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SECTION TWO: DELIVERING CHANGE

CHAPTER EIGHT: HEALTH IMPROVEMENT

Health Improvement was described in the Action Framework as sitting at the heart of Scottish Executive policy and the Framework lists a series of 8 targets which exist to aid Health Improvement.

8.1 TARGETS

Consultees were asked whether targets for health improvement remain relevant for 21 ^st Century Scotland and, as can be seen in table 8.1 below, 4 out of 5 (80%) of those responding to this question agreed that they do.

Table 8.1
1: Whether targets for health improvement remain relevant for 21 ^st Century Scotland

Base: All those responding in each category

HEAT targets

The first of the HEAT targets aims to " reduce health inequalities by increasing the rate of improvement across a range of indicators … for the most deprived communities by 15% by 2008." Two consultees commented that that the range of issues covered is too wide and perhaps health inequalities merited a separate section.

The target for reducing the suicide rate attracted more comments and the key theme to emerge was the need to include wider mental health targets; mentioned by 4 consultees. Two consultees suggested that a reduction in self-harm figures would be more appropriate; especially for pre-teens. Four consultees expressed concern that, since the figures are fairly small, 20% was not a significant figure for pre-teens, with 2 of these consultees commenting that more specific targets for gender or age could be used. One Education Body suggested "We prefer targets such as 'have no signs of ..' rather than 'reduce …by 20"' because the latter gives no indication of scale". In comparison, a Voluntary/ Charity Body felt the 20% target was too low. Two Local Authorities suggested using other, more positive, methods or indicators of well-being, while another pointed out the importance of this target in terms of Child Protection.

Teenage pregnancies; 6 consultees; three from Local Authorities; commented on this target:

• the need for early intervention through education;
• sexual health initiatives should focus on raised awareness of risks and greater understanding of harm reduction;
• possibility of including a target regarding repeat terminations and levels of support following termination and the need to ensure good practice evidence available to all;
• that those aged 16-19 be included in the target;
• the need for baseline figures for 2006;
• that teenage pregnancy is a Child protection issue and that a functional or target approach is not helpful.

In relation to the target on dental disease, 2 consultees commented on a shortage of available dental care and the impact this will have on the ability to meet targets, and an NHS Service provider commented that the target is unattainable. Another NHS Service Provider described the target as "shameful" and felt "Some new thinking must be adopted") Two consultees felt that toothbrush schemes should be included in the targets.

One Local Authority pointed out an inconsistency with the Quality Improvement Framework issued by the Education Department, Children and Young People Social Care Group, which includes a target for 11-12 year olds. A Professional Body highlighted the important contribution made by pharmacies via sugar-free medicine; especially for children requiring long term treatment. A Voluntary/ Charity Body noted that oral healthcare in children with learning disabilities is generally poorer than average and some also have congenital oral health problems, and asked that this issue receive some focus. One NHS Service provider mentioned the importance of nutrition in dental health and felt this should be included.

There were a small number (2) of other, more general, comments on the HEAT targets:

• that the target dates may not be achievable;
• the need to plan with disability in mind.

TCAP targets

Two smoking-related targets were included.

Smoking during pregnancy attracted comments, from 3 consultees, on the need to consider the impact of the new smoking legislation, and a Local Authority wondered whether the target may be unambitious given the ban on smoking in public places. One consultee, an Individual (Professional), thought the target should include alcohol consumption and 4 consultees, including 2 NHS Management & Strategy Groups, thought it should be extended to include breastfeeding. One Professional Body felt the target was modest while an Individual (Professional) expressed concern that the rate of women smoking while pregnant was still rising and that this was a matter of concern.

Many of the previous comments also concerned smoking among young people with, in particular, 4 consultees again commenting on the need to consider the impact of new legislation. Two consultees felt the target should be extended to younger age groups, while an NHS Management & Strategy Group felt it should include smoking among parents. One NHS Service Provider felt that the target was unattainable within the timescale, although a Professional Body again described the target as modest. An Individual felt there had been progress in some areas but pointed out that the numbers are still rising among girls and young women.

THS targets

Two targets from 'Towards a Healthier Scotland" were listed and one Local Authority felt they should be extended to include younger age groups.

The numbers involved in underage drinking were reported, by 3 consultees, to still be rising. Two consultees felt the target was not attainable within the timeframe, although a Professional Body again felt it to be modest. The need to include younger groups was expressed by an NHS Management and Strategy Group and other, single, comments included:

• the need to provide education on the connection between alcohol consumption and the risk of assault;
• the need to reflect enforcement and interagency work;
• that the target should perhaps refer instead to 'harmful' drinking.

There were a great many comments around the target to increase vigorous exercise and these mainly focussed on the need to include some target on reducing the incidence of obesity. Fourteen consultees felt there should be some mention of this; 2 included faltering growth and 2 pointed out the growing obesity problem in Primary age children and asked that the target age range include younger age groups. One NHS Board wanted the target to include all young people. The inclusion of dietary targets was another key comment, from 6 consultees and a further 4 mentioned the need to include some focus on nutrition or healthy eating. A Professional Body highlighted the importance of pharmacies in providing sugar-free medicine for children.

Three consultees commented that the term 'vigorous exercise' should perhaps be replaced with 'physical activity'; with a Local Authority commenting that the term is seen as a disincentive, and a Voluntary/ Charity Body agreed that it must be made attractive to young people. Two consultees noted a need for more emphasis on PE in schools, while another highlighted concern over a shortage of PE teachers and one Local Authority suggested additional training for Primary teachers to counter this. Another Local Authority felt there should be closer links with community providers in order to identify children in need of assistance to access exercise facilities. A multi-disciplinary approach was supported by 2 NHS Service Providers to include action on obesity, snacks, exercise and nutrition in schools, dieting and advertising.

General Comments

There were a great many general comments on the targets relating to health improvement with consultees identifying additional areas which might benefit from inclusion in the targets. The key area identified was that of drug or substance misuse with 10 consultees commenting. In addition, targets were recommended in relation to:

• young carers (2 mentions);
• accidents (2 mentions);
• school attendance (1 mention);
• parenting skills (1 mention);
• 16-18 year olds (1 mention);
• removing the stigma of social deprivation (1 mention).

Concerns over how outcomes will be measured were raised by 6 consultees with 2 of these commenting that measurement may be problematic due to the non-specific nature of the targets. One Local Authority commented "the Framework does not provide much detail on how the impact of such targets will be measured or what the intended outcomes of the actions are." Three NHS Service Providers mentioned the possible use of indicators with one commenting on the need for baseline data to aid progress measurement and 2 asking for intermediate indicators.

The following comments were made by 1 consultee each;

• that the proposals need an evidence based approach;
• there could be a monitoring and evaluation framework;
• Health Boards should allocate performance markers for their areas;
• a regional approach to achieving health improvement could be encouraged.

Two consultees expressed the opinion that the targets are too narrow and restricting and should, perhaps, cover wider issues.

A Royal College commented "The outcomes/ targets are by-products of societal issues in addition to an important health component. An integrated response from many agencies may be usefully led by health but 'measurement' and 'target' diminishes the complexity in an unhelpful way."

There were comments, from 4 consultees (including 2 Local Authorities), that targets seem to be based on behaviour and lifestyle changes with little or no recognition of other factors. This was seen to impact on timescales and achievability which were again questioned on this occasion by 7 consultees. This included 3 NHS Service Providers, one of whom felt "The targets need to be appropriate to long term behaviour change, i.e. more realistic timescales." One Public Body saw the need for long term planning.

Other societal issues were identified:

• one Voluntary/ Charity Body remarked on the need to link with regeneration and to consider the social impact on targets;
• a Professional Body felt changes to society were needed;
• a Public Body commented on the need for the framework to be flexible to accommodate additional targets for emerging issues.

Identifying good practice both in this country and abroad, was important to 2 consultees.

Different age groups have different needs and face different pressures and 1 consultee suggested that the targets need to reflect this while another felt that there should be some focus on the importance of peer pressure. Other comments included:

• the targets may need to be focussed on service delivery and include how they will be achieved;
• the need for clear lines of accountability for service delivery;
• concern over implementation and funding;
• whether a summary of targets is sufficient;
• the need to address inequalities and target vulnerable groups;
• improving the health of those from poorer areas;
• empowering children and their families to shape policy.

The need for joint planning and working, and for more recognition of the "crucial" contribution made by multi-disciplinary involvement, was raised by 4 consultees with specific mention made of the need to include the voluntary sector.

8.2 ACTIONS

A series of 14 actions in relation to health improvement were listed in the Action Framework; one Local Authority felt that it would be better to write out the outcomes that each plan is designed to achieve and another commented on the need for Scotland-wide initiatives to be mentioned rather than only those focussed on the Central belt.

Address inequalities in health among the most disadvantaged; five consultees commented on this action with 2 asking how it will be achieved and 2 who felt it was unspecific. One NHS Service Provider asked for descriptions of the actions needed to achieve this while an Education Body requested clarification on how this action would be evaluated and audited.

Specific groups and their associated issues seen as needing specific approaches in relation to this action point included:

• disabled people experience discrimination accessing health services;
• LGBT young people can face discrimination and need support and reassurance over confidentiality;
• traveller children;
• greater awareness of CYP with learning disabilities;
• young carers;
• young asylum seekers;
• target the most disadvantaged to remove inequality, including accessibility, language and cultural background issues.

Two Local Authorities saw an opportunity for local development, including communities and residential units, in order to tailor services to individual need. One commented that many disadvantaged children "do not attend school. The Health Improvement agenda cannot just target schools". The voluntary sector, school nurses and SLTs were identified, by 1 consultee each, as important partners for a joined-up approach to tackling inequality.

One Voluntary/ Charity Body described this action point as "vital" while another commented that the impact of poverty and deprivation should be a priority with evaluation of health inequality targets essential. One other Voluntary/ Charity Body felt that inequalities in outcomes for babies must be a priority and highlighted a need to include reducing infant mortality rates in targets and targeted interventions to reduce the gap in infant mortality between social groups and geographical areas.

A Breath of Fresh Air for Scotland; one consultee described a useful distance learning pack from NES Pharmacy Directorate while another pinpointed community pharmacists as playing an important role in smoking cessation services and suggested the use of the new community pharmacy contracts to support this role.

Infant Feeding Strategy; again details were given of useful distance learning packs available from NES Pharmacy Directorate. Two consultees mentioned the importance of nutrition and pointed out that it does not feature in the targets. One consultee highlighted the role played by SLTs in the development and implementation of this strategy; supporting those with eating, drinking or swallowing difficulties.

Nutritional Standards for Early Years; again two consultees mentioned the importance of nutrition but pointed out that it does not feature in the targets; this comment was given in relation to all of the actions involving diet, food, oral health or nutrition. One consultee saw this action as an area for development in children's disability services while another commented on the need to ensure implementation in all special needs schools; again this comment was given in relation to all of the actions involving diet, food or nutrition.

Scottish Diet Action Plan; the use of this was questioned by 2 consultees; one NHS Service Provider described it as 'out of date', while a Professional Body saw the need for a longer term project to change eating habits and improve health. This consultee requested that an action reflect the wider team involved in the care of children in need of alternative feeding methods or other nutritional care. A Voluntary/ Charity Body also commented on the need to include children fed non-orally or on a semi or fully liquidised diet.

Eating for Health; a Local Authority noted a lack of knowledge among many parents or carers and highlighted the usefulness of community development approaches in providing support or advice. They also commented on the effectiveness of peer-led approaches to changing habits.

Hungry for Success; one Professional Body commented on the fact that children with special needs are more likely to have weight problems. They also highlighted the need to target parental lifestyles in order to influence children. This consultee wanted to see the inclusion of more performance indicators for non-acute conditions, for example in the management of children with obesity.

Two other consultees highlighted a variety of issues for consideration in implementing Hungry for Success:

• the need for a ban on sugary snacks and drinks from schools and on fast food outlets from the vicinity of schools;
• the need for a ban on TV advertising for unhealthy food;
• compulsory labelling of salt, sugar, fat content on packaging;
• ending commercial sponsorship by fast food / soft drinks companies of dining areas in schools;
• strengthening legislation on the sale of cigarettes and alcohol.

Paths to Health and Safe Routes to School; the Scottish Executive Physical Education Review Group's target of 2 hours per week quality PE was proposed as an additional action by a Local Authority, this consultee felt that the Action Framework should include reference to the National Strategy for Sport.

Two Voluntary/ Charity Bodies commented:

• ensure these are carried out in all special needs schools;
• ensure that Local Authorities operate in line with national targets over numbers and types of PE teachers in their schools - the consultee gave details of their own area where they felt that this needs to be addressed.

Improving Oral Health; again, banning sugary snacks and drinks from schools and banning fast food outlets from the vicinity of schools was seen by a Professional Body as important to the success of this action point, while another highlighted the role played by community pharmacists in improving oral health including the use of sugar-free medicines. One NHS Management & Strategy group felt that the prescription of sugar-free medicine should be routine; this consultee highlighted NES pilot projects which could be a useful reference and highlighted the need to work closely with NES Dentistry Directorate on education and training. One Local Authority felt that this action should be a target.

Respect and Responsibility; a Local Authority commented that this action should be a target while a Voluntary/ Charity Body welcomed the action to implement this strategy which, they felt, provided " many much needed actions and policies for improving sexual health in Scotland's young people".

Second Phase of the National Health Demonstration projects; one Local Authority felt that this action should be a target.

Being well, Doing well; there were no comments specific to this action.

Children and Young People's Mental Health; one Royal College commented that SLTs could make a significant contribution "Given the emerging link between CYP mental health and CSN." The need for special emphasis and a co-ordinated approach to address mental health needs and reduce high levels of anxiety, depression, self harm and suicide was highlighted by an Individual (Professional). One Professional Body commented " There is a danger in placing too much emphasis on prevention when it comes to mental health in the young. The younger the child, the less they will know about depression or self-harm etc unless their parents are well informed. Therefore, we would argue that more resources are needed to improve the mental health workforce situation."

European Strategy; there were no comments specific to this action.

General Comments on the action points for health improvement; there were comments, from 4 consultees, that some of the actions do not map to targets, and breastfeeding, school meals, dental health and diet were specifically cited.

Other areas where actions were seen to be needed included:

• drugs and substance misuse (4 mentions);
• alcohol (2 mentions);
• young carers (2 mentions);
• education in road, home, water and leisure safety (1 mention);
• self-awareness (1 mention);
• life circumstances (1 mention);
• child protection and vulnerable children (1 mention);
• bullying (1 mention);
• STDs (1 mention);
• obesity (1 mention);
• breastfeeding (1 mention);
• infant feeding (1 mention);
• smoking prevention as well as cessation (1 mention);
• the need to embed child protection in all actions "to move from it being regarded as punitive to being a positive action of all adults protecting children and helping them protect themselves." (1 mention).

The role of parents and carers featured in 4 responses. One consultee stressed the importance of involving them in the health improvement agenda while 2 highlighted the influence of parents and carers in improving health. One Voluntary/ Charity Body commented on a link between parental relationships and children's health and wanted to see acknowledgement of the role that relationship counselling can play.

Many other groups and influences were identified as important to improving health:

• the valuable role of the voluntary sector, including the need to strengthen partnership working (3 mentions);
• School Nurses; the need to include Scottish Framework for Nursing in Schools and the possibility of joint funding from Education and Health to support their role (2 mentions);
• Community Health Partnerships, including a need for clarification of their role (2 mentions);
• Community Nursing and a need for clarification on how the actions are related to the review of nursing in the community (2 mentions);
• that media and advertising have a role to play (1 mention);
• the crucial role of Public Health Departments, however these were seen to lack leadership, training, infrastructure and resources (1 mention);
• Planning and Transport Departments promoting physical activity outwith schools (1 mention);
• involving children in setting achievable targets (1 mention);
• the need to link or integrate actions, as many interlink at community level and involve the same practitioners (2 mentions).

Two consultees commented on the need to ensure sustainable funding for health improvement; while funding for voluntary organisations in partnership working, funding for preventative health services and funding to target the most vulnerable children were each mentioned by 1 consultee. One NHS Service Provider commented that action points impact on staff and that staffing levels will need to rise.

Two consultees stressed the need to be clear that the actions are evidence-based and that they have long-term benefits. An NHS Service provider wanted to see more consistent implementation of Health for All Children and suggested a benchmarking exercise. A Professional Body commented that evaluation must be done consistently across Scotland and an NHS Managements and Strategy Group stressed the need to address accountability. One consultee suggested implementation of some of the recommendations of the Health Needs Assessment Report and of the best practice statement Promoting access to healthcare for people with a learning disability. Other comments included:

• concerns over the timescales (3 mentions);
• the need to address links between exclusion and fire safety (1 mention);
• the need to reach children who do not attend school and to add opportunities to improve health outwith school (1 mention);
• flexibility to allow for variations caused by some conditions, and the example given was allergy to sweeteners (1 mention).

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