NHS HIGHLAND – ANNUAL REVIEW – WEDNESDAY, 27 AUGUST 2008

AGENDA ITEM 3

IMPROVING HEALTH AND REDUCING INEQUALITIES

Increasing Healthy Life Expectancy in Scotland

Reducing Smoking, Excessive Alcohol Consumption and other Risk Factors to a Healthier Life

Sexual Health Strategies and the HPV Vaccination Programme

Breaking the link between Early Life Adversity and Poor Health and other outcomes in later life and tackling health inequalities

Reducing Health Inequalities across the Population through Direct Action by Healthcare Services

Playing an active role in Community Planning Partnerships within the Single Outcome Agreement Framework to address local health problems such as violence; and to contribute to Services such as School Education and Working with other Organisations to deliver Shared Outcomes for Improving Health and Tackling Inequalities

IMPROVING HEALTH AND REDUCING INEQUALITIES

INCREASING HEALTHY LIFE EXPECTANCY IN SCOTLAND

Defined as the number of years that a person can expect to live in good health, it has been included in the most recent Health and Wellbeing Profiles at Community Health Partnership (CHP) level. In the 5 year period 1999-2003, for men it is approximately 68-69 years whereas for women it is around 72-73 years. These compare favourably with Scotland for both genders.

Whilst there are no direct earlier comparators for each CHP, it is possible to compare with Boards and Scotland for the period 1999-2000. The 2 year improvement in Scotland for men between these time periods has been exceeded in each of North, Mid and South East CHPs when compared to Highland Health Board. For women, the 3 year improvement in Scotland has been exceeded in each of North, Mid and South East CHPs. Examination of trends for ArgyllBute CHP is difficult as the only comparator is for the former ArgyllClyde Health Board which would have included such areas as Paisley resulting in a lower expectancy for 1999-2000. However, healthy life expectancy in Argyll & Bute is similar for both genders to the rest of NHS Highland for 1999-2003, all of which exceed Scotland.

1999-2000 / 1999-2003
Scotland / Males / 64.3 / 66.3
Females / 66.8 / 70.2
Highland Health Board / Males / 66.1 / n/a
Females / 69.0 / n/a
Argyll & Clyde Health Board / Males / 62.6 / n/a
Females / 65.6 / n/a
North CHP / Males / n/a / 68.5
Females / n/a / 72.9
Mid CHP / Males / n/a / 68.5
Females / n/a / 73.3
South East CHP / Males / n/a / 69.2
Females / n/a / 73.1
Argyll & Bute CHP / Males / n/a / 68.5
Females / n/a / 72.5

Sources: 1999-2000 from ISD; 1999-2003 from Health and Wellbeing Profiles 2008.

In summary, between 2000 and 2003 there have been improvements in healthy life expectancy of at least 2.5 years for men and 3.5 years for women in NHSHighland. This compares favourably with Scotland with improvements of 2.0 years for men and 3.4 years for women.

IMPROVING HEALTH AND REDUCING INEQUALITIES

REDUCING SMOKING, EXCESSIVE ALCOHOL CONSUMPTION AND OTHER RISK FACTORS TO A HEALTHIER LIFE

Reducing Smoking

The latest available percentage of adults smoking in Highland is 24.6% (2006), an improvement on the base year, 25.9% in 2004.

NHS Highland became a smoke free zone on 1 January 2008.

Over 1,700 people used Smoking Cessation Services in 2007, three times more than in 2006.

Last year an estimated 2.9% of the smoking population attempted to stop, just over three times higher than in 2006. Quit rates at one month were improved from 41% in 2006 and 45% in 2007.

All primary and secondary schools in Highland provide some tobacco education and all 2,500 primary 7 pupils in Highland Council area received information on the risks of smoking.

Over 2,000 young people from 15 secondary schools across the Highlands saw the “Whatever” play for young people during its two week tour.

Based on 2007 quit rates, just over 3,700 clients will need to set a quit date with NHS Highland smoking cessation services to achieve the HEAT target H6.

We plan:

  • To have a trained smoking cessation adviser in each secondary school to support smoking cessation and prevention.
  • To ensure all 220 primary schools in Highland Council area receive training to provide a programme of tobacco prevention.
  • To roll out the Smoke Free Homes initiative in Highland this year. Households with children are asked to make either the “Gold Pledge” to keep the completely smoke free at all times; or the ‘Silver Pledge’ to smoke only in one well ventilated room, and not in front of children. Households making a ‘Pledge’ are sent an information pack, a ‘goody’ bag containing various promotion items for their home, and a baseline questionnaire to assess their knowledge and attitudes towards smoking.
  • To continue supporting the Fire & Rescue Service to offer the public free home inspections and advice.

In addition NHS Highland Health Information and Resources Service supplies teachers, school nurses and youth workers with information and educational resources, and tobacco is a focus within the Health Promoting Schools Initiative.

ALCOHOL

Highland is steeped in a tradition of hospitality and is renowned for its contribution to the alcohol industry. In 2006/2007 there were 2,884 adult alcohol related discharges from general hospitals, part of a slow but steady upward trend. These included people admitted for alcohol induced pancreatitis and alcohol related liver disease, gastric problems and acute intoxication.

Progress 2007/2008

In the Northern 3 CHPs, GPs recorded surveillance and counselling for problem alcohol use 1,350 times, similar to the previous year (1,332). GPs in Argyll Bute achieved about 730 brief interventions in 2007/2008, which is in line with the projected trajectory.

Work is ongoing in schools to ensure that young people have the right information and support to prevent alcohol related problems developing. Highland is developing a Prevention & Education Strategy for Substance Misuse. Youth services have also had significant investment over the years for those who are already struggling with their alcohol intake.

To date 6staff have been trained as brief intervention trainers across the 4 CHPs and RaigmoreHospital and a training delivery plan has been established. An increase in alcohol prevention and treatment services has been identified within CHP development plans, but an increase in capacity is needed to maintain services for identified dependant users.

The Board is committed to partnership working through two multi-agency Drug and Alcohol Action Teams. Service training needs assessment for screening is underway and the eKSF and ATL systems will be used to monitor uptake of training. This will help in identifying and recruiting a workforce to deliver interventions. Training plans are focussed on those delivering services to people with substance use issues. This includes mental health and voluntary sector workers. Services available across the area include alcohol counselling services, detoxification support and self-help groups.

Work in 2008/2009 – The Forward Agenda

In line with national priorities to improve early intervention services, work is underway on development of screening and brief interventions within primary care, A&E and maternity. Relevant staff across NHS Highland will take up the Health Scotland “Training for Trainers” course on Alcohol Related Harm and Brief Interventions during the year. This will allow a cascading of training throughout each area to a variety of staff working in different settings, including A&E, primary care and ante-natal care. A screening and brief intervention handbook which has been used successfully in Tayside has been adapted for use in Highland.

Written and on-line material on the brief intervention conversation will be produced to support the use of this tool.

The main areas of action for alcohol services are:

  • Brief interventions in primary care and A&E – this includes developing the Local Enhanced Service (LES) and continuing the specialist elements of the previous NES – follow-up treatment in conjunction with specialist services and detox by the primary health care team.
  • Increasing the capacity for alcohol liaison in wards, A&E, Antenatal Clinics and Primary Care Emergency Centres.
  • Maintaining and increasing the capacity for treatment – specialist services.
  • Partnership working through the Drug and Alcohol Action Teams. This includes work with both local authorities and the voluntary sector.

This work will be under-pinned by training, development and implementation of appropriate information systems.

For primary care, a cumulative target is set as 75% of those identified as requiring screening and a brief intervention will receive this by 2010/2011. By 2008/2009 NHS Highland will have developed services and information systems that capture the number of screenings and brief interventions delivered. Table 1 below details the calculation of targets and trajectories for brief interventions in primary care for the next 3 years.

Table 1. Numbers for NHS Highland by CHP for Primary Care delivery of screening and brief interventions for alcohol consumption
CHP / Pop’n aged 16+ / Requiring
screening
(19% of 16+ pop’n) / Requiring
Brief Interv’n (25% of screened pop’) / Annual target / Cumulative 3 year target 2010/11
2008/09 / 2009/10 / 2010/11
Screen / Brief Interv’n / Screen / Brief Interv’n / Screen / Brief Interv’n / Screen / Brief Interv’n
A&B / 75,699 / 14,383 / 3,596 / 2,876 / 539 / 11,506 / 2,158 / 14,383 / 2,697 / 14,383 / 2,697
North / 31,151 / 5,919 / 1,480 / 1,184 / 222 / 4,735 / 888 / 5,919 / 1,110 / 5,919 / 1,110
Mid / 73,356 / 13,938 / 3,484 / 2,788 / 523 / 11,150 / 2,090 / 13,938 / 2,613 / 13,938 / 2,613
SE / 71,411 / 13,568 / 3,392 / 2,714 / 509 / 10,854 / 2,035 / 13,568 / 2,544 / 13,568 / 2,544
Total / 251,617 / 47,807 / 11,952 / 9,562 / 1,793 / 38,245 / 7,171 / 47,807 / 8,964 / 47,807 / 8,964

Table Notes

Data Source: GRO (S) Small Area Population Estimates 2006.

Annual Target is cumulative: calculated as ¼ yr of year one and full year in year two and three.

Screening Target is 100% of screening required (ie 19% of 16+ population that require screening as per SIGN 74 criteria).

‘Brief Intervention’ Target is delivery of 75% of 'Brief Interventions' required (ie 25% of the 19% that require screening).

A LES for Alcohol is being revised to deliver the HEAT target. This will retain elements of the previous NES - follow-up treatment in conjunction with specialist services and detox by Primary Health Care Teams. Over year 1, all GP Practices will be encouraged to sign up to the new LES. Participating Practices will opportunistically screen patients withclinical risk markers in consultations, using an approved screening tool and deliver alcohol brief interventions to achieve agreed trajectories.

We are working to determine the trajectories for screening and ‘brief interventions’ in A&E and how this will link with primary care. The number of attendances at A&E due to alcohol misuse was estimated to be 11% of all A&E attendances in an audit of A&E departments carried out by NHS QIS. The annual throughput of unscheduled care at Raigmore A&E alone is around 45,000 attendances (32,000 A&E and 13,000 GP Out of Hours). This would indicate that around 8,550 persons would be eligible for screening per year and 2,137 would require an intervention. Further modelling is required to determine the workload on A&E and Out of Hours staff, plus the numbers likely to be referred to an intervention clinic. We are also working to identify a suitable screening tool for use in unscheduled care settings, develop an intervention clinic and care pathway.

Screening will inevitably disclose a number of dependent drinkers for whom Brief Interventions are not appropriate. Work will be done to estimate this increase in load on services and to modify in the light of this experience.

The recent allocation for training will fund a short term post of Training Coordinator, to co-ordinate delivery of training in alcohol screening and brief interventions across a variety of settings including primary care, A&E and maternity services.

HEALTHY WEIGHT

With rates of overweight and obesity at 64% of the adult population,Highland has taken an approach which promotes health at any weight. During 2007/2008 the Highland Healthy Weight Strategy was endorsed by NHS Highland and we have initiated work to promote a healthy weight environment. For example:

  • removal of sugary fizzy drinks from vending machines in 2 major sites and planned removal from other sites;
  • a catering strategy for the whole of NHS Highland will oversee increased fruit and vegetable sales and achievement of the Healthyliving award;
  • 260 staff have purchased bikes under the “Cycle to Work” scheme;
  • Healthy Working Lives and the Health Promoting Health Services are being implemented through locality health improvement groups.

We are developing both child and adult care pathways.

  • Funding has been secured through the “Well North” anticipatory care programme – with a cluster of remote and rural GP Practices to shape both clinical and community interventions to promote healthy weight locally; the aim is to provide appropriate and effective lifestyle advice in the GP setting and replicate these messages in the community.
  • The national Counterweight programme is being rolled out to Highland during the next 2 years. It is planned that 40 GP Practices will develop their expertise in providing treatment for overweight and obese clients.
  • The need for a secondary care service for obese adults was identified and a proposal is being developed for local specialist dietetic and psychology interventions to support our agreed referral pathway to NHS Grampian under the North of Scotland service agreement for bariatric surgery.

We are also developing a child health care pathway, and initial work to deliver HEAT target H3: child healthy weight intervention programme is underway:

  • A social marketing approach to the introduction of the interventions is to address parentalconcerns.
  • A variety of family based interventions will be developed, for both groups and individuals, to be delivered by developing the existing community workforce, from January 2009. In Highland, 1,200 overweight and obese children will be expected to complete a family based healthy weight intervention by 2011.

Partnership Working

NHS Highland continues to work with the Highland and Argyll & Bute Councils on the Schools (Nutrition and Health Promotion) (Scotland) Act; the development ofPhysical Activity Strategy; and the delivery of training and finance to support healthy eating in preschool settings. All schools in Highland have achieved Health Promoting Schools status. Work has been undertaken to support healthy eating in schools throughout the school day with a staged approach to taking the ‘tuck’ out of ‘tuck shops’. All Highland primary schools will comply with the Act by August 2008 and all secondary schools by January 2009 – ahead of the deadline of August 2009.

NHS Highland supports partnership working to promote the consumption of local produce, particularly fruit and vegetables. Examples include:

  • a weekly vegetable stall at Raigmore run by REAL (Real Education Active Lives)
  • a community interest company of InvernessHigh School
  • support for local shops through the Fun with Fruit initiative in pre-school settings
  • increasing amounts of local produce in school meals – organic carrots, free range eggs, Fionnair water, meat from a local butcher etc.

IMPROVING HEALTH AND REDUCING INEQUALITIES

SEXUAL HEALTH STRATEGIES AND THE HPV VACCINATION PROGRAMME

HEAT Targets

There are no HEAT targets which are specific to sexual health. However, there is a national requirement to reduce teenage pregnancy in the 13 – 15 age group 20% by 2010 from a 1996 baseline. Recent rates are:

Teenage Pregnancy (13 – 15) 2010 Highland target:5.1

Teenage Pregnancy (13 – 15) 2006 notional Highland target5.4

Teenage Pregnancy (13 – 15) 2006 Highland outturn:4.7

Teenage Pregnancy (13 – 15) 2006 Scottish outturn:8.1

Reducing rates of teenage pregnancy is also extremely important in reducing health inequalities. NHS Highland’s Health Knowledge and Information Team has identified that rates of teenage pregnancy in the North of Scotland show one of the steepest gradients in relation to inequalities.

It is difficult to establish other population outcome levels for sexual health. Women becoming pregnant in the 16 – 19 age group may be married and/or intending to start a family. As most people who have STIs will not have symptoms, increased rates of testing will inevitably lead to increased rates of diagnoses. Reductions in STIs may indicate genuine improvements or may indicate problems within the testing system.

Respect and Responsibility

NHS Highland has worked towards delivery of the action plan set out within Respect and Responsibility. NHS Highland’s second Sexual Health Strategy is fully congruent with Respect and Responsibility. It was developed using an Ethical Decision Making Framework ensuring its sensitivity to all faiths and cultures. Following the NHS Highland’s integration with Argyll Bute, we have consulted widely and during 2007/2008 Argyll Bute CHP and Council signed up to the Strategy now known as the Highland and Argyll Bute Sexual Health and Relationships Strategy. Strategic aims are to positively influence culture, to implement a comprehensive programme of sexual health promotion and develop appropriate and accessible sexual health services.

NHS HIGHLAND – ANNUAL REVIEW – WEDNESDAY, 27 AUGUST 2008

AGENDA ITEM 3

Key Clinical Indicators for Sexual Health Services

We are working towards using the complete suite of these indicators to monitor the performance of the Sexual Health Services in the NHS Highland area against the QIS standards. NHS Highland’s own sexual health service, Highland Sexual Health has provided Long Acting Reversible Contraception (LARC) for some time now. It is also provided in GP settings, particularly by many of those providing Locally Enhanced Services in Sexual Health. Rates of uptake of LARC are higher than the Scottish average.

Over 2007–2008, NHS Highland maintained its partnership with the voluntary sector to provide sexual health advice, counselling and services to young people under the age of 25. Highland Brook Advisory Centre was given resources to enable them to begin to offer LARC on a pilot basis. Four doctors who are able to provide LARC have been recruited by Brook and further training of nursing staff was provided with the intention of increasing use in 2008. In 2007/2008 Highland Brook Advisory Centre provided 201 staff sessions for 1,176 clients, this equated to 2,280 client visits; (24.4% increase from previous year).

Though rates of female sterilisation in Highland are amongst the lowest in Scotland, rates of LARC uptake are high while vasectomy rates are around the national average.

Proportions of pregnancies terminated in Highland at under 10 weeks gestation are slightly lower than the Scottish average, but this is against the background of Highland’s generally low termination rates.

QIS Standards 2008

We are already delivering on many of the criteria of the QIS Standards in Sexual Health issued in March 2008. For example:

  • An integrated specialist sexual health service delivering the full range of contraceptive and STI interventions as well as HIV testing and counselling.
  • Targeted services for communities and individuals with specific needs. A young person’s service is run in partnership with Highland Brook Advisory Service and a service focusing on high risk groups/HIV is provided in partnership with Terrence Higgins Trust Highland.
  • Use of the voluntary sector (Terrence Higgins Trust Highland) to provide a range of sexual health promotion initiatives at a population level but focussing particularly on high risk groups and HIV.
  • A specialist strategic sexual health promotion resource working closely with the voluntary sector and local multi-agency forums to promote sexual health.

NHS Highland and Highland Council continue to advocate the use of Living and Growing in primary schools and Sexual Health And Relationships Education (SHARE) in secondary schools.