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3. Lessons learned

3. There are lessons to be learned from what is getting better

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We often feel that there is not enough progress in improving health and narrowing inequalities, but it is important to recognise that many aspects of health are improving and that we can learn lessons from them to apply to other areas.

Progress is being made in increased life expectancy, the prevalence of smoking, immunisation rates, and unemployment and in reducing some causes of death such as heart disease, stroke, some cancers and reducing infant mortality. This section discusses what lessons we can learn from improvements in reducing smoking and coronary heart disease and in increasing employment and in delivering health protection programmes.

Reducing smoking

Smoking is a significant public health challenge for NHS Greater Glasgow and Clyde, which has the highest smoking rates of any NHS area in Scotland, and where smoking remains the primary cause of preventable death and ill health. However, adult smoking rates have fallen considerably in the past 30 years (3).

The NHS Greater Glasgow and Clyde area contains communities where levels of smoking are much lower and much higher than the Scottish average. The areas of lowest prevalence have levels of smoking 9.5 percentage points below the Scottish average of 28%, and in the areas of highest prevalence, smoking rates are 9.5 percentage points higher (Figure 3.1) (4).

Figure 3.1

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Smoking is becoming concentrated in the poorest households and in socially excluded groups such as prisoners and homeless people.  The most recent figures indicate that 8 in 10 (78%) (5) prisoners smoke and prevalence rates estimated at 62% (6) for the homeless population in Glasgow city. Smoking is the greatest single factor in the different life expectancy between social classes.

The cost of smoking also weighs most heavily on the poorest. The Family Expenditure Survey estimates that the average household spends about 1.5% of its weekly income on tobacco compared to 15% in the poorest households (7).

Reducing smoking in pregnancy is a priority activity locally and nationally. The rates are falling but levels are still high, especially in deprived areas, and maternal smoking rates range from 9% in Eastwood to 43% in Clydebank and Drumchapel.

There is a great deal of health promotion activity designed to reduce exposure to second hand tobacco smoke, which increases the risk of coronary heart disease by 25 to 35% and the risk of lung cancer by 20 to 30%, and causes at least 1,000 deaths a year in the UK - 100 in Scotland alone (8).  Children, pregnant women and those with heart problems and respiratory diseases are more at risk.

Research shows that, since people smoke for many different reasons, no single intervention can be universally successful. The most successful approach combines prevention, cessation, legislation and protection. Since 2000, NHS Greater Glasgow and Clyde – in line with national guidelines – has focused on developing smoking cessation services in a range of settings including community, pharmacy, secondary care, maternity and mental health services.

There is evidence that this approach is working. For example, information from the NHS Greater Glasgow and Clyde smoking cessation database shows that 45% of people who attended smoking cessation projects offered by CH(C)Ps in the Greater Glasgow area between January 2006 and March 2007 stopped smoking four weeks post quit date.  Figures for people attending projects offered in secondary care and maternity settings were 32% and 37% respectively.

As well as a focus on cessation, there are preventative measures being taken.  The legal age for buying cigarettes in Scotland has risen from 16 to 18.  The move attracted cross-party support and also took place in England and Wales on the 1st October 2007.  NHS Greater Glasgow and Clyde delivers prevention programmes in schools for example, ‘Smoke Free Chicks’ in nurseries, Smoke Free Me in primary schools and Smoke Free Class in secondary schools.

Building on the Smoking, Health and Social Care (Scotland) Act 2005, which outlawed smoking in enclosed public places, and which is predicted to bring about a reduction in smoking of between 4% and 10% (9).  NHS Greater Glasgow and Clyde is developing a programme of tobacco control initiatives. Among these are workplace no smoking policies, which have been pioneered at all its hospital sites. The organisation has also piloted a Smoke Free Homes and Zones project in the east of Glasgow, and developed smoking cessation services for young people looked after and accommodated by local authorities.

Our pharmacy led smoking cessation service has been working with one of our community based health initiatives called ‘Reach’. Reach provides preventive health services and information to the Black and Ethnic Minority (BME) community. Smoking cessation services are being provided through this initiative and therefore benefit from Reach’s expertise of delivering culturally sensitive and accessible care.

Lessons from working on smoking

  • We need a comprehensive strategy to address public health challenges. This should include prevention through education, media campaigns, work in schools and communities, appropriate pricing and availability policies, legislation where appropriate, and treatment and care services. This strategy must include a mixture of local, national and international action. The strategy will require a range of agencies working in partnership and the enforcement of legislation must be adequately resourced.
  • We must develop and evaluate strategies and services to take account of inequalities in relation to resources, targeting, engagement and interactions with individuals.
  • We must ensure that public organisations take a lead role in developing workplace policies, services and staff support.

Reducing coronary heart disease

Coronary heart disease is the leading cause of death and morbidity in Glasgow. However, as Figure 3.2 shows deaths from heart disease have fallen by more than half in the Greater Glasgow and Clyde area during the past 25 years.

Figure 3.2

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While this is encouraging, the reduction is less than the Scottish average. Within the NHS Greater Glasgow and Clyde area, there are wide variations, by geographical area and by gender (10).

Primary prevention targets people at risk of developing coronary heart disease, and secondary prevention targets people who already have chronic stable coronary heart disease, for example, angina.  This includes medical treatments as well as changing lifestyle.

Mortality rates decline as a result of primary prevention (reducing the number and severity of the risk factors) and secondary prevention (providing better treatment and working to reduce the risk factors in people with coronary heart disease). The relative contribution from these two efforts is around 60% primary prevention and 40% secondary prevention, which emphasises that we need both primary and secondary prevention if we are to continue to see declines in coronary heart disease mortality.

NHS Greater Glasgow and Clyde has developed a number of initiatives to achieve further reductions of deaths from coronary heart disease. These include the Heart Disease Managed Clinical Network, practice nurse based programe to ensure good secondary prevention of coronary heart disease; Have a Heart Paisley and more recently Keep Well.

The Heart Disease Managed Clinical Network works to ensure consistent services and standards across the NHS Greater Glasgow and Clyde area. Its health improvement sub-group works across stroke, diabetes and heart disease, since so many of the pre-disposing risk factors are common to them. One particular success has been the incorporation of health improvement as a substantial part of the local enhanced service for each of these. The sub-group is also redesigning cardiac rehabilitation services to ensure a common approach across the area with equitable staffing and access. This includes cardiac rehabilitation services, and ensuring that there are close links between that and all community health improvement services.

The Managed Clinical Network has set up a patient forum and is also developing a website that will offer one-stop access for the public, patients and health professionals to local services, standards and health-related information on heart disease, stroke and diabetes.

NHS Greater Glasgow and Clyde is also active in the secondary prevention of coronary heart disease. Secondary prevention can substantially reduce the risk of myocardial infarction and progression of the disease once it is diagnosed. The MCN has introduced a system of enhanced coronary heart disease care in general practices in Greater Glasgow and will soon implement this in the Clyde area. The locally enhanced services ensure a systematic approach to secondary prevention not only using the medical model but also by paying attention to other risk factors that can contribute to risk reduction, including effective management of depression. It links to the rehabilitation service and also to community based services to support smoking cessation, getting more physically active, managing overweight, healthy eating and managing alcohol problems and dealing with depression.

The national Have a Heart Paisley demonstration project operates within the Renfrewshire Community Health Partnership. This primary and secondary prevention project, which is now in its second phase, targets 45 to 60-year-old people most at risk of developing heart disease and those with established heart disease, and is designed to demonstrate the degree to which primary and secondary preventative measures can improve heart health by tackling behavioural risk factors and unmet needs for treatment. The project is piloting health coaching as an approach to the primary and secondary prevention of coronary heart disease. Health coaching provides one to one support and guidance to help individuals to make positive lifestyle changes, focused on the risk factors of physical inactivity, unhealthy eating and smoking.

The Keep Well programme is designed to improve the health of people living in areas with high levels of deprivation.  Keep Well, which covers around 20 general practices in the north and east of Glasgow, will help us find out what different approaches are effective in engaging people who do not usually come forward for preventive care. Practices are offering detailed health screening for everyone aged between 45 and 64 years-of-age, whether they are well or have any health problems. People who are registered at these practicies and who have risks identified will be offered fast access to health improvement services, such as those for smoking, eating, weight, alcohol, anxiety and depression, and physical activity. Keep Well builds on the existing relationship of trust that exists between patients and GPs and their teams. It has also developed local directories of services that help people in the Health Service and other services to find out easily what support is available locally for health-related behaviour change.

Both Have a Heart Paisley and Keep Well are being thoroughly evaluated and the results will be used to inform the planning of preventive services across the NHS Greater Glasgow and Clyde area and beyond.

Lessons from working to reduce coronary heart disease

  • We must recognise the crucial role of primary care in prevention initiatives.
  • Prevention programmes must take account of social determinants of health.
  • Relevant clinical research should be both translated into guidelines and adapted for local use.
  • We need to use a range of strategies and methods of engagement to ensure our preventive activities are accessible to all.
  • Engaging with local authority partners and voluntary organisations, and involving patients in the design of services, are essential if we are to have services that are accessible and successful.
  • Using the latest developments in computers and software supports and encourages primary care staff to follow a systematic approach and to monitor and evaluate outcomes.
  • Training staff in communication and engagement with people is crucial to success.

Action on increasing employment

While official measures show great reductions in the numbers of people claiming unemployment benefit during the past 10 years in the West of Scotland, the unemployment rate is not an adequate measure of worklessness. The “employment deprived” figures in the Scottish Index of Multiple Deprivation (11) show the number of people not in work because of unemployment, illness or disability.  According to the index, 235,000 adults were employment deprived in 2002 in the West of Scotland council areas, a third of whom (85,000) lived in the Glasgow City Council area. Glasgow City Council also had the highest percentage of the working age population who were employment deprived at 23%, while the lowest percentages were in East Renfrewshire and East Dunbartonshire, both at 9%.

Data from the 2001 census show that there is a massive variation in the proportion of working age adults who are employment deprived across the West of Scotland. In the 10 data zones with the lowest rates, between 1.4% and 2.4% of adults were employment deprived, and in the 10 areas with the highest rates, the figures were all more than 50%. In one part of Calton, in the east end of Glasgow, the percentage was more than 60%.

Responsibility for increasing employability lies with a number of agencies and local policies. The national policy on employability is Workforce Plus which includes a strategy for young people who need more choices and chances.

For NHS Greater Glasgow and Clyde, the process of increasing employability in a community can help deal with the social and economic causes of ill-health and with the inequality gap through attracting sustainable employment that lifts people above the poverty line. The process of increasing employability also encourages supportive and encouraging environments that enable working age people to sustain and improve their health and well-being.

Health and social services link directly with employability in a number of areas such as primary care, addictions, learning and physical disability, mental health, services for offenders, children’s services including parents and young people, and community work. In particular the services that employability relates most closely with include: children’s services in relation to barriers to work particularly childcare and early intervention, services to young people, learning communities and community education, money, debt advice and financial inclusion and housing.

Through these relationships the public sector has many roles in employability as employer, investor, partner, provider of services, health improvement organisations and through engaging with communities. All of these roles can be carried out in ways that increase employability.

Examples of these roles are summarised for NHS Greater Glasgow and Clyde in Figure 3.3, but the principles of the relationships can be applied to any other public sector organisation (12).

Figure 3.3 - NHS roles in relation to employability

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Lessons from working on increasing employment

  • We should recognise that much can be achieved through effective partnerships involving the NHS, local authorities, the Scottish Government, Scottish Enterprise and others on projects that address social determinants of health.
  • We should assess how initiatives to increase employment affect inequalities, since generating more jobs in a given area does not necessarily mean that locally deprived or unemployed people will benefit.
  • We must consider the opportunities for the NHS to reduce worklessness as an employer and as an investor as well as in its more traditional roles as a partner and a provider of services.

Delivering health protection programmes

The Public Health Protection Unit is responsible for public health aspects of communicable disease and infection control, waterborne incidents, environmental hazards and the co-ordination of immunisation within NHS Greater Glasgow and Clyde.

As a public health measure, immunisations have been hugely effective in reducing the levels of disease and premature death. Immunisation programmes are designed to both protect the individual and prevent the population from contracting specific infectious diseases.

Low immunisation uptake rates are a public health concern because they increase the possibility of disease transmission and complications arising from outbreaks of infectious diseases. To this end, the Scottish Government has set a national target rate of 95% uptake among children aged 24 months for completed courses of the pre-school immunisations such as diphtheria, tetanus, polio, pertussis, Hib, Men C and pneumococcal vaccine. It has also set a target rate of 95% uptake in children by age 5 years for MMR vaccine.

Encouragingly, uptake is consistently high across all the CH(C)P areas, despite differences in deprivation levels. In the year ending December 2006, across the NHS Greater Glasgow and Clyde area, 97.9% of infants aged 24 months had completed their primary immunisations and 94.1 % of five-year-olds had had a first dose of MMR (13).

NHS Greater Glasgow and Clyde is encouraging all health professionals who are involved in immunisation in any way to complete a new e-learning educational resource. This will help staff to meet the training needs following the changes to the national immunisation schedule in 2006 and to address parental concerns more effectively.

Screening is a public health service in which members of a defined population are offered a test to determine whether they are at risk of contracting or have already contracted a specific disease. Screening for certain conditions is a highly effective public health measure. For example, the rate of cervical cancer in the UK has almost halved in women younger than 65 years since 1988, when national call-recall systems began (14).

One fifth of the population in NHS Greater Glasgow and Clyde, approximately 240,000 people, are invited to take part in national screening programmes each year.  Screening is offered in pregnancy, new born, vision, breast and cervical cancer programmes.  A diabetic retinopathy screening programme has recently been introduced and a bowel cancer screening programme will be implemented in 2009.

These programmes, based on sound evidence, are coordinated, monitored and evaluated by NHS Greater Glasgow and Clyde’s Public Health Screening Unit and are assessed by rigorous standards set by NHS Quality Improvement Scotland (15).

Lessons from delivering health protection programmes

  • Health protection programmes must be evidence-based, quality assured and take a systematic population approach.
  • We should positively target services, since unequal uptake of health protection services will increase health inequalities.
  • The primary care setting is crucial in delivering health protection services and ensuring uptake is high in immunisation and screening programmes
  • A well-trained, well resourced workforce is essential to maintain and improve programmes.
  • New technology provides many opportunities for improving programmes, for example in information handling, and in training.
  • Clear pathways and protocols are required to make sure that consistent integrated and appropriate care is provided for everyone in health protection programmes.

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