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4. TACKLING HEALTH INEQUALITIES
4.1Better Health, Better Care emphasises the importance of identifying and prioritising practical actions to reduce the most significant and widening health inequalities in Scotland. Equally Well, the report from the Ministerial Taskforce on Health Inequalities, outlines a range of actions to break the link between early life adversity and adult disease, tackle the big "killer" diseases and support individual behaviours that promote good physical and mental health and wellbeing.
Mortality
4.2 There is clear evidence that people living in deprived areas of Scotland are more likely to die from CHD than those in more affluent areas, with the standardised mortality rate in the most deprived tenth of the population being almost five times that in the least deprived tenth. As Figure 7 demonstrates, the relationship between CHD mortality and deprivation occurs at all ages, but is particularly strong in the 0-64 age group.
Figure 7: Coronary Heart Disease Standardised Mortality Ratios males and females by age group and SIMD decile; 2002-2006
4.3 Figure 8 demonstrates increased risk of mortality from stroke amongst the under 65s in the most deprived sections of Scottish society. The same relationship is not seen in those aged 65 or more.
Figure 8: Cerebrovascular Disease Standardised Mortality Ratios males and females by age group and SIMD decile; 2002-2006
Anticipatory Care
4.4Better Health, Better Care sets out an increased focus on the concept of "anticipatory care", the process of shifting from a reactive system of healthcare to one which seeks to anticipate and prevent health problems before they develop. In particular it focuses on:
- identifying people who have established CVD and ensuring a structured approach to risk modification, pharmacological treatment and health behaviour change to prevent further CVD events (secondary prevention); and
- identifying through a formal risk assessment those at high risk of CVD and then ensuring modification of their risk factors through health behaviour change or medical therapy to prevent disease onset (high-risk primary prevention).
Keep Well Programme
4.5 The Keep Well programme provides anticipatory intervention for those at high risk of CHD and diabetes. 45-64 year olds within deprived communities are invited to attend a health check, and those found to be at risk are either referred on to further services/ brief interventions or are prescribed appropriate medications.
4.6 The first wave of Keep Well is operating currently in Community Health Partnerships in the Greater Glasgow and Clyde, Lanarkshire, Tayside and Lothian NHS Board areas. A further wave will begin shortly in areas covered by NHS Grampian, NHS Ayrshire and Arran, NHS Fife and NHS Greater Glasgow and Clyde. The programme is supported by £12.5 million per year from the Scottish Government until 2010-2011.
Well North
4.7 The Well North programme is being implemented in the North of Scotland and aims to widen the reach of anticipatory care in remote and rural areas. The programme covers six projects supported by £750,000 from the Scottish Government. It will provide targeted evidence-based interventions for individuals or households of any age at risk of preventable serious ill-health, taking account of the unique dispersion of deprivation in remote and rural Scotland.
Have a Heart Paisley
4.8Have a Heart Paisley was originally established in 2000 for a three-year period. Phase 2 of the project started in 2004 and focuses on primary and secondary prevention of CHD, together with menu-based cardiac rehabilitation in a community setting. The primary prevention work stream is targeted at a similar (although not identical) age group to Keep Well and offers a risk assessment of CVD for those at high risk, along with health coaching to encourage behaviour change. Key learning from the evaluation of Phase 2 is now available and is being used to inform the development of the anticipatory care model in the Keep Well pilots.
ASSIGN Risk Calculator ( SIGN 97)
4.9ASSIGN, which was developed in Scotland by Professor Hugh Tunstall-Pedoe as part of SIGN Guideline 97, is a new concept in terms of CVD risk calculation. It is based on the Framingham risk score, but includes the two new elements of family history (as a proxy for ethnic background) and a measure of social deprivation (the Scottish Index of Multiple Deprivation). It will enable those at greater than 20% risk of CVD over 10 years to be offered lifestyle interventions and be considered for treatment with statins and aspirin.
4.10ASSIGN features in the Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management published in March 2008 on behalf of the UK National Screening Committee. The approach set out in the handbook recognises the commonality of risk factors for CHD, stroke, Type 2 diabetes, peripheral vascular disease and chronic kidney disease. ASSIGN is being implemented and assessed initially through GP practices involved in the Keep Well pilots and will then be available throughout Primary Care as a web-based tool. In due course, it is anticipated that ASSIGN will be the preferred CVD risk calculator across Scotland.
ISSUES TO CONSIDER
What further actions should we take to tackle the impact of inequalities on CHD and stroke?
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