Health Improvement and Public Health Activity Report 2016-17

Despite a reduction in resources, the Directorate has continued to perform well on a number of national health improvement and public health targets, and has improved performance in some areas. However, because of the nature of the targets and the data being collected, some of the most recent figures are for previous years rather than the 2016-17 period.

1. Life Expectancy Life expectancy is an overarching measure showing how long people can expect to live: however it does not take into account how healthy or independent people are, simply their age at death. Shetland has traditionally a good life expectancy and a level of health amongst the best in Scotland, reflecting the high quality of life in Shetland, as well as the quality of local services. However the most recent life expectancies for men and women have fallen compared to the previous year. For men the life expectancy at birth using the three year rolling average for 2013-15 was 77.6 years, down from 78; and for women it was 81.9 years, down from 82.45. Neither have reached the ambitious local targets of 79.2 and 86.2 years. Life expectancy is still better than many other parts of Scotland but there are health inequalities within Shetland that are often hidden and not reflected in available data. This slight reduction reflects a pattern recently seen across the UK and in Europe which is being further researched.

2. Healthy Life Expectancy Healthy Life Expectancy (HLE) is an estimate of how long the average person might be expected to live in a 'healthy' state. It is a useful measure in that it provides a single summary measure of a population's health, which takes account of the population's health status and death rates at different ages. HLE can be used to look at health trends over time and to compare the health of different populations and population sub-groups. It is useful in resource allocation, planning of health and other services, and evaluation of health outcomes.

The table below shows the Healthy Life Expectancy for men and women in Shetland, as at 2015. Men in Shetland, Orkney, the Western Isles and Grampian have some of the shortest periods of ‘not in healthy life’, while Orkney, Borders and Grampian had the shortest periods among women.

Life Expectancy

Health Life Expectancy

Expected period in 'not healthy' health

Men 78.1 66.6 11.5 years Women 81.9 68.4 13.5 years

http://www.scotpho.org.uk/population-dynamics/healthy-life-expectancy/data/nhs-boards/

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The healthy life expectancy calculation is based on self reported levels of health and wellbeing. There are a number of ways that we can influence the length of time spent in healthy life expectancy; by working together to create conditions in which good health can flourish (e.g. Creating healthy environment and good quality housing), by preventing those diseases and conditions that can be prevented, and by increasing people’s levels of independence and capacity to look after themselves.

3. Healthy lifestyles Small changes to our lifestyle can have a big impact on our health and wellbeing. As part of the Public Health effort we deliver a range of programmes to support lifestyle behaviour change: whether this is losing weight, giving up smoking, getting more active or improving wellbeing. Our approach has three components:

• Raising awareness of the need to change and the support that is available

• Creating environments where the healthy choice is the easier choice, and

• Identifying, advising and supporting those most at risk.

This report provides an update on our activity which contributes to national programmes or targets.

Smoking: According to data collected this year from GP practices, the percentage of people in Shetland who smoke is 15.8%. This is likely to be an overestimate because we know that smoking status is not always recorded for non-smokers, or updated for those who have stopped smoking.

There has been a downward trend in smoking prevalence since we first started using this system to gather the information in 2012, when the GP data showed that 24.4% of people in Shetland smoked.

Key messages

Stopping smoking can make a huge difference to your life and to your health, with the benefits starting as soon as you stop. Stopping smoking improves your health and the health of people close to you. We know that quitting smoking isn't always easy, but people who receive help and support from their local stop smoking service are much more likely to successfully quit and are four times more likely to stay smoke-free.

Raising awareness

There is now agreement that ‘vaping’ e-cigarettes carries less risk than smoking tobacco. Although the long-term health effects of vaping is not known, any smoker switching entirely to e-cigarettes will be taking in far fewer cancer-causing chemicals. Public Health experts encourage anyone who smokes to find a way of quitting that works for them, which could include using e-cigarettes, and to make use of the free NHS stop-smoking support available to help.

Creating healthy environments

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Another strand to tobacco control is creating smoke free environments to protect people from second hand smoke and help smokers to reduce smoking or quit. We facilitated a consultation on the potential introduction of a smoking ban 15 meters from hospital grounds. Some people need more help in changing their behaviour. We have worked with Pharmacy staff to increase their confidence in delivering stop smoking support, and promoted the ban on smoking in cars which are carrying children.

Identifying and supporting those at risk

This year we met and exceeded the Government set target of 43 successful smoking cessation quits at 12 weeks, in the 60% most deprived areas of Shetland. We were one of only three board areas in Scotland which met the target. The target set by the Scottish Government was an increase of 30% on the previous year; this has represented an enormous challenge to the Health Improvement Team (which delivers most of the smoking cessation interventions in Shetland), given the reduction in staffing levels and the fact that the people who are now smoking are those that find it the hardest to give up. In total, there were 80 quits when measured at three months. The pharmacy team in Shetland are developing their skills, with one the highest quit rate in the country, although we would like to see an increase in the numbers of people using this accessible service.

Giving up smoking prior to pregnancy remains an important way of to increase the chances of having a healthy baby. Thirty one pregnant women were recorded as smoking this year, and although there were 6 attempts to quit, only one was successful when measured at 12 weeks.

Quit attempts

4-week quits 12-week quits

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Alcohol:

Key messages

No-one can say that drinking alcohol is absolutely safe, but by sticking within these guidelines, you can lower your risk of harming your health:

• Men and women are advised not to regularly drink more than 14 units a week. • Spread your drinking over three days or more if you drink as much as 14 units a

week.

Everyone should have at least a couple of alcohol-free days (days when they don't drink at all) each week.

Raising awareness

Our local programme of culture change on alcohol use, known as “Drink Better”, is being informed by the result of successful local engagement with the Shetland public, including focus groups, which have given a fascinating insight into the relationships in Shetland between alcohol and culture, family functioning, and mental health.

Creating healthy environments

From a healthy public policy perspective, we have undertaken a lot of work this year with the Licensing Board and Forum and Community Planning Partnership on understanding the relationship between accessibility and affordability of alcohol and alcohol misuse, and potential solutions.

Identifying those at risk

Alcohol Brief Interventions are one of the most effective ways of identifying people who are drinking at harmful levels and offering them support.

We missed the target for delivering Alcohol Brief Interventions, having met it in previous years. In 2016-17 220 ABIs were undertaken against a target of 261. This partially represents the reduction in resources in the Health Improvement Team, who had been delivering the majority of the interventions with very few being done in Primary Care. A change in the IT system in Accident and Emergency also meant that only the interventions completed by A&E staff in the last month of the year are included in this figure. A solution has now been found, which means that these figures are being captured, and we will certainly meet and exceed the target this year.

The latest national data for alcohol-related admissions to hospital shows that the rate increased in Shetland during 2015-16. It was 671.3/100,000 (155 individual admissions) against a rate of 580.3 / 100,000 (136 individual admissions) last year. Some of the increase in this number is due to planned alcohol detoxifications in the Gilbert Bain Hospital; unfortunately, there are also people who go through repeat detoxifications.

Training in Alcohol Brief Interventions is planned for all Criminal Justice staff, and we are in the process of developing the non-GP referral pathway for Tier 2 and 3 substance misuse services in Shetland.

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Child Healthy Weight & Adult Healthy Weight The percentage of Primary1 Children who do not have a ‘healthy’ body mass index (BMI) has decreased according to the latest annual figures published at the end of 2016. It has reduced from 27.1 % the previous year, down to 22.3% last year. However, this is still higher than the target of 21.7%, and there is a year on year fluctuation with the underlying trend being fairly flat. (The rate is not getting much better, but not getting much worse eitherover time). Children may be outwith the health BMI range because they are underweight or overweight; in Shetland nearly all the children outwith the range are overweight.

Raising the issue

We have completed training sessions on 'Raising the Issue' and 'Behaviour Change' with all Dental staff in Shetland, including dental technicians and administrateive staff; the aim is that, on an opportunistic basis, they can talk to patients about diet, weight, alcohol and smoking, provide positive reinforcement to people who are able to make changes in their own behaviour, provide basic advice and onward referral if necessary. We have also trained Community Nursing Staff and some Allied Health Professional groups.

Creating a healthy environment

We continue to work with our Community Planning partners on tackling food poverty and creating access to reasonably priced nutritious foods for all in Shetland - recognising the work of the Inequality Commission in Shetland last year which underlined the understanding that the Minimum Income Standard for people in Shetland is significantly higher than equivalent areas in mainland UK, and becomes worse, the further away from Lerwick you are.

We work jointly with the local authority Adult Learning Team in localities focusing on areas with higher numbers of people who don't speak English, working on the issues that affect them most e.g. how to shop, cook and store food. We have worked with the Additional Support Needs team on learning disabilities and dietary needs, and education and support for carers.

Identifying and supporting those at risk

The Health Improvement Team have continued to deliver SCOTT (children's weight management programme) throughout Shetland - at school, home, local leisure centre - depending on the family and what they find easiest. The aim of the programme is to help the whole family make healthy lifestyle changes and for BMI maintenance of the children concerned (NOT weight loss). This has been our busiest year so far, with over 20 children on programmes at any one time. We have a 55% success rate in weight maintenance over 6 months.

We are continuing to support School Health and Child Health teams in taking family based approaches. From working with families on weight issues, we continue to see the range of issues that families are faced with, that often manifest themselves in child overweight or obesity, but have many complex and underlying needs which aren't being either recognised or met. Two members of staff were part of a multi agency group of 10 trained in 'The

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Incredible Years' which is about supportive and appropriate parenting skills rather than a focus on diet, exercise and weight. This is described in more detail in the Public Health Annual Report.

We also have a number of parents on the Counterweight Programme, which is aimed at adults, but the adults often report that it is having an impact on their children's weight as well.

The Adult Pathway for Weight Management is now in place, including an extremely cost-effective Counterweight Plus programme for adults who might otherwise require bariatric surgery.

Physical Activity We want more people to be active more often. People who are currently inactive will benefit most from becoming more active. The easiest ways of increasing physical activity are to build it into your day. So, if you’re starting from scratch, try walking for ten minutes a day and build up from there.

In 2013, the WHO developed a new voluntary target for member states to reduce physical inactivity by 10% by 2025. Adults who participate in only 30 minutes or less physical activity per week are considered to be inactive.[i] Children who are active for less than 30 minutes per day are considered to be inactive. The figures for Shetland are shown below:

Indicators Scotland Shetland Source

% of active adults 63% 64% Scottish Health Survey

% of inactive adults 25% 25% Scottish Health Survey

% of inactive children 82% 85% Scottish Health Survey

Children & adolescents who meet physical activity guidelines

18% 15% Health Behaviours of Scottish Schoolchildren (HBSC)

Vigorous exercise 4+ times per week 49% 46% HBSC

Vigorous exercise 2+ times per week 60% 60% HBSC

Active travel to school (walking & cycling) 49% 19% HBSC

Childhood obesity Primary 1 21.8% 27.1% Child Health Surveillance System

The figures which suggest that 85% of our children take less than half an hour exercise a day are particularly alarming; and this may well link to the extremely small numbers of children who are walking or cycling to school.

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During the year, we were awarded £16,000 from Paths For All to train 14 volunteers from across Shetland to be Walk Leaders. We now have Health Walks up and running in almost every locality across Shetland, with support offered by Health Improvement staff as appropriate. People can be referred to the groups or join themselves.

Suicide: Suicide still remains a significant area of concern although the most recent available figures show a sustained reduction in the numbers. A programme of prevention continues including tackling stigma around mental health issues, training and a local audit of all sudden deaths and suicides to help us understand local risk factors and target our preventative work.

Karen Smith and Lauren Peterson in the driving seats on the Yell Ferry as part of Suicide Prevention Week.

Keep Well: Keep Well is the programme that pulls together the lifestyle topics above. National funding has ceased for this programme, but a key element of our work with GP practices is to identify early and offer support to those at risk of experiencing health problems due to their behaviours and/or the circumstances that they live in.

We also visit local workplaces to identify and offer support to people who may not otherwise access help for a wide range of health related risk factors, not just cardiovascular disease risk. We feel that continuing to offer health checks was a valuable element of the work that we do locally.

Health checks are offered primarily by the health improvement team. Individuals who are not in regular contact with the GP surgery have been invited in for a health check in some areas. Keep Well contributes to the NHS Shetland Public Health Ten Year Plan in supporting work to reduce inequalities in health and prevent future ill health where possible.

Health checks consist of physical checks, such as weight, glucose, cholesterol (age 40+ or family history) and blood pressure, but also include a number of different questions about health e.g. diet, physical activity, mental health and wellbeing, alcohol consumption and

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smoking. The check is holistic i.e. it is designed to understand life circumstances as well as risk factors.

We did 201 health checks during 2016/17. Patients from all 10 GP surgeries received health checks although practitioners in some areas have been much more proactive at inviting patients in than others. We reached a range of ethnic groups and recognise the need to target specific groups at most risk of health inequalities.

13% of people who had health checks were smokers and 27% reported that they were ex smokers. All smokers were given information about support available to them should they want to quit and they were also given information about harm reduction if appropriate.

33.5% were drinking at potentially harmful levels (recorded as moderate and above) and they all had an alcohol brief intervention delivered at the time of their health checks. There was no significant difference between men and women, although slightly higher in men in the under 40 group. 33 individuals were recorded as having a FAST score of 3+ (indicating hazardous or harmful drinking). 21 of them were men and 17 were aged under 40.

Due to a change in the way we record information about how physically active people are we can now report that 48% of people who had a health check met the recommended 30 minutes on 5 days of the week or more and 37% were active on 3 or 4 days.

67% of people who had a health check were either overweight (BMI 25-30) or obese (BMI >30) with no significant difference between men and women or different age groups. All of these people were given information and offered further support if required.

The high percentages of people overweight and obese suggest that we are reaching those who are most in need of brief advice and intervention. Referrals to Counterweight have increased dramatically over the past years but it is difficult to know how much of this is directly due to a health check and how much is due to increased availability due to locality working.

13% answered yes to having felt down, depressed or hopeless in the month prior to their health check. They were offered further support and onward referral as appropriate.

4. Life-stage Specific Programmes We also deliver life-stage specific programmes, focussing on, for example, Early Years and Older People. This is where groups of people have characteristics in common because of their age, and where there are specific pieces of work that can be shown to be effective in promoting health and wellbeing, or reducing the chance of ill health.

Early years: The most recent available figures show that we met the target of 80% of pregnant women in each SIMD centile booking by 12 weeks, with 82.3% booking by 12 weeks in 2015-16. The most recent figures for breastfeeding at 6-8 weeks show that the rate for Shetland is 54.2% (quarterly rolling average at end 2016), above the national target of 50% but below the ambitious local target of 58%.

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Young people This year we combined School health checks for S3 and S4 pupils across Shetland, as we had not managed to deliver S3 Health checks last year. This was an enormous piece of work, but has provided useful information for all children’s service planning. The full report is still being written, but some highlights and lowlights are shown below:

Falls Prevention We often tend to see falling over as an inevitable part of growing older. But falls in older adults cause distress, pain, injury, loss of confidence, loss of independence and sometimes

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death. The good news is that falls are often preventable; one of the most effective ways to maintain independence and ensure we stay steady on our feet and reduce balance problems is to keep taking exercise.

This year’s NHSScotland Event was held in June in Glasgow. The theme was ‘Working Differently Across Boundaries: Transforming Health and Social Care’. The team that delivered the successful Otago Falls Prevention programme last year in Unst, entered a poster describing their work, and were runners up in their category.

As a result of the pilot and positive evaluation, funding has been awarded for a coordination post to roll this approach out across Shetland. The Shetland Recreational Trust will be playing a key role by delivering sessions to participants to continue their strength and balance exercises after the initial input from the multidisciplinary team.

5. Communities of interest As well as Life-stage approaches, we sometimes what to work with people who are part of a particular community, whether that is a geographical community, or because a group of people might have particular characteristics that make them more vulnerable to exclusion or poorer health. This year we have focused on the first stage of an minority ethnic group health needs assessment because we know that in other areas of Scotland, there can be higher rates of some preventable diseases such as coronary heart disease and Type II diabetes and we want to know whether we should be targeting our services differently.

Minority Ethnic Groups Health Needs Assessment The first stage of an Ethnic Minority Health Needs Assessment has now been completed. The main findings are that the range and spread of people from Ethnic Minority backgrounds across Shetland means that there probably aren’t enough of any one grouping to develop specific services, (as might happen in other areas), but we need to emphasise the need for services to be open, welcoming, inclusive, alert to potential barriers and willing to adapt to individual needs.

Data capture is poor across services in Shetland and we are still often relying on national data and assuming it applies to Shetland; the next stage of the needs assessment will be a consultative component, which will be more helpful in understanding the reasons why, for example, we don’t see people from different ethnic backgrounds asking for smoking cessation support. At the moment we don’t know whether it is because they don’t smoke, or do smoke and don’t want to stop, or want to stop but don’t know that support is available, or don’t know how to access it.

6. Protecting Health

Cancer screening programmes The purpose of cancer screening programmes is to identify the early stages of cancer, or pre-cancerous changes, before the individual has any symptoms or signs. The earlier cancer can be diagnosed, the earlier treatment can start which generally leads to a better outcome

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for the individual. Uptake of cancer screening in Shetland remains good with all our uptake rates amongst the highest in Scotland. The most recent published figures show uptakes of:

• 66.5% for bowel cancer screening (May 14-Apr 16) above the target of 60%; • 77.1% for cervical screening (2014-15) slightly below the target of 80% but highest in

Scotland • 84.4% for breast screening (3 yr rolling average 2013-16) above the target of 80%.

Immunisation The most recent immunisation rates show uptake for the calendar year 2016 was slightly below the national target of 95% for primary immunisations of children by the age of one year (except Meningitis C) but had reached 97% for children aged two. However, the rates for MMR, and Hib/Meningitis C were below 90% in this age group. Uptake of the first dose of MMR by age five years has just reached the target of 95%, but uptake for the full course that should have been received by then is only 82.3%. This is leaving nearly 20% of children entering school potentially unprotected against measles, mumps and rubella. Published figures for the uptake of seasonal flu vaccine are not yet available, but the unpublished figures suggest that for adults, most of the rates are lower than last year (which is the same across Scotland). Shetland has slightly higher rates than the Scottish average for adults in risk groups and carers. The rates in Shetland for children were higher than last year, and higher than the Scottish average. The uptake amongst health care staff did increase in the 2016-17 season.

The national Vaccination Transformation Programme commenced in 2017; this aims to change the way vaccinations are delivered in Scotland and locally we will be using this as an opportunity to review what we do in Shetland and how we can maximise our uptake rates, particularly for MMR and amongst pre-school children.

Communicable disease control A large proportion of the Public Health Department’s work is day to day communicable disease surveillance, prevention and control along with strategic planning for health protection. Activity in this area is detailed in the Control of Infection Committee Annual report 2016-17.

Emergency planning and resilience This is an expanding area of work covering the Boards’ response to major emergencies, including terrorism and security threats. Activity in the past year is detailed in the Emergency Planning and Resilience Annual Report 2016-17.

7. Other Public Health and Health Improvement Activity These figures and targets only represent a proportion of the Board’s public health and health improvement work. For the Public Health Directorate, there has also been a significant focus on tackling health inequalities and supporting the most vulnerable in our community.

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We are involved in local partnership working, and often regional or national working, across a wide range of work areas including:

• poverty and exclusion, • financial resilience, welfare reform and fuel poverty • domestic abuse and sexual violence • early years, children and young people • sexual health and bloodborne viruses (BBVs) • mental health and wellbeing • physical activity and sport • LGBT issues; • community safety and resilience; • community learning and development • community justice.

As part of this wider work, senior Public Health staff chair a number of Shetland wide partnerships including those for Community Learning and Development; Mental Health; Sexual Health and BBVs; Domestic Abuse and Sexual Violence.

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[i] About another fifth of the population do some activity, but insufficient amounts to meet the guidelines.

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