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Health in Scotland 2002

CHAPTER 4

HEALTHCARE PROBLEMS

This chapter covers selected healthcare problems which have been the focus of significant SEHD activity during 2002.

Long-term illness

The Registrar General's 2001 Census Report to the Scottish Parliament revealed a large increase in recorded long term illness. 20% of the population indicated that they had a long term illness, health problem or disability that limited their daily activities or the work they could do in 2001. This was an increase from 14% reported in the 1991 census. The proportion varied among Council areas with Glasgow City (26% in 2001) and North Lanarkshire (23%) highest, and Aberdeenshire (15%), East Renfrewshire (16%) and Shetland Islands (16%) lowest. Allowing for the general increase in reporting such illness across Scotland from 1991 to 2001, the distribution among Council areas changed relatively little.

A new question was included in the 2001 Census about each person's general health over the twelve months before the Census. Around two-thirds reported that their health had been 'good', just over a fifth said it had been 'fairly good' with a tenth in the remaining category 'not good'.

As might be expected, there was a strong relationship between the responses to the question on health and those on long term illness. Only 15% of those with a long term illness said their health had been 'good' compared with 81% of those with no long term illness. Conversely, 44% of those with a long term illness said their health had been 'not good', while for those with no long term illness the figure was 1%.

This relationship was fairly uniform across Council areas except in the two areas (Glasgow City and North Lanarkshire) reporting high levels of long term illness. Those two areas showed the lowest rates of reporting health as 'good' among those with a long term illness and Glasgow City reported the lowest rate among those with no long term illness.

When the response to the question on health is analysed by the tenure of household, high proportions of reporting of health 'not good' were found in the social rented sector and in households living rent-free (both 18% compared with 10% for all persons in households). Low proportions of health 'not good' were seen in households buying their accommodation with a mortgage or loan (5%).

Table 4.1

Cancer

Cancer in Scotland: Action for Change - Implementation

In February 2002 the Minister for Health and Community Care increased the additional funding for implementation of the Cancer Plan to 60m up to the end of 2003-04 and during the year significant progress has been made with implementation. Regional Cancer Advisory Groups have successfully developed robust regional planning of cancer services in partnership with NHS Boards and regional planning structures. Not only that, but cancer services across Scotland have successfully put in place many investment plans which have resulted in marked improvements in waiting times, service quality and better patient experiences of care. Fuller information is available from the Cancer in Scotland: Action for Change Annual Report,
published in October 2002 at the second Cancer Open Forum. Details of specific investments and twice yearly regional progress monitoring reports are also available from www.show.scot.nhs.uk/sehd/cancerinscotland , the Cancer in Scotland website.

Open Forum

The second Cancer Open Forum was a resounding success with almost 500 delegates including patients, carers, clinicians and others. This and the first annual Chemoprevention Seminar which preceded it attracted international experts from Europe and the United States, sharing their knowledge and experiences to inform the continuing development of cancer services in Scotland.

In particular, the Director of the European Centre for Oncology in Milan spoke of the challenges and opportunities for improving colorectal cancer treatment and care but he also spoke of emerging evidence of a strong association between alcohol consumption and breast cancer in women. Full report of the Open Forum and the Chemoprevention Seminar are in preparation and will be available from the Cancer in Scotland website in due course.

Alcohol Consumption and Breast Cancer in Women

Potentially, one of the most important developments in the last year has been the confirmation of the association between alcohol consumption and risk of developing breast cancer. Previous studies have suggested a dose-dependent relationship and a meta-analysis published in November 2002 reviewed fifty-three studies of this issue involving more than 58,000 breast cancer patients and 95,000 controls.

After allowing for other known risk factors, the relative risk of breast cancer was 1.32 (CI 1.19-1.45, p<0.00001) for an intake of 35-44g alcohol per day and 1.46 (CI 1.33-1.61, p<0.00001) for an intake of greater than 45g per day when compared with women who reported drinking no alcohol. (One unit equals a glass of wine or half pint of beer and contains approximately 10g alcohol). The relative risk of breast cancer increased by 7.1% for each additional 10g per day intake of alcohol. When allowance was made for alcohol consumption, smoking was found to have little or no independent effect, making breast cancer one of the very few cancers for which smoking appears not to be a risk factor. The authors estimate that on current figures for alcohol consumption, alcohol could be responsible for as many as 500 cases of breast cancer per year, making breast cancer the most common cancer caused by alcohol (rather than head and neck cancer as previously thought).

The nature of these studies precludes any effect yet from the recently documented increase in drinking amongst, in particular, young women - the so-called 'binge-drinking' phenomenon. Although breast cancer is currently very rare in young women, these data suggest that an 18 year-old who makes a habit of binge drinking is building up a significant breast cancer risk in twenty to thirty years time. These important findings will be reflected when the 'European Code Against Cancer' is revised, but there is now another compelling reason to step up the effort against habitual binge drinking.

Scottish Cancer Group

The Group has continued to oversee the implementation of Cancer in Scotland and through a variety of standing and short life working groups has further developed policy and guidance both for the SEHD and NHSScotland. For example,

• Scottish Referral Guidelines were published in May 2002

• IM&T report has been issued to NHSScotland to provide a platform for decision making in developing electronic data capture and analysis to support cancer services

• Scottish Cancer Research Network is being established, based on similar founding principles, and as an active partner in the UK National Cancer Research Network/National Cancer Research Institute. Targeted funding of 1m is available to support this new research framework which will aim to at least double patient entry to clinical trials. It is anticipated that the network will be up and running by spring 2003.

Managed Clinical Networks

Tumour specific managed clinical networks are the cornerstone of cancer service provision. In Glasgow and West of Scotland, the colorectal and gynaecological managed clinical networks are particularly successful examples but are by no means the only ones. The South East and North of Scotland regional cancer networks are also progressing well and every opportunity is taken to share and learn from experiences between and across the networks. Two network workshops have been held during the year and there are plans for a number of tumour specific workshops during 2003.

Beatson Oncology Centre

An individual cancer centre would not normally warrant specific mention in the context of an annual report with a national strategic focus. However, the Beatson Oncology Centre in Glasgow has not only been the subject of ongoing public, media and Parliamentary interest and debate, but it has also seen a year of remarkable progress in many of the issues which were fundamental to its reported problems.

In addition to the 2m additional targeted investment provided in February 2002, the Beatson has also benefited from the regional prioritisation and planning of cancer investment in general. This past year has therefore seen unprecedented increases in staffing in relevant clinical support professions and disciplines, marked improvements in equipment and the clinical environment and the commissioning of a dedicated chemotherapy day bed facility at Gartnavel General Hospital which has greatly improved on the cramped conditions at the Western Infirmary site.

There are recognised continuing difficulties in recruiting clinical oncologists. However, targeted recruitment efforts continue and, with the appointment of a new Medical Director (who will take up post in the summer of 2003), there are great hopes that the situation will resolve over time. In the meantime, work has continued to develop the business case to support the planned new West of Scotland Cancer Centre building programme at the Gartnavel site and the associated discussions with relevant NHS Boards as to the configuration of services now and in the future.

Clinical Standards Board for Scotland

In the past year CSBS has undertaken a comprehensive programme of visits to breast, lung, colorectal and ovarian cancer services throughout the country. Cancer clinicians, other professionals, patients and carers were actively involved as members of review teams. National overview reports were published in March and April, providing a comprehensive baseline of current service provision along with the challenges and opportunities for continuing quality improvements.

The Scottish Cancer Group and its Quality Improvement Sub-group will continue to work in close collaboration with its successor, NHS QIS.

Prostate Specific Antigen (PSA)

The level of PSA in the blood is one of a range of investigations which may be undertaken to help confirm a diagnosis of prostate cancer. However, the currently available test cannot differentiate between men whose prostate cancer will grow rapidly and aggressively and others in whom it will remain localised to the prostate for the rest of their lives. PSA levels may also be raised in a number of conditions unrelated to cancer. The value of routine PSA testing as a method of population screening therefore remains uncertain and controversial.

The letter Prostate Specific Antigen (PSA) Testing for Prostate Cancer (SEHD/CMO (2001) 20) therefore advised GPs in Scotland to adopt a similar position to that taken by colleagues in England on PSA testing of asymptomatic men, with the proviso that this was accompanied by full information on the reliability of the test itself and on the problems and side effects of further diagnostic procedures and treatment. GPs were asked to use the Department of Health (England) Prostate Cancer patient information leaflets pending the outcome of the evaluation of their Informed Choice Project pilot which was subsequently subsumed into the Prostate Cancer Resource Management Pack (PCRMP) which also includes evidence based materials.

This PCRMP Primary Care resource pack, aimed at primary care clinicians advising and counselling asymptomatic men, is generally agreed to be as relevant and useful to primary care teams in Scotland as it is in England. At the end of 2002 it was therefore widely circulated throughout NHSScotland, including a copy to every GP in Scotland.

Coronary Heart Disease and Stroke Strategy for Scotland

Scotland is making progress in terms of reducing mortality from CHD and Stroke, but not as fast as other countries, and there is no doubt that these conditions will remain a major concern for many decades to come. (See Table 4.2 CHD Mortality and Table 4.3 GP consultation rates for CHD).

For this reason the SEHD published its Coronary Heart Disease and Stroke Strategy for Scotland in October 2002, the culmination of four years' work. The CHD/Stroke Task Force spent three years drawing up its report, based on extensive consultation with patients, clinicians and managers. That report met with a very favourable response and the CHD/Stroke Reference Group, which included representation from relevant clinical specialities and patients, was established in early 2002. The CHD and Stroke Strategy represents the Reference Group's proposals for implementing the recommendations of the Task Force Report in the light of the outcome of the consultation process. The Strategy carries with it 40m additional resource over the next three years and has a number of recommendations grouped under the headings of

• Prevention

• Managed Clinical Networks for CHD and Stroke

• Workforce Issues

• Information Technology and the Development and Use of Databases

• Next Steps

It includes an Implementation Plan summary with timelines against key priority actions for CHD and Stroke.

Table 4.2

Notes:
(1) From January 2000, deaths in Scotland have been coded using ICD10. Note that any apparent change in trend between 1992-2000 may be due to the move to ICD10 rather than a real change. The trend over this period should be treated with caution.
(2) Rates age standardised using the European standard population.

The most important of these priorities for both CHD and Stroke is the establishment of Managed Clinical Networks (MCNs). In the case of CHD, each NHS Board will be expected to have a local cardiac services MCN in operation by April 2004, with a quality assurance programme agreed with NHS QIS. A similar priority action has been identified for Stroke. The first call on the additional 40m investment for CHD and Stroke will be the pump priming of these local MCNs which are expected to feature in all Local Health Plans currently being finalised by NHS Boards. The pilot cardiac services MCN in Dumfries and Galloway has addressed and provided answers to many of the practical problems which will be encountered by those developing both CHD and Stroke MCNs. The MCN website www.show.scot.nhs.uk/mcn contains a wealth of material which should be utilised to avoid unnecessary duplication of effort.

Table 4.3

Source: ISD Continuous Morbidity Recording (CMR)
Note: (1) Includes small number of patients under 25

The CHD MCNs will relate to an overarching Scottish Cardiac Intervention Network (SCIN) which will be developed over the next few months. The CHD component of the Reference Group has been reconstituted as a project group, with specific responsibility for drawing up detailed plans for SCIN, including a timetable, costings and the identification of a lead clinician with clinical and managerial credibility. It is expected that SCIN will establish a number of sub-groups. Until it is up and running, the project group will provide advice on the generality of CHD issues, including cardiac interventions.

The Stroke component of the CHD/Stroke Reference Group has been reconstituted to form the National Advisory Committee on Stroke. The Committee will act as a source of expert advice on all matters relating to Stroke (including workforce issues, service activity, distribution of resources and priorities for new investment) in a similar way to SCIN for CHD.

Source: ISD Continuous Morbidity Recording (CMR)
Note: (1) Includes small number of patients under 25

The other key funding priority flowing from the Strategy is the establishment of national databases for CHD and Stroke. The CHD database will draw together existing databases in this area and in particular aim to fill the information gap in primary care. The SCIN Project Group has already set up an IT Sub-Group which is finalising a Business Case to develop a work programme aimed at the creation of a national CHD database integrating all existing databases, and expanded to cover primary and community care data.

The ultimate aim is to have an equivalent national database for Stroke. In the meantime, all hospitals which routinely admit patients with Stroke are being encouraged to join the pilot phase of the Clinical Resource and Audit Group (CRAG) project to establish a national monitoring system for hospital based Stroke services. Hospitals are also being encouraged to introduce systems which would allow the collection of a nationally defined minimum dataset for each Stroke patient admitted, to allow monitoring of performance against nationally agreed standards. In due course further work will be carried out to establish the feasibility and methods of linking hospital based systems with those in primary care, resulting ultimately in an integrated national database for Stroke. Lessons learned from the development of the national CHD database will be drawn on as appropriate.

To progress implementation of the Strategy, NHS Boards have been asked for nominations from local MCNs to link with the SCIN Project Group and the National Advisory Committee on Stroke and bids for other funding priorities from the additional 40m. Both newly constituted National Advisory Groups will be involved in the assessment and prioritisation of funding bids. A Project Manager is to be appointed to oversee implementation of the Strategy and a Departmental Implementation Group will also be established, analogous to that set up for cancer.

Chapter 4 continued

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