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Health in Scotland 2002

CHAPTER 1

IMPROVING SCOTLAND'S HEALTH

Health Determinants

Poverty and Social Exclusion

September 2002 saw the death of Sir Douglas Black, a notable Scot whose 1980 report Inequalities in Health highlighted the link between deprivation and ill-health and has thrown spotlights on the subject ever since. His work influenced Sir Donald Acheson's Independent Inquiry into Inequalities in Health nearly 20 years later. Its themes lie at the heart of the Scottish Executive's approach to health improvement - an approach which has tackling inequalities as its 'overarching aim' and which recognises that 'action on life circumstances is the rock on which work to improve lifestyles and tackle disease will stand or fall' ¹.

Poverty and social exclusion go hand in hand with a propensity to suffer more ill-health and to die younger than more affluent citizens. While such differences are a common feature of health experience across the UK and EU, they are generally greater in Scotland than elsewhere.

Table 1.1: Directly standardised mortality rates per 1,000 population, 1990-92,
by country and deprivation quintile

(source: PHIS 'Chasing the Scottish Effect', November 2001)

Towards a Healthier Scotland identified the life circumstances that have particular relevance for health. Many of these have subsequently been picked up in the Scottish Executive's Social Justice framework. A review of the progress and challenges in key areas of this agenda was set out last year in a report entitled Health Inequalities in the New Scotland².

• Employment & Income: exclusion from the labour market is the principal route into poverty. The continuation of historically low levels of unemployment and a minimum wage are therefore welcome.

• Housing: In the mid-1990s, 34% of houses in the public rented sector (25% in Scotland as a whole) suffered dampness and condensation and 16% of council houses were in poor repair (visible repair costs greater than 1,200) ³. How this situation is being addressed should become apparent in the summer of 2003, with the publication of the Scottish House Condition Survey 2002.

• Fuel poverty: Over 140,000 homes have been improved through the Warm Deal since 1999 and almost 10,000 central heating systems have been installed through the Central Heating Programme since 2001.

• Homelessness: Homeless people face even greater risks to their health than do people in poor housing. At the launch of the final report ⁴ of the Homelessness Task Force in February 2002, the SE pledged that every homeless person would be entitled to permanent accommodation by 2012. Meanwhile, the SE's health and homelessness co-ordinator continues to help NHS Boards in developing action plans to tackle the health needs and problems of homeless people across Scotland.

Problem Drinking

Problem drinking is increasing in Scotland. The level of binge drinking is rising and young people and women are drinking more than ever before. There are also sharp upward trends in alcohol-related illness and death, particularly in alcoholic liver disease in women, which is being seen at younger ages. The link between alcohol and mental health problems is well established.

Currently

• 33% of adult men and 15% of adult women exceed the recommended weekly alcohol consumption limits

• One in four Scottish women say they binge drink

• 23% of 13 year olds and 46% of 15 year olds report that they have drunk alcohol in the previous week

Targets aim

• To reduce the incidence of exceeding weekly limits to 31% for men and to 12% for women by 2005

• For young people, to reduce the level of drinking from 20% of 12-15 year olds to 18% by 2005

Health in Scotland 2001 highlighted the publication, in January 2002, of the Plan for Action on alcohol problems. The Plan establishes a framework for reducing alcohol-related harm and action is now underway in culture change, prevention and education, the provision of support and treatment services and protection of individuals and the community.

The Plan places a priority on the need to reduce harmful drinking by children and young people, through education programmes in schools, resources for parents and advertising which challenges Scotland's binge drinking culture. Children affected by alcohol problems are one of the priority groups for the Changing Children's Services Fund, whilst joint working by Scotland's Health at Work (SHAW), Health Education Board for Scotland (HEBS) and Alcohol Focus Scotland (AFS) is supporting the development of alcohol policies within the workplace.

In September 2002, the SE published a framework for alcohol problems support and treatment services to help local Alcohol Action Teams (AATs) plan and commission effective services. A gender issues network is being set up by HEBS and AFS with support from the SE. The network, which will focus initially on women and alcohol, will provide a vehicle for the development and dissemination of good practice and information.

Smoking

Smoking in pregnancy is an important and preventable cause of harmful effects on the unborn baby, including miscarriage, premature birth and low birth weight. Most recent figures for Scotland show that 26.1% of women continued to smoke during their pregnancy in 2001.
The current government target is to reduce the proportion of women recorded smoking at the start of their pregnancy to 23% by 2005.

Links with deprivation

The problems with smoking during pregnancy are closely related to health inequalities. Women with partners in manual occupations are more likely to smoke during pregnancy than those with partners in non-manual occupations. 33% of women themselves in manual occupations smoked during pregnancy compared with 10% of women in non-manual occupations. 70% of smokers are in lower socio-economic groups and smoking rates are highest among lone mothers, over 60% of whom begin their pregnancies as smokers.

The SE continues to make progress in implementing the White Paper " Smoking Kills". Priorities are:

• To reduce smoking among children and young people

• To help adults, particularly the disadvantaged, to give up smoking

• To help pregnant women give up smoking

Passive Smoking

Passive smoking has adverse effects on children's health and is known to increase significantly the risk of sudden infant death, middle ear disease, meningitis and admission to hospital for respiratory disease. The Royal College of Physicians of London has estimated that as many as 17,000 hospital admissions per year of children aged under 5 are due to parental smoking. They also estimate that a quarter of cot deaths could be caused by mothers' smoking.

In 2002-03, the SE allocated 1.5 million to HEBS for anti-tobacco health promotion work including passive smoking. Activity in this area aims to raise awareness of the health risks associated with passive smoking, especially where it impacts on children. Work is currently underway to update the HEBS information leaflet on passive smoking and an extensive poster campaign on the risks associated with passive smoking will be undertaken during 2003.

Tobacco Advertising and Promotion Act 2002

The SE made a commitment in its Programme for Government to ban tobacco advertising and promotion in Scotland and backed the Tobacco Advertising and Promotion Act 2002, which received Royal Assent in November 2002. This legislation will control advertising in the press, on billboards and on the Internet, as well as brand sharing and sponsorship.

The ban will provide much greater protection for children and young people from the exposure to messages from multinational tobacco companies. It is estimated that it will lead to a 2.5% fall in the number of people in Scotland who smoke and, longer term, to a saving of around 300 lives per year from smoking-related diseases.

Healthy Eating

Good nutrition can help to reduce the prevalence of many common diseases in Scotland today: cardiovascular disease, cancer, diabetes, obesity and osteoporosis are all linked to poor diet. The Scottish diet is characteristically high in fat and low in fruit and vegetables and, although recent statistics have shown that it is getting better, improvements are not happening fast enough. The Health Behaviour in School-aged Children Report on the Eating Patterns of Children, undertaken between 1990 and 1998, reveals a 10% increase in the proportion of all eleven to fifteen year olds consuming fresh fruit and a small increase in the number of children eating cooked vegetables on a daily basis. However, the research also discloses an increase among the eleven to fifteen year olds who consume sugary fizzy drinks and sweets daily.

Table 1.2

The Food Chain

In recognition of the need for greater improvement at a faster pace (a step-change) in Scotland's health, the SE is mounting a renewed and sustained effort to meet the dietary targets set for 2005. It is pursuing a food chain based approach and a strategic framework for this work has been developed involving every part of the food chain.

The dietary targets for 2005 set in the Scottish Diet Action Plan are

• Increasing the consumption of fruit and vegetables

• Reducing the consumption of fats, particularly saturated fats

• Increasing the consumption of complex carbohydrates (potatoes, wholemeal bread, cereals)

• Reducing the consumption of salt and sugar

Current work is aimed at increasing understanding and awareness of healthy eating messages as well as changing consumer habits. The healthy eating campaign "Healthy Living" aims to increase consumer demand for healthier food. It delivers important basic healthy eating messages and directs people to a new telephone advice line and website for practical advice and information.

It is also important to influence those who cook and prepare food. The Scottish Executive Health Department (SEHD) is working with the public and private sector catering services and companies to increase the availability of healthy food choices. The Scottish Healthy Choices Award Scheme (SHCAS) is in place for the catering and food service industry. A Food and Health Vocational Training course has been developed in partnership with the Royal Environmental Health Institute of Scotland (REHIS), HEBS, the Food Standards Agency Scotland, Scottish Community Diet Project and SHCAS. This course provides basic food and health training to individuals working with food in a range of settings, including local authority and commercial catering establishments and the voluntary sector. The Clinical Standards Board for Scotland (CSBS) is also consulting on nutritional standards for hospital food.

Widespread accessibility of healthier food choices will be key to success in meeting the dietary targets. Work continues through retailing, community and local planning processes, local nutrition action plans and reviewing targeted food distribution programmes including fruit in schools. The Scottish Community Diet Project continues to work with low-income communities across Scotland to address the practical obstacles to healthy eating. There are now over 400 community food initiatives in operation.

The Scottish Food and Health Co-ordinator and Scottish Enterprise are working with manufacturers, processors and retailers to encourage them to develop new products and processes through advances in food production. The healthy eating campaign aims to create the necessary demand for healthier produce.

The SEHD is working with the Agriculture and Fisheries sector to help promote and develop the sustained availability of core Scottish produce as part of a healthy diet. This involves the prioritisation of current grant schemes in favour of projects that support Scottish dietary targets as well as adding value to Scottish produce.

Physical Activity

Physical activity or, rather, inactivity constitutes one of the most widespread health determinants in Scotland. Research over the past 50 years has demonstrated that inactivity leads to increased risk of coronary heart disease, stroke and many other health problems. It is an independent risk factor for the entire population and also affects people of normal weight. Six out of ten men and seven out of ten women in Scotland put their health at risk by taking less than the minimum recommended levels of physical activity. Three in ten boys and four in ten girls also fall short of the amount of physical activity required for good health.

The SE intends to tackle the causes and to reverse the trend of growing inactivity in Scotland. The Physical Activity Task Force (PATF), set up in June 2001, was charged with developing a plan to increase the physical activity levels in Scots of all ages.

The targets are ambitious:

• To increase the number of Scottish children achieving the recommended level of physical activity to 80%

• To increase to 50% the number of Scottish adults reaching the recommended 30 minutes of physical activity on most days of the week

A number of initiatives are already underway to increase physical activity:

Drug Misuse

Reported drug use among young people has not changed significantly since 1998. In 2002, 9% of 13-year-old boys and 6% of 13-year-old girls, 24% of 15-year-old boys and 21% of 15-year- old girls report having used drugs in the last month. Use in the last year also remained steady at 13% for 13-year-old boys and 10% for 13-year-old girls. 35% of 15-year-old boys and 32% of 15-year-old girls reported use in the last year. 1% of 13 and 15 year olds reported using heroin.

A study undertaken in 2000 and reported in 2001 estimated the number of problematic drug users (opiates and benzodiazepines) to be around 55,000. Heroin misuse accounts for 79% of new attendances to services, compared with 67% in 1997/98. This trend, however, applies only to older age groups, reported heroin use among the under 20s having declined. Of those reporting to services for the first time, the percentage of injectors is fairly stable at 39%, although the percentage of young injectors has fallen consistently since 1998/99 and now stands at 25%.

Some measures of progress in 2002

Additional SE funding for tackling drug misuse enabled the expansion of shared care arrangements, improvements in specialist provision, improved criminal justice interventions with treatment conditions, expansion of needle exchange facilities and increased rehabilitation to allow clients to progress to training and employment opportunities.

The last few years have seen an increase in the reported use of cocaine and crack cocaine in Scotland from 2% in 1997/98 to 7% in 2001/02. Existing services, mainly opiate-based, face the challenge of responding to this. To aid planning and delivery of services to psychostimulant users, a guide was issued to Drug Action Teams (DATs) and service providers during 2002.
A pilot service for cocaine and crack users in the Aberdeen area has recently been established, funded by the Executive.

Recent achievements

• The Executive provided 5.3 million in additional resources to support treatment services across Scotland and 6.8 million for drug rehabilitation for the financial year 2002/03

• 18 more General Practices signed up to local shared care schemes

• The range of specialist drug treatment and care provision was expanded - returns from the DATs indicate that 52 new services started in 2001

• Doses of methadone dispensed increased by 37%

• Facilities for needle and syringe exchange are provided in all DAT areas

Know the Score

In March 2002, the SE launched a new Drug Communications Strategy, entitled 'Know the Score' to provide more information about the effects and risks of drugs and where help and support can be found.

Publications include

• a Directory of Services

• a leaflet on Cocaine and Crack Cocaine

• Cannabis: Know the Score

• Hepatitis C: Essential Information for Professionals

• Hepatitis C: Your Questions Answered

• Harm reduction materials (distributed to drugs services, prison service etc.) on hepatitis B immunisation, avoiding overdoses and breaking the cycle of initiation into dangerous injecting practices

Occupational Health

In 2000 the UK Government and the devolved administrations published a joint strategy for occupational health entitled Securing Health Together. This strategy represents a commitment by Government bodies concerned with occupational health and other interested parties to work together to:

• Reduce ill health (in both workers and the public) caused, or worsened, by work

• Help people who have been ill, whether caused by work or not, to return to work

• Improve work opportunities for people currently not in employment due to ill health or disability

• Use the work environment to help people maintain or improve their health

The SEHD's focus is on improving health by promoting healthy workplaces. In December 2001 a resource pack with information on occupational health was issued to 77,000 small and medium sized enterprises (SME). Since then, in partnership with others, the SEHD has developed and implemented occupational health policies for the NHS, for business generally and for SMEs in particular to create an integrated occupational health strategy for Scotland. An occupational health and safety strategy has been developed for general medical and dental practitioners and staff and its implementation was supported by providing an additional 3 million between 2000/1 and 2003/4.

Scotland's Health at Work (SHAW), an organisation which brings together NHS Boards, HEBS, COSLA, Scottish Enterprise, the Confederation of British Industry, the Scottish Trades Union Congress and the Scottish Executive, is taking forward a range of initiatives to support employers and employees as they work together to develop healthy workplaces.

By January 2003 some 27.9 per cent of the Scottish workforce were participating in SHAW and a total of 569 workplaces with 250 or fewer employees were registered.

Since its inception in 1996, evaluation of SHAW has been routinely carried out. Independent research commissioned by HEBS and carried out by the Institute of Occupational Medicine in 2002 found that workplaces participating in SHAW perceived the main positive impacts to be

• An improvement in staff knowledge about health (reported by 78% of workplaces)

• An improvement in staff health behaviours (reported by 66%)

• An improvement in staff morale (reported by 47%)

The evaluation provided valuable information for continuous improvement of the scheme, highlighting in particular that the recruitment of workplaces to SHAW has tended to favour larger employers. An additional 2m in funding has been allocated to SHAW from 2001/2-2003/4 in order to extend participation from 20% of the Scottish workforce to 40% within five years and to double the participation of SME by the end of 2003, an increase of some 300 companies.

HEBS, working with NHS Boards and others, is taking forward an initiative to improve Scotland's health, enterprise and economy by giving all small businesses and their workers equal access to confidential, high quality information, advice and support, which empowers them to address and recognise occupational health and safety problems.

Addressing the Issues

Health Improvement

Throughout 2002, the SE and key partners including local government and NHSScotland, have pursued the public health improvement objectives within the framework established by Towards a Healthier Scotland and Our National Health: A plan for action, a plan for change. Some activities have been summarised above but there is also a need for a holistic approach.

A potentially significant development was the establishment of the Health Promoting Schools Unit, launched in May 2002, which will support schools and local authorities as they develop the health promoting ethos within the school community.

The endeavour benefited from the Health Improvement Fund (the 26m p.a. investment stream established in 2000 with revenues from higher tobacco tax) which appears to be having a significant impact. Funding from the Lottery has also been a valuable source of support and a network of 44 Healthy Living Centres has been established since October 2000, with a final 12 projects being awarded funding in August 2002.

The Health Improvement Fund and the Lottery are just two of the funding channels directed at health improvement work. It is difficult to quantify the level of health improvement investment. Calculations of inputs can seem to be inherently arbitrary and of limited value, so the main concern must be with health outcomes. Work proceeds to bring greater focus and understanding to this area. Discussions between the SE and COSLA for testing the potential of local outcome agreements, linking national policy priorities with local service outcomes, offer potential for the future.

National Health Demonstration Projects

Four of Scotland's key health challenges are the focus for National Health Demonstration Projects, which test new ideas and activity prior to wider implementation.

• Starting Well: demonstrating in Glasgow how child health can be improved by a programme of activities that supports families and provides them with access to enhanced community-based resources

• Healthy Respect: demonstrating in Lothian how young people can be helped to develop a positive attitude to their sexuality and that of others and a healthy respect for their partners, with the aim of reducing unplanned teenage pregnancies and sexually transmitted infections

• Have a Heart Paisley: demonstrating in Paisley how providing a focus for action across a broad front can prevent coronary heart disease, promote good health and reduce health inequalities

• Cancer Challenge: demonstrating in the North East and East of Scotland how a screening programme can improve the early detection of colorectal cancer

A progress report was published last spring ⁵ and updates are available on www.show.scot.nhs.uk/demonstrationprojects . The evidence base for complex community interventions is still at an early stage of development, so it is essential that innovative practice be thoroughly evaluated.

Working in Partnership

Over the last four years, the legislative and strategic support outlined in Towards a Healthier Scotland (1999), Our National Health: A plan for action, a plan for change (2000) and the Local Government in Scotland Bill (2002) has created a strong foundation to deliver the national health improvement agenda. To make a real difference to the health and wellbeing of communities, there has to be a consistent and co-ordinated drive focused on priority areas. Tackling inequalities in health is fundamental to achieving an improvement in the health of the population of Scotland.

Many of the initiatives to improve Scotland's health and wellbeing are based on partnership, with agencies co-operating and breaking down traditional boundaries. The message about the importance of partnership working is not new and its practical realisation cannot be taken for granted. Difficulties such as differences in culture, language and timescales still need to be surmounted.

Local authorities in Scotland contribute to the reduction of ill health and the promotion of wellbeing by tackling health inequalities, addressing life circumstances and promoting healthy lifestyles. Co-operation through community planning partnerships is the key to health improvement. In January 2002 the SE issued ' Our Community's Health: Guidance on the Preparation of Joint Health Improvement Plans' to help Community Planning Partners prepare a set of objectives expressing a community's shared vision for health.

Local authorities are clearly key players in Community Planning Partnerships and enabling them to contribute fully to the preparation and implementation of Joint Health Improvement Plans has continued to be an important focus of activity. One strand to that activity continues to be the work of the Executive funded public health team in COSLA, which contributes to policy formulation at a national level and works with individual authorities on local developments. This work was supplemented in 2002 with the approval of proposals for joint-funded posts in each of Scotland's 32 local authorities. The aim of these posts, for which the SE has agreed funding of 1.5 million over three years, is to assist the development of local authorities as public health organisations and ensure further progress to embed health improvement in the whole range of relevant local authority activity.

Capacity building by the local authority has been matched by capacity building in the health service. There is a particularly important role for the new Public Health Practitioners, the LHCC-based champions for health improvement, who are shifting the focus of public health activity nearer to communities, making the service better able to listen to the needs of local people and to apply skills and resources in addressing them.

Health Improvement Challenge

Much has been done in recent years to attempt to tackle Scotland's bad health record, to shift the balance from responding to ill health to promoting and sustaining good health. Progress has been steady but often slow, which should be neither a surprise nor a cause for despair: it was always going to take time to reverse the deeply embedded social and cultural legacy that lies at the root of the problem. Progress has been made and will continue but there is no room for complacency.

In autumn 2002, Scottish Cabinet Ministers gave a commitment to prioritising health improvement, with a major increase in spending on public health. This translated into additional resources over the next three years of 23/50/100 million across the SE for investment in such areas as

• Integrated early years action building on the childcare strategy

• Expanding the Active Primary Schools Programme and supporting a School Sports Development Officer in every secondary school to raise the level of physical activity for school children

• Implementing the recommendations of the school meals expert panel, in particular improving the nutritional content

• Improving mental wellbeing across Scotland and action to reduce the rate of suicide.

Underpinning this endeavour, plans are in place to bring together from April 2003 the two organisations which are leading delivery of progress and developments at national level: HEBS and Public Health Institute of Scotland (PHIS) will form NHS Health Scotland.

Making the most of every resource, optimising their health impact for the benefit of the people of Scotland, particularly the most disadvantaged, will be a major challenge for the coming years.

References

1. Towards a Healthier Scotland, Scottish Office, February 1999

2. Health Inequalities in the New Scotland, PHIS/HEBS/HPPU, May 2002

3. Scottish House Condition Survey 1996, Scottish Homes, 1997

4. Homelessness: An Action Plan for Prevention and Effective Response, ScottishExecutive 2002

5. National Health Demonstration Project Programme, Learning to Make a Difference, Scottish Executive 2002

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