5. Our least healthy communities are unlike our healthy communities in every way
Different communities in Greater Glasgow and Clyde have very different social circumstances and health outcomes. The best health outcomes are in the communities that show economic success and good physical and social environments, while poor health outcomes are consistently linked to adverse social circumstances.
The Greater Glasgow and Clyde area includes communities that are opposite ends of the spectrum of good and poor health and supportive and adverse social circumstances as described in ScotPHO community profiles (34).
Figures 5.1 and 5.2 show how two communities in the NHS Greater Glasgow and Clyde area can have vastly different experiences.
This section focuses on a small number of selected topics to illustrate the relationship between health and difficult social circumstances in our worst affected communities. The topics we have chosen to highlight are pregnancy and parenting, crime and violence, and mental health.
Pregnancy and Parenting
There are strong associations between socio-economic factors such as lone parent households and children in workless households, and maternity-related indicators. A range of maternity and child-related indicators at postcode sector level across Scotland show notable correlations between maternal age, smoking during pregnancy, breastfeeding, being a lone parent and children in workless households. For example, in areas where the proportion of women smoking during pregnancy is high, maternal age is lower, and areas with a high level of teenage pregnancy have high levels of smoking in pregnancy. Areas where there are high levels of smoking during pregnancy are also associated with higher levels of lone parents and lower levels of breastfeeding. Areas with a higher average age of first-time mothers tend to have lower proportions of lone parents and higher levels of breastfeeding(35).
While none of these associations necessarily indicates a causal relationship, they underline the importance of understanding the interactions among social, cultural and economic factors and health behaviours particularly at a local level.
How NHS Greater and Clyde and its partners are responding
Mainstream services, innovation within services and local projects provide support for improving health outcomes related to pregnancy and parenting. CH(C)Ps bring together integrated or joint children’s social work and health services. Examples of other initiatives are Parents and Children Together (PACT Teams), the Breathe project and breastfeeding support.
Parents and Children Together (PACT) teams have been set up to improve the physical, social and mental well-being of children and families among vulnerable and disadvantaged groups. The initiative, which emphasises early interventions, has links to a variety of other programmes including child health development, workforce development in public health nursing and other disciplines, integration of children’s services, and life-long learning through supporting mothers to access education and training. Multi-disciplinary and multi-agency working is at the heart of the teams, which provide a combination of intensive home-based and centre-based support to vulnerable and disadvantaged families. The project promotes better access to services, health promotion and social care initiatives, parenting education and childcare provision. This model has informed the NHS Greater Glasgow and Clyde review of health visiting.
The Special Needs in Pregnancy Service (SNIPS), provided by specially trained midwives in the Clyde area, is an example of an effective service to support vulnerable women and women with disabilities during pregnancy. The Breathe project offers help for stopping smoking during pregnancy in maternity units. The project measures pregnant women’s carbon monoxide levels at their first visit to a clinic. Women who smoke are then referred to a specialist smoking cessation midwife who supports the women to devise their own action plans for quitting.
Renfrewshire CHP promotes breastfeeding in some of its most deprived areas through breastfeeding networks and support groups and through engaging and training breastfeeding lay supporters. They also facilitate creative cascading of breastfeeding awareness by working with local “champions”, grandparents, local community groups and businesses. These initiatives are recognised by and have informed the development of the NHS Greater Glasgow and Clyde infant feeding strategy.
Crime and violence
Detailed analysis of violent crime patterns in Glasgow city shows that male offenders outnumber females by more than three to one, and that the peak ages for offending and being a victim are from the mid-teenage years to mid-twenties. The area of residence of offenders and victims is highly correlated with deprivation and in some smaller, deprived communities in Glasgow more than one in ten people have been victims of a violent crime in the past three years (see Figure 5.3). Unsurprisingly, incidents of violent crime are highly concentrated in the centre of the city.
Other related measures further highlight the problem of violence. West Dunbartonshire and Glasgow City have the highest recorded rates of domestic abuse, both more than 50% above the Scottish average (36), with the lowest rate being in East Renfrewshire at 58% below the Scottish average. Meanwhile, rates of hospital admission for assault are also much higher in Glasgow than the Scottish average across all ages. The most common specific diagnosis of assault in Glasgow is “assault by sharp object” - a reflection of the high rates of knife crime in the city. People from more deprived areas suffer far higher levels of assault that result in hospitalisation.
There are significant differences between the areas with the most and fewest victims of violent crime.
Importantly, the same communities have the most and the fewest violent offenders.
How NHS Greater Glasgow and Clyde and its partners are responding
The Violence Reduction Unit in Strathclyde Police has developed an innovative public health response to crime and violence. The unit was set up to identify good practice in reducing violence and is designed to contribute to building a society where children and young people can live without fear of assault. The unit’s approach involves prevention of violence and extending better care and safety to affected population groups in partnership with health, education, transport and justice organisations, and operates alongside both law enforcement and reducing tolerance of violence in communities. The unit operates on three levels of prevention. Primary prevention maintains an injury surveillance database which can be shared with the NHS and other agencies to give accurate information on which to base preventive action. Prevention at this level also facilitates parenting and early years support, based on evidence for the importance of early years development in preventing violence in older age groups. Secondary prevention targets those most at risk of developing violent behaviour or of becoming a victim and tertiary prevention includes working with the prison service to have violence prevention and parenting programmes as mandatory requirements for prisoners (37).
This short description of mental health focuses on two specific areas: suicide and addictions. Suicide rates in Glasgow City between 1989 and 2004 for men and women aged over 15 were significantly higher than the Scottish rates each year. The same study showed that suicide rates were significantly higher in deprived areas and that there was a widening suicide gap across Scotland (38). Another recent analysis (39) has highlighted a persistent clustering of suicide deaths in Glasgow during a 20-year period.
Another aspect of mental health, problem drug use, affects an estimated 51,500 adults between the ages of 15 and 54 in Scotland more than a third of whom live in the NHS Greater Glasgow and Clyde area. More than 11,200 of these live in Glasgow, representing more than 3% of 15 to 54-year-olds while, by contrast, the equivalent figure for East Dunbartonshire is 0.7%. Another study estimated in 2003 that 3.1% of all children aged 0-15 in Glasgow lived with a parent with problem drug use (40).
Between 1996 and 2005 there have been more than 1,200 drug-related deaths in the NHS Greater Glasgow and Clyde area and across the 10 Community Health Partnerships fully within NHS Greater Glasgow and Clyde, there is a six-fold variation in death rates.
There are wide differences in the proportion of drug-related deaths in the 10 CH(C)Ps in the NHS Greater Glasgow and Clyde area (Figure 5.4).
Working in partnership with communities is essential. All public sector services should contribute to reducing poverty and disadvantage in the least healthy communities. Examples of this approach include:
Examples of this approach include:
In order to improve the experience of our most unhealthy communities the following things need to happen: the must be a focus on interventions while people are young as these will be the most cost-effective in building empathy, attachment and self-esteem, as well as contributing to reducing health inequalities in the population.
Key public health messages and priorities for action
As well as services for individuals, the public health response to drug misuse includes population based prevention, such as the pharmacy-based needle exchanges that were established to prevent the spread of blood-borne viruses which succeeded in 2006-07 in having 73% of injecting equipment returned which was well above the Scottish average. They also aim to introduce people who misuse drugs to education, training and employment by working with Local Economic Development Companies, training providers, colleges and employers to support service users to take and up and maintain employment. Other initiatives aimed at reducing inequalities are guided by the Addictions Equalities Plan and include an addiction service for people from black and minority ethnic communities within the mainstream service, and the continued development of gender-sensitive services.
The addiction services are part of the public health response to drug misuse through working to improve access to services, to identify people most at risk, to protect the health of the whole population and to contribute to reducing health nequality. Examples of these aspects of their work include new developments such as talking therapies and new prescription drugs for detoxification and substitute prescribing and by increasing the engagement of drug users not already in the service.
Addiction Teams (42) are accessed through CH(C)Ps and the Addiction Services Partnership. Between them, NHS Greater Glasgow and Clyde and Glasgow City Council co-ordinate all directly-provided NHS and local authority addiction services including in-patient, hospital and outpatient services. The Council also contract manages the Drug Crisis Centre, community rehabilitation, community support and carers services. This model of integrated services recognises that drug isuse happens in a context of significant social, economic and individual problems, and they support people to address these issues as part of helping them to overcome their drug misuse. Their main aim is to help people sustain drug-free lifestyles, but recognise that individual and social transformation is needed for a person who misuses to become drug-free. These services provide a good example of the value of integrated service delivery between health, social care and voluntary services.
Projects to reduce suicide are just some of the local actions designed to improve overall levels of mental health and to prevent mental health problems. These include mental health improvement work in community health projects and Healthy Living Initiatives, and work on equality aspects of mental health such as the Mosaics of Meaning programme in black and ethnic minority communities.
Other actions to prevent suicide across the NHS Greater Glasgow and Clyde area include raising public awareness through such means as seminars, media work and joint work with football clubs. There has also been policy work, such as the development of a protocol to assist school staff to respond to young people who appear suicidal or are self harming, and service developments, such as the Life Coaching Project run by the Wise Group and the Scottish Prison Service.
In the NHS Greater Glasgow and Clyde area, actions to reduce suicide have involved many agencies and groups. Activities have included the Esteem service, which provides early intervention for people at the first onset of psychosis when they may be at a higher risk of suicide and the Asist (Applied Suicide Intervention Skills) training course for professionals, carers and volunteers, which prepares people to intervene competently with a person at risk of suicide.
The then Scottish Executive launched the Choose Life strategy in 2002 in response to rising rates of suicide in Scotland (41). The strategy has drawn together multiple community planning partners across the country.
How NHS Greater Glasgow and Clyde and its partners are responding