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Chapter 7

THE POTENTIAL OF PREVENTIVE HEALTH APPROACHES IN IMPROVING WELL-BEING AND PREVENTING DISEASE

The aim of this chapter is to consider some practical ways in which health services can contribute to preventing the onset of disease or limit the effect of ill health on the well-being of individuals and groups. There are many examples of preventative health approaches, e.g. all of our screening programmes, about which there is a separate annual report, the Hepatitis C Action Plan and immunisation programmes.(121,122) This chapter, however, will focus on two population groups that carry a disproportionate burden of ill health - people who live in deprived areas and the older population.This work also contributes to the range of actions that are
required to address health inequalities.

WHY IS PREVENTION OF MAJOR DISEASES IMPORTANT?

Everyone has the right to good health, regardless of their personal circumstances. We know that it is not possible to prevent every single occurrence of the major diseases, cancer and diseases of the heart, lungs and circulation however certain risk factors make the disease much more likely to occur and many of these risk factors are preventable. If these risk factors changed on a big enough scale across the population, the health experience of the NHSGGC population could be transformed. Moreover, many of the diseases that cause the greatest burden of ill health share common preventable factors, offering the added advantage of reducing several diseases and health problems simultaneously. Therefore it is vital that our prevention activities are as powerful, effective and accessible as we can possibly make them. Although it is clearly not possible to prevent all causes of death, over half of all premature deaths, those that occur before the age of 75, in NHSGGC are potentially preventable. Table 1 shows the size of the contribution made by preventable risk factors to circulatory disease in developed countries.

Table 1
Individual and joint contribution of common preventable risk factors to premature deaths (under 75) caused by diseases of the circulation(123)

The health experience of the NHSGGC population is far from evenly distributed, with some communities systematically experiencing much poorer health and greater health risks than more advantaged social groups. The underlying reasons are complex and rooted both in history and in contemporary social influences that affect some communities more than others. There are clearly many different ways of categorising social groups, for example from the perspective of age, gender, ethnic group or socio-economic status. In this chapter, we focus on the socioeconomic dimension of health equity. The Scottish Index of Multiple Deprivation (SIMD)
identifies small area concentrations of multiple deprivation; SIMD is commonly used as a proxy for socio-economic status at a population level.(15) Using this proxy, it is clear that the health experience of the most deprived areas, SIMD Quintile 1 and the most affluent areas, SIMD Quintile 5, is strikingly different (Figure 1). In this case, we have used premature death as an indicator of poor health, although we could have selected any one of a range of other measures.

Figure 1
Premature mortality (age 0-74) in NHS Greater Glasgow and Clyde, 2006-2008

Figure 1 shows two striking features; firstly, that the absolute burden of premature deaths falls largely on NHSGGC’s most deprived communities, shown as Quintile 1. Secondly, the underlying causes of this premature mortality burden show very different patterns across the five deprivation quintiles, with a higher proportion of deaths due to preventable causes in the most deprived quintiles. External causes of injury/poisoning, including suicide, drugs, alcohol and violence related issues, are important as preventable causes of premature morbidity and mortality in the younger population from our most deprived communities. There are a number of
important health improvement and prevention activities being undertaken in this area, which are outwith the scope of this particular chapter.

Although we now have effective prevention interventions, such as smoking cessation support, blood pressure lowering medication, statins and many other prevention strategies, the extent to which this potential effectiveness translates is not fully realised. Many factors systematically make it harder for some sections of the population to access, uptake and maintain preventive interventions than others (Figure 2). Those who have the greatest capacity to benefit face the greatest barriers to accessing and sustaining evidence based preventive interventions.  Concerted action on these barriers will improve the equity and the overall impact of our total
prevention effort.

Figure 2
The equity gap: potential v. ‘real world’ effectiveness in prevention

A FRAMEWORK FOR PREVENTION

There are important opportunities for health gain at each stage in the development and progression of all major diseases, which can be considered along the continuum of primary prevention, secondary prevention or tertiary prevention (Figure 3).

Figure 3
An integrated approach to disease prevention

Primary prevention is intended to prevent the development of a disease and includes action on wider health circumstances and health determinants, as well as interventions that are delivered at individual level, either the whole population (for example, childhood immunisation) or targeted towards certain population subgroups, such as those at greater risk of developing cardiovascular disease. Secondary prevention aims at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease. Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications.

Disease prevention in deprived areas: Keep Well
Keep Well is a large scale national anticipatory care initiative originally launched in 2006.(125)  Anticipatory care is an umbrella term for a spectrum of planned, systematic and structured approaches intended to prevent or delay the onset of disease. It seeks to engage all individuals in the target population to prevent disease, rather than solely reacting to those who present with problems. The Keep Well programme has been developed across Scotland in four distinct developmental ‘Waves’. NHSGGC currently incorporates two Wave 1 pilot sites and three Wave 2 sites, collectively trialing a range of innovative anticipatory care approaches in the most
deprived geographical areas of our Board. The five pilot sites differ in their strategic focus at CH(C)P level (Table 2).

Table 2
Overview of Keep Well in NHSGG&C

In NHSGGC, the primary focus of Keep Well is on reducing cardiovascular disease and its risk factors among 45-64 year olds in our most deprived areas. Circulatory diseases, including stroke and coronary heart disease, are a major driver of poor health in our least affluent communities. The reasons for this are complex and multifactorial.

Some of the key explanations, however, are likely to lie in clustering of individual risk factors which are linked to the social and environmental characteristics of disadvantaged areas that make it difficult for people to adopt and/or sustain healthy behaviours. The Keep Well programme in NHSGGC involves detailed cardiovascular screening; data recording; practicebased lifestyle counselling; referral to relevant services where appropriate; follow up of referrals and systematic documentation of outcomes. This ensures that the actions which are focused on the patient’s health improvement become part of core primary care services. This offers the potential for sustained support at subsequent consultations with their general practitioner over future years. More ambitiously, Keep Well seeks to influence patients’ life circumstances in a range of ways by offering practical help with financial issues, employability and literacy, as well as action on the more traditional health associated behaviours, such as smoking, healthy eating, physical activity and mental health support.

As well as a detailed discussion about individual lifestyle and life circumstances, the health check includes key biological measurements, including calculation of the patient’s estimated risk of cardiovascular disease over the subsequent ten year period. NHSGGC’s three primary prevention Keep Well areas are currently piloting the ASSIGN risk assessment tool, which will be rolled out to the rest of Scotland in the near future. Patients who are identified as being at higher risk of a cardiovascular disease event in the next ten years are offered medical therapy, as well as referral to health improvement services relevant to their individual needs. The Keep
Well programme recognises long-term benefits on CVD risk that can be achieved by populationwide changes in lifestyle. A recent re-analysis of the British Regional Heart Study showed that men with none of the adverse lifestyle characteristics had a 53% lower risk of having a major cardiovascular event than men with one risk factor, a 67% lower risk than men with two factors, and a 74% lower risk than men with all three risk factors.(126)

A major concern of Keep Well in NHSGGC has been to find ways of reaching the entire target group regardless of the barriers that exist. Uptake of Keep Well health checks in the Wave 1 areas, North and East Glasgow, began to plateau in mid 2008 and the cumulative proportion of the target population who have engaged has remained in the region of 62-67% since then, despite sustained engagement effort, using a range of methods (Figure 4).

Figure 4
Uptake of Keep Well to 31 March 2009, by CH(C)P

Analysis of the characteristics of the subgroups who remain persistently unengaged, shows that they are more likely to be male and to live in the most deprived areas of the North and East CH(C)Ps, which are already characterised by high overall levels of multiple deprivation.  A programme of work began in August 2009 that will build a more systematic understanding of the needs and current patterns of service use of those who remain unengaged within the Keep Well Wave 1 programme. This will establish and formally test out the best ways of providing anticipatory care to those who need it most.

Accordingly, the main priority actions for Keep Well Wave 4 will involve new developments intended to strengthen area-wide engagement effort. Clinical coverage of the programme will be intensified in two geographic areas within the North and East CH(C)Ps. This will capitalise on the referral potential of a wide range of community organisations, including healthy living centres, workplaces, employability services, social work, criminal justice, mental health and addiction services, housing associations and the third sector, to ensure closer alignment with engagement efforts in primary care at the level of individual patients.

PREVENTING AND REDUCING ILL HEALTH IN THE OLDER POPULATION

Older People’s Care
The skills and life experience of NHSGGC’s older people are one of its major assets. Older individuals constitute an increasingly larger share of our population. Although many people in older age groups in NHSGGC still consider themselves to be in good health, the proportion of the population living with long-term illnesses and self-reported ill health increases steeply with age.

NHSGGC works closely with its community planning partners to support healthy active ageing, which optimises older people’s opportunities for health, participation and quality of life as they age. Accessible transport services are continually improving and enable older people to participate and access opportunities in the community. It supports a range of physical activity interventions, including Silver Deal Active and the Vitality programme. Silver Deal Active aims to get older adults more active more often. It is a programme of free activity and arts sessions for people aged over 60, living in South West, West and East Glasgow. It aims to keep older people fit and healthy and give them the  opportunity to socialise. The Vitality programme replaces a number of disease specific rehabilitation classes, such as cardiac rehabilitation classes, with a renewed focus on ability and fitness, rather than disease or condition. People can self refer into Vitality, or may be signposted into it by other services.

Falls prevention is a key component of healthy active ageing; up to one half of people over 65 years old living in the community fall each year, many fall repeatedly and the risk of falling increases with age. Falls carry serious risks for older people, who are more likely to suffer serious injury, hospitalisation and long-term complications. However, there is good evidence that risk assessment and multifactorial intervention programmes are extremely effective in achieving a substantial reduction, 15-30%, in the incidence of falls among older people. NHSGGC offers an integrated osteoporosis and falls service, using a single point of referral. Home assessment includes an assessment of the environmental safety of the home, need for care and repair services and an occupational therapy assessment. Onward referrals may be made to consultant
geriatrician-led falls clinics, pharmacy-led medications review, osteoporosis services and money advice services.

Economic equity is a key challenge for older people in NHSGGC, particularly in the current economic climate. The proportion of pensioners in relative poverty is increasing. Older people are the least likely of all societal groups to claim the benefits that they are entitled to and many are unaware of available services and entitlements, or how to access them.

Glasgow City Council has provided a Quick Guide to services for all older citizens living in Glasgow. 20,000 guides have been provided and distributed throughout Glasgow City in day centres, libraries, local older people organisations and community groups. This resource is utilised by health and social care staff to improve uptake of this service and to facilitate effective signposting, not just to health and social care but to learning, employment and benefit services.  The Stroke Money Advice Service was piloted between November 2008 and April 2009 in five hospitals throughout NHSGGC and provided a simple-to-access holistic support service covering all aspects of money advice. A total of 93 patients and carers used this service within this six month period, with 51 successfully completed applications for benefits resulting in around £200,000 in benefits being generated for stroke patients.

LONG-TERM CONDITION MANAGEMENT

Although long-term conditions occur at all ages, they are more common in older age groups.

Long-term conditions are an umbrella term for a range of health problems which require ongoing medical care, limit what a person can do for a year or more and have a clear diagnosis.  Approximately 37% of the NHSGGC population report at least one long-term condition, with the older population much more likely to report that long-term conditions interfere with day-to-day activities.

Long-term conditions exert a powerful impact on human health and well-being. One way of capturing this impact is to use an integrated measure of premature mortality and health impairment, called a Disability Adjusted Life Year (DALY). DALYs are a measure of years of healthy life lost due to the combined effect of dying at a young age and living for a long period of time with ill health. This way of thinking about health burden, contrasts with more traditional measures such as mortality or health service use, which are much blunter measures of the true impact of long term conditions. This is shown very clearly in Figure 5, which demonstrates
powerfully the health impact of common conditions, such as depression and adult hearing loss, on health and well-being. Even although they do not lead directly to high mortality or hospitalisation rates, their high overall disease burden arises from the fact that they cause widespread disability in a very large number of people.

Figure 5
Age standardised DALYs per 100,000 by ‘top ten’ causes, UK

NHSGGC has developed a long-term conditions strategic framework to improve the health and well-being of people with long-term conditions; to keep people as healthy as possible for as long as possible and thus reduce the incidence and impact of long-term conditions.(127) The framework incorporates a foundation level of Supported Self Care, in conjunction with two additional levels of interventions. The aim is to encourage individuals to cope and live well with their condition by equipping them, and their carers, with the necessary knowledge, skills and confidence. Expert patient courses are being offered in conjunction with partner voluntary
organisations.

Acting in a complementary way with Supported Self Care, the framework includes two additional levels:

Level 1: Disease-specific care management, which targets people with complex single need or multiple conditions, providing them with information, monitoring and proactive management.

Level 2: Complex care management involves the identification of very high intensity users of unplanned secondary care services. The overall aim of this tier of long-term condition management is to identify and anticipate the care requirements of this more complex group of patients and coordinate a multidisciplinary, multi-agency care package to prevent emergency
situations leading to admission.

PRIORITIES FOR ACTION

  • NHSGGC must start planning now for board-wide anticipatory care after the end of the Keep Well pilots. This planning must incorporate evidence from the project to identify and deliver the most appropriate practical actions for providing anticipatory care services to those who remain unengaged and are likely to be most in need. It is likely that this will involve our partners and therefore we need a clear communication plan and set of objectives for joint working
  • An evidence-based debate is required on the appropriate balance between individual level cardiovascular risk reduction delivered through health checks and intensifying our current actions to create health promoting communities and environments
  • In addition to NHSGGC maximising its effectiveness in relation to preventive measures, it needs to consolidate and step-up joint working with its partners, which focuses on addressing the structural, financial, social barriers which people face when trying to prevent health problems
  • Primary care leadership in tackling health inequalities must be defined, encouraged and supported. The evolving Primary Care Framework offers an opportunity to support this agenda and there should be clear implementation plans to ensure that change occurs
  • CH(C)Ps should work with the Glasgow Centre of Population Health and academic departments of both General Practice and Public Health, to improve their understanding and relationship with primary care in the most deprived communities
  • We must continue the process of learning from and continuously improving successful prevention programmes, including screening and vaccination, ensuring that their equity dimensions are actively monitored and appropriate action taken to deliver the programme in ways that reach those who are less likely to take part
  • CH(C)Ps and their community planning partners must ensure that older people, irrespective of their personal circumstances or where they live, can access services and their opportunities for health, active participation and quality of life as they age