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Health in Scotland 2002

Unintentional Injury

In the UK and other developed countries, unintentional injury is a major cause of death and disability, especially in younger people but also in older age groups. In Scotland during 2001 there were 1,350 deaths and 80,251 discharges from hospital due to unintentional injury. Of these, 41 deaths and 13,193 hospital discharges were in children under 15 years old. (Figure 4.1)

Scale and nature of the problem

Deaths in Scotland from accidents actually fell by 40% between 1980 and 1995 but this decline has not continued since then. In the same period hospital admissions due to unintentional injury rose by around 12%. Death rates from injury are consistently around a third higher in Scotland than in England and Wales and there is good evidence that the rate of reduction of child injury rates in the UK lags behind other European countries. Death rates from accidents are three times higher for the most deprived children compared with their most affluent contemporaries. (Figure 4.2)

Injury is also a problem for older people. As the proportion of older people in society increases, there has been a steady rise in the numbers of falls and fractures requiring treatment. (Figure 4.3) Although treatment is now much more effective than before, these injuries cause pain and distress to patients and place considerable strain on health services. Treating injuries has been estimated to cost NHSScotland over 200m every year. Over half a million bed days in Scotland were taken up in 2001 in treating the results of injury, as many as for heart disease and over half that for all cancer treatment.

Prevention

The use of the term 'accident' is misleading. It implies events that are inevitable and unavoidable but a high proportion of so-called accidents are, in reality, preventable. Some countries such as Sweden have lowered their injury rates through prevention programmes and injury rates vary quite markedly among different countries. There are preventive measures of proven value such as child-proof containers, window guards to prevent falls, hip protectors for vulnerable older people and smoke alarms which, when properly applied, can reduce rates of death and injury.

While there is a degree of certainty about the numbers of injuries occurring, derived from data collected on cause of death, hospital admission and on poisoning for example, there is much less information on the cause and severity of the injuries. This makes directing and evaluating preventive efforts very difficult.

There is already a wide range of preventive activity across Scotland, led by local authorities, bodies such as RoSPA and the Child Accident Prevention Trust and Health Boards. ISD has taken a lead in publishing a wider range of data on injury and current work on procuring A&E data collection systems and on developing child health data sets with child protection as a priority should offer opportunities to improve this situation.

However, there are undoubtedly other ways in which the current situation could be improved

• Better co-ordination of prevention at national and local level

• Sharper focus on preventive measures

• A more effective framework for taking action on the data already available.

Work in the UK has highlighted a number of priority areas for action. These include pedestrian deaths in children aged under 14 and in the over 60s, fire-related deaths in the same age groups, falls in older people, deaths in older car occupants and play and recreation injuries in children aged under 14.

The evidence suggests that if progress is to be made on the protection of vulnerable children and older people and in reducing health inequalities, then injury prevention should be a focus of action.

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME)

Following the publication of the Independent Working Group's Report on CFS/ME to CMO (England) in January 2002, the SEHD's next steps were announced in May 2002 to the Cross Party Parliamentary Group on CFS/ME. The SEHD had sent observers to the English Working Group's meetings, which covered services for young people and adults who are affected by this common but controversial condition. A short life working group, with representatives of the user and carer interests, was set up to translate the findings of the Report to meet Scottish circumstances.

The outcome of this activity indicated that people who have symptoms and signs of CFS/ME have clearly definable care needs which should be addressed in a coherent way. The report will be published in 2003, but it is possible to say at this stage that these needs can and should be met by healthcare workers in both primary and secondary care, in collaboration with partner organisations, statutory and voluntary, on an evidence base. Nevertheless, this requires extension and development

Diabetes Mellitus

Diabetes continues to present a serious health challenge for Scotland, affecting about 3% of the population. At least 13,000 new cases are diagnosed each year and the number of people with diabetes is estimated to double within the next 10-15 years.

The Scottish Diabetes Framework, published in April 2002, provides an inclusive national strategy for the improvement of diabetes care, based on collaboration between people with diabetes and the range of professionals and organisations involved in their care. There is already close co-operation among the statutory and voluntary agencies concerned with diabetes care.

The Framework sets out how to achieve a high quality, patient-centred diabetes service.
It identifies first stage priorities, including patient information, education and empowerment, heart disease, eye care, strategy, leadership and teamwork, education and training for professionals, IM & T and Diabetes Registers and implementation and monitoring. To take forward this last item, the Scottish Diabetes Group has been established as a national steering group.

The Framework maps the path for the evolution of the Local Diabetes Service Advisory Groups, which exist in each NHS Board area, into full MCNs offering fully integrated diabetes care. HDL(2002)81 drew the attention of NHSScotland to the milestones and action points in the Framework and indicated that NHS Boards and their planning partners should include these in their local health plans.

On 15 November 2002 a major national conference with some 650 delegates, Diabetes in Scotland 2002 - the Way Forward, was held. As well as providing a showcase for the work being done to implement the Framework, the Conference also saw the launch of a new Diabetes in Scotland website www.DiabetesinScotland.org

In keeping with the priority to be given to eye care, the Health Technology Board for Scotland (HTBS) published in April 2002 its first Health Technology Assessment (HTA), on Diabetic Retinopathy Screening. The HTA contains detailed advice on putting in place a national programme of diabetic retinopathy screening aimed at ensuring that everyone in Scotland with diabetes can be offered a high quality examination each year. An Implementation Group was set up as a Sub-Group of the Scottish Diabetes Group to plan the introduction of the programme across all NHS Board areas.

The development of IM & T and diabetes registers was taken forward during the year by SCI-DC, the diabetes collaboration which operates under the umbrella of the Scottish Care Information initiative. Phase 1 of the project will ensure that all hospital-based diabetes clinics have basic functional diabetes systems as soon as possible and that regions have the opportunity to implement a central server to provide audit and register functions.

Putting patients at the centre of care is an essential theme for the Scottish Diabetes Framework. The publication in November of Hearing the Voices of People in Scotland who have Diabetes brings together the experiences and views of people on the realities of living with diabetes and the opportunities they have, or would like to have, to influence what happens to them. This will help ensure that diabetes services develop in directions that yield the greatest benefit to those for whom they are provided.

Oral Healthcare for Older People

Increasing life expectancy has served to highlight oral healthcare issues for older people in Scotland and there is now a growing expectation that good oral health and appropriate oral healthcare services should be an essential component of healthy ageing. It is estimated that by 2030, the number of adults aged 65 and over will increase by just over 50%, with over-80 year olds representing the fastest growing section of the population.

In August 2000, the Action Plan for Dental Services in Scotland recognised the value of good oral health in older age and made a commitment to improve preventive services for older people in Scotland. A review of oral health issues for this group of adults has now been carried out as part of the implementation of the Action Plan.

Adult oral health in Scotland is currently poorer than in other parts of the UK, with 18% of all Scottish adults having no natural teeth, compared with 13% of UK adults. Currently, only 45% of Scottish five year olds are free from decay, some way short of the national target of 60% by 2010. Improving children's oral health is a priority.

Towards a Healthier Scotland set a national target for adult oral health, that by 2010, 95% of 45 to 54 year olds should retain some natural teeth. Among the age cohort (35 to 44 year olds) who will be 45-54 in 2010, 96% had retained some natural teeth, indicating that good progress is being made towards the national target. The proportion of adults with 21 or more natural teeth (the number consistent with a functional dentition) has also risen, from 64% in 1972 to 78%
in 1998.

Recent surveys suggest that attitudes to dental and oral care have changed significantly in the last twenty years, with many more people requesting conservation of natural teeth. Thus, future oral healthcare provision for adults will have to reflect the changing needs and expectations of an increasingly dentate population.

Deprivation, systemic disease, poor nutritional status and drug associated changes in the oral tissues have an important influence on the ability of older people to maintain good oral health. Conversely, poor oral health may also impact significantly upon general health by impairing the ability to maintain an adequate diet.

Oral cancer is found more frequently in older people. Smokeless tobacco consumption increases risk for oral cancer, an issue of particular relevance for older Scots from an Asian cultural background, where such habits may be commoner and where communication difficulties often compound lack of awareness of risk.

As only 50% of Scottish adults are registered with a general dental practitioner, adults at risk of oral cancer may not consult a dentist. In addition, if there has been the loss of natural dentition the need for an examination may not be well understood. All those involved in the care of older dependent patients should be aware of oral health issues, including the risk factors and signs of oral cancer and pre-cancer.

The key oral health messages that should be promoted for older adults include

• Reduce the amount and frequency of intake of sugar-containing food and drinks

• Clean teeth and gums thoroughly twice a day with fluoride toothpaste

• Have an oral examination

• Stop smoking and drink sensibly to reduce the risk of developing oral cancer

Healthcare Services in Remote and Rural Areas

Scotland's geography and population spread have a major impact on the way health services are provided. It is all too easy to focus on the central belt where most of the population lives but the fact that a large number of people live in rural areas, often at a considerable distance from the main centres, cannot be ignored.

NHS Highland covers an area similar in size to Wales with a significant proportion of its population based well away from the nearest general hospital in Inverness. Large parts of Grampian, Borders, Dumfries and Galloway and Argyll have a predominantly rural aspect. The various Island groups also have to cope with expanses of sea which, combined with the vagaries of the Scottish weather, bring an extra dimension to the definition of 'remote'.

All of this presents very real and demanding challenges to the delivery of healthcare. People who live in remote and rural areas have a right to expect NHSScotland to attend to their health and healthcare needs as effectively as it does to those of their urban counterparts. It is not possible or sensible to try to replicate urban models in rural areas. A major task in 2002 has been to work towards sustainable rural service models which are appropriate to needs and maximise access without compromising safety or quality.

The SEHD has taken and will continue to take a strategic integrated approach to this. Not all problems affecting remote and rural areas are unique to these areas: they often represent the 'sharp end' of difficulties which also arise in the more populated parts of Scotland. The key difference is the fragility of services. Loss of health services can have a very wide-reaching effect on rural communities, to the extent that it can affect their viability and sustainability.

The status quo is not an option. New factors, both positive and negative, are driving the need for change. New technology offers scope for radical changes in service delivery in remote and rural areas, for example through increased use of telemedicine, but the technology itself is not enough. It must be used to change the way service is delivered, as traditional methods may no longer be appropriate. The impact of the European Working Time Directive and the erosion of generalist skills at the expense of increased specialisation amongst healthcare professionals are among the factors that make change imperative.

The strategic planning framework combines sustainable service development with education and training and effective workforce planning. The last of these will need a strong focus on recruitment and retention of staff to work in remote and rural areas. Within the framework are a number of key tasks for SEHD and NHSScotland, including

• Devolving resources to NHS Boards to enable them to integrate funding streams

• Involving local communities in the development of and changes to their health services

• Engaging with partner agencies and others to ensure an integrated approach to service planning and delivery

• Identifying links between projects and initiatives and avoiding duplication.

During 2002, the Remote and Rural Areas Resource Initiative (RARARI) has played an important part in co-ordinating and promoting the remote and rural health agenda. Its role will continue to be crucial in the final phase of its existence (funding for the Initiative ceases in March 2004). Its main task will be to facilitate change through close engagement with NHS Boards and others in NHSScotland. This will involve helping the Service to develop and extend projects that will support the key strategic aims of developing sustainable services models, providing education and training appropriate to local needs and recruiting and retaining staff with the requisite skills to provide services in remote and rural Scotland.

Healthcare Services for People with Hearing Impairment

Healthcare services in Scotland struggle to provide an adequate service to people with significantly impaired hearing. Most hearing losses occur at older age with 70% of people over 70 years of age having difficulty hearing whispers or faint speech ¹. The prevalence of permanent congenital hearing impairment is estimated to be 130 per 100,000. Of the 52,500 births in Scotland in 2001 ², it can therefore be estimated that there were 70 congenitally deaf children.

Deaf people with health problems share much in common with their hearing counterparts. They require access to the same range of effective health services, provided by the same range of services and professionals, as conveniently located as possible. The challenges to delivering healthcare to people who have impaired hearing include

• Providing effective health services for the deaf community is more costly, pro rata, than mainstream services

• A lack of national demographic knowledge (including the numbers of deaf adults in prison and their mental health needs) and the lack of a solid evidence base for specialised clinical interventions

• The relative geographical isolation of some parts of the country

• The shortage of staff able to use British Sign Language (BSL) and of interpreters between BSL and English

• The inexperience of medical staff and associated disciplines in the treatment of patients who have impaired hearing, especially the acutely ill

• The need for communication support and respect for the cultural diversity of the deaf community (described as Deaf Awareness) which is fundamental to improving their health

The provision and potential development of a service for the treatment of patients with both a hearing impairment and a psychiatric illness are a particular healthcare problem in Scotland. The majority of hearing and deaf people who have mental health problems live in the community ³. Indeed, the first point of contact by a person with impaired hearing and mental health problems will generally not be a psychiatrist with specialised knowledge. Thus the provision of a specialised service for this patient group requires that primary care is able to manage patients and, when indicated, to refer them to appropriate services.

However, no GPs within primary care in Scotland have yet been identified as able to use BSL. There are no practices in Scotland that specialise in the treatment and support of people who have impaired hearing. Further, the obligation on the NHS to provide BSL/English interpreters, if they are required, is often poorly met.

It is the intention of the SEHD that the NHS does not discriminate against people who are ill and whose hearing is impaired. There is clearly a necessity to develop a comprehensive and integrated healthcare service that can provide treatment to patients throughout Scotland. It has to be recognised, though, that the geography and resources available will guide the development of services. The SEHD is supporting research into methods of improving the treatment in primary care of people with hearing impairment who also have mental health problems. In addition, the Disability Steering Group and its Communications Task Group, along with the BSL and Linguistic Access Group are researching into methods of increasing the ability of the NHS to provide a service to people whose hearing is impaired.

The provision of effective healthcare is largely underpinned by communication and people who have a hearing impairment present a challenge to a health service that is organised largely on the assumption that people can hear. It is a challenge to which the NHS must rise.

Audiology Needs Assessment

A multi-agency needs assessment working group was convened under the auspices of PHIS to look at needs for children's and adults' audiology services in Scotland. It will make a series of recommendations to meet rises in demand and to ensure a modernised audiology service. The children's section is discussed below.

Permanent hearing impairment in children has a population prevalence of 13 per 10,000 live births. If hearing impairment is not detected and managed effectively early in life, it leads to an irreversible communication deficit, which can affect the cognitive, social and educational development of the child.

Specialist skills and equipment are required for the diagnosis and management of children. The planned introduction of universal newborn hearing screening will mean that the need for diagnostic assessment of babies will rise, as will the need for fitting of hearing aids in the very young. These are specialist skills which are currently in short supply in Scotland.

Newborn screening will only identify around half of the children who will subsequently suffer permanent hearing impairment. There is a role for audiology and related services in the identification of the older children with hearing impairment, and in children with other problems which may either mask this condition or for whom hearing impairment may be a contributing factor. There is also an ongoing need for services to ensure adequate audiological monitoring of children with conductive hearing loss (for example as a result of 'glue ear').

Audiology services are inherently multi-disciplinary in nature, involving functioning links with child health, speech and language therapy, ENT surgery and other medical specialties. Moreover, education and social work services are responsible for crucial aspects of interventions, hence systems which ensure effective inter-agency co-ordination and information flow are required. The needs assessment report was published in January 2003.

Healthcare in Ethnic Minority Communities

The guiding principle in this area is that Scotland's minority ethnic communities, including asylum seekers, refugees, gypsies and travellers, need improved access to and greater involvement in their healthcare service provision.

NHSScotland is delivering a comprehensive three year programme of work to implement the Fair for All framework agreed at a national conference on 22 January 2002. All NHS Chief Executives accepted the Commission for Racial Equality (CRE) 'Leadership Challenge' to demonstrate their personal commitment to this agenda.

A National Resource Centre for Ethnic Minority Health (NRCEM) was established within PHIS on 1 April 2002 to support and assess the progress of NHS organisations in delivering their obligations under the Fair for All Framework and the Race Relations (Amendment) Act 2000 (RRAA). Under the supervision of its widely based Steering Group, the work of the NRCEM is well underway. Networks of the organisations and individuals charged with delivering the agenda for change in NHSScotland have been established at three levels to

• Resolve difficulties encountered at NHS Board lead officer level

• Develop guidance and good practice in training, information and policy

• Share good practice and develop positive action models in specialist areas, for example in chronic disease management

These networks will help NRCEM deliver its role of challenging discriminatory practice and mainstreaming racial equality.

All NHS organisations must produce a Race Equality Scheme and Action Plan setting out how they will meet the duties placed on them by the RRAA. The NRCEM, working with the CRE, is analysing these documents, highlighting areas of strength and achievement, progress and learning and identifying weaknesses that need to be addressed. The report of this work, due to be published in May 2003, will offer guidance to support NHS Boards deliver this agenda as part of an integrated programme of work, including

• Training and development: a needs assessment is informing the development of modules and guidelines which will support NHS Boards develop the skills and competencies of their staff in delivering culturally sensitive services

• Chronic Disease Management: the Scottish Diabetes Group has been supported to plan services for people from ethnic minority groups. A themed Diabetes Network group is developing a report on the epidemiology of diabetes among Scotland's ethnic minorities that will be launched at an international symposium in October 2003

• Information: gathering information on epidemiology in areas of chronic disease management, including supporting the Scottish Diabetes Group address the lack of good quality, easily accessible information for people with diabetes

• Haemoglobinopathies: a working group is developing a needs assessment for screening in this area

• Travellers and gypsies: an action-orientated review will lead to the development of an action plan by March 2003

The NRCEM also supported the work of the Scottish Refugee Integration Forum (SRIF) in developing a National Action Plan for the integration of refugees and asylum seekers in Scotland. The Centre will have a key role in supporting the NHS take forward the SRIF report's health and social care actions as part of the wider Fair for All agenda.

References

1. Milne JS. A longitudinal study of hearing loss in older people. Br J Audiol 1977; 11;7-11

2. Fortnum, H, Davis, A.C. Epidemiology of permanent childhood hearing impairment in Trent Region, 1985-1993. Br J Audiol, 1997, 31, 409-446

3. Goldberg DP, Huxley PJ. (1992) Common Mental Disorders - A Bio-Social Model. London:

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