NHSScotland Chief Executive's Annual Report 2013/14

Chapter 4 Improving the Health of the Population

Scoring goals and transforming lives.

"The motivation comes from being part of a team and wearing the club badge. Getting to train at Easter Road has been absolutely great....I can't think of an aspect of my life which hasn't changed."
Glenn, Hibs fan and FFIT success story

Glen's Story

Die-hard Hibs fan Glenn, weighed 25 stone in 2002 when he was diagnosed with dangerously high blood pressure and put on medication. He began to diet and quickly lost six stone, but then found it difficult to make further progress. The turning point came when Glenn signed up for Football Fans in Training (FFIT) at his beloved Easter Road stadium.

Initially apprehensive about joining a course where he didn't know anyone, Glenn soon found he was making friends - and progress. "The coaches really helped us to get to grips with what we were trying to do", he says. "And if anyone was feeling down, the group as a whole tried to encourage that person."

Glenn made great progress, and kept up the momentum after completing the programme. Now he's maintaining a healthy weight on the BMI scale, he's been able to come off the hypertension medications, and his replica Hibs top is an 'M' rather than the 'XXXL' he was wearing three years ago. Even wife Linda has become fitter, initially losing a couple of stone by adopting Glen's healthier eating habits, and then joining him on vigorous walks.

FFIT began in 2010 as a unique collaboration between the SPFL Trust and 16 of Scotland's professional football clubs, with academic input from five leading universities. FFIT incorporates some of the latest scientific approaches to exercise and diet, delivered typically through an initial 12-week programme at professional club grounds all over the country.

While most weight management programmes are attended largely by women, FFIT's success has been in reaching men who might otherwise find it difficult to maintain interest and commitment. So far, more than 2,000 men have attended FFIT, with continued growth expected.

The Scottish Government has been a major backer from the beginning, providing funds to set up and maintain the scheme, as well as a budget for the FFIT Tournament in June 2014. NHSScotland is working to increase the number of GPs referring patients to the scheme, and a number of local NHS Boards across the country are supporting the programme.

The FFIT programme has attracted a number of prestigious awards and award nominations. In 2012, FFIT received the Community Wide Programme Award from the Physical Activity and Health Alliance. It also received a European Professional Football League (EPFL) 2011 Best Practice Award for Social Responsibility, and in 2011, received the Herald Society's Health Provider of the Year Award.

NHSScotland has a vital role in improving and maintaining the good health of the people of Scotland, and in reducing health inequalities. This is central to the aim for NHSScotland to become a world-leader in terms of healthcare quality, and to the wider Scottish Government objectives to support people to live longer, healthier lives, and to reduce inequality through early intervention and anticipatory care.

While Scotland's health is improving, with year on year improvements, it is improving more slowly than comparable European countries. From the middle of the last century, Scotland's health has dropped below that of its neighbours and the rate of improvement of health in the poorer areas of Scotland is significantly slower that in more affluent areas.

The origins of health inequalities are complex and they are to be found in the many interactions between social, economic, educational and environmental determinants. During its most recent review of progress in delivering Equally Well^[77], the Ministerial Task Force on Health Inequalities recognised the continued need for concerted action across this range of determinants. The specific focus of the Task Force on this occasion was to consider how better health might be supported within Scotland's communities through considering the role of Community Planning Partnerships, the recommendations of the Christie Commission on the Future Delivery of Public Services^[78],and how aspects of 'place' impact on health.

The Task Force heard evidence that while the health of Scotland was improving, it was doing so more slowly than other European countries. It heard that conventional approaches to the problem that involve attempts to modify the health-related behaviours of poorer people have failed. It heard that the level of deaths in the 15-44 age group was contributing significantly to the relatively poor position of Scotland's health in a European context. It also heard that despite many similarities, Glasgow and the West of Scotland were experiencing many more deaths than comparable cities and regions in the UK. Evidence was presented that showed that people's immediate environment plays an important role in their health and wellbeing.

The Task Force re-iterated its view that it was not solely the responsibility of the NHS in Scotland to resolve the problems arising from health inequalities. All parts of local and national government, and the wider public and voluntary sectors, have a significant part to play in achieving the reduction in inequalities.

The Task Force identified the need to make further progress in adopting approaches which are asset-based, co-produced and person-centred, to bring about effective and sustained change. There is strong evidence of the effectiveness of this distinctive Scottish approach to government and delivery of public services. Partnership working between the public sector, third sector, business and local communities is essential. Community planning has a critical role to play in making public service reform happen at local level. It provides the foundation for partnership working between NHSScotland and its partners in local authorities and other public bodies alongside their local communities. Greater levels of integration are increasing the focus on prevention and securing continuous improvement in service delivery.

For most Community Planning Partnerships, one development priority has been to give effect to the Agreement on Joint Working on Community Planning and Resourcing^[79], which was published alongside the Scottish Government Draft Budget for 2014/15, so that partners work together to deploy resources towards joint priorities as set out in their Single Outcome Agreement. The forthcoming Community Empowerment Bill will create new opportunities for people and communities to co-produce services around their needs - supporting them to build and use their own assets, including their skills and networks.

Preventable, lifestyle-related illnesses including many cancers, heart disease, type 2 diabetes, arthritis and dementia are not an inevitable feature of life. They are the unintended, long-term consequences of sometimes poor lifestyle choices, compounded by the fact that many people lack the support needed to make important and truly beneficial changes to their health.

The impact on health of physical activity, smoking cessation and sensible alcohol consumption in preventing the onset of disease is unequivocal. It is well understood that simply warning people about the detriments of physical inactivity and smoking, for example, does not necessarily translate into them making healthier choices. However, health improvement advice that is followed through by further one-to-one or group support, tailored to the individual's needs and circumstances, is more likely to have a significant and lasting effect. Glen's story of his involvement with Football Fans in Training and resulting health benefits is just one example of the work underway within our communities and NHSScotland that reach out to tackle real people in their everyday lives and sometimes by harnessing what interests them.

GPs in the most deprived communities too often have to deal with patients (one in five consultations) whose primary concern may be a non-medical issue but one which is impacting adversely on their lives.

The Link Worker Programme, delivered in partnership with the Health and Social Care Alliance and the Deep End General Practitioners, aims to explore how the Primary Care team can support people to live well in their community.

While GPs and health professionals manage the patients' medical issues, the Link Worker assists by helping deal with other issues that are causing them concern including debt, social isolation and stress, poor housing and fuel poverty issues. This can ensure that people receive the right support and minimise the demand on GP services and other NHS services. The current Link Worker programme is made up of two inter-related interventions: the provision of a practice-attached Link Workers (seven in Glasgow and two in Dundee) and the development by the practice team of a link approach.

ALCOHOL BRIEF INTERVENTIONS

Alcohol-related harm has an impact not only on the individual but on families and communities. Alcohol Brief Interventions (ABIs) play an important preventative role in tackling this, as one component of a wider strategic approach to tackling alcohol misuse.

The ABI programme has focused delivery on three priority settings: Primary Care, Accident & Emergency and antenatal services. In 2013/14, 104,356 ABIs were carried out, exceeding the target of 61,081 by 71 per cent^[80]. In order to support the long term aim of embedding ABI delivery into routine practice, the target will continue into 2014/15 for a final year.

Consideration is also being given to how a better service can be provided in Primary Care settings that contributes to building social capital. 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.

SMOKING

Tobacco remains the primary preventable cause of ill health and premature death. Each year in Scotland, it is associated with over 13,000 deaths (around a quarter of all deaths in Scotland every year) and 56,000 hospital admissions^[81]. Annual costs to NHSScotland associated with tobaccorelated illness are estimated to exceed £300 million and may be higher than £500 million^[82].

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.

On 27 March 2013, the Scottish Government's latest Tobacco Control Strategy, Creating a Tobacco-free Generation^[83], was published. This reaffirmed the vision for a tobacco-free Scotland and set a world-leading target to achieve this by 2034. This will mean that a child born in 2013 will become an adult in a Scotland that is largely devoid of tobacco-use with all the health, social and economic benefits that entails. This is a challenging target and achieving it will require a determined effort to support people to choose not to smoke. The strategy sets out a package of measures to progress along this journey over the next five years.

Part of this journey will be to help people who smoke to quit the habit. Between 2011 and 2014, NHS Boards exceeded the Scottish Government target to help people quit tobacco for at least one month with 124,734 quits compared to a target of 80,000. Even more encouraging are the numbers in our most deprived communities. In these areas a target was set for 48,000 people to quit for at least a month. The actual figure achieved was 70,162^[84]. To build on the success of our one month target, NHS Boards are now working towards a new target of supporting people in our poorest areas to quit smoking for at least three months. This is a challenge but it is known that tobacco use is much more common in poorer communities. The latest statistics show that smoking rates in the 20 per cent least deprived areas are now around 11 per cent compared to around 39 per cent in our most deprived areas^[85].

It's not just the 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 five hours. The harmful toxins will pass still from room to room, and be breathed in by others. The recently-launched campaign, Take it Right Outside, takes a message to smokers - particularly parents - that, if they must smoke, they should go outside and close the door.

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, for many, become a convenient front-line smoking cessation service which can provide 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) or at www.canstopsmoking.com or www.rightoutside.org.

PHYSICAL ACTIVITY

Physical inactivity results in around 2,500 premature deaths in Scotland each year and the costs to NHSScotland have been calculated at around £94.1 million annually^[86]. It is generally agreed that, with regular physical activity, mortality can be reduced by 30 per cent, and a risk reduction for many chronic diseases of around 20-40 per cent can be seen^[87]. In addition, regular physical activity can help prevent obesity and many associated health complications, while improving physical and mental health outcomes.

In 2014, Scotland was presented with an opportunity to inspire people to be more physically active through hosting the XX Commonwealth Games and The Ryder Cup. A 10-year Physical Activity Implementation Plan A More Active Scotland - Building a Legacy from the Commonwealth Games^[88] was launched in February 2014 to help achieve lasting change and by the time of the Opening Ceremony, over 50 national Legacy 2014 Programmes and over 80 Supporting Legacy 2014 Projects were already in place encouraging people to be active and connected in their communities.

NHSScotland, along with many workforces across Scotland, has taken part in the Fit in 14 physical activity campaign which encourages staff to take small, simple steps towards a more active lifestyle. In addition, work is continuing to make the promotion of physical activity a routine part of clinical care.

HEALTH PROMOTING HEALTH SERVICE

An NHSScotland which places health improvement at its core is a strongly held ambition and is beginning to be realised through Health Promoting Health Service^[89] in hospital settings. In addition to working in local communities to improve health, NHSScotland is also being challenged to ensure it is doing everything it can to promote health within NHS settings.

Antenatal Alcohol Brief Intervention Service in NHS Ayrshire and Arran

The Antenatal Alcohol Brief Intervention (ABI) Service aims to improve the health of future generations by providing the best possible start for babies in Ayrshire, as well as improving the health of their mothers. The service was designed to effectively screen all pregnant women for alcohol use, deliver an ABI as appropriate, raise awareness of the potential harmful effects of using alcohol during pregnancy and to signpost to other services when necessary. So far, all community midwives have been ABI trained and the focus is now on offering ABI training sessions for hospital-based staff.

Yvonne, one pregnant mother, acknowledged heavily binge drinking in early pregnancy and, following an ABI by the Midwife, a home visit was arranged. She planned to abstain for the remainder of her pregnancy due to the potential harmful effects, but could not guarantee that she could do it alone. Referral was made to a local Alcohol Counselling Service where she attended for one-to-one sessions. She remained alcohol free and support remained in place for her in the immediate postnatal period. This was a very positive outcome that Yvonne feels was due to the midwife raising the issue of alcohol at the booking appointment.

Historically, health promotion activity has tended to fall within the Public Health sphere and has been focused on activity outside of hospitals. Secondary care settings, however, offer the chance to engage with patients when they may be highly motivated to make changes that will positively impact on their health and wellbeing. Many hospital patients have multiple long term conditions and there are significant opportunities to support them to make healthier choices. NHSScotland has a substantial workforce and, with many patient interactions, hospital settings can be exemplars in promoting healthy lifestyle choices.

Promotion of healthier choices amongst patients, staff and visitors has been increasingly evident in the last year. There has been a rise in the number of patients referred to smoking cessation support from secondary settings and a substantial increase in the conversations between patients and health professionals on the benefits of physical activity. Improvements in the hospital environment are also clear, with healthier food choices on offer to staff, patients and visitors, and action is being taken to eradicate smoking on NHSScotland premises by March 2015.