|
|
|
|
 |
Promoting Better HealthThe innovative
strategy set out in "Towards a Healthier Scotland" |
Improving our poor health record in Scotland remains the biggest challenge facing the NHS. The Public Health White Paper "Towards a Healthier Scotland", was published on 17 February 1999. This sets out an innovative strategy for improving health and for tackling the health inequalities which impose a major burden on the most vulnerable sectors of the community.
There is a consensus across the new Scottish Executive that improving Scotland's health should be a key priority and they have fully endorsed the principles of the White Paper as the foundation for action to achieve better health for the population.
The White Paper adopts the radical new approach of addressing Scotland's poor health on three-levels, tackling simultaneously - reduced life circumstances such as poverty, unemployment and bad housing; poor lifestyles, including smoking, diet and alcohol and drug misuse; and priority health topics, with an emphasis on coronary heart disease and cancer, Scotland's major killer diseases.
The strategy is concerned with the health of the population as a whole, but has a particular focus on the health of children and young people, given that good health when young offers the very real potential of continuing good health in adulthood. Partnership working between agencies, including the NHS, local authorities, the private and voluntary sectors and local communities themselves, is central to the strategy. The full engagement of local government is regarded as crucial, in view of its key role in the provision of many of the services which influence health status.
One of the key initiatives in the White Paper is the establishment of four demonstration projects which will point the way towards integrated working between agencies and encourage dissemination of best practice. The demonstration projects will focus on the health of young children, the sexual health of young people including teenage pregnancies, coronary heart disease and cancer. The cancer project has already been awarded to Tayside, Grampian and Fife Health Boards jointly and Notes of Interest in the remaining 3 projects, which were invited by the Scottish Executive Health Department, are currently being considered.
National and local targets
Eight years ago, Scotland's health priorities and targets were identified. The priorities were to cut death from cancer and heart disease; to tackle the high levels of smoking, of accidents and of alcohol and drug misuse; to reduce HIV infection and AIDS; and to improve dental and oral health.
The targets set to be achieved by the year 2000 across Scotland were:
Additional oral health targets were set in 1995. These were:
by the year 2005
by the year 2008
How far have the previous targets been met?
Progress is being made towards these health targets. Targets for cancer have been met and there has been a substantial reduction in premature deaths from coronary heart disease. Nevertheless, there are still high levels of preventable illness and early death from these conditions. Only very slow progress is being made in the improvement of dental health of 5 year olds. Particular problems exist in more deprived areas - the poorest 10% of children have over 50% of the dental decay.
Smoking
The targets set for the year 2000 are unlikely to be achieved. More than a third of Scots adults aged 16 and over are regular smokers, with prevalence rates higher among women than men. The trend is similar among young people, with more girls being smokers than boys. Latest figures on the smoking behaviour of Scottish secondary school children aged 12 _15, indicate that just under a quarter (23%) of the sampled children claimed to smoke _ 14% regularly, and 9% occasionally. The continuing high levels of smoking among the female population, and among young people, are of particular concern and will be a specific focus for action.
Smoking remains the single most preventable cause of ill health in this country. There are more that 13,000 deaths each year in Scotland from tobacco-related illness, and around 35,000 people are admitted to hospital because of conditions caused by smoking. The Scottish Executive is determined to take vigorous action to reduce these statistics, which will be taken forward in the context of the UK Tobacco Control White Paper "Smoking Kills" published in December 1998. This sets out an overall strategy for action at all levels, from international to the individual. Proposals include actions to reduce smoking among pregnant women and low income groups. This will be addressed through the development of smoking cessation services, and health education activity. A ban on tobacco advertising and promotion will also be introduced. The Public Health White Paper "Towards a Healthier Scotland" confirmed that action to tackle smoking would be taken as a matter of priority. New targets have been set, focusing on children and adults smoking and smoking during pregnancy.
Alcohol Misuse
It is highly unlikely that the alcohol target set for the year 2000 will be attained. The most recent Scottish Health Survey showed that 33% of men and 13% of women were exceeding recommended drinking levels (the upward trend is particularly marked among women, the number of whom drink at high levels has almost doubled since the mid 1980's). Latest statistics on Scottish secondary school children aged 12-15 reveal that 23% of sampled pupils said that they had had an alcoholic drink in the last 7 days (this compares with 14% in 1990).
The Scottish Executive is committed to tackling alcohol misuse as a matter of priority. To achieve a cohesive and coherent approach to the problem a new alcohol strategy will be developed in Scotland. Recommendations on how this should be taken forward were set out in the report published in February 1999, by the Alcohol Conference Action Plan Working Group. This report provided a starting point for the development of a national strategy. One of the key recommendations in the document was subsequently confirmed in the White Paper "Towards a Healthier Scotland". This was the establishment of a national advisory committee on alcohol misuse charged with driving forward the new strategic agenda. The White Paper also announced new targets for Scotland aimed at reducing the frequency and level of drinking among adults and 12-15 year olds. These targets will help to inform the new strategy and ensure that a range of measures will be put in place to combat misuse of alcohol within Scottish society.
Drug Misuse
The NHS continues to play a key role in tackling drug misuse in Scotland in partnership with other agencies and services. In October 1998, an additional £2 million boost to NHS drug treatment services in 1999/2000 was announced as part of a £5 million package of measures to combat drug misuse. The treatment services funds were subsequently allocated to Health Boards for the provision of drug misuse services in line with the action priorities set out in the enhanced drugs strategy "Tackling Drugs in Scotland: Action in Partnership", published in March 1999. The increased spending brings overall funding for drug treatment services to over £11 million per annum.
At local level, the NHS and other bodies continue to work with Drug Action Teams to further develop services. The five-year planning framework in the Health Improvement Programme of each Health Board allows drug misuse services to be clearly prioritised and funded appropriately. Linkage of national drug misuse and Health Board strategic objectives provides opportunities for all of Scotland's objectives to be implemented at a local level.
Action on treatment is one of the four strategic aims of "Tackling Drugs in Scotland: Action in Partnership". Action priorities specifically relating to drug treatment include the provision of shared care arrangements, integrated drug misuse services and targeted services for women, as well as improvements in services for young people, and outreach work.
The refocused Scotland Against Drugs continues its innovative work at community level, and acts as a catalyst for business involvement in tackling local drug misuse problems. Business continues to show an encouraging level of interest in the Scottish Drugs Challenge Fund which encourages a partnership approach in local anti-drug projects.
HIV/AIDS
170 new HIV infections were reported in 1998, which is close to the average for the previous five years. Although this is a low level by international standards, it is of concern that the numbers are not yet on a downward track. An expert group to review HIV health promotion policy has therefore been set up, and the Group's report is expected later in 1999. In March 1998, the report of another expert group was issued to Health Boards to help them in planning services; it recommended a treatment protocol for HIV patients and provided estimates of the number of patients likely to be coming forward for combination drug therapy in each Health Board area in the foreseeable future. These drug therapies are proving effective in delaying the onset of AIDS and in keeping patients well.
Immunisation
Immunisation remains a key component of the continuing efforts to control childhood diseases. The target of 95% of Scottish children vaccinated before the age of 2 is being achieved for diptheria, whooping cough, tetanus, Haemophilus influenza b (Hib) and polio. The uptake rate for MMR (mumps, measles and rubella) vaccine was slightly lower because of the impact of media reports suggesting links between the vaccine and Crohn's disease or autism. The Chief Medical Officer wrote to all doctors in March 1998 in support of the vaccine and the rates achieved later in the year and into 1999 suggested that public confidence was returning.
Oral Health
The oral health target for 5-year-olds will not be achieved by the year 2000 and this target has now been reviewed with a view to achieving the same target by the year 2010.
The target for 45-54 year olds, of only 10% of this age group to be without their own teeth will not be achieved, although the Adult Dental Health Survey 1998 showed that 13% of this age group in Scotland were without teeth, and it is anticipated that within 2-3 years this target will be achieved.
The dental health of 5 year olds has not shown any significant improvement over the last 10 years, however for children aged 12 years, seven Health Boards have already achieved the target set for the year 2005, and all indications are that this target will be achieved for the whole of Scotland.
Scottish Breast Screening Programme
The Scottish Breast Screening Programme was first introduced in Scotland in 1988 and the Programme is now well established. The aim of the Programme is to contribute to reducing breast cancer deaths by early detection of the disease, although it will take some time before it is possible to know whether this has been achieved. Attendance rates of at least 70% are required if the Programme is to meet its target of a 25%
The National Health Service in Scotland Annual Report
reduction in breast cancer deaths by the year 2000 and improving attendance has been a key priority for all Health Boards over the last year. Over the last three years Scotland has achieved at least 71% each year, with a range from 65% in urban areas to over 80% in rural areas. Health Boards have launched a number of initiatives to improve attendance in low-uptake areas, including working with local minority groups and with general practitioners to increase awareness of the value of breast screening. The West of Scotland introduced an innovative media campaign, timed around the mobile screening programme, and the early feedback from this is very positive.
The UK NHS Breast Screening Programme has developed a set of standards to monitor the performance of the Programme and results for Scotland from 1995/96 are shown in table 15 (page 62). The Scottish Programme meets the key UK standards and has a well-structured quality assurance programme which aims to routinely monitor performance and to identify and address issues before they become problems.
Following a serious incident in Devon and Exeter in 1998, the then Scottish Office Minister for Health commissioned a review of the Scottish Programme's management and quality assurance arrangements. This was carried out by the Programme's National Advisory Group, with co-opted experts. The Group found that, in general, the arrangements in place were satisfactory. The review did, however, identify aspects of the Programme that required revision and guidance on all aspects of the Programme was updated during 1998/99.
In particular, it was noted that all Scottish screening centres, with the exception of that in the North of Scotland, have experienced difficulty in complying with the three year screening interval. There are three key reasons for this:
Each centre has developed plans to address extended screening intervals on a long-term basis. However, as these plans involve recruitment and training of additional staff and procurement of extra equipment and mobile units, the Programme will not be back on schedule before April 2000.
Women's views about the service remain a priority and during 1998/99 the number of complaints totalled 30, which is the lowest since 1995/96, despite an increase in the number of women screened. The main complaints are still pain and staff attitude, and considerable time is being invested to reduce complaints in these categories.
Scottish Cervical Screening Programme
Since 1986, cervical cancer has dropped from the seventh most common female cancer to the twelfth most common. Each of the Scottish Health Board achieves the target attendance of 80% of women aged 20-60 screened for cervical cancer over a 3-5 year period, although there is some variation within Boards. The Programme is now well established in Scotland and since 1986, there has been a 34% reduction in the number of cases and deaths from cervical cancer.
The revised laboratory proficiency testing scheme has been introduced across Scotland and Northern Ireland and in general, all laboratories are performing well. A Scotland-wide audit of invasive cervical cancers has also been introduced, and the results of this will be published in 1999.
During 1998 there were serious screening incidents in both the breast and cervical screening Programmes in England, and UK Departments of Health commissioned reviews of both Programmes. The review of the Cervical Screening Programme in Scotland was carried out by an expert multidisciplinary group especially established with co-opted experts. As in the case of breast screening, the review found that arrangements were, in general, satisfactory, but certain areas required revision. The following areas were updated and developed during 1998:
The review also recommended that women should receive confirmation of their smear result in writing, and this will be introduced in Scotland later this year. Information leaflets and model letters to support this have recently been developed and successfully evaluated.
What are the new public health targets?
The White Paper "Towards a Healthier Scotland" sets new targets which will provide impetus for improving health by the year 2010. The headline targets are:
Secondary targets have been set for diet, smoking among adults, alcohol misuse among young people, physical activity, strokes and adult dental health. Health Boards are responsible for making sure that these targets are achieved, taking account of local circumstances.
Research lies at the heart of a modern NHS. The White Paper has sharpened the focus of public health research, which is supported through a mixture of grant and core funding. Investment in public health research in recent years has been substantial, with around thirty projects supported at any one time.
|
|
|