NHSScotland chief executive's annual report 2016/17

Chapter 3 - Improving the Health of the Population

' NHSScotland and its partners are committed to reducing the deeply ingrained health inequalities that continue to persist in Scotland'

Visit www.nhsscotannualreport.com for the online version of the Annual Report, including peoples' stories and key facts and figures.

NHSScotland and its partners are committed to reducing the deeply ingrained health inequalities that continue to persist in Scotland. At its root this is an issue of income inequality – the rising cost of living combined with stagnant incomes makes life more difficult for many, which can have both direct and indirect effects on health and wellbeing.

The Scottish Government continues with decisive action to address alcohol consumption, reduce smoking rates, encourage active living and healthy eating, and to invest in improving mental health services. It is doing so whilst seeking a shift in emphasis from dealing with the consequences to tackling the underlying causes, such as ending poverty, promoting fair wages, supporting families and improving our physical and social environments.The actions we need to take are a key part of the Health and Social Care Delivery Plan. They are issues which are not for the NHS to address alone, but require collaborative working across agencies and organisations.

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 16 per cent since 2006 to a death rate of 439.7 deaths per 100,000 population in 2016 (see Chart 1). Early deaths due to cancer – the leading cause of death – have reduced by 15 per cent over the last decade. Deaths due to heart disease and cerebrovascular disease are down by 39 per cent and 33 per cent respectively, while deaths due to diseases of the respiratory system have reduced by 12 per cent ^[152] . The overall rate of premature mortality remained relatively stable in comparison to 2015, where there had been an increase from 2014 of 4 per cent – likely due to the impact of the specific flu strain prevalent over the winter period, as similar patterns were seen in other European countries.

Chart 1 - 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

Promoting Healthier Behaviours

NHSScotland has a key responsibility for promoting health and wellbeing in the population it serves; it recognises that it should also be an organisation that values and promotes health among its workforce and those that engage with the service. This is implemented through the Health Promoting Health Service programme.

The Health Promoting Health Service is about promoting health and addressing health inequalities in NHSScotland settings, and has actions to support staff, visitors and patients. Examples are the development of pathways for smoking cessation and weight management services and linking them to clinical care. To help people to make healthier choices, healthy options are available along with appropriate support and encouragement. Taking an holistic, person-centred approach, Health Promoting Health Service goes further than just treatment, recognising broader issues that impact on people's health and recovery, such as money worries and housing issues, so that those at risk of poverty and inequality achieve the best possible health outcomes. The focus in 2016/17 has been the particular actions the NHS can undertake to address inequalities.

Improvements in the hospital environment have been particularly evident over the reporting year, with healthier food choices not just being offered in staff canteens and visitor cafés, but also within the retail areas, and the continued ban and forthcoming legislation on smoking on NHSScotland grounds.

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. A whole-population approach is at the heart of Scotland's alcohol strategy, Changing Scotland's Relationship with Alcohol: A Framework for Action ^[153] , 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 coverage of harder-to-reach groups and supporting a focus on communities where deprivation is greatest. In 2016/17, 86,560 ABIs were carried out, exceeding the target of 61,081 by 42 per cent ^[154] . The target will be continued into 2017/18 to support the long-term aim of embedding ABI delivery into routine practice.

In the case of the 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. In 2016/17, 45,524 people who started their first drug or alcohol treatment waited three weeks or less, which helps ensure that people with problem drug and alcohol use can continue to quickly access treatment and support to aid their recovery ^[155] .

In 2016/17, responsibility for drugs policy in the Scottish Government moved from Justice to Health, opening up the possibility of problem substance use being tackled as part of wider health inequality strategies.

Reducing Smoking and Tackling its Harmful Effects

Considerable progress has been made in reducing the devastating impact of tobacco on society. Once a social norm, smoking rates are decreasing. Only 21 per cent of adults now smoke ^[156] and the number of young people lighting up regularly has dropped by more than two-thirds in the last decade.

Yet, tobacco remains the biggest cause of preventable ill-health and premature death in Scotland. Over 10,000 people die (one fifth of all deaths) and 128,000 are admitted to hospital each year from smoking-attributable illness ^[157] . The impact of tobacco also costs NHSScotland more than £300 million per year ^[158] . Lowering this death toll and narrowing the social inequalities which see smoking rates of up to 35 per cent in some deprived communities are core Scottish Government aims.

In 2013, the Scottish Government published the Tobacco Control Strategy – Creating a Tobacco-Free Generation ^[159] , which set out targets to reduce the prevalence of smoking to five per cent or less by 2034. We continue to work towards creating a tobacco-free generation where young people do not want to smoke or suffer the negative health and economic impacts nicotine addiction creates.

The need to minimise the risks to public health led to the introduction of the historic ban on smoking in enclosed public spaces in 2006. While this has transformed work and leisure spaces in Scotland, more action was needed to protect young people in particular from second-hand smoke and to de-normalise smoking itself.

The Take it Right Outside campaign of 2014 further raised awareness of the dangers of second-hand smoke in enclosed spaces such as homes and cars. The world-first target to substantially reduce children's exposure to second-hand smoke to six per cent by 2020 was met in 2015. There was a slight increase to seven per cent in 2016, although this change was not statistically significant ^[160] .Safeguarding the right of children to grow up in smoke-free environments was bolstered by the Smoking Prohibition (Children in Motor Vehicles) (Scotland) Act 2016, which makes it an offence to smoke in a private vehicle when someone under 18 years is present.

While hospitals are exemplars in providing smoke-free environments for staff, patients and visitors, some challenges remain in encouraging people to comply with the policy. The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 includes measures to introduce new laws which will make it an offence to smoke within a designated perimeter around hospital buildings. This aims to support NHS Boards' smoke-free grounds policies by extending the existing indoor ban a set distance from the structure of a hospital building making it an offence, liable to penalties or fines on conviction, to smoke or knowingly allow others to smoke tobacco products within this perimeter area. The regulations are currently in planning.

The reduction in smoking prevalence among adults is testimony to the key role NHSScotland plays in tobacco control efforts. The 2016/17 performance target for smoking cessation was significantly higher than the 2015/16 target, at 9,404 successful 12-week quits in the 40 per cent most deprived communities (60 per cent for island NHS Boards) between April 2016 and March 2017. Amidst falling numbers of smokers making quit attempts, NHSScotland did not achieve the 2016/17 target. 7,842 successful quit attempts were achieved in the 40 per cent most deprived most communities ^[161] .

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, Scotland has a high proportion of its population overweight or obese. The Scottish Health Survey Results 2016 ^[162] showed almost two-thirds of adults (65 per cent) in Scotland are overweight or obese, with 29 per cent classified as obese. Work continues to support a series of healthy weight interventions, including supporting adult and child healthy weight interventions in NHS Boards.

Overweight and obesity, though, cannot be tackled by just 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. The prospect of the Soft Drinks Industry Levy ^[163] has encouraged manufacturers to lower the calorie content of many soft drinks.

Implementing the Healthcare Retail Standard

As part of the Health Promoting Health Service, NHSScotland 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. Early signs suggest that consumers are responding positively to the changes, with a noticeable shift away from confectionery and sugary drinks towards options that are better for people's health ^[164] . A formal evaluation is underway and will report in 2018.

Many consumers are NHSScotland 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. The evaluation will therefore ask the views of consumers as well as retailers and will consider whether any of these healthier practices could be rolled out in other settings.

Promoting Physical Activity through Football Fans In Training

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 ^[165] . The programme was also cost-effective. With funding from the Scottish Government, the SPFL Trust has continued to deliver the programme in 32 football clubs across Scotland: now almost 3,000 men 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 the weight they lost off three and a half years after starting the programme.

Football Fans In Training 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 and Torquay actively involved. Work is also underway to transfer the programme to the German Bundesliga. This is just one of a number of programmes delivered by football clubs in Scotland which is promoting physical activity and helping to deliver positive outcomes.

Expanding the Care... About Physical Activity Programme

In Scotland, older adults are significantly less likely than younger adults to achieve the recommended amount of 150 minutes of moderate to vigorous physical activity per week ^[166] . Physical inactivity is particularly common amongst older people who use care services, whether at home or in a care home. Some do not receive the support that is needed to encourage them to participate in physical activity and many spend much of their day seated.

In 2016/17, the Scottish Government provided nearly £1 million in funding to the Care Inspectorate to further develop and expand their successful Care… About Physical Activity ( CAPA) programme ^[167] . Working with eight Health and Social Care Partnerships across Scotland, the programme will run until October 2018 and the CAPA team will build on the skills, knowledge and confidence of staff to enable those they care for to increase their levels of physical activity and move more often. People who work in community health and social care services will also discover ways to be more active themselves.

The programme includes:

• Working with care homes for older people to embed the use of CAPA;
• Working with care at home, housing support and other support services for older people to equip staff to promote physical activity and scope out what specific resources they may require to be developed;
• Developing Care Inspectorate staff;
• Developing and testing a module on physical activity to embed into the health and social care curriculum; and
• Holding a national event in September 2018 to share good practice widely and to celebrate success.

Although at an early stage, the programme is already demonstrating impact ^[168] .

Reducing Health Inequalities

Links Workers

As we develop the medical and wider clinical support in the community, new forms of professional practice are developing. This includes links workers, who help people primarily in socially deprived communities access and make the most of resources to improve their health and life chances. The Scottish Government has committed to recruiting an additional 250 links workers in practices in deprived areas, with the first 40 in place by September 2017. The roll out will be phased until 2021, with the first 40 links workers based in Inverclyde, North Ayrshire, Edinburgh, Dundee and Glasgow. The first phase will be evaluated in 2017/18. The focus in 2016/17 has been on completing the pilot projects and developing plans to roll the programme out across Scotland.

Child Poverty

Income matters to health; poverty adversely impacts on children's social, emotional and cognitive outcomes and subjects families to additional stress ^[169] . One in four children in Scotland is living in poverty and 70 per cent of those children are in households where at least one person is working ^[170] . Increasing income amongst pregnant women and families with young children contributes to reducing child poverty. NHS Health Scotland supported NHS Boards, Health and Social Care Partnerships and partners across Scotland to map current referral pathway activity, develop national tools and deliver learning sessions to embed good practice models. This work will support midwives and health visitors to ask pregnant women and families with young children about money worries and offer referral to a local advice service. E-learning modules on child poverty were also developed to raise awareness of poverty and its impact on health and wellbeing, and these were embedded in undergraduate and continuing professional development programmes.

Human Papilloma Virus Vaccination

Vaccination programmes in Scotland continue to protect our population against serious vaccine preventable diseases. The Human Papilloma Virus ( HPV) vaccination programme was introduced in 2008 with the aim of helping to protect girls against developing cervical cancer. Around 80 per cent of cervical cancers in Scotland are caused by the human papilloma virus, in particular types 16 and 18 ^[171] .

The efficacy of the HPV vaccine has been monitored since the programme began in 2008 and it has already begun to show encouraging and positive signs of preventing the occurrence of cervical cancer caused by HPV. A recent longitudinal population study measuring the impact of the HPV vaccination programme has shown that following its introduction, the level of cancer-causing HPV in Scotland has dropped by 90 per cent in young women who have received the HPV vaccine. The study compared the anonymous cervical screening results of women born in 1995, who would have been eligible for vaccination, with women born between 1989 and 1990, who were unvaccinated. In doing so, the researchers could assess the presence and levels of HPV, including genotype, for both groups of women. The researchers found that 21.4 per cent of women born between 1989 and 1990 tested positive for HPV 16/18 compared to only 0.5 per cent of women born in 1995. These new findings demonstrate the significant and continued benefits of the HPV vaccination programme in Scotland ^[172] .