabetes is associated with deprivation; those living in the most deprived areas of Scotland are more likely to develop diabetes.

Diabetes and Children

One of the most troubling trends in recent years has been the increasing number of younger people developing type 2 diabetes as a consequence of rising rates of obesity among the young. Type 2 diabetes is now being found in children as young as 13 and has been diagnosed in those from ethnic minority groups (who are known to be at greater risk of developing diabetes) and more recently in white children.

Treatment of Diabetes

Treatment of diabetes has changed considerably over recent years with the traditional focus on control of blood sugar now matched by an equal emphasis on the management of risk factors, including hypertension, hyperlipidaemia and smoking. Central to diabetes management is the annual review which should include assessment of glycaemic control, surveillance for cardiovascular risk, surveillance for long-term complications (e.g. of the eyes and feet), surveillance for psychological complications and advice on lifestyle.

SIGN Guidelines: Management of Diabetes

There is now a substantial body of research indicating how diabetes can be prevented and how outcomes for people with diabetes can be improved. The Scottish Intercollegiate Guidelines Network (SIGN) has played a central role in collating the evidence base for clinical practice in diabetes. In November 2001 SIGN published a guideline on Management of Diabetes (SIGN 55). This revised and updated six earlier diabetes guidelines. The SIGN guideline provided the main source of evidence to support the development of the Scottish Diabetes Framework and the Clinical Standards for Diabetes published by the Clinical Standards Board for Scotland.

Scottish Diabetes Framework

Our National Health included a commitment to publish a Scottish Diabetes Framework to draw together existing guidance and best practice and to establish a national screening strategy for diabetic retinopathy. A multi-disciplinary working group was set up in April 2001 to produce the Framework. A consultation paper was widely circulated in July and the key milestones of
the Framework were published on World Diabetes Day - 14 November 2001 - to coincide with the publication of the CSBS standards and the SIGN guideline. The full framework was published in 2002. The Health Technology Board for Scotland published an assessment of diabetic retinopathy screening in April 2002.

With an ageing population, the prevention and treatment of chronic disease will be one of the central concerns of NHSScotland in the 21st century. The current work being undertaken in diabetes will not only help towards tackling one of the most common and serious chronic diseases, but it can also provide a model for improving the management of other conditions.

The Size of the Problem

Adults' Oral Health

In the year ending March 2001, approximately 2 million adults and 750,000 children were registered with a general dental practitioner in Scotland, with many more patients accessing care through the community dental services and hospital dental services. Total tooth loss amongst Scotland's adults has reduced dramatically in the last 30 years, with only 18% of adults suffering loss of all natural teeth in the most recent Office for National Statistics (ONS) Adult Dental Health Survey in 1998, compared with the 44% of Scottish adults suffering this fate as recently as 1972.

Children's Oral Health

However, despite substantial improvements in adult oral health in Scotland since the 1970s, children's oral health in Scotland remains poor, with only 45% of Scottish 5 year olds free from dental decay (in 2000), well short of the national target of 60% decay free by 2010.

Strategic Direction

The Action Plan for Dental Services in Scotland, published in August 2000, set out a range of strategic measures to improve oral health in Scotland, placing particular emphasis on improving oral health in children and in tackling the inequalities which impact significantly upon both dental health and access to oral health care. A raft of measures have now been put in place to tackle dental decay at key stages in life and to attempt to overcome the effects of deprivation:

• free distribution of toothbrushes and paste to all children aged 8 months, and targeted distribution to 2- and 3-year-old children in more deprived areas

• the Early Years Enhanced Capitation Scheme was introduced in 1998 to increase preventive activity for 0-5 year olds

• expansion of supervised nursery toothbrushing programmes in Scotland

• a Caries Prevention Scheme was introduced in November 2001 for children aged 6 and 7,
  to provide advice on preventing decay and to provide fissure sealing of newly erupted
  molar teeth

• significant projects on healthy eating in young children funded through the Health Improvement Fund Programme

• significant increased support through health promotion programmes from health visitors, pharmacists, nursery playgroup leaders and parents.

Children's Oral Health and Deprivation

Tooth decay is the major dental disease of childhood. The causes of the disease are well understood and may be broadly attributed to consumption of dietary sugars. Reduction of dietary sugars and improved toothbrushing at least twice daily with a suitable fluoridated toothpaste will reduce levels of tooth decay and gum disease. However, it is known that children from less advantageous circumstances are less likely to have had their teeth brushed with a fluoride toothpaste or to have visited a dentist by their first birthday and hence changing the diet of Scotland's young people is a priority.

Our greatest challenge is to reach those in the most disadvantaged circumstances. Consideration should be given to how we might most effectively achieve oral health improvement in this sector of the population. The role of water fluoridation in reducing dental decay in our most deprived communities should be considered as part of an overall strategy for oral health improvement. It is only by a multi-faceted approach that progress in improving the oral health of all of our children can be achieved. NHS Boards, local authorities, the dental profession, medical professionals and health visitors, educational establishments together with playgroups, parents and carers are all crucial to achieving our aim of improving oral health. An example of work in Forth Valley is given below.

Fig. 2.5 Dental health and social deprivation

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