Chapter 3 - Improving the Health of the Population
‘The causes of inequalities in health and wellbeing are multiple and complex…. NHS Scotland and its partners have a key role, supporting individuals to manage their health concerns while accessing support for the wider issues.’
Visit www.nhsscotannualreport.scot for the online version of the Annual Report, including peoples’ stories and key facts and figures.
The causes of inequalities in health and wellbeing are multiple and complex. Social inequalities are a significant contributor – employment, housing, education and income. Stagnant wage growth, precarious work, reforms to welfare benefits cutting incomes and the growth of foodbank use are all impacting on the health of individuals and their families.
NHS Scotland and its partners have a key role in addressing these issues, supporting individuals to manage their health concerns while accessing support for the wider issues.
The Scottish Government continues with decisive action to address alcohol consumption, reduce smoking rates, tackle obesity through active living and healthy diet, and invest in mental health services. It is doing so while seeking to place a greater emphasis on the underlying causes of health inequality – ending poverty, promoting fair work and fair pay, supporting families and improving the places in which we live and work. These latter issues cannot be tackled by the NHS alone, but require collaborative working across organisations and agencies.
New Public Health Landscape
Scotland’s current health challenges are complex and go far beyond the control of the NHS: an ageing population; enduring health inequalities; and changes in the pattern of disease. Tackling Scotland’s health challenges needs a different way of working to create a culture for health in Scotland, supporting everybody to work together more effectively towards a shared vision for the public’s health.
The public health reform programme is working with national and local government, the third sector, private sector and communities to create a ‘culture’ for health in Scotland that supports more-effective collaboration to improve the public’s health. Creating a culture for health in Scotland will need effective leadership nationally and locally. To support this, and in line with a key commitment of the Health and Social Care Delivery Plan, a new public health body for Scotland will be established, bringing national public health information and intelligence, together with health protection and health improvement expertise and knowledge in a single body.
The new body will provide a clear vision and strong voice for the public’s health in Scotland by 2019. It will be accountable to the Scottish Government and COSLA and will support, enable and provide challenges to the whole system of partners in the public, private and third sector to improve and protect people’s health.
Reducing Premature Mortality
As a result of improved treatments and a greater focus on prevention, premature mortality (deaths among those aged under 75 years) has reduced substantially, down 18 per cent since 2007 to a death rate of 425.2 deaths per 100,000 population in 2017 (see Chart 2). Early deaths due to cancer – the leading cause of death – have reduced by 17 per cent over the last decade. Deaths due to heart disease and cerebrovascular disease are down by 39 per cent and 38 per cent respectively, while deaths due to diseases of the respiratory system have reduced by 17 per cent. The overall rate of premature mortality decreased in comparison to 2016, where there had been little change from 2015.
Chart 2 – European Age-standardised Mortality Rates per 100,000 Population for People Aged Under 75 in Scotland
Source: National Records of Scotland: Age-standardised Death Rates Calculated using the European Standard Population
Reducing Smoking and Tackling its Harmful Effects
In 2013, the Scottish Government published the Tobacco Control Strategy – Creating a Tobacco-Free Generation, which set out targets to reduce the prevalence of smoking to 5 per cent or less by 2034. Work continues towards creating a tobacco-free generation where young people do not want to smoke or suffer the negative health and economic impacts created by nicotine addiction.
Smoking rates in Scotland continue to fall. Rates are falling faster in Scotland than anywhere else in the UK. The latest reported figures (for 2017) show that 18 per cent of adults smoke, down from 25 per cent in 2012. The number of people quitting and the number using free NHS stop-smoking services, however, has also declined. In early 2018, the Scottish Government worked with NHS Scotland to re-brand and unify the provision of stop-smoking services throughout Scotland
A review of cessation services by NHS Health Scotland identified specific improvements to raise awareness amongst smokers of the free, local services they can access to help them quit smoking. A key recommendation was that stop-smoking services should have a unified national identity. That national identity is now being established under the banner of Quit Your Way, with all local services identified as Quit Your Way and the Smokeline service now Quit Your Way Scotland. The aim is to provide a single, identifiable and higher-profile service delivering more‑consistent services and
outcomes across Scotland. The national stop‑smoking campaign Getting Through 72 encourages smokers to try the service, or try it again. As part of the identity change, services have been revitalised to focus more on the various ways that smokers choose to quit, including with electronic cigarettes. A national advertising campaign promoted the re‑branding.
We all want to give our children the best possible start in life, and to protect them from harm as they grow up. One way we can all help with this is to fight the influence of tobacco over children and young people. Following a number of successful actions, including banning tobacco advertising, price increases and raising the age of purchasing cigarettes to 18, the proportion of young people in Scotland who smoke has fallen to the lowest level since surveys began.
Most children who smoke get their tobacco from friends, family and other people they know. Often these adults think they are ‘doing them a favour’. In response, the #notafavour campaign, launched at the end of 2017, made it clear that helping anyone under-age to get hold of cigarettes was helping them into addiction, ill-health and financial problems. The campaign was developed by Action on Smoking and Health (ASH) Scotland, with Scottish Government funding and strong support from Trading Standards groups. A new campaign website hosts a range of free campaign materials for use locally by trading standards, retailers, health and community groups and others.
Encouraging and Enabling a Healthy Weight
Excess weight brings with it a risk of disease and a cost to society. Similar to other developed countries, a high proportion of Scotland’s population is overweight or obese. The Scottish Health Survey Results 2017 showed that almost two-thirds of adults (65 per cent) in Scotland are overweight or obese, with 29 per cent classified as obese. The Scottish Government recently published its Diet and Healthy Weight Delivery Plan. Among other measures, it commits to investing £42 million over five years to give people with, or at risk of, type 2 diabetes better access to effective weight management services to help them achieve a healthy weight.
Overweight and obesity, though, cannot be tackled merely by relying on people to change their behaviour, as the factors that contribute to gaining weight have been interwoven into the very fabric of our lifestyles to such an extent that weight gain is almost inevitable in today’s society. It is therefore imperative that the obesity-promoting environment is tackled to make it easier for people to make healthier choices. In October 2017, the Minister for Public Health, Sport and Wellbeing launched a consultation for a new Diet and Healthy Weight Delivery Plan. The proposals set out a range of steps, including the restriction of promotions of food and drink high in fat, salt and sugar, and an investment of £42 million over five years to establish supported weight management interventions as a core part of treatment services for people with, or at risk of, type 2 diabetes.
Implementing the Healthcare Retail Standard
As part of the Health Promoting Health Service, NHS Scotland has implemented the new Healthcare Retail Standard (HRS) in all stores and trolley services operating in its hospitals. This work complements the Healthyliving Award Plus that already requires restaurants and cafés to meet certain standards for healthy food and is the first of its kind in the UK.
The HRS means that at least 50 per cent of food and 70 per cent of drinks have to be healthier and it puts restrictions on what can be promoted in-store, whether by price or position. Retailers like the Royal Voluntary Service and WHSmith have worked hard to change their offer, especially on snacks and soft drinks, in order to meet assessments carried out by the Scottish Grocers Federation. Consumers are responding positively to the changes, with a shift away from confectionery and sugary drinks towards options that are better for people’s health. A formal evaluation is under way and will report late in 2018.
Many consumers are NHS Scotland staff so the move has been made very much with staff in mind, not just in the purchase and consumption of food, but also in consideration of their own health and wellbeing and as role models for patients and visitors to hospitals.
Along with maintaining standards set through the Healthyliving Award in catering settings and the HRS, the Scottish Government will look toward other areas of food provision in 2018 such as vending, hospitality and pop-up shops, to ensure that they follow the same principles.
Active Scotland Delivery Plan
The Scottish Government published A More Active Scotland: Scotland’s Physical Activity Delivery Plan in July 2018. The Delivery Plan sets out the wide range of actions the Scottish Government and its delivery partners are taking to encourage and support people in Scotland to be more active, more often, using wide-ranging approaches including active travel funding, support for both formal sports and informal physical activity, and partnership working across the transport, education, health and planning sectors.
It contains 90 actions, including: development of community sports hubs in the most deprived areas; more opportunities for pupils to participate in sport before, during and after school; support and development for helping people move from school sport to clubs; increased funding for cycle and walking paths; supporting the Cycling Without Age project to expand across Scotland; promoting good practice to ensure children have safe places to play; and addressing barriers to women and girls participating.
The Delivery Plan sets out the aim of cutting physical inactivity in adults and teenagers by 15 per cent by 2030, in line with the global target set by the World Health Organization (WHO) in its Global Action Plan on Physical Activity, More Active People for a Healthier World. Scotland is one of the first countries to publish a national action plan demonstrating how it will contribute to the target and themes set out in the WHO global plan.
Promoting Physical Activity through Football Fans In Training (FFIT)
Losing weight is difficult but keeping it off is even harder. Most people who lose weight are back at their original weight three to five years later. One promising programme in Scotland is Football Fans In Training (FFIT), run by the Scottish Professional Football League (SPFL) Trust. Developed by a Scottish research team led by the University of Glasgow, a randomised controlled trial in 2011/12 found that 12 months after starting FFIT, men who took part in the programme lost 5.56 kg, or 4.96 per cent of their baseline weight. The unpublished, commercially sensitive data indicates a shift in behaviours. A randomised controlled trial of a gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs was shown to be cost-effective.
With funding from the Scottish Government, the SPFL Trust has continued to deliver the programme in 33 football clubs across Scotland: now almost 4,500 men and woman have taken part in FFIT. The research team has now followed up the original participants in the trial to see if they managed to keep their weight off three and a half years after starting the programme.
FFIT is now internationally recognised and the programme has successfully been extended to women. It has been transferred to the English Leagues with clubs such as Southampton, Middlesbrough, Blackburn Rovers, Wycombe Wanderers and Torquay actively involved. Work continues to grow the programme to the German Bundesliga where 12 clubs are now delivering.
This year has seen the introduction of testing for type 2 diabetes for participants taking part in the programme and the introduction of training in the signs and symptoms of Bowel Cancer to the FFIT coaches delivering it. The programme continues to have a retention rate of over 70 per cent in both men and woman who take part. This is just one of a number of programmes delivered by football clubs in Scotland that are promoting physical activity and helping to deliver positive outcomes.
Tackling Child Poverty
Health services have a key role to play in managing the complex links between health and family poverty. It is known that Scotland’s substantial health inequalities are driven by poverty and that the problem is cyclical in many ways. In its simplest form, this means low income making health problems worse or illness making it more difficult to earn enough to get out of poverty.
Over the period 2014–17, it is estimated that 24 per cent of children, or 230,000 children each year, were living in relative poverty after housing costs – with two-thirds of those children living in households where at least one person is working.
In March 2018, the Scottish Government published Every Child, Every Chance: the Tackling Child Poverty Delivery Plan . This outlines action to progress towards achieving the ambitious child poverty targets set in the Child Poverty (Scotland) Act 2017 and includes a commitment from the Scottish Government to invest an additional £500,000 over two years to support income-maximisation services in health settings.
In recognition of the importance of local action, and in order to meet their new reporting duty outlined in the Child Poverty Act, NHS Boards across Scotland will be working with Local Authorities to describe how they contribute to meeting the child poverty targets. Non-statutory guidance, co-produced by a cross-sectoral group including key NHS Board colleagues, was published in June 2018. This outlines that it would be helpful for these reports to be published by the end of June each year to align with Scottish Government reporting windows.
Tackling Alcohol-related Harm
Scotland continues to be seen as a world-leader in addressing alcohol-related harm. It was recognised several years ago that Scotland’s relationship with alcohol had become unbalanced, and bold action has been taken to tackle alcohol misuse. During 2017/18, preparations began to implement the world’s first minimum unit price for alcohol, at a rate of 50 pence per unit, from 1 May 2018.
A whole-population approach is at the heart of Scotland’s alcohol strategy, Changing Scotland’s Relationship with Alcohol: A Framework for Action, which includes a package of over 40 measures to reduce alcohol-related harm by helping to prevent problems arising in the first place. This strategy is currently being refreshed to ensure it continues to meet Scotland’s needs in tackling alcohol-related harm.
Alcohol Brief Interventions (ABIs) play an important preventative role in tackling problem alcohol use as part of a wider strategic approach. The ABI Programme has focused delivery on three priority settings: primary care, Accident and Emergency and antenatal services. There is also increased ABI delivery in wider settings, increasing the coverage of harder-to-reach groups and supporting a focus on communities where deprivation is greatest. In 2017/18, a total of 81,177 ABIs were carried out, exceeding the target of 61,081. The target will be continued into 2018/19 to support the long-term aim of embedding ABI delivery into routine practice.
In the case of the Local Delivery Plan (LDP) Standard, which states that 90 per cent of clients will wait no longer than three weeks from referral to receive appropriate drug or alcohol treatment, national standards continue to be met or exceeded. Of the 43,862 people who started their first drug or alcohol treatment from 1 April 2017 to 31 March 2018, 94 per cent had waited three weeks or less and 57 per cent had waited one week or less. This helps ensure that people with problem drug and alcohol use can continue to quickly access treatment and support to aid their recovery.
Improving Joint Working Between Health and Justice
In September 2017, the Scottish Government established the Health and Justice Collaboration Improvement Board. This enables senior leaders from health and justice organisations to come together to improve joint working and enhance health and social care services for individuals who have contact with the justice system. The Board has held valuable discussions about how they, as senior leaders, can influence change within their organisations by identifying and addressing organisational and systemic barriers to working collaboratively. The Board’s priorities are: policing and mental health distress; supporting the work of the Chief Medical Officer’s Taskforce on Forensic Medical Services for victims of sexual assault and rape; and health and social care in prisons. The Board has also developed advice on how to deliver Action 15 of the Mental Health Strategy 2017‑2027 and improve information-sharing between partners to enable frontline staff to make informed decisions based on users’ needs.
Building on the Success of the Human Papillomavirus Vaccination Programme
Health Protection Scotland (HPS) co-ordinated the national implementation of the HPV vaccination programme in 2008 and through the Scottish Immunisation Programme it continues to co-ordinate the development and routine delivery of the programme. Vaccination data is recorded through the Child Health Programme School system managed by NHS National Services Scotland (NSS), with uptake collated by ISD Scotland (ISD). Uptake of the vaccination remains consistently high, with uptake of the full course for pupils living in both the least and most deprived areas in Scotland exceeding 85 per cent.
In 2017, the vaccination programme was extended to men who have sex with men and, following advice from the Joint Committee on Vaccination and Immunisation (JCVI), plans are in place to extend the programme to adolescent boys.
Email: Andrew Wilkie