THE HEALTH OF THE PEOPLE OF WEST DUNBARTONSHIRE

Needs assessment report

July 2007

0 Contents Page No.

SUMMARY 2

1. Introduction and general aspects 14

2. Historical aspects and geography 18

3. Demography and socio-economic determinants of health 19

4. Life-style and behaviour 24

5. Mortality and life-expectancy 29

6. Cancer 31

7. Coronary Heart Disease 34

8. Cerebrovascular Disease - Stroke/TIA 44

9. Diabetes 48

10. Chronic Obstructive Pulmonary Disease 50

11. Child Health 53

12. Mental Health 54

13. Local provision of Primary Care Services 57

14. Local provision of Secondary Care Services 59

15. Activity in Secondary Care 60

16. Waiting lists 64

17. Palliative care 65

18. Healthcare provided by the independent sector 69

19. Transport and Access 71

20. Conclusions 73

21. Recommendations 74

22. Bibliography 77

23. Appendices 80

1 1. SUMMARY OF KEY FINDINGS

The term ‘Needs Assessment’ is often used synonymously with the term ‘Health Needs Assessment,’ to mean an assessment of need based on the health status of the population. For the purposes of this report, we are accepting a broad definition of ‘health needs’ to include those needs that are amenable to both clinical (NHS) and non-clinical (socioeconomic) interventions, in keeping with the ‘wider determinants of health’ theme of the report.

This assessment of the health needs of West Dunbartonshire residents emphasises the importance of poverty and disadvantage in the creation of poor health. The key findings of high levels of health damaging behaviour and chronic diseases emphasise the need for effective community and primary care health improvement services.

Geographical and historical aspects

West Dunbartonshire is located to the West of Scotland with a total population of approximately 92,000. The area of West Dunbartonshire CHP is coterminous with that of West Dunbartonshire council. West Dunbartonshire lies north of the River Clyde and encompasses the urban communities of Clydebank, Dumbarton, Balloch, Alexandria and Renton. There is also a more rural area that runs south of Loch Lomond.

The area conforms, in many respects, to the pattern of industrial and post-industrial phases of other urban centres in Scotland and elsewhere in the UK. Clydebank, Dumbarton and the Vale of Leven were important urban centres for manufacturing and shipbuilding during the industrial revolution, and this led to the development of a large local working class mainly dependent on shipbuilding for employment. Small residual clusters of asbestos-related disease are an unwelcome part of the legacy of that bygone industrial and shipbuilding era.

The status of Clydebank as an important industrial centre meant that it became a target for bombing raids during the 2nd World War and had to be largely rebuilt in the years that followed. In the post-industrial phase of its development, the area also became host to ‘overspill’ populations from Glasgow, and in consequence of this, it shares some of the social problems of the peripheral housing estates in its city neighbour

Demography

Like many council areas of the West of Scotland, West Dunbartonshire has a falling population, particularly in the younger age groups. As death rates continue to fall in West Dunbartonshire, the elderly will make up an increasing fraction of this smaller population. The resulting age distribution is similar to that for the rest of Scotland.

At the same time, it is predicted that there will be more individual households, and therefore greater demand for housing, as more people will be living alone or in single parent families. Single parent households in West Dunbartonshire (14.3%) are significantly more common in West Dunbartonshire than in Scotland as a whole (10.5%). Single lone mothers are rising most rapidly as the head of a subgroup of single parent families in West Dunbartonshire as well as across Scotland. Pensioner households now make up 23% of households in West Dunbartonshire (similar to the Scottish average); many of these elderly people will have multiple chronic diseases and some will be living in isolation and deprived conditions. All

2 these demographic changes have implications for healthcare and social services, particularly community care and services for older people.

Socioeconomic determinants of health

West Dunbartonshire is a socio-economically mixed area that has considerable pockets of severe under-privilege. According to the Scottish Index of Multiple Deprivation (SIMD), West Dunbartonshire has far less of its population living in the most deprived 1% of data zones than either Greater Glasgow and Glasgow City. In 2004, 37% of the West Dunbartonshire population lived in the 20% most deprived datazones compared to 20% for the Scottish population. According to the Carstairs Deprivation Score, the socioeconomic profile of West Dunbartonshire deteriorated significantly between 2001 and 2004.

In addition, West Dunbartonshire has experienced an economic downturn over the past 10 years whereas Glasgow City is experiencing an economic boom. As a result, unemployment is high in West Dunbartonshire (second only to Glasgow in a national league table of ‘employment deprived’) and there is a heavy reliance on low wage, part-time jobs and state benefits. Almost one quarter of the West Dunbartonshire population have all their income from state benefits, a similar percentage for Glasgow City. Significantly, the average wage in West Dunbartonshire is the lowest of all West of Scotland councils and is 10% lower than that in Glasgow City (12.3% lower than Scottish average wage), perhaps explaining why self-reported difficulty making ends meet was much higher in West Dunbartonshire than in Greater Glasgow in the 2005 Health and Wellbeing Survey. This impacts on the quality of life for West Dunbartonshire’s children, 25% of whom qualify for free school lunches.

Finally, of some concern are the high per capita rates of domestic abuse incidents and crime where West Dunbartonshire assumes top position and second position, respectively, in comparative league tables of West of Scotland councils. Relatively high drunk-driving rates also implicate alcohol in the aetiology of dangerous and illegal behaviours.

Despite the similar nature of socioeconomic deprivation experienced in West Dunbartonshire compared to Glasgow City, and the fact that by some measures the extent of social deprivation is less than that experienced in Glasgow City, the health and well being survey revealed a considerable number of areas where West Dunbartonshire residents responded more negatively than their Greater Glasgow counterparts.

These issues will require considerable and concerted multi-agency efforts, involving both the public and private sector. Unless these socio-economic determinants are successfully addressed, the current difficulties faced by roughly 25% of the West Dunbartonshire population can be expected to continue. This will have important knock-on effects in terms of unhealthy lifestyle, increasing prevalence of risk factors and disease.

3 Unhealthy lifestyles

The effects of unemployment and poverty in West Dunbartonshire have been exacerbated by the adoption of unhealthy lifestyles. A significant published literature links poverty with unhealthy lifestyle and premature death, complicated by a sense of loss of control and disempowerment. Unhealthy lifestyles are self-reported in the NHSGG&C Health and Wellbeing Survey of 2005 and can be compared to a wide range of statistics in Greater Glasgow. This demonstrated considerably higher prevalence of smoking, excessive alcohol intake, binge drinking, higher consumption of junk food and lower uptake of physical exercise amongst West Dunbartonshire residents compared to their Greater Glasgow equivalents. Drug misuse is a problem in West Dunbartonshire although far less common than in some parts of Glasgow City.

These problems will need to be tackled with more assertive and more imaginative health improvement initiatives aimed at making it easier and more enjoyable to adopt healthier lifestyle habits.

High prevalence of risk factors

It is also clear that unhealthy lifestyles have translated into higher prevalence rates of the risk factors for serious disease and premature death. These include high blood pressure, obesity/overweight, poor oral health and diabetes as reported by various sources including the primary care reporting systems1 and Health and Wellbeing Lifestyle survey. All these risk factors will need to be proactively identified in the community and treated using pharmacological and behavioural approaches before they progress to frank disease. Primary and secondary coronary heart disease prevention schemes currently being considered for West Dunbartonshire by NHSGG&C should help to bring these risk factors under control.

High prevalence of chronic disease

Not surprisingly, the high prevalence of risk factors has translated into high prevalence rates of common chronic diseases that are also the main causes of death in Scotland and significant causes of hospitalisation, namely coronary heart disease, smoking-related cancer, stroke, chronic obstructive pulmonary disease, and diabetes. Alcoholic cirrhosis in West Dunbartonshire has been climbing since 1985 and more steeply than anywhere else in Scotland, which itself exceeds European rates. Coronary heart disease, cerebrovascular disease (including stroke), diabetes, and chronic obstructive pulmonary disease are described in more detail below given their roles as common causes of morbidity, health service usage and death in Scotland.

Prescribing differences

Reported differences in prescribing rates for common drugs used to treat chronic diseases, between West Dunbartonshire and other parts of Scotland, and between the Vale/Dumbarton and Clydebank halves of West Dunbartonshire, reflect the historical difference in approaches used by Argyll and Clyde NHS Board and Greater Glasgow NHS Board and the fact that Managed Clinical Networks (MCNs) in the latter were further advanced. An examination of

1 A key source of data on risk factor and chronic disease prevalence is the Quality Outcomes Framework, a data collection system linked to payment within Primary care across Scotland.

4 these prescribing differences is a useful reminder of the need to standardise case finding, treatment protocols and patient pathways that will be used throughout NHS Greater Glasgow and Clyde.

High incidence of chronic disease and high death rates

The overall outcome of this combination of socioeconomic deprivation and unhealthy lifestyles is a position at the top, or near the top, of the Scottish council league tables for all- cause mortality, coronary heart disease incidence, acute myocardial infarction incidence, lung cancer incidence (assumed to be mostly smoking-related), domestic violence, suicide, and alcoholic cirrhosis mortality.

Coronary Heart Disease (CHD)

According to the SMR01 database, the crude prevalence of CHD for West Dunbartonshire residents, at 4.2%, is considerably higher than the national average of 3.6%. The prevalence of CHD for West Dunbartonshire as measured by the QOF is 4.9%, which is higher than the national Scottish QOF prevalence of 4.5%.

In the last ten years, the ‘incidence’ rates of CHD in Scotland have declined by 26% and 27% in males and females, respectively. This trend is very encouraging and provides a benchmark figure against which equivalent falls in mortality in West Dunbartonshire and elsewhere may be compared. The declines in incidence in the male and female population of Greater Glasgow NHS Board area were respectively 31% and 28%, and in Glasgow City, 28% and 23%, respectively. The incidence of acute myocardial infarction (acute MI) in Scotland has dropped even more dramatically by 37% in males and 36% in females in the same time period. The equivalent declines in acute MI in Glasgow City were 32% in males and 29% in females.

Corresponding downward trends in incidence of CHD are less marked in West Dunbartonshire. In the male population of West Dunbartonshire, the decline in CHD incidence has been relatively modest, from 612 to 490 per 100,000 between 1995 and 2005, a decline of 20% in the period of ten years. In the female population, there is no evidence of any decline in the same period. The rates in West Dunbartonshire females in 1996 and 2005 were 318.3 and 317.5 per 100,000, respectively (i.e. remaining virtually unchanged). Remarkably, the absolute number of incident cases of CHD in the female population of West Dunbartonshire exceeded the number in the male population in 2005. This reflects the persistence of several risk factors including social deprivation, smoking, obesity, hypertension, diabetes, and excessive alcohol consumption and the possibility that men are adopting healthier lifestyles in West Dunbartonshire more readily than the women.

The pattern of declining incidence of acute myocardial infarction in West Dunbartonshire evident in the early part of the last decade was not sustained either in males or females, especially after 2002. The incidence of myocardial infarction in women increased from 125 to 188 per 100,000 between 2002 and 2005, and the numbers of new cases in women (153) exceeded that for men (148) for the first time in history in 2005. This again reflects the fact that unhealthy lifestyles in West Dunbartonshire women are catching up with them and enabling their CHD rates to catch up with those of their male counterparts.

5 When examined on a Scottish-wide comparative basis, West Dunbartonshire has the third highest incidence of CHD in males and the highest incidence in females. The incidence of myocardial infarction tops the league tables in both West Dunbartonshire males and females, suggesting that a life-threatening presentation of CHD is more common on a per capita basis in West Dunbartonshire than in any other part of Scotland. This suggests that more efforts should be aimed at primary and secondary prevention of CHD. Primary prevention targets people before they have confirmed disease but who have risk factors and secondary prevention targets people with confirmed disease and prevents them from going on to develop advanced disease requiring high tech intervention including surgery.

There is limited evidence available that suggests that, despite concerted efforts in recent years to make health services more accessible to users, some West Dunbartonshire residents in need from socio-economically underprivileged areas do not access health services for coronary heart disease as quickly or effectively as they should. This apparent under- hospitalisation for CHD is relative to the position near the top of the league table for incidence and mortality for coronary heart disease and was far greater at the beginning of the study period (1996) when it was evident for both genders. In the most recent year studied (2005) this appears to have been rectified for West Dunbartonshire females but persists for their male counterparts.

This tendency for those most in need to access services less commonly than expected is a Scottish-wide phenomenon that was well articulated in the Scottish Executive report of the Coronary Heart Disease and Stroke Task Force. It is attributed to a tendency in males, in particular, to deny symptoms of serious illness and/or the mistaken perception that there is nothing that can be done for them. Pursuing modern sophisticated treatments requires cooperation and compliance on the part of the patient at all stages of the diagnostic and therapeutic relationship and there may be a breakdown in this process if the patient perceives that other day-to-day concerns (including financial worries) take priority over his health.

Given that this apparent under-utilisation in West Dunbartonshire does indeed apply far more to males than females, it is believed that a behavioural component exists that needs to be addressed by improving mechanisms that proactively bring more resistant patients in contact with the specialist services when they need it and permit diagnosis of risk factors and disease in hard to reach patients. A wide range of services provided by Managed Clinical Networks for chronic diseases in the Greater Glasgow area are being extended into the remainder of the Greater Glasgow and Clyde area. These include Local Enhanced Service contracts and related on-line tools, patient referral pathways and integration and improvement of the wide range of community services that exist to tackle unhealthy lifestyles and clinical risk factors.

However, it should also be borne in mind that reported experience of using health services (for all conditions and not just CHD) does not support the notion that West Dunbartonshire residents resist using health services when they need it. Evidence from the Greater Glasgow Health and Well-being Study 2005: West Dunbartonshire Report suggests that there is a consistent tendency for West Dunbartonshire residents to report higher rates of usage of GP, outpatient departments, A&E departments and hospital inpatient facilities in the past year combined with almost double the likelihood of reporting difficulty getting a GP appointment or accessing health services in an emergency compared to their Greater Glasgow equivalents.

The overall angiography rates in Scotland and Greater Glasgow have gradually increased over the last decade. This reflects the growth of interventional cardiology. The trend in

6 angiography rate in West Dunbartonshire is much less clearly defined. Although the rate shows marked fluctuation in different years, the angiography rate in West Dunbartonshire has not shown the sustained increase that is evident nationally for both genders. For example, the female angiography rate in 2005/6 was 218 per 100,000 West Dunbartonshire females, slightly less than the rate 10 years earlier in 1996/7, 225 per 100,000. Similarly for West Dunbartonshire males, the rate in 2005/6 was considerably less at 388 per 100,000 than in 1996/7 at 493 per 100,000. Scottish council league tables suggest that in 2005/6, the rates of angiography in West Dunbartonshire were not commensurate with the scale of incidence of CHD in West Dunbartonshire for both males and females in that the level of investigation does not appear to match the scale of the problem.

Prescribing rates for statins (cholesterol-lowering drugs) in West Dunbartonshire were considerably lower than those for NHSGG&C over the 27 month period studied, ending in October-December 2006. This is an unexpected finding given that CHD and acute MI incidence rates are considerably higher in West Dunbartonshire than in this larger geographic area and one would expect commensurate increases in prescribing of statins in West Dunbartonshire. However, there also appears to be a west-east divide within West Dunbartonshire in that statin prescribing rates are considerably lower in the Vale/Dumbarton half than in the Clydebank half. This suggests that clinical guidelines are being implemented differently in the two halves of the CHP area, in keeping with the fact that Managed Clinical Networks and related clinical pathways and referral guidelines for CHD were at different stages of implementation in the two former NHS Boards (Argyll and Clyde versus Greater Glasgow). A similar anomaly appears to have existed over that time period for state-of-the- art antihypertensives, only part of which could be attributed to higher rates of CHD in Clydebank.

The mortality for coronary heart disease in West Dunbartonshire males declined by 42% (4.2% per annum) from 370 to 215 per 100,000, and for acute myocardial infarction, by 46% from 253 to 136 per 100,000 which is very encouraging. This is in keeping with strong and steady declines in mortality for acute MI and CHD as an average across Scotland and at Board level. The decline in CHD mortality for females from 162.3 to 122.7 per 100,000 (24% decline) was less marked. Of some concern is the fact that mortality from CHD in West Dunbartonshire females has increased since 2002 and remained above Glasgow City rates for three consecutive years, rising from 112 to 123 per 100,000. This reversal of the expected decline in mortality rates for females meant that the absolute number of deaths from CHD were equal in West Dunbartonshire in 2003 for men and women for the first time. This equalisation supports the hypothesis that there has been a recent decline in progress in the disease profile for West Dunbartonshire women, which has been responded to by an increase in hospitalisation, investigation and treatment, but that some excess in mortality has nevertheless still occurred.

Cerebrovascular disease (including stroke)

Prevalence of CVD is higher in West Dunbartonshire than for the other regions examined, perhaps reflecting an accumulation of historical disease in those people, largely women, who are living longer with the permanent effects of a previous cerebrovascular accident. Incidence rates for new CVD in West Dunbartonshire are lower than for Glasgow city and are between the rates for Scotland and Greater Glasgow. Incidence is declining as expected in West Dunbartonshire, but less quickly than for Glasgow and Scotland, at least in males.

7 Mortality rates for CVD and stroke show much less inter-regional variation over time and West Dunbartonshire mortality rates appear to straddle those for the other 3 regions.

Nevertheless, an unexpected finding is the fact that hospital discharge rates amongst West Dunbartonshire males and females for CVD are similar to their Scottish equivalents and for stroke are considerably lower than those for their Scottish equivalents. League tables of stroke discharge rate for council areas confirm that West Dunbartonshire is in the bottom half for both genders. Given that stroke mortality rates in West Dunbartonshire are similar to those for the other 3 regions, it is notable that discharge rates are around 75% of the Scottish average. This may reflect effective community-based pharmacologic treatment of hypertension. There is no evidence to suggest that patient with acute CVD or stroke are unable to gain access to stroke unit levels of care in hospital when required.

Diabetes

Diabetes is an important cause of disability and increases the risk of coronary heart disease and other health problems. Type 1 diabetes often starts at a young age and is due to a lack of insulin. It accounts for 10-15% of all cases of diabetes. Type 2 diabetes is characterised by a resistance to the action of insulin and is associated with older age, overweight and obesity. The prevalence of type 2 diabetes is increasing rapidly in Scotland, as in many other countries. Part of this increase is likely to be due to increased levels of awareness of diabetes among health professionals and the public and more complete recording of diagnoses of diabetes as a result of improved information systems. However, the largest part of the increase is likely to be due to poor diet (specifically excess energy intake), low levels of physical activity and the resulting increase in levels of obesity. Type 2 diabetes is much more common at older ages and the increase in the number of older people in Scotland also contributes to the increase in numbers of those with diabetes. In addition, it is thought that many cases of diabetes remain undiagnosed. Proposals to introduce screening for risk factors including undiagnosed diabetes, of all people aged 45-64 years in selected socio- economically deprived CHP, (under plans to introduce ‘Keep Well’ scheme), will help identify this hidden element of the problem.

According to the West Dunbartonshire Health and Well-being Study, the risk factors for diabetes are all considerably more common in West Dunbartonshire than in Greater Glasgow.

The QOF disease register for diabetes also confirms that the prevalence of diabetes in both Scotland generally and West Dunbartonshire has increased between 2004/5 and 2005/6. According to the PTI, the overall Scottish prevalence of diabetes for both genders combined in 2005/6 was estimated to be 3.5%. This is similar to the national estimate of 3.4% prevalence based on the QOF data. Unfortunately, PTI data is not available at CHP level. However, QOF data is collected at practice level and can be used to approximate CHP prevalence. The prevalence of diabetes in West Dunbartonshire in 2005/6 was 3.5%.

Both QOF and PTI estimates are an underestimate of the genuine prevalence at national and local level, although for entirely different reasons. The QOF does not include the “under 17 year olds” and the PTI risks missing patients who have not consulted for that condition within that year of study.

8 Chronic obstructive pulmonary disease

In keeping with the high prevalence of smoking in West Dunbartonshire, the prevalence of COPD is higher than for Scotland. Although the prevalence of COPD in West Dunbartonshire, according to QOF statistics, fails to reach those of Greater Glasgow and Glasgow City, which are notorious for their smoking prevalence rates, the mortality rates appear to be higher than expected and increasing moderately steeply for women in contrast to the static or declining equivalent rates for these larger areas. Furthermore, there does appear to be an historical relative under-utilisation of hospital admission by both West Dunbartonshire male and female residents for COPD given that their COPD mortality is similar to that of Greater Glasgow residents. The rise in hospitalisation in both genders, but particularly for females, suggest that this is being rectified in recent years. However, this would require further study to confirm.

Of further interest, is the markedly different prescribing habits for bronchodilators and steroids, two categories of drugs used for COPD, amongst many other conditions, between the two halves of West Dunbartonshire. The relative excess in prescribing for Clydebank compared to Vale/Dumbarton would need to be explored via further studies and reassurance provided that prescribing was clinically appropriate by 2007.

Child Health

High rates of smoking in pregnancy and low breastfeeding rates in West Dunbartonshire will have important implications for child health and future adult health. It is encouraging to note the high immunisation rates in West Dunbartonshire, which are high compared to Scotland and some other areas of NHS Greater Glasgow and Clyde.

Mental health

Primary care data on mental health suggests that the prevalence of severe mental illness in West Dunbartonshire is near the Scottish average and that some Glasgow CHPs have a higher prevalence than does West Dunbartonshire.

However, other data suggests that milder forms of mental ill health may be more common in West Dunbartonshire on the basis of lower prevalence of self-reported perception of general mental or emotional wellbeing, higher prescription rates for psychoactive drugs and more objective quantification of mental ill health (including poorer scores on the GHQ12).

Considerable differences in prescribing of psychoactive drugs between the Vale/Dumbarton versus Clydebank halves of West Dunbartonshire confirm the fact that different clinical approaches were adhered to, and access to psychiatric services differed, in the two Board areas that will be standardised and improved by the new Clyde Mental Health Strategy.

Suicide rates in West Dunbartonshire males have climbed steeply since the early 1980s and now occupy a position near the top of the Scottish league table, exceeding rates for Glasgow City and only topped by the Highland and Island councils, which have historically had the highest rates in Scotland. There is no evidence to suggest that these high rates are due to the proximity of West Dunbartonshire populations to the Erskine bridge.

9 Provision of primary care services

Primary Care is an integral part of the delivery of community based health and social care services in West Dunbartonshire. There are 20 Practices in the CHP area, which between them register almost exclusively West Dunbartonshire residents. Nine practices are situated in Clydebank, four at Alexandria Medical Centre and six at Dumbarton Health Centre. One practice is based at separate premises (Bank Street) in Alexandria.

There were 84 GPs working in West Dunbartonshire as of September 2006. This amounted to 70.7 WTE GPs and a per capita provision of 76.9 per 100,000 population (compared to a national provision of 71.0 per 100,000 across Scotland) as of October 2004 (most recently published data on Scottish Local Authorities Compendium of Health Statistics). The only non-Island councils that had higher per capita GP provision than West Dunbartonshire in October 2004 were Argyll and Bute (89.9 per 100,000), Dumfries and Galloway (83.0 per 100,000) and Highland council (101.4 per 100,000). It is reassuring to know that West Dunbartonshire has been able to attract sufficient GPs over the years to provide an adequate per capita provision of service.

Community Pharmacy has an important role in the provision of primary care services to the public, and the introduction of the new pharmacy contract presents opportunities for development. These include support for the self-management of conditions and support to General Practice in their prescribing.

Provision of secondary care services

Hospital services for the population of West Dunbartonshire which lies to the West of Old Kilpatrick are mainly provided from the Vale of Leven Hospital in Alexandria and from the Royal Alexandra Hospital (RAH) in Paisley. The full range of Accident and Emergency services and emergency surgery, trauma and orthopaedic services as well as consultant-led obstetric and paediatric services are provided from the RAH. The vast majority of emergency medical receiving services, elective medical, surgical and orthopaedic services, rehabilitation services, minor injury services, diagnostic services and day and outpatient services in all specialties are provided at the Vale of Leven Hospital.

In the year 2005/2006, the population of West Dunbartonshire accounted for 9,725 day- cases, 3,991 elective admissions to NHS hospitals and 11,486 emergency admissions or transfer episodes. The in-patient care amounted to a total of 81,546 bed-days of care, approximately equivalent to the use of 52 in-patient beds in the year. Ten clinical specialties accounted for 90% of the 15,477 episodes of in-patient care generated by the population of West Dunbartonshire.

The hospital at which the largest proportion of in-patient episodes for West Dunbartonshire residents from all parts of the council area occurred was the Western Infirmary or Gartnavel Hospital (44%). In total, 6,803 episodes of care occurred in these hospitals. A further 3,814 (24%) episodes took place at the Vale of Leven Hospital and 2,482 (16%) episodes at the Royal Alexandria Hospital.

10 Activity in secondary care

Activity data in secondary care is notoriously difficult to interpret given the large number of confounding variables that influence referral and admission behaviour to secondary services by GPs and other primary healthcare professionals, some of which remain obscure and difficult to quantify. In some specialties, the elective and day-case admission rate in West Dunbartonshire is less than that in the standard and in other cases, greater. The range and extent of variation in elective admission rates from the standard reflects the operation of a range of non-demographic factors that may influence admission in ways that are difficult to predict. These include referral behaviour by general practitioners, supply factors and admission criteria.

Waiting Lists

Waiting list data is routinely collected and responded to at Board level by efforts to reduce the numbers of patients waiting for a procedure and shortening the time they spend on such lists in keeping with national targets.

Compared to the other 10 CHPs within Greater Glasgow and Clyde minus the Lanarkshire councils2, West Dunbartonshire compares reasonably in terms of size of the waiting list. Only two councils have a smaller waiting list than does West Dunbartonshire (East Renfrewshire CHP at 8 per 1,000 population and North Glasgow CHP at 9 per 1,000 population).

This rate of 10.9 per 1,000 patients is based on 992 patients on a waiting list as of the end of 2006. Of these, 476 or 48% were waiting to enter the Western Infirmary/Gartnavel General complex in Glasgow; 220 or 22% were waiting to enter the Vale of Leven hospital in Alexandria; and 134 or 14% were waiting to enter the Royal Alexandra in Paisley. The remaining 162 or 16% were waiting to enter a large variety of hospitals throughout west- central Scotland.

Palliative Care

The section on palliative care is different from other parts of this needs assessment in that it contains more information about palliative services and less about the extent of the need for these services. This is because no routinely collected data exists on the number and nature of patients throughout either West Dunbartonshire or NHSGG&C that are receiving palliative care. Nevertheless, palliative care was identified as an area requiring review by the Needs Assessment Reference Group, especially by the local GPs.

The service available to West Dunbartonshire residents, which is offered from St Margaret’s Hospice in Clydebank and from non-specialist beds at the Vale of Leven, has developed as a result of a range of local initiatives and support from the voluntary sector in conjunction with the West Dunbartonshire CHP (e.g. Macmillan cancer nurses, Marie Currie nursing services). A range of recommendations have recently been made to GG&C NHS Board by the

2 It is reasonable to exclude the data from the two Lanarkshire councils because NHSGG&C only includes a very small portion of these council areas as most of their populations are covered by NHS Lanarkshire. In addition, the residents from the two Lanarkshire councils experience remarkably small waiting lists, which skew the overall figures.

11 palliative care nurse specialists operating within the West Dunbartonshire/Helensburgh area and the Oncology Clinical Nurse Specialist based at the Vale of Leven.

Use of the independent sector

There are two main independent sector hospitals providing healthcare of a largely elective nature to the Glasgow area. These are Ross Hall (BMI Hospitals group) located at Crookston Road on the south side of the city, and the Nuffield Hospital Glasgow (Nuffield Hospitals group) located at two sites at Beaconsfield Road and Great Western Road, 2 ½ miles northwest of the city centre.

The combined data for the two hospitals for all of West Dunbartonshire for 2005 and 2006 suggests that healthcare activity obtained in the private sector increased modestly for West Dunbartonshire residents between 2005 and 2006, despite an overall modest decline in total healthcare activity obtained from the private sector from these two hospitals. Most of this increase was for medical daycase work and to a lesser extent for outpatient surgical work. Nevertheless, the number of inpatient surgical procedures obtained privately by West Dunbartonshire residents actually decreased between 2005 and 2006 (from 160 to 155). The table also shows that more of the Vale/Dumbarton residents engaged with Ross Hall while more of the Clydebank residents engaged with Nuffield hospital Glasgow.

In 2005, the total number of patient contacts with the two private hospitals experienced by Vale/Dumbarton residents was almost the same as for residents of Clydebank and the number of inpatient surgical procedures was identical for the two halves of West Dunbartonshire. Given the similar population sizes of the two halves, this suggests that in 2005, use of the private sector was very similar in the two halves of West Dunbartonshire despite indices suggesting that Clydebank has more socioeconomic deprivation.

However, in 2006, increased use of the private sector by Vale/Dumbarton residents and reduced use by Clydebank residents meant the Vale/Dumbarton residents overtook their Clydebank equivalents by almost 100 patient contacts. All categories of contact by Vale/Dumbarton residents experienced an increase except for surgical daycase work; most of this increased use by Vale/Dumbarton residents was for surgical outpatient contacts.

Transport issues

In West Dunbartonshire, 56.8% of households had a car at the time of the 2001 census, and this means that for over half of households in the area, access was not a particular problem. However, the level of car ownership is considerably lower than the national average of 65.8%.

West Dunbartonshire has a population of 3,244 Blue Badge holders. Many of these Blue badges have substantial disability and require the Blue Badge to find appropriate car parking. Unfortunately, designated car parking in car parks or on residential streets is often abused. This can make access difficult or at times, impossible, for disabled people.

About 17,625 households, or just over 43%, of West Dunbartonshire households (40,781 households in 2001) were required to rely on public transport. The only two councils in Scotland who had a greater percentage of households dependent on public transport were

12 Glasgow City and the City of Dundee, both of which have extensive public transport systems.

In relation to local access, public transport provision has several components including trains, taxis, buses and demand responsive transport (DRT) initiatives.

Most of the population resides less than 1.5 km away from one of the thirteen railway stations in the area. This provides good access into Glasgow City and from there to the national network. In particular, the train network provides direct transport to Hyndland and Partick Stations which allows good access to a range of hospitals, including Gartnavel General Hospital, RHSC, the Western Infirmary and, in future, the Southern General Hospital. A key issue for the train network in the area (and elsewhere in Scotland) is disabled access. None of the thirteen local stations is fully wheelchair accessible.

It is noted in the West Dunbartonshire Local Transport Strategy that there appears to be a deterioration of bus services within some small communities (e.g. the withdrawal or reduction of services that enter and go about small estates) whilst at the same time an improvement of services along major routes. In West Dunbartonshire, as in many areas in the West of Scotland, there is a significant reduction in bus services after six pm. At the time of writing, all bus services linking Balloch and Dumbarton with Gartnavel General Hospital had been cancelled.

Demand responsive transport includes community transport providers and Local Authority Transport Services. Often these DRT initiatives provide door-to-door transport for certain communities. For example, West Dunbartonshire Council runs a fleet of minibuses for the transport of children with special needs to school or older people to care centres. Community Transport providers often use minibuses for group hire and these are increasingly being used in Scotland to provide transport for certain vulnerable communities to essential services. There is scope for development of this form of transport in West Dunbartonshire. Strathclyde Partnership for Transport (SPT) runs two DRT type of services, Dial a Bus and Dial A Ride. After April 2008, all Scottish Executive DRT funding will be channelled through SPT. This may allow for greater co-ordination and may see the evolution of services which are more accessible to the elderly or disabled.

13 1. INTRODUCTION

1.1 Background

This Needs Assessment report has been prepared as part of the work of NHS Greater Glasgow and Clyde to develop a clinical strategy for the North Clyde area. An assessment of population need is an important stage in the planning of services for a geographical area. Health needs assessment can provide a method of monitoring and promoting equity in the provision and use of health services.

The aim of this exercise has been to carry out an assessment of needs in the population of West Dunbartonshire. This wide-ranging exercise has entailed examination of demographic and epidemiological factors and of comparative methods of service use. The report also contains a summary of information from local surveys of people’s views of their own health and self-reported health behaviours. Considerable use has been made of routinely-collected sources of information.

The term ‘Needs Assessment’ is often used synonymously with the term ‘Health Needs Assessment,’ to mean an assessment of need based on the health status of the population. The meaning of the terms ‘health’ and ‘needs’ will be discussed in the following sections. For the purposes of this report, we are accepting a broad definition of ‘health needs’ to include those needs that are amenable to both clinical (NHS) and non-clinical (socioeconomic) interventions, in keeping with the ‘wider determinants of health’ theme of the report.

Unless, specified otherwise, reference to West Dunbartonshire CHP refers to the population resident in the geographic area covered by the CHP of the same name. Services offered by West Dunbartonshire CHP will be referred to specifically by name when relevant.

1.2 Health

The term ‘health’ is applicable either to individuals or to populations. Health status is relatively easy to define but difficult to measure. One of the most frequently-cited definitions is that of the World Health Organisation (WHO), that ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.' According to this definition, the operational measurement of health at the level of a population, for example, of West Dunbartonshire, would include measurement of each of the three dimensions of the definition, physical, mental and social health status. These components of health would need to be measured at the individual level in a sample of residents of the population using a suitable tool.

1.3 Models of health

In older concepts of health, health was considered to be synonymous with the absence of disease and, by implication, largely a function of medical care. This model, the Medical Model, is now generally regarded as unduly simplistic and outmoded. In more modern models of health, for example, the Evans and Stoddart model, it is acknowledged that a wide range of factors may affect health (Figure 1.1).

14 Two important points should be considered regarding the Evans and Stoddart model. Firstly, the medical model is still embodied in the wider social model. The boxes in the central part of the diagram reflect the importance of disease activity as an influence on health and also of medical care as a method of modifying disease. Secondly, the model shows that factors related to both the social and physical environment are important in determining health. In the context of West Dunbartonshire, the high levels of material deprivation and crime described in following sections would be considered as components of the social and physical environment that adversely affect health in the population.

Although multifactorial models are important in formulating the determinants of health, the direct measurement of health status in populations remains difficult. Any attempt to directly measure health would entail carrying out surveys using specific tools in sample populations. There are no usable summary measures of health at the level of populations analogous to the summary measures of morbidity (ill health) frequently employed. Further difficulties would be associated with the translation of the results into information that could be used operationally. This explains the apparent anomaly that most assessments of health consist almost exclusively of assessments of levels of morbidity in a population.

1.4 Morbidity

In contrast to health and its determinants, morbidity is relatively easy to measure as a number of events in a defined population in a defined period. Two measures of morbidity in populations are particularly important, incidence and prevalence. Both of these measures are of great practical importance in the planning of health services.

1.5 Incidence

Incidence is a measure of risk of disease in a defined population or community. It is expressed as the number of new cases of disease per unit population per year. For example, health service planners might wish to know the incidence of diseases as disparate as multiple sclerosis, stroke and myocardial infarction. Knowledge of the expected numbers of new patients in a given population each year would allow an assessment to be made of requirement for diagnostic facilities and treatment.

1.6 Prevalence

Prevalence is a measure of the total burden associated with a particular disease in a defined population. It is a measure of the total amount of morbidity in the population and is expressed as the number of cases of disease per unit population. Knowledge of the expected prevalent numbers of patients in a given population would allow an assessment to be made of the total requirements for care, both within and outside the health service. Prevalence reflects both the number of new cases of disease and the duration of illness and is therefore higher for common chronic diseases that do not immediately end the life of the patient.

15 1.7 Proxy measures of morbidity

Calculation of incidence and prevalence depends on the availability of measures of morbidity in a population. In some forms of disease, for example, cancers, a population register of disease may be available. In other forms of disease, even for coronary heart disease and stroke, diseases that make major contributions to the total mortality, a disease register is usually not available. In these circumstances, proxy measures of morbidity are required. For example, measures derived from routinely-collected mortality or hospital morbidity data are usually available.

In practice, the proxy measure most commonly employed is the Standardised Mortality Ratio (SMR). Analogous measures may be calculated for other types of data, for example, the Standardised Admission Ratios (SAR). An SMR could be calculated for all causes of death or for specific causes, for example, for coronary heart disease or stroke. These indicators are also routinely used in Needs Assessment exercises, and this underlines the relation between health and the needs of any population for health care. The requirements for health care should in principle be determined by the health status of the relevant population.

1.8 Definition of need

Need may be defined as the ability to benefit from an intervention of any kind. Like health, the term need may be applied at either the individual or population level. In a needs assessment for a defined population, the needs would comprise the ability of the entire population to benefit from a range of interventions, both socio-economic and clinical (health service-based). The needs of a population are closely related to the profile of health of the population.

1.9 Definition of demand

A distinction should be made between need and demand. Demand may or may not coincide with need, but in general represents the perceived ability of a population or group to benefit from an intervention. Demand is often expressed by highly interested groups, for example, patients’ groups, politicians and clinical staff. In many cases, the level of demand may be incommensurate with need. Recent changes in attitude, working terms and conditions and life style have been associated with increasing inappropriate demand for healthcare, particularly out of hours.

1.10 Evidence-based medicine

Evidence-based medicine is the corpus of knowledge about interventions that may be effective in groups of patients with different forms of need. Knowledge of effectiveness is derived from the results of clinical trials or other less rigorous types of observational study. For example, stroke patients may derive clinical benefit from a range of treatments that encompass secondary prevention, acute therapy and rehabilitation. A rigorous definition of need would include reference to both the epidemiological scale of morbidity in a population and to the effective measures available for management. The corollary of this definition is that a form of morbidity for which no effective intervention was known to be available would not represent need, however great the scale of morbidity in the population.

16 1.11 Absolute measures of need

Absolute measures of need usually comprise direct epidemiological indicators of morbidity in a population. The most commonly-used indicators are incidence or prevalence of disease, measures that are discussed in a previous paragraph. Absolute indicators allow the index of need to be directly translated into a requirement for services. For example, knowledge of the expected annual number of new strokes in a population would allow calculation of the required numbers of admissions, numbers of beds and clinical staff. Most absolute assessments of need are expensive and epidemiologically uncommon, and for this reason, assessments of this kind are rarely carried out by Health Boards and other commissioning authorities.

1.12 Relative measures of need

Most practical assessments of need are relative assessments. In this type of assessment, the scale of a local service is compared with that in a standard population, for example, a national population. The assessment is usually carried out using routinely-derived data, for example, about admissions to hospital or attendances at out-patient departments. The level of supply of the service is compared with that in the standard population, usually taking account of any discrepancies in the demographic structures in the two populations. It is usually the case in a needs assessment of this kind that the required level of service is unknown. The results of a relative needs assessment are usually interpreted as a level of unmet need.

In the Needs Assessment of West Dunbartonshire, there were several relevant standard populations, including the population of Greater Glasgow and Clyde, the population of Greater Glasgow, the population of Glasgow City and the national Scottish population. The choice of standard varied according to the nature of the analysis. In some cases, the choice of the population of Greater Glasgow as the standard reflected the fact that the analysis antedated the creation of the new Greater Glasgow and Clyde Board. In some cases, the population of other council areas was included in the range of comparator areas.

1.13 Sources of Data

The most important sources of data used in Needs Assessment are described in Appendix 1b.

17

2. HISTORICAL ASPECTS AND GEOGRAPHY

2.1 Geography

West Dunbartonshire is located to the West of Scotland with a total population of approximately 92,000. The area of West Dunbartonshire CHP is coterminous with that of West Dunbartonshire council. West Dunbartonshire lies north of the River Clyde and encompasses the urban communities of Clydebank, Dumbarton, Balloch, Alexandria and Renton (Figure 2.1). There is also a more rural area that runs south of Loch Lomond.

West Dunbartonshire is made up of 22 electoral wards: • 11 located in Clydebank (Whitecrook, Dalmuir/Central, Mountblow, Parkhall, Linvale/Drummy, Kilbowie, Kilbowie West, Faifley, Hardgate, Duntocher, Bowling/Milton/Old Kilpartick). • 5 located in Dumbarton (Dumbarton East, Barloan/Overtoun, Dumbarton North, Dumbarton Central, Dumbarton West). • 6 located in the Vale of Leven (Renton/Alexandria South, Alexandria, North/Tullichewan, Ballcoh, Haldane/Jamestown/Kilmarnock, Ronhill East and Riverside).

2.2 Historical Aspects

The area has enjoyed a long and sometimes distinguished history. West Dunbartonshire has been settled for millennia and the castle on Dumbarton rock was the seat of power of the kings of Strathclyde during the 8th and 9th centuries. The later history of the area conforms, in many respects, to the pattern of industrial and post-industrial phases of other urban centres in Scotland and elsewhere in the UK. Clydebank, Dumbarton and the Vale of Leven were important urban centres for manufacturing and shipbuilding during the industrial revolution, and this led to the development of a large local working class mainly dependent on ship- building for employment. The vitality of the area was also reflected in significant popular cultural achievements. For example, the Renton village football team achieved world-class status at this time.

The status of Clydebank as an important industrial centre meant that it became a target for bombing raids during the 2nd World War and had largely to be rebuilt in the years that followed. In the post-industrial phase of its development, the area also became host to ‘overspill’ populations from Glasgow, and in consequence of this, it shares some of the social problems of the peripheral housing estates in its city neighbour (Figure 2.1).

18 3. DEMOGRAPHY AND SOCIO-ECONOMIC DETERMINANTS

3.1 Overall structure of population

According to the Mid-Year Estimate for 2005, the population of West Dunbartonshire was 91,400 (Table 3.1). The age-structure of the population of West Dunbartonshire is similar to that of Scotland (Figure 3.1). Eighteen point four percent of the population was aged between 0 and 14 years, 65.5% between 15 and 64 years and 16% is aged over 65 years.

3.2 Demographic change

The population of West Dunbartonshire is declining (Figure 3.2). The projected proportional reduction in the population between 2004 and 2014 is about 8% (Figure 3.3). It is predicted that by 2017 there will be (Figure 3.4):

• a 19% reduction in those between 0 and 14 years, • a 9% reduction in the population aged 15 to 64, • an 18% increase among those aged 65 to 74 and • an 8% increase in the population aged over 75.

In 2002, there were more deaths than live births among West Dunbartonshire residents (1,126 deaths compared to 938 births, giving a natural fall of 188). In addition, there has been a net migration of people out of West Dunbartonshire in recent years. Declines in the younger population have outweighed gains in the older age-groups and the population will decline overall and increasingly become elderly in the future.

The population of children and young people aged 0-19 years in West Dunbartonshire is estimated to have fallen by over 2,500 between 1996 and 2005 (Table 3.1). The decline in the population of children and young people is projected to continue until at least 2020 (Figure 3.5), although this projection is sensitive to assumptions about mortality, fertility and migration (and will be relevant to planning considerations of house construction and demolition). In part, these changes reflect the declining rate of births. The number of births to mothers resident in West Dunbartonshire is projected to fall by around 200 per year between 2006/7 and 2022/3 (Figure 3.6).

These changes are in keeping with the pattern of demographic change that is most common in western societies. The projected increases in the elderly population have particular significance for the future provision of services. The larger number of older people with multiple chronic diseases, in many cases living in isolation and in deprived conditions, will mean a greater requirement for both medical and social care in the future.

3.3 Demographic composition

The RGOS’ mid year estimate for 2006 is 43,505 households, considerably more than counted at the 2001 Census (40,781) (Figure 3.7). Twenty three percent of households were pensioner households. More than 6,400 (15%) were lone pensioner households and 14.4% or 6,252 were lone parent households, compared to the Scottish average for lone parent household of 10.5%. It is predicted that by 2016, West Dunbartonshire will have 42,200 households i.e. a 3% increase over the 2001 Census figure (Figure 3.7). Of these 7,150 (17%) will be lone pensioner households. West Dunbartonshire is predicted to increase its

19 percentage of lone parent households as a percentage of all households with children from 29% in 2002 to 39% in 2016. This would be above the Scottish averages of 23% in 2002 and 33% in 2016, and the third highest in the West of Scotland Council areas after Glasgow City and North Ayrshire. It has also been reported that 17% of West Dunbartonshire residents consider themselves to be carers.

In contrast to the excess of lone parent households in West Dunbartonshire, the 2001 census indicates similar percentages of lone pensioner households in West Dunbartonshire and Scotland. Projections from 2002 to 2016 for West Dunbartonshire indicate increases for the numbers of lone person, lone pensioner and lone parent households, but decreases for conventional household with two or more adults and one or more children.

3.4 Ethnicity

According to the 2001 census, only a small proportion of residents of West Dunbartonshire, less than 1%, were of ethnic minority origin. About 0.1% were of Indian origin, 0.2% were of Pakistani or South Asian origin, 0.2% of Chinese origin and 0.2% of other origins.

3.5 Socio-economic determinants of health

3.5.1 Material deprivation

The levels of material deprivation in West Dunbartonshire may be assessed by several measures, including income/employment deprivation; social grade; Carstairs deprivation categories and the Scottish Index of Multiple Deprivation (SIMD).

West Dunbartonshire is second in the thirty-two council areas in Scotland ranked for income- deprived population and third for employment-deprived population.

At the time of the 2001 census, 13.2% of the population was of social grade A or B, compared to 19% of the Scottish population. In addition, 27.6% of the population belonged to social grade E, compared to 22.4% of the Scottish population.

The profile of Carstairs deprivation scores in West Dunbartonshire also indicates a greater level of material deprivation than in Scotland, in both 1991 and 2001. In addition, in the period between the two censuses, West Dunbartonshire became slightly more deprived relative to Scotland. In 2001, one in three people living in private households in West Dunbartonshire belonged to households that did not own a car, compared to one in four Scotland-wide.

Material deprivation may also be assessed using the Scottish Index of Multiple Deprivation (SIMD). West Dunbartonshire has 118 Scottish Index of Multiple Deprivation (SIMD 2006) data zones (each zone covering about 750 households). In 2004, the proportion of the population of West Dunbartonshire that lay in the most deprived 5% of datazones was similar to that in Scotland, about 5%. In 2004, the proportion of the population of West Dunbartonshire that lay in the most deprived 15% of datazones was 13% (33 out of 118). In 2004, the proportion of the population of West Dunbartonshire resident in the most deprived 20% of datazones was almost twice as great, at 37%, as that in Scotland as a whole at 20%. The extent of deprivation is shown in Figure 3.3. In order to identify the most deprived ‘pockets’, the most deprived 20% of datazones are shown coloured in dark blue

20 (Figure 3.9). The map shows that deprivation in West Dunbartonshire CHP is concentrated in several areas, including Clydebank (Yoker & Faifley), Dumbarton (Dalreoch, Castlehill, Brucehill & Bellsmyre), Renton and parts of Balloch.

3.5.2 Educational achievement

Twenty one percent of the working-age population in West Dunbartonshire have no educational qualifications whatsoever (marginally less than the Glasgow City figure of 22% and considerably higher than the Scottish figure of 16%). Fifty one percent of the working age population have three or more Highers (which is similar to that of Glasgow City figure of 52%); and 8% of the working age population have a degree (which is the second lowest of the West of Scotland councils after Glasgow whose prevalence is 5%).

3.5.3 Housing

Around 15% of West Dunbartonshire households have an occupancy rating of -1 or less which suggests overcrowding. This is the fourth highest in Scotland after Glasgow, Dundee and Inverclyde. West Dunbartonshire has an estimated proportion of properties with rising/penetrating damp of 6.5% and an estimated proportion of properties with mould in any room of 9.5%, compared to Scottish averages of 6% and 11% respectively and compared to Glasgow City averages of 6.2% and 11.2%. This suggests that the housing stock is average. The percentage of properties in West Dunbartonshire with any urgent disrepair (25.7%) was considerably lower than the Scottish average of 33.0% in 2002. Most of the housing stock in West Dunbartonshire is of lower value (below Council Tax band F.

3.5.4 Strength of the local economy and nature of the local job market

The West Dunbartonshire economy has performed below that of the West of Scotland and Scotland as a whole over the last ten years. The mean gross weekly pay for all employees in West Dunbartonshire is £348 which is the lowest of the West of Scotland councils, 12.3% lower than the Scottish average and 10% lower than the Glasgow City average (Figure 3.10). This indicates that despite the fact that many indices of poverty are worse in Glasgow City, it is more difficult to earn a ‘living wage’ locally in West Dunbartonshire.

In 2004, approximately 58.2% (circa 18,205) of total employee jobs in West Dunbartonshire were based on full-time employment, compared to the national average of 67.8%.

3.5.5 Unemployment, employment deprivation, economic inactivity

The claimant unemployment rate is not a proxy for total unemployment or for overall levels of worklessness as it represents only a subset of those unemployed. However, it is useful as a comparator for all areas and for secular trends over time. The claimant unemployment rate has dropped dramatically for all council areas since a peak in 1992/3 when the Scottish average was almost 8% and Glasgow City was in a league of its own at almost 13%. For much of the time between 1992/3 and 2000, Glasgow City and West Dunbartonshire held the highest and second highest position in the West of Scotland, respectively, for the proportion claiming job seekers allowance, far ahead of the remaining West of Scotland councils. The claimant unemployment rate in West Dunbartonshire (4.2%) was higher than the overall rate in Scotland (3.3%) in 2003. However, it was exceeded by that for Inverclyde and North Ayrshire and very close to that for Glasgow City and East Ayrshire. This demonstrates how

21 Glasgow City has improved more dramatically than West Dunbartonshire over the past 12 years, resulting in a merger of their rates in recent years.

West Dunbartonshire had the second highest percentage of people who are ‘employment deprived’ of the West of Scotland Councils in 2002, with a figure of 19.0% compared to the Glasgow City figure of 23.1% (Figure 3.11). The percentage of ‘employment deprived’, which refers to working adults who are not in work either because of unemployment, illness or disability, was 13.8% for Scots as a whole in the same year.

In 2004, 24% of West Dunbartonshire residents (about 22,000) were ‘economically inactive’ (the term ‘economic inactive’ refers to people who are not in work and are not seeking work; this group includes retired people, homemakers, unpaid carers, the permanently sick/disabled, and students). This compares to 30% for Glasgow City and 21% for Scotland in the same year. The percentage of ‘economically inactive’ declined modestly for Scotland and declined by various amounts for all West of Scotland councils between 2003 and 2004, with the exception of East Ayrshire where it increased slightly. It is less of a reflection of economic hardship than is ‘employment deprivation’.

3.5.6 Dependency on state benefits

Given the above, it is not surprising that the uptake of benefits by the West Dunbartonshire population is consequently greater.

Almost twenty four percent of West Dunbartonshire residents had all their income from state benefits compared to 26.8% in Glasgow. The proportion of working age people in receipt of out- of-work benefits is estimated to be 23% in West Dunbartonshire which is the third highest in Scotland. Furthermore, 17.8% of working age households are in receipt of working family and child tax credit.

More than twice as many people are in receipt of guaranteed Pension Credit in West Dunbartonshire at around 27%, which is the third highest in Scotland after Glasgow and Western Isles. Just over 60% of residents experience difficulty meeting household expenses compared to 42.3% in Glasgow. Of the economically inactive residents in West Dunbartonshire, 8,000 are claiming sickness or disability related benefits, i.e. 1 in 8 of the working-age population.

3.5.7 Child Poverty

At the 2001 census, twenty-four percent of children in West Dunbartonshire were living in workless households compared to eighteen percent Scotland-wide. Although the percentage of pupils entitled to free school meals has declined in recent years (from 34% in 1997), in January 2003, 27% of children in West Dunbartonshire were still eligible in the whole council area compared to 19% Scotland-wide. This is the second highest percentage of all West of Scotland councils, the highest percentage being attributed to Glasgow City (42%). Bear in mind that these are average figures for each council area and reflect a wide range in percentages by school.

22 3.5.8 Antisocial behaviour, domestic abuse and crime

The Scottish Household Survey in 2001-02 indicated that West Dunbartonshire fared worse than Scotland with regards to level of satisfaction with the neighbourhood as a place to live and problems due to noise and particularly vandalism, graffiti and damage to property. When repeated in 2003/4, the same survey revealed that West Dunbartonshire had the second highest prevalence of fear of crime with 33% reporting that they didn’t feel safe walking in their neighbourhood alone after dark. This was second only to Inverclyde where prevalence of fear of crime was 36% and was slightly higher than that measured in Glasgow City (33%). The national prevalence for Scotland is 23%.

Rates of domestic abuse (Figure 3.12) recorded by the Police are also higher in West Dunbartonshire than in Scotland as a whole but accurate comparisons are known to be hampered by under-reporting. Nevertheless, West Dunbartonshire had the highest recorded domestic abuse incident rate per 100,000 by far in all of Scotland, in 2004, with a step change over remaining West of Scotland councils and even exceeding that of Glasgow City, an area that has been historically notorious in this regard. This is an area of concern and efforts should be made to understand the causes of the problem (much of which is assumed to be poverty and alcohol-related) and address these issues.

West Dunbartonshire had the second highest rate of overall crime per 10,000 population (Figure 3.13) of all the West of Scotland council areas with a figure of 120 compared to Glasgow City’s rate of 157. In 2000, 2001 and 2002, the total crime rates recorded by the Police in West Dunbartonshire were between 9% and 15% higher than for Scotland as a whole. Rates were high for many types of crime, particularly serious assault, eighty-five percent in excess of the Scottish rate in 2002. In addition, non-sexual crimes of violence, domestic housebreaking, possession of offensive weapons and fire raising/vandalism were 55%, 41%, 39%, and 32%, respectively, above the mean Scottish levels.

West Dunbartonshire had the fourth highest drunk driving rate amongst the West of Scotland councils in 2003 at 2.5 per 1,000 population aged 17+, after Glasgow City (3.6), North Lanarkshire (2.7), and East Ayrshire (2.6) (Figure 3.14). Although Glasgow City’s rate dwarfs that of the other West of Scotland councils, it is important to be aware that West Dunbartonshire is amongst the highest of the non-Glasgow City rates, another reflection of alcohol abuse in the area.

3.5.9 Negative perception of quality of life and well-being

There is evidence that West Dunbartonshire’s perception of their quality of life and well being is unduly negative despite the evidence of reality. An example is the fact that although Glasgow City experiences the highest crime rates in Scotland at 157/10,000, and West Dunbartonshire occupies second place at 120/10,000, fewer West Dunbartonshire residents than Greater Glasgow residents responding to the survey reported feeling safe in their own homes (88% versus 92%) or walking in the street even after dark (54 versus 58%). In addition, for most social and behavioural parameters studied, residents of West Dunbartonshire reported more negatively than did their NHSGG counterparts as we shall observe in the section on lifestyle.

23 4. LIFESTYLE AND BEHAVIOUR

4.1 Introduction

A range of indicators affecting health related to lifestyle and behaviour were studied in the NHSGG Health and Well-being Study 2005. With the exception of consumption of oily fish, the prevalence of unhealthy behaviours was greater in residents of West Dunbartonshire than in residents of Greater Glasgow NHS Board. Information from other surveys may also be used to shed light on the different prevalence rates in the West of Scotland council areas (e.g. NHSHS Community Profiles, SALSUS, Citizens’ Panel Survey, etc.). These alternative sources of information is also more useful because it allows comparisons to be made between West Dunbartonshire and Glasgow City, a council area closer to West Dunbartonshire in terms of socioeconomic determinants of health.

4.2 Smoking

Currently, the smoking rate for West Dunbartonshire is estimated at 39.8%, compared to 37.2% in Greater Glasgow. Eighteen percent of people reported smoking everyday and 4% reported smoking some days. The proportion of 13 and 15 year olds classed as ‘regular smokers’ by gender in 2002 was considerably higher in West Dunbartonshire where 10% of boys and 17% of girls smoked regularly compared to Glasgow City where 6% and 11% of Glaswegian boys and girls, respectively smoked regularly.

It is estimated that 62.5% of West Dunbartonshire residents are exposed to second-hand smoke most or some of the time compared to 54.9% in Glasgow.

The prevalence of both active and passive smoking are high in West Dunbartonshire. Exposure to this risk factor is particularly harmful early in life and will play be important in the causation of a wide range of diseases. These include heart disease, chronic obstructive lung disease, peripheral vascular disease, and a wide range of cancers including those of the bronchial lining (lung cancer), head and neck, oesophagus and cervix. The high rates of ischaemic heart disease, COPD and cancer registration for these cancers in West Dunbartonshire are in keeping with the high prevalence of smoking in that area.

The synergistic (multiplicative) interaction of combined smoking and occupational exposure to asbestos means that the industrial legacy of Clydebank and related shipbuilding and heavy industry and construction is made far worse by smoking.

Smoking is also associated with a range of problems related to fertility and pregnancy, while passive smoking is a cause of problems in child health (including glue ear and cot death) and may be involved in the aetiology of serious infections such as invasive meningococcal disease. These have not been addressed in this needs assessment.

4.3 Alcohol

Almost 25 percent of West Dunbartonshire residents are estimated to exceed the recommended weekly units of alcohol, compared to 17.7% in Greater Glasgow. Of residents of West Dunbartonshire who had consumed alcohol at all in the past week, almost 50% of were estimated to have exceeded recommended weekly units of alcohol. The corresponding proportion was 39% in Greater Glasgow NHS Board. Thirty seven percent of residents of

24 West Dunbartonshire admitted to binge drinking in the last week compared to 29% in Greater Glasgow. Seventy four percent of West Dunbartonshire residents admitted to binge drinking in the last week amongst those who have drunk alcohol at all in the past week compared to 63% of their Greater Glasgow residents.

Thirteen percent of men and 11% of women reported drinking above the recommended weekly units of alcohol in the last week. The proportion of 13 and 15 year olds who had drunk alcohol during the last week by gender in 2002 was 26% of boys and 30% of girls.

These high rates of alcohol consumption in West Dunbartonshire are of particular concern given the link between alcohol abuse and domestic accidents, drunk-driving, alcoholic hepatitis and cirrhosis, alcoholic encephalopathy and neuropathy, domestic violence, homicide and suicide, death by misadventure (aspiration of vomitus) and cancer of the mouth and larynx. The high rates of cancer of the head and neck and cirrhosis in West Dunbartonshire are in keeping with these high rates of alcohol abuse and health improvement initiatives should be undertaken to reinforce the need to limit intake. The incidence of cirrhosis in West Dunbartonshire has steadily climbed since 1985 and is now rising more steeply and attaining higher levels than in Greater Glasgow. The fact that the incidence of domestic abuse in West Dunbartonshire is greater than in any other council area in Scotland suggests that the high alcohol intake is having a detrimental effect on relationships. Drunk- driving offence rates in West Dunbartonshire are third highest amongst West of Scotland councils after Glasgow City and North Lanarkshire.

4.4 Drug misuse

The proportion of problem drug users aged 15-24 years in West Dunbartonshire is estimated to be 2.2% in 2003 compared to 3.3% in Glasgow City, 2.6% for Greater Glasgow and 1.8% for Scotland. Given what is known about the high rates of alcohol abuse in West Dunbartonshire, this suggests that the drug of solace of choice in West Dunbartonshire is alcohol whereas the higher average wage in Glasgow plus greater availability permits a greater level of abuse of others drugs in Glasgow City.

Nevertheless, whereas the proportion of problem drug users declined considerably in Glasgow City between 2000 and 2003, the proportion in West Dunbartonshire increased slightly (see Figure 4.1).

Table 4.1 (appendix 4) summarises the estimates of the prevalence of problem drug misuse for each of the 32 Council areas in Scotland. As one might have expected, the highest prevalence rates amongst the non-rural Council areas are found in the major urban centres. The highest prevalence rate is Glasgow at 3.31% of the population aged 15 to 54 (95% CI 3.16-3.49%). The next highest is Dundee City at 2.80% (95% CI 2.51-3.22%). The third highest is Inverclyde at 2.57% (95% CI 2.35-2.91%). West Dunbartonshire, at 2.22%, is higher than the Scottish average of 1.84%. The prevalence rate of 2.22% translates into 1,185 people in West Dunbartonshire suspected to be suffering from problem drug use.

Table 4.2 (appendix 4) presents the estimated number of drug injectors by Council area. In West Dunbartonshire there are an estimated 551 people who inject drugs.

During 2005/06, 404 individuals had a new presentation to services with problem drug use.

25 Methadone prescribing for opiate addiction

Methadone prescribing rates are considerably higher in West Dunbartonshire than in Scotland but much lower than in the NHSGG&C area, in keeping with the much higher rate of drug misuse in parts of Glasgow City (e.g. Dennistoun, Bridgeton, Drumchapel) and the well established methadone prescribing programme based on a harm reduction strategy adopted by NHSGG prior to the merger with Argyll and Clyde NHS Board. At the time of writing, both the former Argyll and Clyde and Greater Glasgow Board areas had methadone policies working to the same principles. Nevertheless, methadone prescribing is much higher in the Vale/Dumbarton half of West Dunbartonshire than in Clydebank half (Figure 4.2, appendix 4), which may reflect the fact that the prevalence of ‘problem drug users’ aged 15- 54 in Clydebank was relatively low at 1.2% in 2003 (Figure 4.3, appendix 4, based on LHCC data collected by Glasgow University and Scottish Centre for Infection and Environmental Health) and the fact that there are considerable pockets of drug abuse in the Vale/Dumbarton areas of West Dunbartonshire.

4.5 Obesity

Fifty-two percent of West Dunbartonshire residents, who provided estimates of their weight and height used to calculate body mass index, were deemed to have a BMI exceeding or equalling 25, compared to just 42.2% of their Greater Glasgow equivalents. Of interest is the fact that, within West Dunbartonshire, the proportion deemed to be obese was higher in the non-Regeneration Outcome Area than in the ROA, suggesting that higher disposable income may be a factor in facilitating obesity.

The high obesity in West Dunbartonshire is a risk factor for osteoarthritis, colonic cancer, gallbladder disease, diabetes (Type 2), heart disease and stroke. All of those conditions that we have studied in this needs assessment are elevated in West Dunbartonshire, in keeping with the high rate of obesity.

4.6 Physical activity/Exercise

Thirty-six percent of residents of West Dunbartonshire reported taking at least 30 minutes of moderate exercise 5 or more times per week compared to 50.4% in Greater Glasgow. Almost 21% of West Dunbartonshire residents reported taking at least 20 minutes of vigorous exercise 3 or more times per week compared to 28.1% in Greater Glasgow. About forty seven percent of West Dunbartonshire residents report taking at least 30 minutes of moderate exercise 5 or more times per week or at least 20 minutes of vigorous exercise 3 or more times per week compared to about 58% in Greater Glasgow.

This clear deficiency in exercise levels will be a risk factor in the causation of obesity, coronary heart disease, diabetes, stroke, etc., all of which are more common in West Dunbartonshire, as we shall learn in following chapters.

4.7 Diet

Just 23% of West Dunbartonshire residents consume at least 5 portions of fruit and/or vegetables per day compared to 30% of Greater Glasgow residents. A similar proportion of residents in both areas consume breakfast every day (71% in West Dunbartonshire versus 73% in Greater Glasgow) and at least two portions of oily fish per week (32% in West

26 Dunbartonshire versus 30% in Greater Glasgow). There was a marked difference between the two areas in the proportion of residents who reported that they consumed at least two high-fat snacks per day. Forty six percent of West Dunbartonshire residents reported doing this compared to just 32% in Greater Glasgow.

This tendency for West Dunbartonshire residents to consume less fruit and vegetables and more junk food is a clear marker for a range of problems including obesity, diabetes, heart disease, gastro-intestinal disease, hypertension (due to salt intake) and stroke.

Unhealthy diet in West Dunbartonshire continues to be an issue that needs to be addressed by health improvement tactics based on both health education and empowerment and on health protection where healthier choices are made easier for the consumer. An example of the latter that has attracted recent debate includes the subsidisation of healthy foods and the imposition of additional taxation on unnecessary junk foods.

4.8 Oral Health

The National Dental Inspection Programme (NDIP) in Scotland collects a considerable amount of useful data about the dental health of Scottish children. Unfortunately, all published data is provided at national or Board level and none is routinely available at council or CHP level. The NDIP’s most recent report that is routinely available on the web, published in 2005, reveals that P7 children residing in NHS Argyll and Clyde (NHSA&C) and the former NHS Greater Glasgow (NHSGG) and had the highest and second highest mean number of permanent teeth characterised as decayed, missing or filled (DMF) of all Scottish NHS Boards at 1.58 and 1.57, respectively (Scottish average is 1.29. P7 children residing in NHSGG and NHSA&C had the lowest prevalence of the experience of entirely decay-free decidous teeth in all of Scotland in 2005 (Argyll and Clyde: 43.4% and Greater Glasgow 44.4%). The Scottish average was 50.4%. P7 children residing in Greater Glasgow, Lanarkshire and Argyll and Clyde NHS Board areas (in that order) had the lowest prevalence rates of experience of decay-free permanent teeth in all of Scotland, at 46.6%, 47.4% and 48.5%, respectively. The Scottish average is 52.9%. The Scottish target for 2010 is 60%.

The NDIP’s 2004 Report focused on 5 year old P1 pupils. The NHS Boards with the lowest prevalence of children with decay-free deciduous teeth were Western Isles, Greater Glasgow and Argyll and Clyde (in that order) at 41.8%, 42.0% and 46.8%, respectively. The Scottish average was 50.7% and the target for 2010 was 60%.

Given that West Dunbartonshire straddled these two Board areas until recently, we would expect high DMF rates in West Dunbartonshire children. The data from the two surveys suggest that Argyll and Clyde children start off moderately better than their Greater Glasgow equivalents and then lose some of that advantage by the time the permanent teeth have fully erupted.

The poor dental health of children in West Dunbartonshire is very important because the most common reasons for admission to hospital nationally are dental problems, causing, on average, 13,000 acute admissions annually across Scotland at a time when all-cause paediatric admission to hospital is declining.

27 According to the Health and Well-being Study 2005, 82% of West Dunbartonshire residents say they have some (25%) or all (57%) of their own teeth. This compares to 86% of Greater Glasgow residents. Currently, 9.3% of West Dunbartonshire residents aged 45-54 say they have no natural teeth, against the Towards Healthier Scotland target of 5% by 2010.

Fewer than two thirds of those with at least some of their own teeth (64%) say they brush their teeth at least twice a day. This compares with 67% of those living in Greater Glasgow.

4.9 West Dunbartonshire residents’ perception of their health and illness

On all measures relating to perception of health and illness, West Dunbartonshire residents reported less positive perceptions of their health and illness than did their Greater Glasgow equivalents. Within West Dunbartonshire, self-reported results for those living in Regeneration Outcome Areas tended to be less positive than for those living elsewhere. For some aspects, the perception of West Dunbartonshire residents was considerably less positive.

For example, although the majority of West Dunbartonshire residents perceived their health to be excellent or good, this proportion was lower in West Dunbartonshire (64%) than in Greater Glasgow (68%). Eighty percent and 84% of Greater Glasgow residents reported having a positive perception of their general physical well being and their general mental/emotional well being, respectively, compared to just 69% and 75% of West Dunbartonshire residents. It could be argued that West Dunbartonshire residents are less content than their Greater Glasgow equivalents given that 86% and 83% of Greater Glasgow residents reported a positive perception of happiness and quality of life, respectively, compared to 81% and 75% of West Dunbartonshire residents. Nineteen percent of West Dunbartonshire residents had a score of 4 or above on the GHQ, indicating poor mental health, compared to 12% of Greater Glasgow residents. Finally, 26% of West Dunbartonshire residents report having an illness or condition affecting daily life compared to 22% of Greater Glasgow residents.

28 5. MORTALITY AND LIFE EXPECTANCY

5.1 Life expectancy

Life expectancy is an important measure of public health. It is a measure of the number of years of life that a person born into a particular social group could expect to enjoy. Life expectancy has increased progressively in Scotland in the last decade (Figures 5.1 and 5.2). The life expectancy of a Scottish male increased from 71.5 to 74.2 years between the periods 1991-1993 and 2003-2005. The life expectancy of a Scottish female increased from 77.2 to 79.2 years in the same period.

The life expectancy in West Dunbartonshire has also increased in the period, but has been consistently less than the Scottish average. The male life expectancy in West Dunbartonshire in 2003-2005 was 71 years, more than three years less than the average value for men in Scotland. The female life expectancy in West Dunbartonshire in 2003-2005, 77.5 years, was almost two years less than the average value for females in Scotland.

In the conventional calculation of life-expectancy, no account is taken of the quality of years of life. For example, life-years could be affected in quality by a functional limitation that might result from chronic disease. Using a methodology that attempts to quantify the healthy life expectancy, it is estimated that, on average, a male resident of West Dunbartonshire male could expect to live for over 22 years with a limiting, long-standing illness and a female resident for nearly 22 years.

There is some evidence that the difference in life expectancy in Scotland and West Dunbartonshire is increasing in that although the trajectories over time are both increasing, the gap between them is widening.

5.2 Mortality

Mortality is one of the indicators most frequently used to assess the general health or level of need in populations. The main advantages of mortality data in describing public health are that they are routinely-collected and have universal national coverage. Mortality data are particularly useful for certain causes of death, for example, coronary heart disease, stroke and cancers. The main disadvantage of mortality data in needs assessment is that the data are of limited usefulness for describing diseases that do not lead to death relatively rapidly, for example, multiple sclerosis, rheumatoid arthritis and most forms of psychiatric disease.

The most important causes of death in West Dunbartonshire and Greater Glasgow and Clyde respectively are shown in Tables 5.1 and 5.2. The overall profiles of causes of death are similar in the two populations. For example, in West Dunbartonshire, the single most important cause of death was acute myocardial infarction. This cause accounted for 13.5% of deaths in 2001. Other manifestations of coronary heart disease accounted for a further 6.5% of deaths. This means that coronary heart disease accounted for a total of 20% of the overall mortality in West Dunbartonshire. The corresponding proportion of deaths accounted for by coronary heart disease in Greater Glasgow and Clyde was 18.6%.

As a cause of death, carcinoma of bronchus ranked second in West Dunbartonshire (7.8% of deaths) and third in Greater Glasgow and Clyde (7.8%). Stroke ranked third in West Dunbartonshire (7.6% of deaths) and second in Greater Glasgow and Clyde (8.0%). Chronic

29 obstructive pulmonary disease was the fifth most common cause of mortality in both areas. The importance of coronary heart disease, stroke and chronic obstructive pulmonary disease as causes of death is reflected in the fact that a section in this report is devoted to each of these diseases.

5.3 Mortality and age-group

The overall mortality rate in West Dunbartonshire in 2001 was 12.3 per 1,000 (Table 5.3). The rate was 1.7 per 1,000 in the youngest age-group. The mortality rate declined to its minimum value, 0.1 per 1,000 in young people aged 5 to 14 years, but increased with increasing age-group (Figure 5.3). The mortality was highest, 12.3 per 1,000 in the oldest age-group, people aged over 74 years. A similar pattern was evident in both male and female residents of West Dunbartonshire (Figures 5.4 and 5.5).

5.4 Standardised Mortality Ratio (SMR)

The Standardised Mortality Ratio (SMR) is a summary measure that may be used to compare the overall patterns of mortality in populations with different demographic structures. In the analysis described in this report, mortality in West Dunbartonshire is compared with that in the Scottish population.

Directly standardised mortality rates for each council area in Scotland are shown in Figure 5.6. The mortality in West Dunbartonshire is the second greatest in Scotland, exceeded only by the mortality in Glasgow City. Values of SMR for different causes of death in West Dunbartonshire and Glasgow City are shown in Figure 5.7. For all causes, the SMR was about 110% for both areas. The SMR for homicide in NHSGG&C was more than double the mean level of homicide in Scotland.

5.5 Specific causes of death

Mortality associated with major causes of death will be described in later disease-specific sections of this report. Trends in mortality because of hepatic cirrhosis, demonstrating evidence of a rapid increase in mortality in the last decade, are shown in Figure 5.8. The mortality because of suicide is shown in Figures 12.4-12.6. This shows that the suicide rates in males in West Dunbartonshire have increased more since the 1980-1984 period than for any other council area. The male suicide rate is currently greater than that in Glasgow City. The female suicide rate in West Dunbartonshire has remained static and is less than the rates in Glasgow City and in Scotland.

30 6. CANCER

6.1 Cancer incidence

There were 529 new cases of cancer in the population of West Dunbartonshire in 2003. The five most common cancers in the entire population were carcinoma of the bronchus, breast, colorectum, prostate and skin (Table 6.1). These were also the most common cancers in the population of Greater Glasgow and Clyde in the same period (Table 6.2). The cancers with the highest incidence in men are cancers of the lung, prostate, and colorectal cancer, respectively. In women, breast cancer, lung cancer, and colorectal cancer have the highest incidence rates. These comprise 50% of all new cancers in each sex.

Figure 6.1 shows sex-specific cancer registrations, standardised for age to the European population. It is apparent that lung cancer and head & neck cancer rates are higher than the rest of Scotland in both men and women, although considerably lower than those in Glasgow City. The excess risks for lung cancer in men and women, compared to Scotland, are 18 and 14 per 100,000 population, respectively.

Compared with the rest of Scotland, prostate and colorectal cancers rates are lower in West Dunbartonshire men, and breast cancer rates are lower in West Dunbartonshire women.

The relatively low rates of other cancers may be due to the competing effects of lung cancer, that is, death from lung cancer removes individuals from the risk of developing other cancers. However, this is entirely speculative and difficult to prove. It may also be that men in less affluent areas seek screening for prostatic cancer using prostatic specific antigen testing less often and that their females equivalents have children younger and are genuinely less likely to develop breast cancer than men and women in privileged areas. The aetiology of colonic cancer is uncertain but is thought to be linked to excessive intake of red meet, sugary and fatty foods (a marker for which is obesity), hard liquors as opposed to wines; diabetes (Type II) and genetic predisposition (25%). It is possible that the increased intake of fish by West Dunbartonshire residents reported in the Health and Well-being Study has displaced their dietary beef to some extent. The current epidemic of obesity and Diabetes type II in Scotland may well translate in 20 years time to an epidemic of colonic cancer but the latency period for malignant change means we may have to wait some time to see this phenomenon developing.

The high prevalence of smoking and excessive alcohol consumption largely explain these excess risks. The causes of breast cancer in women are complex. They include young age at menarche, tall adult height, nulliparity or late parity, oral contraceptives and hormone replacement therapy, obesity, lack of vigorous exercise, high fat consumption, and alcohol consumption amongst others.

The West of Scotland has a relatively high rate of mesothelioma compared with the rest of the country, although it is less common than any of the cancers shown in figure 6.1. Although routinely available data for West Dunbartonshire are not available, the standardised incidence rates for mesothelioma in Argyll & Clyde in 1999-2003 was 9.8 per 100 000 (95% CI 8.0 to 11.6), in Greater Glasgow it was 8.5 (95% CI 7.3 to 9.7) per 100 000 and in Scotland overall it was 5.6 (95% CI 5.2 to 6.0) per 100 000.

31 6.2 Cancers of the lung, trachea, and bronchus: changes over time

Figure 6.2 shows incidence rates for cancers of the lung, trachea and bronchus (not including mesothelioma) between 1980 and 2003. While the incidence in men is higher than in women, it has been falling for several decades. In contrast, the incidence in women has been rising over the same period. These paradoxical trends in incidence rates reflect historical smoking trends; a decline in smoking prevalence over time among men and an increase among women. Reflecting the findings of the Scottish Health Survey which include prevalence rates of smoking, male Argyll and Clyde residents had a higher rate of respiratory cancers than the rest of Scotland, but Greater Glasgow has a considerably higher rate.

The incidence of respiratory cancers in women in Argyll and Clyde is not clearly different from the rest of Scotland but this could change if historical smoking rates catch up with women as they are expected to do and have done elsewhere (Glasgow City).

Figure 6.3 shows incidence rates of head and neck cancers between 1980 and 2003. In Scotland overall there was an increase in incidence to 1996 but rates appear to have reached a plateau. Male residents of Argyll and Clyde have higher risks than the rest of Scotland although small numbers lead to much year to year variation. Female residents of Argyll and Clyde have similar incidence rates to the rest of Scotland.

The patterns of head and neck cancers in West Dunbartonshire are characteristic of those in several Western countries. It is likely that they reflect increases in alcohol consumption as they are not consistent with changes in cigarette consumption, particularly in men who have reduced their smoking prevalence.

6.3 Deaths from cancer

West Dunbartonshire had a higher rate of cancer deaths compared with the whole of Scotland between 1997 and 2002. Standardised Mortality Ratios (SMRs) for all cancer types in West Dunbartonshire were 114 in 1997-1999 and 109 in 2000-02, although only the earlier figure is statistically significant. By (indirect) comparison, the NHSGG all-cancer SMR (excluding malignant melanoma) in 2002 was 105.1 (95% CI 101.8 to 108.4).

Figure 6.4 shows SMRs for all 417 deaths from cancer in West Dunbartonshire in 2000-02. The SMRs for all cancers, head and neck, digestive (including oesophageal, stomach, and colorectal cancers), lung and prostate cancers were all higher than the Scottish average. Only head and neck cancers were statistically significantly raised. Oesophageal cancer and malignant melanoma were non-significantly lower than the Scottish average. Non- significant figures may be because there really is no difference, or because numbers are too small to detect a true difference that exists.

6.4 Survival

Survival data are routinely not available to distinguish between survival rates by cancer type for cities, Health Boards, or Local Authorities.

6.5 Cancer prevention

About 53% of cancers are avoidable although estimates range from 25% to 72-96%. A range of interventions has been proposed and many of these implemented including:

32 • Reducing cigarette smoking • Reducing alcohol use • Reducing obesity • Increasing physical activity • Increasing fruit and vegetable intake, reducing beef intake. • Participation in cervical, breast, and colorectal cancer screening programmes • Vaccination to prevent malignancies with infectious aetiologies (e.g. Human Papilloma Virus is causally related to cervical cancer).

6.6 Conclusions

West Dunbartonshire has a higher rate of cancers than the rest of Scotland. The excess is largely due to respiratory and head & neck cancers. Their changing patterns over time mirror patterns of cigarette smoking and alcohol consumption. The risks of many other common cancers are lower than the Scottish national average, and an explanation of this would require further study.

33 7. CORONARY HEART DISEASE

7.1 Introduction

Coronary heart disease (CHD), also known as ischaemic heart disease, is one of the most important causes of illness, demand for treatment, and death in Scotland and other western countries. Coronary heart disease is one manifestation of a process of chronic degeneration that may affect arteries in any part of the body. Arterial degeneration of the vessels supplying the brain and lower extremities results in stroke and peripheral vascular disease respectively. Coronary heart disease (CHD) is the result of degenerative changes in the coronary arteries, the vessels that are responsible for the blood supply to the myocardium, or heart muscle itself. This process of degeneration causes narrowing and occlusion of the coronary arteries and a consequent reduction in the supply of arterial blood to the heart. Coronary heart disease is associated with a number of clinical presentations, including myocardial infarction, sudden death, cardiac arrhythmia, congestive heart failure and angina pectoris. Of these, myocardial infarction, or death of a part of the heart muscle as a result of an acute reduction in the arterial blood supply, is one of the most important syndromes.

From their peak in the 1970s, incidence rates of coronary heart disease have declined steadily in Scotland, but not at the pace of neighbouring northern European countries. CHD will remain a major public health problem in Scotland for several decades to come. Furthermore, in smaller, socioeconomically deprived parts of Scotland, incidence rates have either flattened out or are actually increasing.

The incidence of CHD is generally higher amongst men, the elderly and in deprived areas of Scotland, and a range of other risk factors are known to be associated with an increased in risk. The importance of each risk factor for disease in the population may be expressed as the Population Attributable Risk, the proportion of incident cases that may be accounted for by a given risk factor. For example, the National Heart Forum estimated the proportion of cases of coronary heart disease (CHD) that were attributable to five key modifiable risk factors as follows: high blood cholesterol (46%), physical inactivity (37%), smoking (19%), high blood pressure (13%) and obesity (6%). The value of Population Attributable Risk for cholesterol, for example, means that forty-six percent of incident cases of disease may be attributed to this risk factor. This value underlines the significance for prevention of CHD of interventions at the population level designed to reduce mean levels of cholesterol. The fact that the percentages sum to more than 100% reflects the fact that many people have more than one risk factor. Poor diet, Type 2 diabetes and socio-economic deprivation are also known risk factors. While each factor is important in its own right, the risk of developing CHD is strongly related to a combination of factors and it appears that the effect is synergistic.

In 2005, 10,331 deaths (all ages) in Scotland were attributed to CHD. CHD is the most common cause of premature death (death before the age of 75 years of age) and accounted for 18% of premature deaths in Scotland in 2005 (3,929 deaths under the age of 75 years). Scotland has one of the highest death rates from CHD in Western Europe, a fact that has been attributed to poor diet, inadequate exercise, smoking and poverty. Mortality from both CHD and acute myocardial infarction has been falling in Scotland, as well as in other European countries for several decades, but CHD remains the single largest cause of death in all ages and premature death in Scotland.

34 The rate for under-75s in 2005 (standardised by age) was consistent with the declining overall rate and also with the Scottish target of a 60% reduction between 1995 and 2010. Within Scotland, CHD mortality rates remain higher in West Central Scotland and in deprived areas. Amongst those under 65 years of age, mortality rates are almost five times higher in the most deprived, compared to the most privileged population defined by SIMD decile (Figure 7.1). CHD mortality is strongly related to age, with much higher rates among elderly people.

7.2 Practice Team Information (PTI) data for CHD

The overall estimate of prevalence of CHD derived from primary care based PTI data3 was 3.5% in 2005/6 which is assumed to be an underestimate. The prevalence was higher in males than in females. This is similar to the value of prevalence calculated by the ISD CHD and Stroke Programme, 3.6%, based only on patients admitted to hospital and therefore itself an underestimate. This is in keeping with wider concerns about general under-reporting for PTI since the new GMS contract was implemented. It is considerably lower than the prevalence calculated by the QOF national CHD register (4.5%) based on all Scottish practices in the same year (Table 7.1). Nevertheless, PTI data confirms that the prevalence is higher in males than in females and rises sharply with age, with very low prevalence rates under 45 years (Figure 7.2).

7.3 CHD Prevalence based on CHD and Stroke Programme (SMR01)

The estimated national prevalence of CHD based on admission to hospital is 3.6% of the Scottish population, as referred to above. Prevalence is higher in males (4.2%) than in females (3.0%) and is strongly related to age. This prevalence estimate is published by ISD Scotland and is based on its CHD and Stroke Programme which uses a linked SMR01 and CHI database to create a register of live patients who have experienced hospital intervention for CHD. This provides much detailed information about each patient and can be analysed by NHS Board, council/CHP and by GP practice. Prevalence rates based on SMR01 have been found to be about 79% of the prevalence estimated by QOF, because the latter includes milder cases that have not required hospital intervention. The SMR01 database is therefore a subset of more seriously affected patients who have required admission to hospital. This confirms the suspicion that PTI prevalence rate is a considerable underestimate for CHD.

According to the SMR01 database, the crude prevalence of CHD for West Dunbartonshire residents, at 4.2%, is considerably higher than the national average of 3.6%.

7.4 CHD prevalence based on QOF

The Scottish prevalence of CHD as measured by the QOF4 is 4.5% (Table 7.2). Differences in the criteria by which the data are collected for PTI and QOF explain the difference in prevalence rates by these two measures5. The prevalence of CHD for West Dunbartonshire

3 For a complete description of PTI data and how it is collected, see appendix 1b. 4 For a complete description of QOF data and how it is collected, see appendix 1b. 5 The QOF register includes people who have ever had coronary revascularisation, myocardial infarction (heart attack) or other CHD diagnoses, even if they do not have a current active diagnosis of CHD. PTI statistics include such patients only if the reason for a consultation was stated to be CHD and only if they consulted for CHD in the year of analysis.

35 as measured by the QOF is 4.9%, which is higher than the national Scottish QOF prevalence of 4.5% (Tables 7.2 and 7.3). This is in accord with the profile of risk factors reported in the West Dunbartonshire Health and Well-being Survey which showed smoking, alcohol consumption, exercise levels and obesity to be problematic in West Dunbartonshire. It is also in accord with the higher prevalence of related clinical conditions as measured by other QOF indicators, for example, diabetes and hypertension. It is not as high as for some Glasgow CHPs, however (Table 7.4).

7.5 Secular trends in incidence of CHD

There is no true measure of incidence of CHD routinely available (that is equivalent, in terms of completeness of recording, to cancer registrations for example). A proportion of patients will suffer from CHD for years and neither be admitted nor immediately die from the condition and will be excluded from the statistics until they are admitted to hospital or die with the condition without prior diagnosis.

For the purposes of this report, our definition of ‘incidence’ is the same as used by ISD Scotland, as follows: The numerator used to calculate the incidence includes new hospital cases (screened back to exclude those with previous admissions) plus deaths with no hospital admission. The denominator is the relevant population in the area of question. Age standardisation using the European standard population for gender specific rates is also carried out.

In the last ten years, the ‘incidence’ rates of CHD in Scotland have declined by 26% and 27% in males and females, respectively. This trend is very encouraging and provides a benchmark figure against which equivalent falls in mortality in West Dunbartonshire and elsewhere may be compared (Figures 7.3 and 7.4). The declines in incidence in the male and female population of Greater Glasgow NHS Board area were respectively 31% and 28%, and in Glasgow City, 28% and 23%, respectively.

The incidence of acute myocardial infarction (acute MI) in Scotland has dropped even more dramatically by 37% in males and 36% in females in the same time period. The equivalent declines in acute MI in Glasgow City were 32% in males and 29% in females.

Unfortunately, corresponding trends in incidence of CHD are less evident in West Dunbartonshire (Figures 7.3 and 7.4). This presumably reflects the persistence of several risk factors including social deprivation, smoking, obesity, hypertension, diabetes, and excessive alcohol consumption. In the male population of West Dunbartonshire, the decline in CHD incidence has been relatively modest, from 612 to 490 per 100,000 between 1995 in 2005, a decline of 20% in the period of ten years. In the female population, there is no evidence of any decline in the same period (an example of the ‘flattening’ described above). The rates in West Dunbartonshire females in 1996 and 2005 were 318.3 and 317.5 per 100,000, respectively (i.e. remaining virtually unchanged).

Remarkably, the absolute number of incident cases of CHD in the female population of West Dunbartonshire exceeded the number in the male population in 2005. In that year, there were 239 female and 235 male incident cases. In Scotland, there were 11,637 male and 8,948 female incident cases, clearly demonstrating that overall, CHD is more common in males and stated in paragraph 3 of the introduction.

36 Incidence of CHD by council area is shown for males and females in Figures 7.5 and 7.6. This is described more fully in paragraph 7.6. In recent years, CHD incidence rates for males in West Dunbartonshire, have merged with those of Glasgow City, which has the highest all-cause death rate in Scotland and, historically, amongst the highest rates of CHD incidence in Scotland.

The patterns of incidence of acute myocardial infarction in the last decade are shown in Figures 7.7 and 7.8. The pattern of declining incidence in West Dunbartonshire evident in the early part of the decade was not sustained either in males or females, especially after 2002. The incidence of myocardial infarction in women increased from 125 to 188 per 100,000 between 2002 and 2005 (Figures 7.7 and 7.8), and the numbers of new cases in women (153) exceeded that for men (148) for the first time in history in 2005. In Scotland there were 6,238 incident cases in the male and 4,734 in the female population in 2005, clearly demonstrating that acute MI is far more common in males in Scotland but more common in females in West Dunbartonshire. This reflects the fact that unhealthy lifestyles in West Dunbartonshire women are catching up with them and enabling their CHD rates to catch up with those of their male counterparts.

7.6 Variations in incidence of CHD by council area

The incidence of CHD and myocardial infarction in West Dunbartonshire compared with other council areas is shown in Scottish league tables in Figures 7.5 and 7.6 and Figures 7.9 and 7.10, respectively. West Dunbartonshire has the third highest incidence of CHD in males and the highest incidence in females. The incidence of myocardial infarction tops the league tables in both West Dunbartonshire males and females, suggesting that a life- threatening presentation of CHD is more common in West Dunbartonshire than in any other part of Scotland. This suggests that more efforts should be aimed at primary and secondary prevention of CHD, primary prevention that targets people before they have confirmed disease but who have risk factors and secondary prevention that targets people with confirmed disease and prevents them from going on to develop advanced disease requiring high tech intervention including surgery.

7.7 Self-reported health service usage

Evidence from the Greater Glasgow Health and Well-being Study 2005: West Dunbartonshire Report reveals considerable differences in self-reported health service usage profiles between residents of West Dunbartonshire compared to Greater Glasgow. These include a consistent tendency for West Dunbartonshire residents to report higher rates of usage of GP, outpatient departments, A&E departments and hospital inpatient facilities in the past year combined with almost double the likelihood of reporting difficulty getting a GP appointment or accessing health services in an emergency. (Table 7.5). It is important to bear in mind that this experience of health service usage is self-reported and that it refers to all conditions and not just CHD.

7.8 Coronary heart disease and hospital discharge data

The trends in rate of discharge from hospital because of coronary heart disease are shown in Figures 7.11 and 7.12. These show that the trend in discharge rates has broadly followed the declining trend in incidence in the last ten years. This demonstrates the use of routinely-

37 derived hospital discharge data as a proxy indicator of incidence and also potentially reveals interesting findings about the NHS’s response to demand for services.

Although the prevalence and incidence of coronary heart disease and acute myocardial infarction are both high in West Dunbartonshire, the rates of discharge from hospital for CHD are lower than might be expected, particularly for males in the earlier years in this study period (1996-2000) and approximates or even undercuts the curve for Scotland, in some years, for both genders. This is in keeping with the well documented lower-than- expected treatment rates in many deprived areas in Scotland described by the CHD and Stroke Task Force Report. The exception is the sudden increase in CHD hospitalisation for females in 2005/6 which is discussed below (paragraph 7.17). This apparent under- hospitalisation would need further ad hoc study to fully elucidate the reasons behind it, but at face value, one would expect hospital discharge rates for CHD commensurate with the high incidence of CHD.

7.9 Variations in discharge rate for CHD by council area

The hospital discharge rates because of CHD by council area are shown in Scottish league tables in Figures 7.13, 7.14a and 7.14b for the fiscal year 2005/6. These show that in West Dunbartonshire the discharge rates for males lay in the lowest third of rates, but the rate for females was the third highest. These suggest that in 2005/6, the rate of treatment of females with CHD was commensurate with the scale of incidence in West Dunbartonshire, but that for males, the level of treatment continued to fail to match the scale of the problem. The importance of the year for which the data is presented is critical as demonstrated by the fact that the equivalent graph for 2004/5, the year before, demonstrates West Dunbartonshire females’ position 13th from the top, highlighting the recent increase in hospitalisation because of CHD in females that is seen in Figure 7.12 and discussed below (paragraph 7.17).

7.10 Acute Myocardial infarction and hospital morbidity data

The trends in rate of discharge from hospital because of Acute Myocardial infarction, an important (acute) subset of CHD, are shown in Figures 7.15 and 7.16. There is a tendency for a convergence of rates over time for both genders for the 3 largest regions studied (Scotland, Greater Glasgow and Glasgow City) such that by 2005/6 there is little difference between them. The direction of the trend for males from all regions is similar to the equivalent trend in incidence rates for males, broadly declining over time. The direction of trend for females is more complicated, with a clear downward trend in the first half of the study period, followed by a clear reversal of the trend since 2003 as demonstrated by the considerable increase in hospital discharge rate until 2005/6. Again, there appears to be an element of relative under-hospitalisation for acute MI for both genders, where rates approximate or undercut the average discharge rates for Scotland, particularly for the early years studied. The steep rise in hospital discharge for acute MI in females from 2003 onwards is discussed below (paragraph 7.17).

7.11 Investigations for CHD

Patients with narrowing or occlusion of the coronary arteries may be treated by means of a revascularisation procedure, for example, coronary angioplasty and coronary artery bypass graft (CABG). The aim of the treatment is to increase the arterial blood supply to the myocardium. Before the treatment can be carried out, it is necessary for an assessment to be

38 carried out of the number of coronary arteries affected by disease and the extent of disease in each artery. Coronary angiography is the investigation used to make this assessment.

Trends in the rates of coronary angiography are shown in Figures 7.17 and 7.18. The overall angiography rates in Scotland and Greater Glasgow have gradually increased over the last decade. This reflects the growth of interventional cardiology. The trend in angiography rate in West Dunbartonshire is much less clearly defined. Although the rate shows marked fluctuation in different years, the angiography rate in West Dunbartonshire has not shown the sustained increase that is evident nationally for both genders. For example, the female angiography rate in 2005/6 was 218 per 100,000 West Dunbartonshire females, slightly less than the rate 10 years earlier in 1996/7, 225 per 100,000. Similarly for West Dunbartonshire males, the rate in 2005/6 was considerably less at 388 per 100,000 than in 1996/7 at 493 per 100,000.

7.12 Variations in angiography rate for CHD by council area

The angiography rates because of CHD by council area are shown in Scottish league tables in Figures 7.19 and 7.20 for the fiscal year 2005/6. These show that the angiography rates for males lay in the 12th position from the top and the rate for females was 8th from the top position. These suggest that in 2005/6, the rates of angiography in males and females with CHD were not commensurate with the scale of incidence of CHD in West Dunbartonshire males and females in that the level of investigation does not appear to match the scale of the problem. This superficial analysis would require further detailed investigation to elucidate the reasons for this apparent relative under-investigation.

7.13 Surgical treatment for CHD

Trends in the rates of CABG are shown in Figures 7.21 and 7.22. There is evidence that the CABG rates in Scotland, Greater Glasgow and Glasgow City have been declining in the last decade due to changing incidence and severity of disease. The trend in CABG rate in West Dunbartonshire males is also declining and has been fluctuating, based on small numbers, around the average. The trend in CABG rate for West Dunbartonshire females is much less clearly defined. Although the rate shows marked fluctuation over the years due to the very small numbers on which it is based, there is some evidence that the rate was on the low side historically and only achieved its commensurate position in the league table in the most recent year (2005/6) (see paragraph 7.14).

7.14 Variations in CABG rate for CHD by council area

The CABG rates because of CHD by council area are shown in Figures 7.23 and 7.24 for the fiscal year 2005/6. These show that the CABG rates for males lay in the 6th position from the top and the rate for females was second from the top position. These suggest that in 2005/6, the CABG rate in females with CHD was commensurate with the scale of incidence in West Dunbartonshire females in that the level of one form of advanced treatment matches the scale of the problem for that gender. However, the numbers are too small, without further detailed study, to enable conclusions to be made about the appropriateness of the CABG rate for West Dunbartonshire males in 2005/6.

39 7.15 Prescribing rates for statins and selected antihypertensives

Prescribing rates for statins (Figure 7.33, appendix 7) in West Dunbartonshire are considerably lower than those for NHSGG&C over the 27 month period studied, ending in October-December 2006. This is an unexpected finding given that CHD and acute MI incidence rates are considerably higher in West Dunbartonshire than in this larger geographic area and one would expect commensurate excesses in prescribing of statins (cholesterol lowering drugs) in West Dunbartonshire. However, in addition Figure 7.33 reveals that there is a west-east divide within West Dunbartonshire in that statin prescribing rates are considerably lower in the Vale/Dumbarton half than in the Clydebank half, suggesting that West Dunbartonshire rates are pulled down by under-prescribing in the Vale/Dumbarton half of the population. This suggests that clinical guidelines are being implemented differently in the two halves of the CHP area, in keeping with the fact that Managed Clinical Networks and related clinical pathways and referral guidelines for CHD were at different stages of implementation in the two former NHS Boards (Argyll and Clyde versus Greater Glasgow). This difference narrowed slightly over the 27 month period, as the Vale/Dumbarton rates rose slightly to approximate the Scottish prescribing rates, but was still present by October- December 2006 at which time prescribing rates for statins were 18% higher in Clydebank. It is conceivable that CHD incidence is 18% higher in Clydebank than in Vale/Dumbarton given the higher smoking prevalence in parts of Clydebank. However, the fact that statin prescribing was 40% higher in Clydebank at the beginning of the study period suggests that there was a prescribing anomaly rather than solely a response to genuine differences in disease incidence. This is an area of concern that is currently being addressed by NHSGG&C via the extension of MCN guidelines, including the introduction of new GG&C prescribing formulary throughout the NHSGG&C area. This will also address the fact that although generic prescribing was the norm in both halves of West Dunbartonshire, prescribing of cheaper statins (e.g. simvastatin) was practised more commonly in Clydebank whereas more expensive statins, thought to be more effective by clinicians at lowering cholesterol (e.g. atorvastatin), were preferred in Vale/Dumbarton.

Prescribing rates for state-of-the-art anti-hypertensives shows similar anomalies which are also assumed to be due to the difference in advancement of MCNs and lack of uniformity of prescribing formularies in addition to what may well be an excess of hypertension in Clydebank. The antihypertensive drug of choice in Clydebank was an angiotensin converting enzyme inhibitor (ACEI) while the drug of choice in Vale/Dumbarton was angiotensin II receptor antagonist (AIIRA) (Figures 7.34 and 7.35, appendix 7). The latter may reflect that fact that the consultant running the Blood Pressure Clinic held at the Vale of Leven reportedly prefer to prescribe AIIRAs.

When prescribing rates for these two categories of anti-hypertensive drugs are combined, the rate in October-December 2006 was still 13% higher in Clydebank than in Vale/Dumbarton (Figure 7.36, appendix 7). The gap had reduced from an excess of 29% at the beginning of the study period, suggesting that the gap contains an element of prescribing anomaly rather than purely a response to genuine differences in disease incidence. This is an area of concern that is assumed to be similar to the statin issue, and that is currently being addressed by NHSGG&C.

40

7.16 Mortality

Trends in mortality for coronary heart disease and myocardial infarction are shown in Figures 7.25 - 7.28. These are in keeping with the well-known decline in mortality associated with coronary heart disease that is underway in Scotland and in all western countries. The declining mortality probably represents both declining incidence of the disease and also improved survival due to better secondary prevention and treatment. In Scotland, between 1996 and 2005, the CHD mortality rate in males declined dramatically from 300 to 185 per 100,000 males (38% decline or 3.8% decline per annum) and from 144 to 91 per 100,000 females (37% decline). These excellent results mean Scotland is on schedule to achieve the targets outlined in strategy documents.

The trends in mortality in this period for acute MI and CHD in West Dunbartonshire are of less concern than the trends in incidence for these conditions and in fact have been very good for West Dunbartonshire males. The mortality for coronary heart disease in West Dunbartonshire males declined by 42% (4.2% per annum) from 370 to 215 per 100,000, and for acute myocardial infarction, by 46% from 253 to 136 per 100,000. This is in keeping with strong and steady declines in mortality for acute MI and CHD at national and Board level. The decline in CHD mortality for females from 162.3 to 122.7 per 100,000 (24% decline) was less impressive. Of some concern is the fact that mortality from CHD in West Dunbartonshire females has increased since 2002 and remained above Glasgow City rates for three consecutive years, rising from 112 to 123 per 100,000. In Scotland, the mortality rate fell from 110 to 91 per 100,000 in the same four year time period. This deterioration in mortality rates for females meant that the absolute number of deaths from CHD were equal in West Dunbartonshire in 2003 for men and women for the first time. They stayed roughly equal for the next two years although a male:female mortality ratio from CHD of 1.2:1 would be expected. This equalisation supports the hypothesis that there has been a recent decline in progress in the disease profile for West Dunbartonshire women, which has been responded to by an increase in hospitalisation, investigation and treatment, but that some excess in mortality has nevertheless still occurred.

In the first half of the study period (1995/6 to 2000/1), death from acute MI was particularly high in West Dunbartonshire males while hospitalisation rates for acute MI were particularly low in the same period (Figure 7.29). The curves for each of these indicators are almost mirror reflections in that early study period (Figures 7.15 and 7.27). A less dramatic version of the same paradoxical combination is seen for women in those early years (Figure 7.30). However, when the second half of the study period is examined, the mis-match between death and hospitalisation is much less obvious for West Dunbartonshire males (Figure 7.31) and is virtually absent for females (Figure 7.32).

7.17 Conclusion regarding CHD burden of disease in West Dunbartonshire

Although there is considerable fluctuation in the various coronary heart disease and acute myocardial infarction trends for West Dunbartonshire, presumably because of the smaller populations on which these statistics are based, there is a consistent evidence of higher prevalence and incidence rates, than for the NHS Board area and Scotland. The West Dunbartonshire incidence rates are also declining more slowly than those of the larger regions. Mortality rates are also high in West Dunbartonshire but are declining well for men

41 and more slowly for women, with some suggestions of a recent increase of mortality from myocardial infarction for women.

League tables demonstrate West Dunbartonshire’s position experiencing the highest CHD incidence for women and the highest incidence for acute myocardial infarction for men and women in 2005, the most recent year for which data are published on the web. In contrast, league tables of hospitalisation rates for CHD reveal that West Dunbartonshire males and females experienced less hospital treatment than expected in the fiscal year 2005/6 and 2004/5, respectively, in that they were placed at the opposite end of the Scottish council league table.

Recent exacerbations (incidence or mortality) or reversals (hospitalisations, angiography) in these trends, particularly in females, would need to be studied using more recent data and monitored in the longer term. This assessment suggests that in the most recent year studied, there was a precipitous increase in investigation and treatment of women with heart disease.

It is well known that the most deprived parts of Scotland receive treatment for CHD disproportionately less than they should, according to the CHD and Stroke Task Force Report. This is in part attributed in the Task Force Report to the belief that men in deprived areas assume that there is nothing that can be done for them and delay seeking a visit with their GP and are less likely to assert themselves in discussions with healthcare services about treatment options. This needs assessment reveals that West Dunbartonshire experiences an incidence of CHD even higher than Glasgow City. In combination with this nation-wide tendency for the most needy to under-utilise available services and treatments, this becomes particularly relevant. However, the fact that the Health and Wellbeing Survey suggests higher self-reported usage of health services of all kinds and reported difficulty accessing both a GP and emergency services does not support the view that West Dunbartonshire patients are not seeking help when they should (Table 7.5).

Mechanisms have been recently introduced via the MCN in the Greater Glasgow area, particularly in primary care, to find and refer CHD patients. Efforts are currently underway to extend these important community-based services to geographically remote and socially deprived areas, as recommended by the CHD and Stroke Task Force Report, including to the remainder of West Dunbartonshire and indeed other CHPs in the newly formed NHSGG&C area and these are expected to further standardise treatment in terms of its nature, quality and rates of delivery.

Recent increases in incidence and mortality in females, responded to with commensurate recent increases in investigation and treatment, provides some evidence that the smoking, drinking and eating habits of West Dunbartonshire women are catching up with them and that appropriately targeted health improvement initiatives (aimed at primary prevention) need to be introduced or reinforced. Of some concern, is the slower impact of increased investigation and treatment on mortality rates for West Dunbartonshire females.

Considerable though narrowing differences in prescribing of statins and state-of-the-art antihypertensive drugs between West Dunbartonshire and the Board area and between the Vale/Dumbarton and Clydebank halves of the West Dunbartonshire suggest historical differences in the level of advancement of MCNs between the two Boards and differences in application of prescribing protocols that are currently under investigation and will be

42 rectified via the full implementation of NHSGG&C-wide MCNs and related prescribing protocols.

43 8. CEREBROVASCULAR DISEASE

8.1 Introductions and definitions

Cerebrovascular disease results from degenerative change in the arteries that supply the brain. Cerebrovascular disease is associated with two main syndromes, stroke and transient ischaemic attack (TIA). The difference between stroke and TIA lies in the different time- scales of the respective clinical presentation. A stroke may be defined as a neurological deficit of sudden onset which lasts more than 24 hours and is of vascular causation. TIA is defined as an episode of temporary and focal cerebral dysfunction of vascular origin that is rapid in onset and of variable duration, ordinarily lasting 2 to15 minutes but rarely as long as one day.

The main types of stroke are cerebral infarction, subarachnoid haemorrhage and non- traumatic intracerebral haemorrhage. Cerebal infarction is the most common type of stroke in western countries.

The mechanism of cerebral infarction is analogous to that of myocardial infarction. The infarct represents ischaemic loss of cerebral tissue as a result of narrowing or occlusion of a cerebral artery. In strokes of the subarachnoid and intracerebral haemorrhagic types, the tissue damage occurs as a result of haemorrhage from a ruptured cerebral artery. Cerebrovascular disease is predominantly a disease of elderly people. Both the incidence and mortality rates are much higher among older than younger people. Cerebrovascular Disease (CVD) is the third leading cause of mortality in Scotland (5,801 deaths in 2005), and treatment of CVD is a major part of the work of NHS Scotland. ISD Scotland holds data on incidence of CVD, based on the SMR01 data, obtained by linkage of data from the CHD and Stroke Programme and mortality data for both NHS Boards and council areas. ISD Scotland holds no accurate data on the prevalence of the long-lasting effects of cerebrovascular disease, including stroke (which are acute events), which will be much higher than incidence as mean duration of illness/disability in stroke patients can be measured in years.

8.2 Prevalence of stroke/TIA

The PTI data6 confirms that prevalence of stroke/TIA, (a subset of CVD), is rising slightly over time, in keeping with the aging population. Prevalence rates rise steeply with age (Figure 8.1). Stroke is uncommon under 55 years of age. The prevalence of stroke is higher in males in most age-groups than in females, but the consultation rates in primary care are marginally higher for females than for males. This reflects the fact that women seek primary care services more readily than do men.

According to the PTI (Table 8.1), the overall Scottish prevalence of stroke/TIA for both genders combined in 2005/6 was provisionally estimated to be 0.99% (9.9 per 1,000). This is much less than the prevalence of stroke measured by the QOF7 which was 1.9%, almost double. This is largely explained by the fact that the QOF register includes people who have ever had a stroke or TIA and the PTI statistics reflect current active problems and include such patients only if the reason for consultation was stated to be stroke or TIA. We would therefore expect under-estimation by the PTI.

6 For a complete description of PTI data and how it is collected, see appendix 1b. 7 For a complete description of QOF data and how it is collected, see appendix 1b.

44 The QOF data (Tables 8.2, 8.3) suggest that prevalence has increased slightly between 2004/5 and 2005/6 for both Scotland and West Dunbartonshire. According to Table 8.2, the prevalence of stroke/TIA in West Dunbartonshire is 2.2% which is 16% higher than the national average of 1.9%. This is in keeping with the higher prevalence of relevant risk factors in West Dunbartonshire including high blood pressure, high blood cholesterol, poor diet, obesity, smoking, physical inactivity, excessive alcohol intake, diabetes and socio- economic deprivation. QOF prevalence rates for Glasgow City and Greater Glasgow are equal to those for Scotland. This may mean that West Dunbartonshire has a particular problem with an expanding burden of patients with cerebrovascular disease.

The QOF prevalence figures for West Dunbartonshire, Glasgow City and Greater Glasgow can not easily be cross-checked against other sources of routinely collected data, as the latter collect no data on prevalence at those units of analysis.

8.3 Incidence of CVD (all categories)

In the Scottish population, the incidence of stroke, as measured by new cases admitted to hospital for the first time or dying with the disease with no prior record of the disease, has fallen over time. Although a greater number of women (7,000 new CVD events in 2005) have strokes than men (5,654), women tend to have strokes at an older age, and the age- standardised incidence rates for different age groups are higher for men than for women. Although the incidence of stroke has declined (Figures 8.2 and 8.3) in the last decade, this has fallen short of the decline that has occurred in other western countries. Stroke remains a considerable public health problem in Scotland.

The incidence of stroke has also declined in Greater Glasgow and Glasgow City, although there was an unexpected increase in the incidence for females in these two regions in the early years of the 21st century that was not evident for Scotland as a whole. The rates for these three regions follow a logical sequence with rates highest for Glasgow City, intermediate for Greater Glasgow (which includes socially more privileged areas than Glasgow City) and lowest for Scotland (which includes still more areas of greater social privilege from across the country). Figures 8.2 and 8.3 also show the trends for West Dunbartonshire males and females with CVD rates fluctuating (based on smaller numbers) between the Scottish and Greater Glasgow trajectories. This is in contrast to the situation for coronary heart disease, where West Dunbartonshire rates were clearly at the top of the Scottish league table. Figures 8.4 shows best-fitting least-squares regression lines fitted to the data shown in Figure 8.2. This demonstrates that West Dunbartonshire incidence rates in males are not declining as quickly as those of Glasgow City and Scotland males, which are declining in parallel. Unfortunately, incidence trends for stroke (an important subset of CVD) are not routinely published. Nevertheless, although CVD incidence rates in West Dunbartonshire males are not declining as quickly as we would hope, they are closer to the national rate than to the Glasgow City rate, which is encouraging.

8.4 Cerebrovascular disease hospital discharge

The unlinked age-standardised discharge rate for patients with cerebrovascular disease have declined in recent years in Scotland, Greater Glasgow, Glasgow City and West Dunbartonshire (Figures 8.5 and 8.6), which reflects declining incidence rates. The decline in discharge rate in Scotland corresponded to a fall in the number of discharges from 24,658 in 2003-04 to 22,055 in 2005-06. A comparison of standardised hospital discharge rates for

45 CVD for Scotland, Greater Glasgow, Glasgow City and West Dunbartonshire reveals that West Dunbartonshire males and females experience similar discharge rates (using unlinked data) to that of their Scottish counterparts for all CVD combined which is reasonable given that West Dunbartonshire incidence was between Scottish and Greater Glasgow rates for both genders.

A pattern of declining hospital discharge rates was also evident for patients with stroke (an important subset of CVD) from all four regions (Figures 8.7 and 8.8). These graphs indicate that hospital discharge rates for stroke for West Dunbartonshire males are declining more rapidly even than their male Scottish counterparts, which is unexpected given that the incidence of CVD (all categories) was between Scottish and Greater Glasgow rates. This implies that West Dunbartonshire males are not being admitted to hospital for stroke as much as their Scottish counterparts who experience less CVD. The same picture is demonstrated for West Dunbartonshire females. In 2005/6, both West Dunbartonshire males and females are being admitted for stroke less than their counterparts in the other three regions. The reasons for this would need to be explored. They may result from effective community- based pharmacological treatment of hypertension (see paragraph 8.5). There is no reason to believe that acute stroke patients in West Dunbartonshire could not access hospital when required. Clydebank patients would access the Western Infirmary or RAH stroke units. There has been a dedicated stroke ward at the Vale of Leven Hospital since 1998 with 12 designated beds for stroke and 4 for chronic neurological conditions. Prior to this time stroke patient shared a special ward with orthopaedic rehabilitation patients supervised by a consultant with special interest in stroke from the Care of Elderly Unit. Acute patients are now admitted via the Medical Assessment Unit and usually transferred to the stroke ward within 24 hours if a bed is available. The protocols followed are identical to those at the stroke unit at Royal Alexandra Hospital Paisley. The SIGN Guidelines for stroke are followed as the hospital has a CT scanner with ultrasound scanning in the X-ray department. There is a team of nurses, physiotherapists, speech therapists and occupational therapists with a special outreach team to follow patients on discharge home.

When compared to other Scottish councils for the most recent year for which data are available, the discharge rate for stroke in residents of West Dunbartonshire falls in the lower half of the league table (Figures 8.9 and 8.10). West Dunbartonshire men, in particular, experience a hospital discharge rate for stroke that is less than half of their Midlothian equivalents and is just over half (55%) that of their Glasgow City equivalents.

8.5 Antihypertensive prescribing rates

A number of clinical and behavioural measures are advocated to prevent stroke (including pharmacological control of blood pressure, reduction in dietary salt, weight loss, increased exercise) and treat stroke (clot dissolvers (TPA), antiplatelets, anticoagulants, etc.). The data on antihypertensive prescribing rates in West Dunbartonshire are shown in Chapter 7 on coronary heart disease. This data suggests that combined prescribing of ACEI and AIIRAs was considerably higher in West Dunbartonshire than in NHSGG&C and Scotland, in keeping with higher prevalence of hypertension and strokes. Of interest was the higher prescribing rates for both types of drugs combined in the Clydebank half compared to the Vale/Dumbarton half which is probably due to the more advanced state of implementing managed clinical networks in the former NHSGG compared to that in the former Argyll and Clyde. This would need to be further explored. This difference in compliance with

46 guidelines is supported by the marked preference for ACEI in Clydebank and the marked preference for AIIRA in Val/Dumbarton (see paragraph 7.15) .

8.6 Mortality

Stroke mortality in Scotland has fallen more dramatically over time than has incidence, but the rates remain high compared to most other western European countries (Figures 8.11 and 8.12). More women than men die from strokes, but as the female deaths tend to occur at an older age, the age-standardised mortality rates for several age groups are higher for men than women. Within Scotland, mortality rates remain higher in west-central Scotland and in deprived areas. Age-standardised mortality rates from CVD have dropped in Scotland by 32% and 23% in males and females, respectively, between 1996 and 2005. Age-standardised mortality rates from stroke have dropped in Scotland by 43% and 40% in males and females, respectively over the same time period. The Scottish target is a 50% reduction between 1995 and 2010 in the age-standardised death rate from stroke for people aged under 75 and Scotland is on track to meet the target.

Mortality rates from CVD are dropping for all 4 regions examined and for both genders and the inter-regional gaps are far narrower than for incidence (Figures 8.13 and 8.14). The highest mortality rates are for Glasgow City males and females. West Dunbartonshire males and females experience mortality rates from CVD and stroke that are similar to their Scottish counterparts, albeit with greater fluctuation due to the smaller numbers.

47 9. DIABETES

Diabetes mellitus is a disorder of carbohydrate metabolism caused by an absolute or relative deficiency of insulin. Insulin is a hormone that is secreted into the blood by the pancreas. Insulin is the hormone chiefly responsible for the removal of glucose from circulating blood by promoting uptake of glucose in the tissues. In patients with diabetes, the deficiency of insulin means that the blood glucose level is higher than normal. A diagnosis of diabetes is made if the fasting level of blood glucose is greater than seven mmoles per litre. The complications of diabetes include disease of the retina, kidney and nervous system. In addition, diabetes is an important risk factor for all forms of vascular disease, including ischaemic heart disease and stroke.

Diabetes occurs in two main forms, Type 1 and Type 2 diabetes. Type 1 diabetes results from an absolute deficiency of insulin and is most common in relatively young patients. It is thought to be of infectious origin and influenced by genetic inheritance. Type 2 diabetes results from a condition known as insulin resistance, in which the uptake of glucose by the tissues is impaired. In patients with Type 2 diabetes, insulin is usually detectable in the circulating blood. Obesity, excessive intake of sugar and fats, old age and low levels of physical activity are risk factors for Type 2 diabetes. The fact that both the incidence and prevalence of Type 2 diabetes are increasing means that this form of diabetes is projected to increase as a major public health problem in the future.

In addition, it is thought that many cases of diabetes remain undiagnosed. Proposals to introduce screening for risk factors for coronary heart disease, including undiagnosed diabetes, of all people aged 45-64 years in selected socio-economically deprived CHPs, (under plans to introduce ‘Keep Well’ scheme) , will help identify and treat this hidden problem.

The prevalence of diabetes increases with increasing age to a maximum in the 65-74 age- group (Figure 9.1). This pattern reflects the fact that most cases are cases of Type 2 disease. The much lower rates of prevalence in the population aged less than 25 years mainly reflects those with type 1 disease. There is also evidence that the prevalence of diabetes is increasing in recent years (Table 9.1). Both the prevalence and consultation rates increased considerably between 2003/4 and 2005/6.

The QOF disease register for diabetes also confirms that the prevalence of diabetes in both Scotland generally and West Dunbartonshire has increased between 2004/5 and 2005/6 (Table 9.2). According to the PTI, the overall Scottish prevalence of diabetes for both genders combined in 2005/6 was estimated to be 3.5% (34.8 per 1,000). This is similar to the national estimate of 3.4% prevalence based on the QOF data. Unfortunately, PTI data is not available at CHP level. However, QOF data is collected at practice level and can be used to approximate CHP prevalence. The prevalence of diabetes in West Dunbartonshire in 2005/6 was 3.5% (Table 9.3). Information related to lifestyle and risk of diabetes is shown in Table 9.4.

This shows remarkably good correlation between QOF and PTI national prevalence figures for diabetes. However, this suggests that both QOF and PTI estimates are an underestimate of the genuine prevalence at national and local level, although for entirely different reasons. The QOF does not include the “under 17 year olds” and the PTI risks missing patients who have not consulted for that condition within that year of study.

48 The QOF rules exclude people aged less than 17 years and those with gestational (pregnancy) diabetes. QOF guidance assumes that review will be carried out annually. PTI statistics reflect those who consult for a condition. If reviews are carried out less frequently than annually the number included will be smaller than those who are on the disease register but have not attended for review. Additionally, diabetes prevalence rates from QOF uses the whole practice population as the denominator but includes only those aged 17 and over in the numerator. This will lead to an underestimate of total prevalence.

49 10. CHRONIC OBSTRUCTIVE PULMONARY DISEASE

10.1 Introduction

COPD clearly identifies Scotland’s problematic relationship with tobacco when mortality rates for COPD are examined against those of other European countries. Scotland achieves second place amongst men aged 15-74 (Figure 10.1). Areas such as West Dunbartonshire and Glasgow City, where smoking prevalence has been high for some time and all-cause mortality is high, contribute significantly to these statistics.

COPD is the fourth most common cause of death in Scotland, responsible for about 5% of deaths (after combined acute MI and CHD which are responsible for almost 19% and lung cancer which is responsible for almost 7%). Approximately 80% of cases of COPD are caused by smoking and therefore COPD is considered to be one of the smoking-related diseases along with lung cancer and heart disease. The pathology involved is of two main types: chronic bronchitis (primarily a disease of inflamed and narrowed airways and secondary air retention) and emphysema (primarily a disease of the pulmonary parenchyma). A small percentage of COPD cases are genetically linked. The incidence rises sharply with age, duration of smoking career, and age at commencement of smoking. If deaths amongst those aged under 65 years is considered, COPD drops to 7th place, as the cause in 2.5% of all deaths (being superseded by deaths due to alcoholic liver disease, breast cancer and mental and behavioural problems due to alcohol).

A recent study showed that 13% of Britons over 35 years of age have evidence of COPD, and that most of these have never been given a diagnosis, suggesting that a sizeable fraction of the population has a degree of lower respiratory tract disease which they can apparently ignore and for which consultation with a GP seems unnecessary.

Reliable prevalence and incidence data is scanty in Scotland considering the extent of utilisation of hospital services by COPD patients, the position in the cause-of-death league table and the high incidence rate of illness from COPD in smokers (a recent prospective study lasting 25 years showed that 25% of smokers will develop COPD). Indeed the problem may be worse than suspected as a recent study of more than 8,000 adults by Cancer Research UK estimated that 13.3% of Britons over 35 years of age may have developed features of COPD and that 80% of those affected (based on results of salivary and lung function tests) said they had not received a diagnosis of any kind.

PTI data provides nationally calculated annual prevalence, incidence and consultation (contact) rates for COPD in Scotland based on the data collected by 44 practices. The figures for 2003/4 and 2004/5 are summarised in Table 10.1 and the age-specific prevalence rates are demonstrated in Figure 10.2. More female patients present with COPD to their practice team than do male patients for every age group other than the 65 year and above group where male prevalence, incidence and consultation rates exceed those for females. The prevalence of COPD increases rapidly with increasing age (CF CHD) although does exist in those under 35 years of age.

The PTI database suggests that the overall prevalence of COPD is higher in females than in males and that the prevalence across Scotland for both sexes combined was 1.9% in 2004/5. This is exactly the same prevalence as calculated by the QOF national asthma register based on all Scottish practices in the same year (Table 10.2).

50

10.2 West Dunbartonshire epidemiological data

In West Dunbartonshire, the estimate of prevalence is 2.1% in 2005/6 which is 17% higher than the Scottish average of 1.8% in the same year. This is in keeping with the higher prevalence of smoking in West Dunbartonshire. However, it trails behind the prevalence rates for both Glasgow City and Greater Glasgow, largely because of the high QOF-based prevalence rates for COPD obtained from the North Glasgow CHCP (3.6%) and the East Glasgow CHCP (3.5%) areas.

As a result of the paucity of epidemiological data on prevalence and incidence of COPD, SMR1 admission and death data are most relied on to provide the epidemiological profile of those most affected by COPD. Admission rates to hospital for COPD could also be examined for West Dunbartonshire and compared to the national average, accepting that admission rates are influenced by referral patterns and bed availability. Death rates due to COPD in West Dunbartonshire could be compared to the national average for this condition to confirm that smoking has been a prevalent risk factor in this area.

QOF versus PTI proviso: The QOF estimate for COPD may be an underestimate of genuine prevalence of COPD and may provide lower estimates than those provided by the PTI as the QOF rules do not allow patients to be on both the asthma and COPD register and some patients with COPD have reversible airways obstruction. PTI statistics do include COPD patients with asthma as long the reason for a particular consultation was stated to be COPD.

10.3 Hospitalisation for COPD in West Dunbartonshire

The age-standardised hospitalisation rates for both male and female West Dunbartonshire residents are considerably lower than for their Greater Glasgow and Glasgow City equivalents, in keeping with the lower prevalence of COPD according to the QOF disease registers (Figures 10.3 and 10.4, Appendix 10). However, they are arguably lower than would seem appropriate given the mortality rates depicted in Figures 10.7 and 10.8. Furthermore, the trend lines for West Dunbartonshire hospitalisation rates in males and females are clearly increasing where those for Greater Glasgow and Glasgow City males are declining.

10.4 Prescribing of bronchodilators and steroids

Bronchodilators and steroids can be used for a number of conditions other than COPD, including asthma. However, prescribing rates for these two categories of drugs are worth examining in the context of West Dunbartonshire’s higher prevalence rates of COPD and lower hospitalisation rates when compared to Scotland. Prescribing rates of bronchodilators per 100 patients are declining for all regions studied and over the 27 month period from October 2004 to December 2006 (Figure 10.5, Appendix 10) and are roughly the same for West Dunbartonshire as for NHSGG&C for that period. However, there is a marked difference between the prescribing rates for the two halves of West Dunbartonshire with the Clydebank half experiencing very much higher prescribing for bronchodilators than the Vale/Dumbarton half for most of this period. At its most extreme, prescribing of bronchodilators in Clydebank was almost double that of Vale/Dumbarton. This suggests clinical guidelines were complied with differently in the two halves which would need to be retrospectively explored as it is unlikely that differences in genuine disease rates explain this

51 observed difference. Although Clydebank is famous for shipbuilding, the absolute number of cases of asbestos-related disease (i.e. asbestosis) in Clydebank is unlikely to explain the excess of prescribing for bronchodilators. Note that by October-December 2006, although the prescribing rates for the 4 regions studied had had merged considerably, the Clydebank rates were still 15% higher than the Vale/Dumbarton rates (5,307 versus 4,607 DDDs per 100 patients). This residual excess is more in keeping with excess rates of chest disease that might exist in Clydebank due to the synergistic effect of combined smoking and occupational exposure to asbestos and a possible excess of asthma that might exist in Clydebank.

Prescribing rates for steroids, which are used for a wide range of inflammatory and infectious conditions in addition to COPD, have been more stable for the 27 month period studied. Nevertheless, these are still 14% higher in Clydebank than in Vale/Dumbarton (3,511 versus 3,082 DDDs per 100 patients) in October-December 2006, raising questions about different levels of adherence to clinical guidelines for a range of conditions that would need to be explored with separate ad hoc studies.

10.5 Mortality from COPD

Mortality rates from COPD fluctuate considerably in West Dunbartonshire, presumably because they are based on a relatively small number of deaths every year. Mortality rates from COPD for males appear to have climbed until 2000 at which point they started a broad decline ending up intermediate between rates for Glasgow City and NHSGG (Figure 10.7, Appendix 10). Mortality rates from COPD for females appears to be climbing quite steeply against more level trends for Glasgow City and NHSGG (Figure 10.8, Appendix 10). The latter reflects the historical increase in prevalence of smoking in females and the latency period for a chronic respiratory disease that takes its toll, in terms of shortened life, years later.

52 11. CHILD HEALTH

11.1 Breastfeeding

Breastfeeding rates in West Dunbartonshire CHP are lower than the national average, and may have dropped slightly since 2000 (Figures 11.1 and 11.2). West Dunbartonshire has the lowest breastfeeding rates in Scotland at first visit at 28.3% and a rate of 25.8% at 6-8 week review compared to a Scottish average 36.5%.

11.2 Accidents

Both the number and rate of emergency admissions for (non-RTA) accidents in West Dunbartonshire CHP have declined between 2004 and 2005 (Figure 11.3). Admission rates can only be used as a proxy for accident rates, and so caution must be applied when interpreting these data.

11.3 Mental health

There are very few measures of mental health routinely collected for children and young people. One proxy measure that can be used is the discharge rate for self-harm. The number of admissions is relatively small, but this is likely to represent only the tip of the mental health iceberg amongst children in the board area (Figure 11.4).

11.4 Immunisation

The immunisation rates at 12 and 24 months in the West Dunbartonshire CHP are slightly higher than the Scottish average (Figure 11.5) for every primary immunisation regardless of whether quarterly or annual statistics are examined.

11.5 Health behaviours – Smoking, Alcohol and Drug Use amongst 13 and 15 year olds

The proportion of children who smoke, drink alcohol and use illicit drugs can be estimated from the SALSUS studies. These figures are all based on the 2002 SALSUS report which surveys 13 and 15-year-old children. This shows that the proportion of children using tobacco, alcohol and drugs increases between the ages or 13 and 15 years, and that girls are more likely to smoke and drink, and boys are more likely to use drugs (Figures 11.6 and11.7).

11.6 Smoking in pregnancy

Although the prevalence of smoking during pregnancy was lower in 2005 than in 2004 for all regions studied, the prevalence was nevertheless higher in West Dunbartonshire than in Glasgow City, Greater Glasgow, Greater Glasgow and Clyde and Scotland for both years. In 2005, almost 27% of West Dunbartonshire women admitted smoking during their pregnancy compared to under 23% in their Scottish equivalents.

53 12. MENTAL HEALTH

12.1 Introduction

Most mental health statistics relate to service usage by hospital catchment for more serious mental illness (including seriously suicidal behaviour, schizophrenia and serious unipolar and bipolar depressive illness). They are therefore difficult to translate into a more representative picture of mental health in West Dunbartonshire, including milder forms of mental ill health that include anxiety, neurosis, panic attacks and milder forms of depression. What is known from routinely collected data of mental health service usage is that more than 99% of contacts with the NHS relating to mental health take place in the community and less than 1% in hospitals.

12.2 Primary care statistics

Primary care based statistics from the Quality Outcomes Framework suggest that the prevalence of people with ‘severe long-term mental health problems who require and have agreed to regular follow-up’ was the same for West Dunbartonshire in 2005/6 as for Scotland and East Glasgow CHP at 0.6% and lower than for NHS Greater Glasgow, Glasgow City, Southwest Glasgow CHP and West Glasgow CHP (0.7%), and lower than for North Glasgow CHCP and South East Glasgow (0.8%). Based on these QOF statistics, there is no suggestion that serious mental illness was a particular problem in West Dunbartonshire in 2005/6. In contrast, some Glasgow CHPs have much higher prevalence and are therefore assumed to pose a greater problem.

12.3 Self-reported mental ill health

Nevertheless, there is some evidence to suggest that milder stress-related mental ill health may be more common in West Dunbartonshire than suggested by the above statistics. A lower percentage of West Dunbartonshire residents self-reported a perception of general mental or emotional wellbeing (75%) than their Greater Glasgow equivalents (84%); and a higher percentage (19% versus 12% in Greater Glasgow residents) scored poorly (a score of 4 or higher) on the General Health Quiz 12, indicating poor mental health, as reported in the Health and Wellbeing Survey of 2005. The largest discrepancy in reported health and illness statistics related to subjective perceptions of quality of life, where 75% of West Dunbartonshire residents, compared to 83% of Greater Glasgow residents, reported that they experienced quality of life. This latter indicator may reflect the poor socio-economic conditions and prospects in West Dunbartonshire than in Glasgow City, where despite the considerable pockets of extreme poverty, economic opportunities are far greater.

12.4 Prescribing of psychoactive drugs

The number of ‘defined daily doses’ (DDDs) of psychoactive drugs prescribed per hundred West Dunbartonshire patients for anxiety and sleeplessness (hypnotics), depression (antidepressants) or psychosis (antipsychotics) is considerably higher than the national average. This supports the hypothesis that there is considerable mental ill health in West Dunbartonshire and more than expected given prevalence rates from other primary care data collection systems (e.g. QOF). Furthermore, the prescribing rate for these three classes of drugs is considerably higher in the Vale/Dumbarton half of West Dunbartonshire than the Clydebank half (Figures 12.1-12.3). By the end of 2006, 44% more antipsychotics, 69%

54 more hypnotics and 35% more antidepressants were being prescribed in terms of DDDs per 100 patient in Vale/Dumbarton than in Clydebank. This raises questions about the nature and availability of mental health services offered in the two halves of West Dunbartonshire . For example, historically, psychology and psychiatric services were reportedly less available to Vale/Dumbarton residents than Clydebank residents and anecdotally there have been reports of GPs prescribing psychoactive drugs as an alternative to referral to secondary services. Generic prescribing predominates in both halves of West Dunbartonshire but adherence to the recommended formulary and clinical guidelines, based on marked differences in specific choice of psychoactive drugs, probably differs in the two halves. This is an area of concern that is being currently addressed via the Mental Health Services Review currently in preparation by NHSGG&C.

12.5 Self-harm and suicide

Self-harm and suicide are strongly associated with gender and with social deprivation. Suicide rates in males are approximately twice that in females, conversely females experience much higher rates of para-suicidal behaviour. Deaths from intentional self-harm and events of undetermined intent (broadly assumed to be suicide) are almost 25% more common than the national average in the most socially deprived SIMD decile 10 and is about 45% less common than the national average in the most privileged SIMD decile. Standardised mortality rates (SMRs) for deaths caused by presumed suicide by council area demonstrate that for 2002-4, the all-persons risk was statistically significant higher for West Dunbartonshire, City of Glasgow and Highland Councils than for Scotland as whole. When broken down by gender, SMRs for ‘presumed suicide’ in males are statistically significantly higher than the national average in West Dunbartonshire (45% higher), City of Glasgow (30% higher), Highland (55% higher), and the Shetland Isles (60% higher). The risk in Highland and Island Councils has for some time been assumed to be an artefact of the fact that some people who plan to take their lives, migrate north to commit the act itself. However, this RGOS data is based on council of residence, hopefully obviating this confounding variable. The risk of presumed suicide in females is statistically higher than the national average in Glasgow City only (40% higher), approximating national rates in West Dunbartonshire. These statistics suggest that in the recent period for 2002-04, the suicide rate in West Dunbartonshire males was third highest in Scotland, exceeding that of Glasgow males and approaching that of high-risk northern rural areas.

When secular trends for suicide are examined, this position near the top of the Scottish league is confirmed and explained by a consistent steep rise in suicide in West Dunbartonshire since the early 1980s (Figure 12.4). Although the statistics are based on relatively small numbers, the steep climb is in contrast to much more stable rates over time for Scotland and Glasgow City. In West Dunbartonshire, 81 suicides in males were reported during the 5 year period from 2000-04 and in 2005, just 15 suicides in males and 2 suicides in females, necessitating the calculation of rolling averages and grouped data. Nevertheless, the conclusion is that suicide rates in West Dunbartonshire males have climbed more steeply (Figure 12.5) (on average at 3% per annum8, Figure 12.6) than for any other council area in Scotland over this 20 year study period and that this climb has brought West Dunbartonshire near the top of the Scottish league table, exceeding Glasgow City, and only topped by

8 This is based on the slope of the linear trend line. The slope for West Dunbartonshire’s linear trend line is three times that for East Dunbartonshire, the rates of which are also much lower. The slope of the linear trend lines for all other councils is less than 3% p.a. on average.

55 Highland and Island councils9. The RGOS has yet to publish data on suicide for 2006 by administrative area.

A detailed study of the reasons for suicide in individual cases would need to be carried out to attribute causality. However, given the statistics suggesting average prevalence of severe mental illness, and the lower self-reported quality of life and emotional wellbeing, the possibility of economic hardship can not be ruled out. There is no evidence to suggest that these high rates are due to the proximity of West Dunbartonshire populations to the Erskine bridge and suicide rates are not raised in the vicinity of the Forth and Tay Bridges. ‘Jumping from high places’ was the cause of just 10% of all deaths due to ‘intentional self-harm and events of undetermined intent’ in Scotland in 2005 although it has become more common as a method of suicide in males than 20 years ago.

Choose Life is a 10 year plan aimed at reducing suicides in Scotland by 20% by 2013. Its website makes it clear that the majority of suicides occur in people with no history of contact with formal mental health services and the associated factors include Its strategy and action plan aims to ensure action is taken nationally and locally to build skills, improve knowledge and awareness of 'what works' to prevent suicide, improve opportunities to prevent premature loss of life and provide hope and optimism for the future.

Quality of life, poverty, social injustice, bereavement, emotional competence, abuse and relationship problems are just some of the risk factors that may be faced by a person with suicidal thoughts. It becomes clear that communities are at the heart of starting to tackle this problem.

9 The rates have also been historically high in males in the Western Isles and can be high in males in the Shetland Islands (although with considerable fluctuation) . However, in the 5 year period 2000-2004, there were just 25 and 23 suicides in these two council areas respectively, so the confidence intervals on the rates are wide and include 100%. For this reason the data is not included in Figures 5.10 and 5.11.

56

13. LOCAL PROVISION OF PRIMARY CARE SERVICES

Primary Care is an integral part of the delivery of community based health and social care services in West Dunbartonshire. There are 20 Practices in the CHP area, which between them register almost exclusively West Dunbartonshire residents. Of these 20 practices, 19 deliver their services under the new GMS Contract, with one delivering its services around the PMS (or 17c) Contract. The practices are based in the major centres of population in West Dunbartonshire. Nine practices are situated in Clydebank, four at Alexandria Medical Centre and six at Dumbarton Health Centre. One practice is based at separate premises (Bank Street) in Alexandria (Figure 13.1, appendix 13).

There were 4,367 GPs in Scotland as of September 2006 and 84 of these were working in West Dunbartonshire. This amounted to 70.7 WTE GPs in Wets Dunbartonshire and a per capita provision of 76.9 per 100,000 population (compared to a national provision of 71.0 per 100,000 across Scotland) as of October 2004 (most recently published data on Scottish Local Authorities Compendium of Health Statistics). The only non-Island councils that had higher per capita GP provision than West Dunbartonshire in October 2004 were Argyll and Bute (89.9 per 100,000), Dumfries and Galloway (83.0 per 100,000) and Highland council (101.4 per 100,000). It is reassuring to know that West Dunbartonshire has been able to attract sufficient GPs over the years to provide an adequate per capita provision of service.

The levels of and types of services provided by general practitioners in the area are enshrined in their respective contracts with the NHS. The contract includes targets and priorities for general practice with respect to provision of access, identification of patients with long-term conditions and difficulties associated with the roles of carers or housebound patients.

Community Pharmacy has an important role in the provision of primary care services to the public, and the introduction of the new pharmacy contract presents opportunities for development. These include support for the self-management of conditions and support to General Practice in their prescribing.

A number of professions and staff work alongside GPs to deliver services to patients in multiple settings. In Partnership with Community care colleagues the CHP provides the following services:

• Assessment and Care Management • Rehabilitation and enablement • District Nursing • Allied Health Professionals e.g. Podiatry, Dietetics Physiotherapy, Occupational Therapy • Older People’s services in Partnership with West Dumbarton Council • Chronic Disease Management programmes • Sensory Impairment services • Palliative Care • Management of long term conditions

Priorities in tackling long term conditions in primary care include:

57 • Diabetes - delivering models of multi-disciplinary care • Developing exercise referral, weight management and smoking cessation • Working with Coronary Disease MCN and Heart Failure Team to deliver services locally • Piloting a Chronic Obstructive Pulmonary Disease programme with a local Practise • Continue to develop Primary Care Mental Health Services • Continue to develop and support Practices to provide end of life care.

Further details on the role and work of West Dunbartonshire Community health Partnership (CHP) is available within its Development Plan for 2007-2010.

58 14. LOCAL PROVISION OF NHS SECONDARY CARE SERVICES

Hospital services for the population of West Dunbartonshire which lies to the West of Old Kilpatrick are mainly provided from the Vale of Leven Hospital in Alexandria and from the Royal Alexandra Hospital (RAH) in Paisley. The full range of Accident and Emergency services and emergency surgery, trauma and orthopaedic services as well as consultant-led obstetric and paediatric services are provided from the RAH. The vast majority of emergency medical receiving services, elective medical, surgical and orthopaedic services, rehabilitation services, minor injury services, diagnostic services and day and outpatient services in all specialties are provided at the Vale of Leven Hospital.

The number of beds, the range of day-case facilities and the patient numbers treated at the Vale of Leven are outlined in the following tables. These figures include activity from some areas of Argyll and Bute for which the Vale serves as the local hospital (Tables 14.1, 14.2 and 14.3).

In the year 2005/2006, the population of West Dunbartonshire accounted for 9,725 day- cases, 3,991 elective admissions to NHS hospitals and 11,486 emergency admissions or transfer episodes (Table 14.4). The in-patient care amounted to a total of 81,546 bed-days of care, approximately equivalent to the use of 52 in-patient beds in the year. The ten specialties shown in the table accounted for 90% of the 15,477 episodes of in-patient care generated by the population of West Dunbartonshire.

The NHS hospitals at which residents of West Dunbartonshire received treatment in the year 2005/2006 are shown in Table 13.5. The hospital at which the largest proportion of in- patient episodes occurred (44%) was the Western Infirmary or Gartnavel Hospital. In total, 6,803 episodes of care occurred in these hospitals. A further 3,814 (24%) episodes took place at the Vale of Leven Hospital and 2,482 (16%) episodes at the Royal Alexandria Hospital. More than 95% of in-patient episodes were accounted for by the hospitals shown in Table 14.5. The flows of patients resident in West Dunbartonshire to different hospitals as elective or emergency cases respectively in three specialties are shown in Figures 14.1 and 14.2.

59 15. ACTIVITY IN SECONDARY CARE

In the National Health Service, the general practitioner acts as the gatekeeper at the interface between primary care, the services provided by the primary care team, and secondary care, the range of specialised services provided in hospital. In this section, two main aspects of secondary care will be considered, referral to clinics or out-patient departments, and admission to hospital. The broad outline of these services is considered in the following sections.

15.1 Referral to out-patient clinics

For many patients, referral to a specialist out-patient clinic comprises the first contact with secondary care. The initial response of most patients to symptoms, illness behaviour, is to consult a general practitioner. Many forms of morbidity are suitable for management entirely by the primary care team, but in cases in which a specialist consultant opinion is required, a referral may be made to a specialist clinic. The referral rate may be expressed as the rate per 1,000 population, and this may be expressed as a crude referral rate or as a standardised rate or ratio.

15.2 Admission to hospital

Patients may require to be admitted to hospital for a spell of in-patient care. This may be considered in the following main categories.

Elective admission: Patients may be admitted to hospital for a planned or elective treatment. In many cases, this planned treatment will comprise a therapeutic or diagnostic surgical procedure, and for this reason, the proportion of elective workload is greater in most surgical than in most medical specialties. Elective admission usually follows an assessment at an out- patient clinic and a wait of variable length on a waiting-list. The admission rate may be expressed as the rate per 1,000 population. The rate may be expressed as a crude referral rate or as a standardised rate or ratio.

Emergency admission: Patients may also have to be admitted to hospital for emergency treatment. This may comprise a surgical procedure carried out as an emergency or emergency medical treatment. A large proportion of patients admitted to general medical beds are admitted as emergencies. Most patients admitted as emergencies undergo initial assessment in an A and E department. They may have been seen prior to attendance by a general practitioner, but a large number of patients are self-referred. The former category should be considered to be patients who have undergone a form of assessment prior to arrival at the A and E department. The admission rate may be expressed as the rate per 1,000 population. The rate may be expressed as a crude referral rate or as a standardised rate or ratio.

Day-cases: Patients may also be managed electively as day-cases. In this form of care, the patient is not formally admitted but receives treatment usually in a day-care unit. Most of the treatments comprise relatively minor diagnostic or therapeutic surgical procedures and patients are discharged later on the day of treatment. Most day-care has historically been related to the surgical specialties, but the growth in medical interventionist care has meant that increasing numbers of minor procedures are now carried out by physicians. The elective admission rate and the day-case rates together reflect elective activity in secondary care.

60

15.3 Referral and admission rates

The processes of referral and admission may be described as a population rate in which the number of events is related to the size of the local population. The population could be that of a practice, CHP or Health board, but in this section, the rates will be described for West Dunbartonshire and other CHPs in the Greater Glasgow and Clyde Health Board. The rates will, in general, be determined by the following types of variables.

Demography: Demographic variables reflect the composition of the population in respect of age-group and sex. Demographic variables are fundamental in determining the incidence and prevalence of morbidity, for example, coronary heart disease, and the associated requirement for services.

Deprivation: The degree of material deprivation is also important in determining rates of referral and admission. Material deprivation affects the prevalence of risk factors, for example, of smoking, which is a major risk factor for respiratory and cardiovascular disease and also for certain cancers. In this analysis, the system of quintiles derived from the Scottish Index of Multiple Deprivation will be used in the analysis.

Supply-related variables: Supply-related variables are in general important in accounting for differences in referral and admission rates in different populations. These variables are related to hospitals rather than to populations but they reflect the sites to which most referrals or admissions form a given area are made. Supply-related variables include numbers of beds, consultants, theatres and out-patient sessions.

Admission criteria: Admission criteria may be important in determining the numbers and types of admissions, and may be different at different hospitals. Admission criteria are related to the supply-related variables described above.

Referral behaviour: General practitioners vary in the extent of their experience and specific interests, and this may affect their propensity to refer patients with specific types of morbidity to out-patient clinics.

15.4 Standardisation

The number and diversity of variables that may affect both referral and admission rates means that account should be taken of differences between populations when variations in rates are considered. For example, the admission rate could be greater in one area than in another not because of any intrinsic difference in need but because the population in the first area was generally older and more deprived.

This problem may be addressed by indirect standardisation, in which adjustments are made for differences in demographic variables. In the process of standardisation, a comparison is made with the rates of referral and admission in a defined standard population. In this case, the population of the Greater Glasgow and Clyde Board is taken as the standard population, and standardisation has been carried out in respect of age, sex and deprivation category. The significance of standardisation is that any remaining variation in rates may not be explained by these three variables, and must relate to differences in the other variables described above.

61 The results of standardisation may be expressed either as a rate or as a ratio.

Standardised rate: The standardised rates discussed in this analysis are analogous to crude rates and represent absolute levels of referral or admission corrected for demographic variables. The rates are expressed as a number of events per 1000 per year.

Standardised ratios: The outcome of standardisation may also be expressed as a ratio, expressed as a percentage. The standardised ratio is a purely comparative measure. The level of referrals or admissions in the standard population would be 100% by definition. A referral ratio of 120% in one area, for example, would mean that the level of referrals exceeded that in the standard population by 20%, and that this could not be accounted for by differences in the three demographic variables.

15.5 Referrals from West Dunbartonshire

The total numbers of referrals to thirteen specialties in secondary care are shown in Table 14.1. The most important comments about this table are as follows:

• In total, the population of West Dunbartonshire accounted for 20,174 referrals to the twelve selected specialties in the year 2005.

• The specialties which accounted for most of the referrals were general medicine, orthopaedics, general surgery and gynaecology.

• The referral rate in several specialties was significantly different from the rate in the standard population of Greater Glasgow and Clyde (GGC). For example, the Standardised Referral Ratio for orthopaedics was 118.2%. This means that the level of admission of residents of West Dunbartonshire was about 18% in excess of the level in the standard population of GGC, and that this difference cannot be attributed to differences in demographic factors.

• The referral rates in West Dunbartonshire were not significantly different from those in Greater Glasgow and Clyde in cardiothoracic surgery, neurosurgery, gynaecology and renal medicine. The level of referral of referral was significantly higher in oncology and orthopaedics and lower in the other specialties shown. The range and extent of variation in referral rates from the standard probably reflect differences in referral behaviour by general practitioners.

15.6 Admissions from West Dunbartonshire

The total numbers of elective admissions and day-cases to thirteen specialties in secondary care are shown in Tables 14.2 and 14.3. The most important comments about these tables are as follows:

• In total, the population of West Dunbartonshire accounted for 12,355 elective in- patient or day-case admissions in the twelve selected specialties in the year 2005.

• The specialties which accounted for most of the elective admissions were general medicine, general surgery, urology and orthopaedics.

62 • Overall, there were 8,703 day-cases and 3,652 elective admissions to hospital. The total proportion of elective admissions as day-surgery was 70%.

• The population of West Dunbartonshire accounted for 8,033 emergency admissions in the twelve selected specialties in the year 2005.

• The specialties which accounted for most of the emergency admissions were general medicine, general surgery, and orthopaedics.

• The elective admission and day-case rate in several specialties was significantly different from the rate in the standard population of Greater Glasgow and Clyde (GGC). For example, the Standardised Admission Ratio for general surgery was 119.6%. This means that the level of admission of residents of West Dunbartonshire was almost 20% in excess of the level in the standard population of GGC, and that this difference cannot be attributed to differences in demographic factors.

• In some specialties, the elective and day-case admission rate in West Dunbartonshire is less than that in the standard and in other cases, greater. The range and extent of variation in elective admission rates from the standard reflects the operation of a range of non-demographic factors that may influence admission in ways that are difficult to predict. These include referral behaviour by general practitioners, supply factors and admission criteria.

• The emergency admission rates in West Dunbartonshire were not significantly different from the rates in the standard population except in one specialty, urology. In this specialty, the SAR of 62% meant that the emergency admission rate was 38% lower than in the standard population, and that this difference could not be attributed to demographic factors. In all the other specialties, there was no evidence for a difference in admission rate from that in the standard population.

63 16. WAITING LISTS

Waiting list data is routinely collected and responded to at Board level by efforts to reduce the numbers of patients waiting for a procedure and shortening the time they spend on such lists in keeping with national targets. In addition the data is collated centrally at Information and Statistics Division in Edinburgh.

16. 1 West Dunbartonshire’s position in the league table of waiting list rates for NHSGG&C CHPs

As of 31st December 2006, this routinely collected waiting list data revealed that the number of patients on such lists on a per capita basis was 7.9 per 1,000 for the total population within the entire geographic area of the 12 CHPs within Greater Glasgow and Clyde CHPs. When North and South Lanarkshire councils are removed from the data, on the grounds that they provide only a very small portion of NHSGG&C and have exceptionally low numbers of patients on waiting lists10, this rate increases to 11.7 per 1,000 population. The numbers of patients on waiting lists for the West Dunbartonshire population is 10.9 per 1,000 population which is considerably higher than the GG&C rate that includes the two ‘low-rate waiting list’ councils and slightly lower than the Greater Glasgow and Clyde average minus the Lanarkshire councils. Compared to the other 10 CHPs within Greater Glasgow and Clyde minus the Lanarkshire councils, West Dunbartonshire compares reasonably in terms of size of the waiting list. Only two councils have a smaller waiting list than does West Dunbartonshire (East Renfrewshire CHP at 8 per 1,000 population and North Glasgow CHP at 9 per 1,000 population).

16.2 Destination hospitals for West Dunbartonshire patients on lists

This rate of 10.9 per 1,000 patients is based on 992 patients on a waiting list as of the end of 2006. Of these, 476 or 48% were waiting to enter the Western Infirmary/Gartnavel General complex in Glasgow; 220 or 22% were waiting to enter the Vale of Leven hospital in Alexandria; and 134 or 14% were waiting to enter the Royal Alexandra in Paisley. The remaining 162 or 16% were waiting to enter a large variety of hospitals throughout west- central Scotland.

10 One in a thousand North Lanarkshire Council residents are on a waiting list and two in a thousand South Lanarkshire Council residents are on a waiting list. Most of these two councils are covered by NHS Lanarkshire. These rates are remarkably low and are so much lower than the remainder of Greater Glasgow and Clyde CHPs that they are considered outliers and should be excluded from comparisons.

64 17. PALLIATIVE CARE

17.1 Introduction

Palliative care is the term used to describe the care that is given when cure is not possible. It means ‘relieving without curing’. It addresses all of a persons needs, mental and emotional as well as physical, and is commonly associated with the later stages of cancer. However, palliative care is also relevant in a wide variety of incurable conditions, and from the time of diagnosis onwards. It is an integral part of the care delivered by any health or social care professional to those living and dying from any advanced, progressive and incurable disease. It is also about enabling someone to live with a life threatening condition, maintaining, and as far as possible, improving quality of life for patients and their families.

The section on palliative care is different from other parts of this needs assessment in that it contains more information about palliative services and less about the extent of the need for these services. This is because no routinely collected data exists on the patients throughout either West Dunbartonshire or NHSGG&C that are receiving palliative care. Nevertheless, palliative care was identified as an area requiring review by the Needs Assessment Reference Group, especially by the local GPs.

17.2 Clydebank

Palliative care services in the Clydebank portion of West Dunbartonshire are provided by St Margaret of Scotland Hospice. St Margaret is owned by a church called the ‘Sisters of Charity’ and receives funding from Greater Glasgow and Clyde NHS Board.

St Margaret’s is run by a board of directors and served by two palliative care consultants, one consultant geriatrician and three GPs as well as two home care sisters and a range of nursing and support staff. The service offered is based on a Palliative Care Home Team, 30 ‘care of the elderly’ beds, 20 palliative care beds, a day centre for palliative care patients and is provided by segregated staff (staff dedicated to either palliative care or elderly patients).

Additional specialist advice is sometimes obtained from Hunter’s Hill Hospice (near Stobhill Hospital in Glasgow) and the Beatson Oncology Centre (BOC, Western Infirmary site, Glasgow).

In the community, there are four MacMillan Nurse facilitators who have a dual function aimed at educating nurse colleagues in palliative care for 3 days per week (to certificate of attendance level) and working as district nurses 2 days of the week.

17.3 Alexandria and Dumbarton

The following section highlights the current provision of palliative care across the Dumbarton and Alexandria area. It also seeks to highlight current gaps in services and makes recommendations to address these gaps.

Over the past 3 years considerable developments have been made in palliative care services to the area. Local individuals drove many of these and the Palliative Care Network for Argyll & Clyde supported others, further investments were initiated by external funding, mainly Macmillan Cancer Support and Marie Curie Cancer Care (MCCC).

65

Currently, the Vale of Leven hospital (VOL) has access to one Macmillan Palliative Care Nurse Specialist who is well integrated into the oncology team. There are no dedicated beds and no formal arrangements for access to specialist palliative medicine advice and support. This contrasts with south of the river where there are three hospice units, thirteen community specialist nurses and one hospital-based Macmillan Palliative Nurse Specialist, and a dedicated area within the Royal Alexandria hospital for patients with surgical palliative care needs. A significant number of patients from the above geographic areas are admitted to this ward and other areas within the RAH for symptom control and end of life care, and at times it can be difficult to transfer these patients back to their local areas.

Details of local provision include:

• Education for Primary Health Care teams, hospital staff, Macmillan Carers Service. • Development of the clinical nurse specialist (CNS) role to incorporate provision of local chemotherapy regimes on a weekly basis. • Symptom control for all patients improved by the ability of the CNSs within the team to prescribe medication as Independent Prescribers. • Implementation of the Liverpool Care Pathway for the Dying (pending) which will be rolled out this year in the community and then the VOL hospital thereafter. • Macmillan Carers Service extended to the Clydebank area. • Macmillan Benefits Scheme. • Transport pilot project, which accommodates local people and transports them to appointments to health centres, hospitals and BOC. • A Macmillan GP facilitator is working with GPs in the Vale/Dumbarton area to enable the merging of the two services.

17.4 Marie Curie developments

• Service level agreement (SLA) with West Dunbartonshire CHP to provide Marie Curie Nursing service ((MCNS). MCNS is funded 50% by MCCC and 50 % by WDCHP. MCNS will visit non-cancer patients but this must be funded 100% by CHP. • Two contracted Health Care Assistants and 13 bank staff available to cover referrals from the District Nurses ( DN). • MCNS Available 24 hrs per day dependent on patient need. • MCNS working in partnership with Macmillan carers to provide large packages of care and continuity of care. • MCNS can access training from CHP i.e. syringe driver training. • Involved in roll out of LCP within West Dunbartonshire. • MCNS involved with clinical governance within the charity both nationally and locally. • DN Evaluation carried out giving DNs the opportunity to comment on the service and workshops organised to discuss way forward. • Patients interviewed about the service and feed back shared with DNs. • Marie Curie Nurse specialists have access to training in the form of clinical updates and short courses and study days shaped by clinical governance issues and needs highlighted by staff. • Introduction of prioritisation criteria and acuteness scoring ensuring patients receive the right nurse with the right skills at the right time.

66 The development of the Marie Curie Nursing Service is dependant upon appropriate use of the service, i.e. early introduction of the MCNS to patients and carers, effective communication, public and professional awareness of their local MCNS, DN assessment and reassessment of patients needs and working in partnership with primary care services and voluntary organisations to develop local services which meet the needs of patients and their families.

17.5 Oncology/Palliative Care Provision

17.5.1 Responsibilities

The Oncology CNS works closely with the Palliative Care CNS. Responsibilities encompass four main areas of palliative/cancer care:

• The provision of support and advice to patients admitted to the Vale of Leven with palliative care needs. • Responsibility (in conjunction with the respiratory physician) for the management of patents diagnosed with cancer of the bronchus. • Contributes to Oncology clinic and manages a nurse led chemotherapy unit (including delivery of chemotherapy to patients with advanced disease). • Provision of advice to patients in the community with palliative care needs.

17.5.2 In-patient Palliative Provision for cancer patients

Provision of local access to in-patient beds essential for effective management of patients with palliative care needs.

Patients fall into three main categories:

1. Admission for end stage (terminal care) within the hospital due to inability of carers to continue to manage patients at home or effective symptom control cannot be delivered in the home environment. 2. Patients with metastatic disease require delivery of haematology support (e.g. blood transfusion) or correction of biochemistry (e.g. hypercalcaemia). 3. The delivery of in-patient chemotherapy regimes to patients with advanced carcinamatosis of the lung. 4. The management of patients admitted with suspected (or known) neutrapenic sepsis.

The nearest oncology/palliative care unit at the Beatson West of Scotland cancer centre are unable to accommodate patients from this locality due to the pressures on beds. The transfer of patients with advanced disease or in need of palliative support to the RAH rarely occurs and is viewed by patients carers and local clinicians as inappropriate and unjustified and therefore not in patients best interest. The Oncolgy CNS and Palliative Care CNS are both trained as independent prescribers and are experienced at providing advice to medical and nursing colleagues on use of pharmacology (including opiates) for symptom control. The access of in-patient beds is required for the rapid management of patients with chemotherapy related problems (including sepsis)

The previous model of a part time palliative care consultant (one session weekly) was not viewed favourably by the cancer nurse specialists.

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17.5.3 Lung Cancer Service

Patients currently have local access to respiratory service for investigation of possible bronchial carcinoma. Local MDT meeting monthly with input from thoracic surgeon. Patients has input from the oncology nurse at point of diagnosis and is available for advice support throughout the trajectory of the illness (inc local administration of chemotherapy). The continuation of outreach oncology from the BOC essential for the continued local provision of lung cancer service.

17.5.4 Oncology Chemotherapy Clinic

Oncology /Chemotherapy clinic delivers service predominantly to patients with cancer of the breast and lung. In excess of 60% of patients have advanced disease where the purpose of treatment has a palliative intent. The service has seen increasing numbers of patient many requiring second and third line treatment. Year 2006/07 in excess of 700 treatments delivered to approx 100 patients. Good integration of breast care nurse/palliative care nurse and oncology nurse (all independent prescribers) results in effective nurse led chemotherapy clinic where after initial treatment plan is decided the nurse specialists normally prescribe cytotoxic agents. Many patients attending the clinic have symptoms of advanced disease and require advice on optimal management of symptoms. A commitment from the BOC to continue outreach clinic is essential to ensuring local equitable service, and to build on developments by cancer nursing team.

68 18. HEALTHCARE PROVIDED BY THE INDEPENDENT SECTOR

18.1 Introduction

There are two main independent sector hospitals providing healthcare of a largely elective nature to the Glasgow area. These are Ross Hall (BMI Hospitals group) located at Crookston Road on the south side of the city, and the Nuffield hospital Glasgow (Nuffield Hospitals group) located at two sites at Beaconsfield Road and Great Western Road, 2 ½ miles northwest of the city centre.

18.2 Ross Hall

Between 2005 and 2006, there was a 7.5% decline in total activity (from 20,399 to 18,867 unlinked patient contacts) at Ross Hall, including a 13% decline in inpatient surgical procedures (from 2,445 to 2,134). The percentage of total activity at Ross Hall that was performed on West Dunbartonshire residents was 2.005% and 2.07% in 2005 and 2006, respectively. This amounted to 409 unlinked West Dunbartonshire patient contacts (including 70 inpatient surgical procedures) in 2005 and 391 unlinked patient contacts (including 57 inpatient surgical procedures) in 2006. Of the 409 unlinked patient contacts with West Dunbartonshire patients in 2005, 239 (58%) were with Vale/Dumbarton patients and 170 (42%) were with Clydebank patients. Of the 391 unlinked patient contacts with West Dunbartonshire patients in 2006, 265 (68%) were with Vale/Dumbarton patients and 126 (32%) were with Clydebank patients.

18.3 Nuffield Hospital Glasgow

The Nuffield Hospital Glasgow does not record the number of medical outpatient contacts nor does it record the number of surgical outpatient contacts unless the contact culminates in a surgical procedure. Nevertheless, we can glean some information from the data provided.

Between 2005 and 2006, there was a 2.1% decline in total activity excluding medical outpatient contacts (from 5,680 to 5,563 unlinked patient contacts) at the Nuffield, although this concealed a 2.2% increase in surgical inpatient procedures and a 61% increase in medical daycase contacts. The percentage of total activity at the Nuffield hospitals that was performed on West Dunbartonshire residents was 5.5% and 6.5% in 2005 and 2006, respectively.

The volume of activity for West Dunbartonshire residents amounted to 310 unlinked patient contacts excluding medical outpatients and including 90 inpatient surgical procedures in 2005; and 359 unlinked patient contacts including 98 inpatient surgical procedures in 2006. Of the 310 unlinked patient contacts in 2005, 191 (62%) were with Clydebank patients and 119 (38%) were with Vale/Dumbarton patients. Of the 359 unlinked patient contacts in 2006, 202 (56%) were with Clydebank residents and 157 (44%) were with Vale/Dumbarton residents.

18.4 Combined datasets

The combined data for the two hospitals by region (Vale/Dumbarton versus Clydebank) within West Dunbartonshire and for all of West Dunbartonshire for 2005 and 2006 is shown in Table 18.1, appendix 18. It suggests that healthcare activity obtained in the private sector

69 increased modestly for West Dunbartonshire residents between 2005 and 2006, despite an overall modest decline in total healthcare activity obtained from the private sector from these two hospital groupings. Most of this increase was for medical daycase work and to a lesser extent for outpatient surgical work. Nevertheless, the number of inpatient surgical procedures obtained privately by West Dunbartonshire residents actually decreased between 2005 and 2006 (from 160 to 155). The table also shows that more of the Vale/Dumbarton residents engaged with Ross Hall while more of the Clydebank residents engaged with Nuffield hospital Glasgow.

In 2005, the total number of patient contacts with the two private hospitals experienced by Vale/Dumbarton residents (358+) was almost the same as for residents of Clydebank (361+) and the number of inpatient surgical procedures was identical for the two halves of West Dunbartonshire (80 each). Given the similar population sizes of the two halves (roughly 50,000 each), this suggests that in 2005, use of the private sector was very similar in the two halves of West Dunbartonshire despite indices suggesting that Clydebank has more socioeconomic deprivation.

However, in 2006, increased use of the private sector by Vale/Dumbarton residents and reduced use by Clydebank residents meant the Vale/Dumbarton residents overtook their Clydebank equivalents by almost 100 patient contacts (422 versus 328 patient contacts). All categories of contact by Vale/Dumbarton residents experienced an increase except for surgical daycase work; most of this increased use by Vale/Dumbarton residents was for surgical outpatient contacts.

70 19. TRANSPORT AND ACCESS

19.1 Transport and Access

In general, availability of transport underpins access. Good provision of transport enhances access to many aspects of life that may have a positive influence on health, including education, childcare, employment, fresh food as well as healthcare. Poor transport provision may have the opposite effect. Most people in Scotland have access to a car. In West Dunbartonshire, 56.8% of households had a car at the time of the 2001 census, and this means that for over half of households in the area, access is not a particular problem. However, the level of car ownership was considerably lower than the national average of 65.8% according to the 2001 census. In general, car ownership improves access.

People with access to a car may experience some difficulties with travel, for example, adverse weather, traffic congestion or difficulty associated with convenient parking. Disabled drivers also face a range of specific and serious issues. West Dunbartonshire has a population of 3,244 Blue Badge holders. Many of these Blue badges have substantial disability and require the Blue Badge to find appropriate car parking. Unfortunately, designated car parking in car parks or on residential streets is often abused. This can make access difficult or at times, impossible, for disabled people.

About 17,625 households, or just over 43%11, of West Dunbartonshire households (there were a total of 40,781 households in West Dunbartonshire in 2001) were required to rely on public transport. The only two councils in Scotland who had a greater percentage of households dependent on public transport were Glasgow City and the City of Dundee, both of which have extensive public transport systems by comparison to West Dunbartonshire. In the remainder of this section, issues related to access associated with public transport only will be considered.

19.2 Provision of Public Transport

In relation to local access, public transport provision has several components, trains, taxis, buses and demand responsive transport (DRT) initiatives.

Demand responsive transport includes community transport providers and Local Authority Transport Services. Often these DRT initiatives provide door-to-door transport for certain communities. For example, West Dunbartonshire Council runs a fleet of minibuses for the transport of children with special needs to school or older people to care centres. Community Transport providers often use minibuses for group hire and these are increasingly being used in Scotland to provide transport for certain vulnerable communities to essential services. There is scope for development of this form of transport in West Dunbartonshire. Strathclyde Partnership for Transport (SPT) runs two DRT type of services, Dial a Bus and Dial A Ride. Currently, the Scottish Executive funds DRT services in a variety of ways. After April 2008, all Scottish Executive DRT funding will be channelled through SPT. This may allow for greater co-ordination and may see the evolution of services which are more accessible to the elderly or disabled.

11 According to the 2005/6 edition of the West Dunbartonshire Social and Economic Profile, 45% of households in West Dunbartonshire did not own a car.

71 Outside London, the SPT area enjoys the best suburban train network in the UK. Most of the population resides less than 1.5 km away from one of the thirteen railway stations in the area. This provides good access into Glasgow City and from there to the national network. In particular, the train network provides direct transport to Hyndland and Partick Stations which allows good access to a range of hospitals, including Gartnavel General Hospital, RHSC, the Western Infirmary and, in future, the Southern General Hospital. A key issue for the train network in the area (and elsewhere in Scotland) is disabled access. None of the thirteen local stations is fully wheelchair accessible. Wheelchair access is a useful indicator of ease of access for those groups most likely to require hospital services. For example, stations with steep stairs are likely to present difficulties to the elderly or infirm.

Buses provide the majority of public transport trips. However a number of issues relating to bus provision present challenges for those reliant on them for access to services. Since 1985, the bus industry has been deregulated. As such buses are run by the private sector and are not designed to provide primarily a socially inclusive service. Commercial operators can decide where and when to run buses. As has been seen in West Dunbartonshire in Jameston, Bonhill or Brucehill recently, bus operators may reduce or remove services if they are not commercially viable. SPT does have the power to subsidise bus services but the funding for this is limited. It is noted in the West Dunbartonshire Local Transport Strategy that there appears to be a deterioration of bus services within some small communities (eg the withdrawal or reduction of services that enter and go about small estates) whilst at the same time an improvement of services along major routes. This is reflected across other Local Authority areas and highlights the use of buses to commute to work and to access main centres of population. This usage is reflected in the timing of operation of bus services. In West Dunbartonshire, as in many areas in the West of Scotland, there is a significant reduction in bus services after six pm. At the time of writing, all bus services linking Balloch and Dumbarton with Gartnavel General Hospital had been cancelled.

Other issues affecting ease of access in using buses include; poor information provision, lack of through ticketing, physical barriers to use, policy barriers to use (eg policy towards taking buggies on board), safety issues and perception of safety. Again these issues are common across the West of Scotland and particularly impact on older people, people with disabilities and those with young children. Overall, a higher percentage of people living in West Dunbartonshire have a negative perception of public transport than those living in Greater Glasgow (11% versus 7.7%). However, when asked how difficult it is to travel to hospital (by any means) for an appointment, 14.4% of Greater Glasgow residents say they experience a difficulty in reaching hospital as opposed to 9.5% in West Dunbartonshire. This may be a result of lower car ownership in Glasgow, historical land planning, perception etc. However, it should also be noted that there are certain geographical communities which report greater difficulty in travelling to hospital than the Glasgow average. These are primarily the former SIP areas (for example the Dumbarton and Vale of Leven ROAs (Regeneration Outcome Areas).

72 20. CONCLUSIONS

Socioeconomic determinants of health play a major role in the quality of life, the quantity and spectrum of disease experienced and the life expectancy of the local population in West Dunbartonshire and therefore need to be addressed in West Dunbartonshire before any lasting change to health outcome can be expected.

Socio-economic disadvantage is strongly linked to unhealthy lifestyle, whether by association or causal linkage, and mediated by a sense of lack of control and disempowerment. This association is clearly visible in West Dunbartonshire. In addition, unhealthy lifestyle, independent of socioeconomic level, is a risk factor for future disease and premature death. Therefore, unhealthy behaviour, regardless of socioeconomic status of the individual, must be robustly and firmly targeted by tried and tested health improvement efforts, as well as novel or experimental approaches. These findings support the need for improved prevention and chronic disease management. These services are delivered in primary care and the community and promote the need for a shift in balance of care from hospitals to the community.

There is a tendency for the most socio-economically deprived residents throughout Scotland to undergo sophisticated investigation and treatment for coronary heart disease less often than expected given their incidence and mortality rates for CHD. This phenomenon is also seen in West Dunbartonshire males, and until recently West Dunbartonshire females, although this underutilisation is less than observed 10 years ago. Evidence suggests that this relates to differences in sickness response behaviour by gender and a historical tendency for women to be deemed poorer candidates to cardiac surgery. Efforts need to be made to ensure that both men and women with genuine disease are identified and referred to the appropriate specialist services in order to maximise their clinical outcome, regardless of socioeconomic status. There is, therefore, a pressing need to extend the various mechanisms of the Managed Care Networks for chronic disease, including CHD, already implemented in the Greater Glasgow area to the remaining Clyde areas, including West Dunbartonshire.

Chronic diseases are better managed in the community than in acute hospitals. For all disease conditions combined, use of health care by socioeconomically deprived residents of West Dunbartonshire will tend to be reactive and reliant on more advanced forms of treatment whereas use of healthcare by more privileged residents will tend to be more proactive and reliant on preventative services. Therefore, important ways to reduce the need for more interventionist treatment in West Dunbartonshire is to monitor socioeconomic conditions, prevalence of lifestyle and clinical risk factors, disease incidence and death rates in response to:

1) economic regeneration 2) targeted and global health improvement initiatives 3) primary and secondary prevention of common chronic diseases including CHD, stroke and diabetes. 4) extension of fully functioning Managed Care Networks for common chronic diseases across NHSGG&C to ensure that, once diagnosed with confirmed disease, residents of West Dunbartonshire have equal access to modern specialist services, including evidence-based and guideline-directed prescribing.

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21. RECOMMENDATIONS

1) Substantial and sustainable regeneration (especially in relation to the local economy, the quality of local housing stock and transport infrastructure) that can be shown to have demonstrably positive impacts on the health status of local communities is essential. This would be helped by more consistent use of integrated impact assessment approaches (within which “health” is a strong element). There is also a need to reinforce current, and explore potential for further economic regeneration in West Dunbartonshire.

2) There is a need to improve educational attainment, especially those in most disadvantaged communities and amongst looked after and accommodated children. The CHP and the Council should continue to develop the Health Promoting Schools programme locally. All stakeholders (especially local voluntary and community groups) have an important role to play in developing aspirations and resilience amongst children and young people.

3) There is a need to tackle employability locally in a coherent manner through emerging Community Planning structures. In addition, local employers should seek opportunities to develop themselves as healthy workplaces; and welfare right programmes need to be developed further.

4) All stakeholders should identify the contributions that they can make to reversing the “obesogenic” environment to improve diet and increase physical activity. The NHS should further develop exercise referral and weight management schemes. The Council should ensure that promoting walking and cycling feature strongly in local transport schemes; and increase the range and accessibility of opportunities for physical activity for children, young people and older people in particular. The Council and schools should take a lead in providing free, nutritionally balanced school meals, with free fruit schemes resourced in across all schools as a minimum (potentially in partnership with local voluntary organisations).

5) Explore local initiatives aimed at increasing uptake of physical exercise for the general population, including by promoting walking or cycling to school or work. This should be in conjunction with West Dunbartonshire council, local voluntary sector groups, Sustrans and the private sector.

6) All stakeholders should identify the contributions that they can make to reducing incidence and prevalence of smoking locally, especially amongst pregnant women. The CHP should lead on the development of a comprehensive local tobacco control plan that emphasizes “de-normalising” smoking. The NHS (especially general practice) should increase provision of and access to different levels of effective smoking cessation support. The Council should strengthen its role in reducing the visibility of cigarette promotions and illicit sales.

7) Efforts aimed at curbing alcohol abuse are particularly critical in West Dunbartonshire given the many locally observed effects of high alcohol consumption and binge-drinking, including high blood pressure and stroke; domestic abuse; drunk driving and alcoholic cirrhosis. All stakeholders should identify the contributions that they can make to reducing incidence and prevalence of alcohol misuse, both in terms

74 of binge-drinking amongst young people and chronic drinking amongst adults/older people. The NHS and Council should further develop addictions services locally, ensuring that mainstream services meet the needs of different groups. The Council should use existing licensing legislation to curb availability (e.g. limiting sales at outdoor events) and cheap sales (e.g. drinks promotions in pubs and shops). Local multi-agency forums should ensure that there is a strong emphasis on “denormalisation” and incidence reduction in their activities. Education programmes to increase awareness and knowledge should be clearly outcome-focused and evidence-based (e.g. ensuring local campaigns underpinned by social marketing principles). Initiatives involving GPs querying their patient’s intake and encouraging and supporting efforts to reduce intake are required that are similar to existing efforts aimed at encouraging smoking cessation in primary care.

8) Review the aims and objectives and the action plans of the existing Alcohol and Addictions Action Team, and strengthen its efforts in tackling alcohol misuse, with a view to enabling it to refocus more strongly on alcohol in addition to drugs in conjunction with the NHSGG&C, West Dunbartonshire council licensing authority, the WDCHP and relevant NGOs (Alcohol Concern and Alcohol Focus Scotland).

9) All stakeholders should identify the contributions that they can make to increase the levels of breastfeeding amongst new mothers. This should include encouraging a positive breastfeeding culture (e.g. the Breastfeeding Nursery Initiative) along with further investigation of local barriers to breastfeeding (particularly within most deprived communities).

10) Develop screening for unhealthy lifestyles and clinical risk factors in high risk populations to underpin both primary prevention (i.e. well people) and secondary prevention (i.e. people with confirmed chronic diseases) interventions. This should be in line with relevant clinical guidelines, with a focus on coronary heart disease, stroke and diabetes.

11) Develop further, and extend into West Dunbartonshire (and the remainder of the Clyde area), existing Greater Glasgow Managed Care Networks, and their various component services (such as LES contracts and referral pathways) for common chronic diseases such as coronary heart disease, lower respiratory disease, stroke and diabetes. Monitor the uptake of services to ensure those in need access them appropriately.

12) Utilise national funding for ‘Keep Well’ to implement a Locally Enhanced Service for CHD and increase capacity of Health Improvement Services in the community required to underpin the scheme.

13) Further work is required on palliative care to ensure equity of access and quality of care.

14) Bear local statistics in mind when planning new services. Ensure that the demographic and epidemiological disease profile of West Dunbartonshire residents, and the nature of their existing unmet need, is fully understood and considered, when planning new health services in the Greater Glasgow and Clyde area.

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15) The Community Planning Partnership should be strengthened as a mechanism for setting strategic direction for and co-ordinating health improvement across local stakeholders. The Joint Health Improvement Plan should be outcome-focused, with priorities that reflect the key findings of this assessment.

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22. BIBLIOGRAPHY

1) Blot WJ, Devesa SS, McLaughlin JK, Fraumeni JF jr,. Oral and pharyngeal cancers. In: Doll R, Fraumeni JF jr, Muir CS (eds). Trends in cancer incidence and mortality. Cancer Surveys. Vol 19 & 20. Cold Spring Harbor Laboratory Press, New York, 23-42. 2) Census 2001. Available at: www.poverty.org.uk/S36/index.shtml#g2. 3) Citizen’s Panel for West Dunbartonshire by Hexagon Consulting. Summary report available on: www.west-dunbarton.gov.uk. 4) Coronary Heart Disease and Stroke: Strategy for Scotland. (2002). Scottish Executive. Available at: http://www.scotland.gov.uk/Resource/Doc/46997/0013955.pdf. 5) Coronary Heart Disease and Stroke Strategy Update (2004). Scottish Executive. Available at: http://www.scotland.gov.uk/Publications/2004/12/20325/47446. 6) Coronary Heart Disease/Stroke Task Force Report, (2001) NHS Scotland, Edinburgh. Available at: http://www.sehd.scot.nhs.uk/publications/cdtf/cdtf.pdf. 7) White Paper: Delivering for Health (1999). Available at: http://www.scotland.gov.uk/library/documents-w7/tahs-02.htm. 8) Geographic Analyses, HM Revenue & Customs available at: http://www.poverty.org.uk/S07a/index.shtml#g2 -the data is for April 2006 9) Greater Glasgow Health and Well-being Study 2005: West Dunbartonshire Report. August-December 2005. RBA Research Limited. Available at: http://library.nhsgg.org.uk/mediaAssets/CHP%20West%20Dunbartonshire/West Dun_Boost_Report_2005.pdf. 10) ISD Website on Breastfeeding: ISD (CHSP-PS, February 2006 extract) http://www.isdscotland.org/isd/files/bf_ca_select_yob.xls. 11) ISD Website on Child Health (obesity in children): ISD (CHSP-PS, May 2004 extract) http://www.isdscotland.org/isd/. 12) ISD Website on Coronary Heart Disease statistics (incidence, mortality, hospital discharge rates, intervention). Available at: http://www.isdscotland.org/isd/2421.html. 13) ISD Website on Stroke statistics (incidence, mortality, hospital discharge rates). Available at: http://www.isdscotland.org/isd/1984.html. 14) ISD via SIMD available at http://www.poverty.org.uk/S37/index.shtml#g2.

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15) Hanlon P, Walsh D, and Whyte B. Let Glasgow Flourish. (2006). Glasgow Centre for Population Health. 16) Lokke, A et al.(2006). Developing Chronic Obstructive Pulmonary Disease: a 25 year follow-up study of the general population. Thorax 2006; 61:935-939. 17) Olsen JH, Andersen A, Dreyer L, Pukkala E, Tryggvadottir L, Gerhardsson de Verdier M, Wither JF. Avoidable cancers in the Nordic countries. APMIS Suppl 1997;105:1-146. 18) Practice Team Information websites on coronary heart disease, stroke, diabetes and chronic obstructive pulmonary disease. Available on ISD Scotland website. Available at: http://www.isdscotland.org/isd/1284.html. 19) Quality Outcomes Framework website on prevalence of coronary heart disease, stroke, diabetes and chronic obstructive pulmonary disease by CHP and NHS Board, via. ISD Scotland website. Available at: http://www.isdscotland.org/isd/3305.html. 20) Royal Burgh of Dumbarton. Ancient capital of Strathclyde. Available at: http://www.turningwood.fsnet.co.uk/dumbarton.html on 28/12/06]. 21) Scottish Health Survey (2003), Scottish Executive, Edinburgh. Available at: http://www.scotland.gov.uk/Publications/2005/11/25145024/50251. 22) Scottish Public Health Observatory Website on diabetes, available at: http://www.scotpho.org.uk/web/site/home/Healthwell- beinganddisease/Diabetes/diabetes_keypoints.asp. 23) Shahab l, Jarvis MJ, Britton J, West R. (2006) Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax, Dec 2006; 61: 1043-1047. Cancer Research UK Press release available at: http://info.cancerresearchuk.org/news/pressreleases/2006/september/222530 24) Soerjomataram, de Vries E, Pukkala E, Coebergh JW. Excess of cancers in Europe: a study of eleven major cancers amenable to lifestyle change. Int J Cancer 2006; online publication. 25) Swerdlow A, Dos Santos Silva I, Doll R. Cancer incidence and mortality in England and Wales. Trends and risk factors. Oxford University Press, Oxford, 2001. 26) Tomatis L, Aitio A, Day N, Heseltine E, Kaldor J, Miller A, Parkin DM, Riboli E. Cancer: causes, occurrence and control. IARC Sci Publ 1990;100:1-352.

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27) West Dunbartonshire Council Social and Economic Profile 2005-2006 available at: http://www.wdcweb.info/council/documents/SEP%5F2005%2D06%5Fsize%5F reduced%2Epdf. 28) West Dunbartonshire Workforce Plus Action Plan 2007-10 p14 West Dunbartonshire Community Health Partnership available at: www.westdp.co.uk. 29) Work and Pensions Longitudinal Study, DWP and ONS population estimates, data from February 2006 available at http://www.poverty.org.uk/S01a/index.shtml?2#g1.

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APPENDIX 1a - Evans and Stoddart Model

Figure 1.1: Evans and Stoddart Model of Health and its Determinants

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APPENDIX 1b - Sources of data

The information that can be presented in any Needs Assessment exercise reflects range and quality of available sources of data. The most important sources of routinely-collected data include the following:

Mortality data: Data about the immediate and underlying causes of death are collected in the process of death certification. The mortality rate, usually expressed as a Standardised Mortality Ratio, is one of the most important proxy indicators for health in the population. Mortality is a useful proxy for incidence in a range of diseases, for example, ischaemic heart disease, stroke and most forms of cancer. It is less useful as a proxy for other more chronic types of illness, for example, diabetes mellitus, multiple sclerosis and mental illness.

Disease Registers: Disease registers are registers of all known cases of specific diseases, usually within a defined population. The presence of a disease register means that information is directly available about the incidence and prevalence of the disease, and that recourse to proxy measures of morbidity will not be required. One of the most important disease registers is the national Cancer Register. Disease registers are available for a range of other types of morbidity, including motor neurone disease and established renal failure, but not for the most important causes of mortality, ischaemic heart disease and stroke.

Scottish Morbidity Records: Scottish Morbidity Records (SMR) are the sources of hospital morbidity data. These data are put to extensive use in Needs Assessment exercises. Different SMR schemes are in use in different parts of secondary care and the records are completed either on admission to or discharge from secondary care. Discharge from hospital is an important proxy for morbidity, but careful interpretation is required. For example, admission rates in different populations could be affected by supply factors and admission policies at different hospitals.

The SMR schemes that are most useful in Needs Assessment exercises are as follows:

SMR 0 record: Information about referrals to out-patient clinics is recorded in the SMR 0 record. This record is the source of information about referral rates from primary care to secondary care.

SMR 1 record: The SMR 1 form is the most frequently-used SMR document. The document is completed at discharge from all general hospitals and includes information about the principal diagnosis and other comorbidities.

SMR 2 record: The SMR 2 form is completed on discharge from a maternity hospital. The document is more specialised than the more general SMR 1 document and is the main source of information about delivery rates. The document contains a considerable amount of clinical data.

SMR 4 record: Different sections of the SMR 4 record are completed on admission to and discharge from a psychiatric ward. This reflects the relatively long lengths of

81 stay in hospital of patients with psychiatric illness. The record allows information to be produced about the number of current in-patients as well as the discharge rates. This is the main proxy indicator for psychiatric morbidity.

Practice Team Information (PTI): There are no sources of routinely-collected data in primary care that are analogous to the SMR schemes in Secondary Care. In the recently-established PTI scheme, primary care data are collected in a relatively small number of Scottish practices. These data cover consultations with any member of the Primary Care Team, and may be used to calculate practice consultation rates.

Population data: Most indicators in population-based needs assessment consist of a rate per unit population. The two principal sources of population data are the National Census and the Board’s Community Health Index (CHI).

National Census: The National Census in the UK is carried out decennially. The census data are the source of Mid-Year Estimates (MYE) and Projections. Mid-Year Estimates of the population are available at the levels of Health Boards, CHPs and local government areas.

Community Health Index (CHI): A Community Health Index is a list of all residents of a Health Board who are registered with a general practitioner in the Board’s area. The Community Health Index is the only source of information about practice populations.

SIRS modules: The Community Health Index is the basis for the operation of a number of specific functions, corresponding to the SIRS modules. Data are collected in each module about an aspect of community health. One of the most important modules serves the needs of the immunisation programme. Information is available from the module about the level of uptake of routine immunisation in childhood.

Chronic Disease

A wide range of different sources of data was used to study the disease profile of 4 selected common chronic diseases in West Dunbartonshire, namely coronary heart disease (CHD), stroke, chronic obstructive pulmonary disease (COPD) and diabetes.

Routinely collected data

These include data obtained from ISD Scotland’s CHD and Stroke Programme, Primary care-based QOF within new GMS contract, Practice Team Information primary care data, hospital discharge data (SMR01), Scottish Health Survey, Community Health and Well-being Profiles, and General Registrar Office for Scotland.

Prevalence of chronic disease

There are two sources of data on prevalence of chronic disease in Scotland at national level (PTI and QOF) and one source that provides prevalence data at CHP and general

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practice level. The PTI data is useful for providing estimates of national burden of disease, based on sampling of 44 general practices across Scotland, and broadly characterizing the epidemiology of the condition while the QOF data is useful for providing practice and CHP/council specific data that provides a useful basis of comparison.

Quality Outcomes Framework (QOF)

GPs are encouraged to gain points and increase remuneration under a voluntary scheme that is part of the new GMS contract by collecting information about patients with 10 specified chronic conditions. These include:

1. coronary heart disease, 2. chronic obstructive pulmonary disease, 3. asthma, 4. cancer, 5. diabetes, 6. epilepsy, 7. hypertension, 8. hypothyroidism, 9. mental health, 10. stroke/TIA.

Twenty out of 20 general practices in WDCHP volunteered to comply with the QOF payment system. The prevalence for these conditions in West Dunbartonshire has risen modestly since then as a result of newly registered cases such that the ‘prevalence’ rates for coronary heart disease, stroke/TIA and diabetes were 5.1%, 2.4% and 3.8% as of 5th February 2007 (according to GMS Contract Administrator Assistant at NHSGG&C).

In addition, the WDCHP prevalence rates for 2004/5 for each of the 10 conditions are also provided in the relevant section. The national averages for these conditions for Scotland in 2004/5, provided by QOF, is useful as it can be compared to the most recent national prevalence figures calculated by the Practice Team Information on the basis of a more limited sample of 44 Scottish general practices, which is available for 2004/5.

The QOF provides the first measure of prevalence of these chronic diseases by practice and by CHP (and therefore by council if the CHP and council boundaries are co-terminous) that can allow comparisons between practices, councils/CHPs and the national prevalence for Scotland. In this sense, QOF prevalence figures are very useful, with a few provisos. Unfortunately, the QOF data is an average for all ages and both genders combined and it is not readily standardised. In order to make direct comparisons with QOF prevalence rates, other routinely collected and ad hoc data has to be un-standardised and aggregated to provide a crude estimate of combined prevalence (males and females combined). In addition, the data associated with many of the chronic conditions have additional disease-specific provisos linked to their interpretation which is included in the text below.

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Practice Team Information (PTI)

The Practice Team Information scheme collects what is normally considered high quality data from practice team records of contacts with patients for a range of common conditions seen in primary care. These include:

1. angina, 8. depression, 2. anxiety, 9. diabetes, 3. asthma, 10. epilepsy, 4. back pain, 11. hypertension, 5. coronary heart disease, 12. hypothyroidism, 6. chronic obstructive pulmonary 13. osteoarthritis, and disease, 14. stroke/TIAs). 7. dementia,

This list overlaps with, but is not the same as, the QOF list. Forty four practices are sampled across Scotland, one of which is located in WDCHP (Clydebank). This enables us to estimate the national burden of disease and the epidemiology of this burden based on a limited sample but does not tell us anything about the individual practices in WDCHP. Normally, the data collected from the 44 practices is analysed as an aggregate for all the 44 practices and only the participating practice has access to their individual data set and statistics. ‘Prevalent’ cases are those patients with at least one first, recurrent or persistent diagnosis of the specified condition. The prevalence from the aggregate sample is used to estimate the burden of chronic disease across Scotland to provide the numerator for national prevalence measures. The denominator is obtained from the CHI and is based on all patients registered with a GP in Scotland.

At the time of writing, ISD information officers were confirming that recent PTI data had come into question because of suspected under-recording related to the new GMS contract and that historical data from 2002 might be more accurate. Unfortunately, all of the PTI dataset (including historical data) is undergoing adjustment and the historical data was not available until 27 March 2007, at which time the provisional 2005/6 data also became available. This might explain why, in many cases, prevalence rates for Scotland according to the PTI dataset are lower than those provided by the national QOF disease register, despite restrictions on what GPs would record on their QOF disease registers.

Nevertheless, although PTI prevalence estimates are likely to be underestimates, the data is still useful in elucidating the epidemiology of primary care utilisation, including age-specific prevalence, incidence and consultation rates for various conditions.

84

APPENDIX 2 - Historical Aspects and Geography

Figure 2.1: Map of West Dunbartonshire Community Health Partnership

85

APPENDIX 3 – Demography and socio-economic determinants of health

Table 3.1: Population of children and young people in West Dunbartonshire (Source: General Registrar’s Office Scotland 2004 Mid Year Estimate)

Year 0 -19 yrs 20 plus yrs Total 1996 24,611 70,709 95,320 1997 24,594 70,606 95,200 1998 24,514 70,416 94,930 1999 24,351 70,069 95,320 2000 24,166 69,764 93,930 2001 23,621 69,699 93,320 2002 23,243 69,587 92,830 2003 22,916 69,404 92,320 2004 22,519 69,451 91,970 2005 21,910 69,490 91,400

Figure 3.1: Age structure of council areas, 2005 GRO mid-year (% of population under 16, 16-44, 45-64 and 65+ years)

100% 16.4 14.8 16 80% 21.7 25.9 25.8 60%

40% 39.6 46.5 39.6

20% 18.2 17 18.4 0% SCOTLAND Glasgow City West Dunbartonshire

0-15yrs 16-44yrs 45-64yrs 65+yrs

Figure 3.2: West Dunbartonshire population projection 1996 – 2015, all ages

98 95,320 96

94 91,321 92

Thousands 90 88,059 88 86 84 82 80

6 7 8 1 2 3 4 5 9 9 9 99 00 0 0 0 0 0 11 12 13 9 9 9 9 0 0 0 0 1 1 1 1 2 20 20 20 20 20 2006 2007 2008 2009 2010 2 2 2 2014 2015

86

Figure 3.3: Projected percentage change in populations by (2004-based) Council area, 2004 - 2024 25 20 15 10 5 0 -5 -10 change Percentage -15 -20 -25 -30

Fife Moray Angus Falkirk Stirling

Highland Galloway Inverclyde Midlothian East West Eilean Siar Dumfries & Dumfries SCOTLAND Dundee City Dundee East Lothian ArgyllBute & Renfrewshire Glasgow City West Lothian East Ayrshire Aberdeen City North Ayrshire Aberdeenshire South Ayrshire Orkney Islands Orkney Dunbartonshire Perth & Kinross Dunbartonshire Dunbartonshire Scottish Borders Shetland Islands North Lanarkshire North Edinburgh, City of South Lanarkshire South East Renfrewshire Clackmannanshire

Figure 3.4: West Dunbartonshire population projection 1996 – 2015, by age group450 40287 400 37149

350 Hundreds 32475 300 24158 25632 250 21345 200 15549 13931 18926 150 14392 100 13507 12919

50 1546 1629 1255 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

0-14 15-44 45-64 65-84 85+

87

Figure 3.5: Projected population of children and young people in West Dunbartonshire.

Figure 3.6: Projected annual number of births to mothers resident in West Dunbartonshire CHP (Source: GROS 2004)

88

Figure 3.7: 2004 Based Household & Population Projections: West Dunbartonshire (Source: GROS)

100

90 Thousands 80 Decrease 2004 to 2024 (n=7,969) 70

60

50

40 Increase 2004 to 2024 (n=2,280) 30

20

10

0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Households Population

Figure 3.8: Percentage of West Dunbartonshire, Glasgow City and NHS Greater Glasgow & Clyde residents living in 5% and 20% most deprived areas of Scotland

60

50 40

30

20 10

0 5% Most deprived data zones 20% Most deprived data zones

Glasgow City West Dunbartonshire NHS Greater Glasgow & Clyde

89

Figure 3.9: SIMD 2006 Datazones in the worst 15% in Scotland

90

Figure 3.10 Mean grossly weekly pay for all employees in all of West of Scotland council areas and for Scotland, 2005.

£600 £481 £500 £456 £458 £424 £396 £395 £398 £372 £386 £394 £400 £348 £367

£300

£200

£100 Mean grosspay Mean weekly £0

e yr de an h' yr Lan A ly A . Dun . . L ws . Ren cotland N E. gow C. S e N. Ayr E S. E. Dun S W s verc la In G Renfr

Region

Figure 3.11 Percentage of working age population who are ‘employment deprived’ in all of the West of Scotland council areas, West of Scotland and Scotland in 2002.

30

25 23.1 18.6 18.8 19.0 20 17.9 17.4 15.5 15.7 16.1 13.8 15 13.7 8.8 9.1 10

5 % of working age pop'n of working % 0

d r r un de un an and . Ay y D otl . D S. Ayr S. Lan E N. Ay cotl E. Ren E N. LanW. S Invercl lasgow City of Sc Renfrewsh'e W G Region

91

Figure 3.12: Domestic abuse incidents per 100,000 population, 2004 by West of Scotland council area. Source: Scottish Executive.

1600 1409 1400 1339 1200 939 957 967 1000 875 893 860 812 800 708 600 364 368 Rate per 100,000 per Rate 400 200 0

e e e ire de C ir hire hire ly tland s shir c w o w ks go e r er Sc r Ayr as rtonsh nf Inv e anarkshireN AyrshirE Ayrsh ana S Gl L Renfrewshire R S N L E Dunba E Dunbartonshire W West of Scotland councils

Figure 3.13: Index of overall crime rate per 10,000 population, West of Scotland council areas, 2004/5.

180 157 150 120 113 120 100 103 89 91 95 90 79 80 58 59 60

30 Index (Scotland 100) = 0

d e e e e e e r ire r ir r ire r r an h hi hire lyde hi s sh shi s otl nshi k r r ksh rc o r r e on rt rews a Ay Ayrshi frews v t Sc f na n In a n S Ay E N Glasgow C Re Re S Lan N La E Dunbar E Dunb W West of Scotland Council

92

Figure 3.14: Drunk-driving offences, rate per 1000 population aged 17+, 2003 for selected West of Scotland council areas and for Scotland.

Drunk-driving offences, rate per 1000 population aged 17+, 2003 West of Scotland council areas Source: Scottish Executive Justice Department

4.5 Number of offences: 4.0 Scotland: 11,566 3.6 West of Scotland: 4,544 3.5 Glasgow: 1,666

3.0 2.9 2.7 2.7 2.6 2.5 2.5 2.5 2.5 2.3 2.3 2.4

population aged 17+ aged population 2.0 1.6 1.7 1.5

1.0 Rate per 1000 0.5

0.0

e e e e e e nd ir r ir ir re ir a hire hir l tland City shi s shi ot nsh w ks ow o ewsh Sc rt r Ayrshire rton ar f Sco nf h Inverclyde a an o nba Lanark L Glasg u Re East Ayrsh th North Ayrsh Sout Dunb r D t o West st N East Renfre South es Ea W Council

93

APPENDIX 4

Drug Misuse

Table 4.1: Estimates of the number of problem drug users by Council area (age 15 to 54)

Area Estimate Prevalence n 95% CI % 95% CI Aberdeen City 2,810 2,587-3,147 2.03 1.87-2.27 Aberdeenshire 1,220 1,056-1,581 1.10 0.95-1.42 Angus 1,038 779-1,837 1.99 1.50-3.53 Argyll & Bute 609 490-974 1.35 1.09-2.16 Clackmannanshire 297 251-436 1.05 0.88-1.53 Dumfries & Galloway 1,806 1,597-2,184 2.43 2.15-2.94 Dundee City 2,522 2,255-2,899 2.80 2.51-3.22 East Ayrshire 1,387 1,255-1,606 1.92 1.73-2.22 East Dunbartonshire 401 301-879 0.69 0.51-1.50 East Lothian 814 658-1,343 1.74 1.40-2.86 East Renfrewshire 723 561-1,896 1.40 1.09-3.67 Edinburgh, City of 5,667 5,176-6,374 2.10 1.92-2.37 Eilean Siar1 21 0.16 Falkirk 856 746-1,066 1.08 0.94-1.34 Fife 3,022 2,690-3,707 1.60 1.43-1.97 Glasgow City 11,235 10,719-11,830 3.31 3.16-3.49 Highland 898 695-1,611 0.81 0.63-1.46 Inverclyde 1,178 1,081-1,335 2.57 2.35-2.91 Midlothian 640 549-975 1.46 1.25-2.22 Moray 310 182-1,627 0.66 0.39-3.48 North Ayrshire 1,342 1,229-1,530 1.85 1.69-2.11 North Lanarkshire 1,894 1,711-2,172 1.06 0.96-1.22 Orkney Isles1 16 0.16 Perth & Kinross 1,187 968-1,645 1.76 1.44-2.44 Renfrewshire 2,295 1,953-2,867 2.41 2.05-3.01 Scottish Borders 680 516-1,295 1.25 0.95-2.38 Shetland Isles 85 45-607 0.71 0.38-5.07 South Ayrshire 951 781-1,318 1.88 1.55-2.61 South Lanarkshire 2,755 2,245-4,453 1.72 1.40-2.77 Stirling 713 504-1,739 1.49 1.05-3.62 West Dunbartonshire 1,185 968-1,312 2.22 1.81-2.46 West Lothian 1,025 918-1,236 1.11 1.00-1.34 SCOTLAND 51,582 51,456-56,379 1.84 1.84-2.01

94

Table 4.2: Estimates of the number of drug injectors by Council area (mainland Scotland, age 15 to 54)

Area Total Estimate Prevalence Rate Aberdeen City 2,050 1.48 Aberdeenshire 681 0.61 Angus 322 0.62 Argyll & Bute 144 0.32 Clackmannanshire 219 0.77 Dumfries & Galloway 663 0.89 Dundee City 475 0.53 East Ayrshire 559 0.77 East Dunbartonshire 115 0.20 East Lothian 83 0.18 East Renfrewshire 102 0.20 Edinburgh, City of 1,260 0.47 Falkirk 395 0.50 Fife 1,124 0.60 Glasgow City 4,473 1.32 Highland 373 0.34 Inverclyde 393 0.86 Midlothian 91 0.21 Moray 111 0.24 North Ayrshire 644 0.89 North Lanarkshire 630 0.35 Perth & Kinross 297 0.44 Renfrewshire 1,195 1.25 Scottish Borders 87 0.16 South Ayrshire 512 1.01 South Lanarkshire 650 0.40 Stirling 287 0.60 West Dunbartonshire 551 1.03 West Lothian 251 0.27 MAINLAND SCOTLAND 18,737 0.67

95

Figure 4.1 : Estimated proportion of 'problem drug users' (aged 15-54), 2000 vs. 2003 Source: Glasgow University/SCIEH 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 % of population aged 15-54 aged of population % 0.5 0.0 Scotland 2000 Scotland 2003 Inverclyde 2000 Inverclyde 2003 Glasgow City 2000 Glasgow City 2003 East Ayrshire 2000 East Ayrshire 2003 Renfrewshire 2000 Renfrewshire 2003 North Ayrshire 2000 North Ayrshire 2003 South AyrshireSouth 2000 AyrshireSouth 2003 North Lanarkshire 2000 North Lanarkshire 2003 South LanarkshireSouth 2000 LanarkshireSouth 2003 East Renfrewshire 2000 East Renfrewshire 2003 Council/Year East Dunbartonshire 2000 East Dunbartonshire 2003 West Dunbartonshire 2000 West Dunbartonshire 2003

Figure 4.2 Prescribing rates for methadone in in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004- October 2006.

Prescribing of Methadone in W.Dunbartonshire CHP DDDs per 100 patients per quarter 1,800

1,600

1,400

1,200

1,000

800

600

400

200

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06

Vale & Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

96

Figure 4.3 Prevalence of ‘problem drug users’ (aged 15-54 years) by selected LHCCs in Greater Glasgow in 2003 (University of Glasgow and SCIEH).

Estimated proportion of 'problem drug users' (aged 15-54) within Greater Glasgow LHCC areas, 2003 Source: Glasgow University/SCIEH

12 11.2

10

8 7.3 6.4 6 4.8 4.0 4 3.4 NB Clydebank 3.0 2.6 2.8 % of population aged 15-54 of population aged % prevalence of 1.2% 1.8 1.8 1.9 2 1.6 1.2 0.6 0.6 0.2 0

k n en od n e el un lvi an ow o e tOn g gow to two s s get hk deb a id C areas t mchap Gl nnis Scotland C Bearsd Eas ly Camglen t Glas u Br e / C s n Glasgow r Stra r Shawlands r D rth D e te o side/We We s N er h Ea iv Maryhill/Woodside All GG LH R Great Anniesland Sout South East Glasgow LHCC area

97

APPENDIX 5 - Mortality and life-expectancy

Figure 5.1: Male life expectancy at birth (years) : West of Scotland Council Areas vs. Scotland1991-1993 to 2003-2005 (Source: Office for National Statistics)

78 77.7 76.8

76 74.7 74.2 74.0 74

72 71.5 71.0 Years 69.9 69.5 70 68.2 68

66 1991-1993 1992-1994 1993-1995 1994-1996 1995-1997 1996-1998 1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 East Dunbartonshire East Renfrew shire Glasgow City West Dunbartonshire Scotland

Figure 5.2: Female life expectancy at birth (years); West of Scotland Council Areas vs. Scotland; 1991-1993 to 2003-2005 (Source: Office for National Statistics)

82 81.2 81 81.0

80 79.3 79.2 79 78.8 78 77.2 77.5 Years 77 76.7 77.1 76 75.0 75

74 1991-1993 1992-1994 1993-1995 1994-1996 1995-1997 1996-1998 1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005

East Dunb art o nshire East Renfrewshire Glasgow City West Dunb art o nshire Scot land

98

Table 5.1: Most important causes of death in West Dunbartonshire (2001)

Cause of death Number Proportion (%) Acute Myocardial infarction 111 13.5 Carcinoma of bronchus 65 7.8 Stroke 62 7.6 Coronary heart disease 53 6.5 Chronic obstructive pulmonary disease 44 5.3 Pneumonia 41 5.0 Dementia 28 3.4 Alcoholic liver disease 25 3.0 Colorectal cancer 22 2.7 Carcinoma of breast 15 1.8 Carcinoma ovary 10 1.2 Diabetes 9 1.1 Carcinoma of stomach 8 1.0 Carcinoma of prostate 8 1.0 Carcinoma of pancreas 8 1.0 Cardiac failure 8 1.0 Urinary tract infection 8 1.0 Carcinoma of bladder 7 0.9 Suicide 7 0.8 Mesothelioma 5 0.6 Other 276 33.5 Total 825 100

Table 5.2: Most important causes of death in NHS Greater Glasgow and Clyde (2001)

Cause of death Number Proportion (%) Acute Myocardial infarction 1628 11.5 Stroke 1131 8.0 Carcinoma of bronchus 1106 7.8 Coronary heart disease 341 7.1 Chronic obstructive pulmonary disease 767 5.4 Pneumonia 676 4.8 Dementia 443 3.1 Alcoholic liver disease 393 2.8 Colorectal cancer 354 2.5 Carcinoma of breast 280 2.0 Carcinoma of oesophagus 194 1.4 Diabetes 173 1.2 Carcinoma of prostate 165 1.2 Carcinoma of stomach 155 1.1 Carcinoma of pancreas 150 1.1 Suicide 149 1.1 Fall 143 1.0 Cardiac failure 135 0.9 Carcinoma of bladder 121 0.8 Urinary tract infection 89 0.6

Others 4946 34.8 Total 14212 100.0

99

Table 5.3: Mortality Rate by Age group and Sex in West Dunbartonshire (2001) Rates Age-group Total 0-4 5-14 15-44 45-64 65-74 over 74 Males 0.9 0.1 0.5 4.1 11.7 37.0 4.0 Females 0.3 0.0 0.4 2.0 8.8 30.7 4.2 Total 0.6 0.0 0.4 3.0 10.0 32.8 4.1

Figure 5.3: Overall mortality rate by age-group in West Dunbartonshire, 2001

35.0

30.0

25.0

20.0

15.0

10.0

Mortality rate (per 1,000) 5.0

0.0 Total 0-4 5-14 15-44 45-64 65-74 over 74 Age-group

Figure 5.4: Mortality rate by age-group in males in West Dunbartonshire, 2001

40.0

35.0

30.0

25.0

20.0

15.0

10.0

Mortality rate (per 1,000) 5.0

0.0 Total 0-4 5-14 15-44 45-64 65-74 over 74 Age-group

100

Figure 5.5: Mortality rate by age-group in females in West Dunbartonshire, 2001

35.0

30.0

25.0

20.0

15.0

10.0

Mortality rate (per 1,000) 5.0

0.0 Total 0-4 5-14 15-44 45-64 65-74 over 74 Age-group

Figure 5.6: All-cause deaths by council area: directly age/sex standardised rates per 100,000 population, 2005 – (Source: General Registrar’s Office Scotland)

1100

1000

900 800 700

600

500

400 300 200

100

0

g e k e d n y if n y y n e ds re e re ss ds in rs t n y re ia F h it kir re e e re e re y r i n rl e u la a h ora rg C l i ir hir i ia ly d ire lan hi ro ti B w t u h h s sh S c h s sh in la S rd ig h rs hi o M b Angus n Fa ks rs n s Is en Is o l & llo y L in e r y wshir a n d e K y B H a st e a A e le o n d & e h G a Midlothiard n h fr i Inver la r n s rgyl th A E f Ed e a t Dundee Cit n Lanark E t e rth rk A & u b L We st Loth ia mannanshi n e b e y o A th Re k East Ayrth a Glasgow Cit h t RenfrewshiA P O So it u Nor c r n S s Scotti fries C o a a S Cl No irle E um a East Dunba rton D West Dunbart omh C Council area of residence

101

Figure 5.7: Standardised Mortality Ratios (SMR) 2003-2005 by cause of death 250

200

150

100

50

100) = (Scotland SMR 0 I r er D y e c H M ve ide de uses C tor liv ici a an Stroke esti c C C ig oli Suic om D h H All Respira co Al Cause of death NHSGGC SMR WD SMR

Figure 5.8: Hepatic cirrhosis age standardised mortality rates among men aged 15-74 years in Scotland, NHS Greater Glasgow and West Dunbartonshire in the context of maximum, minimum and mean rates for 16 Western European countries.

100

90

80 70 60 50 40

30

20

year per 100,000 per Rate 10

0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Year Min Max Mean Scotland Greater Glasgow West Dunbartonshire

102

APPENDIX 6 - Cancer

Table 6.1 : Numbers of new cases of cancer in West Dunbartonshire in 2003

Type of cancer Number of cases Proportion (%) Bronchus 110 20.79 Breast 85 16.07 Colon 44 8.32 Prostate 36 6.81 Skin 19 3.59 Pancreas 17 3.21 Stomach 15 2.84 Oesophagus 12 2.27 Mesothelioma 12 2.27 Uterine body 12 2.27 Ovary 12 2.27 Bladder 12 2.27 Rectum 11 2.08 Kidney 11 2.08 Non-Hodgkin’s Lymphoma 11 2.08 Others 119 22.50 Total 529 100.0

Table 6.2: Numbers of new cases of cancer in Greater Glasgow and Clyde Health Board in 2003

Type of cancer Number of cases Proportion (%) Bronchus 1303 20.25 Breast 874 13.58 Colon 523 8.13 Prostate 468 7.27 Stomach 211 3.28 Skin 204 3.17 Rectum 198 3.08 Oesophagus 197 3.06 Bladder 180 2.8 Pancreas 157 2.44 Ovary 143 2.22 Kidney 134 2.08 Unspecified 134 2.08 Secondary tumour 128 1.99 Uterine body 103 1.6 Lymphoid leukaemia 103 1.6 Hodgkin's lymphoma 92 1.43 Others 1,282 19.93 Total 6,434 100.0

103

Figure 6.1. Annual average (1998-2002) cancer registration rates per 100,000 by site of cancer and local council area. Ten most common cancers in each sex. Source: Scottish Cancer Registry, ISD.

160.0

140.0

120.0

100.0

80.0

60.0

40.0

20.0 age-standardised average rate 0.0 Lung Lung Breast Ovary Non- Non- Skin Skin Neck Neck Bladder Prostate Stomach Stomach Hodgkin's Hodgkin's Head and Head and Colorectal Colorectal melanoma melanoma Leukaemias Corpus uteri Oesophagus Oesophagus Male Female cancer site, sex

West Dun. Glasgow City All Scotland

Figure 6.2. Age standardised incidence rates of cancer of the trachea, bronchus and lung (ICD-10 C33-C34), by sex and NHS Board area of residence, from 1980 to 2003

250.0

200.0

Male ACHB 150.0 Male GGHB Male All Scotland Female ACHB Female GGHB 100.0 Fem ale All Scotland

age standardised rate per 100,000 50.0

- 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 year

104

Figure 6.3. Age standardised incidence rates of head neck cancers (ICD-10 C00- 14, C30-32), by sex and NHS Board area of residence, from 1980 to 2003.

45.0

40.0

35.0 Male ACHB 30.0 Male GGHB 25.0 Male Scotland Female ACHB 20.0 Female GGHB 15.0 Female Scotland

10.0

5.0 standardised incidence rate per 100,000 - 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 year

Figure 6.4. Standardised mortality ratios for deaths by cancer in West Dunbartonshire, 2000-02. Point estimates and 95% confidence intervals shown. All Scotland = 100. Cancers not necessarily mutually exclusive (e.g. 45 bowel cancers included in 116 digestive system cancers).

300

250

200

150

100

50 Standardised Mortality Ratio

0 Breast 25 Lung 114 20 45

417 Prostate 23 Cervical 3 Head and Neck 18 Oesophagus 13 Gynaecological 17 Digestive System 116 Cancer of Stomach Bowel (colo-rectal) Malignant Neoplasms (All) Malignant Melanoma 3 Lymphatic/Haematopoietic cancer site

105

APPENDIX 7 - Ischaemic Heart Disease

Figure 7.1: Coronary Heart Disease mortality, measured as standardised mortality ratio (Scottish average is equal to 100%), for the 10 SIMD deciles, for Scots aged 0-64 years, those aged 65+ and all ages combined.

Coronary Heart Disease Standardised Mortality Ratios males and females by age group and SIMD decile ; 2001 - 2005

250.0

200.0

150.0 SMR 100.0

50.0

0.0 12345678910 SIMD Deprivation Decile

all ages 0-64 65+

Table 7.1: Summary of PTI rates for CHD in Scotland based on 44 practices for 3 successive years, 2003/4, 2004/5 and 2005/6. p denotes provisional data.

PTI annual prevalence rate per 1,000 PTI annual consultation/contact rate per 1,000 Year 2003/4 2004/5 2005/6 p 2003/4 2004/5 2005/6 p Gender Males 38.1 41.9 40.4 93.6 100.0 94.5 Females 32.9 31.4 30.4 62.8 69.9 66.5 Both 32.9 36.6 35.4 78.0 84.8 80.3

106

Figure 7.2: CHD annual prevalence rate per 1,000 of the Scottish population by gender and by age group for 2005/6. Source: PTI

250

200

150

100

Rate per 1,000 50

0 34 years & 35-44 45-54 55-64 65-74 75 years All ages under years years years years and over Age groups

Males Females

Table 7.2: Summary of the QOF prevalence data for CHD for WDCHP and Scotland for 2004/5 and 2005/6, based on all practices combined (new GMS, 17c, and 2c).

Year Total Combined WDCHP Total Combined Scottish Difference CHD Practice ‘prevalence CHD Practice Size prevalence between disease size in ’ per 100 disease in Scotland per 100 WDCHP register WDCHP patients on register and (Number patients on and size in and the for all of practices) the Scottish WDCHP (Number of combined Scottish combined prevalence practices) patient practices Scottish (ratio register patient WDC:Scot- register land) 2005/6 4,816 98,203 4.9% 242,648 5,359,029 4.5% 9% (20) (1,019) higher 2004/5 4,854 98,631 4.9% 243,797 5,363,866 4.5% 9% (20) (1,025) higher

Table 7.3: Summary of the QOF prevalence data for CHD for WDCHP, Glasgow C, Greater Glasgow and Scotland for 2005/6, based only on practices with the new GMS contract.

Year WDC Glasgow City Greater Glasgow Scottish prevalence per 100 ‘prevalence’ per prevalence per prevalence per 100 patients on the combined 100 patients on 100 patients on patients on Greater Scottish patient register the combined Glasgow patient Glasgow patient patient register register register 2005/6 4.9% 4.4% 4.4% 4.6%

107

Table 7.4: Summary of the QOF prevalence data for CHD for WDCHP, Glasgow City, and the CHPs within Glasgow City for 2005/6, per 100 patients on the patient register, based on all practices (new GMS contract and 17c and 2c).

Year WDC Glasgow E. W South North South East CHP City Glasgow Glasgow West Glasgow Glasgow CHP CHP CHP Glasgow CHP CHP CHP 2005/6 4.9% 4.4% 5.4% 3.5% 4.7% 4.9% 3.9%

Table 7.5: Selected indicators of health service usage for residents of West Dunbartonshire and Greater Glasgow, Greater Glasgow Health & Well-being study 2005: West Dunbartonshire.

Indicator GG W. Dun W. Dun ROA W. Dun ROA Seen a GP at least once in last year 78.0% 84.0% 85.4% 83.3% Out-patient to see a doctor at least once in last year 22.9% 26.3% 27.1% 25.9% A&E at least once in last year 14.4% 19.9% 22.9% 18.5% Hospital stay at least once in last year 13.1% 18.7% 17.6% 19.2% Difficulty getting GP appointment 11.3% 20.3% 24.9% 18.1% Difficulty accessing health services in an 5.2% 11.4% 14.9% 9.8% emergency.

Figure 7.3: Coronary Heart Disease, Trends in incidence, by year, 1996 – 2005, Age standardised incidence rates for males in Scotland, Greater Glasgow, Glasgow City and WDCHP. Numbers refer to Scotland and WDCHP in 2005.

700

650

600

550

500 n=235 450

Rate per 100,000 400 n=11,367 350

300 1995 1997 1999 2001 2003 2005 2007 Year Scotland Greater Glasgow Glasgow City West Dunbarton

108

Figure 7.4: Coronary Heart Disease, Trends in incidence, by year, 1996 – 2005, Age standardised incidence rates for females in Scotland, Greater Glasgow, Glasgow City and WDCHP. Numbers refer to Scotland and WDCHP in 2005.

400

350 n=239 300

250 n=8,948 Rate per 100,000 200

150 1995 1997 1999 2001 2003 2005 2007 Year

Scotland Greater Glasgow Glasgow City West Dunbartonshire

Figure 7.5: CHD Incidence by council in 2005, Males, Age standardised Rates using European standard population.

700.0

600.0

500.0

400.0

300.0

200.0 Rate100,000 per

100.0

0.0 Shetland Is. Shetland D & G E. Dunbarton E. Lothian Highland C. of Aberdeenshire A & B Moray S. Borders E. Angus Kin & Perth S. Ayrshire Fife W. Isles E. Ayrshire C Aberdeen Stirling W. Lothian N. Ayrshire Dundee C. Renfrewshire Clackman S. Lanarkshire Midlothian Orkney Falkirk C. of Glasgow W. Dunbarton N. Inverclyde

Council

109

Figure 7.6: CHD Incidence by council in 2005, Females, Age standardised Rates using European standard population

350.0 300.0 250.0 200.0 150.0 100.0

Rate per 100,000 50.0 0.0 E. Dunbarton E. Is. Shetland Aberdeenshire W. Isles Lothian E. Highland & Kin Perth BordersS. AyrshireS. C Aberdeen Renfrewshire Midlothian N. Ayrshire Dundee C. AyrshireE. Lana S. Lothian W. Glasgow of C. Clackman Inverclyde Dunbarton W. E. G D & of C. Orkney Fife Angus Moray Stirling Falkirk B A & N. rkshire

Council

Figure 7.7: Acute Myocardial Infarction, Trends in incidence, by year, 1996 – 2005, Age standardised incidence rates for males in Scotland, Greater Glasgow, Glasgow City and WDCHP. Numbers refer to Scotland and WDCHP in 2005.

450

400

350

n=148 300

250 Rate per 100,000 n=6,238 200

150 1995 1997 1999 2001 2003 2005 2007 Year

Scotland Greater Glasgow Glasgow City West Dunbarton

110

Figure 7.8: Acute Myocardial Infarction, Trends in incidence, by year, 1996 – 2005, Age standardised incidence rates for females in Scotland, Greater Glasgow, Glasgow City and WDCHP. Numbers refer to Scotland and WDCHP in 2005.

250

200 n=153

150

Rate per 100,000 per Rate 100 n=4,734

50 1995 1997 1999 2001 2003 2005 2007 Year Scotland Greater Glasgow Glasgow City West Dunbartonshire

Figure 7.9: Acute Myocardial Infarction Incidence by council in 2005, Males, Age standardised rates using European standard population.

350.0 300.0 250.0 200.0 150.0 100.0 Rate per 100,000 50.0 0.0 Shetland Is. Shetland E. Lothian Edinburgh & Kin Perth Ayrshire S. Inverclyde Aberdeenshi Renfrewshire Dundee C. Midlothian Ayrshire E. Clackman N. Ayrshire C Aberdeen W. Lothian Borders S. D & G W. Isles E. A & B Moray Fife Ren E. Stirling Highland Angus Lanark S. Falkirk Lanark N. Glasgow DunW.

Council

111

Figure 7.10: Acute Myocardial Infarction Incidence by council in 2005, Females, Age standardised rates using European standard population.

200.0 180.0 160.0 140.0 120.0 100.0 80.0 60.0

Rate per 100,000 40.0 20.0 0.0 Shetland W. Isles D & G Edinburg Perth & Aberdeen Inverclyde E. Lothian E. Dun E. Ren Highland Falkirk Angus Fife Stirling Renfrews Midlothian S. Dundee Moray N. A & B Aberdeen E. Ayr S. W. S. Lan Glasgow N. Lan Clackman W. Dun

Council

Figure 7.11: CHD hospital discharge rates per 100,000 for males, trends from 1996/7-2005/6, for Scotland, Greater Glasgow, Glasgow City and West Dunbartonshire, age-standardised to European population. Numbers refer to Scotland and WDCHP in the fiscal year ending in 2006.

1700 1600 1500 1400 1300 1200 1100 n=30,239 Rate per 100,000 per Rate 1000 900 n=767 800 1996 1998 2000 2002 2004 2006 2008 Year

Scotland Greater Glasgow Glasgow C West Dunbarton

112

Figure 7.12: CHD hospital discharge rates per 100,000 for females, trends from 1996/7-2005/6, for Scotland, Greater Glasgow, Glasgow City and West Dunbartonshire, age-standardised to European population. Numbers refer to Scotland and WDCHP in the fiscal year ending in 2006.

900 850 800 750 700 n=489 650 600 550 Rate per 100,000 500 450 n=18,723 400 1996 1998 2000 2002 2004 2006 2008 Year

Scotland Greater Glasgow Glasgow C West Dunbarton

Figure 7.13: League table of hospitalisation rates for CHD for males by council showing position of WDCHP against the other councils in fiscal year 2005/6, age- standardised rates using European standard population.

1800.0 1600.0 1400.0 1200.0 1000.0 800.0 600.0 400.0 Rate per100,000 200.0 0.0 Shetland Is. Shetland Clackman Lothian E. Edinburgh S. Ayrshire Lothian W. Ayrshire N. S. Borders Perth & Kin E. Ayrshire Renfrewshire Midlothian Aberdeenshir of Glasgow C. C Aberdeen C. Dundee Highland Lanark S. Inverclyde Lanark N. D & G D & A & B E. Dun Isles W. Moray W. Dun E. Ren Stirling Angus Orkney Fife Falkirk

Council

113

Figure 7.14a: League table of hospitalisation rates for CHD for females by council showing position of WDCHP against the other councils in fiscal year 2005/6, age-standardised rates using European standard population.

900.0 800.0 700.0 600.0 500.0 400.0 300.0 200.0 Rate per100,000 100.0 0.0 Shetland Is. Shetland S. Borders Perth & Kin Edinburgh S. Ayrshire Lothian E. Aberdeenshire Midlothian Renfrewshire Ayrshire N. Clackman Lothian W. Highland E. Ayrshire C. Dundee Glasgow C Aberdeen Lanark S. Inverclyde Lanark N. D & G D & Orkney E. Ren E. Dun Isles W. A & B Stirling Falkirk Fife Angus Moray W. Dun

Council

Figure 7.14b: League table of hospitalisation rates for CHD for females by council showing position of WDCHP against the other councils in fiscal year 2004/5, age-standardised rates using European standard population. This highlights the fact that hospitalisation rates for CHD increased suddenly in 2005/6.

900.0 800.0 700.0 600.0 500.0 400.0 300.0 200.0 Rate per 100,000 100.0 0.0 Shetland Is Shetland S Borders C Edinburgh Lothian E Is Orkney S Ayrshire Midlothian Perth & Kin Clackman Aberdeenshire Ayrshire N Highland Scotland Lothian W C Aberdeen Renfrewshire E Ayrshire C Dundee C Glasgow Inverclyde D&G W Isles E Dun Stirling Angus E Ren A & B Moray W Dun Fife Falkirk Lan S Lan N

Council

114

Figure 7.15: Acute myocardial infarction hospital discharge rates per 100,000 for males, trends from 1996/7-2005/6, for Scotland, Greater Glasgow, Glasgow City and West Dunbartonshire, age-standardised to European population. Numbers refer to Scotland and WDCHP in the fiscal year ending in 2006.

600 550 500 450 400 350 n=9,727

Rate per 100,000 300 n=156 250 200 1996 1998 2000 2002 2004 2006 2008 Year

Scotland Greater Glasgow Glasgow C West Dunbarton

Figure 7.16: Acute myocardial infarction hospital discharge rates per 100,000 for females, trends from 1996/7-2005/6, for Scotland, Greater Glasgow, Glasgow City and West Dunbartonshire, age-standardised to European population. Numbers refer to Scotland and WDCHP in the fiscal year ending in 2006.

280.0 260.0 240.0 n=180 220.0 200.0 180.0 160.0 n=6,593 Rate per 100,000 140.0 120.0 100.0 1996 1998 2000 2002 2004 2006 2008 Year

Scotland Greater Glasgow Glasgow C West Dunbarton

115

Figure 7.17: Coronary angiography rates, males, for Scotland, Greater Glasgow, Glasgow C. and West Dunbartonshire, activity trends for fiscal years ending in 1997 to 2006, age-standardised to European standard population. Numbers refer to WDCHP and Scotland for the fiscal year ending in 2006.

550

500

450

400 n=184 350 n=10,705 300 Rate per 100,000 250

200 1996 1998 2000 2002 2004 2006 2008 Year

Scotland Greater Glasgow Glasgow C. W. Dun

Figure 7.18: Coronary angiography rates, females, for Scotland, Greater Glasgow, Glasgow C and West Dunbartonshire, activity trends for fiscal years ending in 1997 to 2006, age-standardised to European standard population. Numbers refer to WDCHP and Scotland for the fiscal year ending in 2006.

300

250

n=131 200

n=6,360

Rate per 100,000 150

100 1996 1998 2000 2002 2004 2006 2008 Year

Scotland Greater Glasgow Glasgow C. W. Dun

116

Figure 7.19: League table of angiography rates for CHD for males by council showing position of WDCHP against the other councils in fiscal year 2005/6, age- standardised rates using European standard population.

700 600 500 n=184 400 300 200 Rate per 100,000 100 0 Shetland Lothian W Dumf Gall & Perth & Kin C Dundee Highland N Ayrshire Orkney Is Clackmannan Lothian E Renf East C Edinburgh E Ayrshire SCOTLAND Dunbarton E Renfrewshire Aberdeenshir Lanark N C Aberdeen Midlothian Lanark S Glasgow Inverclyde W Isles Fife Angus Borders A & B Moray Stirling W Dun S Ayrs Falkirk

Council

Figure 7.20: League table of angiography rates for CHD for females by council showing position of WDCHP against the other councils in fiscal year 2005/6, age- standardised rates using European standard population.

600 500 400 n=131 300 200

Rate per100,000 100

0 Perth & Kin Dumf Gall & Highland W Lothian Renf East Is Shetland Orkney Is C Dundee E Lothian Dunbarton E C Edinburgh E Ayrshire Aberdeenshir SCOTLAND Ayrshire N Midlothian Renfrewshire Dunbarton W Clackmannan Lanark N Lanark S C Aberdeen Glasgow Inverclyde W Isles Fife Borders Angus S Ayrs Falkirk A & B Stirling Moray

Council

117

Figure 7.21: Coronary Artery Bypass Graft (CABG) rates, males, for Scotland, Greater Glasgow, Glasgow C. and West Dunbartonshire, activity trends for fiscal years ending in 1997 to 2006, age-standardised to European standard population. Numbers refer to WDCHP and Scotland for the fiscal year ending in 2006.

140

120

100 n=35 80

60 n=1,712 40 Rate per 100,000 Rate per 20

0 1996 1998 2000 2002 2004 2006 2008 Year

Scotland Greater Glasgow Glasgow C. W. Dun

Figure 7.22: Coronary Artery Bypass Graft (CABG) rates, females, for Scotland, Greater Glasgow, Glasgow C. and West Dunbartonshire, activity trends for fiscal years ending in 1997 to 2006, age-standardised to European standard population. Numbers refer to WDCHP and Scotland for the fiscal year ending in 2006.

45 40 35 30 n=16 25 20 n=607 15 Rate per 100,000 10 5 0 1996 1998 2000 2002 2004 2006 2008 Year Scotland Greater Glasgow Glasgow C. W. Dun

118

Figure 7.23: League table of Coronary Artery Bypass Graft rates for CHD for males by council showing position of WDCHP against the other councils in fiscal year 2005/6, age-standardised rates using European standard population.

140 120 100 n=35 80 60 40

Rate per100,000 20 0 E Ayrshire Orkney Is C Dundee Renfrewshire PerthKin & Lothian W C Edinburgh Clackmannan DumfGall & Aberdeenshire City Aberdeen Lothian E Ayrshire N SCOTLAND Is Shetland Glasgow Dunbarton E Midlothian Dunbarton W Highland Lanark N Lanark S Renf East Inverclyde Angus Falkirk S Ayrs Fife Stirling Borders A & B W Isles Moray

Council

Figure 7.24: League table of Coronary Artery Bypass Graft rates for CHD for females by council showing position of WDCHP against the other councils in fiscal year 2005/6, age-standardised rates using European standard population.

60

50

40 n=18 30

20

Rate per 100,000 10

0 Shetland Is Clackmannan W Isles Orkney Is Perth & Kin Renfrewshire W Lothian Angus Fife Edinburgh C Dunbarton E Ayrshire E Borders Dundee C N Ayrshire Stirling E Lothian East Renf Highland S Ayrs SCOTLAND Gall & Dumf Aberdeenshire Falkirk Glasgow Moray A & B Lanark S Midlothian City Aberdeen N Lanark W Dunbarton Inverclyde

Council

119

Figure 7.25: Comparison of CHD age-standardised mortality for Scottish, Greater Glasgow, Glasgow City and West Dunbartonshire CHP males, 1996- 2005 (ISD Scotland 2007). Numbers refer to WDCHP and Scotland in 2005.

400

350

300

250 n=109

Rate per 100,000 200 n=5,629 150 1995 1997 1999 2001 2003 2005 2007 Year

Scotland Greater Glasgow City of Glasgow West Dunbarton

Figure 7.26: Comparison of CHD age-standardised mortality for Scottish, Greater Glasgow, Glasgow City and West Dunbartonshire CHP females, 1996- 2005 (ISD Scotland 2007). Numbers refer to WDCHP and Scotland in 2005.

180

160

140 n=110 120

Rate per 100,000 per Rate 100 n=4,702 80 1995 1997 1999 2001 2003 2005 2007 Year

Scotland Greater Glasgow Glasgow City West Dunbarton

120

Figure 7.27: Comparison of acute MI age-standardised mortality for Scottish, Greater Glasgow, Glasgow City and West Dunbartonshire CHP males, 1996- 2005 (ISD Scotland 2007). Numbers refer to WDCHP and Scotland in 2005.

275 250 225 200 175 150 n=69 Rate per 100,000 125 n=3,288 100 75 1995 1997 1999 2001 2003 2005 2007 Year

Scotland Greater Glasgow Glasgow City West Dunbartonshire

Figure 7.28: Comparison of acute MI age-standardised mortality for Scottish, Greater Glasgow, Glasgow City and West Dunbartonshire CHP females, 1996- 2005 (ISD Scotland 2007). Numbers refer to WDCHP and Scotland in 2005.

140

120

100

80 n=67

Rate per 100,000 60 n=2,758 40 1995 1997 1999 2001 2003 2005 2007 Year

Scotland Greater Glasgow Glasgow City West Dunbarton

121

Figure 7.29: Hospitalisation versus mortality rates in WDCHP in the early part of the study period. Comparison of West Dunbartonshire males’ position in the council league table for acute MI age-standardised mortality in 1997 and the acute MI discharge rate in 1996/7.

Acute MI discharges in 1996/7

700 600 n=191 500 400 300 200

Rate per 100,000 100 0 Argyll & Bute Eilean Siar Islands Orkney Ayrshire North Ayrshire South Borders Scottish East Ayrshire Dumfries & Islands Shetland Highland Renfrewshire East Lothian East Inverclyde West Dun of City Edinburgh, Kinross & Perth Clackmannanshire Scotland East Dun Aberdeen City Aberdeenshire Lanarkshire South Dundee City Renfrewshire Midlothian City Glasgow Lothian West Lanarkshire North Moray Stirling Fife Angus Falkirk

Council

Acute MI deaths in 1996

300.0 n=116 250.0 200.0 150.0 100.0

Rate per 100,000 50.0 0.0

fe n n n ty rk re e e i ia ia ia i i r ir F ross yde h h rders th n alk s s o nshire lo F rcl yrshire nshi n to d Ki ighland een Ci ve ew to H d fr A Ayrshire ast LothMi & est Loth In th E ber en or erth W ity of GlasgowA R outh N cottish B P C S S lackmanna ast Dunbar Council est DunbarC E W

122

Figure 7.30: Hospitalisation versus mortality rates in WDCHP in the early part of the study period. Comparison of West Dunbartonshire females’ position in the council league table for acute MI age-standardised mortality in 1996 and the acute MI discharge rate in 1996/7.

Acute MI discharges in 1996/7

350.0 300.0 n=152 250.0 200.0 150.0 100.0

Rate per 100,000 50.0 0.0

s s e k e d ire r nd fe ire ire r h lyde a Fi h h ian lkir s s tirling ngus s h City slan n Siar n nshir A n w I & Butea ighl S a Lot Fa ewshi y l H ee r Inverc ile d rgyl E ish Borde est lasgo enf rkne outh Ayr A ber W G R O S cott A Dunbarto S lackmann C est W Council

Acute MI deaths in 1996

140.0 n=109 120.0 100.0 80.0 60.0 40.0

Rate per 100,000 20.0 0.0

s s e ) d ty s y s d e w n n e re e d d if s n i u ra s n ir o ia ia t i ir n n F le la C g o ro la h g h h u h h la la Is h e n in t rs s t t B ks s Is Is ig e A M co y la lo o & r n rn d K A id L ll a to d y e H n & S G st y n r n e t u th f M a g a a la n s th u o r L b t rk e D r o y E A h n e W e S it t u h O ( P C u D S r o st ia S e S n W a Council ile E

123

Figure 7.31: Hospitalisation versus mortality rates in WDCHP in the later part of the study period for males. Comparison of West Dunbartonshire males’ position in the council league table for acute MI age-standardised mortality in 2005 and the acute MI discharge rate in 2005/6.

Acute MI discharges in 2005/6

600

500 n=156 400

300

200

Rate per 100,000 100

0 Eilean Siar Clackmannan Shetland Is Dum & Gall S Ayrshire Argyll & Bute Stirling Inverclyde N Ayrshire Moray East Ren E Lothian E Ayrshire Edinburgh, East Dun Angus Renfrewshire West Dun Orkney Is Scotland W Lothian Perth & Kin Midlothian Falkirk Aberdeenshire Glasgow C South Lan Aberdeen C Fife Dundee C S Borders Highland North Lan

Council

Acute MI deaths in 2005

200 180 160 n=69 140 120 100 80 60

Rate per 100,000 40 20

0 Shetland Is East Dun Fife Highland Perth & Kin Dundee S Borders Aberdeensh Moray Dum & Gall East Ren Inverclyde E Lothian Stirling Midlothian W Lothian North Lan Scotland S Ayrshire Arg & Bute Angus Falkirk Aberdeen C Western Is Renfrewsh West Dun N Ayrshire E Ayrshire South Lan Glasgow C Orkney Is Clackmann Edinburgh C

Council

124

Figure 7.32: Hospitalisation versus mortality rates in WDCHP in the later part of the study period for women. Comparison of West Dunbartonshire females’ position in the council league table for acute MI age-standardised mortality in 1996 and the acute MI discharge rate in 2005/6.

Acute MI discharges in 2005/6

300 n=180 250 200 150 100

Rate per 100,000 50 0 Eilean Siar Dumfries & Shetland Islands East Renfrewshire Falkirk Renfrewshire Perth & Kinross Argyll & Bute Stirling South Ayrshire Clackmannanshire Midlothian North Ayrshire Edinburgh, City of East Lothian East Ayrshire Orkney Islands Inverclyde Dundee City Scotland East Dun Aberdeenshire Moray Scottish Borders Angus West Lothian Glasgow City Fife South Lanarkshire Highland Aberdeen City West Dun North Lanarkshire

Council

Acute MI deaths in 2005

90 80 n=67 70 60 50 40 30

Rate per 100,000 20 10 0

k s e k C in C ir r re r K e k hi hi ian nd Is gh e thian ngu Bute s a d al A r oth st Dun ur erclyde Lo F ws & y sgow CW Dun Lana a Bordersv re g dl hetl E inb erth & S In Dun E f r Mi S S P A N A Gla Ed Ren Council

125

Figure 7.33: Prescribing rates for statins in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004- October 2006.

Prescribing of Statins in W.Dunbartonshire CHP DDDs per 100 patients per quarter 25,000

20,000

15,000

10,000

5,000

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06

Vale & Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

Figure 7.34: Prescribing rates for angiotensin converting enzyme inhibitors (ACEIs) in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004- October 2006.

Prescribing of ACEIs in W.Dunbartonshire CHP DDDs per 100 patients per quarter 18,000

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06

Vale & Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

126

Figure 7.35: Prescribing rates for angiotensin II receptor antagonists (AIIRAs) in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004- October 2006. Prescribing of AIIRAs in W.Dunbartonshire CHP DDDs per 100 patients per quarter 3,500

3,000

2,500

2,000

1,500

1,000

500

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06 Vale & Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

Figure 7.36: Prescribing rates for ACEIs and AIIRAs combined in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004- October 2006. Numbers refer to rates for Clydebank and Vale/Dumbarton for last quarter.

Combined prescribing of ACEIs and AIIRAs in W.Dunbartonshire CHP DDDs per 100 patients per quarter 20,000 n=17,710 18,000

16,000

n=15,608 14,000

12,000

10,000

8,000

6,000

4,000

2,000

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06

Vale & Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

127

APPENDIX 8 - Stroke/TIA

Figure 8.1: annual prevalence rate per 1,000 of the Scottish population by gender and by age group for 2005/6. Numbers refer to absolute number of cases in Scotland in 2005/6. Source: PTI

80.00 70.00 n=27,400 males 60.00 n=25,700 females 50.00 40.00 30.00

Rate per 1,000 20.00 10.00 0.00 34 years & 35-44 years 45-54 years 55-64 years 65-74 years 75 years All ages under and over Age groups

Males Females

Table 8.1: Summary of PTI rates for stroke and TIA in Scotland based on 44 practices for 3 successive years, 2003/4, 2004/5 and 2005/6. p denotes provisional data.

PTI annual prevalence rate PTI annual consultation/ per 1,000 contact rate per 1,000 Gender 2003/4 2004/5 2005/6 p 2003/4 2004/5 2005/6 p Year Males 8.0 10.0 10.3 22.0 22.3 18.3 Females 7.6 9.79.5 23.7 25.6 20.0 Both 7.8 9.9 9.9 22.8 24.0 19.7

128

Table 8.2: Summary of the QOF prevalence data for stroke and TIA for WDCHP and Scotland for 2004/5 and 2005/6, based on all practices combined (new GMS, 17c, and 2c).

Year Total Combined WDC Total Combined Scottish Difference number Practice ‘prevalence’ number Practice Size prevalenc between in Scotland of size in per 100 of and e per 100 WDCHP and patients WDCHP patients on patients (Number of patients Scottish with and the with practices) on the prevalence stroke/ (Number combined stroke/ combined (ratio TIA on of patient TIA on Scottish WDCHP: disease practices) register disease patient Scotland) register register register in in all WDCHP Scottish practices 2005/6 2,133 98,203 2.2% 101,603 5,359,029 1.9% 16% higher (20) (1,019) 2004/5 2,010 98,631 2.0% 95,558 5,363,866 1.8% 11% higher (20) (1,025)

Table 8.3: Summary of the QOF prevalence data for stroke and TIA for WDCHP, Glasgow City, Greater Glasgow and Scotland for 2005/6, only including practices with new GMS contracts.

Region WDCHP Glasgow C. Greater Scotland Glasgow Prevalence 2.2% 1.9% 1.9% 1.9% 2005/6

Figure 8.2: Cerebrovascular Disease, Trends in incidence 1996 – 2005, Age standardised incidence rates for males and by year for Scotland, Greater Glasgow, Glasgow City and WDCHP. European Standard population. Numbers refer to WDCHP and Scotland.

350

300

250

200 Rate per 100,000

150 1994 1996 1998 2000 2002 2004 2006

Year Scotland Greater Glasgow Glasgow City West Dunbarton

129

Figure 8.3: Cerebrovascular Disease, Trends in incidence 1996–2005, Age- standardised incidence rates for females, by year for Scotland, Greater Glasgow, Glasgow C. and WDCHP. European Standard population. Numbers refer to WDCHP and Scotland.

240 230 220 210 200 190 n=136 180

Rate per 100,000 170 160 n=7,003 150 140 1994 1996 1998 2000 2002 2004 2006 Year

Scotland Greater Glasgow Glasgow City West Dunbarton

Figure 8.4: Cerebrovascular Disease, Trends in incidence 1996 – 2005, Age standardised incidence rates for males and by year for Scotland, Greater Glasgow, Glasgow City and WDCHP. European Standard population. Numbers refer to WDCHP and Scotland. Black lines represent linear trend lines fitted.

350

300

250 n=107 n=5,654

Rate per 100,000 200

150 1994 1996 1998 2000 2002 2004 2006 Year Scotland Greater Glasgow Glasgow City West Dunbarton Linear (West Dunbarton) Linear (Glasgow City) Linear (Scotland)

130

Figure 8.5: Cerebrovascular disease hospital discharge trends for males in 4 different regions: Scotland, Greater Glasgow, Glasgow City and WDCHP, 1997- 2006, age standardized using European standard population. Numbers refer to Scotland and WDCHP.

650

600

550

500 n=10,399 450

400 Rate per 100,000 350 n=169 300 1996 1998 2000 2002 2004 2006 2008 Year Scotland Greater Glasgow Glasgow C West Dunbarton

Figure 8.6: Cerebrovascular disease hospital discharge trends for females in 4 different regions: Scotland, Greater Glasgow, Glasgow City and WDCHP, 1997- 2006, age standardized using European standard population. Numbers refer to Scotland and WDCHP.

450.0

400.0 n=11,656 350.0

300.0

Rate per 100,000 n=216 250.0

200.0 1996 1998 2000 2002 2004 2006 2008 Year Scotland Greater Glasgow Glasgow C West Dunbarton

131

Figure 8.7 Stroke only disease hospital discharge trends for males in 4 different regions: Scotland, Greater Glasgow, Glasgow City and WDCHP, 1997-2006, age standardized using European standard population. Numbers refer to Scotland and WDCHP in 2005/6.

450.0

400.0

350.0 n=7,488

300.0

250.0 Rate per 100,000 200.0 n=87 150.0 1996 1998 2000 2002 2004 2006 2008 Year

Scotland Greater Glasgow Glasgow C West Dunbarton

Figure 8.8: Stroke only disease hospital discharge trends for females in 4 different regions: Scotland, Greater Glasgow, Glasgow City and WDCHP, 1997- 2006, age standardized using European standard population. Numbers refer to Scotland and WDCHP in 2005/6.

350.0

300.0 n=8,235

250.0

200.0

Rate per100,000 150.0 n=144

100.0 1996 1998 2000 2002 2004 2006 2008 Year Scotland Greater Glasgow Glasgow C West Dunbarton

132

Figure 8.9: League table of hospital discharge rates for stroke for males, by council, in fiscal year 2005/6, age-standardised rates (ASR) using European standard population. n= number of discharges.

450.00 Glasgow C: 400.00 ASR=321 350.00 WDC: n=900 300.00 ASR=177 250.00 n=87 200.00 150.00

Rate per 100,000 100.00 50.00 0.00 Clackman Moray Stirling Western Is. Dun E. W. Dun Angus Ren E. D&G A&B Falkirk Aberdeen C. Renfrewshire & Kin Perth Aberdeenshire Ayrshire S. Dundee Edinburgh E. Lothian Fife Highland W. Lothian Ayrshire E. Border Sc. S. Lan N. Ayrshire Shetland Inverclyde Glasgow N. Lan Orkney Midlothian

Council

Figure 8.10: League table of hospitalisation rates for stroke for females by council in fiscal year 2005/6, age-standardised rates using European standard population. n= number of discharges.

300.0 ASR:231.8 250.0 n=1086 ASR: 156.7 200.0 n=144 150.0 100.0

Rate per100,000 50.0 0.0 Shetland Western Is. Clackman Perth & Kin C. Aberdeen Aberdeenshire Border Sc. Renfrewshire Highland Edinburgh Lothian W. Lothian E. Ayrshire N. E. Ayrshire S. Ayrshire Inverclyde Glasgow Midlothian Moray Stirling D&G E. Ren Orkney E. Dun Dundee Angus W. Dun Falkirk A&B Fife S. Lan

Council

133

Figure 8.11: Stroke-only CVD, Trends in mortality 1996 – 2005, Age standardised incidence rates for males and by year for Scotland, Greater Glasgow, Glasgow City and WDCHP. European Standard population. Numbers refer to WDCHP and Scotland.

100

90

80

70

60 n=1,249 50 Rate per 100,000 40 n=39 30 1994 1996 1998 2000 2002 2004 2006 Year

Scotland Greater Glasgow Glasgow City West Dunbarton

Figure 8.12: Stroke-only CVD, Trends in mortality 1996–2005, Age-standardised incidence rates for females, by year for Scotland, Greater Glasgow, Glasgow C. and WDCHP. European Standard population. Numbers refer to WDCHP and Scotland.

70 65 60 55 50 n=2,105 45

Rate per 100,000 40 n=39 35 30 1994 1996 1998 2000 2002 2004 2006 Year

Scotland Greater Glasgow Glasgow City West Dunbartonshire

134

Figure 8.13: Cerebrovascular Disease, Trends in mortality 1996 – 2005, Age standardised incidence rates for males and by year for Scotland, Greater Glasgow, Glasgow City and WDCHP. European Standard population. Numbers refer to WDCHP and Scotland.

140 130 120 110 100 n=2,136 90 80

Rate per 100,000 70 60 50 n=28 40 1994 1996 1998 2000 2002 2004 2006

Year Scotland Greater Glasgow Glasgow City West Dunbarton

Figure 8.14: Cerebrovascular Disease, Trends in mortality 1996–2005, Age- standardised incidence rates for females, by year for Scotland, Greater Glasgow, Glasgow C. and WDCHP. European Standard population. Numbers refer to WDCHP and Scotland.

110

100

90 n=3,665 80

70

60 Rate per 100,000 n=58 50

40 1994 1996 1998 2000 2002 2004 2006 Year

Scotland Greater Glasgow Glasgow City West Dunbartonshire

135

APPENDIX 9 - Diabetes

Figure 9.1: Diabetes: annual prevalence rate per 1,000 of the Scottish population by gender and by age group for 2005/6. Source: PTI

160 140 120 100 80 60

Rate per 1,000 40 20 0 14 years 15-24 25-34 35-44 45-54 55-64 65-74 75 years All ages & under years years years years years years and over Age groups

Males Females

Table 9.1: Summary of PTI rates for diabetes in Scotland based on 44 practices for 3 successive years, 2003/4, 2004/5 and 2005/6. p denotes provisional data. PTI annual prevalence PTI annual rate per 1,000 consultation/contact rate per 1,000 Year 2003/4 2004/5 2005/6 p 2003/4 2004/5 2005/6 p Gender Males 31.1 34.637.1 162.2 181.2 173.1 Females 29.1 31.332.5 174.5 187.0 180.1 Both 29.1 33.034.8 168.4 184.1 176.6

Table 9.2: Summary of the QOF prevalence data for diabetes for WDCHP and Scotland for 2004/5 and 2005/6, based on all practices combined (new GMS, 17c, and 2c).

Year Total Combined WDC Total Combined Scottish Difference diabetes Practice ‘prevalence diabetes Practice prevalence between disease size in ’ per 100 disease Size in per 100 WDCHP register WDCHP patients on register for Scotland patients on and size in and the all Scottish and the Scottish WDC (Number of combined practices (Number of combined prevalence practices) patient practices) Scottish (ratio register patient WDC:Scot- register land) 2005/6 3,539 98,203 3.6% 181,424 5,359,029 3.4% 6% higher (20) (1,019) 2004/5 3,358 98,631 3.4% 171,524 5,363,866 3.2% 6% higher (20) (1,025)

136

Table 9.3: Summary of the QOF prevalence data for diabetes for WDCHP, Glasgow City, Greater Glasgow and Scotland for 2005/6, only including practices with new GMS contracts.

Region WDCHP Glasgow C. Greater Scotland Glasgow Prevalence 2005/6 3.5% 3.4% 3.3% 3.4%

Table 9.4: Summary of lifestyle information of relevance to the aetiology of diabetes extracted from the Health and Wellbeing Lifestyle survey.

Self-reported risk factor WDCHP NHSGG Prevalence % Prevalence % Exceeds recommended weekly unit of 24.8 17.7 alcohol Admitting to binge drinking in last 37.0 28.6 week Takes at least 30 minutes of moderate 36.0 50.4 exercise five times per week Consumes at least 2 portions of high- 46.1 32.4 fat/sugary snacks per day Body Mass Index 25 or over 52.0 42.2

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APPENDIX 10 - Chronic Obstructive Airways Disease

Figure 10.1: Scotland’s position, which is second place, against the maximum, minimum and mean age-standardised mortality rates from COPD in men aged 15-74 years for 16 Western European countries. Compiled by ScotPHO. Source data: WHOSIS & GRO(S).

120

ICD 6/7: A093, A097 ICD8: A093, A096 ICD9: B323, B325 Maximum ICD10: J40 J46 80

40

Mean Rate per 100.000 population per year per population 100.000 Rate per

0 Minimum Scotland's rank: 2 1 2 2 2 2 3 3 3 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 Year of death

Figure 10.2: COPD annual prevalence rate per 1,000 of the Scottish population by gender and by age group for 2005/6. Source: PTI

100 90 80 70 60 50 40 30 Rate per 1,000 20 10 0 34 years & 35-44 45-54 55-64 65-74 75 years All ages under years years years years and over Age groups

Males Females

138

Table 10.1: Summary of PTI rates for COPD in Scotland based on 44 practices for 3 successive years, 2003/4, 2004/5 and 2005/6. p denotes provisional data.

PTI annual prevalence rate PTI annual consultation/contact rate per 1,000 per 1,000 Year 2003/4 2004/5 2005/6 p 2003/4 2004/5 2005/6 p Gender Males 16.7 18.3 17.6 37.4 39.8 40.2 Females 21.1 21.5 20.2 44.2 44.7 44.0 Both 18.9 19.9 18.9 40.8 42.3 42.1

Table 10.2: Summary of the QOF prevalence data for COPD for WDCHP and Scotland for 2004/5 and 2005/6, based on all practices combined (new GMS, 17c, and 2c).

Year Total Combined WDC Total Combined Scottish Difference COPD Practice ‘prevalence’ COPD Practice prevalence between disease size in per 100 disease Size in per 100 WDCHP register WDCHP patients on register for Scotland patients on and size in and the combined all Scottish and the Scottish WDC (Number of patient practices (Number of combined prevalence practices) register practices) Scottish (ratio patient WDC:Scot- register land) 2005/6 2,080 98,203 2.1% 97,735 5,359,029 1.8% 17% (20) (1,019) higher

2004/5 2,121 98,631 2.2% 99,246 5,363,866 1.9% 17% (20) (1,025) higher

Table 10.3: Summary of the QOF prevalence data for COPD for WDCHP, Glasgow City, Greater Glasgow and Scotland for 2005/6, based only on practices with the new GMS contract.

Year WDC ‘prevalence’ Glasgow City Greater Glasgow Scottish prevalence per per 100 patients on prevalence per prevalence per 100 patients 100 patients on the the combined patient 100 patients on on Greater Glasgow patient combined Scottish register Glasgow patient register patient register register 2005/6 2.1% 2.6% 2.4% 1.8%

139

COPD Hospitalisation rates

Figure 10.3: Hospital discharges with chronic lower respiratory diseases (in first or second diag position), Age standardised mortality rates, males NHS Greater Glasgow, Glasgow City and West Dunbartonshire area. Directly standardised to Western European population. Number refers to number of admissions in WDCHP and Greater Glasgow in 2005. Black lines represent trend lines demonstrating the conflicting directions.

850 800 750 n=2,456 700 650 600 550 500 Rate per 100,000 450 n=227 400 350 1996 1998 2000 2002 2004 2006 Year

Greater Glasgow Glasgow C West Dunbarton Linear (West Dunbarton) Linear (Glasgow C) Linear (Greater Glasgow)

Figure 10.4: Hospital discharges with chronic lower respiratory diseases (in first or second diag position) Age standardised mortality rates, females NHS Greater Glasgow, Glasgow City and West Dunbartonshire area. Directly standardised to Western European population. Number refers to number of admissions in WDCHP and Greater Glasgow in 2005. Black line is a trend line demonstrating the increasing mortality rate for WD females.

900 850 n=3,755 800 750 700 650 600 n=391 550 500

Rate per 100,000 450 400 350 300 1996 1998 2000 2002 2004 2006 Year Greater Glasgow Glasgow C West Dunbarton Linear (West Dunbarton)

140

Prescribing rates for drugs that could be used to treat COPD

Figure 10.5: Prescribing rates for bronchodilators in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004 - October 2006.

Prescribing of Bronchodilators in W.Dunbartonshire CHP DDDs per 100 patients per quarter 14,000

12,000

10,000

8,000

6,000

4,000

2,000

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06

Vale and Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

Figure 10.6: Prescribing rates for corticosteroids in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004- October 2006.

Prescribing of Corticosteroids in W.Dunbartonshire CHP DDDs per 100 patients per quarter 4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06

Vale & Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

141

COPD Mortality rates

Figure 10.7: Chronic lower respiratory diseases, age standardised mortality rates, Males, Greater Glasgow, Glasgow City and WDCHP area, Directly standardised to Western European population. Number refers to absolute numbers of deaths in WDCHP and Greater Glasgow in 2005. Black line refers to trend line for mortality rates for WD males.

100.0

90.0

80.0

70.0 n=33 60.0

Rate per 100,000 per Rate n=259 50.0

40.0 1995 1997 1999 2001 2003 2005 2007 Year Greater Glasgow Glasgow C West Dunbarton Linear (West Dunbarton)

Figure 10.8: Chronic lower respiratory diseases, age standardised mortality rates, females, Greater Glasgow, Glasgow City and WDCHP area, directly standardised to Western European population. Number refers to absolute numbers of deaths in WDCHP and Greater Glasgow in 2005. Black line is a trend line demonstrating the increasing mortality rate for WD females.

65.0 60.0 55.0 n=48 50.0 45.0 n=341 40.0 35.0 30.0 Rate per 100,000 Rate per y = 1.9793x - 3918.9 25.0 R2 = 0.253 20.0 15.0 1995 1997 1999 2001 2003 2005 2007 Year Greater Glasgow Glasgow C West Dunbarton Linear (West Dunbarton) Linear (Glasgow C)

142

APPENDIX 11 - Child Health

Figure 11.1 – Breastfeeding rates at first visit in West Dunbartonshire CHP (Source: ISD CHSP-PS February 2006 – data for 2005 are provisional)

Figure 11.2 – Trend in Breastfeeding rate for West Dunbartonshire CHP at 6-8 week review (Source: ISD CHSP-PS February 2006 – the 2005 result being provisional)

143

Figure 11.3 – Number and rate of emergency admissions for ‘home and other’ accidents discharged in 2004 and 2005 who are residents in West Dunbartonshire (Source: NHSGGC Information Services, based on SMR)

Aged 0-14 yrs Aged 10 to 24 yrs Rate / 100,000 Rate / 100,000 Numbers Numbers population population Local authority area 2004 2005 2004 2005 2004 2005 2004 2005 West Dunbartonshire 187 182 1080 1051 228 203 1265 1126 Total GG&C 2,133 2,105 995 982 2,702 2,449 1146 1039

Figure 11.4 – Discharge rates for self-harm emergency admissions for children and young people resident in West Dunbartonshire (Source: NHSGGC Information Services, based on SMR).

Aged 0-14 yrs Aged 10 to 24 yrs Rate / 100,000 Rate / 100,000 Numbers Numbers population population Emergency CHP 20042005 2004 2005 2004 2005 2004 2005 admission type Self Harm West Dunbartonshire 4 5 23 29 72 64 399 355 Total GG&C 52 42 24 20 791 598 335 254

Figure 11.5 – Immunisation rates in the West Dunbartonshire CHP

West Evaluation Period: Dunbartonshire Scotland Jan - Dec 2006 CHP Diptheria 97.4 96.5 Tetanus 97.4 96.5 % of children who have Pertussis 97.4 96.5 completed primary course at 12 months Polio 97.5 96.4 Hib 97.3 96.3 Men C 98.4 97.6 Number in Cohort 1 989 54325 Diptheria 98.4 97.9 Tetanus 98.4 97.9 % of children who have Pertussis 98.4 97.8 completed primary Polio 98.6 97.9 course at 24 months Hib 98.6 97.6 MMR 93.3 92.1 Men C 99.0 97.0 Number in Cohort 2 996 54509 Notes: 1. Aged 12 months : born April to June 2005 2. Aged 24 months : born April to June 2004 3. CHCP is derived from the child's NHS practice. 4. The 5 in 1 vaccine (comprising DTP/Pol/Hib) was introduced in September 2004. These vaccinations are currently recorded separately on the SIRS system and therefore rates may differ slightly. This may be due to children who have received a single vaccine outwith Scotland or due to local recording practices. .

144

Figure 11.6 – Proportion of 13 and 15 year olds smoking, drinking and using alcohol in West Dunbartonshire (Source: SALSUS 2002).

Figure 11.7: Proportion of boys and girls smoking, drinking and using alcohol in West Dunbartonshire CHP (Source: SALSUS 2002)

145

Proportion of low birth babies (<2500g)

West Dunbartonshire Scotland 10.0%

8.0%

6.0%

4.0%

2.0%

% Births Single Live of 0.0% 2001 2002 2003 2004 2005

% of Mothers Smoking During Pregnancy (Provisional data)

31

29

27

25

Percentage 23

21

19 2004 2005 Year

Scotland GG&Clyde Glasgow City West Dunbartonshire

146

% of Babies Breast-Feeding at 6 weeks 2002-2005 (Total Breast Fed consists of 'Breast Fed Only' and 'Both Breast & Bottle' combined)

60

50

40 30

20

Fed Breast % 10

0 2002 2003 2004 2005 Year of Birth

East Glasgow West Dunbartonshire GG&Clyde Scotland East Dunbartonshire

147

APPENDIX 12 - Mental Health

Figure 12.1: Prescribing rates for hypnotics in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004- October 2006.

Prescribing of Hypnotics in W.Dunbartonshire CHP DDDs per 100 patients per quarter 2,500

2,000

1,500

1,000

500

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06 Vale & Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

Figure 12.2: Prescribing rates for antidepressants in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004- October 2006.

Prescribing of Antidepressants (SSRIs & SNRIs) in W.Dunbartonshire CHP DDDs per 100 patients per quarter 8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06 Vale & Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

148

Figure 12.3: Prescribing rates for antipsychotics in Scotland, Greater Glasgow and Clyde, West Dunbartonshire, and the two halves of West Dunbartonshire for the quarterly periods between October 2004- October 2006.

Prescribing of Antipsychotics in W.Dunbartonshire CHP DDDs per 100 patients per quarter 700

600

500

400

300

200

100

Oct-Dec 04 Jan-Mar 05 Apr-Jun 05 Jul-Sep 05 Oct-Dec 05 Jan-Mar 06 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06

Vale & Dumbarton (A&C) Clydebank (GG) W.Dun GG&C Scotland

Figure 12.4: Crude suicide rates in males and females, 1980-2005, based on deaths due to ‘intentional self-harm and events of undetermined intent’ for West Dunbartonshire, Glasgow City and Scotland.

40 5 35

30 25 20 15 10

5 crude mortality per 10 rate 0 1980-84 1985-89 1990-94 1995-99 2000-04 2005 year

Male W est D unbart onshire City of Glasgow Scotland Female City of Glasgow Scotland W est D unb art o nshire

149

Figure 12.5: Standardised mortality rates for suicide in males only, based on deaths due to ‘intentional self-harm and events of undetermined intent’, 1980- 2005, for West Dunbartonshire, East Dunbartonshire, Glasgow City and Highland Council areas. Absolute numbers (n=) refer to the total number of suicides in the 4 regions studied in the final 5 year block ending in 2004 (2000- 2004).

1.8 n=204 1.6 n=81 1.4 n=473 1.2 1.0 0.8 n=51 0.6 0.4

Standardised Mortality Ratio 0.2 0.0 1979 1984 1989 1994 1999 2004 Blocks of 5 years ending in: East Dun City of Glasgow Highland West Dun

Figure 12.6: Standardised mortality rates for suicide in males only, based on deaths due to ‘intentional self-harm and events of undetermined intent’, 1980- 2005, for West Dunbartonshire, East Dunbartonshire, Glasgow City and Highland Council areas. Linear trend lines fitted with slope and correlation coefficients for West Dunbartonshire and East Dunbartonshire aimed at highlighting the difference in rates and acceleration of rates.

1.8 1.6 1.4 y = 0.0315x - 61.673 1.2 R2 = 0.8704 1.0 0.8 0.6 0.4 y = 0.0122x - 23.717 0.2 2

Standardised Mortality Ratio Ratio Mortality Standardised R = 0.923 0.0 1979 1984 1989 1994 1999 2004 Blocks of 5 Years ending in:

East Dun City of Glasgow Highland West Dun Linear (West Dun) Linear (East Dun)

150

APPENDIX 13 - Local Provision of Primary Care Services

Figure 13.1 Map depicting the location of health centres in West Dunbartonshire that accommodate 20 general practices (Clydebank Health Centre: 9; Alexandria Medical Centre: 4; Dumbarton Health Centre: 6; and one at Bank Street Alexandria.

151

APPENDIX 14 - Local Provision of Secondary Care Services

Table 14.1: Current bed numbers at Vale of Leven Integrated Cardiac Unit 10 Beds High Dependency Unit 3 Beds Ward 3 20 beds - Male Medical Ward 5 21 Beds - Male/Female Surgical Ward 6 21 Beds - Female Medical Ward F 16 Beds - Stroke Rehabilitation Ward 14 24 Beds – Medicine for the Elderly (Assess / Rehab) Ward 15 24 Beds – Medicine for the Elderly (incl. 9 Ger Ortho Rehab beds) CMU 7 Beds - Community Maternity Unit Fruin Unit 14 Beds Mental Health - Elderly Patients with Dementia Christie Ward 24 Beds Mental Health - Acute Psychiatry

Total 184 beds (38 pyschiatry, 146 non psych)

Table 14.2: Additional Day Facilities:

Satellite Renal Haemodialysis Unit 8 beds Surgical Day Unit 18 Beds (10 – 12 patients per day) Medical Day Unit 7 Beds (average 18 - 20 patients per day) Haematology Day Unit 10 Places (average 18 - 26 patients per day) Day Hospital 30 Places for elderly patients

Table 14.3: Analysis of Vale of Leven activity

Area Patients MAU (front door) 5,500 Emergency Inpatients 3,800 Rehabilitation Inpatients 1,400 Elective Inpatients 1,150 Elective Daycases (inc. maternity) 6,700 Minor Injuries Unit 8,300 Outpatients 50,000

Table 14.4: Population of West Dunbartonshire and activity in secondary care by specialty

Specialty Day-cases In-patient episodes Bed-days General medicine 3991 6473 32451 General surgery 1728 2800 11086 Orthopaedics 396 1502 6949 Urology 843 554 1597 Gynaecology 487 512 1424 Geriatric Medicine 0 802 18350 Clinical Oncology 453 261 1504 Ophthalmology 527 140 347 ENT surgery 149 495 840 Medical Paediatrics 22 391 715 Others 1129 1547 6283 Total 9,725 15,477 81,546

152

Table 14.5: Population of West Dunbartonshire and activity in secondary care by hospital

Hospital In-patient Day-cases episodes Bed-days

Western Infirmary/ Gartnavel Hospital 4598 6803 39143 Vale of Leven Dist. Gen. Hosp. 3591 3814 25444 Royal Alexandra Hospital 540 2482 8575 RHSC (Yorkhill) 262 773 2215 Southern General 96 611 2826 Royal Infirmary 223 290 1376 Golden Jubilee National Hospital 218 222 604 Canniesburn Hospital 131 135 391 Other 66 347 972

Total 9725 15477 81546

Figure 14.1: West Dunbartonshire residents elective activity to GGC hospitals (selected specialties 2005/2006) *Provisional data.

General Medicine General Surgery

Orthopaedics 2121 936 VOL 231

98 68 74 2078 GJH 1362 423 9 GGH 139 8 95 SGH GRI 4 49 27 231 RAH 148

153

Figure 14.2: West Dunbartonshire residents emergency activity to GGC hospitals (selected specialties 2005/2006) *Provisional data.

General Medicine General Surgery Orthopaedics 2895 49 60 VOL

2827 GJH 1121 341 62 GGH 40 59 19 SGH GRI 8 127 22 819 RAH 449

154

APPENDIX 15 - Activity in Secondary Care

Table 15.1: Standardised referral rates (per 1,000) and ratios in residents of West Dunbartonshire CHP by specialty

Specialty Referrals SRR 95% Confidence Stand Significance Interval Rate Upper Lower (per 1,000) Cardiothoracic 76 106.3 130.2 82.4 0.8 General surgery 3150 96.2 99.5 92.8 32.5 significantly lower Neurosurgery 66 90.6112.5 68.8 0.7 ENT surgery 2123 92.6 96.6 88.7 21.8 significantly lower Oncology 227 123.2 139.2 107.1 2.3 significantly higher Neurology 453 74.781.5 67.8 4.7 significantly lower Urology 1147 81.185.8 76.4 12.0 significantly lower General medicine 4244 93.0 95.8 90.2 43.4 significantly lower Gynaecology 2149 99.6103.8 95.4 22.8 Ophthalmology 2124 88.692.4 84.9 21.7 significantly lower Orthopaedics 4206 118.2 121.7 114.6 43.7 significantly higher Renal medicine 209 107.5 122.1 92.9 2.1 Total 20, 174

Table 15.2: Standardised rates (per 1,000) and ratios for elective in-patient admissions and day-cases in residents of West Dunbartonshire CHP by specialty

Specialty Admissions SAR 95% Confidence Stand Significance Interval Rate Upper Lower (per 1,000) Cardiothoracic 128 119.6 140.3 98.9 1.3 General surgery 2703 115.2 119.6 110.9 27.5 significantly higher Neurosurgery 49 90.4115.7 65.1 0.5 ENT surgery 495 91.4 99.5 83.4 5.1 significantly lower Oncology 638 78.484.4 72.3 6.5 significantly lower Neurology 65 70.087.0 53.0 0.7 significantly lower Urology 1237 104.0 109.8 98.2 12.8 General medicine 4526 119.6 123.1 116.1 45.0 significantly higher Gynaecology 845 100.3107.0 93.5 8.9 Ophthalmology 661 84.691.1 78.2 6.6 significantly lower Orthopaedics 1008 122.7 130.3 115.1 10.3 significantly higher Total 12355

155

Table 15.3: Standardised rates (per 1,000) and ratios for emergency admissions in residents of West Dunbartonshire CHP by specialty Specialty Admissions SAR 95% Confidence Stand Significance Interval Rate Upper Lower (per 1,000) Cardiothoracic 13 75.0115.8 34.2 0.1 General surgery 1554 100.6 105.6 95.6 15.8 Neurosurgery 16 67.3100.3 34.3 0.2 ENT surgery 132 99.8 116.9 82.8 1.3 Oncology 58 130.8 164.4 97.1 0.5 Neurology 12 90.9142.4 39.5 0.1 Urology 76 62.075.9 48.0 0.8 significantly lower General medicine 5100 100.9 103.7 98.2 50.3 Gynaecology 180 99.6114.2 85.1 2.0 Ophthalmology 32 91.7123.5 59.9 0.3 Orthopaedics 820 103.3 110.4 96.2 8.3 Renal medicine 57 85.4 107.6 63.2 0.6 Total 8083

Table 15.4: Numbers and rates of elective in-patient and day-case admission to Cardiothoracic Surgery

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 111 80.6 95.6 65.6 0.9 Glasgow North 93 82.8 99.6 66.0 0.9 Glasgow East 133 91.5 107.1 76.0 1.0 Glasgow South-east 111 104.0 123.4 84.7 1.1 Glasgow South-west 115 89.5 105.8 73.1 0.9 East Dunbartonshire 116 96.7 114.3 79.1 1.0 East Renfrewshire 93 92.3 111.0 73.5 1.0 West Dunbartonshire 128 119.6 140.3 98.9 1.3 Renfrewshire 175 87.7 100.7 74.7 0.9 Inverclyde 186 181.7 207.8 155.6 1.9 Total 1261 100

156

Table 15.5: Numbers and rates of emergency admission to Cardiothoracic Surgery by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 27.0 102.4 141.1 63.8 0.2 Glasgow North 35.0 155.0 206.3 103.6 0.3 Glasgow East 51.0 186.0 237.1 135.0 0.3 Glasgow South-east 13.0 67.1 103.5 30.6 0.1 Glasgow South-west 17.0 71.9 106.1 37.7 0.1 East Dunbartonshire 20.0 122.1 175.5 68.6 0.2 East Renfrewshire 16.0 114.0 169.8 58.1 0.2 West Dunbartonshire 13.0 75.0 115.8 34.2 0.1 Renfrewshire 17.0 55.4 81.8 29.1 0.1 Inverclyde 7.0 42.5 73.9 11.0 0.1 Total 216.0

Table 15.6: Numbers and rates of elective in-patient and day-case admission to ENT Surgery by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 665 83.6 89.9 77.2 4.6 Glasgow North 675 104.0 111.9 96.2 5.8 Glasgow East 855 110.0 117.3 102.6 6.1 Glasgow South-east 709 115.4 123.9 106.9 6.4 Glasgow South-west 848 122.8 131.1 114.5 6.8 East Dunbartonshire 472 85.3 93.0 77.6 4.7 East Renfrewshire 461 94.9 103.6 86.3 5.3 West Dunbartonshire 495 91.4 99.5 83.4 5.1 Renfrewshire 940 94.3 100.3 88.2 5.2 Inverclyde 479 94.5 102.9 86.0 5.2 Total 6599

Table 15.7: Numbers and rates of emergency admission to ENT Surgery by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 209 104.9 119.1 90.6 1.4 Glasgow North 140 90.9 105.9 75.8 1.2 Glasgow East 185 99.7 114.1 85.4 1.3 Glasgow South-east 140 93.2 108.7 77.8 1.2 Glasgow South-west 183 110.5 126.5 94.5 1.5 East Dunbartonshire 121 92.4 108.9 75.9 1.2 East Renfrewshire 103 89.3 106.5 72.0 1.2 West Dunbartonshire 132 99.8 116.9 82.8 1.3 Renfrewshire 267 111.2 124.5 97.8 1.5 Inverclyde 111 89.9 106.6 73.1 1.2 Total 1591

157

Table 15.8: Numbers and rates of elective in-patient and day-case admission to General Medicine by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 5454 107.9 110.8 105.0 40.6 Glasgow North 3873 96.0 99.0 93.0 36.2 Glasgow East 5548 108.5 111.3 105.6 40.8 Glasgow South-east 4518 115.7 119.1 112.3 43.6 Glasgow South-west 4758 105.0 108.0 102.0 39.5 East Dunbartonshire 4708 108.9 112.0 105.8 41.0 East Renfrewshire 3126 84.7 87.7 81.7 31.9 West Dunbartonshire 4526 119.6 123.1 116.1 45.0 Renfrewshire 4577 64.3 66.1 62.4 24.2 Inverclyde 3791 104.2 107.5 100.9 39.2 Total 44879

Table 15.9: Numbers and rates of emergency admission to General Medicine by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 6521 92.6 94.9 90.4 46.2 Glasgow North 6798 112.3 115.0 109.6 56.0 Glasgow East 8786 112.9 115.3 110.6 56.3 Glasgow South-east 4955 95.7 98.3 93.0 47.7 Glasgow South-west 7260 110.2 112.7 107.6 54.9 East Dunbartonshire 4496 107.9 111.1 104.7 53.8 East Renfrewshire 2957 79.8 82.7 77.0 39.8 West Dunbartonshire 5100 100.9 103.7 98.2 50.3 Renfrewshire 7394 85.8 87.7 83.8 42.8 Inverclyde 5118 106.8 109.7 103.9 53.2 Total 59385

Table 15.10: Numbers and rates of elective in-patient and day-case admission to General Surgery by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 3224 100.3 103.8 96.8 23.9 Glasgow North 2797 110.0 114.1 106.0 26.2 Glasgow East 3898 122.1 126.0 118.3 29.1 Glasgow South-east 1357 55.1 58.0 52.2 13.1 Glasgow South-west 1795 63.8 66.7 60.8 15.2 East Dunbartonshire 3299 126.9 131.3 122.6 30.2 East Renfrewshire 1533 68.6 72.1 65.2 16.4 West Dunbartonshire 2703 115.2 119.6 110.9 27.5 Renfrewshire 5153 117.5 120.7 114.3 28.0 Inverclyde 2640 117.5 122.0 113.1 28.0 Total 28399

158

Table 15.11: Numbers and rates of emergency admission to General Surgery by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 2435 104.8 108.9 100.6 16.4 Glasgow North 2073 108.7 113.3 104.0 17.0 Glasgow East 2508 106.1 110.3 102.0 16.6 Glasgow South-east 1414 83.2 87.6 78.9 13.0 Glasgow South-west 1889 93.1 97.3 88.9 14.6 East Dunbartonshire 1436 105.8 111.2 100.3 16.6 East Renfrewshire 954 79.9 85.0 74.8 12.5 West Dunbartonshire 1554 100.6 105.6 95.6 15.8 Renfrewshire 2520 93.4 97.0 89.7 14.6 Inverclyde 1884 129.5 135.4 123.7 20.3 Total 18667

Table 15.12: Numbers and rates of elective in-patient and day-case admission to Geriatric Medicine by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 38 79.4 104.6 54.1 0.3 Glasgow North 39 101.5 133.3 69.6 0.4 Glasgow East 12 23.5 36.8 10.2 0.1 Glasgow South-east 8 23.0 38.9 7.0 0.1 Glasgow South-west 17 36.8 54.3 19.3 0.1 East Dunbartonshire 31 87.1 117.8 56.4 0.3 East Renfrewshire 10 31.5 51.0 12.0 0.1 West Dunbartonshire 30 80.8 109.7 51.9 0.3 Renfrewshire 46 71.7 92.5 51.0 0.3 Inverclyde 209 600.3 681.7 518.9 2.2 Total 440

Table 15.13: Numbers and rates of emergency admission to Geriatric Medicine by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 116 47.9 56.6 39.2 0.9 Glasgow North 65 35.0 43.5 26.5 0.6 Glasgow East 92 38.2 46.0 30.4 0.7 Glasgow South-east 246 133.8 150.6 117.1 2.5 Glasgow South-west 194 85.2 97.2 73.2 1.6 East Dunbartonshire 70 32.2 39.7 24.6 0.6 East Renfrewshire 303 150.6 167.5 133.6 2.8 West Dunbartonshire 90 46.0 55.5 36.5 0.8 Renfrewshire 974 277.7 295.2 260.3 5.1 Inverclyde 47 24.6 31.7 17.6 0.5 Total 2197

159

Table 15.14: Numbers and rates of elective in-patient and day-case admission to Gynaecology by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 1319 92.2 97.1 87.2 8.2 Glasgow North 955 91.5 97.3 85.7 8.1 Glasgow East 1126 92.4 97.8 87.0 8.2 Glasgow South-east 1096 106.8 113.1 100.5 9.5 Glasgow South-west 1347 124.7 131.3 118.0 11.1 East Dunbartonshire 750 85.1 91.2 79.0 7.6 East Renfrewshire 691 90.2 96.9 83.4 8.0 West Dunbartonshire 845 100.3 107.0 93.5 8.9 Renfrewshire 1706 108.5 113.7 103.4 9.7 Inverclyde 763 98.3 105.3 91.3 8.7 Total 10598

Table 15.15: Numbers and rates of emergency admission to Gynaecology by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 206 62.0 70.5 53.6 1.2 Glasgow North 250 99.6 111.9 87.2 2.0 Glasgow East 331 113.3 125.5 101.1 2.2 Glasgow South-east 214 93.7 106.2 81.1 1.9 Glasgow South-west 252 99.7 112.1 87.4 2.0 East Dunbartonshire 137 80.8 94.3 67.3 1.6 East Renfrewshire 163 109.1 125.8 92.3 2.2 West Dunbartonshire 180 99.6 114.2 85.1 2.0 Renfrewshire 484 148.2 161.4 135.0 2.9 Inverclyde 139 83.7 97.6 69.8 1.7 Total 2356

Table 15.16: Numbers and rates of elective in-patient and day-case admission to Neurosurgery by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 60.0 73.0 91.5 54.5 0.4 Glasgow North 77.0 120.5 147.5 93.6 0.7 Glasgow East 99.0 128.5 153.8 103.2 0.7 Glasgow South-east 59.0 95.6 120.0 71.2 0.5 Glasgow South-west 69.0 101.6 125.6 77.6 0.6 East Dunbartonshire 57.0 88.9 111.9 65.8 0.5 East Renfrewshire 54.0 97.5 123.5 71.5 0.6 West Dunbartonshire 49.0 90.4 115.7 65.1 0.5 Renfrewshire 107.0 102.6 122.0 83.1 0.6 Inverclyde 44.0 84.2 109.1 59.4 0.5 Total 675.0

160

Table 15.17: Numbers and rates of emergency admission to Neurosurgery by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 24.0 66.9 93.7 40.2 0.2 Glasgow North 26.0 91.1 126.1 56.1 0.2 Glasgow East 40.0 116.7 152.9 80.5 0.3 Glasgow South-east 33.0 124.4 166.8 81.9 0.3 Glasgow South-west 50.0 162.2 207.2 117.3 0.4 East Dunbartonshire 27.0 104.8 144.3 65.2 0.3 East Renfrewshire 19.0 84.5 122.5 46.5 0.2 West Dunbartonshire 16.0 67.3 100.3 34.3 0.2 Renfrewshire 44.0 100.7 130.5 71.0 0.3 Inverclyde 17.0 76.5 112.9 40.1 0.2 Total 296.0

Table 15.18: Numbers and rates of elective in-patient and day-case admission to Oncology by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 900 87.5 93.2 81.8 7.3 Glasgow North 769 96.3 103.1 89.5 8.0 Glasgow East 919 90.2 96.0 84.4 7.5 Glasgow South-east 811 99.4 106.2 92.5 8.2 Glasgow South-west 1149 123.9 131.0 116.7 10.3 East Dunbartonshire 856 76.1 81.2 71.0 6.3 East Renfrewshire 1100 116.1 122.9 109.2 9.6 West Dunbartonshire 638 78.4 84.4 72.3 6.5 Renfrewshire 2361 144.8 150.6 138.9 12.0 Inverclyde 369 46.2 50.9 41.5 3.8 Total 9872

Table 15.19: Numbers and rates of emergency admission to Oncology by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 87.0 164.9 199.6 130.3 0.7 Glasgow North 59.0 144.9 181.9 107.9 0.6 Glasgow East 55.0 104.5 132.2 76.9 0.4 Glasgow South-east 30.0 70.1 95.2 45.0 0.3 Glasgow South-west 33.0 68.9 92.4 45.4 0.3 East Dunbartonshire 45.0 93.4 120.7 66.1 0.4 East Renfrewshire 30.0 72.9 99.0 46.8 0.3 West Dunbartonshire 58.0 130.8 164.4 97.1 0.5 Renfrewshire 79.0 97.0 118.3 75.6 0.4 Inverclyde 20.0 48.3 69.5 27.1 0.2 Total 496.0

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Table 15.20: Numbers and rates of elective in-patient and day-case admission to Ophthalmology by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 1087 108 115 102 8 Glasgow North 773 95 102 88 7 Glasgow East 1147 108 115 102 8 Glasgow South-east 837 110 117 102 9 Glasgow South-west 1226 129 136 122 10 East Dunbartonshire 812 92 99 86 7 East Renfrewshire 670 87 93 80 7 West Dunbartonshire 661 85 91 78 7 Renfrewshire 1273 89 93 84 7 Inverclyde 779 103 110 95 8 Total 9265

Table 15.21: Numbers and rates of emergency admission to Ophthalmology by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 56.0 113.8 143.7 84.0 0.4 Glasgow North 42.0 104.7 136.4 73.0 0.4 Glasgow East 48.0 96.8 124.2 69.4 0.3 Glasgow South-east 44.0 116.7 151.2 82.2 0.4 Glasgow South-west 53.0 121.9 154.7 89.0 0.4 East Dunbartonshire 39.0 113.2 148.8 77.7 0.4 East Renfrewshire 34.0 110.4 147.5 73.3 0.4 West Dunbartonshire 32.0 91.7 123.5 59.9 0.3 Renfrewshire 45.0 70.9 91.6 50.2 0.3 Inverclyde 28.0 83.4 114.3 52.5 0.3 Total 421.0

Table 15.22: Numbers and rates of elective in-patient and day-case admission to Neurology by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 114 81.0 95.8 66.1 0.8 Glasgow North 81 75.2 91.6 58.8 0.7 Glasgow East 151 116.9 135.5 98.2 1.1 Glasgow South-east 95 89.4 107.3 71.4 0.9 Glasgow South-west 147 128.1 148.8 107.4 1.3 East Dunbartonshire 94 83.2 100.1 66.4 0.8 East Renfrewshire 120 123.9 146.1 101.7 1.2 West Dunbartonshire 65 70.0 87.0 53.0 0.7 Renfrewshire 211 116.0 131.6 100.3 1.1 Inverclyde 88 98.0 118.4 77.5 1.0 Total 1166

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Table 15.23: Numbers and rates of emergency admission to Neurology by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 19.0 95.2 138.0 52.4 0.1 Glasgow North 7.0 45.8 79.8 11.9 0.1 Glasgow East 20.0 109.0 156.8 61.2 0.2 Glasgow South-east 24.0 158.9 222.5 95.3 0.2 Glasgow South-west 31.0 183.5 248.1 118.9 0.3 East Dunbartonshire 17.0 101.4 149.6 53.2 0.1 East Renfrewshire 17.0 118.3 174.6 62.1 0.2 West Dunbartonshire 12.0 90.9 142.4 39.5 0.1 Renfrewshire 19.0 74.1 107.4 40.8 0.1 Inverclyde 8.0 64.5 109.2 19.8 0.1 Total 174.0

Table 15.24: Numbers and rates of elective and day-case admission to Orthopaedics by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 1161.0 103.3 109.3 97.4 8.7 Glasgow North 811.0 93.5 99.9 87.1 7.8 Glasgow East 984.0 91.4 97.1 85.7 7.7 Glasgow South-east 703.0 80.6 86.6 74.6 6.7 Glasgow South-west 1140.0 117.2 124.0 110.4 9.8 East Dunbartonshire 986.0 101.4 107.7 95.1 8.5 East Renfrewshire 724.0 86.7 93.0 80.4 7.3 West Dunbartonshire 1008.0 122.7 130.3 115.1 10.3 Renfrewshire 1719.0 110.1 115.3 104.9 9.2 Inverclyde 740.0 94.3 101.1 87.5 7.9 Total 9976.0

Table 15.25: Numbers and rates of emergency admission to Orthopaedics by CHCP

CHCP Admissions SAR ULCI SAR LLCI SAR Standardised rate Glasgow West 955.0 82.2 87.4 77.0 6.6 Glasgow North 684.0 73.0 78.5 67.6 5.8 Glasgow East 905.0 78.7 83.8 73.6 6.3 Glasgow South-east 1162.0 134.0 141.7 126.3 10.7 Glasgow South-west 1350.0 131.9 139.0 124.9 10.6 East Dunbartonshire 642.0 82.1 88.4 75.7 6.6 East Renfrewshire 721.0 103.2 110.8 95.7 8.3 West Dunbartonshire 820.0 103.3 110.4 96.2 8.3 Renfrewshire 1542.0 109.0 114.5 103.6 8.7 Inverclyde 760.0 100.9 108.1 93.8 8.1 Total 9541.0

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APPENDIX 18 - Healthcare provided by the independent Sector

Table 18.1 Healthcare activity obtained by West Dunbartonshire residents in the independent healthcare sector in 2005 and 2006, by region within West Dunbartonshire. Provided by Ross Hall, Glasgow and Nuffield hospitals, Glasgow. NA refers to the fact that the Nuffield hospitals does not record the number of medical outpatients. This means that the number assigned a + sign is the minimum figure and would be augmented by the number of medical outpatient contacts.

2005 Area of residence Hospital Medical Medical IP Medical Surgical OP Surgical IP surgical Total patient OP Daycase Daycase contacts Vale/Dumbarton Ross Hall 138 4 1 16 37 43 239 Vale/Dumbarton Nuffield NA 0 0 34 48 37 119+ hospitals Vale/Dumbarton Both 138+ 4 1 50 85 80 358+ hospitals

Clydebank Ross Hall 97 18 0 7 21 27 170 Clydebank Nuffield NA 6 12 60 60 53 191+ hospitals Clydebank Both 97+ 24 12 67 81 80 361+ hospitals

West Dun Both 235+ 28 13 117 166 160 719+ hospitals

164

2006 Area of residence Hospital Medical Medical IP Medical Surgical OP Surgical IP surgical Total patient OP Daycase Daycase contacts Vale/Dumbarton Ross Hall 153 10 6 23 34 39 265 Vale/Dumbarton Nuffield NA 0 1 60 47 49 157 hospitals Vale/Dumbarton Both 153+ 10 7 83 81 88 422+ hospitals

Clydebank Ross Hall 72 3 3 14 16 18 126 Clydebank Nuffield NA 44 6 47 56 49 202+ hospitals Clydebank Both 72+ 47 9 61 72 67 328+ hospitals

West Dun Both 225+ 57 16 144 153 155 750+ hospitals

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APPENDIX 19 - Transport and Access

Figure 19.1 Scottish league table by council of percentage with no car ownership at the time of the 2001 census.

60.0 50.0 W. Dun: 43.22%, 17,626 households 40.0 30.0

20.0 10.0 0.0 Aberdeenshire Dun East Shetland Is & Kin Perth Stirling & Gall Dumf E Lothian Midlothian S Ayrshire Falkirk E Ayrshire SCOTLAND N Lanarkshire Edinburgh Dun West Glasgow C Fife % of households with no car with households of %

Council

166