The Scottish Government

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2. PREVENTION

Better Health, Better Care set out a range of initiatives to improve and sustain the health of people living in Scotland. These include actions that can be taken by NHSScotland alone and those that can only be delivered by working together with partners in the public, private and third sectors.

There is overwhelming evidence that people's lifestyles and behaviours have a major influence on their subsequent health. Smoking causes over one in five of all deaths in Scotland and is the leading preventable cause of ill-health and premature death. Evidence is also accumulating that obesity and excess alcohol consumption may increase the risk of cancer.

Exposure to environmental carcinogens also increases the risk of many cancers. For example, exposure to radon in buildings causes lung cancers. The incidence of skin cancers in Scotland increased significantly over the second half of the 20th century and this has been linked with the increasing opportunity for holiday travel to sunnier climates, and with the use of artificial tanning devices.

The relative contributions of lifestyle factors and environmental carcinogens to the burden of malignant disease is difficult to assess, particularly since there is often a complex relationship between the two. However, in either case, where a causative link is evident, appropriate interventions can reduce the risks significantly.

A recent prospective study of over 20,000 people indicated that those who adopt four health behaviours - taking exercise, not smoking, eating five portions of fruit and vegetables and moderate alcohol intake - can live, on average, up to 14 years longer than those who adopt none of these behaviours. Although the trends were reflected most strongly in rates of cardiovascular disease, they were also apparent for deaths from cancer and other causes (Khaw et al, 2007).

It is clear therefore that many of the Scottish Government's broad health improvement initiatives have the potential to impact positively on cancer in Scotland. These include the commitments to:

• Publish a new smoking prevention action plan to build on previous action to ban smoking in public places and raise the minimum age for purchasing tobacco to 18
• Tackle alcohol misuse through cross-Government action, supported by an additional £85.3 million over 3 years to reduce alcohol related harm
• Work with NHS Boards to ensure consistent weight management strategies, including whole community approaches to tackling childhood obesity and a new Food and Health Delivery Plan which will set out action to encourage a healthier national diet
• Encourage physical activity by creating environments that support walking and cycling and working to ensure that we make the most of the opportunities provided by the Commonwealth Games in 2014
• An integrated focus on the earliest years of a child's life including action to enhance the availability of free school meals, encourage participation in physical activity and support Scotland's children in learning about health and wellbeing
• Identify and encourage simple health promoting actions that can be taken to improve the health of patients, staff and visitors across NHSScotland
• Introduce a new Environment and Health Strategic Framework that will provide a mechanism to co-ordinate and direct action on the key environmental impacts on human health
• Promote awareness and reduction of the risks of skin cancer from exposure to ultraviolet radiation from the sun and from artificial tanning devices.

Public Health

Better Health, Better Care identified a range of opportunities to develop a more integrated approach to promoting and protecting public health in Scotland. This is being developed in conjunction with a range of partners and provides opportunities to:

• Ensure the successful introduction of the planned HPV (human papilloma virus) immunisation programme to combat cervical cancer, which will be made available to all girls aged 12-13 from autumn 2008 and its accompanying "catch up" campaign for all girls aged up to 18 at the time of introduction
• Review and clarify the role of the Directors of Public Health in Scotland and develop regional managed public health networks
• Develop an integrated approach to key health promoting messages which better links and integrates the information available from both the third and statutory sectors
• Work with patients, carers and the third sector to improve the quality and accessibility of patient and public information.

Tackling Inequalities

Better Health, Better Care emphasises the priority that the Scottish Government attaches to tackling health inequalities. Given this determination, it is vital that the new strategy identifies actions that can be taken to address the fact that the most deprived members of the Scottish population have the greatest risk of being diagnosed with cancer and the lowest chance of survival (Figure 5).

Figure 5: All malignant neoplasms ( ICD-9 140-208 excl. 173) Incidence ¹, mortality ¹ and cause-specific survival ^{2, 3} at 5 years by deprivation quintile
Patients diagnosed 1991-95

Source: ISD publication 'Trends in Cancer Survival in Scotland 1971-1995'

However, deprivation is only one of the areas of inequity that may be present across cancer provision and outcomes. Geographical influences also play a part (Campbell et al, 2000, 2001), as do factors such as age and sex (see Figures 1, 2, 3 and 4 above for gender differences). Epidemiological differences as a result of culture or race are also to be found.

All public services are subject to the requirements of the relevant equalities legislation
and cancer services will be amongst the first to be looked at across NHSScotland to determine the current position. Action will be taken to address any issues identified, including action to ensure that services are accessible by people with mental health problems or communication difficulties.

Issues to Consider

• How can we take full advantage of the opportunities for cancer prevention provided by the Scottish Government's programme to help people sustain and improve their health?
• What more can we do to improve public awareness about the risk factors associated with cancer and encourage lifestyle choices that mitigate against such factors?
• What more can we do to address inequalities in terms of both access and outcomes?
• What further opportunities are there for taking this whole agenda forward through cooperation and collaboration between the NHS and its partners, e.g. the third sector?

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