Final Draft
NHS Grampian
ANNUAL REPORT OF THE DIRECTOR OF PUBLIC HEALTH
2001 – 2002
CONTENTSPage
Introduction 3
Principles and Priorities 4
A Good Start in Life 7
Teen Transition11
Working Age People17
Communities19
Postscript
Appendix 124
INTRODUCTION
As before this report aims to inform planning for health in Grampian and drive public health activity. Again, I have not deliberately detailed some significant aspects of the work of the Directorate such as communicable diease control or emergency planning. For ease of understanding I have grouped the topics covered in this report in a similar way to current national thinking, that is in terms of “life course groups”. These are infants and children, teenagers, working age people and older people. The health of these groups needs to be considered in terms of their life circumstances, the settings they live in, the priority health issues among them and the interventions that are likely to be of benefit. I have sought to highlight significant or interesting issues relating to health in Grampian in 2001/02.
During the past year, a major outbreak of cryptosporidium infection has highlighted once again the fundamental importance of basic public health measures, in particular the provision of safe drinking water. Similarly the concern about Health Care Acquired Infection has highlighted the importance of basic hygiene measures, including handwashing.
Smoking remains the biggest, avoidable, detrimental factor to the Grampian population's health, streets ahead of everything else. In Grampian in 2001, the estimated number of smoking related deaths was 740, and the number of smoking related hospital admissions of Grampian residents was 4222 in year 2001/02. That means that on average 12 people living in Grampian were admitted to hosipal every day due to smoking and two people died every day from that cause. These figures are a solemn testimony to the effectivness of the tobacco industry’s policies in promoting smoking within the Grampian. NHS Grampian and its partners need to take evidence-based action to counter the tobacco industry’s sales promotion policies, and to help people to stop.
The strategic management of health services for health gain remains a very real challenge with a serious ongoing tension between clinical governance and delivering financial probity.
As in other parts of the UK, Scotland's Census was held on Sunday 29 April 2001. The Census is the most complete source of information about Scotland's people because by law it has to include everyone. It provides accurate and reliable information on the number and characteristics of people in each local area, comparable for all parts of the country. Because of the important uses to which they will be put, it is essential that Census statistics are objective, reliable and impartial. To ensure this, the Census is run by the Registrar General for Scotland. The Registrar General has his own statutory powers and duties and ensures that the statistics produced from the Census are authoritative and politically neutral. As such these statistics are important to public health practitioners for several reasons.
An accurate knowledge of the size and structure of the population at risk of disease is an essential pre-requisite to epidemiology. The social information recorded in the Census is also useful for assessing the deprivation or affluence of areas and their influence on health. It therefore is important information to use in forming policy, making resource distribution decisions and delivering services for particular groups of people.
The census population of Aberdeen City was 212,125, that of Aberdeenshire as 226,871 and Moray as 86,940, a total of 525,936 for Grampian. Demographic change has been very similar to previous years. In 2000/2001an averasge of 15 children were born each day and 14 people died. I hope to be able to rport on furhter, locally relevant analysis of the census dat a inm y next rpeort.
The past year has seen the Directorate and its partners in public health practice embark on a process of radical change to the way in which the public health function is delivered across Grampian. The aim is to achieve signifgicantl;y greater integration between NHS Grampian and the local authrotites in delivering efective interventions in partnership with local communities to achieve ssustained helath improvement. I will describe this in more detail in my next report.
In last year’s report, I highlighted a number of points for action. I review progress on these issues at the relevant point in the report.
The production of this report has, as usual, been a team effort. I wish to thank all members of the Public Health Directorate for their significant efforts over the past year, and also other teams in NHS Grampian, Aberdeen City Council, Aberdeenshire Council and Moray Council without whose help this report would not have been possible.
As ever, I must take responsibility for any errors of omission or commission.
Dr Eric Baijal
Director of Public Health
PRINCIPLES AND PRIORITIES
For NHS Grampian and its local authrotiy partners to continue developing into successful publci health organisations they will need to prvide local leadership in terms of the five levers which the Ottowa Charter for Health highlights. These are Healthy Public Policy, reorientating services, strengthening community action, strengthening individuals and creating healthy environments. The priorites in each of these action areas need to be determined on the baiss of explicit criteria. I am pleased to be ablie to rpeort that NHS Grampian has begun to do just that, using priisation mechanisms to identify the most important cpait devlopments and expensive new drugs for funding.
The criteria used to determine which expensive new drugs should be funded (Appendix 3) have more genreal papblicability and are:
Health benefits: From the information provided about a drug or other intervention, a judgement can be made on the overall health benefits it is likely to offer in the majority of recipients if it were introduced. Factors to consider include evidence of effectiveness, nature and frequency of serious side effects, availability of alternative interventions for the condition.
Number of people benefiting: A judgement can be made about how many people within Grampian are likely to benefit from introduction of the drug or intervention. It is the number of people likely to gain benefit which is important, rather than the overall number of people for whom the drug might be prescribed or on whom an intervention might bne targertted. Not all people who are prescribed the drug or targetted with an intervention will benefit.
Cost effectiveness/value for money: This is the degree to which the drug or intervention represents overall value for money in relation to improving health, and reducing the effects of illness in the total Grampian population. Factors to consider include the overall cost of introduction, including both the actual direct costs plus any indirect costs (such as need for additional investigations, staff to administer the drug or intervention, etc), possible savings which might be associated with the introduction (reduced other drug costs for alternative treatments, reduced hospital admissions, etc), and the nature and extent of health benefits offered.
Effect of equity: Drugs or intervention neede to be assesed in terms of whether their introduction will reduce differences in access within Grampian, will reduce differences in access between Grampian and the rest of Scotland or will increase differences in access to treatment between Grampian and the rest of Scotland.
For ethical decsion making, communites affected by the outcome of any significnat hard choices should be parners in making a decision using such critewria. In my last annual report I recommended that Grampian NHS Board should ensure its decisions on rationing are reached in an open and transparent way that can be understood by local people. While the Board has nmade some progress toweqared this, there is still a distance to go on this issue.
Action Point: NHS Grampian and its partners should use explicit criteria in prioritiing bid for revenue as well as capittal funds.
A GOOD START IN LIFE
Breastfeeding
Breastfeeding is an important factor in giving children a healthy start to their life. In my last Annual Report, I drew attention to the low breastfeeding rates in Grampian. I am pleased to rpeort that a breastfeeding strategy for Grampian was approved early in 2002. This was swiftly followed by the setting up of a strategy implementation group
In line with the Breastfeeding strategy for Grampian, a breastfeeding peer support group has been established in Banff and Buchan. The project is supported by a multi-agency partnership and has been developed in conjunction with mums. Groups are running in Fraserburgh, Turriff, Peterhead, Maud, Banff and a very active Women’s Group has been established in New Pitsligo.
The Banff and Buchan Breastfeeding Coaching Project began within the framework of the Breast Feeding Strategy for Grampian. Some of the results from the baseline audit started in April 2000 are shown in Figure 1 shows breastfeeding rates on the seventh day of life in 2000. It demonstrates the wide variation in breastfeeding rates within Grampian and how unfavourably significant parts of Grampian compare with the rest of Scotland.
The project focuses on the area of Grampian with the lowest breastfeeding rates. It aims to evaluate whether ante- and post-natal untrained peer coaching by actively breastfeeding mothers improves breastfeeding rates and experiences in the Banff and Buchan LHCC area. Workshops and one-to-one coaching started in April 2001 and the research project ends in April 2003. The evaluation is built around the baseline audit, before and after surveys of experiences, qualitative interviews, focus groups, group observations and group activity diaries.
Figure 2 summaries the interim results.
Figure 2:
It shows that untrained breastfeeding peer coaching appears to be effective in increasing breastfeeding rates until 4 months in the study area. These encouraging initial results suggest it may be possible to increase breastfeeding rates at 6 weeks from the current Grampian average of 40% to 45% by 2005 and to 50% by 2010 as I recommended in my last report. However, I remain concerned that NHS Grampian still has not implemented systematic local data collection to monitor infant feeding beyond the seventh day of life. This remains an important action point. I hope to report further on this project in my next annual report.
Other areas currently being addressed include training of all health professionals in breastfeeding and looking at the feasibility of supplying formula milk to beneficiaries from other outlets in the community such as pharmacies and family centres instead of health clinics. Most pharmacy input to the promotion of infant and child health is currently reactive such as the promotion of folic acid supplements pre and post conception. Work is currently ongoing around the role of the pharmacist in the Grampian welfare milk scheme and the promotion of breastfeeding.
Oral and Dental Health
Toothnology is a complete tool-kit for promoting dental and oral health from strategy to implementation. The approach was developed using the expertise of healthcare workers, dentists, local authority education staff and health promotion specialists.
It provides a framework for working towards the achievement of national oral health targets, based on practical experience in the field, and has been independently evaluated. The project aims to reach groups in designated areas who have traditionally been ‘hard to reach’ and specifically targets children under 5.
Toothnology was launched in Grampian in January 1998, and has been widely welcomed by ‘Toothnologists’ of all descriptions: dentists, dental nurses, teachers, parents, carers and others. It includes - children’s activity blueprints; a wide range of colourful promotional materials; teaching resources pack; awareness talks for parents & carers.
Toothnology was awarded first prize at the British Dental Health Foundation Awards 1999, for ‘The Best Education Initiative for a Health Unit’.
Toothnology is currently being updated and new posters and postcards will be produced in 2003. As part of this work oral health policy guidelines for nurseries and playgroups have recently been developed and disseminated. These will be followed up by 4 one-day workshops in November/December 2002 to assist nursery staff in writing their own policies. Further dates for training will be set in early 2003.
In my last report, I recommended that NHS Grampian should actively work with the dental profession to improve the availability of manpower in the local dental services. I am not aware that progress on this issue has been satisfactory and the availability of NHS dentistry remains a matter of concern.
Action Point: NHS Grampian should actively work with the dental profession to improve the availability of manpower in the local dental services.
Immunisation
The past year has seen continued unhelpful debate in the media about MMR. This must have contributed to some extent to the poor uptake of this immunisation in Grampian. Appendix X suggest there might be a reversal of thius trend beginning.
First Aid for under 5’s
This Aberdeen Inner City LHCC (AICC) project initially aims to provide multi agency professionals with the skills to deliver an introductory short course in the community, covering unintentional injury prevention / home safety; basic First Aid; choking and resuscitation. Piloted and evaluated within AICC, with potential to be rolled out further.
Health promoting ‘goody bags’ for 3-7 year olds
This promoting health initiative aims to target the section of the population who attends Accident and Emergency at Royal Aberdeen Children’s Hospital (RACH). There is evidence to show that the highest % of children who attend hospital are from the designated areas within Grampian and therefore may be at a health disadvantage because of this.
Health Promoting Schools
Complementing the New Community School concept NHS Grampian and the three local authorities have developed a health promoting school programme. The programme has identified key messages for each of the nine priority topics, highlighted useful resources for use in the classroom, developed a training programme to support teachers and identified wider whole community activities to support implementation.
Aberdeen City currently has 53 out of 77 schools actively working towards health promoting school status. The interactive health promoting lifestyle programme for primary school pupils “Kids in Condition” supports the promotion of physical activity in the school.
All schools in Moray are now committed to being New Community Schools. The NHS now has two full-time workers in the Health Promoting School/New Community School setting. Milnes and Forres areas are both funded by the Scottish Executive, while the others are seeking such support for the future.
Breakfast clubs
Funding provided by the Scottish Executive to Aberdeenshire Council is going to see funding being allocated for the development of breakfast club provision for those New Community Schools working in areas of deprivation. The focus will be on the expansion of breakfast club provision not only through school premises but also within community settings, working closely with the childcare partnership initiative to assist with such development.
Peterhead New Community School over the last year has worked with about two thirds of its schools to pilot breakfast club provision. Early evaluations from education personnel associated with the project have indicated that they have seen improvements in the behaviour, concentration, social interaction and attendance of those children who have participated in the pilot.
The NHS in Grampian needs to ensure consistent and effective dialogue with the local authorities on the health promoting role of new community schools, including co-ordination and audit of health input and outcomes.
Fresh fruit provision in Fraserburgh Primary Schools
A scheme was proposed whereby pupils would be invited to join a scheme which would entitle them to fruit twice weekly for a school year. Pupils purchased a fruit card at the beginning of each term at a cost of 1 pound. This was presented a break time or in the classroom and ticked to show that they had been given their piece of fruit.
The money raised from the sale of the fruit cards was banked by the school to allow them to continue the scheme once the HIF funding ended. In effect pupils were receiving fruit at 10p per portion which compared favourably with crisps, sweets and biscuits. Tuckshops did not sell crisps or biscuits on fruit days. Uptake ranged from around 50% to 100%. One school which had previously sold 10 portions weekly now has 80 pupils taking fruit twice weekly.
Disruption in the schools has been minimal with classroom assistants or senior pupils taking responsibility for distribution. An underspend has meant that the scheme is to continue for another two terms until Christmas, after which the income banked will be used to support the continuance of the scheme.
TEEN TRANSITION
Within Grampian a number of the New Community School initiatives have developed transition groups/initiatives to assist pupils identified as being at risk in making the transition from their primary education into a secondary setting. It has been observed that some young people having made the transition successfully, drawing on the group support, come back to provide assistance facing the same dilemma.