The Scottish Government

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2. Rationale

Have a Heart Paisley was developed in 1999 within a spirit of enthusiasm to see Scotland's largest town enjoy the benefits of aspects of a comprehensive approach in tackling heart disease. Recent evaluation reports have suggested this has been an over-ambitious goal for Scotland in the present day. Experience from HaHP and other complex community health initiatives suggests that positive health improvement changes may only be expected and demonstrated over a longer period, driven by a project that focusses on a high risk population and is supported by wider prevention activities.

Coronary heart disease ( CHD) is a major cause of mortality and morbidity in Scotland, responsible for nearly one in four of all deaths. It is a priority area for health improvement in Scotland, with a target of a 60% reduction in CHD mortality between 1995 and 2010 for those under 75 years of age. Despite a substantial decline in the CHD death rate since the 1970s Scotland persistently has higher rates than its Western European neighbours. The overall CHD death rate in Paisley is 8% higher than the Scottish average. Within the town, the CHD death rates for different areas range from 24% less than the overall Scottish rate to 50% more.

In common with many other major preventable health problems CHD shows a gradient across socio-economic groups and deprivation categories, with the toll of illness and death being greatest among the most disadvantaged people and communities. For people from the most deprived areas of Scotland, the annual risk of dying from CHD is more than two and a half times that of people from the least deprived areas. Many of the influences that impact on the causes and treatment of CHD are beyond an individual's direct control. These are factors such as life circumstances, environments, services and amenities that affect an individual's risk of CHD and access to primary and secondary care treatments.

Health inequalities are starkly apparent within the parliamentary constituencies in which the town of Paisley sits. The recent constituency profiles published by NHS Health Scotland (2004), found that in Paisley North (made up of some of the most deprived wards in Scotland) annual rates of CHD related deaths were 25.5% higher than the Scottish average. Within Paisley South, annual CHD related death rates were 14.6% higher than the Scottish average.

There are eleven postcode areas within Paisley and the table below categorises those which have a DEPCAT score of 4 or above according to the Carstairs and Morris deprivation category (7 being the highest level of deprivation). These data are extracted from work by McLoone (2004) on behalf of the MRC Social Policy and Public Health Unit and uses 2001Census data.

Table 1: Extract of Deprivation Categories in Paisley

It is estimated that a total of 65% (48,210) of the Paisley population falls within DEPCAT 4-7. This is further broken down to reveal approximately 39% of the population (28,926) fall within DEPCAT 4-5 and 26% of the population (19,284) fall within DEPCAT 6-7.

In order to narrow this health inequalities gap the Phase 2 interventions will, where appropriate, focus upon people living in DEPCAT areas 6 and 7 who fall within the target population for Phase 2.

Publication of the Scottish Index of Multiple Deprivation ( SIMD) in June 2004 described the development of multiple deprivation scores for data zones in Scotland. The local Community Planning Partnership is currently considering which data zones will be targeted in the three year Regeneration Outcome Agreement.

Policy matters

The policy context in Scotland has evolved substantially from the early stages of Phase 1, with significantly greater funding streams currently being directed at health improvement activity. This plan for Phase 2 has been considered alongside the relevant, key health improvement policy areas (see Table 2). The proposed national Smoking, Health and Social Care (Scotland) Bill along with Renfrewshire Council's Policy and Initiatives to Control Smoking at Work will help in the development of healthy environments and support change in Paisley.

Table 2: Policy Context

What has been learned?

The many evaluation reports that are now available through the Heart Health Learning Network website, www.healthscotland.com/hearthealth, highlight areas of success as well as providing key lessons about how to take forward health improvement in Scotland. Annex 1 summarises the key lessons from Phase 1. HaHP believes that the successes and challenges experienced at the commissioning, implementation and evaluation stages echo the experiences of others involved in improving health. It is essential to ensure that effective ways of working are better understood and that knowledge that is generated is shared with others. The Heart Health Learning Network based at NHS Health Scotland plays an essential role in sharing that knowledge.

How has the evidence base shaped Phase 2 plans?

In developing this plan for Phase 2 HaHP has absorbed best available evidence, both local and national and used a number of planning and evaluation tools, including RE-AIM (Reach, Effectiveness/Efficacy, Adoption, Implementation, Maintenance) see www. RE-AIM.com. The RE-AIM framework assisted in delineating those interventions that are drawn from the existing evidence base and those that seek to generate evidence of effectiveness. Drawing on that evidence HaHP will now move from a broad population approach to an approach that focusses support for those most at risk of developing heart disease and makes services accessible to those most in need.

Guiding principles

The strategic partners of HaHP have agreed to revisit the partnership values and principles, with reference to the Madrid Framework dimensions (Marinker 2005). This framework outlines many dimensions of health policy and governance and the partners consider that work on this area will help to strengthen joint working. Such continued improvements to partnership working are partly achieved through the process of clarifying the cultural beliefs and values that underpin partner organisations. This clarification may identify areas of difference that can be explored and better understood as well as areas of similarity that can be built upon.

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