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Towards a Healthier Scotland - A White Paper on Health
 

"Reducing the number of premature deaths and illness from coronary heart disease, and the associated problems of stroke, remains a huge challenge for Scotland."

"Mental health is profoundly influenced by life circumstances and by lifestyles."
 
Chapter 5 Action: Health Topics
 
The Health of Children
49. The profound effects of early influences on lifelong health have been emphasised repeatedly in this White Paper and the recent Acheson Report. The future health of children is greatly influenced by their early years. The lifestyle and health of their parents - especially the mother's diet and smoking status prior to conception and during pregnancy - have particular importance. Breastfeeding and good care in their early years significantly improve a child's chances in life. The identification of child health as a priority area in this White Paper has been reflected in the Priorities and Planning Guidance for the NHS for 1999/2002, which urges health boards and NHS Trusts to put children at the heart of their work to improve health and tackle health inequalities.
50. Broad measures to support better child health have already been described in Chapter 3 and include Family Centres, the Childcare Strategy, opportunities for pre-school education, Children's Services Plans and New Community Schools. The health potential of these initiatives can be enhanced by offering families a co-ordinated programme of action in the following areas:
  • parental health, with emphasis on lifestyle, nutrition and avoiding substance misuse in the period prior to, during and after pregnancy
  • children's nutrition, with a focus on breastfeeding, healthy diet and dental health
  • reducing accidents, the principal cause of death and injury to children
  • comprehensive screening, surveillance and immunisation programmes for maternal and child health, in line with national guidance and targets
  • work across agencies to help children at risk through behavioural disorders and educational failure.
51. To pull together these strands, a Scottish resource pack will be issued by the Government to help the planning and implementation of co-ordinated programmes of this kind.
52. But there is a need also to explore and develop ways in which existing and emerging approaches can best be organised and delivered to ensure that our children are given the best possible start in life. The Government will, therefore, establish a demonstration project which will develop and disseminate best practice in this field.
 
Action
  • The Government will make available a Scottish resource pack which will assist agencies to plan and implement co-ordinated programmes to support children and their families in fulfilling their potential.
  • A demonstration project - "Starting Well" - will develop and disseminate best practice in supporting children's health from pre-conception through to school entry.
 
Dental and Oral Health
53. Sugar in foods and drinks is the leading cause of Scotland's poor dental health. Earlier improvements in children's dental health _ seen during the 1980s - seem to have come to a halt. Levels of decay are strongly related to deprivation: the poorest 10% of children have over 50% of the decay in surveys of the dental health of Scottish 5, 12 and 14 year olds. Adult dental health also remains poor, although advances in restorative care and a change in public attitudes to dental care over the past 30 years have more than halved the number of adults with no remaining teeth.
54. The Government believe that fluoridation of the water supply, where possible, offers the most effective means of improving the dental health of Scotland's children, particularly those living in disadvantaged circumstances. A recent study has shown that in the only naturally fluoridated area in Scotland (Moray), 87% of 5 year old children were free of caries, compared with 36% in a socially matched group elsewhere. We recognise that there are strongly held views on both sides of the argument, and that decisions about the introduction of schemes must continue to be taken at the local level in ways that reflect the weight of local opinion. To help this process, the Government consider that consultation should be more comprehensive and visible.
55. Health boards are already required to publish their proposals in local newspapers and to consult local authorities. There is scope for them to do more. New guidance will further require boards to undertake, or commission, a range of measures to gauge public opinion regarding proposals for water fluoridation and to engage the community in the consultative process. Measures could include public opinion polls, commissioned through independent agencies. The results from such consultation should form part of the board's submission to the water authority.
56. There will be progress along other routes. For example, pilot projects, involving local authorities and other organisations concerned with the care of children, are in operation to help develop policies which promote children's consumption of low sugar food and drink products and regular toothbrushing. And the NHS will step up information to the public and to professional staff working in the health, education and care services, about achieving, and maintaining, good oral and dental health.
 
Recognising the particular focus on children, the Government's headline target is that 60% of 5 year olds should have no experience of dental disease by 2010.
 
Action
  • Health boards should commission measures, including public opinion polls, to ensure full dissemination of their proposals and gauge the support for water fluoridation.
  • Water authorities will be advised that, where local views firmly favour fluoridation, they should focus, thereafter, on issues of technical feasibility, not on the arguments for or against fluoridation.
  • The Government will fund pilot schemes to provide fluoridated milk in rural areas where fluoridation of the public water supply is not feasible.
  • The Government will commission, and fund, the development of a prevention from birth programme, involving registration with a dentist, dental education for all new parents, toothbrushing with a fluoride toothpaste for infants and advice on how to reduce sugar in the diet of infants.
  • The demonstration project - "Starting Well" - described in paragraph 52, will include dental and oral health and hygiene within its remit and will link closely with the initiatives described above.
 
Sexual Health
57. Health services have found it hard to tackle the issue of sexual health which sets deeply private relationships within a legal and ethical framework. Physical and emotional needs, self-respect and respect for others are involved as well as the risk of infection and disease. Developing a set of sexual values within this framework is particularly important for young people.
58. Scotland's high rate of unwanted teenage pregnancies remains a matter of immense concern. A high proportion of these pregnancies occur in the most deprived areas. Many teenage mothers keep their babies; already socially and educationally disadvantaged, they may find themselves excluded from further education and employment opportunities and locked into a cycle of events with limited prospects of escape.
59. Teenage pregnancy rates continue to be much higher than in most other Western European countries.
 
The Government's headline target is to reduce the pregnancy rate among 13-15 year olds by 20% between 1995 and 2010.
 
60. Good sexual health is a positive dimension of a healthy lifestyle and is also important for the wider community. Sexually transmitted diseases, such as HIV infection, chlamydia, gonorrhoea and hepatitis, are damaging but preventable. Public attitudes to sex education need to be addressed and service provision reviewed. Vigilance is still needed in the fight against HIV infection in Scotland and the risk of acquiring the disease in high incidence areas of the world requires repeated emphasis.
61. A demonstration project will bring all these dimensions together.
 
Action
  • A demonstration project - "Healthy Respect", as discussed in Chapter 7 - will develop best practice in the promotion of sexual health and the prevention of unwanted teenage pregnancies. It will build on the principles of the Scottish Needs Assessment Programme's overview of Teenage Pregnancy in Scotland.
  • Funding will be provided to enable the voluntary sector's expertise to be made available to many more schools in Scotland and so promote a more informed and responsible approach to sexual matters on the part of young people.
 
Coronary Heart Disease
62. Reducing the rate of premature deaths and illness from coronary heart disease (and the associated problem of stroke) remains a huge challenge for Scotland. Common contributory causes are smoking, poor diet and lack of physical activity. Changes in life circumstances and lifestyles can help to avoid these illnesses, while advances in screening for risk factors, better diagnosis and improved disease management will help to prevent early death. Despite marked and welcome progress, morbidity and mortality are still far too high, and much remains to be done.
63. The White Paper, Tobacco Kills, sets out a range of measures to reduce smoking, measures which, if successful, will have profound effects on the incidence and severity of disorders such as coronary heart disease. Much more is needed to drive home the message that we can all reduce our risk of coronary heart disease by paying attention to our diet and taking more exercise. In addition, Scotland could profit from experience in other countries where monitoring of blood pressure and targeted serum cholesterol level measurement have been used to identify those at risk and trigger lifestyle changes and pharmacological intervention, where appropriate.
 
The Government's headline target is to reduce the age standardised mortality rate from coronary heart disease in people under age 75 by 50% between 1995 and 2010, ie from 143 to 72 deaths per 100,000 population.
 
Action
  • Heart disease will be a leading priority for the NHS in Scotland.
  • A demonstration project - "The Heart of Scotland", profiled in Chapter 7 - will develop an inter-sectoral community-based approach to the prevention of heart disease, recognising that many of the measures will also help to avoid cancer and stroke.
  • HEBS will step up its national media campaign to address the factors which contribute to coronary heart disease as one of Scotland's main killing diseases. Health promotion teams will stimulate, support and deliver local action.
  • Accelerated action on smoking and diet will help drive down rates of heart disease.
 
Cancer Prevention and Screening
64. Cancer has recently overtaken coronary heart disease as the commonest cause of death in Scotland. Approximately 30,000 new cases of cancer are recorded each year; and at present one in three Scots will develop the disease and one in four will die from it. Lung cancer is now the commonest cause of cancer death in both sexes, followed by breast cancer in women and colorectal cancer in men. Skin cancer is also on the increase.
65. The measures described in the White Paper, Tobacco Kills, will be fully implemented in Scotland as part of a major assault on cancer prevention with particular reference to lung cancer. As described elsewhere in this White Paper, every effort will be made to improve Scotland's diet and so diminish another major cancer risk factor.
66. Scotland already has successful national screening programmes aimed at the early detection of breast and cervical cancer. As part of their attack on cancer, the Government will now establish a demonstration screening project for the early detection of colorectal cancer, a disease which some 3000 Scots develop each year. There is compelling evidence (from randomised controlled trials) that the detection of minute traces of blood in the stool, followed by internal examination (colonoscopy) to detect the cause of bleeding, allow the earlier diagnosis of large bowel cancer and that this improves survival prospects for those with the disease. What is needed is the demonstration that such screening programmes offer a feasible, safe and effective proposition when used outwith the confines of a controlled trial to safeguard the health of populations.
 
The Government's headline target is to reduce the age standardised mortality rate from all cancers in people under age 75 by 20% between 1995 and 2010, ie from 188 to 150 deaths per 100,000 population.
 
Action
  • Cancer will be a leading priority for the NHS in Scotland.
  • A demonstration screening project - "The Cancer Challenge" - will be established in Scotland to test the feasibility of a national programme to detect colorectal cancer.
  • Linking with its work on coronary heart disease and stroke, HEBS will increase its national media activity to promote awareness of the factors which help to make cancer one of Scotland's main killing diseases.
  • Accelerated action on smoking and diet will help drive down cancer rates.
 
Mental Health
67. Mental health is profoundly influenced by life circumstances and by lifestyle, so many of the actions set out in this White Paper will yield mental health benefits. Social disadvantage, emotional strain and family disruption can lead to mental health problems in childhood, adolescence and early adulthood. Children at particularly high risk of mental health problems are those living in poverty, showing behavioural difficulties or living in families undergoing divorce or bereavement. Parental mental health has such significance that intervention to safeguard the mental health of children may need to start for the mother and/or the father during the mother's pregnancy or in the early post-natal period. The demonstration project - profiled in Chapter 7 - aimed at young children will also target post-natal depression in mothers. Steps to tackle domestic violence should address another source of mental ill health.
68. Much can be gained from enhancing protective factors in childhood with reference to the role of primary health care, pre-school day care and schools. Ready access to appropriate services and support is essential, particularly for those living in deprived circumstances. A combination of statutory services and voluntary agencies may be required to provide the necessary level of sustained and focused response.
69. Research which is currently underway and which will enhance our ability to address/prevent mental health problems includes:
  • a major project to examine mental health in the context of recent dramatic social change, and assess the impact of economic restructuring on the everyday lives, well-being and future aspirations of children aged 8-12 years
  • a survey to identify what best promotes health, development and well-being among 5-15 year olds
    •
  • participation in a national (UK) survey of untimely deaths of mentally disordered people and any involvement in serious incidents of harm to others to identify risk factors
    •
  • a study to redefine, and thus reduce, risk factors in the community for acts of deliberate self-harm.
    • 70. Mental health promotion is an important and evolving aspect of overall health promotion. It involves work to improve lifeskills, identify and reduce risks (including work-related stress), and strengthen and support communities.
    71. The Framework for Mental Health Services in Scotland, launched in 1997, has been widely welcomed as a means of enhancing services for those with mental health problems. By the end of December, 1998, health boards and their partner organisations were well on their way to completing their Joint Mental Health Strategies, with strong commitment on all sides. Emphasis will remain on improving working relations between agencies, and on promoting common understanding and co-ordinated responses to the mental health needs of vulnerable individuals and groups.
    72. The Government have set up a review of the services for learning disabled people to develop a strategic framework of social and health care for children and adults with learning difficulties. The review will also take account of the importance of access to a range of other relevant services and opportunities. It will report at the end of 1999.
     
    Action
    • Mental health will be a leading priority for the NHS in Scotland.
    • The demonstration project on child health will be used to promote mental health in both parents and children.
    • HEBS and health boards will work in conjunction with the Health and Safety Executive and others to safeguard and promote mental health.
    • Social inclusion initiatives will help improve well-being and so enhance mental health.
     
    Accidents and Safety
    73. Accidents can occur at home, at work, in sport and recreation, on the roads, and at school. For example, in 1997/98, 74 people were killed by fires in the home and 13 people died in other fires. Very young and older people are particularly vulnerable. A range of central and local agencies, including the Health and Safety Executive, are advancing the cause of accident prevention. Several respondents to the Green Paper stressed the need to improve local inter-agency co-operation in promoting accident prevention. Common data sets are needed to inform the development of prevention initiatives, while local agencies need easier access to up-to-date information about best practice in home safety initiatives.
    74. Safe communities are also important to well-being and mental health. Safer Communities Through Partnerships - A Strategy for Action, as described in paragraph 34, aims to improve community safety in Scotland through partnerships between public, private and voluntary bodies. It encourages local authorities to take the lead in these local partnerships, involving the police and other bodies who can influence community safety. Detailed Guidance Notes will be published to help develop local strategies for community safety, targeting the commonest causes of injuries and death.
     
    ACTION
    • The Information and Statistics Division of the NHS Common Services Agency will work with health boards and other interests to develop national criteria for data collection.
    • Health boards will be encouraged to foster, and participate in, local inter-agency accident prevention work.
    • The Government will commission and fund an initiative to deliver a web-site database of best practice in home safety for use by local authorities and others; and to help establish information networks to inform the development of co-ordinated local strategies.
    • A new target for reducing road accident casualties will be set up for the period to 2010 and published, together with a strategy for its achievement.

     

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