------Contents Acknowledgements ...... 2 Introduction ...... 3 Localities ...... 4 Health profiling in localities ...... 5 Geographical Localities – Mapping: ...... 16 An Assessment of the Health of a Population: Analysis of the Data: Northmavine, Shetland ...... 44 Communities of Interest ...... 48 Keep Well...... 54 Work and Worklessness ...... 55 Suicide and Sudden Death ...... 58 Older People and their Medicines ...... 61 Building Community Capacity ...... 65 References ...... 75
Acknowledgements
As usual, I am indebted to the contributions and help given by colleagues both within the Department of Public Health, across NHS Shetland, and in partner organisations including Shetland Islands Council, other Community Planning Board partners and other organisations working for the improvement of health in Shetland. In particular my thanks go to: Kim Govier, Wendy Hatrick, Andy Hayes, David Kerr, Dr Susan Laidlaw , Chris Nicolson, Elizabeth Robinson, Karen Smith, members of the Health Improvement Team, colleagues from Primary Care and Benedict Gray for the photo of Fair Isle.
Dr Sarah Taylor Director of Public Health
All maps throughout this document are reproduced by permission of Ordnance Survey on behalf of HMSO. © Crown copyright and database right 2013. All rights reserved. Ordnance Survey Licence number 0100051628
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Introduction
This year‟s Annual Report takes the theme of „localities‟. We look at some of the information we have on health from geographical localities around Shetland, and from communities within Shetland. We look at the nature of communities, and how the communities we live in say something about ourselves and who we are, along with the other things that make up our lives and our health and wellbeing: social, environmental and personal characteristics: who we work with and what we work at, our friends and family, our ethnicity, gender and sexuality, and our environment.
We think about what this means for understanding and improving public health in Shetland.
Fae Flugga…
…ta Fair Isle
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Localities
Why have we chosen a theme of localities and communities for this Public Health Annual Report?
For a number of reasons.
We provide information to help us better understand our health and how to improve it – looking at data in geographical areas and mapping data is a useful way of presenting information and showing what it means. Services are often managed in local areas, and looking at information about services in this way can help us to better plan and manage our resources. We live, work and play in communities - some of these communities are geographical i.e. localities - "I bide in Scalloway", and some of them are „communities of interest‟ – “I work for the NHS”, “I am part of a knitting group”, “I fundraise for Mind Your Head”.
Sometimes the relationship between geographical and interest groups is simple: I live in Weisdale and play football for the Westside; and sometimes it‟s more complicated: I live in Fair Isle and go to school in Lerwick.
Where we live says something about ourselves but of course that‟s only one part of who we are. The other things that make up who we are and how well we are include social, environmental and personal characteristics: how we use our time (work and leisure), our friends and family, our ethnicity, gender and sexuality, and our environment.
In the end we are all defined as people, not places. But in Shetland, where our sense of place is so strong, understanding the role of locality (place) and community in our wellbeing is an important part of understanding the public health.
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Health profiling in localities
Understanding the health and the health needs of communities is a core area of public health work. If we are going to try and improve health then we need to know what our starting point is – and what are the particular health issues that need to be tackled. We need to know what the health needs of the local community are, and how we can match that with service provision. We may also want to compare different communities or populations, and look at the differences in health over time.
Health profiling is not just about the number of people with particular diseases, or the number of people admitted to hospital. It needs to take into account all aspects of health within the community, including the risk factors for poorer health and the consequences of living with poor health. We often speak about health profiling in a geographical sense, and think about specific localities. But we can also profile the health of „communities of interest‟. For example a particular ethnic group, an age group, or a workplace community; prisoners; travellers; people in care settings; people with particular illnesses or disabilities.
There are a number of sources of information that we can use to undertake a health profile, but there can be problems with information: it may not be readily available; may be out of date; not specific to the community you are looking at or not accurate.
There is therefore a skill in being able to assess the range of information available that we might use to describe the health of a particular community (geographical or „community of interest‟) and choose what to use to paint an accurate picture of the health experiences of that community. A lot of the information we can use is not directly related to health; this is because we want to look at all the things that affect health, or may affect health in the future, not just the actual illnesses that people might have at the present time. As well as knowing about the things that might cause ill health, we also want to know what there is in the community that can improve health, or protect against illness. So, if we know that within a community many people commute by car to work in sedentary jobs then we may be concerned by their levels of physical activity and possible problems with obesity and heart disease. But if we see in the same community that there is a local leisure centre, good footpaths for walking, allotments and thriving
5 local dance clubs then we know that there is scope to improve physical activity and health.
Some of the main risk factors for poor health outcomes are poverty, deprivation and social exclusion. So understanding factors like unemployment, education, income and crime within a community can also help identify if there are likely to be health issues now or in the future.
What might we include in health profiling? The list on the following pages focuses mainly on the information that might be available for a defined geographical area. A lot of information can now be collected by postcode, which for many places is a good way of defining geographical area (although not always so good in Shetland where the geographical boundaries for postcode areas can be relatively large). Other information may come from a service that covers just the area in question, e.g. a school or a GP practice. There can be a high degree of overlap between area based services, but this tends to be less of a problem in the more rural and remote communities.
Some information is regularly and routinely collected, such as numbers of births and deaths, and is generally up to date and accurate. Other data may be collected infrequently, such as the population census. Information that is routinely collected can still often be out of date because it takes time to collect, verify, analyse and publish data. Sometimes, we cannot find what we want to know from routinely collected data, and have to undertake research, such as a survey, to collect the information. Because of the problems in collecting data, it is important to look at information from different sources which together can paint a more accurate picture than relying on a small number of pieces of information.
In the list on the next page we have included a number of examples to illustrate the sort of information that is and could be collected (in boxes). These examples have mostly come from the Community Profiles for different parts of Shetland.i The Community Profiles focus on a whole range of factors within a community, not just
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health, and they use a wide range of sources to collect information. The sort of information they include is very relevant to health profiling as described above.
Please note: As described above it can be difficult to get up to date information for profiles and keep it current. Population statistics and services constantly change and so the information included here as examples from the Community Profiles, whilst accurate at the time they were written, may not describe the picture now.
Population (‘demographic’) data – the basics:
Numbers of births and deaths each year over a period of time
The age profile of the community: particularly - how many older people? How many under fives? School age? Working age?
Population projections for the size of the population, and different groups, in the future
The population of the North Mainland area has remained relatively stable in recent years with the total population for the whole area being 3,144 in 2001 and 3,140 in 2008, which is a decrease in population of 0.1%. In 2008 statistics indicated there is a relatively slight disparity between males and females within the North Mainland. There were 1,590 males and 1,550 females. The age group of 40 – 49 year olds is most predominant in the North Mainland. Like Scotland, Shetland demonstrates an ageing population structure and this is replicated in the North Mainland area. The percentage of the total population for the area who are children aged 0 – 15 years has steadily decreased between 2001 and 2009 by 4.6%. This age range is currently roughly 20.1% of the population. Northmavine has seen the biggest drop in this age group with Lunnasting and Nesting showing a slower decrease. At the same time the percentage of pensionable age has steadily grown by 3.6% and stands at around 17.1% of the population in 2009. Northmavine has the smallest increase whereas the Brae, Sullom, Muckle Roe and Burraland data zone has the highest increase with nearly double the percentage increase in the pensioner numbers compared to other areas.
North Mainland Community Profile 2010
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Are there different ethnic groups? Nationalities? Languages spoken? Are there any particular defined groups or communities of interest? (e.g. travelling community, prisoners, particularly vulnerable or hard to reach groups)
Socio-economic data
What sort of housing is there? How many people own their own homes? How many rent? How many are in social housing?
Housing in the North Isles Across the North Isles, housing is an issue. In most cases there is a lack of available housing of the right type in the right place. Many houses are plagued by a lack of efficiency and by damp. Extremely high fuel bills are also a problem throughout. Many families wishing to move to the North Isles struggle to find housing of the preferred style, location or size, and in the case of Fetlar and Yell there is a lack of available housing of any description. A number of young families from Yell have been forced to seek alternative accommodation beyond the North Isles in recent years as a result. Many houses are only seasonally occupied as a holiday home, which has a negative impact on social cohesion and the islands’ economies, particularly during the winter months. North Isles Community Profile 2010
How many people are employed and unemployed? What sort of work are people employed in?
[As described in 2010] A wide variety of employers base themselves throughout the West Mainland contributing to the social sustainability of the area. The range of employment found in this area includes; a bakery; a knitwear factory; aquaculture facilities; a cheese maker; vehicle repairs; community shops and cooperatives; leisure facilities; schools and lifelong learning providers; jewellery makers; health care providers; transport operators; retained fire fighters; builders, plumbers and electricians; a veterinary practice; three mail sorting and delivery offices; and ferry staff. In addition to this a large number of self employed or lone private businesses exist. Employment in the West Mainland is diverse with a large number of people undertaking a number of employment opportunities concurrently.
West Mainland Community Profile 2010
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Employment by Sector in Shetland 2011
Full-Time Part-Time Total FTE** Accommodation & Catering 334 412 746 471 Business Services 266 206 472 335 Construction 778 63 841 799 Energy 390 39 429 403 Fisheries & Agriculture 1,070 354 1,424 1,188 Health, Education & Social Work 692 906 1,598 994 Manufacturing 520 146 666 569 Public Administration 1,834 2,499 4,333 2,667 Transportation & Communications 728 233 961 806 Wholesale & Retail 734 665 1,399 956 Other 303 414 717 441 Total 7,649 5,937 13,586 9,628 Sources: Economic Development, SIC
** Full-Time Equivalent jobs – 3 PT jobs = 1 FTE
http://www.shetland.gov.uk/economic_development/documents/ShetlandInStatistics2013.pdf
Source: Shetland in Statistics 2013, Shetland Islands Council Economic Development
How many people on benefits?
Universal Credit ...... Welfare Reform ...... What Does it Mean for You?
The UK Coalition Government have brought in a number of changes in the way that the poorest people in society receive support. These include:
Housing Benefit being paid direct to tenants, as part of their Universal Credit, on a monthly basis, rather than to landlords, requiring tenants to fully manage their financial
outgoings (this will be phased, 2013-17); The majority of claims will need to be made on line;
The allocation of what is currently Housing Benefit will be based on the number of rooms a household is entitled to, rather than the number of bedrooms in the house, meaning a reduction in monthly incomings for a number of households: a 14% reduction in rent for one additional bedroom, and 25% for two or more; and
Personal Independence Payment (PIP) will replace Disability Living Allowance (DLA); all
those currently in receipt of DLA will have a regular assessment to determine their PIP.
There will be two levels of PIP, compared to three levels of DLA, therefore it is likely that a
number of individuals in Shetland will have a reduction in money coming into the house.
Emma Perring, Policy Manager, Shetland Islands Council, 2013
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What is the crime rate? – how much domestic violence/ other violent crimes? Alcohol related crime? Drug related crime?
Shetland South single manned police station situated at Dunrossness has closed with police provision in the area now based at Sumburgh Airport terminal. During the summer of 2010, 56 incidents were reported for the Dunrossness beat area. Most were routine incidents. South Mainland Profile 2011
Children & Young People
What is local school attendance like? How many children truant?
How many are not in mainstream education?
How many attend nursery? Other pre-school activities?
How many young people stay at school until 18? How many go onto further or higher education? Apprenticeships or training?
School Attendance 2008 Secondary attendance at Aith Junior High School has been rising steadily since 1976 and in 2008 was 105.
Primary attendance fluctuates at all Primary Schools in the West area. During 2008 Aith Primary School had 70 pupils; Foula Primary School had 2; Happyhansel Primary School had 52; Papa Stour Primary School had 0; Sandness Primary School had 5; Skeld Primary School had 25; and Whiteness Primary School had 83 pupils.
Nursery attendance throughout the area has also fluctuated since 1981. During 2008 Aith Nursery had 14 attendees; Foula had 0; Happyhansel had13; Papa Stour had 0; Skeld had 5; and Whiteness had 25.
School leavers 2010 The total number of school leavers (from Aith JHS) in 2010 was 5. Of these 5, further education, full time employment and national training programmes were their destinations West Mainland Community Profile 2010
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How many children are engaged in out of school clubs?
North Isles Youth Clubs in 2010
Youth Club Day Age Group Club Session Membership North Isles Unst youth Centre Monday Seniors S1+ 6:00-8:00 21 Unst youth Centre Friday Juniors P4–7 3:30-5:00 16 Mid Yell Youth Club Friday Juniors P2–7 3:15-5:15 24 Yell Youth Cafe Friday Seniors S1+ 7:30-9:30 32 Burravoe Juniors Wednesday Juniors P1-7 5:30-7:30 16 Burravoe Seniors Closed Fetlar Closed
North Isles Community Profile 2010
How many children have additional support needs?
How many children have a GIRFEC / are on the Child Protection register?
What is the health visitor caseload like?
Is there child care available?
There is a Care Centre at Walls Older people / people with disabilities operated by Shetland Islands Council, which can accommodate up How many people are in care centres / use to 13 full time residents. In addition to respite care? this a Day Care service operates 4 days a week, which can How many have care at home? accommodate 18 clients each day.
How many people are carers themselves? West Mainland Profile 2010
How many people receive Disability Living Allowance (DLA) or Personal Independence Payment (PIP)?
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Lifestyle
What community facilities are there?
Tingwall Hall. Do you use the Hall Public transport? and if you do, tell us how? Other transport options?
When asked if they use the Hall and how, there were 56 completed Adult returns to this question. The responses indicate that adults make very good use of the Hall for a very wide variety of activities and events. Farmers Markets, Sunday Teas and private functions appear high on the list. The vast majority of responses convey a positive message regarding the Hall.
When asked what they would like to see in the Hall, this generated 18 responses representing a wide range of suggestions. These include; yoga; slimming; keep fit; badminton; table tennis; local bands; a community bar; carpet bowling; live music; disco;
morning/afternoon club; car boot sales; supper dance; quiz nights; and “open” community meetings.
Tingwall & Girlsta Community Profile 2012
Bus Service [as described in 2011]
J Leask & Son operate a bus service to the South Mainland from Lerwick via Sandwick to Sumburgh Airport. In 2008 a total of 118,091 passengers used the service. This number is up by 0.3% since 2006. For passengers to and from Fair Isle, the bus service calls in at Grutness Pier on Tuesdays all year round, thus linking with the ferry service. In addition the bus service calls in at Grutness Pier on Thursdays from May to September. Small items of freight for
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delivery to Fair Isle can be left at Lerwick for onward transport to Grutness. There is no internal bus service on Fair Isle itself, but a taxi can be hired.
Bus services between Lerwick and the South Mainland are better than most areas of Shetland due to the need to provide a regular transport link between Lerwick and Sumburgh Airport. There are two Dial-a-Ride services within Shetland South, one for the Levenwick Surgery, which operates Monday – Friday, and shopper services for Sandwick, Cunningsburgh and the Ness area on certain days of the week.
The Council’s Community Work Department offers a Community minibus for groups in the area to use. The bus is based at Sandwick Swimming Pool.
South Mainland Community Profile 2011
How many people attend further / adult education classes?
[As described in 2011] The SIC Adult Learning Service currently runs a total of 11 non certificated adult learning classes in Shetland South. These are held in the Sandwick JH School and at the Hoswick Visitor Centre. The total enrolment (during 2010/11) was 75 people, 22 males and 53 females. 56 Classes in Fabulous Felting and Fleece to Fabric are run from the Hoswick Visitor Centre. A total of 29 people attend; most are fee paying with 10% having fee waivers as they receive benefits. Nine males and 20 females attend with 38% of those whose date of birth is known being aged from 31 to 60 years. There are 17 people on the waiting list for these classes. Evening classes in Sandwick JH School include Baking, Relaxation, Reiki, and Traditional Fiddle. A total of 46 people attended during 2010/11; Most of these are fee paying with 15 % having fee waivers as they receive benefits. 13 males and 33 females are registered (three aged 18 to 30, twelve aged 46 to 60 and two pensioners and the rest unknown). 4% of attendees are registered disabled. There are 3 people on the waiting list for these classes. South Mainland Community Profile 2011
How many people use the leisure centre? Total admissions to Unst Leisure How many in local sportsclubs? centre in 2009/10 were 23,396 …The centre is used for over 23 activities, Other clubs and groups? clubs and private hires including badminton, trampolining, football, Internet access? ladies nights, netball, and pool parties. In total 1,619 people used the leisure Local shops? centre to access an activity, course or class in 2009/10…. North Isles Community Profile 2010
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Amenities, services, and support networks in Northmavine in 2010
Northmavine has … two shops, one fulltime and three part-time post offices and a health centre. There are public toilets at Hillswick and also at Eshaness and Ollaberry, which include disabled facilities. The Northmavine Community Development Company and the Ollaberry Post Office provide public internet access. The Braewick Café in Eshaness offers wifi access through Visit Shetland. There is an internet exchange at North Roe (activate 512 KPBS) and one at Ollaberry and Hillswick (8000 KBPS max). There is weekly access to a mobile banking service. There is no formal childcare in Northmavine.
North Mainland Community Profile 2010
Health – GP / health service data See next chapter…….. How many people are on the disease registers for e.g. asthma; heart disease; stroke; dementia?
How many people are referred to hospital each year?
How many emergency admissions are there each year?
What are the screening uptake rates?
What are the vaccination uptake rates?
Lifestyle risk factors – how many people smoke? Are obese? Drink alcohol to excess? Take exercise?
How many people are registered with a dentist?
How many children take part in child healthy weight interventions?
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Health - survey data
Do we have any health survey information from national or health board level surveys?
The Scottish Adolescent Lifestyle Survey (SALSUS) 2010 – Shetland data
In 2010, 11% of 13 year olds and 35% of 15 year olds said they had drunk alcohol in the week prior to the survey.
The proportion of 13 year olds who had ever had an alcoholic drink has reduced from 63% in 2006 to 50% in 2010.
59% of 13 year olds felt it was ok to “try drinking alcohol to see what it‟s like” (reduced from 73% in 2006).
There has been no change in the proportion of 15 year olds who report ever having had an alcoholic drink, or the proportion who felt it was ok to “try drinking alcohol to see what it‟s like”.
The proportion of pupils in Shetland Islands who have ever had an alcoholic drink is similar to the national average.
The proportion of pupils who reported that they usually drink at least once a week is down from 12% in 2006 to 4% in 2010 (13 year olds), and from 39% in 2006 to 19% in 2010 in 15 year olds.
Of those who had ever had an alcoholic drink, 9% of 13 year olds and 25% of 15 year olds had been drunk more than 10 times.
Should we do a local health survey?
Questions to ask – how do people rate their own health? How happy are they? How satisfied with life? Do you smoke? Do you drink? Do you take exercise? What do you eat?
What are the barriers to good health?
The next chapter looks at the sort of information we can get from health services, GP practices in particular, and how we can map that geographically to help understand the health experiences and health needs of the populations of defined areas.
We also look at data on deprivation and how that can be mapped geographically to identify areas where there may be greater levels of deprivation, or specific issues such as poor access to services or unemployment. 15
Geographical Localities – Mapping:
Sometimes, looking at data about health in terms of geographical spread helps us to explore the reasons behind health and ill health, and what we need to do to address any issues.
We can present the data in different forms, as a graph, a table or a map. Although the map can only display one set of data at a time, this is a good illustration of how the reader can see things more clearly.
Shetland Demography
Population as measured by people registered with GP practices.
The General Register Office for Scotland‟s (GRO) population estimates and projections are based on the most recent Census results. As the Census is taken every 10 years, before the recent publication of the 2011 Census results estimates and projections were based on the 2001 Census and were predicting a decrease in Shetland‟s population. Since then, as we know, migration from eastern parts of Europe has been positive in many parts of Scotland. This has made it difficult for GRO to make consistent migration assumptions. GP registration data, which can be used as a proxy measure for population, showed that our population was in fact steadily increasing. This has now
16 been confirmed by the 2011 Census results which show us having a population of over 23,000 for the first time in many years and projections now predict a growing population over the coming 25 years.
There continues to be an increase in the older population with the 75+ age group projected to become a higher proportion of the total population in Shetland than in other areas of Scotland.
Age by Practice for Under 5s and 75+1
Under 5s and Over 75s by Practice - Rate per 1000 120 100 80 60 Under 5s 40 Over 75s 20 0
The Scalloway practice area has the highest proportion of under 5s within the practice population at 77 per 1,000, with the Bixter practice area next at 70 per 1,000 and Whalsay at 64 per 1,000. Yell, Fetlar2 and Unst have the lowest with an average of 45 per 1,000 across the islands.
1 Throughout this chapter we have used the term rate per 1,000. This gives a better comparison between areas, especially where low populations are compared.
2 Note: Fetlar is included with Yell for GP practice populations. When we use information collected at datazone level, it is part of the Unst area datazone.
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We have divided the Shetland data into 5 equal bands to show where there are higher or lower proportions of under 5s in practice areas. The darker the colour, the higher proportion of under 5s there are in the area. We use the same methodology throughout this chapter - the more deprived an area is the darker the colour, the higher proportion of smokers the darker the colour.
There is a higher proportion of over 75s in the population in Yell, Fetlar and Unst, averaging 105 per 1,000 across the islands, then Whalsay with 96 per 1,000. The lowest rate of the over 75s can be found in the Brae practice area with only 51 per 1,000. It would appear that Yell, Fetlar and Unst populations are aging with fewer under 5s, whereas, although Whalsay has a high rate of elderly residents per 1,000, they also have a relatively high proportion of under 5s at 64 per 1,000. The work traditionally available in the Brae area, especially at Sullom Voe, plus good transport links to Lerwick has probably attracted more young and middle aged people, offsetting the number of over 75s.
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Scottish Index of Multiple Deprivation
The Scottish Index of Multiple Deprivation identifies small areas of deprivation across all of Scotland in a consistent way. It is designed to target policies and funding into these areas to tackle deprivation.
The SIMD ranks small areas (called datazones) from most deprived (ranked 1) to least deprived (ranked 6,505). People using the SIMD will often focus on the datazones below a certain rank, for example, the 5%, 10%, 15% or 20% most deprived datazones in Scotland. In this chapter we describe these datazones in Shetland terms, ranking the 30 datazones within Shetland into 20% bands (numbered 1 to 5), and showing on maps the spread of deprivation across the different areas of Shetland. The table below describes this in more detail:
SIMD Quintile Description Colour shade 1 20% most deprived in Shetland terms Darkest 2 20% next most deprived Dark 3 Middle 20% Medium 4 20% next least deprived Light 5 20% least deprived in Shetland terms Lightest
It is worth noting that Shetland does not have any areas in the 20% most deprived datazones in Scotland, hence the reason for considering this in Shetland terms.
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SIMD – overall
This is the overall SIMD ranking which combines all the domains used to make up the rating, as described in the table overleaf. Within Shetland, Hillswick, Yell and Brae, as well as parts of Lerwick, rank as the most deprived in overall SIMD ranking terms. The Central mainland and parts of Lerwick are least deprived. Due to the weighting of the different „domains‟ or classifications of deprivation Employment and Income have a larger impact on the overall score as they are weighted by a factor of 12. The Access domain will also have an effect on the overall ranking as it is the only domain where Shetland has areas which are among the most deprived in Scotland. This is described in more detail later in
the chapter.
Note: Fetlar is included with Unst in the SIMD maps due to the way in which the datazones were split. It is technically not possible to separate the data to see it on its own or included with Yell, which provides GP services to the island.
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SIMD 2012 Methodology
Employment Income Crime Housing Health Education Access
Domain Domain Domain Domain Domain Domain Domain
•Unemployment Claimant •Adults and children Recorded SIMD •Persons in •Standardised Mortality Ratio •School pupil Drive time sub-domain (weight Count averaged over 12 months in Income Support or crime rates for the households •Hospital stays related to absences = 0.66) •Working age Incapacity Benefit Income-based following which are alcohol misuse •Pupil performance or Employment Support Employment Support over-crowded •Hospital stays related to drug on SQA at stage 4 indicators: •Drive time to GP Allowance recipients Allowance •Persons in misuse •Working age people •Drive time to retail centre •Working age Severe households households •Comparative Illness Factor with no qualifications •Domestic house •Drive time to petrol station Disablement Allowance •Adults in Guarantee without •Emergency stays in hospital •17-21 year olds breaking •Drive time to primary and recipients Pension Credit central •Estimated proportion of enrolling into full •Drug offences secondary schools Households heating population being prescribed time higher •Common assault •Drive time to post office •Adults and children drugs for anxiety, depression or education •Crimes of violence Public transport sub-domain in Job Seekers psychosis •School leavers aged •Vandalism Allowance •Proportion of live singleton 16-19 not in •Sexual offences (weight = 0.33) households births of low birth weight education,
•Adults and children employment or •Public transport time to GP in Tax Credit Families training •Public transport time to retail centre •Public transport time to post office Data zone working age Data zone total population Population
Indicators are ranked, transformed to a normal distribution and then combined Indicator counts summed and divided by population denominator to create domain using weights generated by factor analysis to create the domain score. score for each data zone.
Domain score is ranked to create domain rank. Each domain rank is standardised and transformed to an exponential distribution, these values are combined using the weights shown below.
12 12 2 1 6 6 4
This creates the overall SIMD score for each data zone, which is ranked to create the overall SIMD rank. 21
SIMD Rank for each data zone
Income
The North Isles and Brae are most deprived in terms of income. It should be noted that this is measured by the uptake of various benefits, rather than any measure of actual earnings, so is a proxy measure of income. The Central and West mainland (Bixter area) are the least deprived in income.
Employment
This domain measures employment deprivation in terms of uptake of unemployment benefits. Unst, Hillswick and Brae have most employment deprivation in the rural areas of Shetland. The West, Central and South mainland are the areas with least employment deprivation. Lerwick has areas which are at both ends of the scale, demonstrating that deprivation can occur at a very small area level in Shetland terms and as with bigger cities, there can be large inequalities between areas which are situated very close together.
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Crime
Shetland has very low crime rates as is demonstrated by the map. Unst, Fetlar, Hillswick, the North-East and South mainland have very low crime rates. Many areas of Shetland, including Northmavine, Nesting, Tingwall, Dunrossness, Levenwick, Bigton, Fair Isle, Unst and Fetlar, recorded no incidents of crime in this period (the 2011 Census). The highest rates are recorded in Lerwick and the Brae area, which you would expect as they have the highest densities of population, but these are still low in Scottish terms.
Housing
Housing deprivation is measured in terms of overcrowding and lack of central heating. Hillswick, Walls and Nesting have the highest housing deprivation with the Central mainland and Whalsay, followed by the South Mainland, having the least. Fuel poverty is recognised as a real issue in Shetland and given our harsh climate, can be a serious problem for many people. It occurs in areas where there are concentrations of social housing, and more remote areas, where investment in housing has not been at the same level as the more densely populated areas and their surrounding commuter belt. This is demonstrated by the map.
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Fuel poverty is of course dispersed at an individual household level, so will occur in all datazones as do other aspects of poverty and deprivation. Showing the areas where it is commonest does not mean that everyone in that area lives with fuel poverty, and there are numbers of people in fuel poverty in all areas of Shetland. These maps show the concentration of these indicators.
Education
Achievement at school leaving age is one of the strongest predictors of future deprivation.
Education deprivation is measured in terms of school absences, achievement and what young people move on to do when they leave school. Brae and Whalsay appear to be the most deprived. The reason for Whalsay being in the highest deprivation category in Shetland terms may be due to employment in fishing related businesses. The West, Central and South mainland are least deprived on this indicator.
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Access
As mentioned earlier, the Access domain is the only one for which Shetland scores highly in terms of deprivation at a national level. This is down to the remote and rural nature of our islands. Access deprivation is measured by the travel time taken to reach services such as your GP, local schools, post office, petrol station and shops, either by car or public transport. As many of the rural parts of the mainland and particularly the islands have limited public transport links and face long ferry crossings and/or drives on rural roads to reach many of these services, they score highly in this domain. Unst, Yell, Whalsay, Skerries, Nesting and the West mainland are the most deprived. Due to their
smaller size and populations, Foula and Fair Isle are counted in with parts of the mainland, so they appear to score more favourably but this is obviously misleading. Northmavine is, perhaps surprisingly, less deprived in terms of access, but this is due to many of the services listed being available in Brae. Lerwick, unsurprisingly, has all the least deprived datazones for access.
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Health
The health domain is measured using a number of data items: mortality rates, hospital emergency admissions, drug and alcohol related admissions, how often illness occurs, proportions of the populations being treated for anxiety, depression and psychosis, and finally low birth weight, to assess deprivation in terms of health. It should be noted that Shetland has a very good health „performance‟ when compared to the rest of Scotland. We regularly have very low levels of disease and mortality rates so it is not surprising that we perform well in Scottish terms. Historically Shetland has had very few low birth weight babies, and in fact tends to have a higher birth weight than most other areas of Scotland, so this will be a factor in low deprivation scores in this domain. The West and Central mainland, Whalsay, Yell and Fetlar are the most „healthy‟ areas in Shetland terms. The most health deprived areas are all within Lerwick, which reflects the national trend of larger urban areas of population having poorer health. Within Lerwick, the Upper Sound area scores much better than the rest, possibly reflecting the relative affluence and associated better health.
This data is really useful in helping us plan our services – if we see more smokers in one locality, we might want to target our efforts, such as smoking cessation services, in that area.
Note: More detailed background and methodology is described on the SIMD website. http://www.scotland.gov.uk/Topics/Statistics/SIMD/BackgroundMethodology
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Variation – getting beyond the average
When we look at data at one „locality level‟ such as a GP practice, it can mask or „iron out‟ considerable variation at smaller population levels. The obvious example of this is Lerwick, where the practice is larger than the rural practices and covers a geographical area that has wide variations in its characteristics. Even if we break the Lerwick area down into datazones which have a smaller population, this still can mask variation between different neighbourhoods. A good example is Bressay and Twageos which make up the same datazone but have very different population characteristics.
Lerwick Practice Area – SIMD Access
With good roads, public transport and facilities such as GPs, schools, Post Office, shops and petrol stations, the Lerwick practice area falls into SIMD groups 3, 4 and 5, the 3 least deprived of the 5 SIMD levels. Central Lerwick falls into the least deprived group, SIMD level 5. The exception to this is the Twageos area, however Twageos and Bressay are in the same datazone so the data influence of Bressay is a major factor; the two populations together produce an average of SIMD level 3. Lerwick North, outskirts, Sound and Upper Sound are in SIMD level 4, being the next geographically closest to the town centre. The third SIMD level is occupied by Gulberwick, Quarff and Cunningsburgh and the already mentioned Bressay and Twageos.
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Lerwick Practice Area – SIMD Health
The Lerwick practice area has datazones in all 5 SIMD levels of the health domain. The more prosperous areas: Breiwick, Upper Sound, Gulberwick and Quarff are the least deprived in SIMD level 5. At the opposite end of the scale in SIMD level 1 are the less prosperous areas: Lerwick North, Lerwick North Central and Sound. These areas contain the largest areas of densely populated social housing. The second most deprived areas are: Bressay/Twageos, Lerwick outskirts and Lerwick Clickimin. Bressay and Twageos are in the same datazone and Bressay‟s data will be a major factor influencing the result for Twageos. In the middle of the SIMD levels with SIMD level 3 is the Lerwick harbour area. The second least deprived with SIMD level 4 are Lerwick Sletts and Cunningsburgh.
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Variation – understanding inequalities
Some interesting national work, Making Better Places, Making Places Betterii. explores this small area variation across Scotland. These authors found that there were areas of achievement and deprivation where Scotland compares well on average to other European countries, but the variation WITHIN Scotland is so large as to make the comparison meaningless.
Data on children‟s educational at age 15 illustrates this well. Scotland‟s averaged raw score across tests is 5th in Europe and above Norway, Sweden, England and France. Even adjusting statistically (using 95% confidence level to allow for possible sampling variability), Scotland‟s average is within the upper mainstream in Europe, and this trend has held over time. The problem is that the gap between the top 20% and the bottom 20% in Scotland is the widest in developed Europe with the bottom 20% at age 15 performing as if they have 5 years less schooling than the top 20% (i.e. as if they were 10 years old).
Mair et al‟s analysis highlights another interesting point. Scotland has one of the least socially segregated secondary school systems in Europe. The extreme variation in pupil performance recorded is more within schools than between schools, i.e. children with access to the same school resources achieve radically different outcomes.
The same holds true for health indices and income distribution/deprivation. However, the educational attainment data is interesting because it is the single clearest marker for deprivation in adults, and we are now looking at how we change our children‟s early years experience and get better at early intervention, to improve the life chances of young people.
The scale of variation around the average is a social justice issue, but it is also an entirely pragmatic issue. Raising the average is less helpful if we do not alter the variation within the average. Improving the health, or life circumstances of the average in society, is not helpful unless we specifically improve the health or life circumstances of those worst off – the bottom 20%. This is what reducing inequalities is all about.
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Primary Care Maps
It is estimated that just over 80% of people visit their GP practice at least once a year; and the average number of visits per patient is 4-5 a year.iii
All new patients registering with a practice are offered a „new patient check‟ (though not all take up the offer). We also have the Keep Well checks for folk who have not been to the GP practice for several years; and some practices may offer Well Women or Well Men checks; and health checks for older people. Folk who have a long term condition such as asthma, diabetes or high blood pressure usually attend regularly and are monitored on a regular basis. Folk who get certain repeat prescriptions, women who are receiving contraceptive services and having cervical cancer screening also attend regularly.
When a person has a health check, and also when they attend for many of the reasons above, there is often a lot of information collected including blood pressure, whether or not they smoke, how much alcohol they drink and weight and / or body mass index.
Some of this information is very useful for public health and health improvement work, not on an individual level, but at a practice, community or population level. If the practices know how many people in their practice smoke, or how many are overweight or have high blood pressure then they can put in place appropriate services to help those folk. Resources are scarce so they have to be used to provide the services that are most needed. There is little point in training up a practice nurse to do smoking cessation if there is no one in the practice who smokes; but if half the patients are obese then delivering a weight management programme would be essential. Having this sort of information is also useful to monitor trends and compare practice: we can monitor trends over time to assess if our interventions are working and also to identify particular „hot spots‟. So is there a particular problem with harmful drinking in one practice compared to all the others? Is there an underlying reason for that and should we be working with that community in different ways to help tackle the problem?
Given the amount of information that is collected in primary care, in GP practices, it would seem logical to use that information as much as possible. There are other ways of collecting health information such as population surveys, but these are expensive and
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resource intensive; and reliant on a sample of the population. The information may also be biased because only folk who are motivated and interested in health may respond, which would not give an accurate picture of the whole population. The practice data is being recorded anyway on a database within the practice, as part of the management of the individual patient. So counting the numbers of people with particular health behaviours or conditions seems to be an efficient way of getting hold of this information for individual communities, and Shetland as a whole.
The following section of the Annual Report shows some of this information to describe aspects of the health of people living in different parts of Shetland.
Smoking
Smoking status of patients aged 16 years and over.
Current smokers: Brae and Lerwick have the highest recorded smoking rates with 146 and 141 per 1,000 respectively, whilst Walls, Yell and Whalsay have the lowest with 80, 84 and 87 per 1,000 respectively.
The popularity of smoking has receded over the last 30 years. Whereas once lighting up a cigarette in a restaurant after a meal was the norm, nowadays it would be illegal for the owner to permit smoking on their premises. The fact that smoking has become less socially acceptable is reflected in
both lower take-up rates and reduction in the practice of smoking. Health education by schools, GPs, public health investment in nicotine replacement therapy treatments (often free to the smoker),
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along with support and counseling from health professionals and fellow quitters has helped many smokers beat their addiction. Taxation has had a large impact too, with tax on cigarettes rising at above the rate of inflation. Advertising has played its part, both health information films and cigarette packet advertising warning of the perils of this habit. Sadly governments have caved in to lobbying against plain packaging, mostly on the grounds that this would make counterfeiting easier. Studies show that fewer young people are taking up smoking. Now, we tend to find higher smoking rates in the later middle-aged who started smoking when it was a fashionable thing to do, and tobacco products were openly promoted on all forms of media and in entertainment. We are without doubt a healthier country, and this is at least in part due to the reduction in smoking rates, leading to longer healthier lives.
Ex Smokers:
The number of ex-smokers continues to grow as health education, taxation and drug therapies become more readily available. As the number of ex-smokers increases there are then a larger base of people seeing the positive effects that not smoking is having on their lives to encourage those who remain smokers to stop, as well as discouraging others from taking up smoking.
Lerwick, Brae and Bixter practice areas have the lowest rate of ex-smokers with 189, 188 and 178 per 1,000 respectively. Whalsay has the highest rate with 264 per 1,000.
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Generally, areas with the lowest smoking rates have the most ex-smokers. It would be interesting to know if these areas started off with the most smokers, and have been most successful at helping people to quit.
Never Smoked:
The number of people that have never smoked continues to grow. As a young person you now have more positive role models where smoking is concerned. You will not be exposed to smoking as much in advertising, and your lungs will not be exposed to cigarette smoke in covered public buildings. Not smoking is now the social norm.
Yell, Unst and Fetlar average 448 people per 1,000 who have never smoked, and the Bixter and Levenwick areas average 428 per 1,000. The lowest rates are in the Lerwick and Whalsay practice areas with 315 and 324 per 1,000 respectively.
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Disease Registers
Practices hold registers of patients with a number of chronic diseases to help manage those patients‟ health and for the purposes of identifying patients for QOF (Quality and Outcomes Framework) - one method by which GPs are paid. The numbers of patients on these registers gives us a good idea of the prevalence of the condition (that is, the number of people living with the condition at any one time), telling us how common the condition is.
Asthma
The practice asthma registers include patients with a current diagnosis of asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the previous twelve months. The numbers shown here are for 15+ years and adults. Childhood asthma does not always lead to asthma in adulthood. Adults may have a diagnosis of asthma alongside other respiratory diseases including smoking related diseases such as chronic airways disease (COPD).
Asthma in 15 years + by Practice rate per 1000 140 Bixter 120 Brae 100 Hillswick Lerwick 80 Levenwick 60 Scalloway
40 Unst Walls 20 Whalsay 0 Yell Rate per 1,000 of 15+
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Asthma is a common long-term condition that can cause a cough, wheezing, and breathlessness. The severity of the symptoms varies from person to person. Asthma can be controlled well in most people most of the time. Aggravating factors such as dust mites, pollen, tobacco smoke or exercise can initiate an asthma attack, causing irritation of the airwaves and restricting breathing. Asthma attacks can be treated with broncho-dilators, which open the airwaves and also steroid inhalers, which suppress the effects of the aggravating factors, preventing the onset of an asthma attack. 5.4 million people in the UK are receiving treatment for asthma, roughly 87 people per 1,000. The Hillswick practice area has a high of 118 asthmatics per 1,000 population, whereas Whalsay has the lowest rate of 35 per 1,000. It would be interesting to see the number of people with asthma who smoke when smoking is a proven aggravating factor.
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CHD
QOF register of patients with coronary heart disease.
Coronary heart disease is more prevalent in older people, specifically 65 plus. The disease is caused by a build-up of fatty deposits on the walls of the arteries around the heart. People are more prone to CHD if they smoke, have high blood pressure, have high cholesterol levels, have diabetes or do not take regular exercise. Other risk factors are a family history and being overweight. Giving up smoking, eating a good diet and exercise can remove many of the risk
factors involved with this disease. With a greater number of older people per 1,000 living in Yell, Unst, Fetlar and Whalsay you would expect to see all these areas having a greater rate of this disease, but in fact Unst (40 per 1,000) Rate of CHD per 1,000 by age groups within practices and Whalsay (25 per Practice 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75+ 1,000) are less Bixter 0.0 0.9 4.4 3.5 13.1 13.9 Brae 0.4 0.4 3.2 4.8 11.6 10.8 affected, especially Hillswick 0.0 0.0 2.7 11.0 24.7 26.1 Whalsay, which is Lerwick 0.1 0.1 2.8 6.5 12.5 13.8 Levenwick 0.0 0.4 0.4 3.7 7.4 16.7 particularly low. Yell is Scalloway 0.0 0.3 0.3 5.0 11.2 17.5 at 71 per 1,000. Could Unst 0.0 0.0 1.7 10.3 15.5 12.0 Walls 0.0 0.0 0.0 1.4 5.7 11.5 the lowness of CHD in Whalsay 0.0 0.0 0.0 0.9 7.9 15.8 Whalsay in men under Yell 0.0 0.0 3.7 8.2 20.1 39.3 75 have something to do with the diet of its residents, or its low smoking rate?
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CHD Register by Practice rate per 1000 80 70 60 50 40 30 20 10 0
The prevalence of CHD across localities in Shetland is not directly related to rates of smoking or obesity, presumably partly because there are a number of factors that contribute to the disease, and partly because it may be hidden in individuals until they present with symptoms or are screened for risk factors.
Obesity
The QOF register for obesity counts patients aged 16 years and over with a Body Mass Index (BMI) greater than or equal to 30 measured in the last 15 months. The body mass index is a scale commonly used by medical practitioners where a calculation is performed based on weight and height. The ranges are: -
BMI Up to 18.5 - underweight 18.5 to 25 – normal 25 to 30 – overweight 30 to 35 – moderately obese 35 to 40 – severely obese 40 and over – morbidly obese
The BMI test works as a measure of obesity for most people in the population, but is not the best test for those with high muscle mass. Obesity is avoided by keeping a good balance between energy consumed and expended. Obesity is a risk factor for a number of diseases including CHD and type 2 diabetes.
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However, measuring the number of obese people identified in different GP practices shows some of the difficulties in interpreting data from this source.
We extracted information from the GP databases on the number of people in each practice who are obese3, and then worked out a percentage for each practice. The results are shown in the chart below:
The percentage of adults registered with each Shetland GP practice who are obese 25.0
20.0
15.0
10.0 Percentage
5.0
0.0 Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice A B C D E F G H I J GP Practice
This chart shows that the percentage of obese patients ranges from 4.7% (one in twenty) in Practice H to 20% in Practice J (one in five). So that means that four times as many people in the community covered by Practice J are identified as obese compared to Practice H. That is a significant difference and has implications for how that practice uses resources, and how public health and health improvement resources are directed.
However, these figures do not tell the whole story.
Although many people do visit their GP at least once a year, not everyone does, and not everyone gets their height and weight taken to measure their BMI, and therefore assess whether or not they are obese. So we need to know how many people in each practice actually had their BMI measured. The chart below shows what percentage of patients in each practice actually had their BMI measured.
3 BMI of 30+ 38
The percentage of adults registered with each GP practice that had BMI measured 50.0
45.0
40.0
35.0
30.0
25.0
Percentage 20.0
15.0
10.0
5.0
0.0 Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice A B C D E F G H I J GP Practice
This chart shows that nearly half the patients in practice I and J had their BMI measured, and less than 15% of those in Practice H.
So Practice J which had a high rate of obesity, had actually measured a larger percentage of their population. And practice H which had a low rate of obesity had measured a smaller percentage.
That should not make a difference if you were just measuring a random selection of patients. So either these practices are finding less obesity because they are measuring it less, or the practices are generally measuring those patients who are going to their GP with weight related issues, or who „look‟ obese. So this might give a false picture of the obesity rate in the whole community, because only those presenting to their GPs have been counted.
If we look at the percentage of folk who are obese amongst those who were actually measured, the chart looks like this:
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The percentage of adults registered with each Shetland GP practice who are obese and have had their weight measured 50.00 45.00 40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice A B C D E F G H I J
This chart shows that the percentage of patients whose weight has been measured who are obese in each practice varies between 33.3% and 46.1 %. The rates are more similar across practices, and are generally quite high. This would suggest that practices are fairly consistent in measuring those with weight related issues.
Where we know that practices see the majority of their patients over a period of time, we might expect this to be a reasonable representation of the level of obesity in the practice population. For some practices in Shetland participating in the Keep Well programme for instance, we know that they are in contact with 99% of their patients in terms of recording key risk factors such as smoking and blood pressure in older adults. For other practices, the figure is lower, and the purpose of Keep Well is to reach those patients who are not in contact with the practice who have risk factors that might be dealt with in order to prevent illness or early death.
So if you see a statistic that says one practice has a low or high number of obese patients, you need to drill down further to see the full picture.
Public health campaigns such as Keep Well, Well Man and Well Woman raise awareness of lifestyle issues including obesity, and lead to a larger number of patients being appropriately weighed and risk factors identified. 40
This map shows the varying rates of people in different localities across Shetland identified with a BMI of 30+
BMI:
30 to 35 – moderately obese 35 to 40 – severely obese 40 and over – morbidly obese
Note: this takes the obesity rates from practice data and maps it according to post code, which are then grouped into datazones.
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Diabetes (Type 2)
Diabetes can be divided into two types, type 1 and type 2. More than 85% of diabetes sufferers in Shetland have type 2 diabetes. This is a largely avoidable disease that can be prevented in many cases by lifestyle Type 2 Diabetes by Practice choices. You are more likely to develop rate per 1,000 this disease if you are over 40, have a
80 relative with the condition or have certain 60 genetic pre-dispositions, but being 40 20 overweight is the key preventable risk 0 factor. Type 2 diabetes can contribute to developing heart disease, stroke and certain types of cancer.
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Rate of On Type 2 Type 2 Type 2 Diabetes Diabetes Diabetes % Type 2 Diabetes Practice Register >=17 All Ages Diabetes Population per 1,000 Bixter 45 39 39 86.7% 1148 34.0 Brae 120 118 118 98.3% 2506 47.1 Hillswick 54 47 47 87.0% 729 64.5 Lerwick 368 321 321 87.2% 9062 35.4 Levenwick 115 97 97 84.3% 2688 36.1 Scalloway 135 117 117 86.7% 3209 36.5 Unst 38 34 34 89.5% 582 58.4 Walls 16 16 16 100.0% 698 22.9 Whalsay 42 35 35 83.3% 1140 30.7 Yell 79 75 75 94.9% 1093 68.6
Increasingly Scotland is seeing children with Type 2 diabetes due to lifestyle factors. Fortunately in Shetland we are not yet seeing this problem.
The highest rates locally are in Yell and the Hillswick practice areas with 69 and 65 per 1,000 respectively. The lowest rate is in the Walls practice area. Type 2 diabetes is reversible with a program of regular exercise and a healthy diet. The figures appear to match the obesity figures, in that areas with higher rates of obesity also have higher prevalence of type 2 diabetes (as we might expect).
One of the interests we have in these figures is the possibility of using them to develop work with local communities to think about their health, and to act to prevent some of the avoidable disease and risk factors. Can we do something different to promote physical activity and healthy eating in the localities with the highest rates of obesity and diabetes? We explore this further in later chapters of the report.
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An Assessment of the Health of a Population: Analysis of the Data: Northmavine, Shetland Background
How healthy is the Shetland population? Health can of course be measured in many different ways.
This is an extract of a piece of work done to assess the health of the Northmavine population.
When health is a concern the first point of call is usually the local GP. Prompt, early investigation and diagnosis of ailments hopefully allows for early effective treatment, management and care, leading to cure and/or return to best health.
The aim of this study, working together with the Hillswick general practice, was to understand if there are particular differences / higher morbidity (illness) in the Northmavine population to the rest of Shetland. It describes the population in Northmavine and the prevalence of morbidity in the Northmavine area against the Shetland population using national and local routine data sources.
Northmavine
Northmavine is Old Norse meaning "the land north of the isthmus (Mavis Grind)", and a peninsula of Shetland. It is in the north west of the island, and contains the villages of Hillswick, Ollaberry, Eshaness, Sullom and North Roe. Patients registered with the Hillswick Practice live within the Northmavine peninsula. Some patients living in the area just north of Mavis Grind to Sullom may be registered with the Brae Practice.
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Demography
Population Profile
The age profile of the Hillswick population is comparable to the rest of Shetland.
Deprivation
The Scottish Index of Multiple Deprivation (SIMD) is described in more detail in the chapter on Mapping.
Northmavine can be described as the 6th most deprived relative to the other 31 datazones in Shetland. The individual „domains‟ of Housing and Geographic Access are the characteristics where Northmavine is ranked as being more deprived than the rest of Shetland. Northmavine is one of the nine areas of Shetland in the top 100 most geographically deprived datazones in Scotland.
Epidemiology and known health status: Morbidity
Primary Care Data Analysis
Northmavine has a statistically significantly higher prevalence (number of the population diagnosed at any one time) of asthma, coronary heart disease, heart failure, left ventricular disease, mental illness and depression. Hillswick practice has a high prevalence, lower than the conditions above, but still significant statistically, of individuals diagnosed with hypertension, diabetes and individuals who are categorised as obese. Hillswick has the highest prevalence in Shetland of ex-smokers in each age band above age 45, in both genders. Actual numbers are small, but nevertheless this is particularly relevant. Prevalence of smokers and ex-smokers can be linked to other chronic conditions.
Cancer Referral Data
The data shows us that cancer prevalence in Hillswick is no higher than in other areas in Shetland.
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Hospital In and Out-Patient Data
To better understand morbidity in the Northmavine area, primary care referrals into secondary care and their outcomes in terms of follow-up or admission were analysed. The data highlights that the Hillswick Practice
Has a higher rate of Surgical referrals than other Shetland practices; Has the highest rate of patients who receive and attend a first appointment; Has the 2nd highest rate of referrals which result in an in-patient admission to hospital.
Prescribing data
Hillswick Practice is the highest in Shetland at prescribing drugs used in the treatment of asthma, heart disease and mental illness.
Mortality
Overall Northmavine does not appear to have higher death rates than the rest of Shetland. Over the last 30 years the main cause is heart disease, followed by cancer, and for Shetland in total the commonest cause is cancer followed by heart disease. A number of deaths below the age of 75 in males in Northmavine were from heart disease. We consider these to be „premature‟ and potentially preventable, which fits with our understanding of levels of risk factor and morbidity.
Findings
Northmavine has a statistically significantly higher morbidity of specific chronic conditions in their population. It looks likely that the high prescribing as analysed is related to the high number of individuals diagnosed with these conditions.
Hillswick has the highest prevalence in Shetland of individuals with chronic conditions (CHD, stroke, hypertension, diabetes, COPD, asthma, mental illness) who are still smoking.
Further work is needed to understand the relationship between high referral rates into hospital and the higher morbidity of these chronic medical conditions. The full report of this work provides a detailed analysis of the data presented. 46
Conclusions
A number of the conditions that have a higher prevalence in Northmavine are interrelated and potentially preventable, specifically smoking, hypertension and heart disease, obesity and diabetes.
Preventing disease, prolonging life and promoting health is the cornerstone of public health work.
For the issues we have identified in Northmavine, there is potential to change through promoting a positive social lifestyle, eating healthily and exercising regularly.
This is our collective challenge: a challenge for GPs, other health practitioners and especially for individuals and their communities.
NOTE: In small populations, small numbers can show variations year on year, and even a few people dying at a particular age can make Eshaness mortality data look odd in one year. Using practice data for epidemiological analysis such as this has its limitations because practices enter data for their own purposes, so issues of nomenclature or coding may not be relevant within the practice, but may make a difference to numbers extracted from the database for analysis. Nevertheless the data it holds can be very useful as there are few data sources available locally which are broken down to local geographical areas.
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Communities of Interest
The place we live is an important part of our identity, but even then our sense of place can be complex.
If people don‟t feel part of the community within which they live they tend to feel very unimportant and dissatisfied with their life. Those living in communities within which they were brought up are usually able to rely on local networks of family and friends in times of need. This safety net is less readily available for incomers. For most, communities are welcoming and people feel part of society. However, cultural differences, race, disability, health and past history can make people feel discriminated against, leading to extreme feelings of isolation and exclusion, both from the community and community events.
Quote from Deprivation and Exclusion in Shetland Report 2006
In Shetland we have people from a wide range of nationalities - the 2011 Census identified 1.5% of the Shetland population as being from an ethnic minority, with more than 48 different countries of birth.
Many incomers to Shetland move here for very positive reasons and often make friends for life here, but some may still be far away from family and the social support they have relied on, and sometimes it‟s hard to settle into a new community.
An older person may move into a care home because they can no longer look after themselves at home, and still feel part of the community that they lived in all their life - where their family, friends and neighbours still live.
Or an older person can still live in their own home in a community in which they have lived for a long time, and become increasingly isolated because they are less able to get out and about, or because they outlive friends, and neighbours move away.
Sometimes our geography is a very important part of our lives: for numbers of people living in Shetland our very remoteness may be a part of the positive quality of life we experience, but sometimes it can create problems: such as relying on public transport to
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access services (the mapping chapter showed us how many parts of Shetland can be regarded as deprived because of their remoteness).
Where we live says something about ourselves but of course that‟s only one part of who we are.
We often end up describing people in terms of one aspect of themselves (their job - nurse, their relationship – mother), or their disability as opposed to their abilities!
A person may be deaf, and consider themselves as belonging to the deaf community, but would not want that to be a label that defines everything about them.
In recent work on developing support for carers we have tried to find out about young people A Carer: who are carers (usually caring for a family member who has illness either short or long “someone providing unpaid help and support to a relative, friend or term) but we have had great difficulty in neighbour who cannot manage to live identifying who these young people are locally. without the carer‟s help due to frailty, illness, disability or addiction” The 2011 Census figures report that there are over 2,000 adults in Shetland who are carers Definition from the Community Health and Care Agreement 2013 within the definition:
We don‟t yet have an age breakdown of these „If mum or dad are feeling rubbish figures. Work by the Council‟s Children‟s then I can't go out. I have to stay in Services department (2010) identified 29 young to make sure nothing goes wrong‟ carers in Shetland, but we know this will be an Quote from Deprivation and Exclusion in Shetland 2006 underestimate.
A young person may well not even consider this label for themselves, or want others to think of them in this way. They will certainly not want to be defined only in this way.
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But sometimes the Extract from Advocacy Shetland Carers Research Project 2013 definition is useful. If we
“many carers shared examples of trying to discuss what want to provide services was important to them. Carers feel there are services and support to people in that will allow them to speak but there is lack of follow through from there. Carers are asking to be heard and their role as a carer we for support, through tasks and outcomes to be need to identify them, completed within a reasonable time. Carers clearly named their struggles and concerns encourage them to come throughout this report. For carers in Shetland the main forward for the help that is struggles and concerns are Transport, Respite, Personal Time and Being Heard. Carers are seeking support and available, listen to them need real change in these areas in order to relieve the about what does and level of pressure that is a daily life for them.” doesn‟t work within current services, and act on the things that need to be improved.
So a label can be helpful, but what we don‟t want to do is stereotype or categorise people as opposed to treating them as individuals. Being a carer will be only one part of a person‟s life, though it may at times be a very significant part of their lives. Often Carers‟ Support is about giving carers space and time to live the other parts of their lives as well as their caring role.
…The same goes for other aspects of our lives….
How you describe yourself will vary in different situations, some labels might be more or less helpful at different times, and some are particularly relevant to understanding health.
The reality is that if you‟re from a particular ethnic group you will have a different risk of certain diseases: we know that people from Pakistani and South Asian origin are more likely to have Coronary Heart Disease, and Chinese men and women are much less likely to suffer from Myocardial Infarction (heart attack) compared to white Scottish people4.
4 Scottish Health and Ethnicity Research Strategy Steering (SHERSS) group Annual Report 2012 50
Much of the data used in this research comes from recording the ethnicity of people attending health services and on death certificates, and progress in data recording and analysis has enabled a better understanding of complex issues, such as health inequalities and health behaviours. We don‟t yet have good enough recording of NHS Shetland data on ethinicity to see local results, so at present we must rely on national research.
There are other characteristics in relation to which we might expect people to have a different experience of health or illness.
As a gay man you have a higher likelihood of contracting HIV because it is more common amongst men who have sex with men. How it affects your life may well have a lot to do with the community in which you live as well as your individual and personal circumstances: whether you encounter stigma or acceptance, how you feel about yourself and your situation, how quickly you seek medical advice and get early treatment for any AIDS related illness.
That doesn‟t mean that you are or should be defined only by your sexuality or your health.
There is a difference in being defined by a disability or illness that you live with, and other people understanding what impact this might have on your life. Treating each other as individuals with understanding, awareness and sensitivity is what we all want.
At the same time, understanding how many people in a community are affected by a particular problem, or are living in a specific situation, might help us identify those people, work with them to plan services, shape what we do to make our service better suited to meet their needs – whether that is access to public buildings for people in a wheelchair, or making interpreting services available to people without English as a spoken language, or targeting smoking cessation services to the areas in Shetland where most smokers live.
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There are limits to looking at problems geographically: we might know that a particular area has a higher proportion of older people living there, but of course not everyone in that area is elderly. Similarly we can show some areas in Shetland with higher levels of deprivation, knowing that not everyone there is living in deprived circumstances. In fact, the majority of people in an area labeled as deprived will not be living in deprivation, and the majority of those who are deprived live outside of areas labeled as more deprived.
In Shetland we have to understand a more individualized approach to people‟s experience. In a rural area such as Shetland, where deprivation is dispersed, the best way to tackle poverty and social exclusion is to understand it at an individual and household level.
Those individuals who are particularly vulnerable are:
young people whose parents cannot support them to access opportunities and grow up feeling a part of the community within which they live;
adults of any age who have low self-esteem and/or poor mental health, often due to situations which have developed as a result of negative experiences in the past and can result in homelessness and substance misuse. This is particularly acute if their situation is not understood by the community within which they live;
those who are physically disabled or with a long-term illness and their carers, when they do not receive adequate support and understanding;
those looking after a young family without access to their own transport, particularly those living in remote areas of Shetland;
older people unable to access opportunities that would enable them to feel a part of the community.
There is also evidence of social exclusion for ethnic minority individuals in Shetland, whether cultural or as a result of employer barriers, and of degrees of social exclusion for white incomers to Shetland.
A Fairer Shetland - A Framework for Tackling Poverty, Disadvantage and Social Exclusion in Shetland 2013/14
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However, action needs to be at both individual and community level. Outcomes are about „the quality of life, opportunities in life and living circumstances of individuals and communities‟.ii We cannot improve that without an integrated and holistic approach to the whole of people‟s lives - dealing with the lives of individuals and communities in the round.
For any individual outcome to change and improve will require others to change and that requires targeting the whole way that community lives: its expectations, opportunities, values and behaviour. Targeting individuals case by case in isolation from the rest of a community‟s life and in the absence of change at community level does not work.
So, understanding and valuing the experience of individuals, and the communities in which they live, work and play, communities of interest as well as geographical localities, gives us a better basis on which to plan, to develop, to grow solutions to our problems.
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The next section of the report describes a range of projects involved with different ‘communities of interest’ and how they relate to people’s health and wellbeing in Shetland.
Keep Well The Keep Well vision is to work with primary care services to improve health in deprived communities through „anticipatory care‟ ie prevention.
Keep Well checks
In the Keep Well programme, individuals aged between 40 and 64 living in areas of high deprivation are invited to attend a health check. The checks include screening for cardiovascular disease (CVD) and its main risk factors, such as high blood pressure, cholesterol, smoking, diet, as well as discussions around wider life circumstances that might be a barrier to health such as employment and literacy.
Over the years, Keep Well has developed differently in different areas across Scotlandiv. Fundamentally, though, the programme is about changing the way that we deliver services. There are three dominant elements in common across Scotland:
Changing the way that care is delivered: the Keep Well Programme should support organisations to operate more effectively as a system and deliver consistent inequalities sensitive care which is more able to reach, engage and improve outcomes for those in greatest need. Focusing on clinical risk factors: the Keep Well programme should identify individuals at high risk of serious preventable ill health and provide appropriate clinical or other treatments to reduce their risk. Empowerment and co-production: the Keep Well programme should identify those at high risk of serious preventable ill health and support them to take control over aspects of their lives that impact adversely on their health and thus improve their health and wellbeing.
These aims fit entirely with the NHS Shetland Public Health Ten Year Plan and the ways that we should be working to reduce inequalities in health and prevent future ill health where possible.
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The approach used locally to target patients living in the most deprived areas has been through a combination of SIMD areas, and a whole practice approach where we can‟t differentiate geographical areas of deprivation. Remote and rural deprivation affects individual households which are scattered throughout the community; therefore geographical definitions don‟t work so well.
Cardiovascular disease is a key driver, as is a practice understanding the non-health services that are available to patients, such as support into employment. The people coming through the Keep Well programme may have social problems such as lack of money and poor housing, and the Keep Well check is a real opportunity to consider potential solutions to some of these issues.
Work and Worklessness
People are often defined by the work that they do: she‟s a teacher, he‟s an electrician.
„The Chance to Work in Scotland‟, published by NHS Health Scotland in June 2013, demonstrates that work, along with education and income, is one the key social determinants of health.v Death rates and illness (including mental ill health) increase among those who suffer from unemployment, and reduce among those who gain good work.vi vii viii Reducing inequalities in employment, and improving access to decent work, can make an important contribution to narrowing inequalities in health.ix x
In 2012, between 180 – 207 of working-age adults in Shetland were claiming Jobseekers Allowance.
And work is not a panacea. In 2010/11, 320,000 people in Scotland were living in poverty despite having at least one household member in paid employment – and poor quality, poorly paid work can be almost as damaging to health as no work at allxi.
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Work: Employment is generally the most important means of obtaining adequate economic resources, which are essential for material well-being and full participation in today‟s society;
Work meets important psychosocial needs in societies where employment is the norm; Work is central to individual identity, social roles and social status; Employment and socio-economic status are the main drivers of social gradients in physical and mental health and mortality;
Unemployment: There is a strong association between worklessness and poor health. This may be partly because if you have poor health it may be harder to work, but there is also strong evidence that unemployment is generally harmful to health, including:
higher mortality; poorer general health, long-standing illness, limiting longstanding illness; poorer mental health, psychological distress, minor psychological/psychiatric morbidity; higher medical consultation, medication consumption and hospital admission rates.
Re-employment after having been out of work for a period of time, leads to improved self-esteem, improved general and mental health, and reduced psychological distress and minor psychiatric morbidity and there is a long list of the benefits for sick and disabled people working when their health condition permits.
Work can be therapeutic and can reverse the adverse health effects of unemployment. That is true for healthy people of working age, for many disabled people, for most people with common health problems and for social security beneficiaries. The provisos are that account must be taken of the nature and quality of work and its social context; 56
jobs should be safe and accommodating. Overall, the beneficial effects of work outweigh the risks of work, and are greater than the harmful effects of long-term unemployment or prolonged sickness absence. Work is generally good for health and well-being.xii
The Bridges Programme, Shetland - About 10 per cent of the 300 Shetland school leavers each year struggle to follow a path into further education, employment or training. Bridges is run by Shetland Council through a separate building which has a very relaxed and welcoming feel and offers an alternative learning programme for young people aged 15-19 years. The small team of support workers recognise that whilst young people may have particular needs - for example around self esteem, behaviours and interactions with others - their aspiration for making the most of their potential is no different from any other young person. They concentrate on the individual person as an asset and help them gain the confidence to decide their own future, while also building core skills and relationships.
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Suicide and Sudden Death
A real example of where we have used mapping locally to understand a problem is with suicide and sudden death.
Let‟s talk about Suicide Prevention in Shetland‟
The annual statistics for suicide 2012 show that Shetland has the highest rate of death by suicide in Scotland. Karen Smith, Choose Life Coordinator for Shetland, stated in a local press release:
“In the context of Scotland, 7 suicides is a tiny number. But within Shetland 7 lives lost to suicide is too many. The impact these losses have on individuals, families and communities cannot hide behind statistics. Every life lost is a tragedy, every life lost is significant. Whilst we cannot prevent every suicide we would like to understand what can be done to make a difference to people who are thinking of suicide.”
So, how much of a problem with suicide do we have in Shetland? What is the nature of the problem, and what do we need to know to do our best to deal with it?
We know the number of suicides that occur, and we know from recent numbers that the numbers appear to have been rising.
Numbers of deaths by suicide in Shetland 1982 - 2012
10
8
6 Males 4 Average 2
0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
The average is calculated to show the trend over time.
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In most large Board / Local Authority areas if we saw this we would show the data in different ways to get a better understanding - we might map it geographically so that we could see in more detail WHERE the problem is.
And with suicide since we know it is more likely amongst people who are unemployed / living in poverty we might expect to see the numbers focused in areas of deprivation.
But in Shetland our numbers are so small that we can't helpfully show it geographically spread.
We also know that there are features around suicide that are less likely to show up in where people live and more about their individual characteristics. - such as the risk for people living with severe and enduring mental illness, or those living with We have analysed the statistics in terms of: alcohol and drug misuse. Cause of death Known history
Method of death Male/female
When we looked at the known histories Age group Location of death of people who had committed suicide, Month of death Employment or we found the following characteristics: unemployment
Problems identified in people committing suicide in Shetland: From the data we know that we are
Mental Health 30 seeing a higher proportion of Alcohol/Drugs 19 unemployed amongst those Depression 18 Relationship 10 committing suicide than within the Bereavement 7 general population, and more Previous attempts 6 Previous threats 5 people from blue collar / trade / Drugs 2 technical jobs than we might expect Financial 1 compared to national statistics,
(The numbers add up to more than the number of which probably reflects local suicides/sudden deaths because some people had more employment patterns in Shetland. than one characteristic).
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We can see how it is more helpful to show features of the data other than the geographical spread: when we describe and understand the characteristics of the people in Shetland who have committed suicide or have suddenly died, and then we understand the 'communities of interest' or the non-geographical localities that are most helpful to use in work on raising awareness and prevention.
For instance knowing that there are more „Blue collar‟ single handed workers, men between 30-39 (slightly higher than men 40-49) and that alcohol plays a big part, either at the time of death, or as ongoing alcohol issues for that individual.
There is evidence that marriage has a protective buffering effect against socio- economic inequalities related to suicide, particularly for men. Also married men are less likely than non-married men to have problems with drugs, sex, gambling and having used or currently using medication for psychiatric illness.
There is good evidence that resilience factors are better predictors of suicidal behaviour than the amount of exposure to stressful life events.xiii So this can help us develop strategies for prevention, in terms who might be most vulnerable, what to look out for in our friends and colleagues who might be vulnerable at times in their lives, and what Suicide. we can do to help in practical terms. We can‟t entirely Don't hide it. Talk about it. prevent the difficulties that If you are feeling suicidal, the best thing you can do is life brings, whether that is talk. financial hardship, Speak to someone you trust or call a helpline. relationship breakdown, bereavement or mental Breathing Space 0800 83 85 87 Lines open 24hrs at weekends illness. But we can support people we know to protect Samaritans 08457 90 90 90 themselves, we do know Lines open 24hrs some of the things that help
people cope better, we can help folk build resilience and reasons for living.
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Older People and their Medicines
WHAT WE KNOW
Being old, part of the „elderly population‟ is one „community of interest‟ that we all might hope to be a part of one day – inevitable and not without its pain and pleasures.
As we get older we are more likely to be living with illness, and more likely to be taking medication on a regular basis, as well as for immediate problems. We know that polypharmacy (taking lots of different medicine) is common in the frail elderly population and so the potential for side effects and problematic drug reactions is increased. We can potentially prevent some unnecessary hospital admissions by reducing adverse drug effects.
Professor John Cromarty The Royal Pharmaceutical Society. Patients on multiple medications need to be Polypharmacy is an increasing fact of life. For carefully monitored as many some patients however, and particularly for the frail elderly, the side effects of particular medicines drugs have the potential to and medicine combinations can outweigh their interact. When this happens benefits’ medicines start to work less Important Polypharmacy Guidance issued by the Scottish well and sometimes become Government – RPS News 2012: http://www.rpharms.com/what-s-happening- more toxic So the patient feels /news_show.asp?id=691 worse and receives less (if
any) benefit from the medicine.
Research and national guidance xiv, xv has highlighted the need for a change in the way medicines are managed in the frail elderly population and particularly those living in care homes.
Being careful and thoughtful about medicine prescribing and administration should help to improve quality of life and keep people safe. Often having a close look at the medicines people are taking through a system such as medication reviews, will lead to a reduction in the number of medicines prescribed. This often leads to improving wellness and quality of life.
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In addition there is a cost benefit demonstrated simply by reducing the overall number of medications people take. Increasingly pharmacists who are seen as experts in complex medicine regimes do these reviews in conjunction with the patient‟s doctor.
WHAT WE DID LOCALLY
Medication Reviews took place in four care homes in Shetland, The medicines patients were taking and their effects and benefits in each individual case were carefully considered with the patient and carers or family as appropriate.
Changes took place that made sense medically, and the resulting information was used to evaluate potential cost savings. From the actual figures the cost was extrapolated over a 12 month period to give an estimation of the annual savings that had resulted from undertaking medication reviews. The potential savings per annum were then calculated for the 150 medication reviews that need to be done in Shetland.
In addition to this the potential for avoiding emergency hospital admissions was calculated using information from Scottish government publications and news reports, with an estimate of resulting cost savings.
Together these figures gave an overall value for the possible savings that could be made as a result of undertaking medication reviews.
WHAT WE DISCOVERED
Figure 1 details the overall changes made to patients medications in 4 care homes in Shetland. On average medication reviews saw 10% of medicines which were no longer benefitting the patient being discontinued and a further 7% being changed to a more appropriate choice.
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Figure 1
Overall Changes to Medication 180 160 Number of Changes 140 Number Discontinued 120 Initial Number 100 80 60
No.Of Medicines 40 20 0 MSS ET House Taing House Viewforth
Figure 2 Indicates the savings made in four care homes in Shetland as a direct result of undertaking polypharmacy reviews in 2012.
Figure 2
Savings - 12 months No. of Patients Savings per patient MSS £712.12 8 £89.02 ET House £3,675.36 14 £262.53 Taing House £2,368.68 10 £236.87 Totals £6,756.16 32 £588.42
In addition savings from „avoided emergency admissions‟ can be estimated from a 2010 BBC news report which suggested that 4.9 million unplanned admissions cost the NHS £11billion per year.xvi This equates to each admission costing £2,245 per patient). Information from national databases suggests that adverse drug reactions are implicated in 5-17% of hospital admissions.xiv We can estimate that for our group of 150 patients there will be perhaps 15 emergency admissions annually as a result of adverse drug reactions.
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So in Shetland there is the potential through undertaking medication reviews for a total Case Study One saving of £67,350, which coupled with the John takes omeprazole 40mg daily to £33,600 in drug costs would result in total treat his stomach ulcers alongside other medications, 40mg omeprazole capsules savings annually of £100,950. However, the are 4 times more expensive than the 20mg biggest benefit is the benefit felt by patients capsules. This is a high dose. Medication review saw this dose being changed to when they carefully stop taking medicines 20mg daily resulting in a cost saving of that they no longer need. £197.64 over a year and no change in the patient’s condition.
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Building Community Capacity
In the 2011 Public Health Annual Report we stated that „a great measure of success would be if we were no longer needed‟ – a rash statement, perhaps! But we were talking about the potential for health improvement, both at individual and community level to significantly reduce ill health and premature deaths in Shetland.
The Public Health Ten Year Plan, written in 2012, described the need for investment in prevention now, in order to save money through reductions in preventable illness and death in the future. This investment isn‟t just in terms of money for projects and programmes; sometimes the investments by people in their communities can be worth much more and last much longer: taking responsibility for your own health and seeing autonomy and self-determination as health goals, and raising the self-esteem of individuals and communities through valuing their knowledge and experience.
We have tried this approach in health improvement for years, but have focussed on building the capacity of other health practitioners. For example, some of our staff are trained to deliver specialist smoking cessation services, with an expectation that practice nurses would support patients routinely. We provided the training and ongoing support in order to increase skills and confidence...we weren‟t particularly thinking any wider than that – that communities could start to take responsibility for health improvement for themselves, for example.
Community capacity building involves activities, resources and support that strengthen the skills and abilities of people to take effective action and leading roles in the development of their communities.
But successful capacity building relies on co-production which means doing things with people, not to them or for them. A French poster from 1968 describes what might happen if we don‟t work together:
French student poster.
In English, "I participate, you participate, he participates, we participate, you participate...they profit." 1968 65
Co-production offers the potential to bring about imaginative solutions to problems, and even if there isn‟t an obvious solution, or a solution which pleases everybody, at the very least people may understand the reasons why things can‟t necessarily be what they want them to be, or understand the constraints that have to be considered.
Arnstein‟s ladder of participationxvii was developed in the 1960s to describe the differences between true citizen participation, decision making and engagement and more tokenistic forms of interaction with communities.
The idea is simple: people who use services know what they want out of them, and should be involved in shaping them. Using this approach brings service users, their families, friends and communities together as the „design team‟.
The Christie Commissionxviii which reported in 2011 emphasised the need for public services and communities to work not only more closely together but in different ways:
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in this time of less money, we need to find effective ways to make the most of everyone‟s ideas, solutions and resources.
We need to work WITH local communities in Shetland, at neighbourhood level, to shape Insanity: doing the same services and to build on the potential of thing over and over again individuals and the strengths of the community – and expecting different results from it we can no longer rely on the traditional public Albert Einstein 1879-1955 services to carry on providing in the way they have been – this system is not sustainable and it doesn‟t help those in greatest need.
People experiencing positive outcomes tend to control and direct their own lives and make selective and periodic use of public services as a resource to support the lives they wish to lead.ii If we understand households and communities with negative experiences in the same way, they use public services in a more reactive and recurrent way and struggle to use them as a resource for positive outcomes ie they don‟t get the best out of them. Public services are resources that individuals and communities are more or less able to use to achieve quality of life and opportunity in life.
Communities with high quality of life get real value out of public services such as schools, GPs, cultural and leisure assets etc. Those who are less able to „co-produce‟ and use public services as a resource in their lives, experience much more negative outcomes. Their children don‟t get the best out of school, their health is worse and the health service doesn‟t work so well for them, they can‟t afford to get into leisure centres so don‟t get the benefit. So work to develop assets-based approaches and co- production, is about working with those with least, to shape services to better meet their needs, to enable these individuals and communities to use such resources more effectively and get better value from them.
To change the experience of those who are worst off, we need to deal with the lives of individuals and communities in the round.
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Wellbeing:
If you talk to people about health, a large part of their response is about the range of aspects of their lives, only a part of which is their physical health.
In previous Public Health Annual Reports we have talked about definitions of health that take an holistic approach – being healthy is not just about not being ill (either physically or mentally), it is also about a range of factors in people‟s lives that add up to well- being, much of which is about social, economic, environmental as well as personal characteristics.
The model of Fundamental Human Manfred Max-Neef, a Chilean economist, talks about Fundamental human needs Needs as described by Manfred Max- as: Neef [http://www.max-neef.cl/] is
interesting because it describes needs Subsistence Leisure as what make up the human condition,
Protection Creation and considers them as few, finite and classifiable, as distinct from the Affection Identity conventional notion of „economic‟ wants Understanding Freedom that are infinite and insatiable.
Participation He considers them to be constant through all human cultures and across historical time periods. What changes over time and between cultures are the strategies by which these needs are satisfied.
In this system, there is no hierarchy of needs (apart from the basic need for subsistence or survival). Rather, they are a system, interrelated and interactive; satisfying them is a process of trade offs and synergies. He also used them to describe a process by which communities can identify their "wealths" and "poverties" according to how their fundamental human needs are satisfied. We find this helpful in thinking about building our resilience, as people and as communities.
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It is also helpful in putting „freedom‟ and „participation‟ at the heart of wellbeing: we know that people‟s optimism and belief, passion, "control of our own destiny", are characteristics of well-being and of success. Being opportunistic, creative, being good at problem solving, resource-finding, are what make individuals and communities thrive, along with „It takes a village to raise a child‟ being caring and compassionate. African proverb These characteristics are also what drives change, and living positively through change is a necessary survival tactic for the human race – being able to step away from what we've always done, and create what we need.
This might translate into „doing things by ourselves, for ourselves‟ and wanting to build resilience and grow self-reliance. But of course, we vary in how well equipped we are as individuals and communities, to cope with the day to day experience of living, and to “A nation‟s greatness is cope with adversity. measured by how it treats its weakest members.”
Mahatma Ghandi
We have some amazing local examples of where communities (whether geographically based, or sharing common characteristics or interests) have or are coming together to design solutions to the problems affecting them. Three examples of assets-building through co-production and community capacity building in action are shown below, one that has already happened, one that is in the planning stages, and one is an example from Lanarkshire that we might usefully learn from:
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Glasshouse, Baillister, Tingwall – A Community Growing Enterprise?
From this…..………………………………………to this? Photo by courtesy of ‘Good for Ewe’
Transition Shetland (TS) was set up in 2010 to raise awareness in Shetland about the challenges of peak oil, resource depletion and climate change by working with others to develop a low carbon, sustainable and resilient future for the islands.
The Tingwall glasshouse has lain idle for several years and TS believes it should, if possible, be brought back into use for growing food.
The group is currently carrying out a Feasibility Study into converting the building into a Community Growing Centre, which could help satisfy demand for growing space under glass; The project has the potential to increase awareness about growing food locally and substantially reducing Shetland‟s reliance on food imported from the UK mainland and beyond.
To take the project forward the community has to examine the idea in great detail and establish whether, and if so how, it could be made to work and a satisfactory conclusion would allow TS to seek the appropriate funding to deliver the project.
It is important to TS that whilst being financially sustainable the glasshouse would also function for community good and be acceptable to the individual members and community organisations that might take an active role in this enterprise.
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Such community groups might include those already engaged in providing work experience or work programmes for their clients, youth volunteering groups, befriending schemes, schools, groups working with the disadvantaged etc.
It is envisaged that the feasibility study will result in outputs that include a mandate from the community to proceed with the project, a funding feasibility analysis and a business plan for the first three years.
Salmon pipes bear fruit (an' veg)
The Northmavine Community Development Company (NCDC) obtained £41,821 from Climate Challenge Fund (CCF), to develop redundant salmon cage equipment into 12 community polytunnels in the parish.
The project is part of the remit of Northmavine Community Powerdown officer, Colin Dickie, who is employed by the NCDC to find ways of reducing Northmavine's environmental impact and also to reduce fuel costs for local people, where possible.
A significant part of Colin's job is to find ways of increasing local food production to reduce food miles and encourage healthier ways of eating. Due to the tremendous enthusiasm in Northmavine for horticulture, the community polytunnel concept was born. Landowners and crofters have pledged land to 'host' twelve polytunnels throughout Northmavine. Each 'host' has offered spaces in the structure for other members of the community to use.
The frames for the structures were created from recycled pipe from salmon farms clad with rigid polycarbonate sheeting to help withstand the Shetland weather. Redundant walk-ways from the salmon cages were used as paths within the poly tunnels.
Over the past few months the NCDC has rescued almost 5 tonnes of walkway and feed pipe. This equates to around one kilometre of plastic pipe. Reuse will mean reduction in disposal costs for salmon farms and a diversion of the materials from landfill. David Brown of Shetland Seafarms has been especially helpful and has gone out of his way to help with this project.'
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In addition to the environmental and health benefits the community poly tunnel project can bring, Colin sees a wider social benefit to Northmavine. As he explained, 'The poly tunnel project will allow folk of all ages to work together and share their experiences and skills. It's an ideal way of younger folk learning from older, experienced growers. A project such as this brings folk together and provides a common interest that everyone can benefit from'.
Although the number of poly tunnel "hosts" for the project is nearing capacity, Colin is still keen to hear from anyone in Northmavine who would like more information about the venture. The NCDC is also keen to stress that the poly tunnel concept is easily replicated and could be undertaken by any individual or community in Shetland.
Building a service for Older people in Lanarkshirexix – this is an example from elsewhere that might well be used locally to start to determine what a particular community needs and how they might shape it themselves.
In 2009, NHS Lanarkshire and North Lanarkshire Council undertook A Review of Integrated Day Services For Older Adults. The review was conducted very much in
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conjunction with the older people who were the potential users of services. 40 people were surveyed and were asked the following questions:
What do you do with your day now? What do your friends and family do? What would you like to do? What stops you doing this? Where, in your community, could these activities happen?
Staff in the area team, housing office and day hospital services were also involved.
The data gathered from individual interviews indicated that the vast majority of people were very lonely and isolated, with almost 80% spending their day alone watching television or reading.
When people were asked what they wanted to do, 100% stated that they wanted to meet others, the majority (80%) expressed a desire to go to local clubs, 60% wanted to go shopping, 30% to the bookies or pub and 10% wanted to access the cinema, or local church.
It became clear that very few people had access to information about what was available in their community, others had lost confidence in going to places on their own or in meeting new people and some people had significant health needs that resulted in them needing transportation and sometimes support to get out of the house.
What was really interesting was that although all of those interviewed were on a waiting list for day care, no one asked for a day care service and each person was able to identify other resources in the community where they could access activities in line with their interests.
The project has moved on, with the establishment of Locality Link Officers, whose role is to identify alternative resources in the wider community and assist older adults to engage with them. In this way many of the problems of loss of confidence and lack of information are overcome.
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The project team felt that there were a number of factors about the way they worked that allowed success. These factors were considered to be:
Openness Mutual trust and respect Commitment Ability to compromise Shared beliefs and values Sustained effort
The service was designed with the expectation that the following outcomes and benefits of an integrated service would be delivered:
A smoother journey for the person through services A reduction in crises through early intervention and identification A person-centred approach across the agencies A faster response to changing needs A reduction in duplication of assessments Increased staff confidence Designing solutions to changing needs together.
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References
i www.shetland.gov.uk/community_planning_dev/community_work_whatwedo.asp ii Making Better Places: Making Places Better. The Distribution Of Positive And Negative Outcomes In Scotland. Colin Mair, Konrad Zdeb & Kirsty Markie. Improvement Service Scotland 2011 iii Source: ISD. Practice Team Information (PTI) Annual Update 2011/12. https://isdscotland.scot.nhs.uk/Health-Topics/General-Practice/Publications/2012-11-27/2012- 11-27-PTI-Publication-Summary.pdf?27445620299 iv National Keep Well Evaluation report v Taulbut, M., McCartney, G. The chance to work in Scotland NHS Health Scotland 2013 http://www.scotpho.org.uk/downloads/scotphoreports/scotpho130624_thechancetowork_report. pdf vi Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life and livelihood: A systematic review and meta-analysis of unemployment and all-cause mortality. Social Science & Medicine, 72(6), 840–854; 2011. vii Bambra C, Eikemo TA. Welfare state regimes, unemployment and health: a comparative study of the relationship between unemployment and self-reported health in 23 European countries. Journal of Epidemiology and Community Health, 63, 92-98; 2009. viii Brown J, Demou E, Tristram MA, Gilmour H, Sanati KA, Macdonald EB. Employment status and health: understanding the health of the economically inactive population in Scotland. BMC Public Health, 12, 327; 2012. ix Marmot M, Atkinson T, Bell J et al.. Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010. The Marmot Review; 2010. x Scottish Government. Equally Well: Report of the Ministerial Task Force on Health Inequalities - Volume 2. Edinburgh: The Scottish Government; 2008 xi The Chance to Work in Scotland. An NHS Health Scotland publication June 2013 xii Waddell, G., and Burton, A.K 2006 London: The Stationery Office https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/214326/hwwb-is- work-good-for-you.pdf xiii Scottish Government Social Research: (2008) Risk and protective factors for suicide and suicidal behaviour: a literature review http://www.scotland.gov.uk/Resource/Doc/251539/0073687.pdf xiv Polypharmacy Guidance October 2012 – Scottish Government (adverse reactions to medicines are implicated in 5 - 17 per cent of hospital admissions) xv Improving pharmaceutical care in care homes – RPS Scotland 2012 75
xvi Triggle N, Emergency hospital admissions 'unsustainable' for NHS, BBC, 2010. Available from: http://www.bbc.co.uk/news/10490508 xvii Arnstein, Sherry R. (1969) A Ladder of Participation, Journal of the American Institute of Planners, Vol 35, No.4 xviii Christie, C., 2011 Commission on the future delivery of public Services http://www.scotland.gov.uk/Resource/Doc/352649/0118638.pdf (accessed 27.09.13) xix Working Together, Learning Together; Improving Outcomes for Older Adults in Lanarkshire A review of integrated day services for older adults (2008) Joint Improvement team, NHS Lanarkshire and North Lanarkshire Council
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Glossary, Acronyms & Abbreviations
BMI Body Mass Index CCF Climate Challenge Fund CHD Coronary Heart Disease COPD Chronic Obstructive Pulmonary Disease CPP Community Planning Partnership Datazone Key small area statistical geography in Scotland DLA Disability Living Allowance GIRFEC Getting It Right For Every Child – this is Scotland's approach to supporting children and young people and is an important part of child protection policy. It requires that services aimed at children and young people - social work, health, education, police, housing and voluntary organisations - adapt and streamline their systems and practices and work together, particularly on information sharing. The approach encourages earlier intervention by professionals to avoid crisis situations at a later date. GP General Practitioner GRO General Register Office (of Scotland) NCDC Northmavine Community Development Company PIP Personal Independence Payment QOF Quality and Outcomes Framework Quintile One of five classes where the population is divided equally into those classes SALSUS Scottish Adolescent Lifestyle and Substance Use Survey SIMD Scottish Index of Multiple Deprivation
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