HEALTH of the PEOPLE
within the LANARKSHIRE
the
NHS Board Area
2006
Annual Report of
the Director of Public Health
The Department of Public Health
Lanarkshire NHS Board
ACKNOWLEDGEMENTS
I am once again grateful to all staff within
the Department of Public Health for
their painstaking work and commitment
to the practice of Public Health in
Lanarkshire and beyond in 2006.
I am also grateful for their contribution
to the Annual Report.
I would like to thank in particular
Derek Roseburgh for the statistical
appendix and Evelyn Thomas for desktop
publishing, and for their help in the
production of this report.
The Department of Public Health
Lanarkshire NHS Board
14 Beckford Street
HAMILTON ML3 0TA
Telephone: 01698 206335
Fax:
01698 424316
www.nhslanarkshire.co.uk
© Lanarkshire NHS Board
Published October 2007
We encourage the use by others of
information and data contained in this
publication. Brief extracts may be
reproduced provided the source is fully
acknowledged. Proposals for
reproduction of large extracts should
be sent to the address above.
ISBN 0 905453 24 7
CONTENTS
Page
Foreword ................................................................................................................................................ iv
Summary ................................................................................................................................................. v
HEALTH IMPROVEMENT
1.
2.
3.
4.
5.
6.
Health of the People of Lanarkshire................................................................................................. 1
Global Health - Local Action ........................................................................................................... 9
Alcohol ........................................................................................................................................... 15
Cardiovascular Disease Prevention ................................................................................................ 21
Pharmaceutical Public Health......................................................................................................... 29
Oral Health of Children .................................................................................................................. 35
HEALTH PROTECTION
7. Communicable Disease and Environmental Health ....................................................................... 39
8. Tuberculosis Prevention and Control ............................................................................................. 51
9. National Screening Programmes in Lanarkshire ............................................................................ 57
HEALTH SERVICE PROVISION
10. Implementing Health Needs Assessments
10.1
Eating Disorders ................................................................................................................ 65
10.2
Diabetes Retinal Screening ............................................................................................... 70
10.3
Clinical Sexual Health Services ........................................................................................ 72
11. Needs Assessments
11.1
Smoking in Pregnancy....................................................................................................... 77
11.2
Ethnicity and Health.......................................................................................................... 82
11.3
Childhood Obesity............................................................................................................. 87
11.4
Termination of Pregnancy ................................................................................................. 91
11.5
Pregnancy Anomaly Screening Programme...................................................................... 96
11.6
Sudden Cardiac Death in Young People ......................................................................... 100
11.7
Advances in Diabetes Care: Insulin Infusion Pumps ...................................................... 106
11.8
Child and Adolescent Mental Health .............................................................................. 109
11.9
Urological Cancers .......................................................................................................... 114
Data Sources for Tables and Figures .................................................................................................. 121
Statistical Appendix ............................................................................................................................ 122
Staff within the Department of Public Health..................................................................................... 147
FOREWORD
FOREWORD
Public health works across the three main functions of Health Improvement, Health Protection and
Health Service Provision. The Annual Report of the Director of Public Health provides an
opportunity to report on recent activities in these three areas of public health practice and also to look
forward. Information and its correct interpretation is essential for effective public health practice and
quantitative and qualitative information is used widely throughout the report. Global, as well as
regional and local perspectives, affecting the life circumstances in which people find themselves, the
lifestyles they adopt and healthcare provision are highlighted. Preventive, as well as proactive
measures to protect the population’s health, are reported, as is progress in implementing the
recommendations of earlier needs assessments on eating disorders, diabetes and clinical sexual health
services. The healthcare needs of those who smoke in pregnancy, of ethnic groups, of children who
are overweight and those suffering from mental ill health, are assessed along with the specialist needs
of those who suffer sudden cardiac death under 35 years of age and those with a urological cancer.
Working with colleagues in North and South Lanarkshire Council is increasingly necessary to
improve and protect health and well-being and I am grateful for their contributions to this report. I
extend my special thanks to all staff in public health who are committed to promoting, maintaining
and improving the health of the people of Lanarkshire, and in particular to the NHS Board, fellow
Directors and clinical colleagues who have supported the public health endeavour.
This report is presented first to Lanarkshire NHS Board and then distributed throughout the NHS and
partner organisations. It is available on the web and an edited version is circulated widely throughout
Lanarkshire and beyond. Comments and suggestions are greatly appreciated.
Dr Dorothy C Moir
Director of Public Health
iv
SUMMARY
SUMMARY
HEALTH IMPROVEMENT
Health of the People of Lanarkshire
The relationship between health and deprivation is well recognised and various measures of health
differences between affluent and deprived groups are described. Children are Lanarkshire’s future
and measures of children’s health are described also.
While life expectancy is increasing, deprived parts of Lanarkshire have not shown sustained
improvement in recent years. Cancer deaths have declined gradually over the last ten years, but the
gap between the most and the least deprived has gradually increased. A large part of this difference
can be attributed to cancers related to smoking. Coronary heart disease deaths are also steadily
decreasing, but the difference between affluent and deprived communities in Lanarkshire persists.
The birth rate in Lanarkshire has declined for more than 50 years although there has been a slight
increase in the last three years. Over 35% of first-time mothers are in the most deprived 20% of the
Lanarkshire population.
The prevalence of smoking in pregnancy in Lanarkshire continues to be higher than the Scottish
average. However, it is decreasing steadily among women from the most deprived sector of the
population, while among more affluent women there has been very little improvement.
The teenage pregnancy rate in 13-15-year-olds has been stable in recent years with a gradual decline
among those living in deprived areas and a gradual increase in those living in affluent areas.
Although breastfeeding falls short of the national target, the number of women breastfeeding has
increased in deprived areas.
The occurrence of unintentional injuries is also examined and, while deaths as a result of injury are
three times more common in children living in deprived areas, the low rate of admission to hospital
with injury in Lanarkshire is surprising.
Global Health - Local Action
The concept of global health, health issues that transcend national boundaries, is increasingly
recognised. Extremes of weather, with more heatwaves and periods of heavy rain with subsequent
flooding and associated health consequences, are an increasing reality. Diet is influenced by
globalisation and, while some changes have been beneficial in the most part, these changes have been
detrimental to health, contributing substantially to the increased prevalence of chronic disease, as
consumers continue to choose unhealthy high-fat/sugary foods.
Globalisation and increased travel has led to an increase in travel-associated illness, particularly
gastrointestinal infections and malaria. The importance of providing advice on preventive measures
before, during and after travelling to minimise these infections is highlighted, along with the global
action required to tackle environmentally destructive industries.
While globalisation impacts on health, local life circumstances and prevalent risk-taking lifestyle
factors which predispose the population of Lanarkshire to heart disease, stroke, cancer and respiratory
disease also need to be tackled, even more imminently if health is to improve. Evidence-based
lifestyle interventions to improve health in respect of the following:
v
SUMMARY
•
•
•
•
•
•
•
•
•
Alcohol
Drugs
Diet
Mental health
Oral health
Physical activity
Sexual health
Smoking
Ultraviolet radiation
were endorsed by Lanarkshire NHS Board in 2006 and supported by the wider NHS, both Local
Authorities, Police, Fire and Rescue colleagues also, and are being implemented through the
Community Health Partnerships.
Alcohol
Alcohol-related problems in Lanarkshire have continued to worsen. These have resulted in increased
alcohol-related consultations in primary care, along with alcohol-related hospital admissions and
deaths from related disease in Lanarkshire, which is consistently more than twice the UK overall rate.
Relevant education on the dangers associated with excess alcohol consumption, along with fiscal
measures such as reduction in blood alcohol levels permitted for driving, appropriate pricing and
implementation of the new licensing legislation, is required to address this problem. Health and social
care, in collaboration with other agencies who have a significant role in assessment, treatment and
rehabilitation, is required to treat the increasing numbers with alcohol-related illness.
Cardiovascular Disease Prevention
Primary prevention of cardiovascular disease in persons without symptoms can be achieved by
supporting them to stop smoking, lose weight, improve diet, take exercise and medicines to lower
cholesterol and blood pressure, if required. Most Lanarkshire people have some of these risk factors
and the overall risk of developing cardiovascular disease over a ten-year period can be calculated and
those at high risk can reduce that risk by modifying their lifestyle and taking medication. In North
Lanarkshire, the Keep Well National Pilot includes practices in Airdrie, Coatbridge and Wishaw with
a population of around 100,000 people, 25,000 of whom are aged between 45 and 64 and eligible for
Keep Well. Of the first 5453 patients who attended for a screening appointment, 2078 were referred
to the chronic disease management nurse, 591 to counterweight, 257 to smoking cessation and 339 to
an exercise programme. An earlier audit showed under identification of people at high risk of
cardiovascular disease in Lanarkshire and Keep Well provides an opportunity to improve this.
Pharmaceutical Public Health
Other changes in the approach to tackling poor health in Scotland in recent years include pharmacists
working with local authority and voluntary sector colleagues to provide lifestyle as well as advice
about medicines to the general public. Pharmacists also play a key role in the supply of vaccines
stored at the appropriate temperature for effective immunisation. They also have a key role in the
preparation of the Pandemic Influenza Plan, working with local pharmacy contractors and
representatives of the major pharmacy multiples. Local plans have also been progressed to ensure the
provision of essential medicines in the event of a pandemic and to minimise the disruption in their
day-to-day provision.
vi
SUMMARY
Oral Health of Children
Children in deprived areas of Lanarkshire are 3 times more likely to suffer from severe dental decay
and require urgent dental treatment than those who are more affluent. There are also higher numbers
of children living in deprived areas, compared with affluent areas, and promoting oral health is key to
reducing dental decay.
Regular dental attendance is important to prevent and treat dental disease. In 2006, 64% of children
in Lanarkshire were registered with a dentist, continuing the gradual upward trend from the mid1990s. The percentage of dental registration varies across age groups, with those aged 6-12 having
the highest rate of 74%.
The Dental Action Plan has a special focus on improving oral health. To help prevent dental disease,
free toothbrushes and free tubes of fluoride toothpaste are provided by public health nurses for all
children under the age of 1. Children aged 3 and 4 attending nursery receive two free dental packs
each year for home use. This is followed by a free dental pack for all primary 1 children. Other oral
health improvement initiatives include participation in Childsmile West programme for people living
in deprived areas. Oral health is also being built into the school curriculum as part of the Health
Promoting Schools scheme.
HEALTH PROTECTION
Communicable Disease and Environmental Health
During 2006, the focus on strengthening local preparedness for managing large outbreaks or incidents
continued alongside measures to tackle existing concerns, such as healthcare-associated infections and
hepatitis C. In addition to this more strategic work, over 1000 health protection problems were dealt
with directly during 2006. There has also been a steady increase since 2001 in the number of patients
diagnosed with hepatitis C, now totalling 1430. By the end of 2006, 155 males and 47 females known
to be Lanarkshire residents have been diagnosed with HIV infection. The risk to Lanarkshire
residents of acquiring HIV infection through sexual intercourse continues to rise and it is, therefore, of
increasing importance to promote safer sexual practices.
The evolution of the UK vaccination programme continued in 2006, providing immunisation against
diphtheria, tetanus, whooping cough, measles, mumps and rubella and various forms of meningitis.
Pneumococcal vaccination was introduced recently for all children under two who are most at risk of
invasive pneumococcal disease, causing meningitis, septicaemia and severe pneumonia in children
under five. Overall vaccination protection is very high in Lanarkshire at over 98%.
Emergency preparedness is an increasingly important responsibility for NHS boards and in 2006 new
plans were developed for Pandemic Flu and Smallpox Vaccination. Training is an important aspect
and NHS Lanarkshire staff participated in national, regional and local exercises.
Food safety inspection, advice, training and enforcement duties remain high priorities within both
North and South Lanarkshire’s food safety teams and training has been provided for 8500 food
handlers in the county. Both councils operate out-of-hours noise teams to respond to complaints
about noise caused in the main by amplifying equipment. Air quality management has also been
developed, as has implementation of the Civil Government (Scotland) Act 1982 (Licensing of Skin
Piercing and Tattoing) Order 2006.
vii
SUMMARY
Tuberculosis Prevention and Control
TB remains an important chronic infectious disease across the world. Rates of infection are
particularly high in London and the Midlands. Scotland, fortunately, has not yet seen such increases.
However, in 2006, 54 cases were notified in Lanarkshire compared with 24 in 2005 and 34 in 2004.
Completion of treatment is important to reduce the risk of relapse or development of drug resistance.
NHS Lanarkshire participates in the enhanced surveillance of such infections and the importance of
screening new migrants to Lanarkshire from higher incidence countries is highlighted.
With easy frequent national and international travel and the increased risk of resistant TB, the theme
of a recent World TB Day ‘TB anywhere is TB everywhere’ is very appropriate.
National Screening Programmes in Lanarkshire
Screening for cervical and breast screening are well established in Lanarkshire and the uptake meets
the national targets, except for cervical screening in the 20-24 year age group where NHS Lanarkshire
is following the national trend of reduced uptake in this age group. Colorectal screening to enable
earlier detection of colorectal cancer, before people have symptoms, commences in Scotland in March
2007 and will be implemented in NHS Lanarkshire during August 2009. Universal newborn hearing
screening (UNHS) was introduced across Lanarkshire in 2005 and the service has been fully
operational since January 2006 with a programme uptake of 96.2%. Newborn blood spot screening
for metabolic abnormalities such as phenylketonuria, congenital hypothyroidism and cystic fibrosis is
undertaken with 99.9% uptake.
HEALTH SERVICE PROVISION
Implementing Health Needs Assessment
Implementing the recommendations of earlier needs assessments is reported in:
•
•
•
Eating Disorders
Diabetic Retinal Screening
Clinical Sexual Health Services
Eating Disorders
Eating disorders have been the subject of increased attention throughout the UK, with reports
highlighting inconsistency and lack of service provision. Identification and prediction of need can be
difficult as there are significant levels of co-morbidity and a reluctance of sufferers to seek help.
Progress has been made in planning a new local and regional eating disorder service, taking account
of the evidence-based NHS Quality Improvement Scotland recommendations for the management and
treatment of eating disorders.
Diabetic Retinal Screening
In December 2006, 23,400 people, 4% of the Lanarkshire population, had been diagnosed with
diabetes. The long-term complications are serious and common. Diabetes adversely affects the retina
and diabetic retinopathy is the biggest single cause of blindness and visual impairment in Scotland
among people of working age. Laser treatment is very effective at halting the disease. A diabetes
needs assessment in 2003 recommended the introduction of the diabetes retinal screening programme
and the launch of that programme at the Time Capsule, Coatbridge in August 2006 is described. It is
viii
SUMMARY
also available in Hamilton and Wishaw and uptake is predictably high. A priority service
development is to ensure provision of ambulance transport for those with limited mobility.
Clinical Sexual Health Services
Attention has been drawn to the need for more sexual health services and various service
developments have taken place, in particular the appointment of new sexual health clinicians. During
2006, three sexual health clinics were provided for young people across Lanarkshire: more are
required. Working closely with the Alcohol and Drug Action Team during the second half of 2006,
services were developed to reach people in vulnerable groups and make services, including a
specialist clinic, more accessible to them. Training for NHS staff, for teachers and raising awareness
continue to be important, as are relationships with voluntary sector organisations which have been
strengthened.
Health Needs Assessment
One of the starting points for health service planning is the epidemiologically-based assessment of the
health and healthcare needs of the resident population and this Annual Report includes prioritised
needs assessments which make recommendations for development of local services for the following:
•
•
•
•
•
•
•
•
•
Smoking in Pregnancy
Ethnicity and Health
Childhood Obesity
Termination of Pregnancy
Pregnancy Anomaly Screening Programmes
Sudden Cardiac Death in Young People
Advances in Diabetes Care: Insulin Infusion Pumps
Child and Adolescent Mental Health
Urological Cancers
Smoking in Pregnancy
Smoking in pregnancy is the single largest preventable cause of foetal disease and death as it is
associated with spontaneous abortion (miscarriage), premature birth, low birthweight, stillbirth and
foetal hypoxia among other causes. Local research in 2006 showed that pregnant women were less
concerned about smoking while pregnant than about bringing up their children in households with
smokers. Smoking is most common in Lanarkshire among pregnant women under 20 years. There
are about 1600 each year who need to be encouraged to stop. In 2006, only 106 of the 3441 who
attempted to give up smoking were pregnant. All pregnant women who attend an NHS Lanarkshire
booking clinic receive ‘brief intervention’ at the clinic and are encouraged to attend the Smoking
Cessation Services. Better ways of engaging pregnant women need to be found.
Ethnicity and Health
Ethnicity can impact on health in a range of ways. It is, however, difficult to quantify because there is
a general lack of good quality useful ethnic data, as it is optional to record the ethnicity of patients in
the NHS in Scotland. Consequently, it can be difficult to assess ethnic-related healthcare needs which
may be overlooked, resulting in ethnic groups being inadvertently disadvantaged by NHS staff. Some
diseases are genetic, some lifestyle-related and some ethnic groups have been shown to be at greater
risk of coronary heart disease and diabetes. Some are travel-related, such as tuberculosis, HIV and
some gastrointestinal infections. The Infectious Disease Unit at Monklands Hospital provides a range
of services, including inpatient facilities for these. Health-related information and advice for
ix
SUMMARY
travellers is available in different languages. Professional translators can be called when required,
there are a number of useful websites and a training programme for senior managers to raise
awareness of ethnicity issues.
Childhood Obesity
Obesity in children is increasing at an alarming rate. In 2005/06, 20.3% of children in primary 1 in
Lanarkshire were overweight; this includes 8% who were obese and 4% who were severely obese.
The level of overweight, obese and severely obese children is higher in the most deprived groups.
This increase is attributed to children’s eating habits and lack of physical activity. It is estimated that
at least 70% of obese adolescents will remain obese. Actions to tackle childhood obesity are largely
preventive. Healthier food choices in nurseries and schools are actively promoted and Hungry for
Success is well established across all schools in Lanarkshire. A small number of children have a
suspected underlying medical condition and others who have serious obesity-related morbidity may
require admission to hospital. A multi-disciplinary inter-agency group is developing a childhood
obesity strategy for Lanarkshire with the main emphasis on prevention, but with community treatment
options for those who require it.
Termination of Pregnancy
The Scottish Sexual Health Strategy Respect and Responsibility acknowledges the importance of
access to good quality abortion services and, in Lanarkshire, abortion services are provided as part of
a comprehensive strategy to improve women’s sexual and reproductive health. Termination carried
out early in a pregnancy is associated with a lower risk of complications, and women considering an
abortion should be encouraged to consult a health care professional at an early stage. Improving
access and reducing waiting times is an important issue for the termination of pregnancy service.
Providing post-abortion contraception is also important and 86.2% accepted post-abortion
contraception and advice.
Pregnancy Anomaly Screening Programmes
Screening during pregnancy enables identification of abnormalities, such as Down’s syndrome and
spina bifida. More accurate methods, including ultrasound scanning techniques, have been developed
in recent years. In Lanarkshire, all pregnant women are offered a simple ultrasound in the first three
months of pregnancy to confirm that the foetal heart is beating, establish how many foetuses are in the
womb, provide information on the age of the unborn and allow an accurate prediction of the ‘due’
date. Anomaly scans, which look for structural abnormalities in the unborn in the second three
months, are offered to women who have certain risk factors. Approximately 1100 women each year
qualify for an anomaly scan. In 2004, approximately 41% of Scottish obstetric units routinely offered
such anomaly scans. In 2006, only three maternity units did not routinely offer such anomaly scans.
Wishaw General Hospital is one of these three and the introduction of anomaly scanning is
recommended.
Sudden Cardiac Death in Young People
Sudden cardiac death (SCD) in people between 14 and 35 years of age is distinct from sudden cardiac
death in people over 35 years, which is usually related to coronary heart disease. In some cases,
sudden cardiac disease may be hereditary because of a history of sudden cardiac death in the family
and an assessment of the family genetic history is required to identify other susceptible family
members. The Department of Health published a report entitled Arrhythmias and Sudden Cardiac
Death in 2005 recommending that hereditary cardiac conditions should be managed by a dedicated
multi-disciplinary service, including a cardiologist, geneticist, genetic counsellor and cardiac
technicians who specialise in relevant diagnostic investigations. In Scotland, it is estimated by
x
SUMMARY
cardiology experts that around 70 people from all age groups die each year from sudden cardiac death
due to a disturbance of cardiac rhythm. A Lanarkshire analysis identified 31 sudden cardiac deaths in
young people over a 5-year period and on average 5 sudden cardiac deaths can be expected in young
people every year in Lanarkshire. Lanarkshire GPs currently refer concerned first-degree relatives to
the cardiology service. However, some first-degree relatives may not be appropriately investigated,
particularly if the family is dispersed. A combined cardiac genetic clinic is being established in West
of Scotland and Lanarkshire will be able to refer people to the service.
Advances in Diabetes Care: Insulin Infusion Pumps
Diabetes mellitus is a lifelong disease caused by lack of the hormone insulin. The key aim of insulin
treatment is to mimic, as closely as possible, the natural production of insulin to achieve normal blood
sugar levels. Increasing numbers are being diagnosed with diabetes and over twenty-two thousand
were included in the Diabetes Register in December 2006. While conventional treatment achieves
control in the majority of patients, a small number would benefit from administration of insulin by
subcutaneous infusion. Patients have to be selected according to evidence-based criteria and between
25 and 50 patients in Lanarkshire are predicted to benefit from this treatment.
Child and Adolescent Mental Health
At any one time, about 10% of children and young people have mental health problems of sufficient
severity and persistence to impact significantly on the child’s functioning or relationships. The rate is
higher in boys, among 11-15-year-olds, among young black people and among children living in lone
parent households and low income families. At any one time, between 6500 and 7000 school-aged
children in Lanarkshire have such a problem. The Scottish Executive Framework for Promotion,
Prevention and Care recommended three types of services: universal services for all children,
services targeted at those children at the greatest risk of mental ill health and specialist services
including inpatient care. Priority developments include appointing a named mental health worker for
every school, supporting the existing service for accommodated young people, a specific additional
service for children with learning disability and ensuring care for young people who require inpatient
admission.
Urological Cancers
Prostate Cancer is the second most common cancer in men in Scotland. Prostate cancer incidence in
Lanarkshire rose steadily until the late 1990s and then declined until 2003, in contrast to an unabated
increase throughout Scotland over the same period. Lanarkshire has a significantly lower incidence of
prostate cancer than all other health boards for the period 1999-2003, almost certainly reflecting local
PSA testing practice, which may have been less prevalent in Lanarkshire in the past. There has also
been a significant decline in bladder cancer rates in Scotland since around 1996, thought to relate to a
change in classification of some bladder cancers from invasive to non-invasive tumours. Smoking is
the main established risk factor for bladder cancer, with more historical exposure to chemicals in the
dye and rubber industries strongly demonstrated as a further significant risk factor. Kidney cancer has
increased in both sexes mirroring Scottish trends. Lower survival is associated with increasing
deprivation. Recent evidence demonstrates an increased risk of renal cell carcinoma with increasing
weight, while other renal tumours are increased by tobacco smoking.
Healthcare professionals working in the primary care team have an important role, recognising
symptoms suggestive of cancer and organising appropriate referral. The Scottish Referral Guidelines
for suspected cancer published by the Scottish Executive in 2002 have been endorsed for use in
Lanarkshire. The urological cancers are diagnosed and treated by the specialist urology service.
Oncology treatments, including chemotherapy and radiotherapy, are provided from the Beatson
Oncology Centre while relative 5-year survival has been improving for most urological cancer.
xi
SUMMARY
Reduction in key risk factors is important, as is ensuring the time between urgent referral and
treatment is less than 63 days. Emerging evidence about the value of PSA testing should be kept
under review.
xii
HEALTH IMPROVEMENT
Health of the People of Lanarkshire
CHAPTER 1
HEALTH OF THE PEOPLE OF LANARKSHIRE
•
This chapter provides information on
Lanarkshire’s population and various healthrelated measures. It examines, in particular,
the health of children, but first reviews various
measures of differences between affluent and
deprived groups in respect of:
•
•
•
•
•
•
99.5 per cent of all babies born alive in 2006
survived their first year, compared to 99.4% in
2005. These figures show some fluctuation
from year to year.
Life expectancy
Life expectancy
Cancer
Coronary heart disease
Smoking in pregnancy
Teenage pregnancy and
Breastfeeding
Death rates in Lanarkshire remain above the
Scottish average for men and women and for
those under and over 65. While death rates are
improving over time, the gap between
Lanarkshire and Scotland is not decreasing as
detailed in Table 1.1. Lanarkshire’s death rate
has consistently averaged around 7% above
the Scottish rate since the start of the 1990s.
Individual years have been rather better or
rather poorer: 2006 was one of the former.
Poor health is widespread in Lanarkshire.
Standardised mortality ratios (SMRs) enable
valid comparisons of death rates to be made
between populations. The reference value is
100 for Scotland and SMRs greater or lower
than 100 indicate worse or better death rates
respectively.
These measures were reported previously in
the 2004 Annual Report of the Director of
Public Health. Detailed tables are provided in
the Statistical Appendix.
Population
The estimated population of Lanarkshire at 30
June 2006 was 558,139, a slight increase from
the estimate of 557,088 in 2005. The most
recent projections of the future population of
Lanarkshire are 2004-based and project a slow
increase in the population size. The gradual
ageing of the population is not expected to
change.
Table 1.1
Standardised mortality ratios 1981-2006
(Scotland 1981-83 = 100)
Pregnancy and birth
Year
Routinely compiled pregnancy statistics do not
include all conceptions, only those that result
in a hospital admission for a miscarriage, a
therapeutic abortion or a birth. There were
8458 recorded conceptions in Lanarkshire in
2006. Of these, 1211 ended in a therapeutic
abortion, 625 in a miscarriage requiring
hospital admission and 38 in a stillbirth.
1981-83
1984-86
1987-89
1990-92
1993-95
1996-98
1999-2001
2002-04
2005
2006
Scotland
Lanarkshire
Lanarkshire
as a % of
Scotland
100.0
95.6
92.5
87.0
85.5
81.1
77.2
73.7
69.4
68.3
106.6
100.4
96.0
92.4
91.3
86.7
82.0
79.1
74.1
72.5
106.6
105.1
103.8
106.2
106.8
106.9
106.2
107.3
106.7
106.2
,
Life expectancy is slowly increasing in
Scotland and Lanarkshire, though deprived
parts of Lanarkshire have not shown sustained
improvement in recent years as shown in
Figure 1.1.
Of the 6584 babies born alive in Lanarkshire
in 2006 (compared with 6283 in 2005):
•
•
10 died in the next 11 months (12 in 2005)
15 died in the first week (11 in 2005)
9 died in the next 3 weeks (12 in 2005)
1
HEALTH IMPROVEMENT
Health of the People of Lanarkshire
were 40% more likely to die prematurely of
cancer than people in the most affluent areas.
A large part of this difference can be attributed
to cancers related to smoking. Lung cancer,
for example, constitutes approximately 30% of
cancer deaths in Lanarkshire for people under
75 years. About 90% of these deaths are due
to smoking and therefore preventable.
Cancer
Cancer mortality in those under the age of 75
has declined gradually throughout the last ten
years. The death rate in Lanarkshire has
consistently lagged behind the Scottish
average by a small amount. The gap between
the most and the least deprived has gradually
increased, as shown in Figure 1.2. In 20042006 people from the most deprived areas
Figure 1.1
Life expectancy at birth (years), both sexes combined
3-year moving average life expectancy
85
80
Lanarkshire
affluent
Scotland
75
Lanarkshire
70
Lanarkshire
deprived
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
19
94
65
Figure 1.2
Cancer age <75, age/sex standardised mortality rate (deaths per 100,000 population)
250
Lanarkshire
deprived
200
Lanarkshire
150
Scotland
100
Lanarkshire
affluent
50
2
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
0
19
94
3-year moving average rate
300
HEALTH IMPROVEMENT
Health of the People of Lanarkshire
Coronary heart disease (CHD)
Smoking in pregnancy
Coronary heart disease deaths under the age of
75 are steadily decreasing in Lanarkshire but
still remain above the Scottish average rate
and the difference in CHD mortality between
affluent and deprived communities in
Lanarkshire still persists (Figure 1.3). Efforts
are ongoing to reduce CHD mortality across
Lanarkshire by reducing rates of smoking,
providing better care in general practice
through the new contract for general
practitioners, and by improving care in
hospital with the increased use of thrombolytic
drugs, angioplasty and other interventions.
The prevalence of smoking in pregnancy in
Lanarkshire continues to be higher than the
Scottish average except among Lanarkshire’s
affluent women. It is, however, decreasing
steadily among women from the most deprived
sector of the population, while among more
affluent women, there has been very little
improvement over the last ten years
(Figure 1.4).
Teenage pregnancy
The teenage pregnancy rate in 13 to 15-yearolds has been stable in recent years. However,
Figure 1.5 shows a gradual decline among 13
to 15-year-olds living in deprived areas and a
gradual increase in those living in affluent
areas. In 2006, the number of pregnancies in
13 to 15-year-olds in deprived areas was 31
and the number in affluent areas was 10. As
these numbers are small, there can be
considerable year-to-year variation. Data for
Scotland are only available to 2004 and it is
not,
therefore,
possible
to
compare
Lanarkshire and Scottish trends.
In order to address the gap in CHD mortality
between deprived and affluent communities in
Lanarkshire, a national pilot project Keep Well
has been established in Coatbridge, Airdrie
and Wishaw. By enhancing primary care
services in these deprived parts of Lanarkshire,
people with existing cardiovascular disease or
who are at high risk of developing
cardiovascular disease can be identified and
offered appropriate treatment and follow-up to
reduce their risk of dying at a young age from
this condition.
The Keep Well pilot is
described in Chapter 4 of this report.
Figure 1.3
Coronary heart disease age <75, age/sex standardised mortality rate (deaths per 100,000 population)
200
Lanarkshire
deprived
150
Lanarkshire
100
Scotland
Lanarkshire
affluent
50
3
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
0
19
94
3-year moving average rate
250
HEALTH IMPROVEMENT
Health of the People of Lanarkshire
Figure 1.4
Percentage of pregnant women smoking (at booking visit)
3-year moving average %
50
40
Lanarkshire
deprived
30
Lanarkshire
Scotland
20
Lanarkshire
affluent
10
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
94
19
95
0
Figure 1.5
Pregnancies age 13-15, rate per 1000 females age 13-15
3-year moving average rate
15
12
Lanarkshire
deprived
9
Scotland
Lanarkshire
6
Lanarkshire
affluent
3
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
19
94
0
Analysis of national data shows a direct
relationship between deprivation and low
breastfeeding rates. The impact of deprivation
in some areas of Lanarkshire is particularly
evident where recorded rates are half that of
the Scottish average.
Although the
breastfeeding rates for 2006 show that
Lanarkshire has some way to go to achieve the
national target of 50%, nevertheless between
2001 and 2006 the number of women
breastfeeding has increased in deprived areas,
as shown in Figure 1.6.
Breastfeeding
In spite of the recognised substantial health
advantages of breastfeeding for mothers and
babies, fewer women in Lanarkshire choose to
breastfeed.
Since 1996, a series of
breastfeeding
initiatives
have
been
implemented in areas of deprivation to try to
persuade mothers to breastfeed for the first six
weeks. The initiatives include the Unicef
Baby Friendly Initiative, to achieve best
practice standards for breastfeeding, and 3
peer support programmes in targeted areas.
4
HEALTH IMPROVEMENT
Health of the People of Lanarkshire
Figure 1.6
Percentage of babies breastfed at 6 weeks
3-year moving average %
50
40
Lanarkshire
affluent
30
Scotland
Lanarkshire
20
Lanarkshire
deprived
10
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
19
94
0
child health surveillance and immunisation. A
greater range of information is available from
periodic surveys and longitudinal studies, which
include Lanarkshire children in a larger Scottish
or UK-wide sample.
Children’s health
The measurement of children’s health requires
a different focus to that for adults. Long-term
conditions in children are relatively
uncommon; death is a rare outcome in
childhood after the first few weeks of life and
diseases which manifest in adults as a result of
long-term life circumstances and lifestyle
choices do not manifest themselves in the
younger population. Yet the health of children
is critical because there is strong evidence to
suggest that early life experiences have a
strong influence on the pattern of health and
disease in later life. A particularly important
piece of evidence, which has become apparent
only in the last few years, is that the bond
between an infant and its parents in the very
earliest months and years of life has a critical
1
impact on future development. A child that is
not adequately nurtured in the first year is
likely to suffer long-term difficulties in
neurological development, speech, social
control and mental health. These difficulties
may be hard to reverse at a later stage when
they become manifest.
Births
The birth rate in Lanarkshire has declined for
more than 50 years. The rate mirrors a decline
in Scotland over a similar period. There has
been a slight increase in the last three years.
Similar short-lived increases have occurred in
the past in the late seventies and early nineties.
It remains to be seen if the current trend will
become a more sustained increase.
Figure 1.7 shows the high proportion of
Lanarkshire babies born to mothers living in
more deprived areas. Less than 5% of first
time mothers in Lanarkshire live in the least
deprived fifth of Scottish areas, whereas over
35% live in the most deprived fifth.
Lanarkshire mothers also tend to be younger;
69% are aged less than 30 compared with 61%
of all Scottish first time mothers.
A limited amount of information is collected on
children’s health which enables comparison
between Lanarkshire and the rest of Scotland.
What information there is derives from the
Registrar General’s reports on births and deaths,
the analysis of hospital discharges and from the
child health programme, including screening,
Overweight children
Children who are overweight or obese are
much more likely to continue to follow the
same weight pattern into adulthood. The
rising rate of obesity in childhood is
therefore a cause of national and local
5
HEALTH IMPROVEMENT
Health of the People of Lanarkshire
concern. Figure 1.8 shows the percentage of
overweight and obese children born in 2001.
Effectively, it compares children now with
children in 1990 when the currently-used
centile charts were created. It shows, for
example, that 4% of Lanarkshire pre-school
children are in the severely obese category,
whereas only 2% would have been in that
category in 1990.
Injuries
Unintentional injuries are a major cause of
morbidity and death in children. Comprehensive
statistics on all children attending an accident and
emergency department, which would give a best
estimate of the occurrence of accidental injury, are
not yet available in Scotland. Lanarkshire has a
lower rate of hospital admissions of children
because of accidents than the Scottish average.
In general, Lanarkshire children are more
likely to be overweight than the Scottish
average. A total of 21.6% of Lanarkshire
children are either obese or overweight
compared to 15% in 1990.
Deaths as a result of injury are three times more
common in children living in deprived areas, as
shown in Figure 1.9. The low rate of admission
with injury in Lanarkshire is therefore surprising
although not easily explained.
Figure 1.7
First births, by deprivation quintile, Lanarkshire and Scotland, 2004/05
40
35
Percentage
30
25
Lanarkshire
20
Scotland
15
10
5
0
1 - Least
Deprived
2
3
4
Deprivation quintile (Carstairs)
5 - Most
Deprived
Figure 1.8
Pre-school children with high body mass index (BMI), Lanarkshire and Scotland, year of birth 2001
25
Mean number of teeth
20
Severely obese
(>=98th centile)
15
Obese (95th-98th
centile)
10
Overw eight (85th95th centile)
5
0
Lanarkshire
Scotland
6
HEALTH IMPROVEMENT
Health of the People of Lanarkshire
After the first year of life, where a larger
number of infants die as a consequence of
problems arising at the time of birth, deaths in
children are uncommon. The commonest
causes are congenital anomalies, neurological
diseases, cancer and accidental injuries.
Mortality
Figure 1.10 shows the principle causes of
death in children for Scotland in 2005. As can
be seen, the numbers are too small to allow a
separate analysis for Lanarkshire.
Figure 1.9
Deaths from unintentional injury, children aged under 15 by deprivation quintile, Scotland, 2001-2005
Standardised mortality ratio (Scotland=100) with 95% confidence intervals
Standardised mortality ratio
200
150
100
50
0
1 - Least
Deprived
2
3
4
Deprivation quintile (SIMD)
5 - Most
Deprived
Figure 1.10
Main causes of death in children aged under 15, by age group, Scotland, 2005
Percentage of all deaths
100
80
60
40
20
0
Under 1
(284)
1-4
(60)
5-9
(30)
10-14
(48)
Age group
(No. of deaths)
Perinatal conditions
Signs and symptoms
Infectious Diseases
Endocrine, nutritional, metabolic/blood diseases
7
Congenital anomalies
Nervous system
Malignant neoplasms
Accidents & adverse effects
HEALTH IMPROVEMENT
Health of the People of Lanarkshire
REFERENCES
Level of support that children need
In 2005, a new child health programme was
introduced into Lanarkshire. For the first
time, children were categorised by their level
of need. All children receive a core child
health programme of screening, surveillance,
immunisation and health promotion. Some
children require additional support; a
smaller proportion requires intensive
support, often from several agencies. The
first year of the programme in Lanarkshire
demonstrates that about 20% of children
have additional needs and about 5% have
intensive needs. Children in deprived areas
are slightly more likely to have additional or
intensive needs. This information is at an
early stage of development. It is still based
on a mainly subjective judgement by the
public health nurse and comparisons across
areas are limited because there are important
differences in the way in which criteria are
applied. In the future, it is expected that this
information will form an important measure
of health need.
Health in early life
Growing up in Scotland is a major new study
following the lives of Scottish children. It is
based on a sample of children drawn from
across Scotland, but there is no information at
2
board level. Nonetheless, the initial findings ,
based on analysis of two groups of children babies and toddlers - provide important
insights into life circumstances and the health
of young children. The fundamental message
is that adverse family circumstances, including
having a teenage mother, low household
income, and lone parenthood all have adverse
impacts on a wide range of indicators of child
health. These include low birth weight, health
problems requiring a contact with health
services, accidents and admission to hospital.
As the survey develops, it will provide an
important source of information about the
impact of adversity on children’s health and
development.
8
1.
Balbernie R. An infant in context: multiple risks, and
a relationship. Infant Mental Health Journal 2002;
23(3): 329-341.
2.
Scottish Executive Education Department. Growing
up in Scotland: Sweep 1 Overview Report.
Edinburgh: SEED, 2007.
HEALTH IMPROVEMENT
Global Health - Local Action
CHAPTER 2
GLOBAL HEALTH - LOCAL ACTION
the global scale when attempting to tackle major
public health problems such as infectious
diseases, environmental health, obesity, drug and
alcohol abuse and sexual health issues.
GLOBALISATION AND HEALTH
The world is getting smaller - events, social,
political, environmental and economic, impact
directly or indirectly on health. What occurs
in one area can have rapid consequences for
the rest of the world. This phenomenon globalisation - profoundly affects health on a
national, regional and local basis. Travel and
migration are increasing and, while increased
travel
and
migration
bring
many
improvements to health and well-being,
including cultural, social and economic
benefits, they can also affect health adversely.
GLOBALISATION AND CLIMATE
CHANGE
Climate change is perhaps the global health
problem for the 21st century. Extremes of
weather are an increasing reality and it is
estimated that there will be an increase in the
mean annual temperature in the UK of between
2.5 and 3 degrees centigrade by the end of the
3
The health effects are occurring
century.
already.
The concept of global health, health problems,
issues and concerns that transcend national
boundaries and may be influenced by
circumstances or experiences in other countries,
and best addressed by co-operative actions and
1
solutions, has been developed. It is illustrated
2
in Figure 2.1.
The recent heatwave across Europe in 2003 is
reckoned to have led to at least 27,000 heatrelated deaths, of which 2000 occurred in the
3
UK. More heatwaves and periods of heavy
rain with subsequent flooding are predicted as
3
well as droughts and water shortages. The
health effects of these climatic changes are
3
summarised in Table 2.1.
The factors, which affect the population of
Lanarkshire, be they adverse life circumstances
or unhealthy lifestyles, all have global
dimensions. It is therefore important to consider
Figure 2.1
Conceptual framework for globalisation and population health
9
HEALTH IMPROVEMENT
Global Health - Local Action
Table 2.1
Climate change and potential health effects in the UK
Climate-related change
Heatwaves
Flooding
Heavy rain
Droughts
Raised ozone in the air
Increased ultraviolet light exposure
Infectious diseases
Allergies
Potential health effect in the UK
Dehydration, heat stroke
Drowning, injuries, electrocution, carbon monoxide poisoning, exposure to
chemically contaminated water, acute and chronic psychological problems,
infectious disease from exposure to sewage-contaminated floodwater,
affects on health and social care delivery due to disruption of transport,
water and electricity supplies
Failure of water treatment processes due to contamination of the raw water
supply with bacteria
Water shortages
Potentially increased acute and chronic cardiovascular and respiratory
disease
Increased sunburn, skin cancers and cataracts
Travel-associated malaria, airport malaria, Lyme disease (probably due to
changed leisure behaviour rather than increased tick prevalence),
foodborne infections
Increased allergic rhinitis
Flooding and heavy rain are becoming
increasingly common and in the UK there is a
theoretical risk that exposure to sewagecontaminated floodwater can lead to gastrointestinal illness such as campylobacter,
salmonella, E.coli O157 or hepatitis A;
fortunately, the dilution of such contaminants in
floodwater reduces the risk. It is, however,
important that simple infection control advice is
adhered to. Heavy rain can mean that raw water
is more heavily contaminated with organisms
and this can overwhelm water treatment plants
leading to the need to issue ‘boil water notices’
and advise the public of the importance of
4
complying with this advice. Floodwater can
also become contaminated with chemicals such
as oil or diesel. Flash floods, particularly where
no warning has been given, have led to deaths
from drowning, which are often vehicle related.
The psychological consequences of flooding can
be substantial. Both acute distress and more
5
long term anxiety and depression occur.
regarding diet is increasingly influenced by
globalisation. Some of the dietary changes have
been beneficial; fresh fruit and vegetables are
available all year round and choice has greatly
increased. However, for the most part, these
changes in food have been detrimental to health,
substantially contributing to the increased
6
prevalence of chronic disease. Further, while
wealth has increased and the relative price of
food reduced, the dietary discrepancies between
affluent and deprived communities are
increasing.
The social, cultural, economic, technological and
geopolitical changes that have caused the change
in our food culture are complex. However, one
of the key drivers at the heart of these changes is
the profit-making aim of transnational
companies which control the key elements of the
6
food supply chain.
The cheapest produce can be sourced from
across the globe, undercutting local purchasers,
quickly transported at high environmental costs,
processed and sold in their retail outlets. Profit
is maximised and intensive ecologically
damaging farming methods encouraged. The
food produced is demand-led, and consumers
choose unhealthy high fat/sugar foods. More
food is consumed than is required for
increasingly sedentary lifestyles, hence weight
6
gain and obesity follow. This choice, however,
does not take place in a social vacuum.
While local adaptation of the environment
including upgrading of coastal defences is
important to minimise local health and other
effects, the prevention of further climate
change requires a global approach.
GLOBALISATION AND FOOD
Over the last few decades, there have been vast
changes in food consumption as choice
10
HEALTH IMPROVEMENT
Global Health - Local Action
Local and national efforts to change dietary
habits have made limited progress in the face
of the vast persuasive powers of the food
industry. Health education, while improving
knowledge and motivation, has had little affect
on dietary behaviour. Engagement with the
industry has been on a consensual, rather than
legislative or regulatory basis, leading to
6
small, even token, gestures on its part.
indulge in more risky behaviours, especially
when intoxicated.
GLOBALISATION AND SUSTAINABLE
DEVELOPMENT
Sustainable development has been defined as
balancing the fulfilment of human needs with
the protection of the natural environment so
that these needs can be met not only in the
8
present but also in the indefinite future.
Social, as well as environmental, goals are
important.
These economic, social and
environmental spheres, as shown in Figure
8
2.2 , are inter-dependent determinants of the
health of current and future generations;
progress on all fronts is required if the future
of the planet and its inhabitants is to be
secured.
Accordingly, local measures alone cannot begin
to have a significant impact on Scotland’s
unhealthy diet; global governance structures are
required to counteract this global problem.
Global agreements relating to the food chain,
analogous to the WHO Framework Convention
on Tobacco Control, have the potential to force
the aims of social justice, sustainable
development and public health on what is
currently a largely profit-led system. Public
health has an important advocacy role in putting
the case to large corporations, appealing, if all
else fails, to their long-term self-interest, and to
the national and international legislative bodies
6
in Scotland, the UK and the European Union.
Figure 2.2
Environment
Economy
Society
GLOBALISATION AND TRAVEL ASSOCIATED ILLNESS
Sustainable development, health
and well-being for people, and
the world
Infections associated with UK residents
travelling abroad are increasingly recognised.
More people are travelling to more exotic
places. There are many limitations to the
currently available surveillance systems for the
monitoring of travel-associated illness,
particularly lack of travel history and
7
diagnostic samples. The types of infection
associated with travel include gastrointestinal
disease (salmonella, shigella, typhoid,
paratyphoid and malaria). Many of these
infections occur among those visiting friends
and relatives abroad, frequently returning to
their country of origin, often to India, Pakistan
or sub-Saharan Africa. This group may not
access travel health advice before travelling,
missing the opportunity to gain access to, for
example, anti-malarial prophylaxis and
7
advice. Accordingly, there is a need to use
innovative ways to reach communities to
advise of the need for preventive measures
before, during and after travelling.
In
addition, there is a greater likelihood that
while on holiday (younger) people may
While in affluent countries economic gains
have improved life expectancy within these
societies, life expectancy also varies according
to life circumstances. Towns and cities have
been built which promote increased reliance
on transport, furthering consumption of fossil
fuels, causing global warning and subsequent
climate change, but also leading to less
9
personal daily physical activity. Many drive
to supermarkets to purchase heavily marketed
energy-dense foods, which have often been
flown around the world before they reach the
UK. When the built environment is designed
to meet the needs of cars rather than people,
communities become fragmented, individuals
socially isolated, and mental health and well10
being suffers. Modern life has become as
bad for health as it is for the environment.
Many strategies to achieve sustainable
development involve working at the macro11
HEALTH IMPROVEMENT
Global Health - Local Action
economic level. The shift from income to
environmental taxes, the shift of subsidies
from environmentally destructive industries
such as aviation to renewable sources of
energy such as wind farms have been
11
suggested.
healthier eating, promoting oral and dental
health and developing social skills through
play among pre-school children, can bring
benefits that last a lifetime.
The promotion of health as a key concept in the
workplace, and developing work opportunities
and job security, helps to increase the overall
health of those who are employed and thereby
the communities in which they live. Stress
damages health and increases the risk of disease,
and tackling stress and promoting well-being in
the workplace and the community is also
important for health improvement. Tackling
antisocial behaviour and increasing safety in the
community makes an important contribution to
well-being. Public health also continues to
collaborate within regeneration programmes
tackling health issues in the least affluent areas
in Lanarkshire and most pertinently through
Health Impact Assessments, Joint Health
Improvement Planning, community capacity
building and community development.
There is a growing awareness of the need for
public health to take into account the impact of
its actions beyond the health of the public, to
ensure that the health of the environment, of
society and of the economy is included when
considering health improvement. This will help
to sustain the current and future health and wellbeing of the population as well as the
12
The advent of the European
environment.
Parliament provides greater opportunity to
influence larger administrations on the effects of
globalisation.
LOCAL ACTION AND HEALTH
While health in Lanarkshire continues to
improve as evidenced by increasing life
expectancy, deaths in Lanarkshire from heart
disease, stroke, cancer and respiratory disease
remain among the highest in Scotland, the UK
13
The provision of
and Western Europe.
effective treatment for these conditions in
primary and secondary care is essential to
maintain the current level of health
improvement, but so is tackling the lifestyle
factors and life circumstances which predispose
to these illnesses.
LIFESTYLES
This has become increasingly important as the
trends in unhealthy lifestyles, particularly
among children and young people, continue to
increase.
Nine lifestyle factors were identified as being
particularly relevant in Lanarkshire and the
evidence for lifestyle interventions to improve
health locally by addressing these were
examined in respect of:
LIFE CIRCUMSTANCES
•
•
•
•
•
•
•
•
•
Public health works at local level to influence
these key determinants of health.
Life
circumstances have been shown to affect
health and, in particular, the availability of
education, employment, social networks,
healthy food and transport, including walking
and cycling, have been identified as being of
key importance to maintaining and improving
14
health. Health follows a social gradient and
it is important to recognise this and ensure that
reducing and removing inequalities in
opportunity is at the core of the improving
health agenda. One way of achieving this is
through public health contributing effectively
to local planning which in turn determines the
provision of local services.
Community
planning, including early intervention on
Alcohol
Drugs
Diet
Mental health
Oral health
Physical activity
Sexual health
Smoking
Ultraviolet radiation
Each lifestyle factor was considered in the
Lanarkshire context, in the light of national
policy, current provision of services promoting
healthy lifestyles and evidence for interventions
most likely to be successful in ensuring healthier
lifestyles. The evidence was communicated
through an inclusive process involving public
12
HEALTH IMPROVEMENT
Global Health - Local Action
health, health promotion, local authority
planners and clinical and managerial
representatives from across the NHS. The
important contribution which lifestyle makes to
health was highlighted in the opening section of
NHS Lanarkshire’s strategy A Picture of
15
Health.
multidisciplinary seminars. Such interventions
are not only for the individual but are equally
applicable to improving the health of the family,
the community and the wider society thereby
increasing the likelihood of sustaining health
improvement gains.
Managed Clinical Networks (MCN) were
introduced in Scotland in 1999 to ensure
equitable provision of high quality clinically
effective services. Progress and development of
MCNs for coronary heart disease, stroke,
diabetes, vascular surgery and palliative care
have been reported in Annual Reports in 2003
17 18
The unhealthy lifestyle factors
and 2005. ,
described above are of particular relevance to
developing these diseases and it was agreed in
2005
that
a
pan-Lanarkshire
Health
Improvement MCN be established to take
forward these common aspects on behalf of the
other MCNs. The Health Improvement MCN
consists of the MCN managers, public health
and health promotion staff as well as the health
improvement managers from North and South
Lanarkshire Councils. The group has held two
stakeholder events to draw on the contributions
of a much wider group of stakeholders to help
develop the strategic direction and content of the
health improvement effort of the MCNs.
Working across the primary and secondary care
interface has been another important feature of
MCNs, not only for clinical aspects, but has also
facilitated, through joint working with local
authorities, the voluntary sector and the
communities of users and carers, the fasttracking of patients and sometimes their families
into lifestyle improvement interventions such as
smoking cessation and leisure and exercise
rehabilitation programmes.
The detailed evidence about how to intervene
to improve lifestyles, and the activities
required to bring this about, was endorsed by
Lanarkshire NHS Board in 2006.
In
particular, the relatively simple technique of
brief intervention used by relevant health
professionals was seen to be effective in
helping smokers quit, in reducing alcohol
consumption in those habitually drinking to
excess, in changing dietary habits, and helping
those who are physically inactive to become
16
A period of focused
more active.
consultation involving NHS Lanarkshire staff
including independent contractors, North and
South Lanarkshire Councils, Strathclyde
Police, Strathclyde Fire and Rescue, and
Public Partnership Forums took place towards
the end of 2006. There was strong support for
implementing the evidence base from the NHS
most notably the Community Health
Partnerships, both Local Authorities, the
Police, and Fire and Rescue colleagues who
regularly see the effects of unhealthy lifestyles
in their daily work.
HEALTH IMPROVEMENT
MODERNISATION PROGRAMME
Six modernisation programmes including Health
Improvement, Acute Care, Primary Care,
Maternal and Child Health and Mental Health
Services were established in NHS Lanarkshire in
2006. All contribute to improving as well as
maintaining health in Lanarkshire. The Health
Improvement Modernisation Programme is
tasked, in particular, with improving health
through improving lifestyles and life
circumstances as well as protecting health
through screening, immunisation and control of
communicable disease and environmental
hazards. The programme endorsed the evidence
base for lifestyle interventions for the nine
factors, which impact directly on the health of
the people of Lanarkshire and the priorities for
implementation
agreed
at
interagency
Achieving health improvement is challenging,
requiring active collaboration between the
NHS and its many partners, but must also take
account of the national, international and
increasingly global dimensions if health gains
are to be sustained.
REFERENCES
13
1.
Department of Health, Global Health Strategy.
London: Department of Health, 2007.
2.
Huynen M, Maretens P, Hilderink H. The health impacts
of globalisation: a conceptual framework. Globalisation
and Health 2005, 1;14.
HEALTH IMPROVEMENT
3.
Health Protection Agency and Department of Health.
Health Effects of Climate Change in the UK. An
update of the Department of Health Report
2001/2002. (Draft for Comment). Department of
Health and Health Protection Agency, 2007.
4.
Health Protection Agency 2007. Health Advice following
flooding.
http://www.hpa.org.uk/flooding/health_advice.pdf
Last accessed 24 August 2007.
5.
Werrity A, Houston D, Ball T et al. Exploring the Social
Impacts of Flood Risk and Flooding in Scotland.
Edinburgh: Scottish Executive, Social Research, 2007.
6.
NHS Health Scotland. Review of the Scottish Diet
Action Plan. Edinburgh: NHS Health Scotland, 2006.
7.
Health Protection Agency. Illness in England, Wales
and Northern Ireland associated with foreign travel. A
baseline report to 2002. Health Protection Agency,
2004.
8.
HM Government. Securing the future: delivering UK
sustainable development strategy.
London: The
Stationery Office, 2005.
9.
Davis A, Valescchi C, Fergusson M. Unfit for purpose:
how car use fuels climate change and obesity. London:
Institute for European Environmental Policy, 2007.
Global Health - Local Action
10. Radford G. Environment and health: fit for the future in
the east of England. ph.com. March 2006: 9.
11. Brown LR. Plan B 2.0: Rescuing a planet under
stress and a civilisation in trouble. 120
12. New York: W.W. Norton & Company, 2006.
13. UK Public Health Association. The Convergence of
Health and Sustainable Development: A Manifesto and a
Network. London: UKPHA, 2006.
14. Leon D, Morton S, Cannegiater S, McKee M.
Understanding the Health of Scotland’s Population in an
International Context: A review of current approaches,
knowledge and recommendations for new research
directions. London: London School of Hygiene and
Tropical Medicine, 2003.
15. Marmot, M. and Wilkinson, R. Social Determinants of
Health. The Solid Facts. Second Edition. International
Centre for Health and Society. Denmark: WHO Europe,
2003.
16. Lanarkshire NHS Board. A Picture of Health: A
Framework for Health Service Improvement in
Lanarkshire.
Hamilton, Lanarkshire NHS Board,
2005.
17. Lanarkshire NHS Board. The Evidence Base for
Lifestyle Intervention for Health Improvement.
Hamilton, Lanarkshire NHS Board, 2006.
18. Lanarkshire NHS Board. The Health of the People
within the Lanarkshire NHS Board Area. Annual
Report of the Director of Public Health 2003.
Hamilton: Lanarkshire NHS Board, 2004.
19. Lanarkshire NHS Board. The Health of the People
within the Lanarkshire NHS Board Area. Annual
Report of the Director of Public Health 2005.
Hamilton: Lanarkshire NHS Board, 2006.
14
HEALTH IMPROVEMENT
Alcohol
CHAPTER 3
ALCOHOL
The influence of alcohol on health has been
highlighted in many recent Annual Reports
1
of the Director of Public Health. In 1997,
limited statistical information was available
but since then, the importance of collecting
and providing information about substance
misuse has been recognised nationally and
ISD Scotland has provided an alcohol profile
for all health board areas in Scotland for
2
This chapter draws on that
2006.
information. The problem of alcohol misuse
was described in the 2000 report and more
specialist aspects, such as alcohol-related
liver disease in 2001, alcohol-related brain
damage in 2002, and the effects of alcohol
consumption on young people in 2003 and
on older people in that same report.
National action
In 2002, the Scottish Executive launched the
Plan for Action on Alcohol Problems which
set out the national strategic approach for
5
tackling alcohol-related harm in Scotland.
That report estimated that the cost of alcohol
problems across Scottish society, in an
economy exceeding £70 billion, is in excess of
£1 billion, comprising costs to the health
service, social care and justice as well as the
wider economy. The human costs borne by
individuals, their children and families were
not counted.
During 2006, several major national initiatives
are expected to impact on alcohol problems.
These include the review of the Plan for
Action on Alcohol Problems and the draft
Report on Mental Health and Substance
6
Misuse which reviewed progress on the Mind
the Gaps report into co-morbidity and A Fuller
Life, the report into alcohol-related brain
damage. Trends and Geographical variations
in alcohol-related deaths in the U.K. between
1991 and 2004 published by the Office for
7
provide
additional
National
Statistics
information and further emphasise the need for
action.
The damage inflicted by ‘drunkenness’ on
society features regularly in the media and
national and local press, and emerging
information gives cause for concern. This
chapter provides an update on trends in
alcohol consumption and on alcohol-related
morbidity and mortality. The global effects
are increasingly apparent and the evidence
base for lifestyle interventions to reduce this
particular risk-taking behaviour was endorsed
by NHS Lanarkshire Board in 2006 and is
highlighted in Chapter 2 of this report. Local
action, however, is insufficient and tackling
the problem at national level, as for smoking,
is necessary to reduce the effects of alcoholism
on the people of Lanarkshire in particular as
well as Scotland as a whole.
Local information
Young people’s health survey
The recently published Lanarkshire SALSUS
8
report shows a decline in the number of 13year-olds who have ever had an alcoholic
drink from 67% in 2002 to 55% in 2006.
There was a similar decrease in 15-year-olds
from 87% to 85%. However, for those 13year-olds who had had a drink in the last
week, the average rose from 11 units to 17
units; and for 15-year-olds from 13 units to 20.
Lanarkshire’s young people may be slightly
less likely to drink but those who do, drink
more, highlighting the need for local provision
of services for children and young people as
In recent decades the real price of alcohol has
fallen in Britain and the amount consumed has
increased. Current consumption is now 11.4
3
litres of pure alcohol per person per year and
these alcohol sales contribute more than £13
4
billion annually to the UK exchequer.
Although the proportion of government funds
derived from alcohol taxation has actually
fallen over the last fifty years, consumption of
alcohol has nevertheless increased as prices
have fallen in real terms.
15
HEALTH IMPROVEMENT
Alcohol
consumers of alcohol as well as victims of the
effects of the drinking of others.
was estimated at 27.2 per 1000 population
2
compared to 24.3 in Scotland.
Primary care
Hospital care
Estimates of alcohol-related consultations in
general practice are based on practice team
information (PTI) collected from a sample of
practices representative of the population.
Around 15,050 consultations took place with
GPs and practice nurses for alcohol misuse in
Lanarkshire. 10,050 of these consultations
were by men. The contact rate for Lanarkshire
In Lanarkshire in 2004/05, there were 3827
alcohol-related general hospital discharges. Of
these, 2824 were men. This is a 22% increase
over five years. The comparable increase for
Scotland was 21% as shown in Figure 3.1.
The male to female ratio was 2.8 to 1. Figure
3.2 shows that 50% of hospital discharges are
in people aged 35 to 54.
Figure 3.1
Alcohol-related acute hospital discharges, age standardised rates per 10,000 population, by sex,
Lanarkshire and Scotland, 1999/2000-2004/05
150
Rate per 10,000 population
125
Male
Scotland
100
Male
Lanarkshire
75
Female
Scotland
50
Female
Lanarkshire
25
0
1999/2000
2000/01
2001/02
2002/03
2003/04
2004/05
Figure 3.2
Alcohol-related acute hospital discharges, by age group and sex, Lanarkshire, 2004/05
Number of discharges
800
600
400
200
0
0-15
16-24
25-34
35-44
45-54
Age group
Male
16
Female
55-64
65+
HEALTH IMPROVEMENT
Alcohol
Figure 3.3
Alcohol-related acute hospital discharges, age standardised rates per 10,000 population, by deprivation
quintile, Lanarkshire, 2004/05
Rates per 10,000 population
140
120
100
80
60
40
20
0
1 - Least
deprived
2
3
4
5 - Most
deprived
Deprivation quintile (SIMD)
Of the 3827 alcohol-related hospital
discharges in Lanarkshire in 2004/05:
National trends: alcohol-related deaths in the
UK, 1991-2004
•
31% (1194) were classified as resulting
from harmful use (30% in Scotland)
•
21% (797) were attributed to acute
intoxication (19% in Scotland)
•
19% (737) had a diagnosis of alcoholic
liver disease (15% in Scotland).
The Office for National Statistics (ONS)
reported over 8000 alcohol-related deaths in
the United Kingdom in 2004, nearly double
the 1991 total. In 2004, alcohol-related deaths
accounted for nearly 1.5% of all deaths in the
UK compared with 0.6 per cent in 1991. Two
thirds of deaths were in men.
For both males and females, Scotland had
alcohol-related death rates which were
consistently higher than all other countries of the
UK across the period 1991/93 to 2002/04. Male
alcohol-related death rates in Scotland were 80
per cent higher than the overall UK rate in
1991/93, and consistently more than double the
overall UK rate between 1994/96 and 2002/04.
Of the 737 discharges with alcoholic liver
disease, most were aged 45-54. The number
of discharges associated with alcoholic liver
disease increased by almost a third between
1999/2000 and 2004/05.
Alcohol-related
deprivation
hospital
discharges
and
The ONS report split the period covered into
two: 1991-97 and 1998-2004; it also ranked
the 426 local authority areas in the UK in
order to compare regions and examine trends
in alcohol-related deaths.
There is a striking association between the rate
of alcohol-related discharges and deprivation
as measured by the Scottish Index of Multiple
9
Deprivation (SIMD). Those living in the most
deprived quintile were admitted to hospital
with alcohol-related problems nearly six times
more frequently than those in the least
deprived quintile, as shown in Figure 3.3.
For male alcohol-related deaths, North
Lanarkshire was ranked 9th in the earlier
period and 7th in the more recent period. In
neither period did South Lanarkshire rank in
the top twenty for men.
17
HEALTH IMPROVEMENT
Alcohol
For alcohol-related deaths in women, North
Lanarkshire was ranked 9th in the earlier
period and 3rd in the most recent period.
South Lanarkshire had risen from 21st to 8th
between the two time periods.
time as the initial Plan for Action was being
developed, a review of the liquor licensing law
10
was undertaken together with a review of off11
sales. The review led to the development of the
five licensing principles set out in the new
12
Licensing (Scotland) Act , the fourth of which is
protecting and improving public health.
These statistics show that not only is the health
impact of alcohol in Lanarkshire among the
worst in Britain, but also that the impact is
worsening compared to the rest of the country.
It is to be hoped that the new licensing
legislation, together with the new law on
antisocial behaviour, will produce tangible
health benefits. New Licensing Forums are
being established to support Licensing Boards
and local boards have specific representation
from NHS Lanarkshire. Support should be
given to the Scottish Government to bring
about developments in fiscal measures which
will change the binge drinking culture.
Need for national/local action
The excess of alcohol-related deaths in Scotland
in general and Lanarkshire in particular
compared with elsewhere in the United
Kingdom highlights the need to tackle alcohol
issues nationally as well as locally. The
circumstances in which Scottish people live and
the lifestyles they have adopted need to be
addressed as well as treatment and care, where
possible, for those who suffer from serious
illness as a consequence of excess alcohol
consumption. Awareness of the seriousness of
this problem must be constantly raised, so that
action results not only in the NHS and local
authorities but also in the Scottish Government.
Primary care
The main expenditure on alcohol-related harm
by NHS services is through ‘mainstream’
primary care and acute services. Advice on
Prevention of Relapse in Alcohol Dependence
13
was published in 2002 and a national guideline
on Management of harmful drinking and alcohol
14
in 2003.
dependence in primary care
Resourcing to implement these guidelines has
had to compete with other local priorities.
Health education and prevention
Evidence-based health education and health
promotion play a key role in trying to prevent
excessive alcohol consumption.
Lifestyle
interventions have been described elsewhere
and require to be implemented.
The new contract arrangements for GPs allow
for enhanced services for those with alcohol
and drug problems. Locally, drug services
have been enhanced with GPs with a special
interest helping to address drug problem
issues. Alcohol problems have not been
addressed in a similar way. The new GMS
contract encourages asking about alcohol
consumption but not offering specific help.
This requires to be supported. Local Councils
on Alcohol Services in each local authority
area have been introduced. Monklands
Council had 66 and Cumbernauld had 51 new
referrals in 2004/05.
An advertising ban on the promotion of
alcohol by sports teams, for example, would
be expected to have some influence, as would
provision of better information on the alcohol
content of drinks through graded markings on
glasses. Giving information on the calories in
each drink could also be valuable, given the
link between excess drinking and obesity.
Fiscal measures
Secondary care
Reduction in levels of blood alcohol permitted
for driving and legislation on maximising the
strength of drinks merit consideration.
Appropriate pricing of non-alcoholic drinks
should be introduced as they are currently
disproportionately high. It is frequently cheaper
to buy alcohol than soft drinks. At the same
Specialist services include those provided by
the NHS Lanarkshire Alcohol and Drug
Service working together with Local Authority
Substance Misuse Services.
18
HEALTH IMPROVEMENT
Alcohol
Following the Plan for Action, the Scottish
Executive identified specific extra resources
for alcohol services, currently £800,000 a year
in Lanarkshire.
The additional resource,
overseen by the Lanarkshire Alcohol and Drug
Action Team, has been added to resources for
drug services where patients suffer from both
alcohol misuse and drug misuse problems.
The draft report Delivering for Mental Health:
Mental Health and Substance Misuse calls for
increased public health efforts to prevent
alcohol problems arising and developing;
specialist services to support more general
provision, provision of training resources,
better working together; and the integration of
alcohol-related brain damage (ARBD) services
into a wider approach to cognitive impairment
rather than an extension to alcohol treatment
services.
Specific treatments have been
recommended in an earlier needs assessment
for those with liver disease and continue to be
relevant.
This report demonstrates that alcohol-related
problems in Lanarkshire, already serious, have
continued to worsen. These have resulted in
increased alcohol related work for the NHS,
both in primary and secondary care.
Substance Misuse Team, Information Services Division,
NHS National Services Scotland. Alcohol Profile:
Lanarkshire. Edinburgh: ISD, 2006.
http://www.alcoholinformation.isdscotland.org/alcohol
misuse/files/Lanarkshire Profile2006.pdf
Last accessed 25 September 2007.
Statistics on alcohol: England, 2006 (NHS Information
Centre).
5.
Scottish Executive. Plan for Action on Alcohol Problems.
Edinburgh: Scottish Executive, 2002.
6.
Scottish Executive. Delivering for Mental Health
Commitment 13: Mental Health and Substance Misuse
draft report. Edinburgh: Scottish Executive, 2007.
7.
Breakwell C, Baker A, Griffiths C, Jackson G, Fegan G,
Marshall D. Trends and geographical variations in
alcohol-related deaths in the United Kingdom, 19912004. In Health Statistics, Quarterly, Spring 2007, ONS.
8.
Scottish Schools Adolescent Lifestyle and Substance
Use Survey (SALSUS) 2006. Smoking, drinking and
drug use among 13 and 15-year-olds in Lanarkshire.
http://www.drugmisuse.isdscotland.org/publications/a
bstracts/salsus/Lanarkshire_2006.pdf
Last accessed 1 October 2007.
9.
NHS Quality Improvement Scotland. Clinical Outcome
Indicators Report 2005. Edinburgh: NHS QIS, 2005.
12. SE strategy, Getting it Right for Every Child.
http://www.scotland.gov.uk/Topics/People/YoungPeople/ childrensservices/girfec
Last accessed 2 October 2007.
13. Health Technology Board for Scotland. Prevention of
relapse in alcohol dependence. Glasgow: HTBS, 2002.
14. Scottish
Intercollegiate
Guidelines
Network.
Management of harmful drinking and alcohol
dependence in primary care. Guideline 74. Edinburgh:
SIGN, 2003.
REFERENCES
2.
4.
11. Scottish Executive. The Report of the Working Group
on Off-Sales in the Community. Edinburgh: Scottish
Executive, 2004.
Action to reduce alcohol-related harm has
increasingly become necessary. Education and
preventive action, including fiscal measures as
well as improvements in health care and joint
working with other agencies who have a
significant role, are all required to address this
growing problem.
Lanarkshire Health Board. The Health of the People
within the Lanarkshire Health Board Area. Annual
Report of the Director of Public Health 1997, 2000,
2001, 2002, 2003. Hamilton: Lanarkshire Health
Board 1998, 2001, 2002, 2003, 2004.
UK Estimated Gross Value Added (GVA) from the
Office of National Statistics. Annual consumption
comprising 6 billion litres of beer, 600 million litres of
cider, 1.4 billion litres of wine, 120 million litres
equivalent of pure alcohol as spirits.
http://www.statistics.gov.uk/default.csp
Last accessed 1 October 2007.
10. Scottish Executive. The Nicholson Committee, Review
of Liquor Licensing Law in Scotland. Edinburgh:
Scottish Executive, 2003.
Recommendations
1.
3.
19
HEALTH IMPROVEMENT
Alcohol
20
HEALTH IMPROVEMENT
Cardiovascular Disease Prevention
CHAPTER 4
CARDIOVASCULAR DISEASE PREVENTION
•
Primary prevention interventions have been
shown to make a substantial contribution to the
observed decline in cardiovascular deaths during
the last thirty years in Scotland and other
1
countries.
The emphasis placed on the local
development of CVD primary prevention
plans in the 2002 National Strategy for CHD
2
and stroke.
EPIDEMIOLOGY
Primary prevention refers to interventions that
prevent cardiovascular disease (CVD) even
before an individual experiences any symptoms.
Examples include services to help people to stop
smoking, lose weight, improve their diet, take
exercise and the use of medicines to lower
cholesterol and blood pressure. This is distinct
from secondary prevention, which involves a
similar set of interventions being provided to
people that already have CVD, in order to
prevent it from becoming more serious. The
importance of CVD primary prevention is
underlined by the following developments:
•
•
Cardiovascular disease includes coronary heart
disease (CHD), cerebrovascular disease (mainly
stroke) and peripheral vascular disease, and
together they account for around one third of all
deaths in Lanarkshire. Deaths from CVD have
been falling in Lanarkshire and other parts of
Scotland, but in spite of this it is still the main
cause of death in Scotland in people under 65
years and those aged 65 and over. The Scottish
Executive set a target for a 60% fall in CHD
deaths and a 50% fall in stroke deaths in people
3
under 75 years of age between 1995 and 2010
and Lanarkshire is on course to meet these
targets, as shown in Figures 4.1 and 4.2.
Establishment of Keep Well pilots across
five sites in Scotland, including one in North
Lanarkshire, by the Scottish Executive in
2006.
The findings from a detailed analysis of the
contribution of different risk factors and
interventions to the fall in CHD deaths in
Scotland between 1975 and 1994 are
4
summarised in Figure 4.3.
The inclusion of CVD primary prevention in
the new General Medical Services (nGMS)
contract as a direct enhanced service in
2006.
Figure 4.1
250
200
150
100
50
0
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
Standardised rate (3-year moving ave.)
Deaths from coronary heart disease, persons under 75 years, Lanarkshire and Scotland
Lanarkshire
Scotland
21
Lan. target
Scot. target
HEALTH IMPROVEMENT
Cardiovascular Disease Prevention
Figure 4.2
75
60
45
30
15
0
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
Standardised rate (3-year moving ave.)
Deaths from cerebrovascular disease, persons under 75 years, Lanarkshire and Scotland
Lanarkshire
Scotland
Lan. target
Scot. target
Figure 4.3
Decline in CHD mortality in Scotland, 1975-1994
Angina treatment
2%
Not explained
12%
Blood pressure
15%
Secondary
prevention
8%
Cholesterol
6%
Heart failure
treatment
8%
CABG/
angioplasty
2%
AMI (heart
attack) treatment
10%
Smoking
37%
Most of the reduction in blood pressure,
cholesterol and smoking rates as described in
Figure 4.3 is thought to be related to primary
prevention measures.
Overall, primary
prevention is thought to have contributed to
48% of the reduction in CHD deaths in
Scotland during this period, with secondary
prevention and acute treatment services
accounting for 40%. The other 12% of the
reduction in deaths is unexplained, given the
current level of understanding of what causes
CHD.
22
HEALTH IMPROVEMENT
Cardiovascular Disease Prevention
RISK FACTORS
Table 4.1
Risk factors for CHD and stroke and interventions
Modifiable risk factors
Non-modifiable risk factors
Risk factor
Age
Gender (male)
Ethnicity (South Asian)
Family history
Previous cardiovascular event
Intervention
Smoking
Poor diet
Physical inactivity
Obesity
Interventions to change lifestyle
behaviours
Hyperlipidaemia (high
cholesterol in blood)
Raised blood pressure
Diabetes
Lifestyle interventions and drug
treatments where appropriate
It is estimated that around 25,000 people in
Lanarkshire have CHD, which represents
5
between 4% and 5% of the adult population.
In addition, an estimated 1500 people in
Lanarkshire have a stroke or transient
ischaemic attack (TIA or mini-stroke) every
6
year. However, primary prevention focuses
on the majority of people in Lanarkshire that
have neither of the above conditions. The
main risk factors that pre-dispose individuals
to CHD and stroke are summarised in Table
4.1.
factors by a small amount in a large sector of the
population rather than target the highest risk
group. The population approach focuses on
action to influence choices about smoking, diet,
exercise and other CVD risk factors in a nontargeted way as well as trying to influence the
wider determinants of health including socioeconomic conditions, environment, attitudes to
health and others. Rose argued that most illness
events occurred in people at low risk because
they made up the majority of the population.
However, the findings from more recent studies
have cast doubt on the Rose hypothesis. A
recent Canadian study showed that a targeted
CVD prevention approach that focuses on highrisk individuals is likely to be more effective and
9
cost-effective than a population approach. It is
thought that this challenge to the Rose
hypothesis has resulted from developments in
information
technology
and
improved
understanding of CVD risk factors. These
developments have allowed for a more refined
approach to identifying people at high risk of
CVD and targeting interventions accordingly.
The majority of people in Lanarkshire will have
some of the above risk factors for CHD and
stroke. Depending on the number of risk
factors present and their severity, it is possible
to calculate an overall risk of developing CVD
in people that are currently free of this condition
(CVD risk score), expressed as a percentage
chance of having a major CVD event (heart
attack or stroke) over a ten-year period.
Individuals with a CVD risk score that is greater
than 20% are classified as high risk and in need
of intervention to lower their risk. It is
estimated that approximately one-third of the
Scottish population over the age of 40 years will
7
have a CVD risk score that exceeds 20%.
People at high risk of CVD can have their risk
level reduced through specific interventions
designed to modify lifestyles, as well as by
making drug treatments available (such as for
lowering cholesterol and blood pressure).
Targeted health promotion activities and
provision of one-to-one advice, support,
treatment and referral to other agencies by
general practitioners, practice nurses and
others in primary care can help to prevent
CHD and stroke in people at high risk. The
National Heart Forum has led an extensive
APPROACHES TO PRIMARY
PREVENTION OF CVD
Geoffrey Rose, a British epidemiologist in the
1980s, proposed that the population approach
was the most effective and cost-effective
8
strategy for preventing illness. The population
approach to CVD prevention aims to reduce risk
23
HEALTH IMPROVEMENT
Cardiovascular Disease Prevention
programme of research on the possible impact
of an organised high-risk approach to primary
prevention of CHD, which they estimate to be
as follows:
•
CHD rates would fall by 10% if all people
with a very high cholesterol level (over
6.5mmol/litre) were identified and treated.
•
CHD rates would fall by 9% if all sedentary
adults adopted a moderate level of physical
activity such as regular walking.
•
CHD rates would fall by 6% if rates of
high blood pressure could be halved.
•
ƒ
tackling intermediate clinical risk factors identifying, treating and controlling high
cholesterol and high blood pressure, and
promoting the effective application of
tailored CVD secondary prevention
packages among people who already have
CVD and/or diabetes
ƒ
tackling lifestyle risk factors through
smoking cessation services, Counterweight
(addressing
diet),
physical
activity
programmes and brief interventions on
alcohol.
The North Lanarkshire Keep Well pilot
presently covers a total of 21 practices in the
localities of Airdrie, Coatbridge and Wishaw
and an additional 7 practices have agreed to
join in principle. The 21 practices currently
involved in CVD risk screening in North
Lanarkshire serve a total population of around
100,000 people; around 25,000 of these are
aged between 45 and 64 years and therefore
eligible for Keep Well. The Keep Well pilot
focuses on the Airdrie, Coatbridge and
Wishaw localities because they are
characterised by high levels of social
deprivation and people are less likely to
engage with and use local health services in
spite of the fact that their healthcare needs are
often greater than in other parts of
Lanarkshire.
CHD rates would fall by 5% if all who
smoke more than 10 cigarettes per day
reduced this to less than 10 per day.
The National Heart Forum believe that all of
the above changes in risk factor levels are
achievable and they would lead overall to a
30% reduction in rates of CHD over ten
10
years.
CVD PREVENTION IN LANARKSHIRE
A number of local and national initiatives are
underway in Lanarkshire to identify and care
for people at high risk of CVD including a
Keep Well pilot in North Lanarkshire, a
process of audit and guideline development
being led by the Lanarkshire Managed Clinical
Network for Coronary Heart Disease, and the
introduction of a directly enhanced service as
part of the new GMS contract in primary care.
The Keep Well pilot started in Coatbridge in
October 2006 and commenced in Airdrie and
Wishaw shortly after this. People between 45
and 64 years of age are invited to attend for an
initial CVD screening appointment with a nurse.
At this appointment the nurses will assess the
person for CVD risk factors and calculate a
presumptive risk score on the likelihood of a
major CVD event over the next ten years.
Around one-third can be expected to have a
CVD risk score exceeding 20% and will be
referred on to a Chronic Disease Management
Nurse (CDMN) for a complete cardiovascular
assessment. The CDMN then arranges for the
patient to receive interventions and treatment to
lower their CVD risk and follows them up to
check compliance and monitor changes in their
risk level.
Keep Well
Keep Well is a national pilot across five sites
in Scotland including North Lanarkshire. The
aim of Keep Well is to increase the rate of
health improvement in deprived communities
by enhancing primary care services to deliver
11
anticipatory care. Such care focuses on us
identifying and targeting people between 45
and 64 years of age that already have CVD or
that are at high risk of CVD, offering
appropriate interventions and services to them,
and providing monitoring and follow-up. The
interventions centre on:
24
HEALTH IMPROVEMENT
Cardiovascular Disease Prevention
The screening nurses and the CDMNs can
arrange for patients to be referred on to
Counterweight, the smoking cessation service,
an exercise programme, the alcohol service, the
general practitioner, social work or literacy
support if required. Counterweight is a weight
management service that has been established in
all Keep Well pilots across Scotland that
supports people who are overweight in making
lifestyle changes if they are ready to do so.
Smoking cessation services in all Keep Well
pilot areas have also received additional funding
to support clients with giving up smoking.
one in twenty to smoking cessation and one in
fifteen to an exercise programme. Work is
underway to engage the hard-to-reach
population in particular communities by
employing community development workers
to increasingly raise the awareness of Keep
Well, encourage participation and also to
increase the numbers using lifestyle support
services, especially smoking cessation. At
present it is not possible to analyse Keep Well
data in any greater detail, such as by area of
residence, by deprivation or by the presence of
CVD risk factors although this information
will be available at a later stage. Further
analysis of data at a later stage of the pilot will
also be needed to demonstrate the extent to
which the clients’ initial contact with services
is sustained.
Table 4.2 shows the number of people that
have attended for Keep Well appointments in
Lanarkshire and that have been referred on to
other services in the first eight months of the
12
pilot.
The Keep Well pilot in North Lanarkshire will
run for around two years, after which it is
planned to roll out an anticipatory care
programme across Lanarkshire. A local Keep
Well evaluation programme has been set up to
monitor and assess the success of the local
pilot in engaging with people at high-risk of
CVD and in providing services that lower their
risk. The findings from this evaluation should
inform the planned rollout of anticipatory care
across Lanarkshire. A more comprehensive
evaluation programme is also in progress at
national level to assess the impact of Keep
Well against its stated aims and this should
also inform the future provision of services in
Lanarkshire.
In order to improve cardiovascular health, the
Keep Well pilot in North Lanarkshire will
need to make and maintain contact with people
at high-risk of CVD (and those with existing
CVD) and engage them in lifestyle behaviours
and treatments that will help to lower their
risk. The success of Keep Well in changing
lifestyle behaviours depends in part on the
extent to which clients attend support services
such as Counterweight and smoking cessation.
The data in Table 4.2 shows that around 60%
of people who were invited in the first eight
months, have attended for their initial
screening appointment; around one in ten of
these have been referred on to Counterweight,
Table 4.2
Attendances and onward referrals in the first eight months of the Keep Well pilot in North Lanarkshire
Locality
Practices involved in Keep Well
Numbers on practice lists aged 45-64
Patients attended for initial screening appointment
Patients not attending (DNA)
Referrals to Chronic Disease Management Nurse
Referrals to Counterweight
Referrals to smoking cessation
Referrals to exercise programme
Referrals to general practitioner
Referrals to other service
25
Airdrie
Coatbridge
Wishaw
6
6445
816
1182
273
82
41
39
0
1
8
13002
3074
1077
1007
312
139
181
47
13
7
5389
1563
1287
798
197
77
119
13
5
Total
21
24836
5453
3546
2078
591
257
339
60
19
HEALTH IMPROVEMENT
Lanarkshire Coronary Heart
Managed Clinical Network
Cardiovascular Disease Prevention
CVD risk factors in people between 45 and 64
13
Under this
years of age across Scotland.
programme practices are encouraged to collect
and systematically record information on blood
pressure, smoking, family history and other
factors that are relevant to risk of CVD, but
excluding cholesterol.
Because cholesterol
levels are excluded, this initiative currently stops
short of being a population screening
programme for CVD risk, but there is a
possibility that it may be extended at some
future point.
Uptake of the CVD direct
enhanced service is being monitored alongside
other aspects of the nGMS contract in
Lanarkshire.
Disease
The Lanarkshire Coronary Heart Disease
Managed Clinical Network (CHD MCN) coordinated an audit of CVD primary prevention
in clinical practice in summer 2006. This
audit focused on people that had been
prescribed a statin drug to lower their risk of
CVD and sought to measure compliance
against national standards of care for this
patient group across Lanarkshire. The audit
covered a total of 17 Lanarkshire practices and
the main findings were as follows:
•
Under identification of people at high risk
of CVD. In the 17 practices included in
the audit, the total number of people on a
statin for primary prevention of CVD was
only around one-third of that expected.
•
Inconsistent use of CVD risk scores to
inform the decision about prescribing a
statin. It has been suggested that some
practitioners may prescribe a statin on the
basis of a high cholesterol value in isolation
or on the basis of pre-existing hypertensive
disease rather than overall CVD risk score.
•
Only 6% of people that were identified as
being at high risk of CVD had been referred
for support with lifestyle behaviour change
(such as smoking cessation or weight loss),
which is considerably lower than what
would be expected.
FUTURE CHALLENGES
It is important that the lessons from the Keep
Well pilot in North Lanarkshire are used to
inform the development and roll out of the
planned anticipatory care service for
Lanarkshire. While engagement is a key strand
of this process, the quality of clinical care being
offered to people following their engagement is
critical to its success in improving overall
cardiovascular health. Joint working between
the CHD MCN and Keep Well is essential to
ensure that the MCN guidelines and any future
audit work informs the Keep Well pilot and the
planned pan-Lanarkshire anticipatory care
service. The CVD direct enhanced service may
develop into a population screening programme
for CVD risk and, if it does, then its
implementation could also benefit from the
findings of the Keep Well evaluation and the
CVD primary prevention work that is being
taken forward through the CHD MCN.
Lanarkshire guidelines for lipid lowering and
other aspects of CVD primary prevention will
shortly be launched and promoted through the
CHD MCN in order to address some of the
issues that have emerged from the audit and
training will be arranged to support staff with
their implementation. Plans are being developed
to repeat the CVD primary prevention audit in
Lanarkshire practices in order to monitor the
impact of the guidelines and associated
activities.
One of the main challenges for Keep Well in
North Lanarkshire is engaging with hard-toreach groups and sustaining that contact in
order to effect real changes to people’s health.
Although plans are being developed to employ
community development workers to knock on
doors and attend community activities and
venues, it remains to be seen if this will have
the desired effect. Different approaches to
engagement are being adopted across the five
Keep Well pilots in Scotland and Lanarkshire
may be able to learn from the alternative
approaches to engagement that other pilot
areas have adopted.
Direct enhanced service for prevention of CVD
In 2006, a new direct enhanced service was
introduced under the terms of the new General
Medical Services (nGMS) contract to promote
more complete collection of information on
26
HEALTH IMPROVEMENT
Cardiovascular Disease Prevention
10. McPherson K, Britton A, Causer L. Coronary Heart
Disease: Estimating the impact of changes in risk
factors. London: National Heart Forum, 2002.
The interventions being offered as part of the
Keep Well pilot can provide long-term health
benefits if lifestyle changes and compliance with
medication can be sustained. During the pilot
phase of Keep Well, monitoring will necessarily
focus on process measures such as engagement
of the population, adherence to national and
local guidelines for clinical care provision,
trends in smoking rates, prescriptions for
medicines that lower cholesterol and blood
pressure, and numbers engaging with services
that promote exercise and help people to lose
weight. In the long term, these interventions can
contribute to preventing heart attacks and strokes
and reduced deaths from these conditions. A
process for long-term monitoring needs to be
established to determine whether the resource
invested in the Keep Well pilot contributes to the
realisation of measurable health benefits, which
will also inform the ongoing operation of the
planned Lanarkshire programme of anticipatory
care.
11. Scottish Executive Health Department. Prevention
2010; Pilot Projects Phase 1 Specification.
Edinburgh: Scottish Executive Health Department,
2006.
12. Personal correspondence; Madden J. NHS Lanarkshire,
2007.
13. Scottish Executive Health Department. Guidance on
primary medical services contracting arrangements for
2006-07: Delivering investment in primary medical
services. PCA(M)(2006)9.
Edinburgh: Scottish
Executive Health Department, 2006.
REFERENCES
1.
Belgin U, Critchley J, Capewell S. IMPACT, a validated
comprehensive coronary heart disease model.
Liverpool: University of Liverpool, 2005.
2.
Scottish Executive Health Department. Coronary Heart
Disease and Stroke: Strategy for Scotland. Edinburgh:
Scottish Executive Health Department, 2002.
3.
Scottish Office. Towards a Healthier Scotland: A White
Paper on Health. Edinburgh: The Stationery Office,
1999.
4.
Capewell S, Morrison C, McMurray J. Contribution of
modern cardiovascular treatment and risk factor
changes to the decline in coronary heart disease
mortality in Scotland between 1975 and 1994. Heart
1999; 81(4): 380-6.
5.
Towers H. Analysis of linked data on hospital
admissions and deaths from coronary heart disease
in Lanarkshire 1981-2004. NHS Lanarkshire, 2005.
6.
Gordon D. Overview of stroke in Lanarkshire:
Demography, epidemiology and risk factors. NHS
Lanarkshire, 2003.
7.
NHS Quality Improvement Scotland. Management of
coronary heart disease: A national clinical and resource
impact assessment. Edinburgh: NHS Quality
Improvement Scotland, 2007.
8.
Rose G. Sick individuals and sick populations. Int J
Epidemiol 1985; 14: 32-8.
9.
Manuel D, Lim J, Tanuseputro P et al. Revisiting
Rose: Strategies for reducing coronary heart disease.
BMJ 2006; 332: 659-62.
27
HEALTH IMPROVEMENT
Cardiovascular Disease Prevention
28
HEALTH IMPROVEMENT
Pharmaceutical Public Health
CHAPTER 5
PHARMACEUTICAL PUBLIC HEALTH
expected to participate at Tier II (in which
window or other display space for four
nationally agreed health promotion programmes
is made available) when it becomes operational
in July 2007. The incorporation of a public
health component into the new pharmacy
contract will allow NHS Lanarkshire to work
more closely with community pharmacists and
promote public health advice and information to
the general public, particularly in areas of rural
and urban deprivation. Pharmacists already
have an important role in the promotion of
smoking cessation and should be encouraged to
participate more fully in other areas of lifestyle
intervention and the pharmaceutical care of
children.
HEALTH IMPROVEMENT
People today are increasingly aware of the
factors that determine their own health and use
multiple sources of information and support to
try to maintain their individual and family
health over a lifetime. Pharmacists play a key
role in this process, particularly those in
community pharmacies. There has also been a
major change in the approach to tackling poor
health in Scotland with an increase in working
with local authority and voluntary sector
colleagues as well as engaging with the
general public. Pharmacists make a significant
contribution to these health improvement
1
processes at local, regional and national level.
HEALTH PROTECTION
During 2006, the new Community Pharmacy
2
This included a
Contract was introduced.
scheme whereby patients exempt from
prescription charges can, following a
consultation with the pharmacist, obtain
medicines for the treatment of minor ailments
free of charge from a community pharmacy,
with whom they are registered. The electronic
3
Minor Ailments Scheme (eMAS) came into
effect on 1 July 2006. The range of medicines
available include those from the General Sales
List (GSL), Pharmacy (P) Medicines, selected
dressings and appliances and some Prescription
Only Medicines (POM) covered by Patient
4
Group Directions (PGD) which permit written
instructions for the supply or administration of
medicines to groups of patients who may not be
individually
identified before receiving
treatment. The scheme has been well received
by pharmacists and patients alike and all
community pharmacies within the NHS
Lanarkshire area participate in it.
Immunisation and supply of vaccines
Towards the end of 2006, there was
considerable media interest in the storage of
vaccines following a fridge failure in NHS
Grampian which resulted in the revaccination
of several hundred children. The Scottish
Executive wrote to all NHS boards requesting
an audit of all fridges used for the storage of
vaccines in GP surgeries and clinics to
determine if the monitoring of storage
conditions fell below that required by the GP
contract. Initial findings indicated that, while
there is a need to strengthen the monitoring
procedures in a number of practices, there was
no cause for concern regarding the viability of
vaccines within Lanarkshire. The incident
does, however, highlight the need for vigilance
in this area and for the appointment of a
pharmacist specialising in immunisation to
lead the pharmacy vaccine team within the
primary care division.
Tier II of the Public Health Service (PHS)5
component of the contract also became
operational on 1 July 2006. Pharmacists have
always been a ready and accessible source of
advice about medicines and their use and all
Lanarkshire community pharmacies participate
at this basic level. A significant number are
During 2006, the supply of influenza vaccine for
the winter flu campaign was delayed. This was
caused by the manufacturers receiving
information from the World Health Organisation
regarding the component strains for the vaccine
29
HEALTH IMPROVEMENT
Pharmaceutical Public Health
too late to meet the deadline for the start of the
winter flu immunisation campaign. As a result,
supplies were not available until early October
and the campaign extended over the Christmas
period. Community pharmacists worked closely
with their general practitioner colleagues and
NHS Lanarkshire pharmacists in both public
health and primary care to minimise the
inconvenience caused to the public and helped to
ensure that the target uptake in those aged 65
and over was met.
Class 1
Class 2
Class 3
Class 4
Action immediately (including out of hours)
Action within 48 hours
Action within 5 days
Caution in use
In September, the government introduced
changes to the childhood immunisation
programme. The vaccine holding centre at
Hairmyres Hospital, in liaison with the national
vaccine supply subgroup, co-ordinated the
introduction of the childhood pneumococcal
vaccine at both clinic and GP practices, ensuring
that supplies arrived timeously and in sufficient
quantity to ensure a smooth introduction of the
new regimen.
During 2006, 25 (25 in 2005) such notices
were issued in the following categories:
The frequency and number of these alerts is
outwith the control of NHS Lanarkshire,
generated as they are by MHRA, and NHS boards
are required to cascade this information to
prescribers and community pharmacists within the
specified timescales. NHS Lanarkshire uses the
Surefax facility to disseminate the information.
Class 1
Class 2
Class 3
Class 4
2005
2006
2
9
8
6
4
13
7
1
HEALTH SERVICE PROVISION
Prescribing
Emergency planning
Generic prescribing
Work continued throughout 2006 in the
preparation of the Pandemic Influenza Plan.
Discussions have taken place with local pharmacy
contractors, both independent and representatives
of the major pharmacy multiples, on a regular
basis. While the national emphasis has been
targeted at the distribution of antiviral medication
and vaccine development and supply in the event
of a pandemic, local plans have also been
progressed to ensure the provision of essential
pharmaceutical healthcare and to minimise the
disruption to the day-to-day provision of
medicines within both the hospital and
community sectors when normal services become
overloaded, restricted or non-operational.
The prescribing of medicines by their nonproprietary or generic name rather than the
brand name, as recommended in the British
6
National Formulary , enables any suitable
product to be dispensed, reducing delay to the
patient and sometimes expense to the NHS.
Generic prescribing by Scottish NHS boards
7
was initially reported for 2000/01 and
Lanarkshire was ninth among the Scottish
boards, with 74% of all prescriptions being
prescribed generically. By the end of the
financial year 2005/06, Lanarkshire had
moved to fifth position, 81.2% of all
prescriptions being written generically. Figure
5.1 shows that by 2006/07 there was a further
increase in the percentage of prescriptions
being written generically and Lanarkshire
achieved the Scottish average, albeit it has
dropped to seventh place.
Drug alerts
Where a product defect or the discovery of a
dangerous side effect resulting from long-term
use of a medicine poses a risk to public health,
the holder of the marketing authorisation
(product licence) is obliged to withdraw the
product from use. In these circumstances the
Medicines and Healthcare Products Regulatory
Agency (MHRA) issues a “Drug Alert” in one
of four categories:
30
HEALTH IMPROVEMENT
Pharmaceutical Public Health
Figure 5.1
Percentage of all prescriptions
Generic prescribing, by NHS board, 2005/06 and 2006/07
84
2005/06
80
2006/07
76
Bo
rd
er
Sh s
et
la
nd
Ta
ys
id
e
Ay
Lo
rs
th
hi
ia
re
n
G
&
la
A
sg
rr
an
ow
&
C
ly
de
H
ig
hl
an
d
Sc
ot
la
La
na nd
rk
sh
i re
G
ra
m
pi
Fo
rth an
Va
W
l le
es
y
te
rn
I
s
D
le
um
s
fr i
es
Fi
&
fe
G
al
lo
w
ay
O
rk
ne
y
72
Figure 5.2
Statins: defined daily doses per 1000 weighted patients, by NHS board, 2003/04 and 2006/07
DDDs per 1000 weighted patients
100000
80000
2003/04
60000
2006/07
40000
20000
Fi
f
Ta e
ys
s
&
id
e
G
al
lo
w
ay
H
ig
hl
an
G
ra d
m
pi
a
Ay
Bo n
rs
r
de
hi
re
rs
&
Ar
ra
n
Lo
W
th
es
ia
n
te
rn
Is
le
s
Sh
et
la
nd
um
fri
e
D
La
na
rk
Fo shi
re
rth
Va
l le
y
G
la
O
sg
rk
ne
ow
y
&
C
ly
d
Sc e
ot
la
nd
0
Statins
second highest prescriber in Scotland after the
Western Isles. The number of prescriptions
continued to increase and, as shown in Figure
5.2, by 2006/07 Lanarkshire was the highest user
of statins in Scotland. Statins make a significant
contribution to the wider comprehensive
coronary heart disease prevention programme in
Lanarkshire.
Trends in prescribing statins, medicines used for
lowering blood cholesterol, have also been
followed. In 2000/01, Lanarkshire was a
relatively high prescriber of statins in Scotland
and this was very welcome as Lanarkshire has
one of the highest incidences of coronary heart
disease in Western Europe. The number of
prescriptions per 1000 population dispensed in
Lanarkshire doubled by 2003/04, making it the
31
HEALTH IMPROVEMENT
Pharmaceutical Public Health
Other medicines
Dispensing
Trends in prescribing other medicines have
also been observed, most notably hypnotics
and sedatives, and antimicrobials. The slow
downward trend in hypnotic and sedative
prescribing has been maintained in 2006 but
the prescribing of antimicrobial agents has
increased slightly and highlights the
importance of continuing vigilance in
observing trends in this group of medicines
where unnecessary and inappropriate use is a
key factor in the emergence of antibiotic
resistant bacteria.
During 2006, the number of prescriptions
dispensed by community pharmacies in
Lanarkshire rose by 2% (3.6% in 2005) to an
average of 17.5 prescriptions per Lanarkshire
resident per annum, compared with an increase
for Scotland of 3% (4.1% in 2005) to a figure
equivalent to 15.5 prescriptions per person (Table
5.1). The overall cost of prescriptions per person
in Lanarkshire has remained virtually unchanged,
albeit higher than the Scottish average, since 2004
compared with a national increase of 2.5% over
the same period (Figure 5.3).
Table 5.1
Prescriptions and costs (primary care), Lanarkshire and Scotland, 1997-2006
Number of
prescriptions
dispensed '000s
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Lanarkshir
e
6,994
7,259
7,296
7,505
7,925
8,414
8,782
9,220
9,551
9,747
Gross ingredient cost
£'000s
Scotland
Lanarkshire
Scotland
57,250
59,098
58,000
60,000
62,846
66,023
68,630
74,058
77,050
79,391
£62,802
£67,113
£73,209
£76,622
£85,034
£96,410
£106,715
£116,587
£114,001
£114,579
£533,036
£569,503
£605,831
£650,858
£709,956
£795,731
£868,040
£948,218
£957,769
£978,716
Average number of
prescriptions
per person
Lanarkshir
e
12.6
13.1
13.2
13.6
14.3
15.2
15.9
16.5
17.2
17.5
Scotland
11.3
11.6
11.4
11.8
12.4
13.0
13.6
14.6
15.2
15.5
Average cost of
prescriptions per
person
Lanarkshire
Scotland
£112.84
£120.89
£132.03
£138.45
£153.70
£174.27
£193.01
£205.94
£205.00
£205.30
Figure 5.3
Average cost of prescriptions per person, 1997-2006
250
Cost (£)
200
150
100
50
0
1997
1998
1999
2000
2001
Lanarkshire
32
2002
2003
2004
Scotland
2005
2006
£104.86
£112.17
£119.45
£128.55
£140.19
£157.13
£171.73
£186.72
£188.60
£191.27
HEALTH IMPROVEMENT
Pharmaceutical Public Health
FURTHER DEVELOPMENTS
Pharmaceutical public health, the application of
pharmaceutical knowledge, skills and resources
to the science and art of preventing disease,
prolonging life, promoting, protecting and
improving health for all through the organised
efforts of society, is a developing specialism. It
is important that the diverse skills of pharmacists
are mobilized so that their skills and experience
can combine to achieve health gain. The initial
focus is on health improvement and it is
important for NHS Lanarkshire to make
maximum use of its network of community
pharmacies and the expertise of the staff
working in them. Close liaison with the
community health partnerships and the localities
to enable community pharmacy to contribute to
the formulation and implementation of the Joint
Health Improvement Plan is required.
The pharmacist is often the first contact that
the public has with a healthcare professional
when discussing side effects of medicines and
the treatment of minor ailments. Pharmacists
should be encouraged to report adverse drug
events by sending Yellow Card reports to the
Committee on Safety of Medicines and to
promote collection of pharmaceutical data on
the use of “over the counter” medicines as part
of a Lanarkshire-wide study to map out the use
of non-prescription medicines and their impact
on the health of the people of Lanarkshire.
REFERENCES
1.
Public Health Institute for Scotland. Pharmacy for
Health 2002. Glasgow: PHIS, 2003.
2.
Scottish Executive. Community Pharmacy Contract.
PCA(P)(2006)2. Edinburgh: Scottish Executive, 2006.
3.
Scottish Executive. eMinor Ailments Service. Scottish
Directions. PCA(P)(2006)12. Edinburgh: Scottish Executive,
2006.
4.
Scottish Executive. Patient Group Directions.
HDL(2001)7. Edinburgh: Scottish Executive, 2001.
5.
Scottish Executive. New Community Pharmacy Contract;
Public Health Service, Tier II Arrangements.
PCA(P)(2007)16. Edinburgh: Scottish Executive, 2007.
6.
British Medical Association and Royal Pharmaceutical
Society of Great Britain. British National Formulary.
BMJ Publishing Group and RPS Publishing. London,
Biannual.
7.
Clinical Resource and Audit Group. Clinical outcome
indicators. Edinburgh: Scottish Executive, 2002.
33
HEALTH IMPROVEMENT
Pharmaceutical Public Health
34
HEALTH IMPROVEMENT
Oral Health of Children
CHAPTER 6
ORAL HEALTH OF CHILDREN
In 2005, the Scottish Executive published An
Action Plan for Improving Oral Health and
1
Modernising NHS Dental Services in Scotland.
Its aim was to improve the poor oral health
record of Scotland and included a series of
targets, including 60% of 5 and 11-year-olds to
have no dental decay by 2010.
Following examination, each child is placed
into one of three groups:
TRENDS IN CHILDREN’S ORAL HEALTH
In order to assess progress, it is necessary to
collect information about children’s dental
health at national, regional and local level. Such
information can also be used for planning future
programmes aimed at improving oral health.
The National Dental Inspection Programme
(NDIP) was set up in 2002 and provides trend
information on the dental health of Scottish
children. The information is also given to
children and their parents. The National Dental
Inspection Programme involves two age groups:
Primary 1 and Primary 7. There are also two
types of inspection: a basic inspection which
involves all school children in these classes, and
a more detailed inspection using a smaller
sample of school children. The more detailed
sample enables comparisons of children’s oral
health in NHS board areas.
•
High risk - severe decay and in need of
urgent dental care
•
Medium risk - some decay and should
seek dental care in the near future
•
Low risk - no obvious decay but should
continue to see the family dentist for regular
check-ups
The percentage of 5 and 11-year-old children
who have no obvious decay over a number of
years is shown in Figure 6.1. Apart from
2000/2001, it shows the highest number of
decay-free children in 2005/2006. Lanarkshire
compares less favourably than the rest of
Scotland and both 5 and 11-year-olds are short
of the 60% target that is to be achieved by 2010.
Figure 6.2 shows Clydesdale to have reached
the national target of 60% decay-free for 5year-olds. Wishaw, however, only has 35%
who are decay-free. For 11-year-olds, the
figures were less promising with the highest
percentage decay-free being in East Kilbride at
34%. The lowest was Motherwell with 16%.
Figure 6.1
Percentage of 5 and 11-year-olds decay-free, Scotland and Lanarkshire, 1993/1994-2005/2006
Scotland
(age 5)
80
Target: 60% decay-free by 2010
60
Lanarkshire
(age 5)
40
Scotland
(age 11)
20
Lanarkshire
(age 11)
0
19
93
/1
99
4
19
95
/1
99
6
19
97
/1
99
8
19
99
/2
00
0
20
00
/2
00
1
20
02
/2
00
3
20
03
/2
00
4
20
04
/2
00
5
20
05
/2
00
6
Percentage decay-free
100
35
HEALTH IMPROVEMENT
Oral Health of Children
Figure 6.2
100
80
Target: 60% decay-free by 2010
60
40
20
0
C
um
be
rn
au
Ai ld
C rd
oa ri e
t
M brid
ot
h e ge
rw
W ell
i
C sha
ly
d w
Ea es
st da
Ki le
N
lb
or
r
th Ha ide
So L m
a
u t na i lto
h
n
La rks
na hir
e
La rk s
na hi r
e
rk
sh
i re
C
um
be
rn
au
Ai ld
C rd
oa ri e
t
M bri
ot dg
he e
rw
W ell
is
C ha
ly
d w
Ea es
st da
Ki le
N
lb
or
H rid
t
So h L am e
u t ana i lto
h
La rks n
na hir
e
La rk s
na hi r
rk e
sh
i re
Percentage with no obvious decay
Decay-free levels versus national target, by area, 2005/2006
5-year-olds
11-year-olds
Figure 6.3
Risk categories at age 5, by area, 2005/2006
Percentage in each risk category
100
80
Medium
60
High
40
20
ri e
C
Ai
rd
oa
tb
rid
ge
M
ot
he
rw
el
l
W
is
ha
w
C
ly
de
sd
al
e
Ea
st
Ki
lb
ri d
e
H
am
N
or
i lt
th
on
La
na
rk
So
sh
ut
i re
h
La
na
rk
sh
i re
La
na
rk
sh
i re
C
um
be
rn
au
ld
0
The medium and high risk categories for oral
health of 5-year-olds across different areas in
Lanarkshire is shown in Figure 6.3. Airdrie
and Motherwell have the highest percentage of
5-year-olds with the worst decay, requiring
urgent dental care. Airdrie also had the
highest proportion of children requiring
immediate dental treatment in 2004/2005.
Despite this, the greatest improvement was
also in Airdrie. The area with the highest
number of children with decay was Wishaw.
Clydesdale and Cumbernauld have the least
amount of decay in 5-year-olds. Overall,
children with the most decay are not
improving at the same rate as those with less
decay.
Figure 6.4 shows that Airdrie and Coatbridge
have the highest percentage of 11-year-old
children requiring immediate dental care and
Clydesdale has the least. Across Lanarkshire,
75% of 11-year-olds have some decay.
36
HEALTH IMPROVEMENT
Oral Health of Children
Figure 6.4
Risk categories at age 11, by area, 2005/2006
Percentage in each risk category
100
80
Medium
60
High
40
20
C
Ai
rd
ri e
oa
tb
rid
ge
M
ot
he
rw
el
l
W
is
ha
w
C
ly
de
sd
al
e
Ea
st
Ki
lb
ri d
e
H
am
N
or
i lt
th
on
La
na
rk
So
sh
ut
i re
h
La
na
rk
sh
i re
La
na
rk
sh
i re
C
um
be
rn
au
ld
0
Figure 6.5
Dental registration rates, Lanarkshire, 31 March 1995-2005
Percentage registered
80
Children
60
Adults
40
Children
under 3
20
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
are also higher numbers of children living in
deprived areas compared with affluent areas.
DEPRIVATION AND ORAL HEALTH
Surveys show that decay levels in 5-year-old
children depends on the place where the child
2
The amount of decay is lowest in
lives.
England, greater in Wales than Scotland, and
highest in Northern Ireland. In Scotland,
children from affluent areas have less tooth
decay than those from deprived areas but have
higher levels of decay compared with English
children of the same social class.
Currently only those 5-year-olds who live in
the most affluent areas have reached the 60%
national target to be decay free by 2010,
whereas only 32% of those in the most
deprived areas were decay-free.
DENTAL REGISTRATION RATES
Regular dental attendance is important to
prevent and treat dental disease. In 2006, 64%
of children in Lanarkshire were registered with a
dentist, continuing the gradual upward trend
from the mid-1990s (Figure 6.5).
The
Children in deprived areas of Lanarkshire are
3 times more likely to suffer from severe
dental decay requiring urgent dental treatment
than their more affluent counterparts. There
37
HEALTH IMPROVEMENT
Oral Health of Children
percentage of dental registration varies across
age groups, with those aged 6-12 having the
highest rate of 74%.
to be piloted in 2007/08. This resource will
ensure oral health is built into the school
curriculum and environment as part of the
Health Promoting Schools scheme. The schools
involved in the pilot were identified via the
National Dental Inspection Programme (NDIP)
2004/05 data, which highlighted that Airdrie,
Wishaw and Hamilton are areas in Lanarkshire
with the largest percentage of Primary 7 children
experiencing severe decay.
The Scottish Executive has introduced targets
to increase the number of children registered
1
with a dentist . The targets relate to specific
age groups and in 2006 only the 3-5 age group
achieved the target in Lanarkshire.
HEALTH PROMOTION
Local staff training programmes
The Dental Action Plan has a special focus on
All
improving oral health in Scotland.
children under 1 year have received free
toothbrushes and free fluoride toothpaste from
public health nurses to prevent dental disease.
Children attending nursery at 3 and 4 years
receive two packs each year. A free dental
pack is given to all primary 1 children. In
addition, supervised toothbrushing is offered
to all children in nursery and primary schools
across Lanarkshire.
A rolling staff training programme is currently
being developed to improve the capacity of staff
to promote good oral hygiene. The programme
will be available for those in NHS Lanarkshire,
local government partner agencies, and
voluntary organisations within the community.
REFERENCES
A number of other local initiatives are
currently being designed aiming to improve
oral health through health promotion and
progress has been made in the following areas:
Expectant and nursing mothers
Focus groups with expectant parents have
taken place with the eventual aim of
developing a programme which can be
delivered ante-natally and continued after
birth.
Childsmile West
Childsmile West is a programme which
encourages oral health from birth, especially
for people living in deprived areas. Parents of
newborn children who are found to be at risk
of developing tooth decay are referred to the
programme by their public health nurse. After
parents agree to take part, they are visited by a
dental health support worker who gives more
information, advice and arranges regular visits
to a local dental practice.
Secondary Schools
A teaching resource is currently being developed
in sample schools across Lanarkshire and is due
38
1.
Scottish Executive. An Action Plan for Improving
Oral Health and Modernising NHS Dental Services in
Scotland. Edinburgh: Scottish Executive, 2005.
2.
British Association for the Study of Community
Dentistry. Annual Survey Results 2005/06 on 5 year
olds. www.bascd.org/annual survey results.php.
Last accessed 10/07/07.
HEALTH PROTECTION
Communicable Disease and Environmental Health
CHAPTER 7
COMMUNICABLE DISEASE AND ENVIRONMENTAL HEALTH
Scotland has been a theme of national work in
recent years. Taking account of the Scottish
Executive guidance on NHS Boards’ Health
2
Protection Remit , the Guidance on Managing
3
Public Health Incidents , and the work of
Health Protection Scotland Quality Assurance
4
Group , the Chief Medical Officer confirmed
the health protection remit of NHS boards as:
One of the aims of public health, in co-operation
with the wider NHS, local authorities and other
agencies such as Scottish Water and Strathclyde
Police, is to protect the local population from
hazards which endanger their health. It achieves
this by preventing, controlling or reducing
exposure to hazards and limiting damage to
health when such exposures occur. It also
ensures that there are robust policies and
procedures in place to deal with these hazards
and that this guidance is widely and easily
accessible.
Surveillance
Investigation
Risk assessment
Risk management
Communication
Emergency response and management
Business continuity planning
Audit, evaluation and research
During 2006, the focus on strengthening local
preparedness for managing large outbreaks or
incidents continued alongside improving
measures to tackle existing concerns, such as
healthcare-associated infections, and emerging
issues such as hepatitis C.
Self-assessment of NHS board preparedness
for pandemic influenza
In addition to this more strategic work, the
health protection team dealt directly with over
1000 enquiries during 2006. Advice was given
on a wide range of issues; the most frequent
enquiries related to gastro-enteritis (290), routine
immunisation (173) and meningitis (87).
Developing a Lanarkshire plan for the local
management of an influenza pandemic was one
of the major achievements of 2006 and at a
national level Health Protection Scotland
developed a self-assessment tool to enable
boards to check the preparedness of their local
plans.
NATIONAL HEALTH PROTECTION
DEVELOPMENTS
LOCAL PROGRESS
Consultation on public health legislation
Infection control in care homes
The Scottish Executive consulted on the
proposed new legislation for public health in
1
Scotland. The proposals covered are largely on
the health protection aspects of public health,
and a substantial response was made to the
consultation. This is the most important update
of the legal framework for the work undertaken
by public health for many years. The outcome
of the consultation and the proposed legislation
will shape the national and local approach to
health protection.
A training package on infection control for use
by care home staff was developed in 2006 and
will be launched in 2007. The intention is that
the health protection nurses will train a cadre
of care home staff with support from the NHS
Lanarkshire care home liaison nurses, to
enable the care homes to run their own
infection control training programmes.
Infection control in NHS healthcare
establishments
Scottish Executive guidance
2006 has been a year both of consolidation and
progress in preventing Healthcare-Associated
Infections (HAI).
Ensuring that health protection services are of
appropriate and comparable quality across
39
HEALTH PROTECTION
Communicable Disease and Environmental Health
The infection control management arrangements
recommended in 2004 were put in place in 2006
with the appointment of an Infection Control
Manager and Infection Control Doctor to join
the Nurse Consultant HAI.
Food poisoning notifications continued to show
a modest decline in 2006. Campylobacter reports
increased significantly from 487 in 2005 to 571
in 2006. Some of this was due to an increase in
June which, despite investigation, remains
unexplained.
Campylobacter isolates also
5
increased by 6% in 2006 across Scotland.
The single infection control service continued
to develop consistent approaches to service
delivery across NHS Lanarkshire.
Lanarkshire TB notifications increased in 2006
to 54, the highest number since 1999. There
was one outbreak during the year, but no other
explanation for the marked increase in 2006.
TB is discussed more fully in Chapter 8.
There is no room for complacency in
controlling this serious disease, even in a
relatively low incidence country such as
Scotland.
Influenza pandemic preparedness
•
Development of operational plans
Building on the production of a Lanarkshirewide plan in early 2006, considerable
progress has been made in drawing up
hospital and primary care-based plans.
While the Lanarkshire plan is about what is
required to cope with a pandemic, the
operational plans are about how the services
would be delivered.
•
The national outbreak of mumps in young
adults continued to be a concern in the
community.
Awareness raising
Guideline development
Closely linked to local planning, several
events took place aimed at raising awareness
of the Lanarkshire pandemic plan and the
roles that various organisations and
individuals would have.
To help with the delivery of effective and
efficient infection control practice, Lanarkshire
NHS Board issues written guidelines on
infection control covering most aspects of
infection control related to caring for people in
hospital and community care establishments.
Copies of the guidance are available in all
clinical areas within Lanarkshire, readily
accessible to all members of staff. It is essential
that these guidelines are regularly updated. Each
section is reviewed by members of the Area
Control of Communicable Disease Committee
throughout the year and revised if necessary.
COMMUNICABLE DISEASE
Notifiable and reportable diseases
The total numbers of notified or reported
diseases during 2006 are shown in Table 7.1
along with the totals for 2004 and 2005 for
comparison.
Table 7.1
The section on variant Creutzfelt-Jacob disease
and
other
transmissable
spongiform
encephalopathy agents was updated in 2006.
Notified or reportable diseases, NHS Lanarkshire
Disease
2004
2005
2006
Campylobacter
Chickenpox
Cryptosporidiosis
Erysipelas
Food poisoning
Legionellosis
Malaria
Measles
Meningococcal disease
Mumps
Rubella
Scarlet fever
TB respiratory
TB non – respiratory
Viral hepatitis
Whooping cough
515
1727
51
1
270
1
1
69
18
620
47
27
24
10
129
32
487
1473
52
2
184
1
0
42
17
337
23
33
17
7
146
7
571
1566
52
2
161
5
1
47
17
471
25
31
37
17
128
11
Blood-borne virus
Antenatal screening for communicable
diseases
During 2006, 4962 (100%) pregnant women had
a test at an antenatal clinic for rubella immunity
and those women who were not found to be
immune were offered rubella vaccination after
delivery. 4800 (96.7%) women were tested for
hepatitis B and 162 (3.3%) women declined this
test. 4740 (95.5%) women were tested for HIV
and 222 (4.5%) women declined. 4796 (96.7%)
40
HEALTH PROTECTION
Communicable Disease and Environmental Health
women were tested for syphilis and 166 (3.3%)
declined.
HIV (human immunodeficiency virus)
The number of diagnoses of HIV reported
across Scotland to Health Protection Scotland
in 2006 was 346, a reduction of 60 on the 406
reported in 2005 and 18 fewer than the 364
reported in 2004.
Hepatitis C
The number of positive tests for hepatitis C in
Lanarkshire residents in 2006 reported to Health
Protection Scotland was 103, a rate of 18.5 per
100,000 population, and brought the total
number of Lanarkshire residents diagnosed with
hepatitis C since testing was introduced to 1430,
6.5% of the Scottish total. The number of
positive tests in 2006 is a decrease of 52 on the
155 reported for 2005: the highest ever annual
total for Lanarkshire. In those for whom a risk
factor was known (55 of the 103 cases), 44
(80%) were injecting drug users. 11 people
were aged 15-24 years, 35 were aged 25-34
years and 52 were aged 35-59 years. There has
been a steady increase since 2001 in the number
of patients diagnosed with hepatitis C through
contact with the Lanarkshire HIV, AIDS and
Hepatitis Centre based at Monklands Hospital.
During 2006, increased testing for hepatitis C
took place at sexual health clinics, both at family
planning and genito-urinary medicine clinics.
Across Scotland, since 1998 there has been a
gradual decline in the number of males being
diagnosed with hepatitis C, with the number of
females being diagnosed remaining at the same
level.
In 2006, the risk group was sexual intercourse
between men for 41% of diagnoses, and sexual
intercourse between men and women for 47%.
The percentage of injecting drug users
diagnosed with HIV infection stayed the same
at 7% but with a reduction from 26 in 2005 to
21 in 2006. Of the 21, 9 were probably
infected elsewhere in the UK or abroad and, of
the remaining 12, 11 were aged over 30.
These figures and other data suggest that
transmission of HIV infection among injecting
drug users in Scotland is rare.
134 (39%) of the 346 diagnoses in 2006 were
in people reported to have acquired infection
in Scotland, 91 of the 134 (70%) through
sexual intercourse between men and 24 (18%)
through sexual intercourse between men and
women.
112 (32%) of people diagnosed in 2006 were
reported as having acquired infection in subSaharan Africa, 104 of the 112 (93%) through
sexual intercourse between men and women.
It is estimated that more than half of all people in
Scotland who have been infected with hepatitis
C remain undiagnosed. A Royal College of
Physicians of Edinburgh statement on hepatitis
C has emphasised the need to identify former
injecting drug users who are likely to have
hepatitis C disease that would benefit from
treatment. The Scottish Executive published the
Hepatitis C Action Plan for Scotland in
6
September 2006 and has provided funding to
NHS boards to support its implementation. The
action plan is being implemented in Lanarkshire
in each of the plan areas:
•
•
•
•
•
•
30 Lanarkshire residents were diagnosed as
HIV positive in 2006. In 2005, 24 residents
were diagnosed with HIV infection and in
2004 the figure was 19.
The risk group was sexual intercourse between
men for ten people, sexual intercourse between
men and women for 17 people, and injecting
drug use for three people. To the end of 2006
155 males and 47 females known to be
Lanarkshire residents were diagnosed with
HIV infection. At the end of 2006, of the total
of 202 people diagnosed, 47 were known to
have died, though not necessarily due to HIV
infection, and 155 were not known to be dead.
co-ordination
prevention
testing
treatment, care and support
education, training and awareness raising
surveillance and monitoring
The risk to Lanarkshire residents of acquiring
HIV infection through sexual intercourse
continues to rise and it is therefore of increasing
41
HEALTH PROTECTION
Communicable Disease and Environmental Health
importance for positive sexual health including
safer sexual practices to be promoted.
during 2006 with education and training being
provided for staff who provide addiction
services.
During 2006, significant progress was made in
Lanarkshire with the development of the
Lanarkshire Sexual Health Strategy and Action
Plan and development of clinical sexual health
services. The progress made is reported in
Chapter 10.3.
As in previous years, there was ongoing change
during 2006 in the provision of clinical care for
patients with one or more blood-borne virus
infections, with the development of treatment
protocols incorporating new drugs that have
been shown to be clinically effective. The
Lanarkshire HIV, AIDS and Hepatitis Centre
continues to develop the services that it provides
and works with other NHS Lanarkshire staff
who provide sexual health services, and with
voluntary organisations, to support service users
and carers.
The lead voluntary sector
organisation involved in blood-borne viruses
work in Lanarkshire is the Terrence Higgins
Trust Scotland.
During 2006, the NHS Lanarkshire condom
distribution schemes continued to develop, with
more health centres and surgeries taking part in
the scheme, in order to help to achieve the aim
of making free condoms easily accessible across
Lanarkshire. In addition, some pharmacies now
provide free condoms as part of the C card
scheme. Work took place during 2006 to further
develop the Lanarkshire sexual health website
www.lanarkshiresexualhealth.org
and an updated
version will be launched in 2007.
The way forward
The antenatal communicable disease screening
programmes will be reviewed against standards
set by NHS Quality Improvement Scotland for
the delivery of pregnancy and newborn services.
Hepatitis B
In Scotland, during 2006 the number of
hepatitis B cases reported to health protection
Scotland was 375, an increase of 3 on the 2005
figure. Forty-one reports were made by NHS
Lanarkshire laboratories, an increase of 5 on
the 36 reports made in 2005. Twenty-seven
reports were for males, 13 for females and for
1 report the sex of the patient was not known.
The ten-year age bands with most cases were
for people aged 15 to 24 years (11 cases) and
35 to 44 years (11 cases).
NHS Lanarkshire will work with partner
agencies to implement locally the Hepatitis C
Action Plan for Scotland.
Sexual health services will continue to be
strengthened, by the appointment of additional
staff, and integrated, by the bringing together of
family planning and genito-urinary medicine
services.
The regional virus laboratory in Glasgow is
now carrying out DNA sequencing of the
hepatitis B virus found in newly diagnosed
patients, and is developing testing that will
enable acute and chronic hepatitis B infection
to be distinguished when this cannot be
achieved by routine testing. Health Protection
Scotland is considering the introduction of an
enhanced surveillance system for hepatitis B
that would capture clinical and risk factor data
using a new test request form.
The hepatitis B vaccination programme should
continue to become integrated into services for
injecting drug users and hepatitis B
vaccination should be promoted to gay and
bisexual men through sexual health services
and outreach work.
The Lanarkshire blood-borne viruses network
should continue to support education and
training for primary health care staff and work
with Community Health Partnerships to raise
the profile of blood-borne viruses issues in
primary health care.
The NHS Lanarkshire hepatitis B vaccination
programme for people in the community at
increased risk of hepatitis B infection, (mostly
injecting drug users and their sexual partners,
and gay and bisexual men), which was
introduced in July 2002, continued to develop
Accommodation at the Lanarkshire HIV,
AIDS and Hepatitis Centre should be
improved in order to provide more rooms for
clinical consultations and to enable voluntary
42
HEALTH PROTECTION
Communicable Disease and Environmental Health
The programme is also more complicated than
previously because different vaccines are
given at two, three and four months. This
means that more time is required for
appointments and vaccination staff are
currently very reliant on expertise of the
call/recall staff based at Law House. Ad hoc
vaccinations have fallen as staff prefer that
children are called by the computerised
automated call/recall system.
sector staff to provide their services at bloodborne viruses clinics.
IMMUNISATION
Vaccination programme
The evolution of the UK vaccination programme
continued in 2006 with the inclusion of 3 doses
of pneumococcal vaccination for all children and
variable dose catch-up for children under the age
of two years who are at most risk of
pneumococcal infection. A new combined
booster vaccine at 12 months, against
meningococcal group C infection and
haemophilus influenza group B both of which
cause meningitis, was introduced to ensure
strengthened immunity beyond the age of one
year (Table 7.2).
Pneumococcal vaccination
The pneumococcal bacterium is carried in the
nose and throat. It is easily spread by coughing,
sneezing, mouth-to-mouth contact and indirectly
through contamination. Invasive pneumococcal
disease affects between 15 and 50 children per
hundred thousand depending on their age under
five. The case fatality rate is approximately 1 to
2% and those who survive meningitis may do so
with a variety of severe disabilities. The
pneumococcal vaccine protects against the seven
most common types of the bacteria that cause
82% of invasive pneumococcal disease (e.g.
meningitis, septicaemia and severe pneumonia)
in children under five.
Table 7.2
Childhood immunisation timetable, 2006
When to immunise
What vaccines are given
2 months
DTaP/Hib/IPV
PCV
DTaP/Hib/IPV
Men C
DTaP/Hib/IPV
Men C
PCV
Hib/Men C
MMR
PCV
DTaP/IPV or dTaP/IPV
MMR
Td/IPV
3 months
4 months
12 months
13 months
3 years 4 months
13 years
The conjugate pneumococcal vaccine for young
children is an alternative formulation to the
version used for adults. Experience from the
United States has shown it to be 96% effective at
reducing
the
incidence
of
invasive
pneumococcal disease when given as a two-dose
schedule in the first year of life. Although the
vaccine’s main effect is to protect the body
against pneumococcal bacteria entering and
causing infection, there has been an 18%
reduction in pneumococcal pneumonia in
children under five and a 60% reduction in
episodes of otitis media (glue ear).
Key to vaccine antigens:
D
d
T
aP
Hib
IPV
PCV
MenC
MMR
normal dose diphtheria
low dose diphtheria
tetanus
pertussis
haemophilus influenza
polio
pneumococcal
meningitis C
measles, mumps and rubella
Vaccination uptake
Vaccination uptake is routinely assessed for
children reaching their second and sixth
birthdays. In 2006, the Scottish Executive set a
new target for uptake of MMR at five years of
age.
The new programme had a significant increase
on the workload of vaccination staff. Because
of the additional vaccine at 12 months, the
new programme will, on an ongoing basis,
require a 20% increase in the number of
vaccination appointments. The catch-up for
under twos created a further 60% temporary
increase in appointments over a six-month
period.
Vaccination protection against diphtheria,
tetanus,
pertussis,
polio,
haemophilus
influenza and meningitis C is very high in
Lanarkshire, with over 98% of children
43
HEALTH PROTECTION
Communicable Disease and Environmental Health
completing the recommended courses of these
vaccines by two years of age. MMR uptake at
2 years exceeded 90% for the first time in 6
years as shown in Figure 7.1.
Although
2006
uptake
figures
for
pneumococcal vaccine will not be available
until later in 2007, anecdotal evidence is that
parents are accepting the new programme well
and that uptake is anticipated to be on par with
other vaccines.
Similarly, 93.2% of children reaching 5 years
of age during 2006 had one dose of MMR.
Influenza vaccination
By 6 years of age, 95% of children completed
diphtheria, tetanus, polio courses and 94.9% of
all children completed pertussis courses. For
2006, 92.6% of children had one dose on
MMR and 88.2% had 2 doses of MMR.
The national influenza vaccination programme
was implemented in 2005/2006. The start of the
programme was significantly hindered by delays
in vaccine production that resulted in a very
uneven spread of vaccine to general practice.
Local contingency and occupational health flu
vaccine supplies were used to supplement where
possible. It is expected that some people aged
65 and over and at risk were unable to be
vaccinated for six weeks or more after the start
of the programme, became frustrated and did not
receive the vaccine. Overall, the uptake of flu
vaccine in Lanarkshire was 72%, compared to
75% for Scotland. Uptake for people under 65
years is more difficult to calculate as they fall
into different at risk categories based on their
health. The data are not sufficiently robust to
report confidently.
It is very encouraging to see that MMR uptake
is increasing following the well-publicised
concerns that began during the late 1990s.
However, the short-term consequences of the
new vaccine programme led to fewer
appointments available for older children and
this was reflected in a 1.3% decrease in the
uptake of 2 doses of MMR in 6-year-old
children compared to 2005. A variety of
measures, such as ongoing education, routine
reporting of uptake figures and monitoring
available appointments have been actioned.
Figure 7.1
Primary immunisation trends, children reaching 2 years, by quarter, 1995-2006
100
Dip/Tet/Polio
Pertussis
HIB
90
MenC
MMR
85
80
75
31
/12
30 /95
/06
31 /96
/12
30 /96
/06
31 /97
/12
30 /97
/06
31 /98
/12
30 /98
/06
31 /99
/12
30 /99
/06
31 /00
/12
30 /00
/06
31 /01
/12
30 /01
/06
31 /02
/12
30 /02
/06
31 /03
/12
30 /03
/06
31 /04
/12
30 /04
/06
31 /05
/12
30 /05
/06
31 /06
/12
/06
Percentage uptake
95
44
HEALTH PROTECTION
Communicable Disease and Environmental Health
The delay in vaccine production and
subsequent use of occupational health supplies
for the elderly and at risk populations meant
that the vaccine campaign in Lanarkshire did
not start until just before Christmas 2006 and
extended into January 2007.
EMERGENCY PLANNING
Emergency preparedness is an increasingly
high profile responsibility for NHS boards and
was reported on in detail in the 2005 Annual
7
Developing new and reviewing
Report.
existing plans is an ongoing task and, in 2006,
new plans were developed for pandemic flu
and smallpox vaccination. The smallpox
vaccination plan was submitted to the Scottish
Executive in the spring of 2006 and, in
conjunction with North Lanarkshire Council, a
mass vaccination centre was set up in
Glencairn Primary School, Motherwell. The
exercise provided information on the space
and requirements for establishing such a
centre.
The delivery arrangements for influenza
vaccine in Scotland will be subject to a
national review in 2007.
Selective BCG programme
The implementation of the selective BCG
programme was delayed pending the
development of the national screening
questionnaire to identify children and
subsequent amendment of the national children’s
surveillance systems to accommodate the
questions and record vaccination. It is expected
that these will be completed in 2007.
Training and exercises were important aspects
of emergency preparedness in 2006. NHS
Lanarkshire participated in national, regional
and local exercises to ensure all staff who have
to respond to such events are increasingly
exposed to a variety of scenarios.
Area Advisory Group on Immunisation
(AAGI)
The area advisory group on vaccination had a
busy year preparing for, promoting and
implementing the new vaccination programme.
Fifteen NHS Lanarkshire staff participated in
Exercise Cutty Sark, a large multi-agency
continuous counter-terrorism exercise which
took place over 72 hours between 28 and 30
April 2006. It involved the establishment of
the Strathclyde Strategic Co-ordinating Group
supported by, among others, a Joint Health
Advisory Cell. There were a number of liveplay incidents including Prestwick Airport and
railways in Glasgow.
A new AAGI subgroup was set up for locality
vaccination leads, a representative public
health
service
development
manager,
pharmacy and nurse management to ensure
that best vaccination practice was supported at
the locality level. A protocol was developed
on standardising vaccination sites to ensure
good practice and to minimise data recording
and work started on roll out of the web-based
e-learning immunisation package, developed
by Health Protection Scotland.
A&E consultants, the Director of Public Health,
consultants and specialist registrars in public
health medicine, the emergency planning officer
along with other representatives from senior
managerial, communications, administrative and
secretarial staff participated in the event.
Towards the end of 2006, concerns from other
parts of Scotland led to a national cold chain
audit. This was to ensure that vaccine was
held at the correct temperature within fridges.
Although some improvements to these
processes in Lanarkshire were identified, these
were of a relatively minor nature and no
revaccination was required. This reflected
extensive advice and information that has been
issued by pharmacy colleagues, but it is still
incumbent on staff to ensure the advice is
followed and help is sought when required.
Prior to the exercise, most public health
medicine consultants and registrars participated
in training events organized by Health
Protection Scotland designed to familiarise
them with their role in a Joint Health Advisory
Cell.
Eleven A&E staff and the emergency planning
officer received training in the safe use of the
CBRN (Chemical Biological Radiological)
45
HEALTH PROTECTION
Communicable Disease and Environmental Health
Personal Protective Equipment (PPE) suits and
in the erection of the portable inflatable
decontamination tent at Hairmyres Hospital.
The training was provided by the Scottish
Ambulance Service special operations team.
extremely popular, receiving more than 40,000
hits within 3 weeks of its introduction.
The development of alternative interventions,
aimed at targeting resources away from lowrisk premises inspection towards higher-risk
premises, continued to be developed during
the year. Comprehensive sampling also took
place to ensure that the final product is safe to
eat and complies with all compositional and
labelling requirements.
NHS Lanarkshire and South and North
Lanarkshire Councils held awareness raising
events in May 2006. One hundred and twenty
staff from the health service, the local
authorities, police, fire and ambulance service
attended the two events.
Antisocial behaviour
ENVIRONMENTAL HEALTH
North Lanarkshire Council and South
Lanarkshire Council both operate out-of-hours
noise teams to respond to complaints about
noise caused in the main by amplified
equipment. The teams have the capability to
respond immediately and can serve warning
notices and abatement notices to stop the
noise. In the past year, the North Lanarkshire
Council Night Noise Service has received a
total of 655 complaints, just under half of
which required a visit by officers from the
team. 241 complaints were resolved using
verbal warnings, 59 warning notices were
issued and 2 fixed penalty notices served on
individuals. Seizure of equipment was not
required for any of the complaints received.
The service remains available 7 days per week,
all year round enabling effective action to be
taken to curb antisocial behaviour from
domestic dwellings with the minimum of
delay.
Food safety
Food safety inspection, advice, training and
enforcement duties remain high priorities
within both North and South Lanarkshire’s
food safety teams.
Grants provided by the Food Standards
Agency during 2005 and 2006, enabled good
progress in providing support to businesses to
develop
and
introduce
food
safety
management systems based on the principles
of HACCP (Hazard Analysis Critical Control
Point). There is now a legal requirement on
food business operators to introduce and
maintain suitable systems to ensure that food
safety risks are minimised. The support given
included the undertaking of theoretical training
sessions and practical one-to-one mentoring
sessions within the food premises.
Both food safety teams continued to provide
certified food safety training courses for food
handlers employed within local businesses.
Within Lanarkshire, training has now been
provided for 8500 food handlers.
The service is currently being widely
promoted to raise consumer awareness.
Air quality
A draft Air Quality Action Plan has been
submitted for approval to the Scottish Executive,
outlining options for improving air quality
within the Council’s Air Quality Management
Areas. In line with the requirements of the
Local Air Quality Management Process, the
annual Progress Report has also been submitted.
A fourth area within North Lanarkshire has been
identified for declaration as an Air Quality
Management Area, due to high levels of PM10
particulate pollution. PM10 is particulate matter
less than 10 micrometers in diameter. These
very small particles can lodge deep into the
Food safety premises inspection continues as an
important task for both teams, with extremely
high levels of compliance with the national food
safety performance indicator. During the year,
South Lanarkshire introduced a web reporting
system, which posts food safety inspection
reports on the Council’s web site. This provides
information for the public to help them make an
informed choice of where they shop or dine, and
also provides a great incentive for food business
operators to continue to comply with their legal
responsibilities. The site has proved to be
46
HEALTH PROTECTION
Communicable Disease and Environmental Health
lungs and lead to respiratory and heart problems.
The main sources of PM10 arise from
combustion sources such as road traffic although
other environmental factors can impact on
levels. The statutory declaration process is
under way for this site.
manufacturers and suppliers. Local training
was also provided to prepare NLC’s
Environmental Health Officers for their new
enforcement and licensing responsibilities. To
ensure consistency of application across
Scotland, national conditions and guidance
have also been developed by a working group
consisting of representatives from Health
Protection Scotland, the Scottish Executive
and local authorities.
Skin piercing and tattooing
The Civic Government (Scotland) Act 1982
(Licensing of Skin Piercing and Tattooing)
Order 2006, as amended, requires any person
who carries out a business which provides skin
piercing and tattooing including acupuncture,
cosmetic body piercing and electrolysis to be
licensed after 1 April 2006 or to have applied
for a licence.
The Order allows local
authorities up to 12 months to determine
licence applications and specifies a range of
conditions which must be fulfilled by
practitioners when they undertake any skin
piercing or tattooing activity, e.g. sterilisation
of equipment and utensils, age restrictions,
standards for premises and equipment and
procedural requirements.
Waste management
Waste management is subject to a range of
nationally set targets in relation to recycling
and composting, and the diversion of
biodegradable waste from landfill.
The
National Waste Plan sets the framework within
which Scotland can deal with the generation of
waste in a more sustainable manner. The
process is driven by European Directives on
waste designed to minimise the reliance on
landfill as a means of disposal and encourage
reduction, recycling, re-use and safe treatment
of waste. Within Scotland as a whole, efforts
have initially concentrated on increasing the
percentage of waste being recycled and
composted to meet the recycling and
composting target of 25% by 2006.
Local Authority Environmental Health
Departments, as previous, will continue to
enforce the provisions of the Health and Safety
at Work Act 1974 in premises of this nature
including enforcement interventions.
Both North and South Lanarkshire Councils
have been at the forefront of developing
sustainable waste management practices and
exceeded the 2006 recycling and composting
target of 25%. Within Lanarkshire as a whole,
the percentage of waste recycled and
composted is over 30% and the councils are
continuing to develop and implement systems
to increase recycling and composting further.
North Lanarkshire Council Environmental
Services, as part of their Operational Plan for
2006/2007 introduced a protocol for licensing
skin piercing and tattooing practitioners and
progress in now being made to fully licence all
such practitioners. Letters advising relevant
businesses of the new legal requirements were
sent out to 253 businesses within North
Lanarkshire who were thought to be involved
in skin piercing or tattooing activities. To
date, eleven applications have been received
and are currently being processed.
Both councils are working jointly to develop a
sustainable waste treatment solution for
Lanarkshire to meet the landfill diversion
target. Lanarkshire is viewed as a market
leader in this respect and the project has been
given pathfinder status and provisional
funding by the Scottish Executive.
On 11 December 2006, NLC Environmental
Services organised a national skin piercing and
tattooing training event which was attended by
delegates from many of Scotland’s local
authorities.
The programme included
presentations from body art and tattooing
practitioners, Health Protection Scotland, the
Scottish Executive, and sterilisation equipment
Private water supplies
On 3 July 2006, the Private Water Supplies
(Scotland) Regulations 2006 came into force
superseding the previous regulations. The new
47
HEALTH PROTECTION
Communicable Disease and Environmental Health
regulations significantly enhance the local
authorities abilities to bring about improvements
to all aspects of a private water supply. Grant
aid is available for assistance with supplies
which fail to meet the requirements of the
regulation. The regulations categorise supplies
into 2 broad groupings: Type A supplies
(commercial users or supplying more than 50
people) and Type B supplies (all others). In the
Lanarkshire area, it is estimated that there are
approximately 82 Type As and 257 Type Bs.
North and South Lanarkshire are currently in the
process of systematically reviewing the supplies
in their respective areas in order to ensure that all
supplies meet the relevant chemical and
bacteriological standards stipulated in the
legislation.
associated with
Lanarkshire.
a
restaurant
in
South
Scabies
Four outbreaks of scabies in healthcare settings
were notified during the year. Although scabies
is not a serious infection, it is uncomfortable and
has the potential to cause extensive and
prolonged outbreaks. Prompt treatment of cases
and preventive treatment of staff and
residents/patients is essential. This involves
treating a large number of people both in care
homes and the community at the same time.
Tuberculosis
In May, five residents in an Airdrie care home
were found to have tuberculosis. Tragically,
despite treatment, three of those residents who
were frail and had other long-standing health
problems, died. TB was certified as the cause of
death of two residents and a contributory factor
in the death of the third. All residents and staff
were screened and enhanced surveillance put in
place by the care home and TB service.
OUTBREAKS AND ACCIDENTS
Despite efforts to reduce the risks of infection
in the community and in healthcare settings,
outbreaks of infectious disease and incidents
involving risks to others inevitably occur.
Public health, infection control teams across
Lanarkshire, environmental health and water
authority colleagues are available at all times
to minimise the impact of these.
Although tuberculosis in Scotland and
Lanarkshire is an uncommon disease, this
outbreak was a reminder that it remains a
serious public health threat. An update on the
work being done to contain TB is provided in
Chapter 8.
During 2006, there was a wide variety of
incidents, most relatively contained or involving
less serious infections, but a few involving more
serious diseases and/or with potential for more
widespread harm.
SERVICE DEVELOPMENT/CHALLENGES
Updating the Pandemic Influenza Plan in
line with national guidance
Infectious intestinal illness
In healthcare settings, 57 outbreaks of diarrhoeal
and/or vomiting illnesses were reported. These
affected a mix of care homes, long-stay NHS
wards, and wards in acute hospitals. Where a
causative organism was found, this was usually
the norovirus. Norovirus infection typically
causes an unpleasant but usually self-limiting
illness with vomiting and diarrhoea lasting
around 24 to 48 hours.
Considerable planning has been going on at
international and national level because the
world is on pandemic alert while detailed plans
are being drawn up in local hospitals and
primary care.
The Scottish Executive published a National
Framework for Responding to An Influenza
Pandemic which set out a range of impacts that a
8
For
pandemic could have on Scotland.
Lanarkshire, these range from 140,000 people ill
with influenza over a 15-week period with
between 750 and 5600 having to be admitted to
hospital, to 275,000 people ill with influenza
over the same period with between 1500 and
Foodborne disease outbreaks were fortunately
relatively few.
A small outbreak of E. coli O157 in South
Lanarkshire affected four individuals, and 31
people were affected by a norovirus outbreak
48
HEALTH PROTECTION
Communicable Disease and Environmental Health
11,000 requiring hospital inpatient treatment. It
also gives clearer information on vaccination
and the use of antiviral medicines, school
closure, public communications, and how
various sectors would be expected to respond as
the pandemic unfolds. An important new
dimension is the evolving debate on managing a
pandemic in an ethical way, since hard choices
may have to be made should local services come
under significant pressure, as they clearly would
in all but the most optimistic estimates. All of
these issues will have to be considered carefully
in 2007.
Improving air quality
As a result of the PM10 issues identified, North
Lanarkshire Council will undertake a
programme of vehicle emission testing during
2007 to cover the three air quality management
areas within the council area. An advertising
campaign will be introduced to highlight the
testing programme and also to raise awareness of
the problems associated with vehicle emissions.
The testing will be undertaken on a voluntary
basis but primarily as an enforcement campaign
with fixed penalty notices issued to those drivers
whose vehicles fail the appropriate emission test.
It is expected that North Lanarkshire Council
may undertake a minimum of 25 days emission
testing throughout the year.
Developing a Health Protection Plan for
Lanarkshire
An important element of the proposed new
public health legislation would be the
development of a Lanarkshire Health Protection
Plan. This would be developed by NHS
Lanarkshire and would lay out the local
challenges in protecting the health of the public,
each organisation’s roles and responsibilities,
communication arrangements, and how service
quality would be audited and improved.
Achieving reduction
bacteraemia
in
REFERENCES
1.
Scottish Executive. Public Health Legislation in Scotland: A
Consultation. Edinburgh: Scottish Executive, October 2006.
2.
Scottish Executive. NHS Boards’ Health Protection
Remit. CMO (2006) 2. Edinburgh: Scottish Executive,
2007.
3.
Scottish Executive. Managing Incidents Presenting
Actual or Potential Risks to the Public Health: Guidance
on the Roles and Responsibilities of Incident Control
Teams. Edinburgh: Scottish Executive, 2003.
www.scotland.gov.uk/Publications/2003/01/16243/17320.
Last accessed 4 July 2007.
4.
National Services Scotland.
Health Protection
Scotland (HPS) Pandemic Influenza Preparedness
Standards for Overall Strategic, Healthcare and
Health
Protection
Services.
Personal
communication, 2007.
5.
HPS Weekly Report, Volume 41 No. 2007/01.
http://www.documents.hps.scot.nhs.uk/ewr/pdf2007/0701.pdf
.Last accessed 26 September 2007.
6.
Scottish Executive. Hepatitis C Action Plan for
Scotland. Phase 1: September 2006 – August 2008.
Edinburgh: Scottish Executive, 2006.
www.scotland.gov.uk/Resource/Doc/148746/0039553.pdf
Last accessed 20 September 2007.
7.
The Department of Public Health, Lanarkshire NHS
Board. The Health of the People within the Lanarkshire
NHS Board Area. Annual Report of the Director of
Public Health 2005. Hamilton: Lanarkshire NHS Board,
2006.
8.
Scottish Executive. The Scottish Executive National
Framework for responding to An Influenza Pandemic.
(Web only publication), March 2007.
http://www.scotland.gov.uk/Publications/2007/03/15125518/0.
Last accessed 2 October 2007.
MRSA/MSSA
As part of the drive to reduce the risks of
healthcare
associated infections, NHS
Lanarkshire is committed to reduce cases of
blood poisoning (bacteraemia) caused by all
types of staphylococcus bacteria by 30% by
2010. Much of this reduction will depend on
maintaining and improving infection control
and cleaning generally. However, particular
attention will be given to ensuring that
infection risks in the use of intravenous lines
are reduced as much as possible.
Improving awareness and infection control
skills in the care home sector are also
necessary to achieve this reduction.
Finalising the evidence-based training resource
for training staff in the care home sector will
also be a priority for the health protection
team.
49
HEALTH PROTECTION
Communicable Disease and Environmental Health
50
HEALTH PROTECTION
Tuberculosis Prevention and Control
CHAPTER 8
TUBERCULOSIS PREVENTION AND CONTROL
Tuberculosis (TB) last featured prominently in
the 2001 Annual Report.1 A key theme in that
report was that, although the number of cases
of TB in Lanarkshire was stable, there was no
room for complacency. The highest number of
cases in Lanarkshire for many years and a fatal
outbreak in a local care home in 2006
demonstrate that clearly.
all of the adult age bands and areas of
Lanarkshire.
Enhanced surveillance of mycobacterial
infections
Lanarkshire takes part in the Enhanced
Surveillance of Mycobacterial Infections
(ESMI) in Scotland programme run by Health
Protection Scotland (HPS) which is building,
year on year, a clearer picture of TB in
4
Scotland. It collects information on the age
and sex of cases, ethnic origin, treatment,
outcome and risk factors which may have
contributed to the person becoming infected
and ill. The risk factors are shown in Figure
8.1 with alcohol consumption a risk factor for
over 50% of patients developing TB.
TB remains an important chronic infectious
Caused by a
disease across the world.
bacterium, mycobacterium tuberculosis, it
most commonly affects the lungs, but can
develop in the kidneys, bones and other parts
of the body. Vague initial symptoms, such as
prolonged cough, weight loss and loss of
appetite, can delay diagnosis. It is infectious,
spreading through the air, with each person
with active respiratory disease potentially
2
infecting up to 15 people in one year. TB
remains a huge health problem in every region
of the world. The World Health Organisation
has estimated that 1.6 million people died from
TB in 2005. Treatment is usually effective but
is prolonged.
The latest available report shows that in 2003,
366 cases of TB were notified in Scotland, 246
of which were pulmonary, with 129 of these
smear positive and therefore likely to have
4
been infectious. There were 120 cases of the
less infectious non-pulmonary form of the
disease. Most people (76%) had symptoms
when the TB was discovered with a few (24
cases) having had symptoms for 6 months.
In England, Wales and Northern Ireland the
number of cases continue to rise slowly, with a
2% increase between 2005 and 2006. In 2006,
8171 cases were notified in comparison to the
6500 cases reported in 2000.
Rates of
infection are particularly high in London and
3
the Midlands. Scotland, fortunately, has not
yet seen such increases, recording between
351 and 403 cases over the past seven years.
In 139 cases it was possible to determine risk
factors which may have contributed to the
illness. Alcohol misuse remains the single
most common risk factor for TB in Scotland.
The Lanarkshire TB service provides
information on over 96% of cases to ESMI.
This not only makes national surveillance
more accurate but also gives an almost
complete picture of TB in Lanarkshire. Most
cases of TB report symptoms that are found to
be due to TB, 77% in 2004 and 79% in 2005.
The remainder are identified incidentally,
through contact tracing or occasionally at post
mortem.
Unfortunately, 2006 was not such a stable year
in Lanarkshire.
Fifty-four cases of
tuberculosis were notified in the NHS
Lanarkshire area during 2006, the highest
number since 1999. Of these, 37 had the
potentially infectious pulmonary form of the
disease. Other than one small outbreak in
Airdrie, there was little to explain this
relatively high figure. Cases occurred across
51
HEALTH PROTECTION
Tuberculosis Prevention and Control
Figure 8.1
Reported risk factors for tuberculosis, Scotland, 2003
Healthcare
w orker
8%
Immunosuppressed
13%
Drug misuse
2%
Other residential
institution
5%
Homeless
7%
Alcohol
52%
Asylum seeker/
refugee
13%
An important part of the ESMI scheme is that
information is collected on the outcome of the
illness a year after notification. Provisional
ESMI data for Lanarkshire shows that in 2004,
24/35 (68%) cases successfully completed
treatment. Seven cases had died within one
year of commencing treatment; one remained
on treatment at the end of the year. In 2005,
18/23 (78%) successfully completed treatment.
Three individuals died within a year of starting
treatment and two were lost to follow up.
residents conducted over the same period
determined that there had been 20 deaths with
6
MOTT. Based on these two studies, it is
estimated that the true number of deaths with
TB in Lanarkshire between January 2000 and
September 2005 is somewhere between 35 and
40.
It is important to ensure that all reported cases
are followed up closely and efforts made to
ensure that as high a proportion as possible
complete treatment. This helps to reduce the
risk of relapse or development of drug
resistance.
People who have MOTT infection, which is
not a notifiable disease, may have similar
needs for support through their treatment to
TB patients. The TB service will look at ways
to support these individuals in the future.
Reassuringly, most of the TB cases were
known to the TB Service, received treatment
and support over a period of time.
The emerging threat of multidrug-resistant
TB and extensively drug-resistant TB
Lanarkshire deaths from TB or where TB
contributed to death
Treatment for TB, although usually effective,
is fairly lengthy, with the minimum duration
being six months when the bacteria is sensitive
to the drugs, usually referred to as first-line
drugs, and the patient adheres to treatment.
Although effective treatments are available,
those who are vulnerable due to other illness
or alcohol misuse can die from TB. A careful
study of all deaths, either from or with TB,
from January 2000 to September 2005 was
undertaken during 2006. Over that period, 54
Lanarkshire residents had died with a
diagnosis of TB recorded on the death
certificate. However, further investigation
suggested that a number of these deaths were
in fact due to mycobacterium other than TB
5
(MOTT). A further study of Lanarkshire
Treatment where the standard drugs are less
effective is much more difficult. This occurs
when the bacteria becomes resistant to some of
these first line drugs. When the bacteria is
resistant to the two most powerful first-line drugs
(isoniazid and rifampicin), it is referred to as
2
multidrug-resistant TB or MDR-TB. This can be
52
HEALTH PROTECTION
Tuberculosis Prevention and Control
treated by second-line drugs but these may have
to been given by injection and generally have a
higher risk of side effects. Should the bacteria be
resistant to some of these second-line drugs, it is
then referred to as extensively drug-resistant
(XDR-TB). Managing XDR-TB is difficult since
treatment options become very limited.
MDR-TB is still rare in the UK. Figures from
England, Wales and Northern Ireland for 2003
showed that only 1.3% of culture positive
cases were MDR-TB. Only a very small
number are XDR-TB. WHO estimates that
around 10% of MDR-TB in high-income
7
countries in Europe are extremely resistant.
The threat of TB that is more difficult to treat
poses a risk to TB control in the UK and
across the world.
•
improving adherence to treatment by
ensuring that all patients have a risk
assessment and know their key worker
•
screening of new entrants to the UK
•
BCG vaccination of children at higher risk
of TB
Much of this is a development of earlier
guidance. However, one major change is the
recommendation to add a new test for latent
TB infection to screening. Much of the new
guidance has already been incorporated into
local protocols.
However, some aspects,
including changing laboratory testing, are
being discussed at national level in Scotland.
Vaccination
WHO policy
For many decades all schoolchildren have
been offered vaccination against TB (BCG).
Fortunately, TB in the UK and Scotland is
considerably less common than when BCG
was introduced in the 1950s. Most cases in
the UK now occur in those who have some
risk factors, such as having lived in countries
where TB is more common, having parents
who have migrated to the UK, and having
been in contact with a case of TB. The
national expert group on vaccinations took
account of this and recommended that the
vaccination of all children through schools
should stop, and that BCG should be targeted
10
at those who would benefit most.
With easy frequent national and international
travel and the increased risk of resistant TB, the
theme of a recent World TB Day “TB anywhere
is TB everywhere” is very appropriate. WHO
has developed an ambitious global plan to
eradicate TB by 2050. This ‘Stop TB Strategy’
has six key components and aims to reduce
worldwide TB prevalence and death rates by
8
50% by 2015 (relative to 1990).
National guidance
Diagnosis and treatment
Against a backdrop of increasing rates of
infection in England and the developing
concerns about antimicrobial resistance, the
National Institute for Health and Clinical
Excellence (England and Wales) produced
9
updated guidance in 2006. In order to reduce
the population risk of TB, it highlighted the
importance of:
•
Diagnosing and treating active and latent
TB in adults and children
•
Preventing the spread of TB by offering
tests to those at high risk and by vaccination
Local developments
In the 2001 Annual Report, the requirements for
TB Prevention and Control in Lanarkshire were
clearly described. Priority was given to making
better use of the information collected locally on
each case, standardised treatments with support
from community pharmacists, and further
development of cross-boundary working.
In addition, several audits have been undertaken
looking at all aspects of managing TB in
Lanarkshire. These included the uptake of BCG
vaccination in families from higher risk
countries, and the usefulness of information
recorded on new entrant screening forms.
and identified as priorities:
• the use of standardised treatment for active
TB
53
HEALTH PROTECTION
Tuberculosis Prevention and Control
TB Service. Both of these, however, improved
between audits.
Improving and using information
Surveillance
The TB service has continued to refine their
database of cases and contacts so that their
progress can be closely monitored, and
communications take place promptly and
reliably. The format of letters, summaries and
agreements among the team members have all
been reviewed for clarity, including patient
and contact information letters, physician
screening summaries, and Directly Observed
Treatment agreements.
Relevant information about TB cases and their
local treatment is key to understanding how
TB is being tackled.
The Lanarkshire TB service has been working
closely with HPS to ensure that the
information required by ESMI is as complete
as possible. HPS feeds back both a national
and local overview of TB and its management
annually and this information is discussed at
the regular TB Prevention and Control
Committee meetings. To complement this, the
TB service provides a detailed report on
contact tracing and screening for local TB
clinicians.
Standardising treatment and encouraging
adherence to treatment
A laminated TB Therapy Guideline was
produced in 2004 that details the standard
regime for TB treatment in adults. This was
distributed to outpatient clinic and ward areas,
the infectious disease unit and hospital
pharmacies. It brings together information
about daily treatment and intermittent
supervised treatment, and has colour pictures
of the tablets and capsules to aid discussion
with patients, as shown in Figure 8.2. Details
of dosage may seem complex and using the
distinctive appearance of the various
medicines helps patients and staff to be
confident the correct medicine is being taken.
This is important, given the length of the
treatment required over many months. It has
been well received by senior and junior staff.
Detecting clusters or outbreaks of TB can be
difficult due to its long latent and incubation
periods. A number of approaches are used to
ensure that any potential clusters of TB are
detected. The TB service records the home
location of TB cases on a simple wall chart,
and looking for linked cases is an integral part
of contact tracing. As a further check, the
health protection team runs a specially
developed statistical programme at regular
intervals to check for any unusual clustering of
cases in both space and time.
Communications
The TB service has developed links with each
hospital pharmacy and helps patients to
identify a convenient community pharmacy so
that any problems or concerns with medication
can be quickly resolved.
Treating a single case of TB involves close
collaboration among several healthcare
workers. To ensure the best service for
patients and contacts, good communications
are vital. The TB Contact Tracing Service is
very much the focus for managing patients,
their contacts and families. Local protocols
for correspondence to and from the TB
Contact Tracing Service are clear and
therefore relatively straightforward to monitor.
Although communication between team
members is generally felt to be good, audits in
2002 and 2004 showed that the TB Service
received a letter on completion of treatment in
less than half of cases. Up to a quarter of all
laboratory results were also not copied to the
54
HEALTH PROTECTION
Tuberculosis Prevention and Control
Figure 8.2
TB Therapy Guidelines
Cross-boundary working
•
Clinical and public health staff in Lanarkshire
have been active over the past few years in
encouraging and taking part in developments
across Scotland. Examples include:
Communications between those caring for
a case, managing the lengthy treatment
and dealing with public health issues
requires re-audit.
•
Developing multi-agency working with
key partner agencies in the management of
TB patients, e.g. alcohol, drug and
homeless services.
•
Observing the changing pattern of
migration to Scotland and Lanarkshire and
reviewing and revising local policy and
procedures for TB screening of new
migrants to Lanarkshire from higher
incidence countries need to reflect this.
•
People with illness due to mycobacteria
other than TB may benefit from the
integrated approach used to manage TB
and should be developed.
•
Ensuring joint working across Lanarkshire
in relation to the changes to the BCG
programme and implementing the
recommended changes.
•
Chairing the Scottish TB Nurses Group
and developing better links among TB
Nurses across Scotland such as a web page
for sharing practice and providing annual
study days.
•
Involvement in the development of a
national information management system
for managing TB.
•
Contributing to a national review of
guidelines for preventing and managing
TB.
Future Challenges
The main challenge in Lanarkshire is to
maintain an efficient and integrated approach to
managing TB in the context of relatively few
cases. Some areas require further attention:
55
HEALTH PROTECTION
Tuberculosis Prevention and Control
REFERENCES
1.
Lanarkshire NHS Board. The Health of the People
within the Lanarkshire NHS Board Area. Annual
Report of the Director of Public Health 2001.
Hamilton: Lanarkshire NHS Board, 2002.
2.
World Health Organisation. Fact sheet No. 104.
Geneva: World Health Organisation, March 2007.
http://www.who.int/mediacentre/factsheets/fs104/en/
Last accessed 25 June 2007.
3.
Health Protection Agency. Tuberculosis Update.
London: Health Protection Agency, March 2007.
4.
Johnston F, Hopkins A, McMenamin J. Enhanced
Surveillance of Mycobacterial Infections (ESMI) in
Scotland: summary for Scotland for the year 2003. HPS
Weekly Report 2006; 40 (16): 91-94.
5.
O’Dowd JJM. An Audit of TB Deaths in Lanarkshire,
2000-2005. Personal communication, June 2006.
6.
Wilson LE. A review of the mortality associated with
atypical mycobacterial infections in NHS Lanarkshire.
Personal communication, April 2006.
7.
World Health Organisation Regional Office for
Europe. Virtually untreatable TB affects Europe.
www.euro.who.int/tuberculosis/issues/20060908 1
Last accessed 26 June 2007.
8.
World Health Organisation, Stop TB Partnership. The
Stop TB Strategy: Building on and enhancing DOTS
to meet the TB-related Millennium Development
goals. Geneva: World Health Organisation, 2006.
www.who.int/tb/publications/2006/en/index.html
Last accessed 25 June 2007.
9.
National Institute for Health and Clinical Excellence,
Clinical Guideline 33. Clinical diagnosis and
management of tuberculosis and measures for its
prevention and control. London: National Collaborating
Centre for Chronic Conditions, Royal College of
Physicians, 2006. www.nice.org.uk
10. Scottish Executive. Changes to the BCG vaccination
programme. SEHD/CMO(2005)5. Edinburgh: Scottish
Executive, 2005.
11. Wilson LE and Miller J. Audit of return of Enhanced
Surveillance of myobacterial infection forms and
treatment outcomes for TB in Lanarkshire. Personal
Communication, October 2005.
56
HEALTH PROTECTION
National Screening Programmes in Lanarkshire
CHAPTER 9
NATIONAL SCREENING PROGRAMMES IN LANARKSHIRE
Screening is a public health activity, which is
targeted towards specific groups of the
population to identify individuals at risk of a
particular disease. The population targeted is
based on what is known about the disease
process as well as the screening test and
treatment options. The population selected is
calculated to maximise the health gain for the
programme concerned.
pick up abnormal pre cancerous or cancerous
cells in the cervix (neck of the womb) by taking
a ‘smear’. Any abnormal cells can then be
treated to prevent cancer developing, where
lesions are pre cancerous, and to improve
outcomes in lesions which are already
cancerous.
Three-yearly participation in the
programme is the best way for women to protect
themselves against cervical cancer. Women can
also lower their risk of cervical cancer by not
1
smoking cigarettes.
Screening involves offering tests to large
numbers of people, generally at specified
intervals: for example, with cervical cancer
screening, smear tests are offered to all eligible
women aged 20-60 every 3 years. This allows
identification of a small number of women who
are at high risk of cervical cancer for further
investigation and possibly treatment.
Programme developments
A new National Colposcopy Clinical Information
and Audit System (NCCIAS) was introduced in
May 2006. This national database supports data
collection for the purpose of audit and monitoring
of the colposcopy (investigation and treatment)
part of the cervical screening programme.
Screening programmes consume large amounts
of healthcare and public resources. For this
reason, the risks and benefits of any new
screening programme are carefully weighed by a
national body of experts called the United
Kingdom National Screening Committee (NSC).
The NSC considers whether any proposed new
programme fulfils a number of important criteria
such as:
•
the disease being screened for is an
important public health problem
•
a suitable test is available to detect the
disease at an early stage
•
an effective treatment for the disease is
available.
Work on the Scottish Cervical Call Recall
System (SCCRS) progressed during 2006 and
plans for its roll out were finalised. SCCRS
will standardise call and recall arrangements
for women across Scotland and link the smear
taking, laboratory and treatment elements of
screening for cervical cancer.
Programme uptake
Over the financial year 2005/06, 53,999 smears
were processed at the Monklands cytopathology
laboratory: 42,846 were from the NHS
Lanarkshire area and 11,153 from NHS
Dumfries and Galloway area. Of the smears
processed, 2% were unsatisfactory and required
women to have a repeat smear taken. Of those
that were satisfactory, 92% were negative and
8% were non negative, the latter requiring
further smears or colposcopy.
Once screening programmes are in place, they
are closely monitored against specific criteria to
ensure that they operate safely and effectively.
CANCER SCREENING PROGRAMMES
From 1 April 2005 to 31 March 2006, 77.5% of
eligible women in Lanarkshire had had a
cervical smear in the previous 3.5 years and
83.2% in the previous 5.5 years. Figure 9.1
shows the trend in uptake over a 5.5 year period
from 1997/98 to 2005/06.
Cervical screening
Screening for cervical cancer is offered every 3
years to all eligible women aged between 20 and
60 years in Scotland. The programme aim is to
57
HEALTH PROTECTION
National Screening Programmes in Lanarkshire
Figure 9.1
Cervical screening uptake, Lanarkshire and Scotland, 1997/98-2005/06
100
Percentage uptake
90
Scotland
80
Lanarkshire
70
20
05
/0
6
20
04
/0
5
20
03
/0
4
20
02
/0
3
20
01
/0
2
20
00
/0
1
19
99
/2
00
0
19
98
/9
9
19
97
/9
8
60
Figure 9.2
Carcinoma in situ of cervix uteri, registrations, by age group, Scotland, 1980-2004
600
Rate per 100,000 population
500
20-24
400
25-29
30-34
300
35-39
40-44
200
45-49
100
19
8
19 0
8
19 1
8
19 2
8
19 3
8
19 4
85
19
8
19 6
8
19 7
8
19 8
8
19 9
9
19 0
9
19 1
9
19 2
9
19 3
9
19 4
9
19 5
96
19
9
19 7
9
19 8
9
20 9
0
20 0
0
20 1
0
20 2
03
20
04
0
Screening uptake has been gradually falling in
Lanarkshire and Scotland in the last few years
at a time when the programme quality is at its
highest ever.
very poor uptakes within 20-24-year-olds.
Further research is needed to better understand
the reasons for this.
The rate of CIN3 (carcinoma in situ), the precursor lesion of cervical cancer, across all ages
has not changed substantially in Scotland since
1989. However, the rate of CIN 3 by age
group has changed dramatically. The rate has
declined among older women, yet among
younger women, it has increased significantly,
as shown in Figure 9.2. The rates for women
aged 20-24 years and 25-29 years are running
in parallel.
This fall in uptake has been most marked
among 20-24-year-olds. Uptake in this age
group across Scotland for the 3.5 year period
to April 2006 was 57.2 % and 58.8% over a
5.5 year period.
This is paralleled in
Lanarkshire with an uptake of 56.9% over a
3.5 year period and 57.8% over a 5.5 year
period respectively.
A number of factors are thought to contribute
to this national decline, and in particular, the
58
HEALTH PROTECTION
National Screening Programmes in Lanarkshire
levels of CIN3 in young women may lead to
an increase in the incidence of and mortality
from cervical cancer.
Morbidity and mortality
Figure 9.3 demonstrates the standardised
registrations (new cases) of and mortality
(deaths) from cervical cancer for all women in
Lanarkshire and Scotland for the period 19902006 based on 3-year moving averages to
smooth fluctuations which occur due to the
small numbers involved each year.
Breast screening
Screening for breast cancer is offered every 3
years to women aged between 50 and 70. The
aim of the programme is to detect cancerous
cells if they are present on x-ray examination
of the breast. These cells can then be treated,
leading to improved survival for women with
breast cancer.
In 2004, the most recent year for which
complete data are available, there were 26 new
cases of cervical cancer in Lanarkshire
compared with 20 in 2003, with
age
standardised rates of 8.0 and 6.5 per 100,000
population respectively. These differences are
likely to be due to year to year variation in small
numbers. The trend in registrations of cervical
cancer in Lanarkshire continues to be
downwards and in line with the Scottish average.
Programme developments
During the 5th round of breast screening in
2006, age extension of the Lanarkshire
population was completed. Now all women in
Lanarkshire and in the rest of Scotland have
access to the breast screening programme from
the age of 50-70 years. Women older than 70
years can continue to self refer into the
service.
In 2006, there were 14 deaths from cervical
cancer compared with 15 in 2005, with age
standardised rates of 3.9 and 4.5 per 100,000
population respectively. These differences are
likely to be due to year-to-year variation in small
numbers. The overall trend is relatively flat in
Lanarkshire and Scotland.
The community health educator project about
improving breast screening awareness and
knowledge commenced during 2006, when
mobile screening units were sited in the
Airdrie and Coatbridge areas.
The concern is that, set against a backdrop of
falling uptake of cervical screening, increasing
Figure 9.3
Cervical cancer, deaths and registrations, 1990-2006
Standardised rate per 100,000 population
20
3 year moving averages for
the periods 1990-92 to 2004-06
16
Scotland
registrations
Lanarkshire
registrations
12
Scotland
deaths
8
Lanarkshire
deaths
4
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
0
59
HEALTH PROTECTION
National Screening Programmes in Lanarkshire
100,000 population respectively. The overall
trend in registration has been a slow increase
although this has been less marked in the last
few years, mirroring the Scottish experience.
Programme uptake
For the 3-year period, 2003/04 to 2005/06, a
total of 72.3% of eligible Lanarkshire women
attended for breast screening. This is an
improvement on the preceding 3-year uptake
in Lanarkshire of 71.5%. This level continues
to exceed the national target of 70% uptake
over a 3-year period.
In 2006, there were 122 deaths form breast
cancer compared with 116 in 2005. The age
standardised rates were 30.0 and 29.8 per
100,000 population respectively.
During 2003/04 to 2005/06, 803 women older
than 70 years self-referred for breast
screening. During this 3-year period, 2071
women were recalled for further investigation
and 206 cancers referred for surgery. Data on
the outcomes of these referrals is awaited.
The trend in death rates in Lanarkshire as in
Scotland generally remained fairly stable.
Colorectal cancer screening
The Scottish colorectal screening programme
will invite all eligible men and women,
between the ages of 50 and 74, every 2 years
for colorectal screening using a test which
looks for occult (hidden) blood in the bowel
motions.
Morbidity and mortality
Figure 9.4 shows the standardised registrations
(new cases) of and mortality (deaths) from breast
cancer for all women in Lanarkshire and
Scotland for the period 1990-2006 based on 3year moving averages to smooth fluctuations
that occur due to small numbers involved each
year.
If the screening test finds occult blood, this
might indicate that a person is at higher risk of
colorectal cancer and they will be referred to
hospital for colonoscopy (an examination of
the bowel using a flexible tube with a camera)
and possibly treatment, depending on the
result of colonoscopy.
In 2004, the most recent year for which
complete data are available there were 423 cases
of breast cancer compared with 398 in 2003.
The age standardised rates were 117 and 119 per
Figure 9.4
Female breast cancer, deaths and registrations, 1990-2006
150
3 year moving averages for
the periods 1990-92 to 2004-06
125
Scotland
registrations
100
Lanarkshire
registrations
75
Scotland
deaths
50
Lanarkshire
deaths
25
0
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
Standardised rate per 100,000 population
175
60
HEALTH PROTECTION
National Screening Programmes in Lanarkshire
The national programme commences in March
2007 and the implementation across Scotland
will be complete by December 2009.
Colorectal screening will be implemented in
NHS Lanarkshire during August 2009.
0.7% for neural tube defect screening. This is of
the same order as uptake figures for 2005.
Although this is low in comparison with uptakes
in, for example, cervical screening, the decision
to take up the offer of pregnancy screening tests
is very individual.
The programme aim is to enable earlier
detection of colorectal cancer before people
have symptoms suggestive of the disease.
Screening uptake figures for NHS Lanarkshire
are expected to be an underestimate as figures
are based on the hospital where women have
screening performed rather than area of
residence. Women from Lanarkshire who
have their antenatal care in Glasgow hospitals
(approximately 1/5 of the total number of
Lanarkshire women who give birth) are
counted as belonging to ‘Glasgow’ for
screening uptake purposes. It is planned to
collect postcode data in the future which might
make it possible to consider area of residence
as the denominator, accuracy of postcode data
permitting.
The UK screening pilot demonstrated that
programme uptake may be low, particularly in
2
males and those living on low incomes. It
will therefore be important to ensure that
efforts at raising awareness and increasing
knowledge of the programme and its benefits
are maximised, building upon the work of the
Bowel Cancer Awareness Project which
targeted low income communities in
Lanarkshire and Forth Valley.
OTHER SCREENING PROGRAMMES
In 2004, which is the most recent year for
which data are available on congenital
anomalies, there were 61 babies born with
Down’s syndrome across Scotland and 62
cases of neural tube defects.
SCREENING IN PREGNANCY
The purpose of offering screening during
pregnancy is to enable identification of
anomalies (abnormalities) in an unborn baby,
such as Down’s syndrome and neural tube
(spinal cord) defects, such as spina bifida. The
results of such screening tests can provide
parents-to-be with information to allow them
to make decisions about whether to continue
with an affected pregnancy. Other tests can
show up abnormalities which can be treated
either in utero (in the womb) or immediately
after birth. Pregnancy and newborn screening
standards were published by NHS Quality
3
Improvement Scotland (QIS) in 2005.
Over the period 2000-2004, the rate of Down’s
syndrome and neural tube defects among
singleton babies per 1000 births of selected
anomalies detected at birth, during infancy or
abortion following pre-natal diagnosis were: in
Lanarkshire 1.3 per 1000 births compared with
1.06 per 1000 births in Scotland for Down’s
syndrome and 0.51 and 0.44 per 1000 live
births respectively for Lanarkshire and
Scotland for neural tube defects.
The incidence (rate) of Down’s syndrome
and of neural tube defects is on a par with
those rates observed at a Scotland-wide level.
Screening for Down’s syndrome and neural
tube defects in Lanarkshire
Programme uptake
The rate of detection of serious anomalies such
as serious heart defects is lower in Lanarkshire
when compared to the Scottish average. This
is likely to be because anomaly scanning in the
second 3 months of pregnancy is not
performed routinely. Only women whose
babies are thought to be at risk of a problem
are offered an anomaly scan at this stage.
Screening for infections in pregnancy is
covered in Chapter 7.
During 2006, 2524 women had 2nd-trimester
screening (or screening during the second 3
months of pregnancy) to enable estimation of
the risk for Down’s syndrome and neural tube
defects.
Fifty-one women wished to be
screened for neural tube defects only.
The total number of live births to Lanarkshire
residents during 2006 was 6584. This provides
an uptake of 38% for Down’s syndrome and
61
HEALTH PROTECTION
National Screening Programmes in Lanarkshire
consequences for affected babies if they remain
undetected and untreated.
SCREENING IN THE NEWBORN PERIOD
The aim of screening in the newborn period is to
enable early identification of abnormalities in a
newborn baby, such as cystic fibrosis and other
metabolic abnormalities as well as significant
hearing losses. Early detection allows treatment
to be introduced as early as possible to improve
outcomes for affected babies.
Universal
(UNHS)
newborn
hearing
Programme uptake
Uptake of blood spot screening in Lanarkshire
during 2006 was 99.9%, based on 6584 live
births. In a small number of babies, an
insufficient amount of blood is obtained using
the heel prick to permit all screening tests to
be carried out and the test has to be repeated.
screening
During 2006, the percentage of samples with
insufficient blood to carry out all the blood
spot tests on in Lanarkshire was 1.11%
compared with a Scottish average of 0.56%.
This programme screens for serious hearing
problems which are present at birth. There is
good evidence that early detection of these
hearing losses can result in significantly better
outcomes in speech and language skill
4
development than where treatment is delayed.
UNHS was introduced across Lanarkshire at
the end of 2005 and the service was fully
operational from January 2006.
The insufficient rate in Lanarkshire is
significantly higher than the Scottish average
and reasons for this have been examined. As a
result, the device used in Lanarkshire was
changed to the ‘genie lancet’ system in
November 2006, with which other NHS board
areas have been able to achieve significantly
lower insufficient rates. Insufficient results
will continue to be monitored closely.
Programme uptake
Data for the period 1 January 2006 to 30
September 2006 demonstrates a programme
uptake of 96.2%. This meets and exceeds the
NHS QIS standard. Most babies are tested
shortly after birth, while mothers are still in
hospital. This is significant as the catch up
clinic attendance rate has been poor, around
50%.
This has implications for future
maternity service developments such as the
move towards earlier discharge of mothers and
new babies.
During 2006, 5 babies were referred for
further investigation with abnormal PKU
screens, 6 were referred for abnormal thyroid
screens and 6 babies had abnormal cystic
fibrosis screens and were referred for further
investigation to confirm or exclude the
condition.
SCREENING IN CHILDHOOD
For the first nine months of the programme, a
total of 65 babies were referred for diagnostic
testing. Twenty-five had some hearing loss in
both ears and of these babies, seven had
significant hearing loss for which treatment
was necessary.
Developments
Implementation of Health for all Children
5
(Hall 4) made significant progress during
2006.
Pre-school orthoptic vision screening (POVS)
Newborn screening for metabolic
abnormalities
Visual defects are relatively common in young
children (prevalence of 3-6%) but easily
corrected. If, by the age of 7 years, visual
defects are not detected and corrected, this can
lead to irreversible changes in vision which
adversely affect a child’s educational and
social development.
Screening for a range of abnormalities, namely
phenylketonuria, congenital hypothyroidism and
cystic fibrosis, is undertaken by obtaining a spot
of blood by pricking a baby’s heel. The
conditions screened for by the blood spot (or
heel prick), while rare, can have very serious
62
HEALTH PROTECTION
National Screening Programmes in Lanarkshire
There is good evidence that when vision
screening is performed by orthoptists
(specialists in the development of vision) in
the pre-school year, this allows testing for and
correction of vision defects prior to school
entry6, thus fulfilling the aim of pre-school
orthoptic screening.
It is necessary to
implement pre-school orthoptic vision
screening to be fully compliant with the
5
recommendations of Hall 4 .
REFERENCES
1.
McIntryre-Seltman K, Castle PE, Guido R et al.
Smoking is a risk factor for cervical intraepithelial
neoplasia grade 3 among oncogenic human
papilloma-virus DNA positive women with equivocal
or mildly abnormal cytology. Cancer Epidemiology,
Biomarker and prevention: a publication of the
American Association for Cancer Research, cosponsored by the American Society of Preventive
Oncology 2000; 14(5): 1165-70.
2.
UK CRC Screening Pilot Evaluation Team.
Evaluation of the UK Colorectal Cancer Screening
Pilot. Final report, May 2003.
3.
NHS Quality Improvement Scotland. Pregnancy and
Newborn Screening. Clinical Standards - October 2005.
Edinburgh: NHS QIS, 2005.
4.
Davis A, Bamford J, Wilson I et al. A critical review
of the role of neonatal hearing screening in the
detection of congenital hearing impairment. Health
Technology Review 1997; 1 (10).
5.
Hall DMB, Elliman D. Health for all children. 4th ed.
Oxford: Oxford University Press, 2003.
6.
Powell C, Wedner S and Hatt S. Vision screening for
correctable visual acuity deficits in school age
children and adolescents. Cochrane Database of
Systematic Reviews (3): 2006.
63
HEALTH PROTECTION
National Screening Programmes in Lanarkshire
64
HEALTH SERVICE PROVISION
Implementing Health Needs Assessments
CHAPTER 10
IMPLEMENTING HEALTH NEEDS ASSESSMENTS
SECTION 10.1 - EATING DISORDERS
5
Eating disorder is a term used to describe a
group of conditions related to body image
disturbance and abnormal eating behaviour,
including anorexia nervosa, bulimia nervosa and
atypical eating disorder (as well as binge eating
1
disorder). An abnormal thinking pattern is
present, characterised by extreme preoccupation
with body shape and weight and where there is a
drive to achieve or maintain a low body weight,
even when the person is already below average
weight. In addition, there are high levels of
medical and psychological co-morbidity,
including risk of suicide, depression, anxiety,
alcohol and drug addiction, infertility,
osteoporosis, dental problems, heart failure and
2
renal failure. The mortality rate for anorexia
3
nervosa ranges from 3-20%.
services. In order to address this, the Scottish
Mental Health and Well-Being Support Group
commissioned a Short Life Working Group in
2001 to provide a rapid overview of the scale of
eating disorders across Scotland and to outline a
broad strategy for service development. An
additional supplement to the Framework for
Mental Health Services in Scotland was
published, Section 3 of which laid out clear
service profiles for people who have an eating
6
disorder.
The nature of eating disorders means that
identification and prediction of need can be
difficult as there are significant levels of comorbidity and a reluctance of sufferers to seek
help. This leads to differences in population
estimates. The point prevalence of anorexia
nervosa has been estimated as 4 per 1000
2
females and 0.5 per 1000 males. They also
estimate that five times that number will be
2
affected with bulimia nervosa. Young people
are particularly affected by eating disorder - it
is estimated that 1% of females aged between
16 and 19 years are at risk of developing
anorexia nervosa, and 1-3% of females aged
between 19 and 21 years are at risk of
6
developing bulimia nervosa.
There is usually no single factor that causes or
influences the development of an eating
disorder. Often an eating disorder can result
from complex interactions between many things.
Whether a person develops an eating disorder
will depend on individual vulnerability, the
presence of biological or other predisposing
factors, exposure to risk factors and the
2
operation of protective factors. It is thought that
eating disorders have a familial basis and that
other factors can contribute to their occurrence,
including a history of obesity, a history of being
lean or thin, feeding difficulties in infancy, early
menarche, propensity to dieting, perfectionist
personality trait and a severely stressful life
event as a trigger. However, the research into
predisposing factors for eating disorders is not
2
sufficiently strong to draw clear conclusions.
The incidence of anorexia nervosa and bulimia
nervosa has been estimated as 8.1 and 11.4 new
cases per 100,000 total population per year
1
respectively but others have estimated up to 11
3
and 18 per 100,000. This incidence would
suggest at least 45 new cases of anorexia nervosa
and 64 new cases of bulimia nervosa each year in
Lanarkshire. Eating disorders are more common
among females but up to 10% of patients are
male. Patients can complain of symptoms at any
age, but usually after the age of twelve.
An early needs assessment on eating disorders
4
was included in the 1999 Annual Report and
since 2000, eating disorders has been the subject
of increased attention throughout the UK both
politically and publicly, with reports
highlighting inconsistency, and a lack of service
provision. In 2004, a national study reported that
one-fifth of the Scottish population had no
access to NHS specialist eating disorder
The prevalence in young people, under 16
years of age, seen with a new episode of eating
disorder in primary care was 41 per 100,000
compared with 24 per 100,000 for those 16
years of age or older.
65
HEALTH SERVICE PROVISION
Implementing Health Needs Assessments
the Monklands/Cumbernauld Team. If this
rate were applied to the other areas of
Lanarkshire, then 250 new referrals would be
expected of whom 66% had a diagnosis of
anorexia nervosa, 15% are re-referrals and
29% fail to attend. Currently, only Monklands
and Cumbernauld Adult Mental Health
Services have a formally constituted service
for people with eating disorders in
Lanarkshire. It is largely an outpatient service.
INITIAL SERVICE DEVELOPMENTS
The 1999 Annual Report highlighted the need to
improve the level of service to patients with
eating disorders taking account of local need and
the evolving evidence about the benefits of care.
It recommended a simplified version of the
tiered service subsequently recommended by the
Mental Health Framework Group (Figure
10.1.1).
Adult Mental Health Services
The needs of people with an eating disorder in
the Hamilton, East Kilbride and Motherwell/
Clydesdale areas are met through a range of
services including general practitioners, school
nurses, clinical psychologist, psychiatrist, child
and adolescent mental health services
(CAMHS), adult community mental health
teams, (CMHTs), day hospitals, dietetics and
counselling services.
There is substantial variation in the provision
of services for people with an eating disorder
across Lanarkshire. To estimate the number of
people who may be referred to a Lanarkshirewide specialist service, local referral rates to
the Monklands/Cumbernauld team were used.
Within the period 2004-2005, a total of 82
people aged between 16-65 were referred to
Figure 10.1.1
Tiered Model
CASE EXAMPLES/REFERRAL
GUIDELINES
TIER
SERVICE EXAMPLES/INTERVENTIONS
Complex problems requiring very
specialist services including
specialist inpatient care.
TIER 4: Supra Area/Regional
Specialist Service.
Extra contractual referrals for private care.
Regional NHS inpatient care.
Severe and enduring problems.
Complex case of anorexia nervosa
(ICD 10).
Age and sex appropriate.
TIER 3: Specialist Expertise:
Validated psychotherapeutic approaches
and/or drug therapy.
Intensive multidisciplinary care and outreach.
Family Work.
Liaison with other health providers and
agencies.
Consultancy, supervision and advice on
management.
Support to Tier 1 and 2.
Mild to moderate eating disorders
and dual diagnosis.
Uncomplicated cases requiring
mental health care and treatment.
Work on guidelines on who to refer
to Tier 3.
TIER 2: General Locality-based
Mental Health Services.
Mild to Moderate problems.
Work on guidelines on assessment
and management in primary care.
TIER 1: Local Health ServicesPrimary Care.
Complex mental health problems
most likely longstanding and
recurrent, significantly impairing
quality of life, requiring specialist
multidisciplinary working.
Mild to moderate uncomplicated
cases. General mental health
services for adults and adolescents
including CMHTs, local Addiction
Teams and CAMHS.
First point of contact, information,
awareness and training in early
identification, assessment and
management of eating disorders.
Prevention of disorder in high risk
groups, early recognition, ease of
access to services including selfhelp. Development of local
signposts.
Group work.
Medication.
Onward referral and multidisciplinary working.
TIER 0: Community Health and
Well being.
66
Primary care counselling services.
GP prescribed medication.
Self help.
Brief interventions.
Screening.
Management of chronic disability.
Health promotion and illness prevention
programmes.
HEALTH SERVICE PROVISION
Implementing Health Needs Assessments
Table 10.1.1
Inpatient discharges, main diagnosis of eating disorder, Lanarkshire residents, 2002-2006
Patients
Discharges
No.
Mean stay
(days)
No.
Mean stay
(days)
General hospitals
2002
2003
2004
2005
2006
2002-2006
2
7
6
13
9
37
25
13
17
14
33
20
3
7
7
16
18
51
16
13
15
11
17
14
Psychiatric units/hospitals
2002
2003
2004
2005
2006
2002-2006
7
3
7
6
7
30
118
36
153
120
50
102
8
3
10
19
11
51
103
36
107
38
32
60
Hospital Care
FURTHER IMPLEMENTATION ISSUES
Inpatient admissions are arranged as required
to a general medical bed, to a psychiatric bed
or to a private sector bed. The numbers of
patients discharged from medical beds and
psychiatric beds are shown in Table 10.1.1.
Twenty-nine patients were admitted to the
private sector over the same period of time.
The numbers admitted each year ranged from
3 to 7.
NHS Quality Improvement Scotland (QIS)
reviewed guidelines published by the National
Institute for Clinical Excellence (NICE) and
noted that while there have been improvements
across Scotland, provision remains patchy. This
is true of Lanarkshire and a review is currently
underway. The West of Scotland Regional
Planning Group is examining the need for
specialist services.
The number of Lanarkshire residents attending a
general hospital with a main diagnosis of an
eating disorder between 2002 and 2006 was 37;
several patients attended more than once,
resulting in 51 discharges over the period. The
majority of patients, 20, attended Monklands
Hospital, 10 attended Wishaw General Hospital
and 4 Hairmyres Hospital. The number of
patients each year varied from 2 to 13 and the
number of discharges from 3 to 18; 2005 had an
unusually large number of patients.
Taking account of the NICE guidelines , QIS
1
published
recommendations
for
the
management and treatment of eating disorders in
Scotland.
It highlighted in particular the
importance of tailoring treatment to the
individual
and
also
endorsed
the
multidisciplinary model of care.
2
The first point of contact with the NHS for
most patients with an eating disorder is in
primary care. Patients may seek help for their
eating disorder or help for other conditions.
Opportunistic questioning should be nonthreatening and the use of the SCOFF
questionnaire has been validated for patients
over 18 and should be considered. Parents or
carers may also seek advice about a family
member. Sensitive history taking, physical
examination, ECG, laboratory and radiology
examination are required.
Thirty patients were discharged from
psychiatric beds over the same period,
resulting in 51 discharges. The majority of
patients, 16, were discharged from Monklands.
The average length of stay for medical
admissions was 20 days compared with 102
days for inpatient psychiatric admissions.
Anorexia nervosa was the most common
reason for admission. In the main, bulimia
was treated on an outpatient basis.
In addition, there are other important physical
manifestations associated with eating disorders
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HEALTH SERVICE PROVISION
Implementing Health Needs Assessments
which require to be managed carefully,
including screening for diabetes, dental review
for those with regular vomiting and dxa
scanning for those at risk of osteoporosis as a
consequence of their poor food intake.
and 3 who will deliver the core prevention,
care and treatment interventions.
A skills inventory collecting information on
availability of certified and/or accredited skills
to deliver such interventions needs to be
undertaken and considered against the capacity
available within primary and secondary care to
deliver the tiered model of care.
The Quality and Outcomes Framework (QOF)
2006 requires ‘the practice to produce a
register of people with schizophrenia, bipolar
disease and other psychoses’. To facilitate
regular review of patients with eating
disorders, not attending other services, it
would be helpful if practices could include
patients with severe chronic eating disorders in
such registers.
Many of these issues were endorsed by the
Scottish Public Services Ombudsman in 2006
in a report making recommendations about the
care of patients with eating disorders. It
included the need for:
Data collected from a sample of Scottish
practices, including Lanarkshire, suggests that
about 300 people will consult a Lanarkshire
GP about eating disorders each year, of which
7
150 will be new consultations. Each practice
is therefore likely to see 3 cases and one case
per GP each year.
Following early identification and skilled
assessment, people diagnosed with an eating
disorder require access on an outpatient basis to
a range of psychological interventions (for
example, cognitive analytical therapy, cognitive
behavioural
therapy,
interpersonal
psychotherapy, focal psychodynamic therapy),
family work and careful physical management.
Such treatment on an outpatient basis should be
adequate for the majority of those with eating
disorders.
•
adult inpatient and related mental health
services
•
acute inpatient medical services with
specialist expertise for patients whose
physical condition required it
•
integration of the more specialist services
with other medical and psychiatric
services
•
knowledge about the legal position with
respect to treatments for eating disorders.
PRIORITY SERVICE DEVELOPMENTS
The following developments are recommended
in order to meet the needs of people who have
an eating disorder:
1. Increase awareness and training in
identification,
assessment
and
management of eating disorders.
More intensive care needs to be available for
those who do not respond to treatment in
primary care. Certain key clinical factors
suggest that referral to specialist services is
required and body mass index (BMI) can be
used as one of the key indicators in adults.
2. Encourage practices to include patients
with severe chronic eating disorders on
QOF registers.
3. Develop a consistent approach to the
assessment treatment and care of people
who have an eating disorder across
Lanarkshire.
Take account of the
recommendations of NHS QIS and the
ombudsman’s report when reviewing the
service including the development of
protocols, and pathways ensuring equality of
access across Lanarkshire at tiers 0, 1, 2 and
3.
The interface between primary, secondary and
tertiary care services is important as is the
interface between mental health service and
medical inpatient services. It is important not
to lose contact when patients move between
services or between regions. Local referral
pathways and clinical protocols based on
NICE and QIS Guidelines need to be
developed and implemented as well as the
training needs of practitioners at tier 0, 1, 2
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HEALTH SERVICE PROVISION
Implementing Health Needs Assessments
4. Ensure contact is maintained with users of
the eating disorders service in particular
including the interface between primary,
secondary and tertiary care services and
the interface between mental health care
services and medical inpatient services.
5. Continue to explore options for the
development of a regional specialist eating
disorder service for people requiring
intervention at tier 4 and review the
procedure for the use of unplanned care.
6. Complete a training needs analysis of health
care professionals and develop a workforce
development strategy to ensure the
workforce have the appropriate skills
required to deliver services at tiers 0, 1, 2
and 3.
7. Consider, as part of the implementation of
eHealth Strategy, whether the generic
clinical system customised to meet local
patient and clinician needs should be
deployed in Lanarkshire.
REFERENCES
1.
NHS Quality Improvement Scotland. Eating Disorders in
Scotland.
Recommendations for Management and
Treatment. Edinburgh: NHS Quality Improvement Scotland,
2006.
http://www.nhshealthquality.org/nhsqis/files/EATDIS
ORDER_REP_NOV06.pdf
Last accessed 31 May 2007.
2.
National Collaborating Centre for Mental Health.
Eating Disorders, Core interventions in the treatment
and management of anorexia nervosa, bulimia
nervosa and related eating disorders. London: British
Psychological Society and Gaskell, 2004.
3.
Eating Disorders Association.
www.b-eat.co.uk Last accessed 31 May 2007.
4.
The Department of Public Health, Lanarkshire NHS
Board. The Health of the People within the Lanarkshire
NHS Board Area. Annual Report of the Director of
Public Health 1999. Hamilton: Lanarkshire NHS Board,
2000.
5.
Carter H, Millar H. Eating Disorders in Scotland:
Needs Assessment at a National Level. European
Eating Disorders Review 2004; 12:(2):110-116.
6.
Scottish Executive. Framework for Mental Health
Services. Edinburgh: Scottish Executive, 2001.
7.
National
Services
Scotland
Practice
Information. Edinburgh: ISD, 2006.
Team
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HEALTH SERVICE PROVISION
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SECTION 10.2 - DIABETES RETINAL SCREENING
Diabetes mellitus is a lifelong disease caused
by an absolute or relative lack of the hormone
insulin with high concentrations of sugar in the
blood. In Lanarkshire, 23,400 people (4% of
the population) have diabetes. The numbers
are increasing, mainly due to ageing of the
population, obesity, increased awareness and
reduced diagnostic threshold for diagnosis.
disease and a new national screening
programme for diabetic retinopathy to enable
early detection and treatment began in
Scotland in 2006.
Underpinning the principles of the new
national screening programme was the first
health technology assessment (HTA) report
published in 2002 by the Health Technology
3
The HTA’s key
Board for Scotland.
recommendations were to use digital retinal
photography within a national programme
approach with a small number of trained
graders to ensure high quality comprehensive
service delivery.
Obesity is a major preventable risk factor for
diabetes. In the UK, obesity has trebled in
women and quadrupled in men over the last 22
years. Greater obesity gives a greater risk of
acquiring diabetes, such that a person who has
a body mass index (BMI) of 30 is 10 times
more likely to develop diabetes over a 10-year
period than a person with a BMI less than 22
(BMI being defined as body weight divided by
body height in meters squared). The risk
increases in those with a BMI over 35 up to 80
1
times.
INITIAL SERVICE DEVELOPMENTS
Newly commissioned retinal image capture
and call/recall software for the national
programme became available in 2006 and the
Lanarkshire retinal screening programme was
launched at the Time Capsule in early August
2006. A retinal image is shown in Figure
10.2.1 below.
The long-term complications of diabetes are
serious and common. They include heart
disease, stroke, kidney failure and nerve
impairment. Diabetes also adversely affects
the lining of the inside of the eye (retina) that
enables people to see. This is called diabetic
retinopathy and is the biggest single cause of
blindness and visual impairment in Scotland
among people of working age. Approximately
5% to 10% of all people with diabetes will
develop sight-threatening retinopathy. It is
more common in those who have had diabetes
for many years or in those whose diabetes
control has been poor. Blindness has high
personal and social costs for both the affected
individual and society.
Figure 10.2.1
A retinal image of a right eye
A diabetes needs assessment in the 2002
2
Annual Report recommended the introduction
of the diabetes retinal screening programme
and this report describes the launch of that
programme by NHS Lanarkshire.
Diabetic retinopathy, in its early stages, does
not cause symptoms and so can develop
undetected. Laser treatment is very effective
in halting or delaying progression of the
Digital image capture is much more
comfortable and quicker for the patient than
the previous clinical examination which
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required eye drops and use of an
ophthalmoscope (a handheld torch) to examine
the retina. After reading letters on a chart,
patients simply sit upright in front of the
camera for a matter of seconds. Most people
do not require eye drops and this has the added
benefit of not adversely affecting patients’
ability to drive for the next two hours.
Patients are able to view their retinal images
immediately on a computer screen.
In order for patients to receive the correct care,
ensure clinical care is not duplicated and health
care resources are not wasted, approximately
4000 people are suspended from the retinal
screening programme for a variety of reasons,
including
attending
the
ophthalmology
department and/or are clinically unfit to attend.
PRIORITY SERVICE DEVELOPMENTS
1. The main priority for the retinal screening
service is to ensure provision of
ambulance transport for those people with
limited mobility.
Lanarkshire provides three clinic locations for
retinal photography to ensure accessibility: at
the Time Capsule leisure centre in Coatbridge,
Brandon House in Hamilton and Wishaw
Health Centre.
They are spread
geographically with good access to public
transport. Patients can select which location
they prefer to attend.
2. Due to limitations in the audit facility for
the software, exact figures on coverage are
imprecise at present. Enhancements are
being made to the national software and
should provide this information in 2008.
However, it is projected that the
programme will be on target to achieve
first full round of annual screening for
80% of the eligible population.
Another important feature of the new
programme is communication of results to
patients, their GPs and hospital consultant
physicians. Patients and GPs receive letters
with the results, while results and eye images
are also shared electronically with general
practices and physicians via the national
electronic databases, used for clinical diabetes
care.
REFERENCES
FURTHER IMPLEMENTATION ISSUES
The service continues to bed in well despite a
very sharp increase in the number of people
with diabetes (on the Diabetes Register) from
19,500 at the start of 2006, to 23,400 at the
end of 2007, although a small number of
people will require ambulance transport to the
screening locations.
A mobile camera facility will be provided in
due course for people resident in care homes.
Once care home visits are completed, the least
(geographically) accessible GP surgeries will
be considered for mobile clinics.
A key priority for the screening programme in
Lanarkshire has been to clarify the interface
between the retinal screening programme and
the treatment and surveillance service provided
by the ophthalmology department. Eligible
patients can either be in the retinal screening
programme or under the care of ophthalmology.
71
1.
Diabetes UK. Type 2 Diabetes and Obesity: A Heavy
Burden. London: Diabetes UK, 2005.
http://www.diabetes.org.uk/Documents/Reports/obesity_
0305.doc. Last accessed 15 August 2007.
2.
Lanarkshire NHS Board. The Health of the People
within the Lanarkshire NHS Board Area. Annual
Report of the Director of Public Health 2002.
Hamilton: Lanarkshire NHS Board, 2003.
3.
Facey KI, Cummins E, Macpherson K, Morris A,
Reay L, Slatter J. Health Technology Assessment
Report 1: Organisation of services for diabetic
retinopathy screening. Glasgow: Health Technology
Board for Scotland, 2002.
HEALTH SERVICE PROVISION
Implementing Health Needs Assessments
SECTION 10.3 - CLINICAL SEXUAL HEALTH SERVICES
Rewarding personal and sexual relationships
promote health and well-being. However,
sexual activity can also have undesired
effects such as transmission of infections
(gonorrhoea, chlamydia and HIV/AIDS),
unwanted pregnancy, cervical cancer and
psychological ill health. Measures to reduce
the risk of these undesired consequences
must take place within a context that places a
premium on the understanding of human
sexuality and the forces influencing its
development. The promotion of well-being,
self-esteem and personal responsibility is
key to success.
coincided with the development and
publication by the Scottish Executive of the
Scottish sexual health strategy Respect and
2
Responsibility.
Progress reports on implementation of the
Lanarkshire sexual health strategy and action
plan are regularly provided to a multi-agency
sexual health implementation group and to
groups within NHS Lanarkshire and North and
South Lanarkshire Councils. An annual report is
submitted to the Scottish Executive each year
and is subsequently made available to the public.
These reports and other sexual health reports,
can be accessed via the Lanarkshire sexual
health website www.lanarkshiresexualhealth.org. This
chapter reports on progress made with the
implementation of sexual health service
developments recommended in previous Annual
Reports of the Director of Public Health and
includes details of significant clinical and other
NHS Lanarkshire sexual health service
developments during 2006.
Sexual health issues are among some of the
more complex and sensitive issues that staff
within NHS Lanarkshire and its partner
organisations are required to deal with in order
to protect and promote health. The issues that
need to be addressed may be personal and
private, may involve culturally taboo subjects
and it may be difficult to obtain
comprehensive information about situations
encountered due to client concerns about
confidentiality.
Sexually
transmitted
infections (STI) are usually transmitted as a
result of intimate activity and some of these
infections are associated with serious illness
and reduced life expectancy. A positive test
result can have a very significant
psychological impact on an individual and
affect his or her social relationships.
Trends in the use of sexual health services
in Lanarkshire
There were significant increases in the number
of STIs diagnosed at genito-urinary medical
clinics (GUM) for both Lanarkshire males and
3,4,5
The
females between 2005 and 2006.
number of new episodes of people attending
Lanarkshire GUM clinics increased from 2555
6
in 2005 to 2998 in 2006 - an increase of 17%.
The majority of STI diagnoses are in people
under the age of 25 years - 74% of chlamydia
diagnoses, 70% of gonorrhoea, and 46% of
herpes simplex.
However, out of all
Lanarkshire males that attended a GUM clinic,
only 55% attended a Lanarkshire-based clinic
in 2005 and 59% in 2006. The equivalent
figures for Lanarkshire females were 63% and
66%. Most of the Lanarkshire residents who
attended a GUM clinic outwith Lanarkshire
attended a GUM clinic in the NHS Greater
Glasgow and Clyde area. Sexually transmitted
infections are also diagnosed in other clinics in
Lanarkshire. Diagnoses are made by family
In recent years, the Annual Report of the
Director of Public Health has included several
chapters about sexual health services: sexual
health in 2000, unintended pregnancy in 2001,
blood-borne viruses education and training in
2003, syphilis in 2004 and also blood-borne
viruses in 2004. In addition, during 20052006, NHS Lanarkshire staff worked with
colleagues in North and South Lanarkshire
Councils, voluntary sector organisations,
representatives of faith groups and others to
develop a multi-agency holistic positive sexual
1
health strategy and action plan. Development
of the Lanarkshire strategy and action plan has
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planning services at the Lanarkshire HIV,
AIDS and Hepatitis Centre based at
Monklands Hospital, and by primary
healthcare teams.
education and training for teachers, a project
with looked after and accommodated young
people, and the annual project to raise awareness
of World AIDS Day (1st December).
INITIAL SERVICE DEVELOPMENTS
Relationships
with
voluntary
sector
organisations were developed and strengthened
during 2006, in particular with the Terrence
Higgins Trust Scotland, Lanarkshire Rape Crisis
and Women’s Aid. During 2006, Terrence
Higgins Trust Scotland developed group work
including a Lanarkshire (HIV) positive support
group, public sex environment outreach work,
led or participated in various education and
training events, contributed to or led the
development of several sexual health promotion
events and initiatives, provided one to one
support for men who have sex with other men,
continued to provide a condom postal service,
participated with other organisations in
development work, developed sexual health
resources and carried out internet outreach work.
Clinical service developments
Following the publication of the Scottish
Executive report Respect and Responsibility,
funding was provided by the Scottish
Executive to develop clinical sexual health
services for the period 2005-2008. It enabled
the appointment of new sexual health
clinicians. In May 2006, NHS Lanarkshire’s
first consultant in sexual and reproductive
healthcare was appointed and enabled
significant development of clinical sexual
health services to take place during the second
half of 2006. A sexual health nurse and an
administration support worker were also
appointed. Attempts to appoint a consultant in
genito-urinary medicine were unsuccessful.
Lanarkshire NHS Board has agreed to
continue investment in clinical sexual health
services from 2008 onwards.
Annual reports detailing the work of the BloodBorne Viruses and Sexual Health Team and of
the Terrence Higgins Trust Scotland are
available on the Lanarkshire sexual health
website.
People with addiction problems have
particular needs for contraceptive provision
and screening for sexually transmitted
infections and infections which may be
acquired through injecting drugs, in particular
hepatitis C and hepatitis B. Working closely
with the Alcohol and Drug Action Team and
the Harm Reduction Team during the second
half of 2006, services were developed to reach
people in vulnerable groups and make services
more accessible to them. A leaflet and fast
track card have been developed to help
achieve these aims.
A specialist clinic
provided by staff from genito-urinary
medicine, family planning, the Lanarkshire
HIV, AIDS and Hepatitis Centre, and Terrence
Higgins Trust Scotland was introduced at
Monklands Hospital in November 2006.
IT developments
The Lanarkshire sexual health website was
developed in 2001 and launched in 2002. The
website has been promoted widely and is a
useful resource that people can access to find
answers to simple and more complex questions
and generally to learn more about sexual
health. During 2006, the content, style and
structure of the website has been updated in
order to maintain its relevance and improve its
accessibility. An updated website with the
same website address will be launched in
2007.
Computers were progressively introduced to
family planning and genito-urinary medicine
clinics in 2006, enabling easy access to
guidance and protocols and improving
communication links.
New and existing programmes continued to
develop during 2006, including the sexual health
website, condom distribution schemes, sexual
health social marketing campaigns including the
West of Scotland Equal campaign, information
and resource development, training for
midwives, sexual health and relationships
NHS Lanarkshire made a successful bid to be
the lead NHS board to implement the newly
commissioned national sexual health clinical
IT system. The system is part of the national
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HEALTH SERVICE PROVISION
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generic clinical system that has been
developed as part of the NHSScotland eHealth
Strategy and is underpinned by national
7
standards.
as sexually transmitted infections, unintended
pregnancy and abortion, further service
developments are required. Services need to
be provided across a large geographical area
and to diverse communities, some with high
levels of deprivation. In addition, as in other
parts of Scotland, the demography of the
Lanarkshire population is changing with
increasing numbers of older people and
increased number of people from minority
ethnic groups. Sexual health services need to
develop in order to meet need.
Education and training
A programme of seminars for midwives
about antenatal screening of pregnant
women for immunity to rubella and infection
with syphilis, hepatitis B, and HIV was
established during 2006.
A series of education and training sessions was
held for clinical and non-clinical sexual health
service staff. A wide range of sexual health
and administration topics was covered by this
programme which is based on an assessment
of the education and training needs of staff.
Educational seminars have also been held for
staff in primary care and staff in addiction
services. These have been well received and
are part of a long-term programme of sexual
health education and training.
During 2006, three sexual health clinics for
young people were provided across
Lanarkshire. This has been a priority area for
development, and sexual health service staff
and staff who provide services for young
people in NHS Lanarkshire, North and South
Lanarkshire Councils and the voluntary sector
have worked together to lay the foundations
for the development of more clinics for young
people during 2007. Holistic services, which
incorporate information and advice about
sexual health amongst a range of health issues
of concern to young people - alcohol, drugs,
relationships, money, body weight, skin,
employment - and which are provided in nonthreatening settings alongside other activities
such as youth clubs, are preferred by many
young people. Participation by members of
primary health care teams in these clinics is
also important.
Following awareness raising and training in
pre- and post-test counselling for HIV testing
for sexual health staff, there has been an
increase in HIV testing in sexual health
services. There has also been an increase in
sexual health screening carried out by staff
who provide blood-borne viruses services.
In October 2006, testing for gonorrhoea on
samples sent for chlamydia testing was
introduced.
The number of specialist sexual health staff
available to provide sexual health services in
the West of Scotland is small in comparison to
the level of current and projected need. It can
be seen from the figures above that
considerable numbers of Lanarkshire residents
attend sexual health services provided by NHS
Greater Glasgow and Clyde. It is in the
interests of both the larger and smaller NHS
boards in the West of Scotland to work
together to develop clinical services and the
clinical work force and it may be of value to
explore the case for establishing a West of
Scotland sexual health managed clinical
network.
Key clinical indicators
As part of the implementation of Respect and
Responsibility, five key clinical indicators for
sexual health were developed on behalf of the
National Sexual Health Advisory Committee
(NSHAC). The performance of NHS
8
Lanarkshire against the key clinical indicators
has been noted and used to inform clinical
sexual health service developments.
FURTHER IMPLEMENTATION ISSUES
There was considerable development of
clinical sexual health services during 2006.
However, due to the changing or persisting
epidemiology of sexual health indicators such
For many groups of vulnerable people, sexual
health is of particular importance.
The
approach that has been taken to improve the
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HEALTH SERVICE PROVISION
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sexual health of people using addiction
services will in turn be developed for people
who are homeless, looked after and
accommodated children, people with learning
disability, and people who are lesbian, gay,
bisexual or transgender.
specialist services for under 16-year-olds
who have problems with alcohol and other
drugs as these issues are usually
intertwined with the sexual health of
young people.
4. In conjunction with the Lanarkshire Rape
and Sexual Assault Group, improve
services for people who have been raped
or sexually assaulted.
Good progress with the integration of sexual
health services took place during 2006 and this
should be developed further during 2007. It
includes clinical services, clinical governance,
financial
systems
and
management
arrangements. The integrated service should
continue to link closely with health promotion
staff and with gynaecology services, the
Lanarkshire HIV, AIDS and Hepatitis Centre
and laboratories.
The introduction of an
electronic diary for clinic appointments and a
single telephone number for all sexual health
services in Lanarkshire will facilitate and
promote integrated working.
5. Consider the feasibility of establishing a
service for males who have sex with other
males.
6. Consider funding further development of
sexual health outreach work provided by the
voluntary sector to promote engagement
with people in minority ethnic groups,
particularly those people with links to
African and Asian communities, and people
from Eastern European countries.
NHS Quality Improvement Scotland is
developing sexual health standards and draft
standards will be published during 2007 for
consultation and will be considered in the
Lanarkshire context.
7. Explore the opportunity to develop a West
of Scotland Managed Clinical Network in
collaboration with other West of Scotland
boards.
REFERENCES
PRIORITY SERVICE DEVELOPMENTS
1.
Lanarkshire Sexual Health Strategy and Action Plan
2005-2008. Lanarkshire NHS Board, North
Lanarkshire Council, South Lanarkshire Council.
www.lanarkshiresexualhealth.org/reports/reports_docu
ments/strategy.pdf
Last accessed 17 September 2007.
2.
Scottish Executive. Respect and Responsibility:
Strategy and Action Plan for Improving Sexual
Health. Edinburgh: Scottish Executive, 2005.
3.
Sexually Transmitted Infection Epidemiology Advisory
Group. Moving Forward: Sexually transmitted infection,
including HIV, in Scotland, 2005. Health Protection Scotland
and Information Services Division, Scotland, 2006.
www.documents.hps.scot.nhs.uk/bbvsti/sti/publicatio
ns/moving-forward-20061122.pdf
Last accessed 17 September 2007.
4.
The UK Collaborative Group for HIV and STI
Surveillance. A Complex Picture - HIV and other
Sexually Transmitted Infections in the United Kingdom:
2006. London: Health Protection Agency Centre for
Infections, 2006.
www.hpa.org.uk/publications/PublicationDisplay.asp?
PublicationID=55
Last accessed 17 September 2007.
5.
Sexually Transmitted Infection Surveillance Scotland.
Information Services Division, NHS National
Services.
www.isdscotland.org/isd/files/sexh_gum_table4a.xls
Last accessed 17 September 2007.
The following service developments are
recommended:
1. Complete the work undertaken during 2006
to integrate genito-urinary medicine and
family planning services. In order to
support integration and further development
of clinical sexual health services, recruit key
staff to posts already funded by the Scottish
Executive and relocate to a single clinical
and administrative base.
2. Establish additional services for young
people, with priority being given to
developing clinics for young people in
areas where there are no or few clinics,
with appropriate consideration being given
to indicators of deprivation and sexual
health need.
3. Work between sexual health and other
staff in NHS Lanarkshire and staff in
North and South Lanarkshire Councils
should be advanced to address the lack of
75
HEALTH SERVICE PROVISION
6.
Sexually Transmitted Infection Surveillance Scotland.
Information Services Division, NHS National
Services.
www.isdscotland.org/isd/files/sexh_gum_table7.xls
Last accessed 17 September 2007.
7.
NHSScotland Generic Clinical System website.
www.gcs.scot.nhs.uk
Last accessed 17 September 2007.
8.
Key Clinical Indicators for Sexual Health: Action 12
Subgroup. Report on the Baseline Data for 2005.
National Services Scotland, 2006.
www.scotland.gov.uk/Resource/Doc/924/0044637.pd
f
Last accessed 17 September 2007.
Implementing Health Needs Assessments
76
HEALTH SERVICE PROVISION
Needs Assessments
CHAPTER 11
NEEDS ASSESSMENTS
One of the starting points for health service planning is the epidemiologically-based assessment of the
health and healthcare needs of the resident population and each Annual Report includes prioritised
needs assessments which make recommendations for development of local services.
SECTION 11.1 - SMOKING IN PREGNANCY
The aim of all antenatal care is to have a
healthy mother and a healthy baby throughout
pregnancy, birth and the immediate post-natal
period. It also provides the opportunity to
advise on lifestyles which will promote the
health of the mother and baby and provide a
sound basis for future good health among
families.
EPIDEMIOLOGY
Births and stillbirths
There was an average of 6387 births a year in
the NHS Lanarkshire area over the 10-year
period 1997-2006 (see Statistical Appendix
Table A4). Low birthweight is associated with
increased neonatal (less than 28 days old) and
4
post-neonatal (28 days to 1 year) death. For
the period 1997-2006, there was an average of
38 (range 29 to 48) stillbirths each year (see
Statistical Appendix Table A4) of which a few
were due to disorders related to short gestation
and low birthweight. Fortunately, the number
of infants in Lanarkshire who die later each
year from sudden infant death syndrome is
very small but each of these deaths is a
considerable personal tragedy.
Smoking in pregnancy is the single largest
preventable cause of foetal disease and death
as it is associated with spontaneous abortion
(miscarriage), premature birth, low birth
weight, stillbirth, foetal hypoxia, structural
abnormalities in the foetal brain, sudden infant
death syndrome after birth, attention deficit
disorder, impaired physical growth, and
1
impaired academic attainment. Some of these
conditions can have lifelong consequences
and, when caused by smoking, are
preventable.
Low birthweight and smoking
There is a myth, not just in Lanarkshire but
in many parts of the United Kingdom, that
having a small baby results in a less painful
labour, hence pregnant women may be
encouraged to smoke during their pregnancy.
This myth is not true and, as can be seen
above, serious harm can be caused by such
smoking. Local research in 2006 showed
that pregnant women in Lanarkshire were
less concerned about smoking while
pregnant than about bringing up their
2
children in households with smokers.
In Lanarkshire, women who are smokers at
the time of attending their first antenatal
clinic, where they book their subsequent
care, are two to three times more likely to
have a low birthweight baby (less than
2500g) than women who are non-smokers
(Table 11.1.1).
There are a number of
factors associated with low birthweight
which, unlike smoking, are not preventable.
For the year ending 31 March 2005, 25.3% of
Lanarkshire women were smokers at the time
of their booking clinics (equal 10th of the then
5
15 NHS boards). These are self-reported data
and may be under reported if women are
reluctant to admit they smoke.
In recognition of the harm to health of
smoking in pregnancy, one of the Scottish
Executive’s targets is to reduce the
proportion of women who smoke in
3
pregnancy to 20% by 2010.
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HEALTH SERVICE PROVISION
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small numbers in this age range. For most age
groups, the prevalence of smoking has
decreased over the last ten years, particularly
between 2000 and 2005. However, among the
under 20s there has been little improvement
since 1995.
Deprivation and smoking in pregnancy
In North and South Lanarkshire Council areas
in 2006 there were approximately one sixth
(213) of Scotland’s most deprived data zones
of which 133 were in North Lanarkshire and
6
80 in South Lanarkshire. National data show
that smoking prevalence at booking increases
with increasing deprivation.
However,
between 2000 and 2005, although there was
improvement in each socio-economic group,
the amount of improvement increased with
increasing deprivation (Table 11.1.2).
Many smokers begin in adolescence. In 2006,
4% of 13-year-olds and 20% of 15-year-olds
were regular smokers, 95% of whom agreed
that smoking in pregnancy can harm the
7
unborn baby.
The prevalence of smoking among pregnant
women suggests there are about 1600 each
year who need to be encouraged to give up. In
2006, only 106 of the 3441 Lanarkshire
women who attempted to give up smoking
with the support of the Lanarkshire Smoking
Cessation Service were pregnant.
Age at pregnancy and smoking
Smoking is most common in Lanarkshire
among pregnant women aged less than 20
years, and declines steeply until age 25 years
when it tends to level off (Figure 11.1.1). The
exception is among women aged 40-44 years
in 1995 which is partly due to the relatively
Table 11.1.1
Hospital singleton live births to Lanarkshire residents, 1996-2005, percentage weighing <2500g by
smoking status at booking
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Yes
No
Total
Smoking at booking
9.1
3.7
5.4
9.1
3.8
5.5
8.8
3.9
5.4
9.8
4.4
6.0
9.5
3.8
5.4
9.4
3.8
5.5
9.2
3.7
5.3
10.2
3.8
5.6
10.5
3.6
5.4
10.4
3.9
5.6
Ratio of smokers to non smokers
2.5
2.4
2.3
2.2
2.5
2.5
2.5
2.7
2.9
2.7
Table 11.1.2
Smoking at booking* by Scottish index of multiple deprivation (SIMD) for year ending 31 March 2000 and
31 March 2005, Scotland
Current smokers
SIMD
1 (least deprived)
2
3
4
5 (most deprived)
Not known
Year end March 2000
Year end March 2005
Prevalence change
since 2000
No.
%
No.
%
%
952
1636
2320
3453
5803
32
9.7
16.2
23.7
32.6
45.3
16.1
729
1378
2020
2960
4745
36
7.7
13.9
20.8
28.1
38.4
18.1
-2.0
-2.3
-2.9
-4.5
-6.9
+2.0
* Excludes home births and births at non-NHS hospitals
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Figure 11.1.1
Percentage of pregnant women who were smokers at the time of booking clinic, Lanarkshire, 1995-2005
60
Percentage
50
40
1995
30
2000
2005
20
10
0
<20
20-24
25-29
30-34
35-39
40-44
Age group
heavier smokers with 69% smoking less than 20
8
cigarettes daily and 32% smoking 20 or more.
Risk factors
Smoking is an addictive habit and people
experimenting with smoking are soon
habituated. The fact that 20% of 15-year-old
girls in Lanarkshire are already regular smokers
suggests that most of the pregnant women who
7
smoke probably began in their teens.
Unfortunately, there has been no improvement
in its prevalence in this group since 2002.
Smoking has other costs which are not financial
and include the range of health problems
suffered by the unborn child and children in the
first year of life, as described above. In addition
to these, children brought up in households with
smokers are more likely to develop asthma, to
have more severe and more frequent symptoms,
and to have reduced lung function than children
9
in non-smoking households.
There is a lack of peer pressure to quit
smoking as regular adolescent smokers are
more likely to have family, and in particular
friends, who smoke than are non and
7
A similar pattern
occasional smokers.
prevailed among Lanarkshire adults: smokers
were more likely to be exposed to passive
8
smoke at home and work than non-smokers.
However, smoking itself and its impact on
disposable income can both contribute to
lower health status. The money spent on
cigarettes reduces the amount of household
income available for essentials and pleasures.
In some cases this is ameliorated by the
purchase of cheaper smuggled or counterfeit
cigarettes which are widely considered to be
more dangerous as they are of lower quality
and contain increased levels of toxins when
compared with legal cigarettes.
The amount smoked by adolescents is not small
as the average regular adolescent smoker
reported consuming 47 cigarettes each week, yet
had smoked an average of 67 cigarettes in the
7
previous seven days. Cost does not appear to be
a significant factor for these smokers as over
80% bought their cigarettes from shops and 94%
spent on average £11.97 a week doing so. The
most recent data for Lanarkshire women showed
that smoking consumption increased with age:
of those aged 16 to 34 years, 84% smoked up to
19 cigarettes daily and 16% smoked 20 or more,
while women aged 35-54 years tended to be
CURRENT SERVICE PROVISION
The Lanarkshire Smoking Cessation Service
(LSCS) provides high quality support across
Lanarkshire to smokers who wish to quit. All
pregnant women who attend an NHS
Lanarkshire booking clinic receive ‘brief
intervention’ from the midwives or public
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HEALTH SERVICE PROVISION
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health nurses at the clinic and are encouraged
to attend the LSCS for help to quit. The LSCS
works almost entirely with groups of people
rather than on a one-to-one basis as the
evidence shows that this, together with the use
of nicotine replacement therapy (NRT) or
bupropion, which is contra-indicated in
pregnancy, is the most effective route to
10
quitting.
The Scottish Executive’s document Towards a
Future without Tobacco contains a range of
evidence-based actions directed at reducing
1
However,
smoking among young people.
there is little published evidence of successful
initiatives to reduce smoking in pregnancy.
The most recent evidence-based family
planning guidance has provided more stringent
advice on smoking and the use of combined
12
NHS Lanarkshire’s
oral contraceptives.
contraception service is now applying this
guidance which will raise the profile of
smoking cessation amongst the relevant
clients. The service is proposing to use this as
a first step towards future service development
in preparation for conception.
NRT is no longer contra-indicated in
pregnancy and may be recommended to assist
a quit attempt when the risk to the foetus of
the mother continuing to smoke is considered
to outweigh any potential adverse effects of
NRT. The 4000+ chemicals in tobacco smoke
indicate that this is nearly always the case. All
the localities in NHS Lanarkshire have had
their drug budgets top-sliced for NRT to
encourage its use in quit attempts supported by
the LSCS.
There is anecdotal evidence in Lanarkshire
that people do not know how to contact the
LSCS, in part due to the large number of
different telephone numbers for the service.
Pregnant women who smoke do not usually
seek help to quit. Better ways of engaging
them need to be found and implemented, and
the outcomes evaluated.
The LSCS has been restructured so that, in
cases of staff absence, there will be no gaps in
service in the community.
In schools in North and South Lanarkshire,
education on smoking includes the potential
harm to the foetus of smoking in pregnancy.
This is borne out by the high percentage of
regular smokers aged 13 and 15 years who
7
were aware of this fact.
SERVICE DEVELOPMENTS
1. Raise awareness among women in general
that low birthweight does not mean a less
painful labour.
2. Skew resources to reduce smoking in
pregnancy according to the degree of
socio-economic deprivation.
In Airdrie, Coatbridge and Wishaw localities,
there is a pilot initiative with three staff
working with the public health teams in
primary and secondary schools on smoking
issues.
3. Target women aged under 25 years.
4. Make smoking cessation an integral part
of contraception services.
There have been, and continue to be, a range
of smoking cessation initiatives in Lanarkshire
outwith the LSCS.
5. Make smoking cessation an integral part
of antenatal care.
6. Find ways of improving access to
specialist smoking cessation support for
adolescents including provision in schools
and community groups.
PLANNING ISSUES
The overarching challenge is to reduce
smoking in girls and young women. However,
as the people around them are more likely to
be smokers, this challenge needs to be set
against the background of reducing the
prevalence of smoking in the general
population.
7. Seek out unpublished examples of
effective engagement with pregnant
women who smoke, and pilot and evaluate
them in Lanarkshire.
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HEALTH SERVICE PROVISION
Needs Assessments
9.
8. Establish a single telephone number for
contacting the Lanarkshire Smoking
Cessation Service.
10. West R, McNeill A, Raw M. Smoking cessation
guidelines for health professionals: an update.
Thorax 2000; 55(12): 987-999.
9. Inform the manager with operational
responsibility for the Lanarkshire Smoking
Cessation Service of all initiatives being
undertaken in Lanarkshire and provide
him/her with evaluations of them.
11. Smoking Prevention Working Group. Towards a future
without tobacco: The report of the Smoking Prevention
Working Group. Edinburgh: Scottish Executive, 2006.
http://www.healthscotland.com/uploads/documents/3204BDP3906_(SPWG_report_final).pdf
Last accessed 1 August 2007.
10. Improve outreach campaigns in Lanarkshire.
12. Clinical Effectiveness Unit. Clinical Guidance: First
prescription of combined oral contraception. London: Faculty
of Family Planning & Reproductive Health Care, 2007.
http://www.ffprhc.org.uk/admin/uploads/538_FirstPre
scCombOralContJan06.pdf Last accessed 30 July
2007.
11. Implement relevant recommendations of
Towards a Future without Tobacco.
12. Continue to support the smoke-free homes
initiative in Lanarkshire
REFERENCES
1.
Gruer L, Parkinson J, Haw S, Moore M, Duffy S.
Reducing smoking and tobacco-related harm: A key
to transforming Scotland's Health. Edinburgh: Health
Scotland, 2003.
http://www.healthscotland.com/uploads/documents/T
obaccoReport.pdf Last accessed 16 July, 2007.
2.
Swift J, Black D, Lowland Market Research.
Opportunities and barriers to accessing smoking
cessation services for key groups in North Lanarkshire.
Report for NHS Lanarkshire, May 2006.
3.
Scottish Executive.
Clearing the Air: National
targets.
http://www.clearingtheairscotland.com/facts/targets.html
Last accessed 16 July 2007.
4.
Scottish Programme for Clinical Effectiveness in
Reproductive Health. Births in Scotland Publication
Series, Vol 2: Small babies in Scotland: A ten year
overview, 1987-1996.
Edinburgh: Information &
Statistics Division, National Health Service in Scotland,
1998.
http://www.isdscotland.org/isd/files/mat_bb_small_babies.pd
f Last accessed 18 July 2007.
5.
ISD Scotland. Smoking at booking.
http://www.isdscotland.org/isd/files/mat_bb_Smoking
%20at%20Booking_revised.xls
Last accessed 26 July 2007.
6.
Scottish Executive Health Department.
Scottish
index of multiple deprivation, 2006: General report:
Results.
http://www.scotland.gov.uk/Publications/2006/10/131
42739/3 Last accessed 29 July 2007.
BMRB Social Research. Scottish Schools Adolescent
Lifestyle and Substance Use Survey (SALSUS) 2006:
Smoking, drinking and drug use among 13 and 15 year
olds in Lanarkshire. Edinburgh: Scottish Executive,
2007.
http://www.drugmisuse.isdscotland.org/publications/abst
racts/salsus/Lanarkshire_2006.pdf
Last accessed 30 July 2007.
7.
8.
Working Party on Smoking and the Young. Smoking
and the Young.
London: The Royal College of
Physicians of London, 1992.
Department of Pubic Health, NHS Lanarkshire.
Lanarkshire Health Survey 2001, unpublished data.
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SECTION 11.2 - ETHNICITY AND HEALTH
There is general agreement that ethnicity can
be difficult to define but in practice usually
reflects self-identification in terms of shared
origins, or cultural or religious traditions that
give a group meaningful identity.
development of NHS policies and services,
and to demonstrate that staff have met their
legal obligations.
A chapter in last year’s annual report focussed
on issues of access and attitudes in primary care
to ethnicity. This needs assessment focuses on
ethnicity and specific diseases and health issues.
It can impact on health in a range of ways. It
can be an indicator for different cultural habits
such as diet, patterns of illness behaviour,
diseases
relating
to
genetic
origin,
communicable diseases more prevalent in
patients’ countries of origin, social exclusion and
its associated lower health status, or lack of
access for reasons of culture or language to the
full range of healthcare services available
through the NHS. This applies to both ethnic
minority and ethnic majority groups, but
familiarity with one’s own ethnic group can
result in lack of awareness or knowledge of
specific needs of other ethnic groups.
EPIDEMIOLOGY
There is a general lack of good quality or
useful ethnic data. At present, it is optional to
record the ethnicity of patients in the NHS in
Scotland. Data collection is poor, one reason
for this being that staff do not see its relevance
3
to patient care.
Census 2001
The Scottish census uses a mixture of colour,
nationality and country of origin to categorise
ethnic groups and the 2001 categories are
4
currently used in the NHS.
The Race Relations (Amendment) Act 2000
requires the NHS, among other public bodies,
to be proactive in eliminating unlawful
discrimination and promoting equality of
1
opportunity. It was introduced to combat the
findings of the MacPherson report into the
death of Stephen Lawrence which concluded
that institutional racism was present in all UK
institutions and described this racism as ‘the
collective failure of an organisation to provide
an appropriate and professional service to
people because of their colour, culture or
ethnic origin. It can be seen or detected in
processes, attitudes and behaviour which
amount to discrimination through unwitting
prejudice, ignorance, thoughtlessness and
racist stereotyping which disadvantage
2
minority ethnic people’.
In terms of assessing health need the data are
limited. The national census is decennial so in
times of rapid population movement between
censuses, such as the current influx of people
from Poland, its results do not reflect Scotland’s
or Lanarkshire’s ethnic community. Similarly,
the ethnic group categories of the census are in
most cases very broad and do not identify
specific cultural differences which may impact
5
on health. Furthermore, whether people are
first, second or third generation immigrants will,
in some cases, have had an effect on the healthassociated cultural differences between their
families’ ethnic or national origins and those of
Scotland. However, the census is the best proxy
data routinely available.
From this it can be seen that ignorance is no
longer an excuse and that NHS staff need to be
knowledgeable about the health needs
associated with different ethnic groups in
order to provide ethnic groups with
appropriate care, to enable the NHS to provide
equity of care, to ensure that the needs of all
ethnic groups are taken account of in the
Ethnic groups
The 2001 census data reports on 552,819
people in the NHS Lanarkshire area. Among
them, 98.11% defined themselves as white
5
British or Irish and 0.70% as ‘other white’.
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All other ethnic groups constituted 1.19%
(6559 people) of the board’s population, the
two largest groups being Pakistani (0.43%)
5
However, at an
and Chinese (0.22%).
individual level a patient’s ethnic-associated
health problems may have a significant impact
on the life of that individual. Although not
equivalent, at population level the overall
distribution by country of birth was similar to
6
that of ethnicity (Table 11.2.1).
The fact that Lanarkshire has relatively few
people from ethnic minority groups means that
their ethnic-related healthcare needs may be
overlooked resulting in them being inadvertently
disadvantaged by NHS staff.
Risk factors
Some diseases are genetic, most notably the
haemaglobinopathies sickle cell disease, which
is most prevalent among people from subSaharan Africa where malaria is or was
common, and the thalassaemias which are
common in the Middle East, the Indian subcontinent, throughout South East Asia, and in
the southern Mediterranean. These usually
become apparent between 3-6 months of life
and the first few years of life respectively,
need continuing high quality healthcare and
can result in premature death.
Table 11.2.1
Distribution of NHS Lanarkshire population by
ethnic group and country of birth
% of population
Ethnic group
White British or Irish
White other
Non white
98.11
0.70
1.19
The health-related differences between ethnic
groups may be less than the differences within
them
as
most
contain
considerable
heterogeneity. Certain health and lifestyle
differences among ethnic groups have been
established over the years and the more
common have been summarised from a study
11
by the London Health Observatory and are
shown in Table 11.2.2.
Country of birth
UK and Ireland
Other European Union
Elsewhere
98.40
0.39
1.21
Since the 2001 census, there has been the well
publicised influx into Lanarkshire of people
from Poland, who consist mainly of fit adults
7
aged 16 to 34 years , and a small number of
refugees from the Democratic Republic of
Congo resettled in North Lanarkshire as part
of the Gateway Protection Programme.
Migrants
There are two categories of migrants: longterm who stay for at least a year, and shortterm who stay for 3-12 months. Their reasons
for coming to this country will vary from
economic to fleeing from violent man-made
events, and their needs will vary accordingly.
They all have three key determinants of health:
individual characteristics such as age, sex and
ethnicity; their country of origin and the
circumstances of their migration; and their
socio-economic conditions in the host
14
country. Some, but by no means all, will
have a higher incidence of disease compared
with the UK population, and this is usually
associated with infectious diseases. Also,
migrants may be working in the most low-paid
jobs and thereby living in some of the most
deprived areas, which is associated with low
health status.
Population pyramids of the age-sex structure
of different ethnic groups show that ethnic
populations in the UK are younger than the
majority white population with relatively few
members of pensionable age, and that many of
the younger members have been born in the
8
UK.
The prevalence of limiting long-term illness
among people moving into Scotland from
outside the UK in the year prior to the 2001
census was much lower (4.6%) than in the host
9
population (20.3%). This was in contrast to
the prevalence among dependent children
living in Scotland which was almost identical
in white (4.88%) and non white (4.85%)
10
populations.
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HEALTH SERVICE PROVISION
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Table 11.2.2
Differences in health and lifestyle between ethnic groups
Health topic
Fair or poor health compared with
whites
Coronary heart disease
Diagnosed non-insulin dependent
diabetes
Common mental disorders (depression,
anxiety, mixed anxiety and depression
disorder, phobia, obsessive-compulsive
disorder and panic disorder)
Self-reported smoking
Overweight children
Obese children
Ethnic group
Pakistanis and Bangladeshis
Caribbeans
South Asian groups
Poorest groups of Pakistani and Bangladeshi origin
South Asians and Caribbeans
Difference
50% more likely
More likely
Moderately higher
Highest rates
Much higher prevalence
Bangladeshi women
12
Irish men and Pakistani women
Low rates
High rates
Various ethnic groups:
Varies with ethnic group
and survey
44%
17%
27%
More likely than girls and
boys respectively in
general population
Bangladeshi men
Chinese males
General adult male population
African-Caribbean girls and Indian and Pakistani
boys
African-Caribbean and Pakistani girls
More likely than girls in
general population
Adapted from East Midlands PHO summary of LHO report: Ethnic Disparities in Health and Health Care except where indicated
otherwise
Many diseases among migrants will be the
same as those in the UK population, especially
those associated with travel, but their
prevalences may differ. There are few good
quality data regarding disease in migrants
because, as with ethnicity recording, country
of birth is not routinely recorded in UK
surveillance systems. Some data are available,
however, and these show that 70% of
tuberculosis cases and HIV cases reported in
England, Wales and Northern Ireland and 70%
of malaria cases reported in the UK in 2004
were in people born outside the UK. Some
other infectious diseases that may be more
prevalent among migrants than in the host
population are gastro-intestinal infections such
as Shigella spp., Entamoeba spp. and Giardia;
helminthic infections which are usually
associated with migrants from tropical regions;
polio or diphtheria if people have not been
fully immunised; schistosomiasis mainly in
young males who have been in sub-Saharan
Africa; typhoid and typhus, and more familiar
13
diseases such as hepatitis C.
can be mistaken for other pathology, for
example amoebic dysentery and ulcerative
colitis. There have been a few cases in the UK
of preventable diseases such as polio and
diphtheria in children who were living in the
UK but who were not fully immunised before
they visited relatives in their country of origin.
CURRENT SERVICE PROVISION
In the 2005 Annual Report, it was shown that
a few general practices use ethnicity to target
preventive action, while others thought giving
attention to ethnicity was a form of
discrimination.
The Infectious Disease Unit at Monklands
Hospital provides a range of services,
including inpatient facilities, a blood-borne
virus unit and advice for travellers to help
them remain well while out of the country.
Some health-related information is available in
different languages.
Lanarkshire’s acute
hospitals have access to a range of help:
multilingual phrase books, health professionals
who are known to speak specific languages, and
professional translators who can be called on
although there may be a delay of a few hours.
Migrants may have these diseases when they
arrive, or contract them when they visit their
country of origin. Occasionally, diseases may
lie dormant and present with symptoms which
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The National Resource Centre for Ethnic
Minority Health has developed a resource
pack which it distributed widely to healthcare
professionals in Glasgow and elsewhere in
14
Scotland.
For some cultures, such as Muslim, access to a
female doctor may be considered very
important, particularly for contraceptive,
obstetric and gynaecological needs, but in
general practices where this is not always
possible, a female chaperone should always be
offered.
There are a number of useful websites
accessible to both the public and healthcare
professionals which provide a range of
information on, among others, specific diseases,
immunisations and tips for keeping well while
abroad:
•
Some asylum seekers may have significant
mental health problems resulting from
violence and persecution in their country of
origin, and continuing concern about family
members who may have been left behind.
They need access to high quality psychiatric
and psychological services experienced in
dealing with their types of health need.
advice for the travelling public:
http://www.fitfortravel.nhs.uk/
•
travel advice for health professionals:
http://www.travax.nhs.uk/
•
Immigrants
from
developing
countries
sometimes believe they are immune to the
pathogens they may encounter on return visits.
Some may stay in very basic conditions where
clean water, for example, may not be readily
available. These immigrants would benefit from
good quality travel advice and prophylaxis
against the relevant diseases before they leave
the UK.
advice for both these groups:
http://www.nathnac.org/
There is currently a training programme in
NHS Lanarkshire for senior managers to raise
awareness of ethnicity, spirituality and
diversity issues, and tools for assessing the
impact of policies and service developments
on minority ethnic groups.
From the above, it can be seen that it is
important to ensure children of immigrant
families are fully immunised, and to have a
high index of suspicion of travel-related
diseases when patients present with relevant
symptoms.
PLANNING ISSUES
The Race Discrimination (Amendment) Act
2000 requires the health of all ethnic groups to
be taken into account in NHS boards’ policies
and service developments. The small numbers
of minority ethnic groups in Lanarkshire
means there may be NHS staff in Lanarkshire
who are as yet uncertain of this requirement or
how it affects their work.
Travel health advice is relevant to anyone
travelling abroad, but many people do not
seek advice before they travel, only when
they are symptomatic after returning home.
There is a need to raise awareness of the
benefits and sources of travel advice,
immunisations and malaria prophylaxis
among the general public and healthcare
professionals.
The lack of routinely collected ethnic data or
country of origin limits the NHS both
nationally and locally in gaining a true picture
of ethnicity as it relates to health, and therefore
of service developments.
No child should be exposed to diseases
preventable by their childhood immunisations
yet, although rare, there have been tragic
consequences when they have contracted them
abroad.
The range of health topics in Table 11.2.2
indicates the breadth of health issues which
have connotations for minority ethnic groups.
Yet the small number of patients from
minority ethnic groups in Lanarkshire may
mean there is insufficient clinical awareness
among staff which may delay diagnosis,
especially in diseases such as hypertension and
non-insulin dependent diabetes.
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SERVICE DEVELOPMENTS
5.
General Register Office for Scotland. 2001 census:
KS06 Ethnic group and language.
http://www.groscotland.gov.uk/files/key_stats_chbareas.xls
Last accessed 4 September 2007.
6.
General Register Office for Scotland. 2001 census:
KS05 Country of birth.
http://www.groscotland.gov.uk/files/key_stats_chbareas.xls
Last accessed 4 September 2007.
7.
Sim D, Barclay A, Anderson I. Achieving a better
understanding of 'A8' migrant labour needs in
Lanarkshire. Commissioned report by Department of
Applied Social Science, University of Stirling, February
2007.
8.
Gill PS, Kai J, Bhopal RS, Wild S. Black and minority
ethnic groups.
http://hcna.radcliffe-oxford.com/bemg.htm
Last accessed 5 September 2007.
9.
General Register Office for Scotland. 2001 census:
T33 Theme table on migration (people), Scotland.
http://www.gro-scotland.gov.uk/files/theme24-55.pdf
Last accessed 5 September 2007.
1. Ensure that training on ethnicity, diversity
and spirituality, and its relevance is
disseminated throughout NHS Lanarkshire.
2. Set standards for entry of ethnicity data for
all patients in Lanarkshire both in primary
and secondary care and provide relevant
awareness raising and training to enable
the necessary data collection.
3. Prepare and disseminate to all healthcare
professionals in Lanarkshire a booklet on
the clinical issues which relate to minority
ethnic groups as listed in Table 11.2.2 and
provide awareness raising/training sessions
for staff.
4. Provide information to the public and
healthcare professionals about the value to
them of travel health advice and how to
seek it.
10. General Register Office for Scotland. 2001 census:
T24 Theme table on ethnicity of all dependent
children in households, Scotland.
http://www.gro-scotland.gov.uk/files/theme24-55.pdf
Last accessed 5 September 2007.
5. Establish a culture of checking the
immunisation status of all immigrant
children at their first contact with healthcare
professionals and make sure any gaps are
remedied, and of ensuring that all children
with gaps in their immunisation status are
followed up until immunisation is complete
or has been actively refused by their
parent/legal guardian.
11. East Midlands Public Health Observatory. Appendix 1.
Summary of differences in health and lifestyle between
groups.
http://www.empho.org.uk/pages/viewResource.aspx?id=874
7 Last accessed 5 September 2007.
12. Sproston K, Nazroo J, (Editors).
Ethnic minority
psychiatric illness rates in the community (EMPIRIC) Quantitative report.
London: The Stationery Office,
2002.
http://www.dh.gov.uk/en/Publicationsandstatistics/Pu
blications/PublicationsStatistics/DH_4005698
Last accessed 6 September 2009
REFERENCES
1.
Great Britain Home Office.
Race Relations
(Amendment) Act 2000. London: Great Britain, Home
Office, 2001.
http://www.opsi.gov.uk/acts/acts2000/ukpga_20000034
_en_1#pb1 Last accessed 5 September 2007.
13. Health Protection Agency. Migrant health: Infectious
diseases in non-UK born populations in England, Wales
and Northern Ireland. A baseline report - 2006.
London: Health Protection Agency Centre for Infections,
2006.
2.
Great Britain Home Office. The Stephen Lawrence
Inquiry CM 4262-I. London: The Stationery Office,
1999.
http://www.archive.officialdocuments.co.uk/document/cm42/4262/4262.htm
Last accessed 5 September 2007.
14. National Resource Centre for Ethnic Minority Health.
Asylum seekers and refugees resource pack for health care
professionals. Edinburgh: NHS Health Scotland, 2005.
3.
Audit Commission. Information and data quality in the
NHS. London: Audit Commission, 2004.
http://www.auditcommission.gov.uk/Products/NATIONALREPORT/4D598AF6-3894-401d-AA481076125DA38D/Data%20Quality_2.pdf
Last accessed 5 September 2007.
4.
National Statistics. A guide to comparing 1991 and
2001 Census ethnic group data.
http://www.statistics.gov.uk/articles/nojournal/GuideV9.pdf
Last accessed 13 August 2007.
86
HEALTH SERVICE PROVISION
Needs Assessments
SECTION 11.3 - CHILDHOOD OBESITY
Over the last two decades, obesity in children
has risen at an alarming rate, not only in
1
Scotland, but worldwide. It results from a
combination of factors including a diet high in
excess calories from the consumption of foods
high in fat and sugar, low levels of physical
activity and high levels of sedentary
behaviour. The consequences of obesity for a
child pose a significant threat to physical and
psychological health in the short term, as well
as for the adult who was obese as a child.
children have higher levels of obesity compared
to pre-school children and it appears that the
proportion of overweight children increases as
children get older. Overall, there is little
difference in obesity between boys and girls.
Across all age groups, the level of overweight,
obese, and severely obese children is higher in
the most deprived groups compared with
children who are least deprived as measured by
4
the Scottish Index of Multiple Deprivation.
Trends
In simple terms obesity develops when the
amount of calories consumed (energy intake)
exceeds the amount of calories used up (energy
expenditure). Excess calories consumed from
food and drinks results in an increase in stored
body fat which is harmful to health. Body Mass
Index (BMI) is used as an indicator of obesity by
expressing a person’s weight relative to their
height.
Figure 11.3.1 shows the prevalence of obesity
in children in primary 1 between school years
2000/01 and 2005/06 for NHS Lanarkshire
and other NHS boards who participate in the
Child Health Surveillance Programme. This
information is not collected uniformly across
all boards and comparisons between
Lanarkshire and the other participating boards
should be interpreted with caution.
EPIDEMIOLOGY
In 2005/06, 20.3% of children in primary 1 in
Lanarkshire were overweight. This percentage
includes 8% who were obese and 4% who
were severely obese, compared with 21.8%,
9.1% and 4.4% respectively in Scotland.
Adult definitions of obesity cannot be applied
to children. BMI in children and adolescents
varies with age and differs between boys and
girls and comparisons are made with
1
population reference standards for BMI. BMI
2
reference curves have also been established
and it is expected that 15% of children would
be overweight, 5% would be obese and 2%
would be severely obese.
Risk factors
Results from the most recent Scottish Health
Survey3 show that children’s eating patterns and
physical activity levels fall short of national
recommendations. Six out of ten children aged
2-15 years consume sweets and chocolate at
least once a day and around half report eating
biscuits once a day or more. Over four out of
ten usually drink non-diet soft drinks at least
once a day, while around a quarter drink them
more than once a day. Twelve per cent of
children reported eating no fruit or vegetables in
the 24 hours before the survey, while only 12%
said they eat the recommended amount of five or
more portions each day. The average fruit and
vegetable consumption was 2.6 portions in both
boys and girls.
The most recent Scottish Health Survey reported
an increase in overweight and obese boys
compared to previous years but no change
3
among girls. In children aged between 2-15
years, the prevalence of obesity was 18% in
boys and 14% in girls. The Child Health
Surveillance
Programme
also
provides
information about the prevalence of overweight,
obese and severely obese school children at
specific ages (primary 1, primary 7 and senior
3). While the prevalence of overweight, obese
and severely obese pre-school children has been
relatively stable, it is nevertheless higher than
expected in all age groups.
School-aged
87
HEALTH SERVICE PROVISION
Needs Assessments
Figure 11.3.1
High body mass index (BMI) - Primary 1 children
30
Percentage
25
Lanarkshire
All participating boards
20
Overw eight
15
Obese
Severely obese
10
5
20
00
/0
1
20
01
/0
2
20
02
/0
3
20
03
/0
4
20
04
/0
5
20
05
/0
6
20
00
/0
1
20
01
/0
2
20
02
/0
3
20
03
/0
4
20
04
/0
5
20
05
/0
6
0
There appears to be some improvement in
children’s physical activity levels over the last
few years. In 2003, 74% of boys and 63% of
girls aged 2-15 years participated in the
recommended 60 minutes of activity every
day, compared to 72% boys and 59% girls in
1998. Thirteen per cent of boys and 19% of
girls, however, had a low activity level, which
means they took part in fewer than 30 minutes
activity or were not active at all each day.
After the age of 8-10 years activity levels in
girls decline quite sharply with less than half
meeting the daily recommended target.
poor self-esteem, depression, being perceived
as unattractive, disordered eating and body
1
dissatisfaction. It is estimated that at least
70% of obese adolescents will remain obese
and therefore will become obese as adults,
highlighting the need for both prevention and
5
treatment of obesity.
CURRENT SERVICE PROVISION
Services to tackle childhood obesity are largely
preventive.
Across Lanarkshire, there is
ongoing promotion of breastfeeding as the
optimal feeding choice, implementation of infant
feeding guidelines and the healthy weaning
strategy. Healthier food choices in nurseries and
schools are actively promoted and Hungry for
Success is well established across all schools in
Lanarkshire. Specific programmes such as the
High Five for Fruit in nurseries aims to establish
eating fruit in children’s lives, while Water in
Schools attempts to reduce the use of carbonated
sugary drinks.
Information was collected in this survey for
the first time on sedentary behaviour and
showed that Scottish boys spend an average
2.6 hours a day and girls 2.3 hours, sitting in
3
front of a screen outwith school hours.
Thirty-two per cent of boys and 24% girls
aged 13-15 years spend on average fours hours
or more sitting at a screen each day, leading to
less time for physical activity and, therefore,
are more at risk of becoming overweight or
obese.
A more active lifestyle is encouraged by the
provision of curricular time for physical activity
in schools as well as a number of projects such
as Junior Up For It in regeneration areas.
Portable gymnasiums for even younger children
are also in use across Lanarkshire to help start
active living as young as possible. Safer and
more active routes to school such as walking and
cycling are being progressed but are not yet
universally supported.
Childhood obesity has been linked to
increased cardiovascular and other risk factors
including increased blood pressure and
1
adverse lipids (fats) in the blood. It is also
associated with increased risk of diabetes,
asthma, and abnormalities of foot structure and
1
function. Obese children are also more likely
to suffer psychological distress associated with
88
HEALTH SERVICE PROVISION
Needs Assessments
The development of communities enabled to
making healthier choices and encouraging
young people to participate in the Healthy
Living Initiatives such as Get Ready, Get
Cooking, will contribute to obesity prevention.
A multi-disciplinary inter-agency approach is
also being developed in two schools in one
regeneration area.
formed to develop a childhood obesity strategy
for Lanarkshire. The initial focus will be on
children from birth to 11 years of age. The
main emphasis of the strategy will be on
prevention, but community treatment options
including appropriate specialist referral routes
will also be included.
A map of existing services has shown that
there are a number of initiatives and services
already in place that are likely to impact on the
prevention, and arguably treatment, of obesity
in children, but these require to be evaluated.
While the main focus is on prevention, a US
1
expert committee recommended the following
criteria for referral to hospital, general
paediatric or community clinics for children
and young people:
•
Children who may have serious obesity
related morbidity that requires weight loss.
•
Children with a suspected underlying
medical condition such as those who are
obese and also short for their age.
Although there is much that can be done by the
statutory agencies, involvement of the voluntary
sector, parents, carers and children is also
crucial. While the Scottish Executive has
already committed considerable resources to
address this problem with the introduction of
policies such as the National Physical Activity
Strategy and the Scottish Diet Action Plan,
further resources will be required to influence
the obesogenic environment in which children
and their families live.
There is a steady flow of referrals to
paediatrics at Wishaw where a consultant
paediatrican with an interest in diabetes and
endocrinology assesses children referred who
meet the above criteria. A very small number
require inpatient assessment.
SERVICE DEVELOPMENTS
Childhood obesity, and more generally obesity,
has become a major public health problem in
recent years. The importance of a multi-faceted
approach to preventing obesity is well
recognised and the following are recommended:
PLANNING ISSUES
Although much public, political and media
attention has focused on the problem of
6
childhood obesity, the research evidence on
how to effectively prevent and treat obesity in
children is limited. It is clear, however, that a
single course of action is unlikely to reverse
the upward trend in obesity because of the
complex nature of the problem. It is generally
recognised that encouraging eating of healthy
foods, increasing physical activity and limiting
television viewing or use of computers will be
more beneficial than tackling diet alone. It is
also recommended that efforts should be
directed to motivated families where the
family is involved rather than only the child
and that families should be supported for a
longer period of time in order to increase the
likelihood of success.
1. Develop a resource pack and associated
training for midwives on healthy eating
and physical activity during pregnancy.
2. Develop a care pathway to identify and
manage obesity in the antenatal and
postnatal period.
3. Achieve
UNICEF
Baby
Friendly
accreditation in the maternity unit and all
localities.
4. Fully implement NHS Lanarkshire’s
Infant Feeding Policy and Guidelines to
ensure that all mothers are given accurate
and clear information on their chosen
method of infant feeding.
A multi-disciplinary group comprising
representatives from NHS Lanarkshire, North
and South Lanarkshire Councils has been
89
HEALTH SERVICE PROVISION
Needs Assessments
5. Provide practical weaning sessions in all
localities.
6. Increase availability of healthier food
choices across all public sector organisations
accessed by children, including nurseries,
schools, leisure centres and NHS premises,
as well as by the private care sector
including childminders.
7. Provide physical activity in all early years
establishments, the private sector, including
childminders, and all primary schools.
8. Provide access to training and practical
support on physical activity and healthy
eating for parents and staff from all partner
agencies.
9. Improve access to a variety of leisure
services and activities outwith the nursery/
school day.
10. Raise awareness in primary care, the wider
NHS and partner organisations in
Lanarkshire, through the child health
obesity strategy, of the multi-faceted
approach required to prevent childhood
obesity and also of the referral criteria for
children who require medical assessment.
REFERENCES
1.
Scottish Intercollegiate Guideline Network (SIGN).
Guideline 69 Management of obesity in children and
young people: a national clinical guideline.
Edinburgh: SIGN, 2003.
2.
Cole TJ, Freeman JV, Preece MA. Body Mass Index
curves for the UK. Arch Dis Child 1995; 73: 25-9.
3.
Scottish Executive. The Scottish Health Survey
2003. Edinburgh: Scottish Executive, 2005.
4.
www.isdscotland.org/isd/3640.html
Last accessed 13 July 2007.
5.
Reilly JJ. Obesity in childhood and adolescence:
evidence based clinical and public health
perspectives. Postgrad Med J 2006; 82: 429-37.
6.
Summerbell CD, Waters E, Edmunds LD et al.
Interventions for preventing obesity in children
(Review). Cochrane Library Oxford: John Wiley,
2005.
90
HEALTH SERVICE PROVISION
Needs Assessments
SECTION 11.4 - TERMINATION OF PREGNANCY
The Scottish Sexual Health Strategy Respect and
Responsibility acknowledges the importance of
8
access to good quality abortion services.
Induced abortion, also referred to as
termination of pregnancy, is a way of ending
an unwanted pregnancy by either a medical or
1
surgical procedure.
EPIDEMIOLOGY
The Abortion Act 1967 in Scotland, England
and Wales, allows women to obtain an
abortion up to 24 weeks of pregnancy if, in
the opinion of two doctors, continuation of
the pregnancy involves a greater risk to a
woman’s physical or mental health or to her
existing children. In some circumstances,
where pregnancy poses a risk to a woman’s
life or where there is severe foetal anomaly,
abortion may take place at a later stage in the
pregnancy. It is a statutory requirement for
induced abortions to be notified to the Chief
2
Medical Officer.
Statistics on abortions are produced by ISD
Scotland and have been used throughout this
9
section.
Abortions in Scotland
The number of abortions has increased
gradually since the introduction of the
Abortion Act. In 2006, 13,081 abortions
were reported to the Scottish Chief Medical
Officer compared to 12,603 in 2005, an
increase of 3.8%. The rate in 2006 was 12.4
abortions per 1000 women of childbearing
age (15-44 years).
Current sexual practices, trends in sexual
behaviour and the fallibility of contraception
mean that unwanted pregnancies continue to
3
occur. The World Health Organisation and
the Royal College of Obstetricians and
Gynaecologists recognise induced abortion as
a healthcare need and support abortion
services being an integral part of broader
3,4,5,6
Abortion services
sexual health services.
in Lanarkshire are provided as part of a
comprehensive strategy to improve women’s
7
sexual and reproductive health.
Over 95.4% of abortions were recorded as
being undertaken because of risk to the mental
or physical health of the woman, 3.2% on
grounds of risk to the mental or physical
health of existing children and the remaining
1.4% on grounds of foetal anomaly or risk to
the woman’s life.
The highest proportions of abortions during
2006 were in young women: 30.3% in those
aged 20-24 years and 26.3% in those
younger than 20 years. An upward trend
since 1998 is observed for these age groups.
The Royal College of Obstetricians and
has
produced
clinical
Gynaecologists
guidelines for the care of women requesting an
abortion. These guidelines are based on
1
scientific evidence and ethical considerations.
The influence of deprivation on abortion rates is
clear. Rates in 2006 were highest in the most
deprived areas (16.6 per 1000 women aged 1544), nearly double the rate in the most affluent
areas (8.8 per 1000 women aged 15-44).
Abortions carried out early in the pregnancy
are associated with lower risk of
complications.
For early abortions the
medical method is recommended as it is both
1
safer and more effective. The percentage of
abortions carried out at an early gestational
age across NHS boards in Scotland is
monitored.
The proportion of abortions carried out early
in pregnancy has been relatively stable for the
last five years, with 67.3% of all abortions
performed at less than 10 weeks gestation in
2006.
91
HEALTH SERVICE PROVISION
Needs Assessments
In 2006, 66.4% of early abortions (at less
than 10 weeks gestation) were carried out
using the medical method. This percentage
has been increasing steadily since 1992,
when medical abortion was introduced.
Lanarkshire differs significantly from the
Scottish average in the proportion of
abortions carried out early in pregnancy and
the method used to carry out early abortions.
The proportion of abortions carried out early
in pregnancy was significantly lower in
Lanarkshire
compared
to
Scotland,
respectively 51.6% and 67.3% in 2006.
Nationally the trend shows a marginal
increase in the proportion of early abortions
in recent years.
Data for Lanarkshire,
however, showed a distinctive and persistent
decrease in the proportion of early abortions
from 2000 to 2005, but a significant increase
during 2006 from 43.8% to 51.6%.
Abortions in Lanarkshire
During 2006, 1211 women resident in
Lanarkshire obtained an abortion, of which
992 were performed in Lanarkshire hospitals.
The number of abortions has increased year on
year from 1022 in 2003 to 1211 in 2006.
The abortion rate in Lanarkshire is, however,
lower than the Scottish average, with 10.4
abortions per 1000 women aged 15-44 in
Lanarkshire compared to 12.4 for all Scotland.
A significant increase in the proportion of
early abortions performed by the medical
method has been seen in Lanarkshire since
1999 (Figure 11.4.2).
The current
proportion of 55% is, however, below the
national proportion of 66.4%.
The highest number of abortions during
2006 were in the 20-24 age group (350)
followed by those aged 16-19 (319). The
latter age group showed a greater increase
since 2003 (Figure 11.4.1). In women under
16, 32 abortions were reported during 2006.
Figure 11.4.1
Abortions in women resident in Lanarkshire, by age group, 1998-2006
400
Under 16
300
16-19
Number
20-24
25-29
200
30-34
35-39
40+
100
0
1998
1999
2000
2001
2002
92
2003
2004
2005
2006
HEALTH SERVICE PROVISION
Needs Assessments
Figure 11.4.2
Abortions at under 10 weeks gestation using medical method, Scotland and NHS boards, 1998-2006
100
Sco tland
A rgyll & Clyde
Percentage of all abortions
80
A yrshire & A rran
B o rders
Dumfries & Gallo way
60
Fife
Fo rth Valley
Grampian
Greater Glasgo w
40
Highland
Islands
Lanarkshire
20
Lo thian
Tayside
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
A small proportion of women who require
specialist post abortion counselling are referred
to services in Glasgow.
SERVICE PROVISION
Since 2005, all abortions in Lanarkshire have
been performed at a dedicated unit in Wishaw
General Hospital.
Women having a termination of pregnancy are
at increased risk of chlamydial infection and
failure to treat chlamydial infection carries a
25% risk of post-abortal salpingitis. Systematic
chlamydia testing was introduced during 2006,
and every woman attending for an assessment is
offered a chlamydia test, in accordance with
recommendations of the Scottish Intercollegiate
11
Guidelines Network.
Women are referred to the service by a health
professional, such as a general practitioner, a
family planning practitioner or, if later in the
pregnancy, by a midwife.
The Lanarkshire service provides abortions up to
20 weeks of gestation. Abortions above 20 weeks
gestation require additional expertise and women
are referred to the British Pregnancy Advisory
Service (BPAS), which is a registered charity
10
providing independent abortion services. BPAS
provides an assessment clinic in Glasgow.
However, women need to travel to England for
the abortion procedure. In total, 14 Lanarkshire
residents were referred to BPAS in the financial
year 2006-07.
During 2006, the Lanarkshire abortion services
performed a total of 1000 abortions, 992 in
Lanarkshire residents and 8 in residents from
other areas. On average, 83 abortions were
performed each month. The workload of the
service has been increasing in the last three
years, with a 3.7% increase in the number of
abortions carried out in 2006 compared to 2005.9
The performance of the Lanarkshire abortion
services has been audited against the Royal
College of Obstetricians and Gynaecologists
1
clinical guidelines since 2000. The time waiting
for assessment, subsequent time to termination
of pregnancy and the stage of pregnancy at
assessment were recorded. During 2006, over a
fifth (22.4%) of women at the initial assessment
were in their second trimester of pregnancy (>12
weeks gestation). This is reflected in the high
Women referred to the Lanarkshire abortion
service are first seen for an assessment. In 2006,
over a fifth (20.6%) of all women assessed at the
service decided against proceeding with an
abortion. Women who wish to continue return
at a scheduled time for the procedure as a day
case. Assessments and medical abortions are
carried out by specialist nurses and surgical
abortions are performed by a gynaecologist.
93
HEALTH SERVICE PROVISION
proportion of second-trimester
(20.6%) performed by the service.
Needs Assessments
abortions
pregnancy and should have timely access to
the abortion service. This is important, both to
provide women with support in their decision
making and to be able to offer an abortion
early in the pregnancy. Key clinical indicators
have been published for Scottish clinical
sexual health services and include the
proportion of abortions carried out early in
pregnancy (<10 weeks gestation).
Complication rates of termination of
pregnancy were very low, in keeping with
rates observed nationally.
Providing post-abortion contraception is an
important aspect of the service. During 2006,
the majority of women, 86.2%, accepted postabortion contraception.
Improving access and reducing waiting times
for the abortion service is important.
Increasing the efficiency of the service should
be considered, particularly in view of the
current trend of rising numbers of abortion
requests in Lanarkshire.
Review of abortion data and its management
Good quality data are essential for the delivery
of a high quality abortion service. During
2006, a comprehensive review of data
collected on abortions and how it is used to
improve care in Lanarkshire was conducted.
A report of the review recommended
improvement in the following key areas:
•
Information about women presenting late in
their pregnancy to the abortion service in
Lanarkshire is not routinely collected. Such
information is required to inform the planning
of their care in Lanarkshire.
Reporting: data should be reported in a
more comprehensive and structured way.
•
Dissemination: data and analyses should
be easily accessible by all key staff
members involved in the abortion service.
•
Patient journey: information regarding
women’s experiences of dealing with the
decision to request an abortion and during
the care pathway should be collected.
The reasons why women have abortions in the
second trimester were studied in England and
12
no single reason was identified. The study
found that much of the delay occurs prior to
women requesting an abortion, with lack of
early awareness of pregnancy and women’s
concerns about what is involved in having an
abortion being significant factors.
Increasing the number of early abortions
carried out by the medical method will require
increased service capacity. Ways in which this
capacity could be increased should be
explored.
PLANNING ISSUES
In Lanarkshire, a comprehensive multi-agency
sexual health strategy has been developed. It
aims to promote positive sexual health,
through sexual health and relationships
education, and the development of sexual
health services. Implementation of the sexual
health action plan is reported on elsewhere in
this Annual Report.
North and South
Lanarkshire Councils and other agencies also
have key roles to play in helping to reduce the
number of unwanted pregnancies by
supporting young women in areas such as
education, employment and positive mental
health and well-being.
SERVICE DEVELOPMENTS
For those unplanned pregnancies for which
women choose an abortion and in order to
prevent as many unwanted pregnancies as
possible, the following service developments
are recommended:
1. Encourage women to attend for termination
early in pregnancy through the provision of:
Women considering an abortion should be
encouraged to consult a health care
professional at an early stage in their
94
•
education regarding early signs of
pregnancy
•
early support for women when they are
considering whether or not to present to
the abortion service.
HEALTH SERVICE PROVISION
•
Needs Assessments
increased number of terminations
carried out by the medical method (<10
weeks gestation).
2. Implement the recommendations of the
review of the abortion data and its
management, including the collection of
information about factors contributing to
women presenting to the termination of
pregnancy service.
3. Improve the completeness of the local
audit data regarding the abortion service
by amending the data collection form,
providing more feedback to staff who
enter data and continuing to support the
production of timely information on the
performance of the service.
development of condom distribution
schemes
•
fast tracking of particularly vulnerable
patients to sexual health clinics
•
provision of long-acting reversible
contraception
•
development and expansion of sexual
health clinics for young people.
Royal College of Obstetricians and Gynaecologists.
The care of women requesting induced abortion.
Evidence-based Clinical Guideline Number 7.
London: RCOG Press, September 2004.
www.rcog.org.uk Last accessed 2 July 2007.
2.
Abortion Act 1967. London: HMSO, 1967.
3.
Birth Control Trust. Abortion Provision in Britain –
How services are provided and how they could be
improved. London: Birth Control Trust, 1997.
4.
Royal College of Obstetricians and Gynaecologists.
Report of the RCOG Working Party on Unplanned
Pregnancy. London: RCOG Press, 1991.
5.
McKay HE, Rogo KO, Dixon DB.
International
Federation of Gynaecology and Obstetrics (FIGO)
society survey: acceptance and use of new ethical
guidelines regarding induced abortion for non-medical
reasons. Int J Gynaecol Obstet 2001;75: 327–336.
6.
World Health Organisation. Safe Abortion: Technical and
Policy Guidance for Health Systems. Geneva: WHO, 2003.
www.who.org Last accessed 30 May 2007.
8.
Scottish Executive Health Department. Respect and
Responsibility. Strategy and Action Plan for Improving
Sexual Health. Edinburgh: The Stationery Office, 2005.
www.scotland.gov.uk Last accessed 30 May 2007.
9.
National Services Scotland. Information Services
Division. Notifications of Abortions under the Abortion
Act 1967. Edinburgh: ISD, May 2007.
www.isdscotland.org Last accessed 2 July 2007.
11. Scottish Intercollegiate Guidelines Network. Management
of Genital Chlamydia trachomatis Infection. A National
Clinical Guideline No. 42. Edinburgh: Scottish
Intercollegiate Guidelines Network, 2000.
www.sign.ac.uk Last accessed 30 May 2007.
12. Ingham R, Lee E, Clements S, Stone N. Secondtrimester abortions in England and Wales. Centre for
Sexual Health Research, University of Southampton,
2007.
REFERENCES
1.
NHS Lanarkshire, North Lanarkshire Council, South
Lanarkshire Council. Lanarkshire Sexual Health
Strategy and Action Plan 2005-2008. Hamilton: NHS
Lanarkshire, 2005.
www.lanarkshiresexualhealth.org
Last accessed 30 May 2007.
10. British Pregnancy Advisory Service.
www.bpas.org Last accessed 2 July 2007.
4. Reduce the number of unplanned pregnancies
by:
•
7.
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HEALTH SERVICE PROVISION
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SECTION 11.5 - PREGNANCY ANOMALY SCREENING PROGRAMME
The purpose of offering screening during
pregnancy is to enable identification of
anomalies (abnormalities) in an unborn baby,
such as Down’s syndrome and neural tube
(spinal cord) defects, such as spina bifida. The
results of such screening tests can provide
parents-to-be with information to enable them to
make decisions, with appropriate professional
support, about whether to continue with an
affected pregnancy. Other tests can show
abnormalities which can be treated either in
utero (in the womb) or immediately after birth.
been shown to significantly reduce the
5
prevalence of neural tube defects.
There are two forms of neural tube defects:
2.1 Spina bifida is a defect of the spinal
cord and/or spine and the outcome
depends on factors such as the extent of
the defect and where it is located. Spina
bifida can cause significant neurological
defects, such as reduced mobility,
5
sensation and incontinence.
2.2 Anencephaly is a fatal condition where
the brain fails to develop.
Screening programmes, often based upon the
results of blood tests, have been in place to test
for common problems in pregnancy for many
years and, as time has gone by, more accurate
methods of pregnancy screening, including
ultrasound scanning techniques, have been
1
developed.
The occurrence of neural tube defects,
based on EUROCAT data was 1.69 per
6
1000 births. Based upon this, one would
expect 10-11 cases every year in
Lanarkshire. This is split between spina
bifida (frequency 0.88 per 1000 births)
and anencephaly (0.81 per 1000 births).
EPIDEMIOLOGY OF COMMON
PREGNANCY ABNORMALITIES
3. Other foetal anomalies
1. Down’s syndrome is the most common
genetic (chromosomal) abnormality in a live
baby. Often other congenital abnormalities
(i.e. abnormalities present at birth) can
accompany Down’s syndrome. Down’s
syndrome is the commonest cause of
moderate to severe learning disabilities.
Risk factors for Down’s syndrome include
2,3,4
increasing maternal age.
There is a range of other foetal
abnormalities which may be detected by
ultrasound screening in pregnancy. The
most common of these are serious heart
7
defects.
CURRENT SERVICE PROVISION
The current screening tests for foetal
anomalies and ultrasound scanning service
provision during pregnancy are as follows:
Occurrence of Down’s syndrome, based
on EUROCAT data was 1.7 per 1000
5
births Based upon this frequency and on
the fact that there are approximately 6500
births to Lanarkshire women each year, 11
cases of Down’s syndrome would be
expected per year in Lanarkshire.
Screening for Down’s syndrome in
Lanarkshire takes place in the second three
months of pregnancy and involves a blood test
from the mother which is tested for two serum
(blood) markers. The results are combined
with the age of the mother to calculate the risk
for Down's syndrome.
2. Neural tube defects (NTDs) are congenital
abnormalities
which
arise
during
development of the brain and spinal cord.
Genetic and environmental factors are
likely to be important in the development
of these conditions. Appropriate intake of
dietary folate very early in pregnancy has
In screening for neural tube defects, one of the
markers involved in the Down’s screening test
can also highlight if unborn babies are at high
risk of a spinal cord defect.
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HEALTH SERVICE PROVISION
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If a high risk of either is identified, further
tests can be done to confirm if an abnormality
is present or not.
Currently in NHS Lanarkshire, all pregnant
women are offered a simple ultrasound scan in
the first three months of pregnancy to confirm
that the foetal heart is beating, establish how
many foetuses are in the womb, provide
information on the age of the unborn baby(ies)
and allow an accurate prediction of the ‘due’
date. These scans are provided locally by
radiographers or consultant obstetricians in
local health centres and day assessment centres
in Airdrie Health Centre, Wishaw General and
Hairmyres Hospital. This scan does not screen
for major structural abnormalities such as
Down's syndrome or major heart defects in the
unborn baby.
Anomaly scans, which look for structural
abnormalities in the unborn baby in the second
three months of pregnancy, such as severe
heart defects and spinal cord anomalies, are
offered to women in Lanarkshire who have the
factors detailed below:
•
Abnormal serum (blood test) screening
result in mother;
•
Previous foetal anomaly (previous baby
with an abnormality);
•
Family history of:
•
Maternal diabetes mellitus (present before
the pregnancy began);
•
Use of medication which could be
potentially teratogenic (damaging to the
unborn baby), e.g. medication to control
epilepsy (anti-epileptics);
•
Significant confirmed viral illness during
pregnancy (e.g. TORCH). TORCH is an
abbreviation for infection with any or a
combination of the following viruses
Toxoplasma, Other, Rubella (German
measles), Cytomegalovirus (CMV) and
Herpes simplex II);
•
Polyhydramnios (too much fluid in the
womb);
•
Oligohydramnios (not enough fluid in the
womb).
Approximately 1100 women each year qualify
for an anomaly scan. This amounts to around
20% of the approximately 5000 pregnant
women who book their pregnancy care at
Wishaw General Hospital each year.
(Approximately 1500 Lanarkshire babies are
booked and delivered annually in Glasgow
hospitals.) All anomaly scans are carried out
by consultant obstetricians at the three day
assessment centres.
PLANNING ISSUES
A recent review1 of the evidence for ultrasound
scanning in pregnancy for screening purposes
made two key recommendations which, if
implemented, would increase the accuracy of
pregnancy screening in the detection of
abnormalities of the unborn baby such as
Down's syndrome and spinal cord abnormalities.
Neural tube (spinal cord) defect (1st
degree relative or more than one family
member affected);
Renal (kidney)
relative);
problem
(1st
degree
Structural cardiac (heart) problem (1st
degree relative);
All pregnant women should:
Skeletal anomaly (abnormality of the
skeleton and bones) - (1st degree relative);
•
Be routinely offered, in the second three
months of pregnancy, an anomaly scan for
structural abnormalities, such as serious
heart or spinal cord problems.
•
Be routinely offered, in the first 3 months of
pregnancy, screening for Down’s syndrome using CUBS (combined ultrasound of the
unborn baby’s neck area (nuchal
Significant genetic disorder or foetal
abnormality;
•
Multiple pregnancy;
•
IVF/ICSI (assisted fertilization);
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HEALTH SERVICE PROVISION
Needs Assessments
translucency) and blood (serum) biochemical
screening) at approximately 10-13 weeks into
the pregnancy.
Substitution of these approaches for existing
methods of screening has been shown to
significantly increase the detection rate of
1
abnormalities including Down’s syndrome.
In 2004, approximately 41% of Scottish
obstetric units routinely offered an anomaly
scan in the second three months.
The
provision of the scan has increased
significantly and only three maternity units in
Scotland do not routinely offer an anomaly
scan; the maternity unit at Wishaw General
Hospital in Lanarkshire is one of these three.
Option 3
Implementation of Anomaly
scanning in second trimester and
maintenance of second trimester
Down’s screening based on
blood test results.
Option 4
Implementation of both CUBS
screening in the first trimester for
Down’s screening and second
trimester anomaly scanning for
detection of severe defects such
as neural tube and heart defects.
The option scoring the greatest number of
points is the preferred option and the option
scoring the lowest number of points is the least
favourable.
The costs of each option, apart from the status
quo, have been estimated and the total costs of
screening and management of the consequences
of screening per abnormality detected were
similar and ranged between £25,000 and
£28,000. Costs per abnormality detected were
high in comparison with other screening
procedures but these need to be considered
against the lifetime cost to family, society and
the NHS for care of an individual with a
significant abnormality.
Now, as in 2004, at the time of publication of
the review, CUBS screening is routinely
available at only one maternity unit in
Scotland.
In Lanarkshire, any plans for implementation
involve considerable human and other
resources, including training and logistical
planning and other clinical developments in
the maternity service.
A preliminary prioritisation process based on a
8
balanced score card methodology was chosen
to assist planning for implementation of the
ultrasound screening recommendations and
the results have been fed into the Maternal
and Child Health Programme Board.
The overall process identified introduction of
anomaly scanning within NHS Lanarkshire in
the first instance. This would provide a
service similar to those of neighbouring
Scottish NHS boards as well as addressing
public concern in this regard. This will allow
time for national clarification of how best to
progress implementation of other Down’s
screening programmes.
The process considered a range of issues such
as the magnitude of benefit, the strength of
evidence, costs, services provided by other
NHS boards, and scored them for each option
being considered:
SERVICE DEVELOPMENT
Option 1
Status quo - the current service
provision for Down’s screening
and neural tube defects based
upon blood test results.
Screening for foetal abnormalities has
developed significantly in recent years and the
following screening services should be
developed:
Option 2
Implementation of CUBS for
Down’s screening and maintenance
of second trimester blood test for
NTD.
1. Anomaly scanning for foetal abnormality
should be introduced.
2. NHS Lanarkshire should consider how to
implement any further improvements in
Down’s screening, taking account of
98
HEALTH SERVICE PROVISION
Needs Assessments
current and evolving evidence and
developments in other NHS boards in
Scotland.
REFERENCES
1.
Ritchie K, Boynton J, Bradbury I et al. Routine
ultrasound scanning before 24 weeks of pregnancy.
Health Technology Assessment Report 5, 2004.
2.
Anderson DM, Jefferson K, Novak P et al. Dorland’s
illustrated
medical
dictionary.
29th
edition.
Philadelphia: WB Saunders, 2000.
3.
Rodeck C, Whittle M. Fetal Medicine - basic science
and clinical practice. London: Churchill Livingstone,
1999.
4.
Wald N, Leck I. Antenatal and neonatal screening.
2nd ed. Oxford: Oxford University Press, 2000.
5.
EUROCAT working group. Eurocat report 8:
surveillance of congenital anomalies 1980-1999.
Newton Abbey, Co Antrim: University of Ulster, 2002.
6.
Hunter S, Norman J. Screening for congenital heart
disease. Fetal Matern Med Rev 1999; 11 (2): 79-89.
7.
Lumley J, Watson L, Watson M et al. Periconceptual
supplementation with folate and/or multi-vitamins for
preventing neural tube defects. Cochrane Database
Syst Rev 2001; (3): CD001056.
8.
Edmunson-Jones P. Getting the priorities right - a
possible model for the future. ph.com. June 2005: 1011.
99
HEALTH SERVICE PROVISION
Needs Assessments
SECTION 11.6 - SUDDEN CARDIAC DEATH IN YOUNG PEOPLE
In general, cardiac disease becomes more
common with increasing age and it is unusual
for it to occur in young people. However,
sudden cardiac death in young people often
generates considerable public interest because
of the widespread social and economic
consequences as well as the impact on the
1
immediate family and friends.
of a history of sudden cardiac death in the
family or a family history of a cardiac
condition that could predispose to sudden
death at a young age. Because interventions
are available to eliminate or reduce the risk of
death for a number of these conditions, an
assessment of the family genetic history is
needed to identify other susceptible family
members that may benefit from further
1,2
investigation and treatment.
Sudden cardiac death (SCD) is an umbrella
term used for the many different causes of
cardiac arrest. It is defined as unexpected
natural death from a cardiac cause occurring
within a short time (generally within 1 hour of
onset of symptoms) in persons without a
known prior condition that would appear to be
2
fatal. This chapter focuses on sudden cardiac
death in people between 14 and 35 years of
age. This is distinct from sudden cardiac death
in people over 35 years, which is usually
related to coronary heart disease. It is also
distinct from cardiac conditions that manifest
soon after birth and are mainly dealt with by
paediatric cardiology services, including
congenital
heart
problems
such
as
atrial/ventricular septal defects and other less
common disorders.
Table 11.6.1
Major causes of unexpected sudden cardiac death
in young people (14-35 years of age)
Coronary heart disease
Hypertrophic cardiomyopathy
Dilated cardiomyopathy
Myocarditis
Ion channelopathies (including long QT syndrome,
Brugada syndrome, Lev-Lenegre’s syndrome and
others)
Wolff Parkinson White syndrome
Coronary artery anomalies
Marfan syndrome
Restrictive cardiomyopathy
Arrhythmogenic right ventricular cardiomyopathy
Endocardial fibroelastosis
Churg-Strauss syndrome
The English Department of Health published a
report entitled Arrhythmias and Sudden Cardiac
Death in March 2005 as part of the National
Service Framework for Coronary Heart Disease.
This report recommends that hereditary cardiac
conditions should be managed by a dedicated
multi-disciplinary service including a cardiologist,
geneticist, genetic counsellor and cardiac
technicians that specialise in relevant diagnostic
4
investigations. This model of service is endorsed
in the 2006 Scottish Executive publication Review
5
of Genetics in relation to healthcare in Scotland.
The conditions most commonly associated
with SCD in young people between 14 and
35 years of age include blockage of the
coronary arteries that supply blood to the
heart muscle (coronary heart disease),
thickening or abnormal structure of the heart
muscle (cardiomyopathy, myocarditis) and
arrhythmias, which are irregularities of the
electrical impulses that upset the natural
rhythm of the heart (ion channelopathies,
1,3
A
Wolff Parkinson White syndrome).
more complete list of the conditions that are
most commonly associated with SCD in
young people is given in Table 11.6.1.
EPIDEMIOLOGY
It is difficult to find accurate information on the
occurrence of sudden cardiac death in young
people because it is relatively rare, because death
records usually focus on cause of death rather
than how sudden it was, and because the true
cause of death cannot be reliably established in a
proportion of cases. An autopsy is commonly
Cardiac disease that develops in young people
often remains undiagnosed and can lead to
sudden death at first presentation. Some of
these deaths are not predictable or preventable
but in many cases they are hereditary because
100
HEALTH SERVICE PROVISION
Needs Assessments
Table 11.6.2
requested in order to investigate the cause of a
sudden death. However, when no evidence of a
structural cardiac disease or a significant drug
exposure is found at autopsy, the cause of death
may not be ascertainable. These deaths are then
recorded as being of an ill-defined or unspecified
cause such as sudden adult death syndrome or
sudden unexpected death syndrome.
Cardiac deaths in people under the age of 35 in
Lanarkshire, 2001-2005.
Cardiac condition
In an English study, no definitive cause of
death was found in around 4% of sudden
6
deaths in people aged 16 to 64. In the USA, it
is reported that a definitive cause of death
cannot be established in between 5% and 15%
of all sudden deaths and most of these are in
young people that appeared to be healthy
2
before their death. A research investigation
was carried out on 14 sudden deaths where no
definitive cause was found at autopsy in the
USA and the findings were published. The
investigation provided evidence that the
majority of these deaths were likely to be
associated with an irregularity of cardiac
rhythm, even though in all cases the heart
7
appeared to be structurally normal at autopsy.
No. of
deaths
Coronary heart disease
Cardiomyopathy total
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Cardiomyopathy unspecified
Dissection/rupture of aorta
Acute Myocarditis
Cardiac arrhythmia unspecified
Cardiomegaly unspecified
11
7
3
2
2
3
1
1
1
Total
24
The analysis in Table 11.6.2 reveals that
coronary heart disease (CHD) appears to be the
most common cause of cardiac deaths in this age
group in Lanarkshire. However, not all of the
deaths included in this analysis would count as
sudden deaths because it is likely that some of
the people that die from CHD will have had a
diagnosis established before their death. CHD in
this age group may be related to genetic causes
such as familial hypercholesterolaemia, which
predisposes some people to have extremely high
blood cholesterol levels that makes them
vulnerable to CHD at a young age. However,
CHD may also occur spontaneously in this age
group without any major genetic susceptibility,
although this is uncommon.
Although accurate statistics are not available,
cardiology experts have estimated that there
are at least 400 sudden cardiac deaths in the
under 35 years age group every year in the
8
UK, mainly in young men. In Scotland, it is
estimated by cardiology experts that around 70
people from all age groups die each year from
sudden cardiac death due to a disturbance of
9
cardiac rhythm. Drawing on the findings of
these analyses, between 4 and 7 sudden
cardiac deaths per year can be expected in
Lanarkshire in young people.
Cardiomyopathy features prominently in the
Lanarkshire analysis with a total of 7 deaths over
5 years. Most of these are likely to have been
sudden cardiac deaths and some will have a
genetic basis. Dissection/rupture of the aorta can
be associated with a genetic condition such as
Marfan’s syndrome, but can also occur
spontaneously. It is unclear from this analysis
whether the deaths from aortic dissection were
related to an underlying genetic condition. The
remaining three deaths in the analysis were
recorded as myocarditis, cardiac arrhythmia and
cardiomegaly; these are likely to have been
sudden deaths and may be related to a genetic
condition.
Table 11.6.2 shows the results of an analysis
of all cardiac deaths in people under the age of
10
35 in Lanarkshire between 2001 and 2005.
This analysis is based on data from the
General Register Office for Scotland. In all,
24 people were identified who died from a
cardiac cause over this five-year period, 18
men and 6 women. This analysis excludes
conditions that would normally be recognised
soon after birth and dealt with by paediatric
services.
A total of 7 Lanarkshire deaths between 2001
and 2005 in people aged between 14 and 34
years of age were recorded as due to “other or
ill-defined and unspecified causes of
11
mortality”, 4 male deaths and 3 female. This
101
HEALTH SERVICE PROVISION
Needs Assessments
information is based on a separate analysis of
data from the General Register Office for
Scotland. Based on the findings of the
research carried out in the USA, as previously
7
alluded to , it is likely that most of these will
be sudden cardiac deaths in Lanarkshire
residents.
members can be contacted and advised about
the need to have appropriate investigations and
follow-up.
Initial cardiac investigation will be carried out
at the clinic, involving a medical history,
cardiac physical examination and some routine
tests, including an electrocardiograph (ECG)
and/or echocardiogram. The clinic staff will
also co-ordinate other investigations that may
be needed such as a 24-hour Holter monitor and
possibly coronary angiography. The main
purpose of the cardiac assessment is to advise
each individual about the presence of a cardiac
condition and whether further intervention is
indicated. Even if no cardiac condition is
found, individuals can be advised about the
need for future investigation, if appropriate, and
at what intervals this may be required; their
details will be entered on to a database to
facilitate this.
Genetic investigation will
include a comprehensive genetic pedigree,
counselling and genetic testing where relevant
for some disorders with identifiable genetic
mutations. In some cases, this will allow family
members to be stratified according to their level
of risk for acquiring a cardiac condition, which
informs the arrangements for future cardiac
investigation and treatment.
The cardiac
genetic service will also provide information to
family members as well as links to relevant
voluntary agencies where they exist.
In total, the Lanarkshire analyses identified 31
deaths over a 5-year period (2001-05) and it is
likely that the majority of these are sudden
cardiac deaths in young people. This suggests
that on average we can expect around 5 sudden
cardiac deaths in young people every year in
Lanarkshire.
CURRENT SERVICES
When a young person dies suddenly from a
cardiac cause the general practitioner is notified
by the hospital or the procurator fiscal
depending on the circumstances of the death. If
the cause of death is genetic or associated with a
genetic disorder, the general practitioner will
usually wish to seek advice about appropriate
investigations and follow-up for first-degree
relatives. At present, Lanarkshire GPs refer
concerned first-degree relatives to the cardiology
service in order that investigations and follow-up
can be arranged. However, this arrangement
means that some first-degree relatives do not
receive appropriate investigations particularly if
the family is geographically dispersed, there is
breakdown in communication in the family, or
because some individuals will be less proactive
in seeking further investigation. Also, some
genetic conditions manifest at different stages of
people’s lives and will only be detected
proactively if a recall system is in place to
facilitate future investigations at regular
intervals.
Following an assessment at the combined
cardiac genetic clinic, the majority of people will
be assigned to one of the following three
categories:
A combined cardiac genetic clinic is currently
being established at West of Scotland level to
address some of the above issues. The clinic
will be staffed by a consultant cardiologist, a
consultant geneticist, cardiac nurses, cardiac
technicians and genetic counsellors. General
practitioners from all areas in the West of
Scotland, including Lanarkshire, will be able
to refer people to the service to have their
family tree mapped out comprehensively
(genetic pedigree) so that all relevant family
102
•
Some individuals will be classed as low-risk
for sudden cardiac death and discharged for
further follow up through their general
practitioner.
•
Some people will have no cardiac problems
that can be currently identified but will still
be regarded as high-risk for developing
cardiac problems at a later stage. The
cardiac genetic clinic will arrange for these
individuals to have further investigations
carried out at regular intervals. These
investigations would usually be organised
through the local secondary care service
with the option of re-referral to the cardiac
genetic service if required.
HEALTH SERVICE PROVISION
•
Needs Assessments
prevention and management. At the West of
Scotland level, the cardiac genetic service
can provide training and guidance on
referral criteria to the service, and also on
the assessment and management of
individuals that are geographically or
socially separated from their families.
Some people will require immediate
treatment or intervention, which will be coordinated through the cardiac genetic
service, for potentially fatal cardiac
conditions. The most commonly used
interventions are insertion of an implantable
cardiac defibrillator and/or prescription of
an anti-arrhythmic drug to prevent a
potentially fatal cardiac arrhythmia. People
with familial hypercholesterolaemia will
require lifestyle advice and treatment with a
statin drug in order to reduce their
cholesterol levels. Following treatment,
local cardiology services would be expected
to provide ongoing care to these individuals
as appropriate.
•
PLANNING ISSUES
To date, the planning of services for sudden
cardiac death in young people has been carried
out by a short-life working group of the
Lanarkshire Coronary Heart Disease Managed
Clinical Network (CHD MCN). The short-life
working group has produced a pathway of care
for sudden cardiac death in Lanarkshire (see
Figure 11.6.1) as well as establishing links
with the regional cardiac genetic clinic that is
being set up.
SERVICE DEVELOPMENTS
The following are recommended in order to
ensure that a comprehensive specialist service
that is compatible with the standard of care
expected across Scotland is offered to
Lanarkshire people at risk of sudden death
from a cardiac condition:
The Lanarkshire CHD MCN short-life working
group has also identified the following key
issues that need to be addressed in collaboration
with strategic planning, operational managers
and clinical staff in Lanarkshire, at the regional
12
service and nationally.
•
•
Treatment, intervention and follow up for
hereditary cardiac conditions tend to be
provided at a number of different sites and
across several NHS board areas although the
numbers receiving treatment at each site
may be small. In order to promote a
consistently high standard of care across
Scotland, a proposal has been submitted to
the National Services Advisory Group to
establish a national managed clinical
9
network for hereditary cardiac conditions.
It is hoped that this network will be
established in 2008 and will produce
guidelines and protocols on the investigation
and treatment of hereditary cardiac
conditions that are consistent with the best
available evidence and can be used in
Lanarkshire.
1. Local access to the required diagnostic
facilities is required in order to provide a
comprehensive service to people with
hereditary cardiac conditions so that they
can be investigated and managed
appropriately.
Family members are likely to be very
distressed if a young relative has died from
a cardiac cause, especially if this cardiac
condition is hereditary. Support from
primary care-based counselling service
may be required as well as information
about any support groups in the area.
National organisations such as Cardiac
Risk in the Young (CRY), Heart at Risk
Testing (HART) and Sudden Arrhythmic
Death Syndrome (SADS UK) have local
representatives in a number of areas across
Scotland.
2. Training should be facilitated for relevant
staff in primary care and in secondary care
in Lanarkshire on the investigation and
management of people with hereditary
cardiac conditions.
3. The Lanarkshire CHD MCN should
collaborate with the relevant national
agencies to ensure that people that are at risk
of a sudden cardiac death can access
information and support through local
services.
Good awareness in primary care of
conditions that can lead to sudden cardiac
death is an important aspect of their
103
HEALTH SERVICE PROVISION
Needs Assessments
Figure 11.6.1
SUDDEN CARDIAC DEATH
SCREENING PATHWAY
Sudden Cardiac Event / Death
Breaveheart
Screening
GP
SADS / CRY
A&E
Consultant
Cardiologist
Procurutor
Fiscal
Cardiac Genetic
Service
Step 1
Step 2
Step 4
Pathologist
PM & Sample
Step 3
+ve
Cardiac Genetic
Clinic Appointment
Family Tree &
Immediate
Screening
Genetic Test
Call/Recall
Follow-up
Contact Tracing
Step 5
Provide
information re:
Support Groups /
CRY Website
NHSL
Cardiology
Family Screening
Onward
Referral
Consider:
ECG
Echo
24Hr ECG
ETT
Other as indicated
Discharge
Provide
information re:
Support Groups /
CRY Website
104
HEALTH SERVICE PROVISION
Needs Assessments
4. Ongoing monitoring of quality of care is
essential to ensure that people receive a
high standard of care either at the regional
cardiac genetic clinic or through their local
cardiology service.
5. A Lanarkshire clinical representative
should become involved with the national
managed clinical network for hereditary
cardiac conditions, which it is hoped will
get established during 2008.
REFERENCES
1.
Lithbertson R. Current concepts: Sudden death from
cardiac causes in children and young adults. N Engl
J Med 1996; 33 (16): 1039-1044.
2.
Wever FD, Robles EO. Sudden death in patients
without structural heart disease. J Am Coll Cardiol
2004; 43 (7): 1137-44
3.
Cardiac Risk in the Young (CRY) website. Medical
Information Section.
www.c-r-y.org.uk/medical_conditons.htm
Last accessed July 2007.
4.
Department of Health. National Framework for
Coronary Heart Disease. Chapter Eight: Arrhythmias
and Sudden Cardiac Death. London: Department of
Health, 2005.
5.
Scottish Executive. Review of Genetics in relation to
healthcare in Scotland.
Edinburgh: Scottish
Executive, 2006.
6.
Bowker TJ, Wood DA, Davies MJ et al. Sudden
unexpected cardiac or unexplained death in
England: a national survey. Q J Med 2003; 96 (4):
269-76.
7.
Chugh SS, Kelly KL and Titus JL. Sudden cardiac
death with apparently normal hearts. Circulation
2000; 102: 649–654.
8.
Cardiac Risk in the Young (CRY) website. Statistics
Section.
www.c-r-y.org.uk/statistics.htm
Last accessed July 2007.
9.
National Services Advisory Group. Familial Arrhythmia
Network of Scotland. Paper 2007/1.
Edinburgh:
National Services Scotland, 2007.
10. Roseburgh D. Analysis of deaths from cardiac
causes in NHS Lanarkshire 2001-2005. PHI/NHSL
Ref 07- 033_A1.
11. Roseburgh D. Analysis of deaths from ill-defined or
unspecified causes in NHS Lanarkshire 2001-2005.
PHI/NHSL Ref 07- 033_A4.
12. Scottish Executive. NHS HDL (2007) 21.
Strengthening the role of Managed Clinical Networks.
Edinburgh: Scottish Executive, 2007.
105
HEALTH SERVICE PROVISION
Needs Assessments
SECTION 11.7 - ADVANCES IN DIABETES CARE: INSULIN INFUSION PUMPS
Diabetes mellitus is a lifelong disease caused
by an absolute or relative lack of the hormone
insulin leading to high concentrations of sugar
in the blood. There are two types of diabetes:
type 1 and type 2. In type 1 diabetes, no, or
virtually no, insulin is produced by the
pancreas. It usually begins quickly (over days
or a few weeks) in people under the age of 40
years, particularly in childhood. People with
type 1 diabetes need lifelong insulin
replacement to optimise blood sugar control
and reduce the long-term complications of
diabetes.
Diabetes Register in December 2006. The
number with type 1 diabetes was 3396
(15.2%), 1-2% of whom may benefit from
continuing insulin infusion. That report also
noted that a small number of patients were
discharged from hospital when it had not been
possible to achieve good blood sugar control.
CURRENT SERVICE PROVISION
Conventional insulin therapy can achieve good
or excellent control in many patients with two
to four injections per day, using combinations
of quick, intermediate and long-acting insulin.
While the majority of patients are cared for in
primary care, some require hospitalisation and
some have multiple repeat admissions.
In type 2 diabetes, enough insulin is produced
by the body to maintain life in the short term,
but insufficient to maintain normal blood
sugar levels, which in turn leads to long-term
complications. Type 2 diabetes usually affects
people over the age of 40 years. These people
tend to be overweight or obese. Initially after
diagnosis, dietary changes, increased exercise
and normalisation of weight can be sufficient
to achieve excellent blood sugar control. Over
time, the amount of naturally produced insulin
tends to fall, at variable rates. People with
type 2 diabetes commonly go on to require
tablets and some will eventually need insulin
on its own or as a supplement for tablets to
adequately control their blood sugar levels.
Insulin can also be given by continuous
subcutaneous infusion (insulin pump therapy)
where quick acting insulin is stored in a
syringe connected to a pump, which in turn is
connected to the body by a tube and a small
needle that remains under the skin, as shown
in Figure 11.7.1. Throughout the day, insulin
is continuously drip fed into the body to
provide a background level of insulin.
Whenever food is eaten, the dose of insulin is
increased, depending on the size of the meal,
to control the subsequent increase in blood
sugar.
The key aim of insulin treatment is to mimic,
as closely as possible, the natural production
of insulin to achieve normal blood sugar
levels, but also to avoid very low levels of
blood sugar that can be life-threatening.
Insulin needs to be administered by injection.
In both conventional insulin and insulin pump
therapies, patients need to closely monitor
their blood sugar levels and, if necessary,
adjust their insulin doses to optimise control.
Figure 11.7.1
EPIDEMIOLOGY
The increasing prevalence of diabetes in
Lanarksire, diabetes-related deaths and
hospital discharges and links with deprivation
1
were detailed in the 2002 Annual Report.
Attention was drawn to the rate at which
increasing numbers were being diagnosed with
diabetes. Twenty-two thousand, three hundred
and seventy four patients were included in the
106
HEALTH SERVICE PROVISION
Needs Assessments
Insulin pump therapy is likely to be of benefit to
a selected group of people with diabetes who are
determined to do everything possible to
overcome their previously inadequately
controlled disease; this group comprises only a
very small proportion of people with type 1
diabetes. The proportion of people with type 1
diabetes who are suitable for insulin pump
therapy is estimated to be of the order of 1% to
2%.
This treatment is increasingly being
recognised as part of an effective diabetic
service and expertise has been developed locally
in the administration of insulin by subcutaneous
infusion.
NICE recommended insulin pump therapy as
one option for people with type 1 diabetes
provided that:
1. multiple-dose insulin therapy has failed,
and
2. they are willing and able to use insulin
pump therapy effectively.
Multiple-dose insulin therapy has failed when
someone has been carefully trying to control
their diabetes but has not been able to keep
their blood sugar levels within recommended
levels without ‘disabling hypoglycaemia’.
This means that they have repeated and
unpredictable hypoglycaemic episodes, for
which they need help from other people,
which significantly spoil their way of life and
which make them anxious about the episodes
occurring again.
Since early 2006, 33 patients have been
recommended within Lanarkshire for insulin
pump treatment and of these:
•
10 have been established on insulin pump
therapy;
•
8 have been recommended for a trial of
insulin pump therapy;
•
4 require intensive education about insulin
pump therapy;
•
8 are awaiting assessment for insulin
pump therapy;
•
5 were assessed and discharged as not
eligible or unsuitable.
It is vital that people starting insulin pump
therapy should only be commenced on this by
a trained specialist team, including a doctor, a
diabetes specialist nurse and a dietician.
Training includes intensive education and
initial support for the patient. People using
insulin pump therapy also require ongoing
review by the specialist team and some may
need to return to multiple-dose insulin
treatment. It seems likely that the number of
people requiring DAFNE education will
exceed the number of people who eventually
need insulin pumps.
A core part of assessing a person’s need for
and preparing them for insulin pump therapy is
to ensure that current multi-dose insulin
therapy is optimised by a quality assured
structured patient education programme, such
as the Dose Adjustment for Normal Eating
2
(DAFNE) programme. The DAFNE course is
provided to 6 to 8 people at a time over a fiveday period, with input from a consultant
physician, diabetes specialist nurse and
diabetes dietician.
In 2004, the NHS Lanarkshire diabetes strategy4
highlighted the need for insulin pumps. This was
later supported by the Lanarkshire Diabetes
Managed Clinical Network reflecting the NICE
guidance for 1-2% of patients with type 1
diabetes and equating to between 25 to 50
patients in Lanarkshire. In 2005, the Scottish
Executive asked boards to implement the NICE
recommendations and approval was given for 10
patients (0.4% of patients with type 1 diabetes)
to have insulin pump treatment in the first
instance.
PLANNING ISSUES
In 2003, the National Institute for Clinical
Effectiveness (NICE) made recommendations
about those with diabetes who would benefit
from continuous subcutaneous infusion of
insulin and this needs assessment focuses on
3
that small group of patients.
The Scottish Diabetes Group surveyed insulin
pump provision across Scotland in 2006 and
demonstrated a large degree of variation in
provision of insulin pumps ranging from 0.1%
to 2.2%. Diabetes experts predict that clinical
107
HEALTH SERVICE PROVISION
Needs Assessments
need for insulin pump therapy in Scotland is
likely to be a minimum of 5% up to a
maximum of 15% of all type 1 diabetes
patients by 2012 based on current assessments.
SERVICE DEVELOPMENTS
Recognising that continuous insulin infusion
treatment is the only means for a small number
of diabetics of being able to avoid disabling
hypoglycaemic attacks and leading a more
normal life, the following developments are
recommended:
1. Review the clinical service requirements
for and provision of insulin pumps in NHS
Lanarkshire.
2. Produce a revised clinical specification
and business case to support the further
development of insulin pump treatment
and bring NHS Lanarkshire into line with
current NICE guidelines and direction
from the Scottish Executive.
3. Participate in developing a national
standard protocol for insulin pump
therapy.
4. Participate in the national audit of
continuous subcutaneous insulin infusion
treatment.
REFERENCES
1.
Lanarkshire NHS Board. The Health of the People
within the Lanarkshire NHS Board Area. Annual
Report of the Director of Public Health 2002.
Hamilton: Lanarkshire NHS Board, 2003.
2.
Dose Adjustment for Normal Eating (DAFNE)
website.
http://www.dafne.uk.com/scripts/typeonediabetes/daf
necourse.html. Last accessed 31 August 2007.
3.
National Institute for Clinical Excellence. Guidance
on the use of continuous subcutaneous insulin
infusion for diabetes, Technology Appraisal Guidance
No 57. London: National Institute for Clinical
Excellence, 2003.
4.
Lanarkshire NHS Board.
Diabetes Strategy,
Diabetes Managed Clinical Network. Hamilton:
Lanarkshire NHS Board, 2004.
108
HEALTH SERVICE PROVISION
Needs Assessments
SECTION 11.8 - CHILD AND ADOLESCENT MENTAL HEALTH
Mental health problems in children and young
people are common. At any one time, about
10% have mental health problems which are
so substantial that they have difficulties with
their thoughts, their feelings, their behaviour,
their learning and their relationships on a dayto-day basis.
diagnosis should not stand in the way of a child
benefiting from the potential assistance available
from the full range of multi-disciplinary
children’s services.
This
needs
assessment
updates
our
understanding of the epidemiology and the
current challenges for developing the service.
The importance of mental health for young
people is now recognised as a major challenge
for children’s services and one which requires
an integrated approach from universal
services, backed up by specialist professionals
working in teams.
EPIDEMIOLOGY
Overall prevalence
Two major studies have given robust
information on the prevalence of mental health
problems in children in Scotland: a survey by the
2
Office for National Statistics and the Scottish
1
Needs Assessment. In 2000, the Office for
National Statistics (ONS) published the results
of a UK study of over 10,000 children aged 515. They found that 9.5% overall had what they
called a ‘mental disorder’ - a problem of
sufficient severity and persistence as to have a
significant impact on the child’s functioning or
relationships.
The nature of mental health, well-being and
mental health problems in children
Mental health has been described in the
Scottish Needs Assessment Report as an
indicator of the breadth of thinking necessary
to comprehend the concept:
“Mental health is the capacity of each and all
of us to feel, think and act in ways that
enhance our ability to enjoy life and deal with
the challenges we face. It is a positive sense
of emotional and spiritual well-being that
respects the importance of culture, equity,
social justice, interconnections and personal
1
dignity.”
The concept of mental health is influenced by
values, preconceptions and assumptions. The
idea of mental health can never be free of
cultural, moral or ethical considerations.
A wide range of terms is used to describe mental
health problems. The terms ‘mental health
problems and disorders’, ‘mental illness’,
‘emotional and behavioural difficulties’,
‘psychological problems’ and ‘troubled
children’ are all in common usage. Often terms
are used preferentially by different agencies,
reflecting a medical, social or educational model.
It is clearly important that the differences in
terminology do not stand in the way of working
between the various agencies involved and
particularly that the concept of a psychiatric
109
•
The rate was higher in boys (11.4%) than
in girls (7.6%).
•
The rate among 11-15-year-olds (11.2%)
was higher than the rate in the younger
children (8.2%).
•
The rate among young black people (12%)
was higher than the average (9.5%), while
children whose ethnicity was reported as
Indian had the lowest rate (4%).
•
The rate among children living in loneparent households (16%) was twice that of
children living with two parents.
•
Children in low-income families (16%)
experienced almost three times the rate of
those in high-income families (6%).
•
The rate among the 892 young Scots
surveyed was 8.5%.
HEALTH SERVICE PROVISION
Needs Assessments
Table 11.8.1 illustrates the different rates of
the main categories of mental disorders
identified in the studies. As well as the age
and gender patterns described above, we can
see that the commonest problem recorded in
this study is conduct disorder amongst boys,
followed by emotional disorder amongst girls.
robust studies in the United States, Canada,
Australia and New Zealand. The Scottish
Needs Assessment suggests that the overall
number of young people up to the age of 19 in
NHS Lanarkshire with a significant disorder
will range from 11,800 to 19,500.
Some groups of children and young people are
significantly more vulnerable, for example
young people who are looked after and
accommodated by a local authority in Scotland
are five times more likely to have a significant
mental disorder.
There are, at any one time, between 6500 and
7000 school-aged children resident in the NHS
Lanarkshire area who have a mental disorder
of sufficient severity and persistence as to
have a significant impact on the child’s
functioning or relationships (Table 11.8.2).
There is limited evidence that the prevalence
of mental health problems in children and
young people has increased over time.
However, there is clear evidence that the
demand on services has grown. Although
these increases may reflect increasing
prevalence, they can also be due to increased
recognition as a result of changing awareness
and attitude, or may be due to increased
availability of services.
However, this estimate needs to be treated
with some caution. First, it does not include
pre-school children (too difficult to assess in a
survey of this kind), nor teenagers aged 16 and
over, where the prevalence of disorder is
known to be higher. Secondly, how the
individual demographic characteristics of
Lanarkshire would lead the local prevalence to
vary from the national norm is not sufficiently
understood. Thirdly, the prevalence rates in
the ONS study are lower than comparable
Table 11.8.1
Prevalence rates (%) of mental health disorders in young people in Scotland, by age and sex
5-10 years
Emotional disorders
Conduct disorders
Hyperkinetic disorders
Less common disorders
Any disorder
11-15 years
5-15 years
Boys
Girls
All
Boys
Girls
All
All
3.5
7.0
1.6
0.3
8.2
5.7
1.3
0.4
0.4
7.3
4.3
3.6
1.0
0.4
7.7
3.9
7.8
2.5
1.0
10.1
5.8
3.8
0.4
8.8
4.8
5.8
1.3
0.7
9.4
4.6
4.6
1.1
0.5
8.5
Table 11.8.2
Estimated prevalence of mental health disorders in young people in Lanarkshire
5-10 years
Prevalence rate (%)
Population
North Lanarkshire Council
South Lanarkshire Council
NHS Lanarkshire
Prevalence of any mental health disorder
North Lanarkshire Council
South Lanarkshire Council
NHS Lanarkshire
11-15 years
5-15 years
Boys
Girls
All
Boys
Girls
All
All
8.2
7.3
7.7
10.1
8.8
9.4
8.5
12680
11557
21612
11871
11127
20473
24551
22684
42085
10936
10255
18941
10495
9411
17705
21431
19666
36646
45982
42350
78731
1040
948
1772
867
812
1495
1906
1760
3257
1105
1036
1913
924
828
1558
2028
1864
3471
3934
3624
6738
110
HEALTH SERVICE PROVISION
Needs Assessments
delivered in the community by the partners
in children’s services: the NHS primary and
community health services, education, social
work and local authority community
services. There is a distinction between
these universal services for pre-school
children, school-aged children and young
people who have left school.
Risk factors for mental health problems in
children
Established factors which lead to an increase
in vulnerability to mental health problems
include:
•
learning disability of any kind
•
enduring physical ill health
•
physical or sexual abuse
•
witnessing domestic violence
•
an increased risk of mental health
problems among children whose own
parents have mental health problems.
Protective factors are having an adaptable
nature, high self-esteem and strong
relationships with peers and with family
members. Consistent availability of a person
who can be trusted and in whom a young
person can confide leads to greater resilience
in children who experience adversity.
•
The settings/places where young people
live their lives
•
The range of people and organisations
who come into contact with children and
young people
•
The continuum of mental health to mental
ill health
•
Underlying principles such as inequalities,
accessibility and participation.
Specialist services, including both local
specialist child and adolescent mental
health service (CAMHS) teams and highly
specialised services such as inpatient care.
Services in Lanarkshire mirror the three types
set out in the Framework. Universal services
are provided both through primary care
services and in partnership with education,
particularly education psychology services
which concentrate on supporting children’s
access to education. Social work services and
community education provide a range of youth
work in the community. Public health nurses
working with all age groups, but particularly
with primary school children, support parents
and schools whose children have behavioural
difficulties.
Four multi-disciplinary teams, whose members
include psychiatrists, psychologists, family
therapists, child psychotherapists and generic
CAMHS professionals, provide the core of the
local specialist service. The teams are based in
Hamilton, Motherwell and Coatbridge. It is
intended to increase the number of teams to six
during 2007. Teams receive referrals from a
range of professionals both inside and outside
the NHS. An important aspect of their work is
providing
consultation
to
professionals
providing universal services in primary care and
schools.
The Framework broadly sets out three types of
services:
•
•
CAMH services for children and young
people in Lanarkshire
Following on from the National Needs
Assessment, the Scottish Child Health Support
Group commissioned further work to develop
a framework for services. The Framework for
3
Promotion, Prevention and Care is a complex
and comprehensive matrix of the services
required which takes account of:
The life stages of children and young
people
Services targeted at those children and
young people who are at the greatest risk of
mental ill health, including, for example,
children who are homeless, children who are
looked after by a local authority and
children with enduring physical ill health or
disability.
The Framework is the basis of existing
services and for planned developments.
CURRENT SERVICE PROVISION
•
•
Universal services, which should be
available for all children and which are
111
HEALTH SERVICE PROVISION
Needs Assessments
Additional support is provided by a dedicated
team for children who are looked after and
accommodated by a local authority council.
Other children are a focus for networks of local
professionals. Specialist diagnosis and support
for children with autism is provided in this way.
A children’s unit in the Royal Hospital for
Sick Children, Yorkhill and an adolescent unit
at Gartnavel Royal Hospital provide inpatient
care for the whole of the West of Scotland
region.
•
Strategic training plans should be
developed, linked to the strategy for
workforce and service development.
•
Strong regional arrangements must be in
place to secure inpatient provision for
adolescents.
•
Appropriate transition arrangements to be
agreed between NHS specialist CAMHS
and adult mental health services, including
arrangements for handling referrals of
young people between the ages of 16 and
18 years.
•
NHS Quality Improvement Scotland (QIS)
have undertaken work to establish the local
prevalence of children with attention deficit
hyperactivity disorder (ADHD) in Scotland
and to assess services against the SIGN
6
guideline. It was found that, in common
with many other NHS boards, the number of
children with the diagnosis was substantially
less than the 2000 children expected. This
links to the low rate of prescribing of drugs
7
for ADHD in Lanarkshire.
PLANNING ISSUES
All the elements of the Framework are
expected to be in place by 2010.
Apart from the overall achievement of the
Framework elements, specific targets were set
for children and adolescents in Delivering for
Mental Health, the Scottish Executive delivery
4
plan for mental health services:
•
By the end of 2008, a named mental health
link person is available to every school,
fulfilling the functions outlined in the
Framework.
•
Basic mental health training should be
offered to all those working with, or caring
for, looked after and accommodated
children and young people.
•
By 2009, the number of admissions of
children and young people to adult beds
will be reduced by 50%.
SERVICE DEVELOPMENTS
It is clear that the planning and implementation
of CAMHS fit for the future is a demanding
agenda. Achievement of the actions outlined in
Delivering a Healthy Future demands strong
leadership and strategic planning. Specific
priority actions for NHS Lanarkshire are as
follows:
•
Appoint a named mental health worker for
every school to work between the specialist
CAMHS service and the existing school
health service to ensure that public health
nurses working in schools have basic
CAMH training and are effectively
networked to the local specialist CAMHS
team.
•
Support the existing CAYP service (CAMHS
for Accommodated Young People), which
provides training and a specific additional
service to staff and young people in local
authority residential children’s units. The
service needs to be financially secure,
appropriately accommodated and able to
expand in order to support all children who
Six specific actions, based on key elements
within the Framework are identified in
Delivering a Healthy Future, the Scottish
5
Action Plan for children’s health services.
These focus on:
•
The development of an action plan to
implement the Framework, linked to
Integrated Children’s Services Planning
and involving children and young people.
The need for strong senior local leadership
is recognised and progress against the
action plan needs to be regularly
monitored and the plan reviewed.
112
HEALTH SERVICE PROVISION
Needs Assessments
are looked after and accommodated,
including those who are in foster care.
•
Develop a team to provide a specific
additional service for children with
learning disability, identified as a priority
8
during a recent QIS visit , utilising the
model and experience of developing the
CAYP team.
•
Ensure care for young people who require
inpatient admission through the board’s
existing commitment to the new regional
adolescent inpatient unit which will
increase the number of available beds
from 14 to 25. Ensure care also for the
small but important number of children
who are admitted as inpatients to the
paediatric ward at Wishaw General
Hospital and older young people who are
admitted to the adult psychiatric ward.
Strengthen local arrangements to reinforce
collaboration between paediatric, CAMHS
and adult psychiatry staff.
•
Review and implement the local
guidelines for children with attention
deficit hyperactivity disorder in 2004.
REFERENCES
1.
Public Health Institute of Scotland. Needs
Assessment Report on Child and Adolescent Mental
Health in Scotland. Glasgow: Public Health Institute
of Scotland, 2003.
2.
Meltzer H, Gatward R, Goodman R, Ford T. Mental
Health of Children and Adolescents in Great Britain.
London: Office for National Statistics, 2000.
3.
Scottish Executive. Children and Young People’s
Mental Health: A Framework for Promotion,
Prevention and Care. Edinburgh: Scottish Executive,
2004.
4.
Scottish Executive. Delivering for Mental Health.
Edinburgh: Scottish Executive, 2006.
5.
Scottish Executive. Delivering a Healthy Future: An
Action Framework for Children and Young People's
Health in Scotland: Draft for Consultation. Edinburgh:
Scottish Executive, 2006.
6.
Scottish
Intercollegiate
Guidelines
Network.
Attention Deficit and Hyperkinetic Disorders in
Children and Young People. Edinburgh: SIGN, 2001.
7.
NHS Quality Improvement Scotland. Health
Indicators Report 2004. Edinburgh: NHS QIS, 2004.
8.
NHS Quality Improvement Scotland. Learning
Disability Services: Local Report: Lanarkshire.
Edinburgh: NHSQIS, 2006.
113
HEALTH SERVICE PROVISION
Needs Assessments
SECTION 11.9 - UROLOGICAL CANCERS
2
Urological cancer is an important group of
cancers affecting the Lanarkshire population.
In this needs assessment, the four commoner
cancers of the urinary system, prostate,
bladder, kidney and testicular cancer, are
considered and placed in the context of the
public health significance of these diseases
across Scotland. Importantly, modifiable risk
factors include tobacco consumption for
1
bladder cancer and obesity for kidney cancer.
and then declined until 2003. This contrasts
with an unabated increase throughout Scotland
over the same period. In contrast, bladder
cancer rates in Scotland have declined sharply
in both men and women since 1996 to plateau
at levels around half their previous incidence
(Figures 11.9.2 and 11.9.3). This is thought to
relate at least partly to a change in the
5
classification of bladder cancers. Testicular
cancer is now slightly more common than in
the early 1980s.
EPIDEMIOLOGY
PROSTATE CANCER
Information on urological cancers is mainly
derived from the Scottish Cancer Registry which
collects data on all new cases of cancer in
2
residents of Scotland. Data are derived from a
combination of hospital discharges, pathology
reports and notifications of death to the General
2
Register Office for Scotland. Information from
the registry is available until 2004. Table 11.9.1
demonstrates the relative frequency of urological
cancers in Lanarkshire over the ten years from
1995 to 2004. Prostate cancer is the second
3
most common cancer in men in Scotland. More
men than women are diagnosed and die from
1
bladder and kidney cancer in Lanarkshire. For
the 1997-2001 period in Scotland as a whole,
five-year relative survival was 91% for testicular
cancer, 68.3% for bladder cancer in men (60% in
women), 59.9% for prostate cancer and 40.3%
4
for kidney cancer in men (46.4% in women).
Prostate cancer affects males and increases with
2
age over 50 years. By 2003, an estimated
12,303 men in Scotland were alive with prostate
cancer representing around 0.5% of the whole
Scottish male population. Around 3.2% of
Scottish men aged 65 and over had been
2
diagnosed with prostate cancer.
Prostate cancer incidence is sensitive both to
the amount of disease present in the
community and in particular to changes in how
it is diagnosed. The increase in availability
and uptake of prostate specific antigen (PSA)
testing over time has been associated with
increases in prostate cancer incidence in recent
years. The prevailing understanding is that
incidence trends relate both to changes in
lifestyle and increased diagnosis due to PSA
testing. The importance of the effect of PSA
testing on incidence is supported by stable
mortality rates, an increase in early prostate
cancer across the UK and less variation in
1
mortality rates than incidence rate.
Table 11.9.1
Urological cancers, registrations and deaths,
Lanarkshire, 1995-2004
Site
Prostate
Bladder
Kidney
Testicular
Average number of
registrations per
year
Males
Females
180
34
75
25
33
21
Average number of
deaths per year
Males
70
29
20
1
Lanarkshire incidence began to fall away
significantly from Scottish rates from around
2000 onwards and has a significantly lower
incidence of prostate cancer than all other
2
NHS boards for the period, 1999-2003. In
2004, the rate has moved back towards the
Scottish average.
This almost certainly
reflects local PSA testing practice, which may
have been less prevalent in Lanarkshire.
Females
17
13
-
For the period 1980-2004, Figure 11.9.1
shows that prostate cancer incidence in
Lanarkshire rose steadily until the late 1990s
114
HEALTH SERVICE PROVISION
Needs Assessments
Figure 11.9.1
Registrations of prostate cancer, Lanarkshire and Scotland, 1980-2004
Standardised rate per 100,000 pop.
100
80
60
40
20
19
8
19 0
8
19 1
82
19
8
19 3
84
19
8
19 5
86
19
8
19 7
8
19 8
89
19
9
19 0
91
19
9
19 2
93
19
9
19 4
9
19 5
9
19 6
9
19 7
98
19
9
20 9
0
20 0
0
20 1
0
20 2
03
20
04
0
Lanarkshire
Scotland
due to bladder cancer is twice as common in
2
Lanarkshire men as in women.
BLADDER CANCER
Bladder cancer is more than twice as common
in men as women, is rare under the age of 45
and incidence increases with age. Lanarkshire
has significantly higher rates of bladder cancer
for both sexes when compared to Scotland
overall, with Lanarkshire rates of 24.9 per
100,000 person-years at risk for all men
(Scotland 18.5) and 9.3 for all women (Scotland
6.5). In Lanarkshire, there has been only a
small, non-significant reduction in incidence in
men since 1980, while there has been a
significant decline in incidence in Scotland
since around 1994, thought to relate to a change
in classification of some bladder cancers from
invasive to non-invasive tumours, which came
6
Figure 11.9.3
into effect after that time.
illustrates this phenomenon in females in
Scotland, although Lanarkshire subsequently
increased again.
Smoking is the main established risk factor for
bladder cancer, with more historical exposure
to chemicals in the dye and rubber industries
strongly demonstrated as contributing to the
occurrence of disease. The latter exposure to
chemical carcinogens is associated with a long
latency of up to 40 years. Forty per cent of
male bladder cancer and 10% of female
bladder cancer is attributable to tobacco
1
exposure.
At the end of 2003, 1.1% of Scottish men and
0.4% of women aged over 65 years had
2
bladder cancer.
While there has been a gradual decline in
mortality rates for bladder cancer in males in
both Scotland and Lanarkshire, rates in women
have stabilised in recent years. Overall death
115
HEALTH SERVICE PROVISION
Needs Assessments
Figure 11.9.2
Registrations of male bladder cancer, Lanarkshire and Scotland, 1980-2004
Standardised rate per 100,000 pop.
50
40
30
20
10
19
8
19 0
81
19
8
19 2
8
19 3
84
19
8
19 5
86
19
8
19 7
8
19 8
89
19
9
19 0
9
19 1
9
19 2
93
19
9
19 4
9
19 5
9
19 6
9
19 7
98
19
9
20 9
0
20 0
0
20 1
0
20 2
03
20
04
0
Lanarkshire
Scotland
Figure 11.9.3
Registrations of female bladder cancer, Lanarkshire and Scotland, 1980-2004
Standardised rate per 100,000 pop.
15
12
9
6
3
19
8
19 0
8
19 1
82
19
8
19 3
84
19
8
19 5
86
19
8
19 7
8
19 8
89
19
9
19 0
91
19
9
19 2
93
19
9
19 4
9
19 5
9
19 6
9
19 7
98
19
9
20 9
0
20 0
0
20 1
0
20 2
03
20
04
0
Lanarkshire
Scotland
kidney cancer increases steadily with age. In
men aged 65-74, relative survival at 5 years from
diagnosis has improved from under 30% in
1977-1981 to 41.8% in 1997-2001. Comparable
2
figures in women are 24.7% and 42.3%.
KIDNEY CANCER
Kidney cancer incidence increases with age and
is rare in those under 35. It is commoner in men
than women and rates have increased in both
sexes in Lanarkshire since 1980 mirroring
Scottish trends (Figures 11.9.4 and 11.9.5). By
2003, 0.3% of men and 0.2% of women over the
age of 65 in Scotland had been diagnosed with
2
kidney cancer.
Over 85% of kidney cancers are renal cell
carcinomas. The evidence demonstrating an
increased risk with increasing weight is
important. Renal pelvis and ureteric cancers,
included in the overall kidney cancer category,
1
are increased by tobacco smoking.
There has been little change in mortality since
1980, (6.2 per 100,000 person-years at risk in
men and 3.2 in women in 2005). Mortality from
116
HEALTH SERVICE PROVISION
Needs Assessments
Figure 11.9.4
Registrations of male kidney cancer, Lanarkshire and Scotland, 1980-2004
Standardised rate per 100,000 pop.
20
15
10
5
19
8
19 0
81
19
8
19 2
8
19 3
84
19
8
19 5
86
19
8
19 7
8
19 8
8
19 9
9
19 0
91
19
9
19 2
93
19
9
19 4
9
19 5
9
19 6
9
19 7
98
19
9
20 9
0
20 0
0
20 1
0
20 2
03
20
04
0
Lanarkshire
Scotland
Figure 11.9.5
Registrations of female kidney cancer, Lanarkshire and Scotland, 1980-2004
Standardised rate per 100,000 pop.
10
8
6
4
2
19
8
19 0
81
19
8
19 2
8
19 3
84
19
8
19 5
8
19 6
87
19
8
19 8
89
19
9
19 0
91
19
9
19 2
93
19
9
19 4
9
19 5
9
19 6
9
19 7
98
19
9
20 9
0
20 0
0
20 1
0
20 2
03
20
04
0
Lanarkshire
Scotland
4
effective chemotherapy. Lanarkshire had no
deaths from testicular cancer in its residents in
both 2004 and 2005 and relative survival at 1, 3
and 5 years was very similar at over 98.5% for
2
those diagnosed in 1997-2001.
CANCER OF THE TESTIS
Testicular cancer, predominantly a disease of
younger males, continues to be diagnosed into
older age. Incidence has gradually increased
in the Lanarkshire population, mirroring
Scottish trends (Figure 11.9.6). The incidence
rate was just under 4 per 100,000 person-years
2
at risk in 2004 in Lanarkshire.
Genetic predisposition and maldescent of the
testes represent the main risk factors for
6
testicular cancer.
Mortality continues to improve for this cancer,
largely because of continued improvement in
117
HEALTH SERVICE PROVISION
Needs Assessments
Figure 11.9.6
Registrations of testicular cancer, Lanarkshire and Scotland, 1980-2004
Standardised rate per 100,000 pop.
12
10
8
6
4
2
19
8
19 0
81
19
8
19 2
8
19 3
84
19
8
19 5
86
19
8
19 7
8
19 8
89
19
9
19 0
9
19 1
9
19 2
93
19
9
19 4
9
19 5
9
19 6
9
19 7
98
19
9
20 9
0
20 0
01
20
0
20 2
03
20
04
0
Lanarkshire
Scotland
The service plays an active part in the West of
Scotland Managed Clinical Network for
Urological Cancer.
The importance of
urological cancer nurse specialists has been
identified through the network.
CURRENT SERVICE PROVISION
Healthcare professionals working in the
primary care team have an important role in
recognising symptoms suggestive of cancer
and organising appropriate referral.
The
Scottish Referral Guidelines for suspected
cancer, published by the Scottish Executive in
2002, have been endorsed for use in
Lanarkshire.
The urological cancers are
diagnosed and treated primarily by the
specialist urology service in Lanarkshire. This
consultant-led service provides outpatient
clinics and day case surgery in all three
Lanarkshire general hospitals and an inpatient
8
service at Monklands Hospital.
PLANNING ISSUES
As with all cancers, a target was set in Cancer
in Scotland: Action for Change and Our
National Health: A plan for action, a plan for
change that ‘by 2005, the maximum wait from
urgent referral to treatment for all cancers will
be two months’. Waiting times for urological
cancers have been reported since 2005 in
Lanarkshire and this monitoring enables action
to be taken on waiting times for treatment as
appropriate.
Each outpatient clinic provides a rapid access
haematuria clinic so that patients with blood in
the urine, the most common symptom of
bladder cancer, can be rapidly and effectively
diagnosed.
Individual consultants have
developed specialist knowledge and skills in
the management of individual cancer types.
Oncology treatments, including chemotherapy
and radiotherapy, are provided from the
Beatson Oncology Centre in Glasgow, with a
urological cancer clinic held regularly in
Lanarkshire. Individual cases benefit from
expertise shared at weekly multi-disciplinary
meetings.
Mortality rates from prostate cancer have been
stable since 1990 and were not significantly
different in Lanarkshire (26.1 per 100,00 personyears at risk) from the rest of Scotland for the
2
Prostate cancer relative
2001-2005 period.
survival has been steadily improving over time
in Scotland. In men aged 65-74, relative
survival at 5 years from diagnosis has improved
from 44% in 1977-1981 to 74.8% in 19972
2001. This is partly due to improvements in
treatment, including wider use of radical
treatments for early cancer and also because
118
HEALTH SERVICE PROVISION
Needs Assessments
PSA testing resulted in the diagnosis of some
4
‘less aggressive tumours. Apart from age, no
definite risk factors for prostate have been
1
identified. There are currently no available
primary prevention strategies for prostate cancer.
In particular, there is still insufficient proven
benefit from general population PSA screening
for this to be introduced as a secondary
6
prevention measure.
Kidney cancer also has a significant reduction in
survival with increasing deprivation, although no
other trends reach statistical significance. No
conclusions are possible regarding testicular
cancer, mainly because numbers are too small to
reach significance. Continued monitoring of
urological cancers in Lanarkshire is critical in
order to plan future service provision effectively.
SERVICE DEVELOPMENTS
Lanarkshire’s bladder cancer mortality rates
are not significantly different to Scotland.
Survival from bladder cancer in Scotland has
been consistently improving since 1977 and is
2
currently about 70% 5 years after diagnosis.
The capacity for improved outcomes in
bladder cancer indicates the need for continued
action on smoking, rapid diagnosis of the
cancer, rigorous surveillance including
cystoscopy of occupationally at-risk groups,
and a multi-disciplinary approach for people
6
with invasive disease.
The growing numbers of elderly people will
determine cancer incidence in Scotland in the
next 20 years.
By 2016-2020, predicted
increases in urological cancer incidence are over
50% for prostate, 35% for testicular, 73% for
kidney and 30% for bladder cancer compared
7
The following are
with 1996-2000 levels.
recommended:
1. Monitor the trend in the incidence of
prostate and bladder cancer and investigate
persistent differences in the incidence in
Lanarkshire compared to Scotland.
Modifiable risk factors include tobacco
consumption for bladder cancer and obesity
The most important
for kidney cancer.
measures to be undertaken in the secondary
and tertiary prevention of testicular cancer at a
population level are raising public awareness,
including the use of testicular selfexamination, reducing time to presentation,
and rapid access to referral and treatment by
6
specialist services. There is no current scope
for primary prevention and no basis for
6
population-based screening programmes.
2. Keep the practice of PSA testing in
Lanarkshire under review, in the light of
emerging evidence
3. Review and redesign services where
necessary in order to keep the time
between urgent referral and treatment at
less than 63 days.
4. Appoint a cancer nurse specialist for
urological cancer leading to constant
improvement in the provision of services
which may lead to a potential reduction of
mortality of 5% for each of bladder,
kidney and testicular cancer.6
When urological cancer patterns in subgroups
are analysed by the Scottish Index of Multiple
Deprivation (SIMD), important and concerning
patterns emerge. There is a significantly lower
incidence of prostate cancer and lower survival
with increasing deprivation, although mortality
2
was not significantly different. This pattern is
consistent with a higher rate of diagnosis of
earlier cancers in more affluent groups. Bladder
cancer shows a significantly higher incidence, a
significantly higher mortality and decreased
survival among more deprived communities.
This pattern may be explained by the association
between deprivation and smoking and past
1
occupational chemical exposures.
5. Prioritise lifestyle interventions on smoking
and obesity which remain the key risk
factors with the potential to substantially
reduce the incidence of cancers in
Lanarkshire including urological cancers
4
overall.
6. Encourage early presentation with
symptoms and support to ensure access to
diagnosis and treatment, particularly from
the most deprived areas.
119
HEALTH SERVICE PROVISION
Needs Assessments
REFERENCES
1.
Møller H, Quinn M. Cancer Atlas of the UK and
Ireland 1991-2000. Office for National Statistics.
Available at http://www.statistics.gov.uk/
2.
The website of ISD Scotland. Cancer Section.
www.isdscotland.org/cancer_information
Last accessed June 2007.
3.
Information Services Division, NHS National Services
Scotland. Cancer in Scotland. Edinburgh: ISD, 2006.
4.
Information Services Division, National Services
Scotland. Trends in Cancer Survival in Scotland 19772001. Edinburgh: ISD, 2004.
5.
David Brewster, Director of Scottish Cancer Registry.
Personal communication. 6 February 2007.
6.
Scottish Executive Health Department.
Cancer
Scenarios: An aid to planning cancer services in
Scotland in the next decade. Edinburgh: Scottish
Executive, 2001.
7.
Stockton D. Cancer in Scotland: Sustaining Change.
Cancer Incidence Projections for Scotland (2001-2020).
Available at http://www.scotland.gov.uk/
Last accessed July 2007.
8.
A Picture of Health: Proposed centralisation of Urology
and Gynaecology inpatient services: A consultation paper.
http://www.a-picture-ofhealth.org/NR/rdonlyres/EA5F2750-9730-4AB5-8A833A71B298EA2C/0/PropCentrUroGyaneinpat.pdf
Last accessed 5 August 2007.
120
DATA SOURCES FOR TABLES AND FIGURES
DATA SOURCES FOR TABLES AND FIGURES
Table/Figure
Data source
Figure 1.1-1.3
Figure 1.4
Figure 1.5
Figure 1.6
Figure 1.7
Figure 1.8
Figure 1.9
Figure 1.10
Table 1.1
Figure 2.1
Figure 2.2
Table 2.1
Figure 3.1-3.2
Figure 3.3
Figure 4.1-4.2
Figure 4.3
Table 4.2
Figure 5.1-5.2
Figure 5.3
Table 5.1
Figure 6.1
Figure 6.2-6.4
Figure 6.5
Table 7.1
Table 7.2
Figure 7.1
Figure 8.1
Figure 8.2
Figure 9.1
Figure 9.2
Figure 9.3-9.4
Figure 10.1.1
Table 10.1.1
Table 11.1.1
Table 11.1.2
Figure 11.1.1
Figure 11.2.1
Figure 11.3.1
Figure 11.4.1
Figure 11.4.2
Table 11.6.1
Table 11.6.2
Figure 11.6.1
Table 11.8.1
Table 11.8.2
Table 11.9.1
Figure 11.9.111.9.6
Population
denominators
General Register Office for Scotland (GROS)
SMR02 and GROS
SMR01, SMR02 and GROS
Child Health Surveillance Programme and Information Services Division, NHS National Services Scotland (ISD)
SMR02, ISD
Child Health Surveillance Programme and ISD
GROS and Scottish Index of Multiple Deprivation (SIMD)
GROS and ISD
GROS
See Chapter 2, reference 2
See Chapter 2, reference 8
See Chapter 2, reference 3
SMR01
SMR01 and SIMD
GROS
See Chapter 4, reference 4
Keep Well Evaluation Programme
Prescribing Information System for Scotland (PRISMS)
Prescribing Team, ISD and Practitioner Services, National Services Scotland (PSD)
Prescribing Team, ISD and Practitioner Services, National Services Scotland (PSD)
Scottish Health Boards’ Dental Epidemiology Programme and National Dental Inspection Programme (NDIP)
NDIP
Scottish Dental Practice Board Annual Reports
Scottish Infectious Disease System (SIDS)
Standard Immunisation Recall System (SIRS)
ISD(S)13
Surveillance of Mycobacterial Infections in Scotland (ESMI) programme
TB Therapy Guidelines, NHS Lanarkshire
ISD(D)4
Scottish Cancer Registry, ISD
SMR6 and GROS
Mental Health Framework Group
SMR01 and SMR04
SMR02
SMR02 and SIMD
SMR02
2001 Census
Child Health Surveillance Programme
Notifications (to the Chief Medical Officer for Scotland) of abortions performed under the Abortion Act 1967, ISD
Notifications (to the Chief Medical Officer for Scotland) of abortions performed under the Abortion Act 1967, ISD
GROS
GROS
Lanarkshire Coronary Heart Disease Managed Clinical Network
See Chapter 11.8, references 1 and 2
See Chapter 11.8, references 1 and 2
Scottish Cancer Registry, ISD and GROS
Scottish Cancer Registry, ISD
GROS and Community Health Index
121
STATISTICAL APPENDIX
STATISTICAL APPENDIX
LIST OF TABLES
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
A13
A14
A15
A16
A17
A18
A19
A20
A21
A22
A23a
A23b
Sociodemographic summary: by locality/CHP
Estimated mid-year population: by age group and locality/CHP
Projected population: by age group and sex
Births, stillbirths, perinatal deaths, neonatal deaths and infant deaths: by year
Births, stillbirths, perinatal deaths, neonatal deaths and infant deaths: by locality/CHP
Deaths from all causes - trends: by sex, age group and year
Deaths from all causes: by sex, age group and locality/CHP
Deaths from malignant neoplasms: by sex, age group and locality/CHP
Deaths from coronary heart disease: by sex, age group and locality/CHP
Deaths from cerebrovascular disease: by sex, age group and locality/CHP
Deaths from respiratory disease: by sex, age group and locality/CHP
Expectation of life: by age
Cancer registration trends: by sex, age group and year
Cancer registrations: by sex, age group and locality/CHP
Cancer registrations: by year and site and by sex, age group and site
Cancer registrations: by locality/CHP and site
Notifiable diseases - confirmed notifications; tuberculosis notifications: by year
Sexually transmitted infections - diagnoses recorded at Scottish genito-urinary medicine
clinics: by year
Immunisation uptake rates: by locality/CHP
NHS hospital activity: by specialty
Inpatient and day case discharges (non-psychiatric, non-obstetric hospitals): by main
diagnosis, sex and age group
New outpatient attendances, day case and inpatient discharges and inpatient bed days:
by sex and age group
New outpatient attendances, day case and inpatient discharges and inpatient bed days numbers: by locality/CHP
New outpatient attendances, day case and inpatient discharges and inpatient bed days rates: by locality/CHP
General notes relating to the tables:
Localities and community health partnerships (CHPs) have been defined by grouping electoral wards
as they existed in 2006 prior to the introduction of a revised ward structure in 2007. Only areas
within NHS Lanarkshire are included.
Populations shown and used in rates calculations are, for Lanarkshire and Scotland, mid-year
estimates produced by the General Register Office for Scotland (GROS). For localities and CHPs,
populations have been derived from the Community Health Index (CHI) and GROS mid-year
estimates.
Standardised rates are standardised by age and sex to the European standard population.
122
A1
Sociodemographic summary
by locality/CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
54817
48288
47221
CHP
Lanarkshire
Scotland
251409
558139
5116900
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
North
South
64863
38306
53235
58847
86424
106139
306730
Estimated population, 2006
No.
Estimated population
by age group, 2006
Under 5
5-14
15-24
25-44
45-64
65-74
75 and over
%
%
%
%
%
%
%
6.0
12.7
12.8
28.6
25.4
8.7
5.7
5.9
12.8
13.7
28.6
26.0
7.7
5.4
5.9
12.2
14.0
29.1
24.2
8.1
6.5
5.9
13.1
13.0
28.8
26.1
8.0
5.0
6.1
11.8
12.5
29.0
24.1
9.1
7.4
5.3
11.7
13.2
27.6
25.5
9.2
7.4
5.1
12.1
11.9
26.0
28.2
9.2
7.6
5.3
12.6
12.6
27.3
25.8
9.1
7.3
5.7
11.4
12.5
28.1
26.8
9.0
6.5
5.8
12.4
13.2
28.6
25.3
8.4
6.1
5.4
12.0
12.4
27.3
26.8
9.1
7.0
5.7
12.2
12.9
28.0
26.0
8.7
6.5
5.2
11.5
13.1
27.7
26.1
8.9
7.5
Proportion of data zones in the
15% most deprived data zones
in Scotland, 20061
%
21.1
20.6
41.7
3.6
24.5
23.2
3.8
0.0
23.7
21.2
10.4
16.3
15.0
Population of data zones in the
15% most deprived data zones
in Scotland, 20051,2
No.
11476
10086
18514
2114
9290
11218
2588
0
23278
62698
25866
88564
750030
%
%
63.1
36.9
62.0
38.0
59.1
40.9
72.9
27.1
54.1
45.9
57.9
42.1
70.1
29.9
80.4
19.6
71.4
28.6
62.8
37.2
74.1
25.9
67.8
32.2
67.0
33.0
Unemployment, April 2007
No.
4
%
1015
2.9
886
2.8
911
3.2
981
1.9
764
3.4
1070
3.2
765
2.7
1007
2.3
1791
3.8
5627
2.8
3563
3.0
9190
2.9
82803
2.6
Long-term unemployment
(1 year plus), April 2007
No.
4
%
120
0.3
110
0.3
135
0.5
85
0.2
85
0.4
140
0.4
110
0.4
90
0.2
225
0.5
675
0.3
425
0.4
1100
0.3
12915
0.4
3
Housing tenure
Owner occupied
Rented
1
2
3
4
The 15% most deprived data zones in Scotland are from the Scottish Index of Multiple Deprivation (SIMD) 2006.
Populations are mid-2005 Small Area Population Estimates (SAPE) from GROS.
Housing tenure figures for the North and its localities are for April 2006 and figures for the South and its localities are for March 2007. Scotland figures are for 2005.
Numbers claiming Jobseekers' Allowance as a percentage of the economically active population.
Sources: GROS; SIMD;
Community Health Index;
North Lanarkshire Council;
South Lanarkshire Council
A2
Estimated mid-year population
by age group and locality/CHP: 2006
Age group
CHP
Locality
Airdrie
Bellshill
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
North
South
Male
Female
Total
Under 5
3281
2830
2786
5-9
3384
2920
2843
3827
2350
2847
2990
4579
6073
17921
13641
16011
15551
31562
4211
2240
2966
3417
5026
5898
18563
14340
16775
16128
10-14
3590
3243
32903
2933
4293
2283
3280
3684
5851
6239
19622
15774
18189
17207
35396
15-19
3584
20-24
3450
3366
3185
4260
2415
3493
3675
5776
6527
20303
15978
18796
17485
36281
3230
3442
4203
2382
3535
3350
5153
6733
20242
15237
18178
17301
25-29
35479
3299
2891
2962
3810
2302
3098
2932
4439
6259
18363
13630
15776
16217
31993
30-34
3609
3159
3194
4233
2571
3314
3372
4803
6994
20081
15169
16797
18453
35250
35-39
4315
3839
3747
5306
3112
4079
4295
6749
8306
24398
19350
20925
22823
43748
40-44
4454
3900
3848
5353
3106
4212
4674
7572
8264
24872
20510
21686
23696
45382
45-49
3955
3794
3531
4777
2666
3905
4522
6977
7864
22627
19363
20178
21812
41990
50-54
3571
3243
2892
4403
2245
3408
4253
5823
7257
19762
17333
17893
19202
37095
55-59
3475
3135
2732
4352
2275
3426
4333
5083
7264
19396
16680
17500
18576
36076
60-64
2933
2383
2257
3417
2034
2861
3486
4420
6057
15885
13963
14114
15734
29848
65-69
2619
2098
2030
2866
1941
2515
2997
4164
5161
14069
12322
12145
14246
26391
70-74
2150
1634
1790
2315
1554
2375
2404
3668
4384
11818
10456
9823
12451
22274
75-79
1476
1196
1474
1587
1284
1833
1977
3096
3045
8851
8118
6907
10062
16969
80-84
963
835
949
949
881
1196
1330
1935
2076
5772
5341
4055
7058
11113
85 and over
709
593
626
700
666
893
1155
1310
1737
4186
4203
2406
5983
8389
54817
48288
47221
64863
38306
53235
58847
86424
106139
306730
251409
268154
289985
558139
All ages
Coatbridge Cumbernauld
and Kilsyth
Lanarkshire
Sources: Community Health Index; GROS
A3
Projected population
by age group and sex: 2014 and 2024 (2004-based)
2014
Age group
Male
Female
2024
Both sexes
No.
Male
Female
% change
Both sexes
No.
from 2005
% change
from 2005
Under 5
15383
14700
30083
-3.6
15054
14394
29448
-5.6
5-9
16224
15615
31839
-4.9
15571
14986
30557
-8.8
10-14
16426
15939
32365
-10.5
15970
15248
31218
-13.6
15-19
17613
16498
34111
-5.7
16492
15504
31996
-11.5
20-24
18449
17103
35552
0.6
15949
15318
31267
-11.5
25-29
18114
17876
35990
14.3
16860
16393
33253
5.6
30-34
17551
17998
35549
-3.2
17990
17780
35770
-2.6
35-39
15180
16894
32074
-27.8
17862
18606
36468
-17.9
40-44
18352
20526
38878
-14.0
17400
18323
35723
-21.0
45-49
21392
23327
44719
8.3
14957
16736
31693
-23.2
50-54
20634
22680
43314
19.6
17633
20045
37678
4.0
55-59
18090
20185
38275
7.2
20115
22467
42582
19.3
60-64
15744
17257
33001
11.8
18672
21405
40077
35.8
65-69
14452
16327
30779
15.6
15678
18506
34184
28.4
70-74
11196
13524
24720
12.9
13040
15170
28210
28.9
75-79
8539
11370
19909
18.5
10771
13472
24243
44.3
80-84
5324
8267
13591
24.6
7064
9980
17044
56.3
85 and over
3607
7297
10904
37.7
6044
10419
16463
107.9
272270
293383
565653
1.5
273122
294752
567874
1.9
All ages
Source: GROS
A4
Births, stillbirths, perinatal deaths, neonatal deaths and infant deaths
Lanarkshire residents by year: 1997-2006
Births (live and still)
Stillbirths
Perinatal deaths3
Neonatal deaths4
Infant deaths6
1997
1998
No.
Rate1
6836
6652
6489
6249
6064
6021
6090
6532
6316
6622
55.7
54.6
53.6
51.9
50.6
50.7
51.6
55.5
54.1
57.1
No.
Rate2
48
45
35
29
39
29
45
35
33
38
7.0
6.8
5.4
4.6
6.4
4.8
7.4
5.4
5.2
5.7
No.
Rate2
69
57
50
50
52
38
68
42
44
53
10.1
8.6
7.7
8.0
8.6
6.3
11.2
6.4
7.0
8.0
No.
Rate5
25
19
21
33
18
15
34
11
23
24
3.7
2.9
3.3
5.3
3.0
2.5
5.6
1.7
3.7
3.6
No.
Rate5
35
30
29
41
27
26
41
23
35
34
5.2
4.5
4.5
6.6
4.5
4.3
6.8
3.5
5.6
5.2
1 Rate per 1,000 women aged 15-44.
2 Rate per 1,000 births.
3 Stillbirths and deaths in the first week of life.
4 Deaths at ages under 28 days.
5 Rate per 1,000 live births.
6 Deaths during first year of life.
1999
2000
2001
2002
2003
2004
2005
2006
Source: GROS
A5
Births, stillbirths, perinatal deaths, neonatal deaths and infant deaths
by locality/CHP: 2006
CHP
Locality
Airdrie
Births (live and still)
Stillbirths
Perinatal deaths3
Neonatal deaths4
Infant deaths6
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
North
South
Lanarkshire
Scotland
No.
Rate1
691
553
600
779
538
609
594
951
1307
3770
2852
6622
55986
59.4
53.4
57.8
57.1
66.0
55.8
52.1
54.3
59.4
57.9
56.0
57.1
53.1
No.
2
Rate
6
4
4
1
7
5
3
3
5
27
11
38
296
8.7
7.2
6.7
1.3
13.0
8.2
5.1
3.2
3.8
7.2
3.9
5.7
5.3
No.
2
Rate
9
6
5
1
8
7
4
6
7
36
17
53
415
13.0
10.8
8.3
1.3
14.9
11.5
6.7
6.3
5.4
9.5
6.0
8.0
7.4
No.
Rate5
3
2
1
2
3
5
1
5
2
16
8
24
172
4.4
3.6
1.7
2.6
5.6
8.3
1.7
5.3
1.5
4.3
2.8
3.6
3.1
No.
Rate5
4
2
1
3
5
6
3
7
3
21
13
34
248
5.8
3.6
1.7
3.9
9.4
9.9
5.1
7.4
2.3
5.6
4.6
5.2
4.5
1 Rate per 1,000 women aged 15-44.
2 Rate per 1,000 births.
3 Stillbirths and deaths in the first week of life.
4 Deaths at ages under 28 days.
5 Rate per 1,000 live births.
6 Deaths during first year of life.
Source: GROS
A6
Deaths from all causes
Lanarkshire residents by sex, age group and year: 1997-2006
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Males
<65 years
65+ years
All ages
842
2112
2954
868
1999
2867
891
2119
3010
789
2108
2897
795
1998
2793
846
2028
2874
863
2044
2907
817
2011
2828
828
2025
2853
870
1962
2832
Females
<65 years
65+ years
All ages
540
2632
3172
525
2588
3113
517
2676
3193
514
2485
2999
501
2570
3071
548
2596
3144
561
2615
3176
507
2658
3165
507
2518
3025
551
2502
3053
Both sexes
<65 years
65+ years
All ages
1382
4744
6126
1393
4587
5980
1408
4795
6203
1303
4593
5896
1296
4568
5864
1394
4624
6018
1424
4659
6083
1324
4669
5993
1335
4543
5878
1421
4464
5885
Males
<65 years
65+ years
All ages
101.6
110.3
107.7
104.4
104.8
104.6
108.3
107.7
107.9
97.7
111.8
107.6
97.2
107.7
104.5
102.5
107.0
105.6
109.0
105.5
106.5
105.7
107.0
106.6
111.7
107.3
108.5
113.2
106.2
108.2
Females
<65 years
65+ years
All ages
105.1
111.5
110.4
104.0
109.0
108.1
102.6
109.0
107.9
104.2
105.9
105.6
101.3
109.7
108.3
111.3
108.9
109.3
113.1
107.9
108.8
106.6
112.9
111.9
105.7
106.8
106.6
114.9
107.2
108.5
Both sexes
<65 years
65+ years
All ages
102.9
111.0
109.1
104.2
107.1
106.4
106.1
108.4
107.9
100.2
108.5
106.6
98.8
108.8
106.4
105.8
108.1
107.5
110.6
106.8
107.7
106.1
110.3
109.3
109.3
107.0
107.6
113.9
106.7
108.4
Number
Standardised Mortality Ratio
1 Scotland=100.
1
Source: GROS
A7
Deaths from all causes
by sex, age group and locality/CHP: 2006
CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
Lanarkshire
North
South
Number
Males
<65 years
65+ years
All ages
116
186
302
80
188
268
77
185
262
98
178
276
44
151
195
103
218
321
66
220
286
113
299
412
173
337
510
518
1106
1624
352
856
1208
870
1962
2832
Females
<65 years
65+ years
All ages
54
220
274
48
212
260
49
224
273
53
216
269
46
187
233
59
285
344
53
288
341
69
387
456
120
483
603
309
1344
1653
242
1158
1400
551
2502
3053
Both sexes
<65 years
65+ years
All ages
170
406
576
128
400
528
126
409
535
151
394
545
90
338
428
162
503
665
119
508
627
182
686
868
293
820
1113
827
2450
3277
594
2014
2608
1421
4464
5885
Males
<65 years
65+ years
All ages
153.9
115.2
127.5
121.7
136.2
131.5
123.3
127.6
126.3
108.9
100.3
103.2
86.0
111.2
104.3
141.0
109.7
118.1
77.1
96.4
91.2
98.5
96.5
97.0
115.1
95.3
101.2
124.0
115.6
118.2
100.4
96.0
97.2
113.2
106.2
108.2
Females
<65 years
65+ years
All ages
116.2
104.7
106.8
116.7
126.5
124.6
130.3
117.6
119.7
93.6
103.8
101.6
146.8
102.0
108.5
131.5
116.8
119.1
98.7
101.3
100.9
94.3
99.9
99.0
127.0
105.2
108.9
119.8
111.7
113.1
109.3
102.4
103.5
114.9
107.2
108.5
Both sexes
<65 years
65+ years
All ages
139.5
109.3
116.8
119.8
130.9
128.0
125.9
121.9
122.8
103.0
102.2
102.4
109.1
105.9
106.5
137.4
113.6
118.6
85.4
99.1
96.2
96.8
98.4
98.0
119.7
100.9
105.3
122.4
113.4
115.6
103.8
99.6
100.5
113.9
106.7
108.4
Standardised Mortality Ratio 1
1 Scotland=100.
Source: GROS
A8
Deaths from malignant neoplasms
by sex, age group and locality/CHP: 2006
CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
Lanarkshire
North
South
Number
Males
<65 years
65+ years
All ages
21
45
66
15
49
64
22
62
84
26
66
92
8
54
62
22
66
88
22
72
94
24
82
106
51
112
163
114
342
456
97
266
363
211
608
819
Females
<65 years
65+ years
All ages
18
36
54
14
41
55
24
54
78
26
55
81
10
41
51
22
69
91
18
60
78
35
90
125
47
118
165
114
296
410
100
268
368
214
564
778
Both sexes
<65 years
65+ years
All ages
39
81
120
29
90
119
46
116
162
52
121
173
18
95
113
44
135
179
40
132
172
59
172
231
98
230
328
228
638
866
197
534
731
425
1172
1597
Males
<65 years
65+ years
All ages
106.2
88.1
93.2
87.9
114.5
106.9
138.1
137.0
137.3
110.9
117.4
115.5
60.3
128.1
111.9
114.5
108.2
109.7
94.4
104.2
101.7
80.6
85.2
84.1
127.4
102.3
109.0
104.9
114.6
112.0
104.2
96.8
98.7
104.6
106.1
105.7
Females
<65 years
65+ years
All ages
97.5
70.7
77.8
85.7
101.0
96.6
162.2
117.5
128.4
114.8
106.2
108.8
80.7
96.5
93.0
122.5
118.9
119.7
82.5
92.1
89.7
119.7
96.3
101.9
124.0
109.9
113.6
111.1
102.1
104.5
112.4
100.8
103.7
111.7
101.5
104.1
Both sexes
<65 years
65+ years
All ages
102.0
79.4
85.6
86.8
107.9
101.9
149.7
127.2
132.8
112.8
112.1
112.3
70.2
112.3
102.5
118.4
113.4
114.6
88.7
98.3
95.9
100.0
90.7
92.9
125.7
106.1
111.3
107.9
108.5
108.3
108.2
98.7
101.1
108.1
103.8
104.9
Standardised Mortality Ratio 1
1 Scotland=100.
Source: GROS
A9
Deaths from coronary heart disease
by sex, age group and locality/CHP: 2006
CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
Lanarkshire
North
South
Number
Males
<65 years
65+ years
All ages
23
42
65
17
43
60
18
34
52
20
29
49
4
37
41
20
39
59
10
54
64
19
59
78
30
62
92
102
224
326
59
175
234
161
399
560
Females
<65 years
65+ years
All ages
4
38
42
6
33
39
3
53
56
6
31
37
6
42
48
5
51
56
2
45
47
6
73
79
10
70
80
30
248
278
18
188
206
48
436
484
Both sexes
<65 years
65+ years
All ages
27
80
107
23
76
99
21
87
108
26
60
86
10
79
89
25
90
115
12
99
111
25
132
157
40
132
172
132
472
604
77
363
440
209
835
1044
Males
<65 years
65+ years
All ages
180.5
127.5
142.2
154.3
153.1
153.4
174.4
114.9
130.3
132.1
80.1
95.4
46.7
133.7
113.1
161.6
96.6
111.9
66.8
116.8
104.6
97.7
93.4
94.4
116.6
86.2
94.2
145.4
114.9
123.0
98.1
96.5
96.9
123.6
106.1
110.6
Females
<65 years
65+ years
All ages
102.3
109.5
108.8
175.9
119.2
125.4
96.7
168.0
161.6
125.6
90.5
94.8
226.4
138.2
145.3
131.4
126.1
126.6
43.1
95.4
90.7
97.4
113.9
112.4
124.2
92.1
95.2
138.5
124.6
126.0
95.5
100.4
99.9
118.5
112.9
113.4
Both sexes
<65 years
65+ years
All ages
162.1
118.3
126.9
159.4
136.2
141.0
156.4
142.3
144.9
130.5
85.1
95.1
89.1
136.1
128.5
154.5
111.4
118.6
61.2
106.0
98.2
97.7
103.7
102.7
118.4
89.2
94.7
143.8
119.8
124.4
97.5
98.5
98.3
122.4
109.5
111.9
Standardised Mortality Ratio 1
1 Scotland=100.
Source: GROS
A10
Deaths from cerebrovascular disease
by sex, age group and locality/CHP: 2006
CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
North
Lanarkshire
South
Number
Males
<65 years
65+ years
All ages
7
11
18
5
17
22
6
16
22
2
13
15
2
7
9
5
24
29
3
19
22
4
27
31
7
32
39
27
88
115
14
78
92
41
166
207
Females
<65 years
65+ years
All ages
3
34
37
5
23
28
2
21
23
1
21
22
2
23
25
2
38
40
1
41
42
2
55
57
9
73
82
15
160
175
12
169
181
27
329
356
Both sexes
<65 years
65+ years
All ages
10
45
55
10
40
50
8
37
45
3
34
37
4
30
34
7
62
69
4
60
64
6
82
88
16
105
121
42
248
290
26
247
273
68
495
563
Males
<65 years
65+ years
All ages
248.1
75.7
103.7
204.5
133.6
145.0
260.6
120.6
141.3
59.6
81.4
77.6
105.1
56.0
62.5
182.6
129.2
136.1
91.4
87.9
88.4
92.9
94.6
94.4
123.4
98.2
101.9
173.5
100.5
111.5
105.6
94.3
95.8
142.3
97.5
104.0
Females
<65 years
65+ years
All ages
140.6
128.3
129.2
265.6
108.6
121.4
117.0
87.1
89.1
38.4
81.4
77.5
139.5
96.4
98.9
96.4
121.9
120.3
39.8
110.2
105.7
59.3
112.2
108.8
205.5
123.0
128.7
126.7
104.9
106.4
116.9
116.1
116.1
122.2
110.3
111.2
Both sexes
<65 years
65+ years
All ages
201.9
109.7
119.6
231.1
118.0
130.8
199.4
99.0
108.7
50.3
81.4
77.5
119.9
82.6
85.7
145.5
124.6
126.5
69.0
102.0
99.0
78.2
105.7
103.2
159.2
114.2
118.6
153.3
103.3
108.4
110.5
108.2
108.4
133.5
105.7
108.4
Standardised Mortality Ratio 1
1 Scotland=100.
Source: GROS
A11
Deaths from respiratory disease
by sex, age group and locality/CHP: 2006
CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
Lanarkshire
North
South
Number
Males
<65 years
65+ years
All ages
6
38
44
7
29
36
5
27
32
6
28
34
3
23
26
8
27
35
5
28
33
9
40
49
6
44
50
35
172
207
20
112
132
55
284
339
Females
<65 years
65+ years
All ages
1
34
35
5
44
49
3
32
35
3
40
43
6
22
28
7
42
49
8
47
55
5
49
54
17
79
96
25
214
239
30
175
205
55
389
444
Both sexes
<65 years
65+ years
All ages
7
72
79
12
73
85
8
59
67
9
68
77
9
45
54
15
69
84
13
75
88
14
89
103
23
123
146
60
386
446
50
287
337
110
673
783
Males
<65 years
65+ years
All ages
142.8
166.8
163.1
194.1
146.9
154.2
147.6
130.7
133.1
120.5
111.8
113.2
106.0
118.5
116.9
195.6
94.1
106.8
101.6
84.4
86.6
142.4
90.2
96.7
70.6
87.0
84.6
151.5
126.2
129.8
101.3
87.4
89.3
128.4
107.4
110.3
Females
<65 years
65+ years
All ages
28.3
108.7
100.6
162.3
176.3
174.8
106.6
112.5
112.0
69.7
129.8
122.4
250.4
79.8
93.4
203.7
115.1
122.7
192.0
109.8
117.0
90.2
84.8
85.2
234.2
114.7
126.1
127.8
119.2
120.0
176.8
103.2
109.9
150.5
111.4
115.2
Both sexes
<65 years
65+ years
All ages
90.5
133.2
127.9
179.5
163.3
165.4
129.0
120.2
121.2
96.9
121.7
118.2
172.2
95.8
103.4
199.3
105.9
115.5
143.1
98.7
103.4
118.0
87.1
90.3
146.0
103.0
108.0
140.7
122.2
124.4
136.2
96.4
100.8
138.6
109.7
113.0
Standardised Mortality Ratio 1
1 Scotland=100.
Source: GROS
A12
Expectation of life1
by age: 1994-1996 and 2004-2006
Age
1994-1996
Lanarkshire
0
1
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
2004-2006
Scotland
Lanarkshire
Scotland
Males
Females
Males
Females
Males
Females
Males
Females
71.7
71.1
67.2
62.2
57.3
52.6
47.8
43.0
38.2
33.5
28.8
24.4
20.3
16.5
13.2
10.3
7.9
5.9
4.5
76.8
76.3
72.3
67.4
62.4
57.5
52.6
47.7
42.8
38.0
33.3
28.8
24.4
20.3
16.5
13.1
10.1
7.6
5.7
72.1
71.6
67.7
62.7
57.8
53.0
48.3
43.6
38.9
34.2
29.6
25.2
21.0
17.2
13.8
10.8
8.4
6.3
4.7
77.7
77.1
73.2
68.2
63.2
58.3
53.4
48.6
43.7
38.9
34.2
29.6
25.2
21.1
17.2
13.7
10.7
8.0
5.8
73.7
73.1
69.2
64.3
59.3
54.5
49.8
45.0
40.4
35.9
31.3
27.0
22.8
18.9
15.3
12.2
9.4
7.1
5.5
78.7
78.0
74.1
69.1
64.2
59.3
54.4
49.4
44.6
39.7
35.0
30.4
26.0
21.8
17.9
14.2
10.9
8.1
6.0
74.6
74.0
70.1
65.2
60.2
55.4
50.7
46.0
41.3
36.7
32.2
27.8
23.5
19.5
15.9
12.6
9.7
7.3
5.5
79.6
78.9
75.0
70.0
65.1
60.2
55.3
50.4
45.5
40.7
36.0
31.4
26.9
22.7
18.6
14.9
11.5
8.6
6.3
1 Expectation of life is the average number of years left to a person of an exact age who is subject to the current mortality probabilities from birth.
Source: GROS
A13
Cancer registration trends1,2
Lanarkshire residents by sex, age group and year: 1995-2004
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Males
<65 years
65+ years
All ages
489
884
1373
574
1012
1586
521
993
1514
604
967
1571
545
984
1529
527
1023
1550
478
1034
1512
608
1044
1652
633
1016
1649
585
1064
1649
Females
<65 years
65+ years
All ages
554
854
1408
644
952
1596
705
1036
1741
657
1007
1664
688
1000
1688
700
965
1665
694
907
1601
696
984
1680
669
986
1655
677
1127
1804
Both sexes
<65 years
65+ years
All ages
1043
1738
2781
1218
1964
3182
1226
2029
3255
1261
1974
3235
1233
1984
3217
1227
1988
3215
1172
1941
3113
1304
2028
3332
1302
2002
3304
1262
2191
3453
Males
<65 years
65+ years
All ages
89.1
90.9
90.2
97.5
96.1
96.6
92.4
96.3
94.9
107.1
94.6
99.0
98.6
95.6
96.6
94.6
99.2
97.6
84.7
98.3
93.6
103.9
94.5
97.7
107.4
90.0
96.0
97.6
91.2
93.3
Females
<65 years
65+ years
All ages
85.9
92.5
89.8
95.0
95.3
95.2
101.2
104.9
103.4
98.1
102.8
100.9
101.2
101.0
101.1
100.5
96.3
98.0
101.3
89.8
94.4
98.0
96.1
96.9
94.9
92.7
93.6
93.0
102.6
98.8
Both sexes
<65 years
65+ years
All ages
87.4
91.7
90.0
96.2
95.7
95.9
97.3
100.5
99.3
102.2
98.6
100.0
100.0
98.3
98.9
97.9
97.8
97.8
93.8
94.1
94.0
100.6
95.3
97.3
100.6
91.3
94.8
95.1
96.7
96.1
Number
Standardised Incidence Ratio
3
1 Cancer registration is a dynamic process. The figures presented here may therefore differ from previously published information.
2 Non-melanoma skin cancer registrations are included.
3 Scotland=100.
Source: SMR6
A14
Cancer registrations1
by sex, age group and locality/CHP: 2004
CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
Lanarkshire
North
South
Number
Males
<65 years
65+ years
All ages
59
94
153
49
82
131
52
83
135
73
107
180
46
83
129
53
117
170
54
115
169
88
167
255
111
216
327
332
566
898
253
498
751
585
1064
1649
Females
<65 years
65+ years
All ages
67
97
164
54
84
138
50
80
130
65
101
166
45
94
139
54
111
165
82
122
204
126
178
304
134
260
394
335
567
902
342
560
902
677
1127
1804
Both sexes
<65 years
65+ years
All ages
126
191
317
103
166
269
102
163
265
138
208
346
91
177
268
107
228
335
136
237
373
214
345
559
245
476
721
667
1133
1800
595
1058
1653
1262
2191
3453
Standardised Incidence Ratio
2
Males
<65 years
65+ years
All ages
98.7
90.0
93.2
95.1
93.0
93.8
108.8
91.8
97.7
103.8
95.7
98.8
114.6
95.1
101.2
91.3
95.9
94.5
79.2
83.6
82.1
97.2
87.5
90.6
93.3
98.5
96.7
101.3
93.7
96.4
91.1
90.9
91.0
96.6
92.4
93.8
Females
<65 years
65+ years
All ages
95.0
95.8
95.5
85.5
105.6
96.7
87.8
90.3
89.3
75.1
100.0
88.5
93.8
110.4
104.4
79.0
98.3
91.0
100.0
97.2
98.3
111.7
100.6
104.9
94.1
124.8
112.3
85.1
99.7
93.8
101.4
109.6
106.4
92.6
104.4
99.7
Both sexes
<65 years
65+ years
All ages
96.7
92.9
94.4
89.9
98.9
95.3
97.4
91.0
93.4
87.9
97.7
93.6
103.3
102.7
102.9
84.7
97.1
92.7
90.6
90.1
90.3
105.2
93.8
97.9
93.7
111.3
104.6
92.5
96.6
95.0
96.8
99.9
98.8
94.5
98.2
96.8
1 Non-melanoma skin cancer registrations are included.
2 Scotland=100.
Source: SMR6
A15
Cancer registrations1
Lanarkshire residents by year and site: 2000-2004; by sex, age group and site: 2004
Trachea,
Female
Large
bronchus
breast
bowel
Prostate
Bladder
Stomach
Cervix
and lung
Number
2000
520
377
321
183
72
97
38
2001
478
379
295
177
84
105
35
2002
517
370
319
170
114
86
40
2003
498
401
334
153
127
78
20
2004
532
423
355
235
113
106
26
2004
Standardised Incidence Ratio2
Males
<65 years
126.3
x
117.0
98.8
163.5
134.8
x
65+ years
104.8
x
87.6
87.4
124.3
118.9
x
All ages
111.0
x
96.8
90.4
133.7
123.0
x
Females
<65 years
108.1
90.3
102.6
x
158.8
65.6
81.8
65+ years
114.5
118.4
100.8
x
132.1
142.7
93.7
All ages
112.7
101.8
101.3
x
138.2
128.3
85.1
Both sexes
<65 years
117.9
90.3
110.9
98.8
162.0
113.1
81.8
65+ years
109.3
118.4
93.9
87.4
126.9
128.6
93.7
All ages
111.8
101.8
98.9
90.4
135.2
125.1
85.1
1 Cancer registration is a dynamic process. The figures presented here may therefore differ from previously published information.
2 Scotland=100.
x Not applicable.
Source: SMR6
A16
Cancer registrations1
by locality/CHP and site: 2002-2004
CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
Lanarkshire
North
South
Number
Lung
2002
2003
2004
43
51
44
55
44
51
48
53
41
47
59
56
39
38
45
57
57
64
58
45
60
83
62
80
87
89
91
289
302
301
228
196
231
517
498
532
Female breast
2002
2003
2004
28
46
34
35
17
26
17
39
22
34
70
31
49
24
26
47
28
25
61
62
42
45
52
95
54
63
122
210
224
164
160
177
259
370
401
423
Large bowel
2002
2003
2004
21
28
34
19
21
25
21
27
34
29
37
39
34
18
27
35
33
44
32
40
36
58
57
48
70
73
68
159
164
203
160
170
152
319
334
355
101.0
105.0
103.8
139.1
133.7
135.3
121.1
123.9
123.2
109.4
116.2
114.0
124.5
112.2
115.3
111.5
123.3
120.3
106.6
99.3
101.3
117.1
94.3
100.3
104.0
96.5
98.7
116.4
118.8
118.2
108.9
96.4
99.9
113.0
108.4
109.7
Female breast
<65 years
65+ years
All ages
88.5
98.6
92.5
75.3
83.0
78.2
87.5
69.6
79.8
107.5
92.4
102.3
111.5
121.1
115.9
77.8
88.3
82.4
137.1
99.4
121.7
100.9
101.7
101.2
86.3
126.0
102.2
91.3
91.9
91.6
103.5
111.2
106.6
96.9
100.8
98.5
Large bowel
<65 years
65+ years
All ages
79.7
83.9
82.6
73.9
78.9
77.2
84.2
98.8
94.6
96.1
99.2
98.1
135.7
85.2
98.7
117.8
94.6
101.0
84.1
90.3
88.4
78.1
105.5
97.6
137.9
88.0
103.4
96.7
90.5
92.4
105.2
94.6
97.7
100.6
92.4
94.9
Standardised Incidence Ratio (2002-2004) 2,3
Lung
<65 years
65+ years
All ages
1 Cancer registration is a dynamic process. The figures presented here may therefore differ from previously published information.
2 Scotland=100.
3 Standardised rates for three years used because of small numbers.
Source: SMR6
A17
Notifications of infectious diseases1
by year: 2002 to 2006
Lanarkshire residents
Scotland
Number
Notifiable diseases3
All notifiable diseases
Bacillary dysentery
Chickenpox
Rate2
2002
2003
2004
2005
2006
2006
2006
4094
3397
3460
2750
3052
546.8
566.1
0
6
3
4
7
1.3
2.1
2766
2211
1727
1466
1567
280.8
331.7
Cholera
0
0
0
1
0
0.0
0.1
Erysipelas
Food poisoning4
4
3
1
1
2
0.4
0.5
136.5
919
862
785
677
734
131.5
Legionellosis
3
5
1
1
5
0.9
0.7
Lyme disease
1
0
0
0
0
0.0
2.5
Malaria
0
1
1
0
1
0.2
0.4
Measles
78
48
69
41
47
8.4
5.1
Meningococcal infection
31
22
18
22
18
3.2
2.7
Mumps
18
23
620
332
476
85.3
55.1
2.9
Rubella
71
30
47
23
25
4.5
Scarlet fever
32
43
27
31
31
5.6
5.3
Viral hepatitis
135
123
129
145
128
22.9
19.2
36
20
32
6
11
2.0
1.2
Respiratory TB
30
27
24
12
37
6.6
4.6
Non-respiratory TB
12
7
10
7
19
3.4
2.2
Whooping cough
Tuberculosis
Rate2
1 Figures for 2006 are provisional.
2 Rate per 100,000 population.
3 There were no notifications in Lanarkshire of the following diseases in the period shown: anthrax, diphtheria,
leptospirosis, paratyphoid fever, plague, poliomyelitis, puerperal fever, rabies, relapsing fever, smallpox,
tetanus, toxoplasmosis, typhoid fever, typhus fever and viral haemorrhagic fevers.
4 Food poisoning includes campylobacter, E coli O157, salmonella and other foodborne diseases.
Sources: ISD(D)2
A18
Sexually transmitted infections - diagnoses recorded at Scottish genito-urinary medicine clinics
by year: 2004 to 2006
Lanarkshire residents
No. of diagnoses1
2004
2005
Scotland
Rate2
2006
Rate2
2004
2005
2006
2004
2005
2006
Males
Chlamydia
Genital warts, first episode
NSGI (non-chlamydial)
Gonorrhoea
Genital herpes, first episode
Infectious syphillis
HIV infection, newly diagnosed
Other STI (including recurrence)
213
317
130
32
20
13
4
183
286
323
117
45
23
13
3
259
320
387
128
93
38
18
6
262
79.8
118.7
48.7
12.0
7.5
4.9
1.5
68.5
106.9
120.7
43.7
16.8
8.6
4.9
1.1
96.8
119.3
144.3
47.7
34.7
14.2
6.7
2.2
97.7
151.4
138.6
72.8
24.8
21.4
7.5
3.2
125.8
167.4
140.6
70.8
26.4
20.6
7.2
3.8
136.0
177.7
150.6
67.6
29.2
23.8
9.5
2.8
148.3
Females
Chlamydia
Genital warts, first episode
NSGI (non-chlamydial)
Gonorrhoea
Genital herpes, first episode
Infectious syphillis
HIV infection, newly diagnosed
Other STI (including recurrence)
161
243
21
11
32
0
2
138
225
274
18
17
40
2
1
155
258
330
28
35
50
4
1
161
55.7
84.1
7.3
3.8
11.1
0.0
0.7
47.7
77.7
94.6
6.2
5.9
13.8
0.7
0.3
53.5
89.0
113.8
9.7
12.1
17.2
1.4
0.3
55.5
128.6
109.3
12.2
5.9
28.8
0.2
1.2
79.2
150.9
113.6
10.3
7.0
31.3
0.4
0.6
78.5
167.8
119.8
9.1
6.6
30.3
0.5
0.7
89.2
1 The number of separate diagnoses recorded. More than one diagnosis can be recorded for a single patient episode.
2 Rate per 100,000 population.
Source: STI Surveillance System (STISS)
A19
Immunisation uptake rates
by locality/CHP - children born in 2002-2004
CHP
Locality
Diphtheria
Tetanus
Pertussis
Polio
Hib
1
2
MMR
Lanarkshire
Scotland
98.8
98.3
97.6
98.3
98.2
97.4
98.0
98.4
98.3
97.9
98.7
98.3
98.8
98.3
97.6
98.4
98.1
98.3
98.3
98.2
97.5
98.1
98.5
98.6
98.0
98.4
98.3
97.9
97.2
98.1
98.5
98.5
98.2
98.4
98.1
97.3
98.4
98.5
98.3
97.9
98.0
98.2
97.9
97.2
95.4
98.5
98.1
98.5
98.4
98.0
98.3
98.3
97.8
98.4
97.8
97.3
98.4
99.0
98.7
98.3
98.8
98.3
97.6
98.0
98.1
98.8
98.7
98.5
98.1
98.3
98.4
98.2
97.5
98.8
97.7
95.4
98.5
98.0
98.5
98.7
98.0
98.4
98.3
97.9
98.9
98.5
97.9
97.8
97.5
98.2
98.3
98.1
98.2
98.2
98.0
96.9
98.0
97.5
98.0
98.1
98.5
98.5
98.3
98.1
98.1
98.3
97.9
96.9
99.2
98.0
99.1
97.7
95.0
98.9
98.2
98.5
98.4
98.1
98.4
98.2
97.6
2004
91.5
93.3
90.4
90.9
92.3
93.3
89.6
91.6
92.4
91.9
91.5
88.1
88.3
2005
91.0
94.3
87.7
92.7
94.9
95.2
90.8
91.9
90.8
92.5
91.2
89.2
89.9
2006
94.6
94.2
91.3
93.8
91.7
94.5
92.5
92.3
93.0
93.5
92.7
90.8
92.1
Year of
birth
Immunised
by end year
2002
2003
Airdrie
Bellshill
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
North
South
2004
99.2
98.9
98.5
2005
98.7
98.9
97.5
98.4
97.8
97.3
98.4
99.0
98.7
98.3
98.0
98.1
99.1
98.7
98.4
98.1
98.4
2004
2006
99.0
98.6
98.6
97.7
95.4
98.5
98.1
98.5
98.6
2002
2004
99.2
98.9
98.5
98.4
97.8
97.3
98.4
99.0
2003
2005
98.7
98.4
97.5
98.0
98.1
99.1
98.7
2004
2006
99.0
98.6
98.6
97.7
95.4
98.5
2002
2004
99.1
98.9
98.5
98.2
97.8
2003
2005
98.5
98.4
96.9
97.6
98.1
2004
2006
99.0
98.6
98.6
97.7
2002
2004
99.2
98.9
98.5
2003
2005
99.0
98.4
97.3
2004
2006
99.0
98.0
2002
2004
99.1
2003
2005
98.5
2004
2006
2002
2003
2004
1 Haemophilus influenzae b.
2 Combined measles, mumps and rubella.
Coatbridge Cumbernauld
and Kilsyth
Sources: SIRS; ISD(S)13
A20
NHS hospital activity 1,2
by specialty: year ending 31 March 2006
Specialty
New outpatient attendances
Lanarkshire residents
All specialties
Day case discharges
Scotland
Lanarkshire residents
Bed days 3
Inpatient discharges
Scotland
Lanarkshire residents
Scotland
No.
Rate4
Rate4
No.
Rate4
Rate4
No.
Rate4
Rate4
Lanarkshire
residents
323281
57921.2
55778.0
56500
10122.9
8217.6
122423
21934.1
19691.3
1041810
Acute surgical
Cardiothoracic surgery
Ear, nose and throat
General surgery
Gynaecology
Ophthalmology
Orthopaedics
Plastic surgery
Urology
91911
714
12557
20007
12589
12459
22747
2791
6298
16467.4
127.9
2249.8
3584.6
2255.5
2232.2
4075.5
500.1
1128.4
16085.9
73.2
2194.2
3425.9
2063.2
2353.9
3797.2
622.6
1103.2
23668
6
1268
9516
2896
2911
1582
746
4082
4240.5
1.1
227.2
1705.0
518.9
521.6
283.4
133.7
731.4
3948.6
0.2
188.5
1343.5
516.6
594.7
372.3
184.0
583.2
41142
1857
3187
17668
3211
486
7420
1178
4259
7371.3
332.7
571.0
3165.5
575.3
87.1
1329.4
211.1
763.1
7223.5
236.1
495.1
2966.0
587.7
159.5
1443.0
248.6
628.7
187618
9773
6400
80773
8677
975
51061
3572
15839
Acute medical
Cardiology
Dermatology
Endocrinology and diabetes
Gastroenterology
General medicine
Haematology
Medical oncology
Medical paediatrics
Neurology
Respiratory medicine
Rheumatology
38837
4735
11811
2178
3332
2990
1427
888
2367
2097
3019
2039
6958.3
848.4
2116.1
390.2
597.0
535.7
255.7
159.1
424.1
375.7
540.9
365.3
7581.6
789.9
2000.7
362.2
674.4
1111.3
241.7
83.4
599.3
572.2
441.0
364.3
22919
1858
3018
27
652
6284
4794
4350
112
159
470
1106
4106.3
332.9
540.7
4.8
116.8
1125.9
858.9
779.4
20.1
28.5
84.2
198.2
2900.5
214.9
66.6
15.9
603.5
432.6
764.7
446.8
80.2
44.0
80.3
98.1
53811
5548
312
47
93
37197
898
435
6461
416
437
285
9641.1
994.0
55.9
8.4
16.7
6664.5
160.9
77.9
1157.6
74.5
78.3
51.1
7880.0
630.9
41.7
5.3
97.8
5187.1
172.8
116.7
874.5
91.6
313.1
38.2
198106
15352
4989
265
589
136178
7956
1843
7634
2425
2035
2132
9402
1684.5
1788.5
1463
262.1
268.3
999
179.0
162.1
1798
61
10.9
48.1
0
0.0
16.2
716
128.3
382.4
19222
6508
1166.0
1061.2
6051
1084.1
577.5
12859
2303.9
1772.2
21025
0
0.0
0.0
0
0.0
0.0
1099
196.9
148.4
7581
Geriatrics
Geriatric medicine
Geriatric long stay
1466
1466
0
262.7
262.7
0.0
279.6
279.6
0.0
25
25
0
4.5
4.5
0.0
1.3
1.3
0.0
7131
6749
382
1277.6
1209.2
68.4
1066.2
967.3
98.9
200386
122430
77956
Psychiatric 6
General psychiatry
Psychiatry of old age
2704
1546
547
484.5
277.0
98.0
1054.9
695.7
217.9
0
0
0
0.0
0.0
0.0
0.0
0.0
0.0
2862
2099
698
512.8
376.1
125.1
520.5
393.0
119.0
361132
150382
204095
Dental
GP other than obstetrics
Obstetrics 5
Special care baby unit
Learning disabilities 6
Other specialties
Accident and emergency
Clinical oncology
47
8.4
8.7
0
0.0
0.0
32
5.7
40.6
36473
172345
171136
487
30878.5
30661.9
87.3
27869.5
27457.2
213.5
2374
0
2051
425.3
0.0
367.5
505.2
0.0
430.5
1772
598
1059
317.5
107.1
189.7
495.4
213.8
226.4
8469
850
5953
1 Figures are provisional. Comparison of rates between Lanarkshire and Scotland should therefore be made with caution.
2 Shows separately specialties with at least 1,000 inpatient discharges, day cases or new outpatient attendances, or at least 10,000 bed days. Totals include all specialties.
3 Bed days for the year are derived from length of stay on discharge. This can vary widely from year to year as, for example, the discharge or death of patients who have
been resident for many years can greatly inflate the overall number of bed days while patients resident at the end of the year are excluded.
4 Rate per 100,000 population.
5 Includes GP obstetrics.
6 Psychiatric and learning disabilities new outpatient attendances are for the year ending 31 March 2002; discharges and bed days are for the year ending 31 March 2005.
Sources: SMR00;
SMR01; SMR02;
SMR04; SBR;
SMR50; ISD(S)1
A21
Inpatient and day case discharges (non-psychiatric, non-obstetric hospitals)1
Lanarkshire residents by main diagnosis, sex and age group: year ending 31 March 2006
Males
Under 5
All diagnoses
5-14 15-24
25-44
Females
45-64
65-74
75 &
over
All Under 5
ages
3772 3473 3484 11607 22441 15325 13423 73525
5-14 15-24
25-44
Both sexes
45-64
65-74
All
ages
All ages
2700 2694 4395 14446 22387 14674 19406 80702
154227
Certain infectious and parasitic diseases
331
89
63
127
166
107
98
981
263
84
78
114
123
92
Malignant neoplasms
164
192
134
531
3138
2755
1586
8500
71
34
95
1118
4395
2678
75 &
over
966
1947
1808 10199
212
18699
In situ or benign neoplasms etc
17
18
20
200
552
462
355
1624
14
35
59
347
466
298
340
1559
3183
Diseases of the blood and blood forming organs
58
44
51
156
457
333
281
1380
42
12
65
207
391
340
501
1558
2938
Endocrine, nutritional and metabolic diseases
21
85
152
401
733
253
106
1751
25
68
113
272
341
225
264
1308
3059
0
14
18
231
227
67
88
645
0
15
13
75
98
46
102
349
994
Diseases of the nervous system
60
103
71
251
399
239
181
1304
50
57
73
384
424
190
218
1396
2700
Diseases of the eye and adnexa
36
33
34
102
309
389
464
1367
34
39
23
84
336
485
847
1848
3215
Diseases of the ear and mastoid process
75
93
20
68
73
26
9
364
46
74
21
69
65
35
20
330
694
Heart disease
9
4
37
529
2604
2069
1740
6992
3
7
21
180
1357
1489
2242
5299
12291
Cerebrovascular disease
4
0
7
63
309
330
409
1122
0
1
4
48
228
291
739
1311
2433
Other diseases of the circulatory system
4
34
41
305
863
562
593
2402
1
22
38
459
709
544
979
2752
5154
Diseases of the respiratory system
957
456
264
630
1129
1115
1403
5954
630
410
393
670
1230
1089
1877
6299
12253
Diseases of the digestive system
1458 10935
2108 11724
22659
Mental and behavioural disorders
494
691
534
2270
3604
1884
375
674
616
2314
3636
2001
Diseases of the skin and subcutaneous tissue
83
59
184
541
653
227
274
2021
92
92
148
510
521
330
554
2247
4268
Diseases of the musculoskeletal system
36
75
137
594
993
598
390
2823
28
96
137
704
1417
860
789
4031
6854
Diseases of the urinary system
38
36
38
317
554
362
369
1714
18
23
77
318
386
256
290
1368
3082
Diseases of the genital organs and breast
48
135
140
241
304
208
178
1254
7
22
245
1488
960
216
130
3068
4322
Pregnancy, childbirth and the puerperium
0
0
0
0
0
0
0
0
0
4
792
896
5
0
0
1697
1697
Certain conditions of the perinatal period
43
9
1
0
0
0
0
53
10
0
0
0
0
0
0
10
63
Congenital anomalies
254
160
42
56
22
5
3
542
160
64
46
57
22
7
4
360
902
Symptoms, signs and abnormal findings
656
463
345
1717
3186
2042
2204 10613
514
407
805
2266
3231
1859
3102 12184
22797
Injuries and poisonings
236
526 1021
1768
1171
555
659
5936
188
335
373
858
928
721
1753
5156
11092
Factors influencing health status/contact with NHS
148
154
509
995
737
575
3248
129
119
160
1008
1118
622
527
3683
6931
1 Provisional.
130
Source: SMR01
A22
New outpatient attendances, day case and inpatient discharges and inpatient bed days
Lanarkshire residents by sex and age group: year ending 31 March 2006
1
Males
Under 5
5-14
15-24
25-44
Females
45-64
65-74
75 &
All Under 5
over
ages
5-14
15-24
25-44
Both sexes
45-64
65-74
75 &
All
over
ages
All ages
New outpatient attendances
Non-obstetric, non-psychiatric2
2758
4808
5623
15178
17974
8364
5554
60259
2103
4305
7576
25122
8739
82626
142885
42
300
181
432
235
86
121
1397
15
167
165
416
203
97
291
1354
2751
0
0
0
1
0
0
0
1
0
6
2000
4500
1
0
0
6507
6508
2800
5108
5804
15611
18209
8450
5675
61657
2118
4478
9741
30038
24658
10424
9030
90487
152144
617
1017
905
3546
7732
4744
2930
21491
383
795
1628
6033
9291
5206
4012
27348
48839
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1587
4435
0
0
0
6023
6023
617
1017
905
3546
7732
4744
2930
21491
383
796
3215
10468
9291
5206
4012
33371
54862
3183
2458
2553
7956
10497
51607
2365
1913
2800
8443
12945
9435
15678
53579
105186
0
5
165
679
352
127
152
1480
0
0
111
513
359
170
261
1414
2894
643
0
0
0
0
0
0
643
446
16
4242
8550
7
0
0
13261
13904
3826
2463
2718
8635
14847
10592
10649
53730
2811
1929
7153
17506
13311
9605
15939
68254
121984
Non-obstetric, non-psychiatric
Psychiatric and learning disabilities4
5687
4642
6104
23492
62374 60907
80161 243367
4522
3407
5888
23818
56958 58071
141606 294270
537637
0
250
5497
42683 101027 28956
72734 251147
0
0
1977
13534
25831 25779
79337 146458
397605
Obstetrics5
4369
0
0
4369
3188
8
5981
14957
8
89863 152895 498883
7710
3415 13846
52309
82797
Psychiatric and learning disabilities3
Obstetrics5
Total
24454 10327
Day case discharges
Non-obstetric, non-psychiatric
Psychiatric and learning disabilities4
Obstetrics5
Total
Inpatient discharges
Non-obstetric, non-psychiatric
Psychiatric and learning disabilities4
Obstetrics5
Total
14495 10465
Inpatient bed days6
Total
1
2
3
4
5
6
10056
4892 11601
0
0
66175 163401
0
0
Provisional. Excludes geriatric long stay.
Excludes accident and emergency attendances.
Outpatient figures for psychiatric and learning disabilities are for the year ending 31 March 2002.
Inpatient and day case figures for psychiatric and learning disabilities are for the year ending 31 March 2005.
Figures for obstetrics include patients treated in GP obstetrics and special care baby units.
Bed days for the year are derived from length of stay on discharge and could be understated/overstated in some specialities.
0
0
24142
28511
83850 220943 464870
963753
Sources: SMR00; SMR01; SMR02; SMR04; SBR
A23a
New outpatient attendances, day case and inpatient discharges and inpatient bed days1
Lanarkshire residents by locality/CHP: year ending 31 March 2006
CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
North
South
Lanarkshire
Scotland
1340418
Number
New outpatient attendances
Non-obstetric, non-psychiatric 2
13552
12655
11590
17650
9672
13697
14232
22338
27499
78816
64069
142885
Psychiatric and learning disabilities 3
182
373
231
206
196
522
330
284
427
1710
1041
2751
54422
Obstetrics 5
760
583
634
889
510
548
572
955
1057
3924
2584
6508
54303
14494
13611
12455
18745
10378
14767
15134
23577
28983
84450
67694
152144
1449143
5163
4593
4323
5238
3628
5529
5376
6271
8718
28474
20365
48839
376313
0
0
0
0
0
0
0
0
0
0
0
0
0
546
432
438
485
383
745
767
990
1237
3029
2994
6023
29549
5709
5025
4761
5723
4011
6274
6143
7261
9955
31503
23359
54862
405862
11490
10165
10017
10583
7855
11177
10203
14169
19527
61287
43899
105186
875532
328
216
318
276
190
313
298
371
584
1641
1253
2894
28713
1323
1464
1215
1077
1249
1651
1303
1768
2854
7979
5925
13904
98261
13141
11845
11550
11936
9294
13141
11804
16308
22965
70907
51077
121984
1002506
53249
48982
48063
53272
39835
57734
62308
73958
100236
301135
236502
537637
5081996
27452
56761
22172
18779
18046
126877
53924
24831
48763
270087
127518
397605
2844451
2802
2690
2509
3329
2200
2906
2450
3912
5713
16436
12075
28511
258312
83503
108433
72744
75380
60081
187517
118682
102701
154712
587658
376095
963753
8184759
Total
Day case discharges
Non-obstetric, non-psychiatric
Psychiatric and learning disabilities 4
Obstetrics 5
Total
Inpatient discharges
Non-obstetric, non-psychiatric
Psychiatric and learning disabilities 4
Obstetrics 5
Total
Inpatient bed days6
Non-obstetric, non-psychiatric
Psychiatric and learning disabilities 4
Obstetrics 5
Total
1
2
3
4
5
6
Provisional. Excludes geriatric long stay.
Excludes accident and emergency attendances.
Outpatient figures for psychiatric and learning disabilities are for the year ending 31 March 2002.
Inpatient and day case figures for psychiatric and learning disabilities are for the year ending 31 March 2005.
Figures for obstetrics include patients treated in GP obstetrics and special care baby units.
Bed days for the year are derived from length of stay on discharge and could be understated/overstated in some specialities.
Sources: SMR00; SMR01; SMR02; SMR04; SBR
A23b
New outpatient attendances, day case and inpatient discharges and inpatient bed days1
Lanarkshire residents by locality/CHP: year ending 31 March 2006
CHP
Locality
Airdrie
Bellshill
Coatbridge Cumbernauld
and Kilsyth
Motherwell
Wishaw
Clydesdale
East
Kilbride
Hamilton
North
South
Lanarkshire
Scotland
24834.5
Age/sex standardised rates per 100,000 population
New outpatient attendances
Non-obstetric, non-psychiatric 2
23956.2
25305.6
23821.9
26310.7
23747.3
24281.1
22599.8
24446.8
24439.2
24676.0
24004.2
24371.1
334.7
734.9
468.2
306.0
493.8
909.8
545.7
336.7
394.7
535.9
412.0
479.8
1013.2
1466.8
1258.5
1343.8
1462.9
1389.8
1120.3
1176.5
1272.1
1057.4
1346.7
1154.2
1264.2
1136.9
25757.7
27299.0
25633.9
28079.7
25630.8
26311.2
24322.0
26055.5
25891.3
26558.6
25570.3
26115.1
26984.6
Non-obstetric, non-psychiatric
Psychiatric and learning disabilities 4
8689.2
8996.0
8237.0
7568.3
8683.1
9318.4
7899.8
6576.2
7385.6
8523.8
7235.8
7926.4
6640.2
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Obstetrics 5
1056.6
938.9
921.6
788.0
1020.9
1528.1
1557.3
1315.1
1229.6
1036.4
1328.7
1168.3
615.1
Total
9745.8
9934.9
9158.5
8356.3
9703.9
10846.5
9457.2
7891.3
8615.2
9560.2
8564.5
9094.7
7255.3
19362.6
19951.8
19455.1
15356.5
17570.6
18393.6
14699.6
14168.9
16176.5
18206.1
15121.8
16790.5
14819.4
564.6
412.3
624.9
410.1
468.5
539.1
478.0
395.7
504.3
500.0
459.9
482.6
520.7
2620.3
3265.3
2647.1
1803.8
3462.3
3473.9
2722.7
2430.1
2943.8
2807.2
2723.6
2782.5
2124.5
22547.6
23629.5
22727.0
17570.4
21501.4
22406.6
17900.3
16994.7
19624.6
21513.3
18305.2
20055.6
17464.6
82260.0
89875.1
85622.8
73869.1
78286.0
83813.6
75039.0
64311.7
74250.2
81720.2
71079.6
76820.1
72898.0
43585.4
89012.0
45140.1
27154.6
40087.9
213199.4
77511.5
24111.2
39187.5
79569.8
42927.1
61968.8
43493.4
5750.7
6339.9
5818.8
5841.2
6429.3
6604.1
5268.2
5593.8
6147.5
6106.3
5771.3
5979.2
5982.9
131596.2
185227.0
136581.7
106864.9
124803.2
303617.1
157818.6
94016.8
119585.2
167396.2
119778.0
144768.1
122374.3
Psychiatric and learning disabilities 3
Obstetrics 5
Total
Day case discharges
Inpatient discharges
Non-obstetric, non-psychiatric
Psychiatric and learning disabilities 4
Obstetrics 5
Total
Inpatient bed days6
Non-obstetric, non-psychiatric
Psychiatric and learning disabilities 4
Obstetrics 5
Total
1
2
3
4
5
6
Provisional. Excludes geriatric long stay.
Excludes accident and emergency attendances.
Outpatient figures for psychiatric and learning disabilities are for the year ending 31 March 2002.
Inpatient and day case figures for psychiatric and learning disabilities are for the year ending 31 March 2005.
Figures for obstetrics include patients treated in GP obstetrics and special care baby units.
Bed days for the year are derived from length of stay on discharge and could be understated/overstated in some specialities.
Sources: SMR00; SMR01; SMR02; SMR04; SBR
STAFF WITHIN THE DEPARTMENT OF PUBLIC HEALTH
STAFF WITHIN THE DEPARTMENT OF PUBLIC HEALTH
Dr D Moir, Director of Public Health
Dr L Armitage, Consultant in Public Health Medicine
Dr C Clark, Consultant in Public Health Medicine
Dr D Cromie, Consultant in Public Health Medicine
Dr J Darnborough, Consultant in Public Health Medicine
Dr J Logan, Consultant in Public Health Medicine
Dr J Miller, Consultant in Public Health Medicine
Dr B O Suilleabhain, Consultant in Public Health Medicine
Mr E Mallinson, Specialist in Pharmaceutical Public Health
Miss M Taylor, Consultant in Dental Public Health
Dr E Anderson, Specialist Registrar in Public Health Medicine
Dr A Cichowska, Specialist Registrar in Public Health Medicine
Dr J O’Dowd, Specialist Registrar in Public Health Medicine
Dr F Romanes, Specialist Registrar in Public Health Medicine
Dr L Wilson, Specialist Registrar in Public Health Medicine
Mr J Boswell, Health Promotion Strategy Adviser
Mrs R Campbell, Public Health Nutritionist
Mrs J Kerr, Senior Nursing Adviser (Infection Control)
Mr D Roseburgh, Principal Public Health Information Analyst
Mr M Dobson, Librarian
Mr K O’Neill, Lanarkshire Mental Health Needs Assessment Programme Manager
Ms D Keane, Associate Mental Health Needs Assessment Officer (Eating Disorders)
Mr K McAllister, Associate Mental Health Needs Assessment Officer (Older People)
Ms V Kellighan, Lanarkshire Mental Health Needs Assessment Programme Administrator
Mrs E Thomas, Public Health Manager
Miss J Provan, Personal Assistant to Director of Public Health
Mrs L Barr, Personal Secretary
Mrs L Ferguson, Personal Secretary
Mrs C Keachie, Personal Secretary
Mrs H McIntosh, Personal Secretary
Mrs H McLean, Personal Secretary
Mrs L Rodgerson, Personal Secretary
Ms A Coupe, Higher Clerical Officer (Communicable Disease and Environmental Health)
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