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6. KEY HEALTH IMPROVEMENT PROGRAMMES

The Executive has a wide range of programmes on health improvement, but last November the Cabinet agreed that future action would focus particularly on the five key areas of alcohol, tobacco, diet, physical activity and health inequalities. In all of these health improvement areas, our approach remains one of clear action by the Executive and its partners to tackle the life circumstances and lifestyles which lead to ill health, but also building the capacity of individuals to take greater responsibility for their own health and that of their families, and to make healthier choices in their everyday lives. This section reviews progress in these areas. There are of course a wealth of other programmes and areas which also continue to make a difference. For instance, improving mental health ¹³ is recognised by Ministers as a key underpinning theme for all health improvement actions as it is core to people's overall health and sense of well being. There are references to mental health programmes and activities throughout this document and improving mental health and wellbeing clearly supports people's capacity to make healthier choices which impact positively on their health.

Further information on all health improvement actions can be obtained from the Executive's website ¹⁴ and that of NHS Health Scotland. ¹⁵

ALCOHOL

Where we want to be

Alcohol is widely used and enjoyed in Scotland, yet it is the cause of much damage - to health and many other aspects of our lives. We need to reduce the harm that alcohol causes in Scottish life and change cultures around drinking. The recent report by the Chief Medical Officer - Health in Scotland 2005¹⁶ - reinforced the need for a change of culture and attitude in Scotland towards excess drinking. Our challenge is to achieve this.

Progress

• The 2005 Licensing Act puts public health at the heart of the licensing regime. It will be implemented by 2009 and will tackle under-age drinking; tackle binge drinking with the crackdown on irresponsible promotions; and involve and protect communities by requiring Licensing Boards to consider the issue of local over-provision of licensed premises. The Scottish Executive recently announced its intention to work in partnership with the alcohol industry to reduce alcohol-related harm through a series of jointly-agreed initiatives; we can achieve more working together than apart.
• A year-long alcohol test purchasing pilot scheme was launched in June 2006 in the Fife Constabulary area. Its main aim is to trial alcohol test purchasing arrangements to ensure safety, fairness and effectiveness in a Scottish context by the time the provisions of the Licensing (Scotland) Act 2005 are generally commenced in 2009. Establishing measures to ensure the welfare of young people taking part in test purchasing exercises is particularly important.
• Alcohol misuse in Scotland requires long-term cultural change. We are starting to see a much wider and deeper public dialogue on the role of alcohol in Scottish society, and the harms which can be caused by inappropriate consumption. This dialogue should provide the foundation for a step change both in hazardous drinking levels and the negative consequences of these.

Next Steps

• The updated Plan for Action on Alcohol sets out a programme of action for the next three years which builds on progress made since the launch of the Executive's Plan for Action on Alcohol Problems¹⁷ in 2002. The update aims to create a culture where safe and sensible consumption of alcohol is seen as compatible with a healthy lifestyle and sets out a series of actions that will ensure:
• cultural acceptability of excessive drinking in Scotland is challenged through public health messaging in partnership with the Scottish alcohol industry and media;
• record levels of investment in the provision of prevention and treatment services is maintained to help people for whom alcohol related harm is already a reality;
• provisions of the Licensing (Scotland) Act 2005 are fully implemented and that its public health provisions are fully realised;
• the strategic framework for delivery of agreed outcomes at local level is structured to ensure that best value is both provided and maintained; and
• the impact of the actions outlined within the plan are evaluated to ensure that future services and initiatives continue to be developed to reflect evidence-based best practise.
• The roll-out of alcohol test purchasing arrangements to other force areas is planned. The pilot has made good progress and reinforced to licensees who make a living from communities across Scotland that they have a responsibility to ensure their businesses do not contribute to the problem of alcohol-related crime and anti-social behaviour frequently associated with underage drinking. The message is clear: if you cannot tell if someone over 18, and they cannot prove otherwise, do not sell alcohol to them! Given the problems associated with underage drinking the Executive wants the police to have access to this effective means of enforcing licensing laws as soon as possible. We hope to make decisions on the timetable for future roll-out early in 2007, when we have sufficient information from the Fife pilot on which to base them.

TOBACCO

Where we want to be

We want a Scotland in which the harm caused by smoking is substantially reduced, and we want to see a society in which everybody aspires to live a healthy, smoke-free life and has access to the support which can help them realise this ambition.

Smoking remains the most important preventable cause of ill-health and premature death in Scotland. It is also strongly associated with health inequalities, with much higher proportions of people living in disadvantaged communities smoking than those in better off areas.

Progress

• In January 2004 we published the first action plan on tobacco designed specifically for Scotland, A Breath of Fresh Air for Scotland¹⁸ - with an integrated range of measures aimed at helping as many people as possible to stop smoking; protecting the public from the effects of second-hand smoke, and preventing people from starting to smoke.

Key achievements include:

• Development of a nation-wide network of accessible smoking cessation services which are in place across Scotland; and
• Smoke-free public places. On 26 March 2006 Scotland became the first part of the UK to implement a smoking ban in enclosed public places and workplaces. As a result it is now illegal to smoke in most indoor places other than private homes. This includes restaurants, bars, cafes, hotels, theatres, bingo halls, church halls, sports and shopping centres, public transport, schools, hospitals and clubs. It also covers almost all workplaces, including lorries and vans. The Smoking, Health and Social Care (Scotland) Act 2005 under which these provisions are made received unprecedented cross-party support during its Scottish Parliamentary passage and has been implemented seamlessly. 98% of premises inspected are now compliant with the law and there is growing support from members of the public.

Next Steps

• The new smoke-free laws undoubtedly have the potential to make a major contribution to smoking prevention by reducing young people's exposure to second-hand smoke and reinforcing a negative image of smoking. However, if smoking is to be made a thing of the past, as set out in A Breath of Fresh Air for Scotland, there is a need for a new long-term strategy to guide smoking prevention activity targeted specifically at children and young people.
• In order to inform the development of this strategy, a short-life expert group, the Smoking Prevention Working Group, was set up to review existing activity and to make recommendations to Ministers. The Group which met for the first time in August 2005, reported to Ministers on 22 November 2006. In making its recommendations the Group have identified a range of measures which will have an impact, both separately and together, to prevent smoking. Ministers welcomed the report and will publish a response to the Group's recommendations.

DIET AND PHYSICAL ACTIVITY

Where we want to be

The links between diet, physical activity and obesity are increasingly well-known and understood and the Chief Medical Officer highlighted increasing concerns and the need for action in his recent report, Health in Scotland 2005. Obesity is most commonly defined as an excessive accumulation of body fat resulting in a Body Mass Index of 30 and above. Obesity can have a major impact on both mental and physical health and is recognised as a key risk factor in cardiovascular disease, diabetes and cancer. Scotland, consistent with most other developed countries, has witnessed considerable rises in obesity levels in recent years and we are committed to reversing this trend.

The reasons for these increases are complex and are due to a combination of many factors. The World Health Organisation has highlighted, in particular, the worldwide shift in diet towards increased portion size, increased energy, fat, salt and sugar intake, and a trend towards decreased physical activity due to the sedentary nature of modern work, transportation, and increasing urbanisation. That is why our combined Diet and Physical Activity Strategies are so important in tackling obesity.

Inactive life and bad nutrition lead to increased risk of Coronary Heart Disease, stroke and other major health problems such as obesity and diabetes. We can make considerable health gains through increasing activity levels and increasing uptake of physical activity is one of our major challenges in our drive to improve the health of the people of Scotland. L et's Make Scotland More Active¹⁹ was launched as the Executive's national physical activity strategy in February 2003 and remains our blueprint for action. Alongside this we have well-developed food and health strategies set out in the Scottish Diet Action Plan ²⁰ and more recently in Eating for Health - Meeting the Challenge.²¹ We are committed to meeting the continuing challenges of improving Scotland's diet.

Progress

• There has been a transformation of the provision of food in Scottish schools and nurseries through Hungry for Success.
• Nutritional standards have been set and raised across the public sector ( NHS, prisons, schools).
• We have invested in healthy eating in communities through the highly-acclaimed Community Food and Health (Scotland), the Scottish Grocers Federation Healthyliving Programme, Quality of Life Funding and Healthy Living Centres.
• We established the Scottish Food and Health Council and the Healthyliving Food and Health Alliance to provide strong leadership and improved communication.
• We have raised awareness of healthy eating through the Healthyliving Campaign. ( TV, press, posters, leaflets)
• We have worked with the Food Standards Agency Scotland on healthy vending, nutrient profiling, labelling and engagement with food industry on sugar, fat and especially salt reduction
• We have driven up standards in catering through the Scottish Healthy Choices Award Scheme and launched a new Healthyliving Award to improve family and workplace eateries.
• The Independent Review of the Scottish Diet Action Plan ²² published in September 2006 found that all of the 71 recommendations in the Plan have been implemented to some degree. 76% of the actions are assessed to have been progressed at a substantial or moderate level. In particular the review noted 4 areas of substantial progress:
• Support for Breastfeeding - by appropriately trained health professionals - to improve infant diet and child health. 6.9% increase from 2001 - 2005 in mothers breastfeeding at 6-8 weeks;
• Food in schools - the development of health promoting schools and a whole school approach to healthy eating, catering and supply - to improve dietary education and the provision of healthy food in schools;
• Community Food Initiatives - the formation of the Scottish Community Diet Project, now Community Food and Health (Scotland), within the Scottish Consumer Council - to support community level food initiatives, especially in low income areas/groups, and the work of Health Boards and local authorities; and
• Health Education & Marketing - the distribution of nutrition advice to every household in Scotland - to empower consumers, and the ongoing Healthyliving campaign.
• We have implemented a "Whole-school approach" to physical activity involving:
• Active schools programme
• YDance programme
• Safe routes to schools programme
• School travel coordinators
• Two hours of PE per week for all school students
• Physical activity element of Schools (Health Promotion and Nutrition) Bill
• We have established:
• The Paths to Health programme - promoting walking for health under 4 main themes: Community; Health care; Workplace; and National Co-ordination.
• Physical Activity Council - providing leadership.
• Physical activity and health alliance

Next Steps

We will:

• Consult more broadly on health-promoting environments for children and young people.
• Continue to drive up the availability of healthier choices on the high street and in workplaces through the new Healthyliving Award.
• Expand on measures in low income communities through Community Food and Health Scotland and a new phase of the Scottish Grocers Federation Healthyliving Programme.
• Work with industry, food retailers, food manufacturers and others on a continuous programme to reduce salt, fat and sugar levels.
• Support the Food Standards Agency front of pack traffic light scheme and other signposting such as the Healthyliving apple brand to help consumers make the healthier choice the easy choice.
• Support the Scottish Prison Service, NHSScotland and the Care Commission to make further improvements to the provision of healthier foods in the public sector. This work will be underpinned by new Nutritional Specifications in the UK and existing nutritional standards in Scotland.
• The Schools (Health Promotion and Nutrition) Bill include proposals to place a duty upon Scottish Ministers and local authorities to make all schools health promoting, and to ensure that all food and drink meets statutory nutritional standards. Proposals include the production of physical activity standards (with supporting guidance) that will underpin a whole-school approach to physical activity. It is hoped this will drive school-based physical activity for years to come.

CASE STUDIES

DELIVERING A HEALTHIER SCOTLAND

A whole-school approach to physical activity

Ellie Forgan, Active School Co-ordinator at Liberton Primary School says:

"I have been working as an Active School Co-ordinator for over a year now. From Nursery, all the way through to Primary 7, each individual child is recognised for their own individual talent, skill and character traits.

The school has embraced any opportunity to involve children in curricular physical education, extra curricular clubs at school and those within their local community. The school offer break dance, fitness classes, football, relaxation, basketball, Capoeira and Rugby. The response from willing parental volunteers and staff is overwhelming. The football and basketball are completely self - sustaining and all other activities are provided by local sports clubs, Active Schools or have a clear community/development pathway.

The whole school has an understanding of the link between good health and a positive classroom experience. The school actively promotes 'a class moves' programme that involves children in small bursts of activity throughout the day. Teachers are also encouraged to continually develop their knowledge of sport and physical activity through training courses that equip them with at least a basic understanding of a particular sport.

We all know the scenario of the child who does not want to take part in sport and physical activity and we are all striving to understand the reasons why. Not all children are receptive to team games or enjoy competition. All children love to be accepted. The school has actively piloted some very important programmes within the school. A group of primary 7 children are taking part in a pilot relaxation group that aims to build self-esteem, confidence and allows them to express themselves through alternative physical activity. The group takes part in yoga, relaxation and also records their private thoughts in specially created folders. The school has invested in a wonderful mentor for these children and it has been a truly enlightening experience for all involved.

All the activities mentioned above give a 'flavour' of a school, which is very keen to promote good health and physical activities for all its pupils and include parents and carers as much as possible. My role as Active Schools Coordinator to promote and encourage as many opportunities, coupled with Liberton's willingness to be involved, makes for a very healthy and active partnership for its pupils!"

Counterweight

In addition to the work set out in our Diet and Physical Activity strategies, which have a focus on preventing obesity, it is also important we ensure that NHS services are available for those seeking treatment for their obesity. To contribute to this we are currently funding the roll out of the Counterweight programme in three areas within Tayside, Lothian and Lanarkshire. The project is funded for a period of 2 years within which a total of 120 GP practices will be trained to deliver the programme in line with their existing weight management programmes.

Counterweight is an evidence-based weight management programme delivered within the community and led by practice nurses. The programme is individual to each patient and following screening a treatment pathway is developed that may include patient-centred goal setting, prescribed eating plans, a group programme, physical activity and behavioural approaches, and anti-obesity medication.

TACKLING HEALTH INEQUALITIES

Where we want to be

Tackling health inequalities is a top priority for the Executive. We are committed to action with our partners to reduce the health gap between our most deprived and most affluent citizens. When we launched Improving Health in Scotland: The Challenge ²³ we noted that Scotland's poor health record was improving, but not fast enough in our most deprived communities - and we put particular emphasis on the need to narrow the opportunity gap and improve the health of our most disadvantaged communities at a faster rate, thereby narrowing the health gap. The exacting targets set in Building a Better Scotland²⁴ set a back drop and provide impetus for our continuing drive against health inequalities.

Progress

Tackling health inequalities is a multi-agency and cross-cutting activity, but we have recognised that there is more that the NHS can do to make a difference. What follows is progress on the specific NHS contribution to reducing health inequalities; recognising the importance of getting greater equality of outcomes from health care for those in our most disadvantaged communities.

The Keep well Programme

When we launched Delivering for Health, ²⁵ the vision for the NHS in the 21st century, we stated that the most significant thing we could do to tackle health inequalities was to target and enhance primary care services in deprived areas to provide anticipatory care:

• Targeting health improvement action and resources at the most disadvantaged areas;
• Building capacity in primary care to deliver proactive, preventative care; and
• Providing early interventions to prevent escalation of health care needs.

We recognise the important role the Executive's wider strategies play in improving life circumstances and changing health behaviours, but in launching our Keep well Programme we are doing something very practical to address the real health needs of those who have most to gain in the short-medium term.

From October 2006, those aged 45-64 at risk of cardiovascular disease in some of our most deprived communities in Dundee, Edinburgh, Glasgow and North Lanarkshire, are being invited to attend for a Keep well health check.

We will actively seek out and prevent illness by using innovative and new ways of contacting people - using people's existing contacts and relationships with a range of services and in a range of settings, but also taking the service to where people congregate - in community centres or shopping malls or even pubs. The Programme will link people to a range of GP and community-led interventions to help them reduce their risk of getting ill.

For instance, if the health check shows that someone has high blood pressure and is overweight and a smoker, they could be prescribed medication to lower their blood pressure while at the same time being referred to Counterweight, the weight management programme which tackles both diet and physical activity issues. And they could also be encouraged to join a local smoking cessation support group in addition to receiving nicotine patches.

Have a Heart Paisley and Health Coaching

Now in its second phase, Have a Heart Paisley ²⁶, the national demonstration project for heart health, has moved to a targeted programme for the working age population, with a particular focus on those in deprived communities. In Paisley, Health Coaching is offered to people aged 45-60 at risk of Coronary Heart Disease and to people with established Coronary Heart Disease who attend secondary prevention clinics. Health coaches use their skills to encourage people to adopt positive health behaviour changes, specifically in relation to the Coronary Heart Disease risk factors of unhealthy eating, physical inactivity and tobacco use - and also to raise confidence and optimism to aid the change process.

Unmet Needs Pilot Programme

The Executive allocated £15m over two years to Boards with high concentrations of deprivation for pilot studies to focus on tackling inequality of access to and use of, primary and secondary healthcare services. (Tayside - £1.78m; and Greater Glasgow and Clyde - £13.5m for work in the former Argyll and Clyde Health Board area and work in Glasgow City). Boards' proposals specified how studies will impact on improving access for the most disadvantaged populations, and set out arrangements for measurement and evaluation. Pilots will end in 2006/07 and evaluation results will become available after that.

These studies seek to increase the access to services of deprived populations and find new ways of responding to their high levels of need. Results of the pilots will provide a useful source of evidence for the Executive's drive to tackle health inequalities generally, and to reduce the health gap between the most and least affluent. The studies are also informing the review by the National Resource Allocation Committee of the deprivation adjustment in the Arbuthnott funding formula for NHS Boards.

Pilots are wide-ranging for instance heart failure nursing in the community, breast-feeding peer support, outreach health services for homeless people, and focus on health topics where there is good evidence that improved access to services by populations living in the most deprived areas will produce a significant health gain for them.

Suicide prevention

Scotland has a higher rate of suicide than other UK countries and rates of suicide in areas of social and economic disadvantage are almost twice those of more affluent communities. The Executive's strategy to reduce suicide - 'Choose Life' - includes action plans in every local authority, working through the community planning process to develop and deliver local support for suicide prevention. An independent evaluation of the first three years of the strategy, published in September 2006, found that good progress is being made and emphasised the need to further target high-risk groups, including those who misuse alcohol and drugs, and to further target suicide prevention work in areas and communities experiencing inequalities.

The decline in national suicide statistics is encouraging - between 2000 and 2005 there was a 12% decrease in the overall national rate. It is too early to tell however, if this is a long-lasting downward trend and the Executive and its national and local Community Planning partners are committed to continuing their efforts on supporting suicide-prevention work.

Glasgow Centre for Population Health

Another part of our programme to step up action on health improvement was the establishment of the Glasgow Centre for Population Health ^w in April 2004. The Centre provides a focus on the issues which drive the patterns of ill health which characterise Glasgow and west Central Scotland - but it also has relevance for the whole of Scotland. It is a resource which is generating insights and evidence, creating new solutions and providing leadership for action to improve health and tackle inequality. It provides a setting for academics, policy-makers, practitioners and local people to confront the problems facing population health in Glasgow and beyond.

The Centre is a collaboration between NHS Greater Glasgow & Clyde, Glasgow City Council and the University of Glasgow and is supported by the Executive with £1m per annum for 5 years.

Next Steps

We will:

• extend the Keep well approach to more areas in 2007 before applying learning of what works to all those at risk through deprivation, wherever they live in Scotland;
• consider further ways in which we can apply the principles of anticipatory care to tackle health inequalities;
• disseminate learning from the health coaching work in Have a Heart Paisley so that people throughout Scotland can benefit;
• learn lessons from Unmet Needs studies and apply this to our health inequalities work with our partners throughout Scotland; and
• continue our work with the Glasgow Centre for Population Health to derive maximum benefit in our drive against inequalities.

CASE STUDIES

DELIVERING A HEALTHIER SCOTLAND

Health Coaching in Have a Heart Paisley

The Patient

In the 3 months since taking up the health coaching service, 59 year old Mr. X has already seen big changes - especially to his waist line!

"I came on board mainly to lose weight and change my shape, and so far my trousers have gone from a size 44 to a 38 waist. With the help of my health coach I've been able to improve my diet and my shape is changing well. My wife's so impressed that she's changing her diet too! It's made me feel so much better. I walk with the aid of a stick, but I've been walking a lot more and I've been going to the gym! I really enjoy it. It's something I never thought I'd do, but having someone there giving you a bit of support and confidence really spurs you on."

The Health Coach

Health coach Laura is a qualified fitness instructor with extensive experience in community development. Involved in the first phase of Have a Heart Paisley, Laura helped set up and support a large number of community health initiatives throughout the town.

"I experienced at first hand the impact that personal support could make on individuals trying to make lifestyle changes. Many people achieved things they never thought they could, and the knock-on effect of these achievements on their confidence and attitude to their health was amazing. Typically, someone who managed to address one lifestyle issue, such as becoming more active, then had the confidence to tackle something else, such as stopping smoking. A health coach has a real opportunity to help someone significantly improve their health."

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