ShareD/Any Other Reports/Health Improvement 29.01.03
Title of Service:
1.
HEALTH IMPROVEMENT
THE LOCAL POSITION
The Performance Assessment Framework
1.1
An important new indicator in the PAF is the health inequality indicator which will
assess each NHS Board’s performance using a composite score based on a
number of proxies for inequalities in health. These are:
 smoking during pregnancy;
 smoking amongst adults;
 dental decay amongst five year olds;
 age-standardised mortality for all causes amongst people aged under
75 years; and
 life expectancy at birth.
Scoring will be the ratio between the most affluent quintile of the population
against the most deprived for each measure within the overall indicator.
1.2
Additionally, completing the assessment tool for Health Improvement
Performance will enable us to outline our position and monitor our progress. This
emphasises three priority areas (Tobacco, Mental health well-being and Diet) and four
focus areas (Early years, Teenage transition, the workplace and community health).
1.3
We will continue to find our own additional datasets and indicators to put
alongside those we are asked to use by the Scottish Executive when reporting
our progress. Two new data sets that will become available during the lifetime of
the 2003 Lothian Local Health Plan are the 2001 census and the Lothian Health
and Life Survey (LHLS). The LHLS will, in particular, give us robust data for the
first time since the last Scottish Health Survey (1998).
The Lothian Health and Life Survey
1.4
From November 2002, 18,000 adults in Lothian – drawn as a scientifically
representative sample of the whole population – were invited to participate in the
Lothian Health and Life Survey. A special questionnaire was developed and
circulated. Responses are now coming back in and early returns are encouraging
in terms of the response rate.
1.5
The data will allow us to develop robust indicators of health status at the local
level. Using these indicators within the PAF, we can start to monitor the
difference we are making to improve health and reduce health inequalities and
target additional activity.
1
ShareD/Any Other Reports/Health Improvement 29.01.03
Current Issues in Improving Health
1.6 NHS Lothian’s local commitment to health improvement has been clearly stated. As
the Local Health Plan says, ‘Improving health and reducing inequalities are
cornerstones of what we do’. Lothian NHS Board is committed to delivery of its vision
of ‘Improving Health for All’. In last year’s Local Health Plan we set out a number of
important topics that we said needed consideration during 2002/03. These were
outlined in the Improving Health Update Report published in September2002 as part
of the Director of Public Health and Health Policy’s Annual Report.

Developing specific, evidence-based health improvement plans
As the Update Report noted, we have developed a series of specific
health improvement frameworks based on available evidence of what
is effective in improving health. Bringing together this evidence helps
us to focus our strategies to improve health and reduce inequalities
Several health policy framework documents have been developed
and are currently out for comment. These documents have been
designed to provide a backdrop to implementing an evidence-based
approach to future actions for health improvement. Final copies of
these documents will be available in 2003. These cover:






Food & Health;
Mental Health Promotion;
Smoking Cessation;
Promoting Physical Activity;
Childhood Accidental Injury Prevention; and
Alcohol Misuse.
.In addition, NHS Lothian identified funding to focus specifically on six
evidence-based health improvement projects which are targetted in areas
of greatest social and economic deprivation. These are:
 Heartstart Plus – Lothian
 Want2Quit
 Staysafe (formerly Babysafe)
 EC72
 Soapy Stars
 Best Fed

Developing the Public Health Network
In December 2002, we launched our Lothian public health network
which aims to help tackle broader issues around improving health by
strengthening partnership working across all sectors both public and
private . Over 300 Delegates from a wide range of organisations
which included local authorities, voluntary groups and healthcare
2
ShareD/Any Other Reports/Health Improvement 29.01.03
amongst others attended a conference where many examples of
health improvement projects were shared and discussed.

Maximising the use of the Health Improvement Fund
As part of the process of ensuring that the Health Improvement Fund
projects are having the expected impact on health improvement and
reducing health inequalities, specific monitoring programmes have
been agreed with each of the projects that received funding. Reports
on the outcomes of each project will be produced.

Developing ways to refine joint health improvement planning as part
of the community planning processes
In line with the revised new guidance to local authorities, we have
worked closely with our partners to match the Lothian NHS health
improvement work with the health agenda of each local authority. In
each of the four local authority areas there is now a Health Action
Team (or equivalent) which is charged with developing the Joint
Health Improvement Plans. Health Improvement Officers, jointly
funded by NHS Lothian and each local authority, are now in post. All
this goes towards further strengthening the Public Health Network in
Lothian.
1.7
The Joint Health Improvement Plans are now well developed in each local
authority area. The current guidance issued in January 2002, together with the
proposed new statutory duty to be placed on local authorities in promoting wellbeing, has reinforced the essential links needed to promote public health across
the full range of lifestyles and life circumstances experienced by Lothian people.
1.8
Enhanced planning arrangements have already been able to provide summaries
of the joint health improvement plans for each of the local authority areas, copies
attached.
1.9
A further issue for 2003/04 is the anticipated publication of the National Plan for
Health Improvement - Step Change for Health in Scotland. This document will
further focus action on health improvement in Scotland. As the Improving Health
Update Report showed, NHS Lothian is already well placed to contribute actively
both locally and nationally to meeting the challenges of making such a step
change.
Efforts in Lothian have gone towards focussed intervention, capacity building and
mainstreaming the health inequalities agenda across the three areas of
prevention, primary and secondary care.
3
ShareD/Any Other Reports/Health Improvement 29.01.03
2.
CHANGES TO IMPROVE SERVICES
2.1
Our main priorities remain reducing the inequalities in health that exist and
improving the health of the whole population. In the first Lothian Local Health
Plan 2002/2003 we identified a group of central areas where we need to take
early action to reduce inequalities in health and improve health generally. These
areas were:







coronary heart disease;
cancer;
promoting awareness of mental-health problems;
helping people stop smoking;
promoting physical activity;
tackling childhood accidental injury; and
promoting sexual health.
For each of these health improvement areas it is important to address prevention of ill
health, primary and secondary care.
2.2
In terms of the big three killers, coronary heart disease, stroke and cancer,
lifestyle factors have been linked to an increased risk of developing these
diseases. These factors are particularly smoking, diet, physical activity and
alcohol misuse. We have highlighted each of these lifestyle factors as an area for
improving health and we have developed appropriate actions as a result.
2.4
In addition to addressing lifestyles, deaths from CHD can be prevented if people
receive prompt medical attention. Heartstart Plus – Lothian, developed jointly
with the British Heart Foundation, is now being implemented across Lothian, with
members of the community receiving training in Emergency Life Support. These
sessions also provide another opportunity for individuals to further review their
own lifestyle behaviours in relation to coronary heart disease risk factors. They
also provide an opportunity to signpost people into the support services
available, for example: smoking cessation services. Our aim is to progress into
2003/04 with an added focus on locating defibrillators in the community. Work is
currently underway with the Scottish Ambulance Service to implement this in
accordance with national strategy.
2.5
Smoking
We are continuing to establish services to help people stop smoking across
Lothian. Because stopping smoking is hard, we need to ensure that existing
services are appropriately maintained and enhanced to give people every
opportunity to continue trying.
In 2002/03 we placed an emphasis on low-income groups, young people and
pregnant women and their partners where rates are not showing any significant
drop. Want2Quit is now offering tailored services for pregnant women based on
evidence of effectiveness in smoking cessation. The project was launched in
4
ShareD/Any Other Reports/Health Improvement 29.01.03
August 2002 in West Lothian with roll out now progressing across all LHCC
areas. Smoking cessation projects aimed at young people are also underway
across Lothian.
2.6
Physical Activity
During 2002/03 Health and Physical Activity Alliances were formed in all our local
authority areas. These alliances, which bring NHS Lothian together with all the
local authority departments, local voluntary organisations and local businesses,
are responding locally to the recommendations from the national Physical Activity
Task Force. The alliances are all directly linked into the Community Planning
process.
Work that has been undertaken during 2002/03 will continue during the coming
year. Notable amongst this work has been:
–
–
–
–
–
–
2.7
ongoing promotion of physical activity within existing initiatives, for
example ageing well and the Scottish Executive-funded health
improvement funded projects;
providing training sessions to raise awareness of the health benefits
of physical activity amongst health and leisure professionals;
developing “exercise consultations” for adults of working age across
Lothian;
establishing small groups in each SIP area to promote physical
activity – e.g. developing the health walks in Craigmillar; and
supporting schools to develop wider physical activity promotion both
as part of the Lothian Healthy Schools Award and through the New
Opportunities Fund.
Establishing a partnership with Hibernian Football Club to encourage
increased participation in physical activity, particularly by children and
young people.
Food and Health
We are on course to have developed a food and health strategy, with agreed
action to promote healthier eating patterns across the population in 2003. A
multi-agency group has been established to develop the action plan. The plan –
which will be consulted upon during 2003/04 – will build upon the existing
projects that have been put in place as part of the health improvement fund work.
These include food co-operatives and breakfast clubs for schoolchildren. The
Lothian Healthy Schools Award will also link into promoting healthy eating
amongst children.
To address inequalities in breastfeeding and support the work of the infant
feeding adviser, we will establish the Best Fed project. This project will include
training of peer supporters and a programme of actions to increase breastfeeding
rates and improve infant feeding. In the first year the project will focus on two
areas of low income, North West and South East Edinburgh. We will expand
elements of this work to other parts of Lothian over time.
5
ShareD/Any Other Reports/Health Improvement 29.01.03
2.8
Alcohol misuse
In 2003/04, the four Alcohol Action Teams in Lothian will publish their Local
Alcohol Strategies. This will start a 3 year programme of work which will sustain
existing services and bring forth a new range of projects to address the themes
of the National Plan for Action on Alcohol Problems – prevention and education;
protection and controls; support and treatment services and culture change. NHS
Lothian will continue to provide a stepped model of care approach for the
provision of alcohol services. In partnership with local authorities we will sustain,
and if possible increase, the core funding needed to provide specialist alcohol
services in the community, particularly those within the voluntary sector.
Furthermore, NHS Lothian will continue to work in partnership with their planning
partners aiming to provide locally based services and working with priority groups
such as children, young people and women.
As well as addressing the lifestyle factors which are clearly linked to the three big
killers, we are addressing a number of other important lifestyle factors.
2.9
Sexual Health
Lothian NHS Board and its partners are working towards developing a sexual
health strategy for Edinburgh and the Lothians, which in addition to reaching the
performance assessment targets relating to teenage pregnancy and sexually
transmitted infections will also work towards creating an environment in which
positive sexual health can be achieved.
During 2003/04 work will continue on NHS Lothian’s national demonstration
project for sexual health amongst young people – Healthy Respect.
Developments include:
 widening access to sexual health services in a range of settings;
 improving access to chlamydia testing across Lothian; and
 working to improve young people’s self-esteem and helping them to
better understand their sexuality.
One of our developments, specifically targetted at reducing health inequalities is
the EC72 project which will be operational in 2003/04. EC72 aims to provide
emergency contraception (EC) to young women through community pharmacies.
The project aims to make available – under a patient group direction –
emergency contraception for women under 25 years in areas of Lothian where
access to emergency contraception would otherwise be limited. In targeting the
provision in economically deprived areas, the project recognises the financial
constraints on some young women and will provide emergency contraception
free of charge.
6
ShareD/Any Other Reports/Health Improvement 29.01.03
2.10
Oral Health
The Lothian Oral Health Strategy Implementation group has made progress on a
number of oral health improvement initiatives in 2002/03. These include:
 Nearly two-fifths (38%) of 0 – 2 year old children in Lothian are now
registered with a general dental practitioner,
 12,900 toothbrushes and tubes of fluoride toothpaste were distributed
free of charge to 8 month old children during 2002, and 11,000 free
toothbrushes and tubes of fluoride toothpaste were given out to
nurseries and childrens’ centres;
 a document setting out key oral health messages for health
professionals has been consulted on and will shortly be published;
and
 work has commenced to develop a food in schools project in a West
Lothian secondary school.
Some central funding for the expansion of nursery tooth brushing programmes
was received in 2002/03. We want to see nursery tooth brushing programmes
offered in all nurseries in deprived areas by 2003/04. This should subsequently
be expanded to all other nurseries and into targeted primary schools as soon as
possible thereafter.
2.11
Protecting Health
Protecting health is a key feature of health improvement and reducing health
inequalities. Two specific projects in this area are now underway in Lothian and
will continue into 2003/04.
Child accident prevention is a part of early years services. Staysafe (previously
referred to as Babysafe) – based on the successful model from West Lothian is
being rolled out across the rest of Lothian. Home safety equipment is being made
available to those families with children under the age of 5 years with particular
emphasis on areas with highest deprivation.
Simple hand washing is one of the best ways of avoiding gastrointestinal illness
caused by infectious agents. Soapy Stars is a project aimed at teaching nursery
and schoolchildren effective hand washing technique and its importance. This
project is being progressed in association with four Local Education Authorities
and Environmental Health Departments. The project will provide schools with the
support necessary to undertake local interventions.
2.12
Drug Misuse
Drug misuse accounts for a substantial amount of ill health and death in younger
age groups in Lothian, and across Scotland. It is also a priority area for the
Scottish Executive. In particular serious morbidity and mortality is associated with
the practice of drug injecting. While rates are lower in Lothian relative to the rest
7
ShareD/Any Other Reports/Health Improvement 29.01.03
of Scotland, they are increasing. The most problematic forms of drug misuse are
associated with inequalities in socio-economic status. There is an increasing
heroin supply and its use is leading to more injecting across Lothian.
Actions to address the issues faced in dealing with drug misuse are agreed by
the Drug Action Teams (DAT), one in each council area in Lothian.
Arrangements to work with each of the DATs in Lothian have been enhanced
during the year with NHS director level input to each one. NHS Lothian, through
membership of the four Drug Action Teams in Lothian has contributed to the
Corporate Action Plans (CAP) for each. The CAP is the joint planning
mechanism for drug misuse.
In 2002/03 NHS Lothian directed a further £321,000 to work in this area. The
funds were used to:
 address service pressures to reduce waiting times in the Community
Drugs Problem Service;
 fund increased staffing and additional locality clinics; and
 increase fees to GP Practices for providing services for drug users.
Actions to be carried forward into 2003/04 are contained within the CAPs from
each of the DATs.
2.13
Mental Health Promotion
Mental health and well-being is a national priority as indicated by the National
Programme to Improve the Mental Health and Well-being of Scotland’s
population. Poor mental health accounts for a high proportion of illness in the
general population and is closely associated with those with those who are
socially excluded and disadvantaged at all ages. Rising self-harm and suicide
rates are symptomatic of these problems, as reflected in the recently published
suicide and deliberate self-harm prevention framework. In the last year NHS
Lothian supported:
 ten small projects, funded under Scottish Mental Health Week
programme, focusing on young people in transition to adulthood;
 the development of health and wellbeing joint planning groups in
Edinburgh, Mid and East Lothian local authority area. These will help
ensure that mental health and reduction in suicide is on their agenda;
 sustaining mental health promotion in West Lothian through the
mental health sub-group of Health and Lifelong Learning Forum. This
group is currently implementing its agreed action plan; and
 the development of information on mental health for young people and
minority ethnic groups.
 Work on improving mental health services, including reprovision and
the development of community services, which will help de-stigmatise
mental illness and improve mental health and wellbeing.
8
ShareD/Any Other Reports/Health Improvement 29.01.03
For 2003/04 this work will be extended by:
 finalising a mental health promotion strategy with our planning
partners;
 developing local activities to complement national work on the
national anti-stigma campaign; and
 creating clear plans with agreed action in each local authority area to
contribute to the reduction in suicide and self-harm in line with the
recommendations of the national framework.
We are also now developing specific work to address the consequences of life
circumstances. For example substance misuse, suicide and deliberate self harm,
domestic violence and fuel poverty.
2.14
Domestic Abuse
Domestic abuse continues to be an area where significant progress needs to be
made in Scotland. We will act on the forthcoming Scottish Executive guidance for
healthcare workers on responding to domestic abuse in NHS Scotland,
developing a strategy to ensure NHS Lothian responds appropriately to women
who have experienced domestic abuse. A key element in this strategy will be to
carry out an assessment of the training needs of staff in key settings to respond
appropriately to individuals who have experienced abuse and deliver awareness
training to primary care staff in NHS Lothian Trusts.
2.15
Fuel Poverty
Addressing fuel poverty is a significant public health challenge which crosses
organisational and professional boundaries. In Lothian, we are fortunate in
having a well-developed strategy for affordable warmth, which builds upon the
recommendations of the UK fuel poverty strategy. In 2002/03, Lothian NHS
Board provided partnership funding to support the “Warmburgh” initiative. In
2003/04 we will explore more fully how NHS Lothian can provide further support
with our community planning partners to promote affordable warmth.
2.16
Community Partnerships
In the Lothian Local Health Plan 2002/03 we commented on developing
approaches to tackle lifestyle and life circumstances needed to be a feature of
the way in which we tackle inequalities in health and improve health.
During the year, the existing community projects in Lothian, together with new
local partnerships we highly successful in securing funding for a series of new
Healthy Living Centres (HLCs). These provide specific focus for promoting health
and well-being and reducing health inequalities for both geographical areas and
specific communities of Lothian people. Funded through the New Opportunities
Fund which recognises a range of contributions from other agencies, the new
HLCs have been developed by the:
9
ShareD/Any Other Reports/Health Improvement 29.01.03





Pilton Healthy Living initiatives;
Wester Hailes Health Partnership;
South Edinburgh Healthy Living Initiative;
Healthy Living Partnership Project – Midlothian; and the
Lesbian Gay Bisexual & Transgender HLC.
Integrating HLCs into the mainstream of what NHS Lothian does must be a
priority for action in 2003/04 and beyond.
2.17
Transport
The links between transport policy and the health and wellbeing of Lothian
residents are well recognised. For instance, children from disadvantaged areas
have much higher road traffic accident rates than those living in more affluent
areas. A lack of suitable transport is a major factor in certain groups having fewer
job and recreation opportunities. This applies to both urban and rural
communities. People without cars can also find accessing the best value healthy
food difficult. Having transport policies that promote walking and cycling and use
of public transport are also important in tackling heart disease, stroke,
osteoporosis and diabetes.
Therefore, and especially considering that around one third of our population do
not have ready access to a car, NHS Lothian advocates a comprehensive public
transport infrastructure. This will help to reduce inequality in opportunity and
allow all communities better access to the amenities of the region including better
access to NHS premises, be this in the community or hospital setting. NHS
Lothian has been influential in bringing together all local bus companies in an
effort to provide improved public transport links to the new Royal Infirmary of
Edinburgh at Little France. Excellent access to the site is crucial for patients,
visitors and staff and these efforts will continue as the hospital becomes fully
operational during 2003.
This important transport agenda is being taken forward with our Local Authority
partners and will be a key issue for discussion in community planning
discussions, particularly those around the Lothian Structure Plan.
Summary
NHS Lothian has recognised the importance of taking action to improve the health of the
population. It has also acknowledged the importance of targetting action to improve
health so that inequalities in health status are reduced.
To extend further the existing building blocks for health improvement and reducing
health inequalities, NHS Lothian is currently discussing a proposed Health Improvement
& Health Inequalities Forum which would bring together key personnel from NHS Lothian
and its partner organisations to address health improvement in a systematic way across
each organisation.
10
ShareD/Any Other Reports/Health Improvement 29.01.03
As this proposed forum would bring together key parts of the NHS in Lothian and also
councils, it will link into the community planning, joint health improvement planning and
NHS planning structures.
OUTCOMES
Lothian NHS Board has committed significant resources to improving health and
reducing inequalities, using a robust methodology based on best available
evidence. However, this will all be questioned if we are unable to show the
success of our approach.
One significant problem in monitoring this activity is that many of the data sets
currently available do not capture data specific to health experiences, lifestyles or
life circumstances. These are essential to monitoring health improvement and, as
a result, a major health status survey, the Lothian Health and Life Survey, has
been initiated. This will provide usable data on a wide range of health status
indicators at LHCC and local authority level. This will also provide us with a
robust baseline against which we can measure the impact of our interventions to
reduce health inequalities and improve health.
Measuring changes in improving health and reducing health inequalities as a
result of such interventions can take a long time, for example, the effects of
quitting smoking now may have an impact on deaths from lung cancer in 5, 10 or
even 20 years time. With this in mind, Lothian NHS Board has taken a more local
approach to measuring health improvement whilst still monitoring progress
towards absolute , long-term outcomes. The approach adopted has been to use
the evidence base to allow specific indicators and targets to be developed. The
table below gives examples of this approach when applied to two of the
previously-mentioned projects:
Initiative
Staysafe
Want2Quit
Process Target
100 per cent uptake in target
areas
50 per cent uptake of pregnant
women, 10 per cent of young
people
Outcome Target
10 per cent reduction in
reported home accidents
18 per cent remaining nonsmokers at 12 months
For both these indicators, the Process Target set remains achievable with set milestones
being achieved to date.
Similarly, identifying both process and outcome measures for health improvement is
central to the implementation of the Scottish Executive Health Improvement Fund
projects. A Monitoring and Evaluation Officer has been appointed to support the projects
in identifying and reviewing appropriate measures which indicate progress towards their
stated aims.
Evidence of effective intervention is also at the heart of the Health Improvement Fund
and the Healthy Respect projects. The interventions or services are known to improve
11
ShareD/Any Other Reports/Health Improvement 29.01.03
health, it is therefore possible to monitor indicators, which show the process of
implementation. At the same time it is possible to monitor indicators of the short-term
outcomes which the implementation has had. In the case of the Health Improvement
Fund and Healthy Respect, these process and outcome indicators have been developed
in consultation with the service providers.
12