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Health in Scotland 2003

CHAPTER 1 IMPROVING SCOTLAND'S HEALTH

Health and deprivation

By the beginning of 2001, it was well known that Scotland's health, although improving, was poor compared with other nations in Europe. However, the longer-term trends in health were less well understood. Some considered that the current position appeared more pessimistic than it really was: although Scotland's industrial legacy had created very poor health in the past, over the last few decades the changes in Scottish life might have created the conditions for a 'catch-up' phase. This would improve the health of the population of Scotland, given enough time.

To explore these issues, work was commissioned by the Public Health Institute of Scotland (PHIS), now part of NHS Health Scotland. This work confirmed that in Scotland life expectancy for women is the lowest in the European Union and for men the second lowest after Portugal. Scotland is only now achieving levels of life expectancy seen in the best performing European countries in 1970.

While this position within Europe is relatively well known, it is not widely appreciated that life expectancy for the United States of America is closer to that of Scotland than it is to any other part of the United Kingdom. This highlights the danger of drawing simplistic conclusions about the role of national wealth in life expectancy. This point is further underlined by the fact that Scotland's nearest neighbours in terms of life expectancy are Costa Rica, Cuba and the Czech Republic, all of which are far less wealthy than Scotland.

Yet Scotland has not always performed so poorly: in the first half of the 20th century, life expectancy in Scotland was actually higher for both men and women than in a number of Western European countries, including France, Spain and Italy. In the middle of the 20th century, however, things started to change. While other countries, many of which had once lagged behind Scotland, improved, Scotland began to slip down the table of European life expectancy.

To understand why Scotland has performed so poorly, it is necessary to look at differences in deaths at different ages and from different causes. Scotland's position is not exceptional in deaths in infancy and childhood. At older ages, while worse than the European average, it is not the worst. Instead, Scotland's overall poor position is due, to a considerable extent, to the very high mortality among adults of working age.

It is clear that if Scotland is to improve its position, it must reduce mortality at a rate that is faster than the European average. This conclusion disproves the hypothesis that Scotland is already in a catch-up phase. It was this finding, above all, that led to a call for a 'step change' in Scotland's health.

More controversially, it can be argued that, however worthy the efforts might have been over the past 20 to 30 years, there has been a relative decline. This implies that there must be bold changes in the future approach to maintaining, improving and promoting public health and well-being in Scotland.

To what extent does 'deprivation' explain Scotland's poor health?

This question was addressed through research undertaken by PHIS. It is well known that one of the key reasons for Scotland's poor health status is deprivation. However, a major finding of more recent work is that the deprivation profile of Scottish postcodes now explains less of the gap in mortality between Scotland and England than it did in previous analyses. An analysis of the 1981 census data showed that deprivation accounted for all but 3% of the excess mortality experienced in Scotland compared with England and Wales. The implications of this finding were clear: if Scotland successfully addressed its problems of deprivation, then the health gap between Scotland and England would all but disappear.

However, new analysis of census and mortality data from the early 1990s shows that deprivation accounted for only approximately 40% of the excess deaths at all ages and 60% for those under 65 years. The excess deaths in Scotland that are not accounted for by deprivation, in the way that was thought to be the case 20 years ago, have been referred to as the 'Scottish Effect.' It may, of course, be that the technique of basing the estimate of deprivation on data derived from the census is proving less useful in detecting true deprivation than it was in the 1980s. The alternative explanation is that this 'Scottish Effect' is due to psychological and social factors that operated in Scotland during the same decade.

The overall implications are clear: while deprivation is one of the key causes of Scotland's poor health it is not the only factor. Sophisticated, not simplistic, analysis is required of the 2001 census data in order to discover what happened between 1991 and 2001.

If fresh thinking is needed for health improvement in Scotland, what can be learned from how public health policy is developed, implemented and evaluated in other countries? What, for example, can be learned by looking at countries that have managed to outperform the European average? These questions are currently being addressed through a further piece of commissioned work.

The Executive has a clear commitment to refocus traditional ill-health prevention strategies with actions to improve health and well-being. As part of that commitment and aligned with the Executive's strategies for promoting social justice and closing the opportunity gap, tackling health inequalities is a key aim of the health improvement agenda.

Improving Scotland's Health: The Challenge, published in March 2003, provides a strategic framework to support the processes needed to deliver a more rapid rate of health improvement. It aims to provide a clear vision which can be shared by NHS Boards, Local Authorities, the private sector and a range of voluntary bodies, all of whom have a part to play in the effort to improve health. The Challenge includes work on all the determinants of health and efforts will be concentrated in four priority areas: early years, teenage transition, the workplace and communities.

One objective is to improve life expectancy for all men and women in Scotland, as well as reducing inequalities between the most affluent and the most deprived groups. An important part of the health improvement agenda will be partnership working with other sectors. The Executive is leading work on identifying appropriate targets and indicators for reducing health inequalities and the development of 'healthy life' expectancy indicators, to supplement current data on life expectancy.

The merger of the Health Education Board for Scotland (HEBS) and the Public Health Institute of Scotland (PHIS) took place in April 2003 to form NHS Health Scotland. During this year, NHS Health Scotland have developed their workplan and management team to deliver support to the health improvement agenda with a focus on the delivery of Improving Scotland's Health: The Challenge.

The health of homeless people is of particular concern: there is a higher risk of mortality and morbidity amongst homeless people than in the wider population. In order to begin to improve the health of this disadvantaged group, Our National Health: A plan for action, a plan for change outlined the new priority that was to be accorded to the health of homeless people. The Health Department issued guidance to NHSScotland and appointed a Health and Homelessness Co-ordinator. As a result, NHS Boards are implementing Health and Homelessness Action Plans which, together with Local Authorities' Homelessness Strategies, provide the opportunity to deliver the vision of tackling the causes and effects of homelessness in Scotland.

The Health and Homelessness Steering Group assess the progress of Action Plans to ensure that implementation is bringing about the real change needed to improve the health of homeless people. For Boards whose Plans require further work, the Health and Homelessness Co-ordinator and Steering Group provide ongoing support and encouragement.

Physical inactivity constitutes one of the most widespread health determinants in Scotland. Six out of ten men and seven out of ten women put their health at risk by undertaking less than the minimum recommended levels of physical activity. The level of inactivity among children gives greater cause for concern, with three in ten boys and four in ten girls falling short of the amount of physical activity required for good health.

The Executive is introducing policies to tackle the causes of inactivity and has done much in the past year to reverse the current trend of growing inactivity amongst the Scottish population. In February 2003, the Executive published its first National Physical Activity Strategy, aimed at improving Scotland's health record and increasing the physical activity levels in Scots of all ages. It sets the challenging target that 50% of adults and 80% of children will be taking between 30 and 60 minutes of moderate physical activity every day by 2022.

The Executive is working on the recommendations from the Strategy in four key settings: Active Schools, Active Communities, Active Workplaces and Active Homes. The appointment of a National Physical Activity Co-ordinator has helped to unify efforts across the Executive, its agencies, local government and a host of local and national organisations in addressing the action needed to encourage people to lead more active lives. Being active will help improve the health of the nation and reduce the burden on the NHS.

Recent reports show that there is still much to do to improve the eating habits of the nation. The NHS Quality Improvement Scotland's (NHS QIS) Clinical Outcome Indicators Report for 2003 shows that one in three 12 year olds is overweight, one in ten is severely obese and that one in five toddlers is overweight before their fourth birthday.

Significant progress has been made over the last year in encouraging changes to the nation's eating habits. New standards have been set for the provision of food in schools through Hungry for Success, backed by funding of 63.5 million over the next three years. By the end of 2004 every primary school in Scotland should have the new standards in place for school food. Free fruit is made available for all primary 1 and 2 children and guidelines for meals served in nurseries will be published in the near future. Good eating habits should begin early in life.

Product specifications have been developed by the Food Standards Agency in Scotland to set maximum levels for fat, salt and sugar in processed food used in Scottish schools. In response to this, a major food manufacturer has developed a new healthy range of foods with low levels of fat, salt and sugar, initially intended for schools but possibly to be available more widely in future. Work with the food industry continues to develop a 'healthy living' labelling system, so that shoppers can make informed choices when they are buying food.

Hungry for Success recommends that vending machines should promote healthier options such as water and fruit juices, rather than fizzy, sugary drinks, and should have no brand advertising on the casing of the machine. In response to this, an international soft drinks company has agreed to remove its branding from vending machines in Scottish schools and to stock a range of healthier drinks in the machines. Scotland is the first country in the world where this bold step has been taken. This action is now being considered across the UK and the wider soft drinks industry.

In previous reports, attention has been drawn to concerns about rising levels of alcohol-related harm, especially in young women in Scotland. Continuing progress was made in implementing the Plan for Action on alcohol problems. The priorities are:

• to reduce binge drinking, because of the harmful social and individual consequences

• to reduce harmful drinking by children and young people, because of the particular health and social risks.

The first local plans from Alcohol Action Teams were submitted to the Scottish Executive in March 2003. They outline current activity and plans in the areas of culture change, prevention and education, provision of services and protection and controls. The plans will be used to monitor local progress and to inform future decisions about resources.

The Executive launched its Healthy Living - Alcohol campaign in May 2003. The current phase of the campaign aims to encourage 18 to 25 year olds to take responsibility for their behaviour when drunk, to think more about the negative effects and ultimately to adopt more moderate drinking patterns. This complements NHS Health Scotland's Think about it alcohol campaign, which is aimed at younger teenagers.

The Gender Issues Network on Alcohol was launched in June 2003 and will focus on women and alcohol for the first three years. The Network will run local and national events to raise awareness of the issues around women and alcohol and will facilitate communication among service providers.

The Plan for Action sets out the need for the design and delivery of services to be guided by evidence of effectiveness. In 2003 a Scottish Intercollegiate Guidelines Network (SIGN) Guideline was published on the management of harmful drinking and alcohol dependence in primary care. This complements the Health Technology Board for Scotland's (HTBS) Health Technology Assessment on the prevention of relapse in alcohol dependence, which was published in December 2002.

As part of the Partnership Agreement commitment for the Scottish Executive, a review of treatment and rehabilitation services for both adults and young people was undertaken. The terms of reference were to review:

• research and other evidence describing effective drug treatment and rehabilitation interventions

• availability and accessibility to existing drug treatment and rehabilitation services across Scotland

• delivery arrangements to ensure that integrated and person-centred services are available across Scotland

• accountability arrangements between Drug Action Teams and the Scottish Executive.

The review was completed at the end of 2003 and the conclusions are due to be published early in 2004.

Drug misuse continues to take a significant toll on the lives of young people, with 382 drug-related deaths in 2002. In 2003 the Executive commissioned the first national investigation into drug-related deaths. This will make recommendations for policy and practice to help reduce the number of such deaths in the future.

The needs of children of people who misuse drugs and have alcohol problems have been highlighted during 2003, with the publication of Getting Our Priorities Right and the report from the UK Advisory Committee on the Misuse of Drugs Hidden Harm: Responding to the Needs of Children of Problem Drug Users. Hidden Harm estimates that in Scotland 40,000 to 60,000 children may be affected by parental drug misuse, with significant implications for a wide range of services. Getting our Priorities Right sets out good practice in working with families where there is substance misuse and clarifies expectations in terms of information sharing and confidentiality. It also makes clear what is expected of service providers, planners and commissioners in order to protect the welfare and meet the needs of these children. The year closed, sadly, with a graphic example of these issues in the report into the death of Caleb Ness in Lothian.

A substantial and growing group of people with mental health problems also misuse drugs and alcohol. It is estimated that up to 75% of drug users may also have mental health problems, up to 50% of people with alcohol problems may also have mental health problems and up to 40% of people with mental health problems may have drug and/or alcohol problems. They often have complex social backgrounds including unemployment, homelessness, violence and childhood trauma and form a particularly challenging group to providers of mental health services and substance misuse services. The report Mind the Gaps: Meeting the Needs of People with
Co-occurring Substance Misuse and Mental Health Problems (published in October 2003) highlighted the need for early intervention and for services to work together to develop more positive, holistic and integrated responses.

Drug misuse has serious consequences for both physical and mental health. The Executive's Effective Interventions Unit continues to provide evidence about the impact of drugs on health and the action likely to improve health. Current work includes:

• support for the implementation of integrated care to address the multiple health and social problems of drug users

• an examination of the service needs of and current service provision to people with both mental health and substance misuse problems

• an update of the Moving On review on education, training and employment for drug users, which provides further evidence of the link between employability and improving physical and mental health

• the commissioning of five research studies on prevention of transmission of Hepatitis C

• needs assessment and evaluation support for a Scottish Executive funded pilot service for psychostimulant users in Aberdeen.

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