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Health in Scotland 2004

CHAPTER 2 : IMPROVING SCOTLAND'S HEALTH

Health Inequalities

Tackling health inequalities is a major aim of the Scottish Executive's health improvement policies, as set out in the White Paper Towards a Healthier Scotland (1999) and in Improving Health in Scotland: The Challenge (March 2003). Improving the health of people living in the most deprived communities is also one of the high level objectives which have been set in Closing the Opportunity Gap (CtOG) - the Scottish Executive's anti-poverty programme.

Ministers recently announced a health inequalities target in Building a Better Scotland - the 2004 Spending Review. This target is to reduce health inequalities by increasing the rate of improvement across a range of indicators for the most deprived communities by 15% by 2008. Achieving this will be very challenging and requires concerted action by NHSScotland and its partners.

The six indicators are:

• Coronary Heart Disease mortality in people under 75 years old
• cancer mortality in people under 75 years old
• adults smoking
• smoking during pregnancy
• teenage pregnancy
• suicides in young people.

The Coronary Heart Disease and cancer indicators will also be used to measure progress on the health improvement section of the Closing the Opportunity Gap work. Focusing on deprived communities recognises the important role community planning partners have in improving health. Community Planning Partnerships are crucial to delivering an improvement in the rate of change to Scotland's health, by developing and delivering a strategic vision for their communities, through the Joint Health Improvement Plan process, and addressing major issues which affect the social, economic and environmental well-being of communities.

The NHS has an important role to play in respect of its own services. There are inequalities in both access and uptake of healthcare services. People in deprived communities are less likely to use services and often present later and have worse outcomes. There is a need for evidence about what is effective in promoting access and uptake for deprived and excluded populations.

The Scottish Executive is therefore providing £15 million over two years to the three NHS Boards (Argyll and Clyde, Tayside and Greater Glasgow) with the highest concentrations of deprivation for pilot studies which focus on access to and use of` primary and secondary healthcare services and which seek to improve access by deprived populations. Results of these studies will provide evidence of the effectiveness of these strategies to tackle health inequalities and to reduce the health gap between the most and least affluent, and will potentially influence a review of the Arbuthnott funding formula for NHS Boards.

Health and Homelessness

The drive to improve the health of people who are homeless in Scotland has continued this year. All NHS Boards have been scrutinised to ensure that their delivery of Health and Homelessness Action Plans is effective and is giving the direction needed to make a difference to this very vulnerable section of the community. It is a challenge to improve the health status of people whose lives are chaotic in many respects. NHS Boards have received appropriate levels of support to deliver on the expectations set out in the homelessness strategy and the Scottish Executive Health Department (SEHD) has worked closely to assist in the development of effective health interventions.

Over the course of the year, SEHD has supported the development of multi-disciplinary specialist services for homeless people. The Minister for Health and Community Care opened services in Perth and Glasgow and SEHD will work with such services to promote understanding of the benefits of this approach. However, specialist services should only be a short-term response and mainstream health services also need to be accessible, appropriate and responsive to the needs of homeless people.

To develop health and homelessness work, SEHD will publish Health and Homelessness Standards in March 2005. These Standards build on the good practice which has developed since the publication of the Health and Homelessness Guidance in September 2001 and they will provide a renewed focus for NHS Boards from April 2005 onwards.

Smoking

Smoking remains one of the most damaging factors in Scotland's poor health record. It is estimated that every year 13,000 people in Scotland die prematurely from smoking-related diseases including lung cancer, Coronary Heart Disease and stroke. The lives of thousands more are blighted and limited by these diseases. However, it is still relatively uncommon for doctors to mention smoking as a contributory cause of death when completing death certificates. In an attempt to overcome this problem, aetiological fractions are applied to the numbers dying from a range of causes (Table 2.1) in order to arrive at a total of smoking-related deaths.

Table 2.1:
Percentage of deaths from diseases attributable to smoking

(Source: Nicotine Addiction in Britain, RCP)

The age specific mortality rates per hundred thousand of the male and female population in Scotland dying from cancers of the trachea, bronchus and lung are shown in Figures 2.1 and 2.2. Up to 2000, death rates from these cancers had been falling for men and rising for women. Since 2000 the rates have been relatively stable for both sexes.

In 2004, as a crucial component of its health improvement drive, the Scottish Executive reinforced its commitment to tobacco control. The launch early in 2004 of A Breath of Fresh Air for Scotland (1), the first action plan on tobacco control designed specifically for Scotland, was an important step forward.

The Plan is based on the vision of Scotland as a country where everyone is aware of the health risks associated with smoking, where the health of children is protected and where people are not exposed involuntarily to the dangers of second-hand smoke (passive smoking) in the workplace or elsewhere.

Figure 2.1: Age specific mortality rates per 100,000 population for males dying from cancer of the trachea, bronchus and lung.

Figure 2.2: Age specific mortality rates per 100,000 population for females dying from cancer of the trachea, bronchus and lung.

The Plan recognises that a reduction in smoking levels in Scotland requires clear priorities and targets backed by action set out in four broad categories:

• Prevention: action to accelerate reduction in smoking, including a major review of prevention, education and communication efforts.
• Provision of services: action to extend and improve cessation services with new funding (£1m with effect from 2003/04 and a further £4m with effect from 2005/06) from the Scottish Executive to support these.
• Second-hand smoke: action to reduce the health risks of second-hand smoke and to reinforce efforts to change attitudes to smoking in Scotland.
• Protection and controls: legislative and other action to reduce the attractiveness and availability of cigarettes.

The Plan commits the Scottish Executive to a long-term strategy to support structures which are capable of delivering results, monitoring progress and identifying new and subsequent action, based on evidence of what has been effective in Scotland and elsewhere.

Minimising the risks from second-hand (environmental) tobacco smoke

While all of the action identified within the Plan is important, there is little doubt that the commitment to sponsor a major public debate on actions to minimise second-hand smoke has been the most significant step to action designed to improve the health of the people of Scotland in a generation. The scientific evidence of the health risks of second-hand smoke is clear and irrefutable and was extensively reviewed in the report of the UK Scientific Committee on Tobacco and Health (SCOTH), published in 1998 (2). The report concluded that exposure to second-hand smoke:

• is a cause of lung cancer and, in those with long-term exposure, the increased risk is 20 to 30%
• is a cause of heart disease and represents a substantial public health hazard
• can cause asthma in children and may increase the severity of the condition in children already affected.

SCOTH has now reviewed the evidence to emerge since 1998 into the health risk of exposure to second-hand smoke and its latest report, published in November 2004, reinforces the earlier findings (3). Additionally, research commissioned by the Scottish Executive and NHS Health Scotland in 2004 suggests that second-hand smoke is associated with some 865 deaths per year among life-long non-smokers in Scotland. Taking ex-smokers into account, it is estimated that some 1,500 to 2,000 deaths per year in Scotland are related to environmental tobacco smoke exposure (4). Further modelling by the University of Aberdeen (5) has suggested that, of the 865 deaths, 120 are attributable to non-domestic exposure.

The need to take action to extend smoke-free provision in Scotland is clear. Following a consultation in 2004 (which elicited nearly 54,000 responses) and wider evidence-gathering on possible approaches to minimise the impact of second-hand smoke, the Scottish Executive announced its intention to protect public health through the introduction of a comprehensive ban on smoking in public places. This significant decision offers the potential to transform the health of people in Scotland, giving individuals the opportunity to cut down or stop and giving children and young people the chance to grow up with less pressure to smoke and less likelihood of dying early.

As well as directly reducing the risk from environmental tobacco smoke (passive smoking) to non-smokers and those who cannot choose, such as children and the unborn, a ban will increase the number of smokers who quit and reduce the likelihood of the young starting, by removing the perception that smoking is normal. Legislation to implement the decision was introduced to the Scottish Parliament on 16 December 2004 and the proposed date for full implementation is spring 2006.

Problem Drinking

Alcohol has always played a part in Scottish social life. Although the majority of people in Scotland enjoy alcohol without causing harm to themselves or to others, binge drinking and drinking in order to get drunk have become increasingly common and are often associated with high levels of violence and anti-social behaviour. Most of the hospital admissions and deaths due to alcohol occur in middle-aged people and follow years of heavy drinking (Figures 2.3. and 2.4). These issues have been commented upon in previous reports.

Plan for Action on Alcohol Problems (6) which was published by the Scottish Executive in January 2002, heralded a new, integrated approach to reducing alcohol-related harm in Scotland. The Plan set out to tackle the harmful effects of problem drinking by outlining a long-term programme of culture change, covering prevention and education, the delivery of effective support and treatment services and a range of protection and controls.

The Scottish Executive and partner organisations have embarked on a significant programme of change since this Plan was published. A national communications strategy to tackle binge drinking was launched, a support and treatment services framework to assist local service planners was published and the Scottish Executive allocated funding of £8m over two years for treatment, support and prevention activities. Local Alcohol and Drug Action Teams have identified and implemented actions to help address local priorities and the evidence base of what works in treating and supporting people with alcohol problems has been strengthened.

Figure 2.3: Alcohol-related deaths: males and females.

Figure 2.4: Alcohol-related deaths by age group.

These actions will, in time, have a positive effect. Meanwhile, alcohol continues to have a negative impact on the lives of many people in Scotland and to place a heavy burden on society. The estimated cost to Scotland is £1.13 billion per annum in terms of lost productivity and in healthcare and criminal justice costs (7). Alcohol-related hospital admissions and deaths continue to increase for both men and women. Since 1990 there has been a 60% increase in reported drinking by 15 year olds and more than a 100% rise in drinking by 13 year olds. Many more children are living with parents who have alcohol problems and there is justifiable concern about alcohol-fuelled violence and other forms of antisocial behaviour.

Alcohol-related deaths

• There were 1,980 alcohol-related deaths in Scotland in 2003.
• They account for one in 30 of all deaths in Scotland.
• Numbers have risen by 240% since 1980 (from 580 to 1,980).

Alcohol and liver disease

• There were 5,255 admissions to general hospitals with alcoholic liver disease in 2003/04.
• Sixty-nine percent of admissions were male and 31% female.
• There was a 47% increase in admissions for alcohol-related liver disease between 1997/98 and 2003/04 (Figure 2.5).

Alcohol and fires

• Alcohol has been a major factor in fatal fires in recent years.
• In 2002/03, of the 84 people who died in Scotland as a result of fire, misuse of alcohol contributed directly in 32 (54%) fatal fires and indirectly in a further five (8%).

[Source: HMCI of Fire Services for Scotland, Annual Report 2002/2003, TSO, Edinburgh]

Alcohol and violence

• Of respondents who could tell, 72% of the violent incidents were thought to be carried out under the influence of alcohol.
• Male offenders were more likely to be under the influence of alcohol (69%) than female (30%).

[Source: Scottish Crime Survey 2000]

Alcohol and road accidents

• One in six deaths on Scotland's roads are caused by drink driving.
• In 2002, 304 people died in road accidents in Scotland with an estimated 50 of these the result of drink driving.
• In 2002, an estimated 820 accidents with 1,270 casualties in Scotland resulted from drink driving.
• The figures for 2002 (Figure 2.6) are the highest estimated number of drink drive accidents and casualties since 1993.

[Source: Road Accidents Scotland 2003]

Figure 2.6: Accidents involving motor vehicle drivers or riders with illegal alcohol levels, by severity of accident.

Alcohol problems cut across all social backgrounds and circumstances but there are clear associations with inequality and deprivation. In Greater Glasgow, for example, people from the most deprived areas are six times more likely to be admitted to hospital with an alcohol-related diagnosis than those from the most affluent areas. Men living in the most deprived areas are seven times more likely to die an alcohol-related death than those in the least deprived areas.

In 2004, the Scottish Executive, in consultation with partners, reviewed the action within the Plan and it is proposed to publish an updated Plan early in 2005. Retaining the broad structure of the original Plan, it will build on a series of Partnership Agreement commitments and offer a comprehensive range of actions aimed at improving Scotland's health by changing drinking cultures and reducing alcohol-related harm.

Healthy Eating

The recent Health Education Population Survey showed that there are some encouraging signs of improvement in the eating habits of the people of Scotland. Since 1996 there has been a 40% increase in awareness of recommended fruit and vegetable consumption (five servings a day) and 61% of the population mentioned that they have tried or would like to eat more healthily.

The Scottish Executive Food and Health Action Plan 2004/05, published in Eating for Health: Meeting the Challenge in 2004, maps out areas for action, including:

• developing a stronger interface with the food industry
• the introduction of a Scottish Food and Health Council to focus on formulating and delivering an annual plan of action
• the introduction of a Healthyliving Food and Health Alliance to ensure strong and effective engagement with all relevant sectors
• the delivery of a clear and sustained message on healthy eating to the public through the Healthyliving campaign.

Advertising this year has been aimed at parents in their role as food providers for families, men catering or buying food for themselves, women choosing their own food and adults contemplating taking action to tackle being overweight. The advertisements are supported by a website and a telephone line that provide practical advice on how to eat more healthily.

Since the 1980s, Scotland has participated in the WHO collaborative study Health Behaviour in School-aged Children (HBSC) which considers young people's health in its broadest sense. The sixth and most recent survey took place in 2001/02 and involved 1,500 Scottish schoolchildren from each of three age groups. ( www.hbsc.org ).

HBSC is a school-based survey with data being collected in the classroom through self-completion questionnaires which contain a core set of questions looking at:

• Background factors: demographics and maturation, family structure and socio-economic status
• Individual and social resources: body image, family support, peers and school environment
• Health behaviours: physical activity, eating and dieting, smoking, alcohol use, cannabis use, sexual behaviour, violence, bullying and injuries
• Health outcomes: symptoms, life satisfaction, self-reported health, Body Mass Index.

Some of the findings of the 2001/02 survey in the 13-year-olds group are shown in Figures 2.7 to 2.9.

Figure 2.7: 13 year olds drinking sugary drinks every day

Figure 2.8: 13 year olds eating sweets every day.

Hungry for Success

The Scottish Executive's school meals policy Hungry for Success continues to raise standards for food provision in schools. New software and support training materials have been developed and provided to Local Authority caterers to help them meet the nutrient standards and product specifications as laid down by the Food Standards Agency Scotland for school meals. The food industry is responding well to the challenge, with an increasing number of reformulated products meeting the specifications.

Her Majesty's Inspectorate of Education has developed a monitoring scheme and has appointed a specialist Nutrition Associate Assessor to help with inspections, initially in primary and special schools. The target date for implementation of Hungry for Success in this sector was December 2004. Secondary schools have until 2006 to implement the changes fully and many Local Authorities are already on track.

Obesity

It is reported that one in five adults in Scotland are classified as obese. This number has tripled in the last 20 years and is set to continue to increase on present trends. Almost two-thirds of the men and over half of the women are either obese or overweight and, among children, nearly one in three are overweight by 12 years of age.

An array of factors can contribute to obesity, such as endocrine and genetic disorders. However, the fundamental cause of obesity is the consumption of excess calories compared to calories expended - in short, physical inactivity and poor diet. The result is excess body fat, which frequently leads to considerable health impairment.

Physical Activity

Physical activity is one of the most influential factors in the promotion and maintenance of weight loss and is very effective in reducing body fat in moderate obesity. People in Scotland are currently well below the recommended levels for physical activity.

Regular physical activity can produce many health benefits:

• Improves cardio-respiratory function
• Reduces risk of Coronary Heart Disease
• Reduces risk of overweight and obesity
• Enhances bone density
• Improves feelings of well-being
• Improves fitness, muscular strength and flexibility
• Better performance of work, recreational and sport activities.

Physical activity continues to be one of the major determinants of health in Scotland. The recent Health Education Population Survey shows that only 43% of adults aged 16 to 74 are meeting the minimum recommended levels of physical activity (an accumulation of 30 minutes of activity per day). However, 77% believe that taking regular exercise is very important in reducing the risk of Coronary Heart Disease and 62% would like to or have tried to increase activity levels.

The Scottish Executive is continuing to build on this increased awareness of the important role physical activity plays in Scotland's health. This year's phase of the healthyliving campaign incorporated physical activity for the first time. Advertisements aimed at specific groups - older adults and families with young children - demonstrate that simple steps can be taken to increase levels of activity, including active travel, play, climbing stairs and swimming. The advertisements are supported by a website and telephone line that provides practical advice on how to get active.

Walking

Walking is an ideal way to be active. Among those who meet the minimum levels of physical activity (30% of Scottish population), walking is the most common activity. Even among those who fall short of the minimum target, walking is also the most common activity - but they just do not do enough to benefit health. The Scottish Executive has been promoting walking in several ways:

Great Scottish Walk

The Scottish Executive has sponsored the Healthyliving Golden Mile event as part of the Great Scottish Walk. The Healthyliving Golden Mile is aimed at people, of all ages and abilities, who would like to become more active but feel they are unable to manage either of the full 6 or 12 mile walks.
In 2004, 196 participants took part in the event in Edinburgh. Similar support is being provided for the event in 2005, along with additional support for the children's Wee Scottish Walk which will take place in four different Scottish cities (Edinburgh, Glasgow, Dundee and Aberdeen).

Paths To Health

The Scottish Executive is working in partnership with the Paths To Health Project to promote walking - aiming particularly at those who are most inactive - by developing and strengthening the walking infrastructure in local areas. This is a flavour of what has been achieved through in the 12 months up to November 2004:

• Funded an additional 14 Paths to Health Schemes, bringing the total to 62 schemes (Each scheme can have up to 30 individual walking groups within it).
• Ran 33 courses training an additional 451 volunteer walk leaders, bringing the total number of volunteer walk leaders to 933.
• Developed a new 'Next Steps' training course for volunteers to take people from beginner groups to more adventurous off-road walks.
• Delivered monitoring and evaluation training to 13 local schemes to gather improved information about their activity.
• From a sample of five walking groups, a total of 1,600 'new' walkers were identified.

Further work will be undertaken in 2005 to support the development and promotion of walking and cycling for both recreation and as a travel mode, involving a variety of partners such as Local Authorities, the NHS and the voluntary sector.

Play@Home

There is increasing evidence that family involvement in physical activity increases participation for children and also that active children become active adults. Play@Home (P@H) is a physical activity programme for children from birth to five years. It provides parents with guidance on safe and beneficial ways of handling an infant to improve family emotional ties, stimulate motor and sensory development and promote a nurturing environment within the home. P@H is a partnership programme between Fife Council Education Service and NHS Fife but has also been used by the Health Demonstration Projects in Glasgow and Paisley. The Scottish Executive is continuing to provide funding to the P@H resource as part of increasing activity within the home environment and to support the development of P@H across Scotland.

Girls on the Move

Girls on the Move is an exciting new initiative being developed in partnership with the Scottish Executive and The Robertson Trust to increase the physical activity levels of girls and young women. The programme will provide them with opportunities for both participation and training as coaches and leaders. By involving more young women as leaders in promoting physical activities for girls, this may allow them to contribute to the participation of others (particularly younger children) in physical activity within their own communities. At the same time, they will also develop their own self-esteem and competencies that will assist them in their personal development.

YDance

Dance encourages young people to get active and is particularly popular with girls, especially teenage girls who are one of the most inactive groups. The Scottish Executive is working closely with YDance to provide additional capacity within schools to encourage and support the development and delivery of dance for children and young people in Scotland. Initial circulation of CD-ROMs and teaching manuals to schools has taken place and a major programme of dance workshops across Scotland are planned for early in 2005. Further work will then be undertaken to extend the proposed programme to all 32 Local Authority areas over the period from August 2005 to March 2008.

Figure 2.9:
13 year olds meeting the guidelines for moderate to vigorous physical activity (MVPA).

The MVPA guidelines are to take part in at least one hour of moderate to vigorous physical activity on at least five days a week.

Motivation to Move is a community-based project introduced in Tayside to reduce the negative effects of lack of activity. It offers a range of physical activity programmes including chair-based exercise, tailored exercise classes, organised walks and improved access to gyms and swimming pools.

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