Chapter 4: Improving the Health of the Population
The fundamental drivers of inequality need to be addressed to effectively tackle health inequalities. The emphasis needs to shift from dealing with the consequences to tackling the underlying causes.
To read Graham’s story see the online report at: www.nhsscotannualreport.scot
Overall, health in Scotland is improving. This can be seen in the underlying trends for Life Expectancy (LE) and Healthy Life Expectancy (HLE) at birth, which both show a general improvement over recent years.
It is recognised, however, that considerable variations in LE and HLE exist among the people of Scotland. In 2011/12, for example, male LE at birth ranged from 81.7 years in the least deprived populations to 71.3 years in the most deprived populations. The figures for male HLE at birth were 69.1 and 48.3 years respectively (a difference of 20.8 years). For females, LE at birth ranged from 84.0 years in the least deprived quintile to 77.2 years in the most deprived quintile (a difference of 6.9 years), while the figures for HLE at birth were 71.9 and 51.5 years respectively (a difference of 20.4 years).
Tackling inequalities in health has been a focus for NHSScotland for many years and is not without its challenges. The complexity of resolving health inequalities is widely acknowledged: as the Health and Sport Committee of the Scottish Parliament recognised in its report published at the beginning of 2015, this is not a problem the NHS can solve alone.
The fundamental drivers of inequality need to be addressed to effectively tackle health inequalities. The emphasis needs to shift from dealing with the consequences to tackling the underlying causes, such as ending poverty, providing fair wages, supporting families and improving physical and social environments. A Scotland that is both prosperous and socially just needs to be built to get to the root of inequalities in health.
Inequalities in health are neither inevitable nor irreversible, and there is nothing inherently unhealthy about people living in Scotland. Harnessing the power of the entire NHSScotland workforce through working together can make a difference.
Public Health Workforce
People in Scotland’s public health community are seen as pioneers not only within the UK, but also across the world. The workforce is diverse, which ensures the public health voice is heard across the broad determinants of health through working with partners and within the NHS.
Scotland continues to see progress and success in improving the population’s health and wellbeing across a broad range of activities, from influencing lifestyle choices, through providing support within the workplace, to working with partners in the wider public and third and private sectors to impact positively on people’s lives.
Tobacco remains the primary preventable cause of ill health and premature death. It is associated with 56,000 hospital admissions and over 13,000 deaths each year in Scotland – around a quarter of all annual deaths. Annual costs to NHSScotland associated with tobacco-related illness are estimated to exceed £300 million and may be higher than £500 million.
Reducing the number of people who take up smoking, supporting those who do smoke to quit and protecting people from second-hand smoke have long been clear public health priorities.
The Scottish Government’s Tobacco Control Strategy – Creating a Tobacco-free Generation was published in 2013. This sets a bold and ambitious target to reduce smoking rates to 5 per cent or lower by 2034.
As outlined in Chapter 2, the results of the 2014 Scottish Household Survey were published in August and reveal encouraging progress towards achieving this goal. It showed that 20 per cent of adults now smoke – only one in five adults in Scotland. This is a drop of three percentage points on the previous three years and the sharpest year-on-year decline in smoking rates since 1999. Encouragingly, smoking rates in the most deprived areas have dropped from 40 per cent in 2010 to 34 per cent in 2014, although this figure remains significantly higher than the 9 per cent found among those in the least deprived areas.
NHSScotland continues to play a key role in tobacco control efforts. NHS Boards exceeded the Scottish Government target of helping people quit tobacco for at least one month between 2011 and 2014. A new target was set for NHSScotland to support at least 12,000 people to quit for at least three months in the most deprived areas between April 2014 and March 2015. This target presented a challenge to NHS Boards, as reflected in recently published figures that show NHSScotland achieved 58 per cent of the target.
It is important to view this in the context of around a 40 per cent drop in people accessing NHS cessation services since their peak in 2012. This is likely to be due to a number of factors, including the rise in the popularity of e-cigarettes as a means of stopping smoking. Supporting people in deprived communities to stop smoking, particularly given the high smoking prevalence in this group, remains a challenge but will continue to be a priority for tobacco control activity in the NHSScotland.
NHSScotland also rolled out a nation-wide smoke-free policy for all its outdoor grounds as of April 2015. This built on the range of policies already in place across NHS Boards to deliver one Scotland-wide approach and was supported by a national campaign that recognised the efforts of people who smoke in trying to comply with the policy. The Scottish Government is taking forward legislation to help support implementation of smoke-free grounds.
It is not just people who smoke who are affected by the health impact of tobacco. Second-hand smoke also affects children who are exposed to it. Recent Scottish research shows that harmful chemicals from tobacco can linger in a room for up to 5 hours. The Scottish Government’s Take it Right Outside campaign, launched in 2014, was developed with the support of NHS Boards to raise awareness of the risks of smoking indoors and supports people to not smoke in the homes of children.
Help continues to be provided for those who want to quit. GPs provide expert advice and will direct people to a range of local services on their doorstep. Pharmacists have become a convenient frontline smoking cessation service for many people, providing smoking cessation products to help people quit with ongoing advice and follow-up support. Further information and advice is also provided through services such as Smokeline (0800 84 84 84) and the Take it Right Outside campaign.
Scotland is also 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.
A whole-population approach is at the heart of Scotland’s Alcohol Framework, which includes a package of over 40 measures to reduce alcohol-related harm by helping to prevent problems arising in the first place. It also addresses improving support and treatment for those who are already experiencing problems.
Alcohol-related harm has an impact not only on individuals, but also on families and communities. Alcohol Brief Interventions (ABIs) play an important preventative role in tackling this as part of a wider strategic approach to addressing problem alcohol use.
The ABI Programme has focused delivery on three priority settings: Primary Care, A&E and antenatal services. In 2014/15, 99,252 ABIs were carried out, exceeding the target of 61,081 by 62 per cent. The target has continued into 2015/16 to support the long-term aim of embedding ABI delivery into routine practice, with broadened delivery opportunities in wider community settings to increase coverage of harder-to-reach groups. If people feel better supported to live well within their community and to self-manage, they are more likely to avoid reaching crisis point, which can mean ending up in hospital.
The Scottish Government is committed to addressing Scotland’s obesity crisis, but there is no simple solution and we have to maintain activity across a broad front that makes it easier for people, including children and their families, to be more active, to eat less, and to eat better.
In 2010, the Scottish Government published Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight which sets out both national and local governments’ respective long-term commitment. The Programme for Government 2015/16 contains a commitment to update the Route Map. It includes an aim to identify and adopt new actions and highlight the developing link with inequalities.
Since 2008, the Scottish Government has directly funded NHS Boards to deliver Child Healthy Weight Interventions. Between 2011 and 2014, there were 16,820 Interventions completed, 12.8 per cent higher than the agreed HEAT target. Three classes of intervention have been run – one-to-one, family group and school-based – supported by annual funding of £2 million which continues into 2015/16.
A further annual £1.76 million funds services for adults including the internationally-recognised Football Fans in Training in conjunction with the Scottish Professional Football League Trust.
Poor diet and excessive consumption of food and drink remains one of the main contributors to poor health in Scotland, with around two-thirds of Scots overweight or obese and one in 25 diagnosed with type 2 diabetes.
Rebalancing our diet is a shared responsibility between individuals, communities, industry and government, but changing established habits is neither easy nor quick. The most recent Scottish Health Survey showed only one in five adults and 14 per cent of children aged 2-15 are currently meeting the five-a-day recommendation for fruit and vegetable consumption. We need to change the way people think about food and make it easier for people to make healthier food choices.
Through our Supporting Healthy Choices Voluntary Framework, we are engaging with the food and drink industry, the public and third sectors to take action to support people to eat more healthily. Key areas of action include: rebalancing promotions; the responsible marketing of food; and reformulation of products to reduce salt, sugar and fat content.
The Scottish Government’s Eat Better Feel Better social marketing campaign promotes healthier eating as a simple, affordable choice for everyone in Scotland. It offers practical hints, tips, offers and recipes to help families eat more healthily at home.
Food Standards Scotland (previously Food Standards Agency Scotland) continues to play a key role in supporting the Scottish population to eat a healthier diet through the provision of healthy eating information and resources for both consumers and businesses.
Fit for Work
Good work is a key driver of health. Sustained unemployment and worklessness frequently leads to poor and declining health. The longer someone is out of work, the harder it is for him or her to return to it. For those still in work, prolonged sickness absence without access to support often leads to job loss and a move onto benefits.
Fit for Work Scotland was launched in 2014. It is being delivered in Scotland as a collaboration between the Scottish Government and the Department for Work and Pensions through NHSScotland.
A free and confidential advice service is currently being rolled out across Scotland, with an assessment service to provide detailed support for returning to work. Access to occupational health expertise will enable people to get back to work sooner and will reduce the risk of job loss, a move onto benefits and poorer health outcomes.
Acting as a Role Model and Making the Healthier Choice the Easier Choice
NHSScotland has a key responsibility for promoting health and wellbeing in the population it serves, but it has recognised in recent years that it should also be seen as an organisation that values and promotes health among its workforce and those that engage with the NHS. This is being realised through the Health Promoting Health Service (HPHS).
HPHS is about promoting healthier behaviours and discouraging detrimental ones in NHSScotland and is aimed at staff and anyone visiting NHS premises. It seeks to achieve this by ensuring that healthier choices are readily available and that appropriate support and encouragement is in place to help people make better choices.
Improvements in the hospital environment have been particularly evident over the last year, with healthier food choices on offer in staff canteens and visitor cafes, an increase in the number of sites with well-designed, usable green spaces for therapy and to encourage physical activity, and a ban on smoking in NHSScotland grounds.
NHS Boards achieved the Healthyliving Award Plus in all 123 NHS-operated sites, with a further 60 in the third and private sector. The Healthyliving Award rewards caterers from across the length and breadth of Scotland for making it easier to eat healthily when eating out. Award criteria are based on the general principles of a healthy balanced diet and have been developed to reflect Scottish dietary targets, so aim to ensure that healthier ingredients and cooking methods are used to keep fat, salt and sugar to a minimum and options such as water, low-fat dairy products and fruit and vegetables are always available. NHS Boards are asked to ensure that all caterers (such as tea bars, restaurants and cafes) who sell food or drinks in healthcare premises work to maintain the Healthyliving Award Plus, ensuring a consistent approach among food service providers across the NHS: 70 per cent of all food provision must meet Healthyliving criteria.
Regular physical activity of at least moderate intensity provides general health benefits across a range of diseases and for all ages. There is strong evidence that the greatest health benefits are accrued when the least active people become moderately active.
Physical activity reduces the risk of coronary heart disease, cardiovascular disease and stroke and is an effective treatment for peripheral vascular disease and high blood pressure. It is also associated with a reduction in the risk of colon and breast cancer. Active people have a 30 to 40 per cent lower risk of developing type 2 diabetes compared to inactive people: for people who have already developed type 2 diabetes, the risk of premature death is much lower for active and fit patients than for those who are inactive and unfit.
Physical activity promotes strength, co-ordination and balance. This is particularly important for older people, as it helps to reduce their risk of falls and helps them to maintain their capacity to carry out common activities. As a result, physical activity can help older people sustain an independent lifestyle for longer.
Employees who are physically active have fewer days of sick leave, lower staff turnover and fewer industrial injuries. In relation to mental health, physical activity reduces the risk of depression and cognitive decline in adults and older adults.
The health risks of inactivity are stark: inactivity contributes to over 2,500 premature deaths in Scotland each year and costs NHSScotland over £94 million. It is estimated that getting Scotland more active would increase life expectancy by more than a year, given current inactivity levels.
In recognition of the substantial benefits to health that being physically active offers, a 10-year Physical Activity Implementation Plan was launched in February 2014, followed by the Active
Scotland Outcomes Framework for physical activity in December 2014. Promotion of physical activity in the NHS forms a core element of the Health Promoting Health Service.
NHS Boards have been tasked with increasing opportunities for staff, patients and visitors to be more physically active by, for instance, encouraging stair use and setting up walking groups, as well as greening the NHS estate (through setting up community gardens or creating new walking paths around the estate, for example). NHS Boards have also been asked to encourage staff and visitors to make more active, green travel choices by providing more information about active travel options available and putting initiatives such as the bike purchase scheme in place. They are also encouraged to improve the infrastructure to support active travel to hospital sites, where possible.
Childsmile is an innovative Scottish Government initiative that provides free daily supervised tooth-brushing for every child attending nursery in Scotland. Specially trained dental nurses assist nursery staff to deliver daily supervised tooth-brushing with fluoride toothpaste.
In a major study funded by Scottish Government and undertaken by the University of Glasgow, the full impact of the programme in terms of the number of dental extractions and fillings saved has become apparent. Importantly, fewer children needed general anaesthetics. The study looked at the period 2001/02 to 2009/10, estimating that nearly £5 million a year was saved through treatment costs avoided in 2009/10.
These savings are ongoing and show the significant financial impact of preventive health programmes. Very simple health interventions can have a major effect in terms of patient care and savings to the NHS.
Email: Andrew Wilkie