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ANNUAL REPORTof the Director of Public Health 2002/2003
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If you would like:
• additional copies of People in Partnership
• this information in large print, Braille, audio tape or another language
• more information on issues and initiatives which are mentioned
• to fi nd out how to ‘get involved’
• to give us your views on this publication
please contact:
Shaunagh KirbyCorporate CommunicationsWest GateAberdeen Royal Infi rmaryForesterhillAberdeen AB25 2ZNTel: 01224 558814email: [email protected]
People in Partnership is also available online at www.nhsgrampian.org (click on publications)
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CONTENTSINTRODUCTION......................................................................................................................... 4
STRATEGIC OBJECTIVES............................................................................................................. 6 FORCES AND DRIVERS ............................................................................................................... 8 Early Years .......................................................................................................................... 8 Childhood Immunisation .......................................................................................... 8 Antenatal/Neonatal Screening .................................................................................. 8 Breastfeeding............................................................................................................ 8 Child Health Surveillance .......................................................................................... 9 Special Needs ........................................................................................................... 9
Teenage Transition.............................................................................................................. 9 SMS........................................................................................................................ 10 Tobacco.................................................................................................................. 11
The Workplace .................................................................................................................. 11
Communities..................................................................................................................... 12 Health Experience................................................................................................... 13 Healthcare Services ................................................................................................. 14 Protection of Health................................................................................................ 14 Alcohol and other Drugs......................................................................................... 17 Cancer.................................................................................................................... 17 Coronary Heart Disease .......................................................................................... 17 Mental Health......................................................................................................... 18 Food and Health ..................................................................................................... 19 Dental Health ......................................................................................................... 19 Health and Homelessness........................................................................................ 20 Social Inclusion ....................................................................................................... 20 Conclusion ............................................................................................................. 20
CHALLENGES............................................................................................................................ 21 Making it Happen.................................................................................................................21 Fit for Purpose ......................................................................................................................22 Resources ..............................................................................................................................22 The Way Forward .................................................................................................................23
REFERENCES ............................................................................................................................. 23
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This report is made to the three local authorities, Aberdeen City, Aberdeenshire and Moray, whom I serve as Designated Medical Offi cer, as well as to Grampian NHS Board.
The aim of this document is to provide a useful basis for planning the action we need to take jointly to improve health and healthcare in Grampian. However, this is different to Grampian NHS Board’s Annual Report and the Grampian Health Plan in that it gives a personal view, focusing on the population aspects of health and healthcare. It aims to inform and involve both professionals and public, particularly in terms of shaping priorities for the future. While essentially local, it must also be set in the context of Scotland’s health, and national policy and strategy.
The past year, 2002/2003, has been a year of major change, particularly in the NHS. This has involved the NHS in Grampian, as in all other areas of Scotland. The Scottish Executive’s White Paper,
Partnership for Care1 signalled major change in NHSScotland, and in how it works with its partner organisations.
The aims of Partnership for Care are “the promotion of health and the creation of a health service fi t for the 21st century”. The focus is on delivering this through partnership with patients, using national standards to ensure integrated, quality healthcare services, designed around the needs of the individual. In Grampian we had already been changing in anticipation of the publication of this signifi cant policy document. I hope that this report illustrates how we are gearing up for the challenges which undoubtedly lie ahead.
Although this may appear very similar to a number of corporate documents produced by NHS Grampian, it is actually very different. My Annual Report is not a corporate document as such, but a personal review of the health of the people of Grampian over the past year, and an attempt to look forward to the way health could change locally.
INTRODUCTIONWELCOME TO MY ANNUAL REPORT FOR 2002/2003
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In this report I have sought to examine the factors that have affected progress towards these long-term goals over the past year - the so-called ‘forces and drivers’ - and the challenges to delivering these long-term goals. I also look forward to what, in my professional judgement, are some of the important issues for the next few years. By virtue of its very nature, a report of this type can be neither comprehensive nor exhaustive. If this report does nothing other than provoke debate and discussion about health and wellbeing in Grampian it will have gone a long way to achieving its purpose.
The production of this report has, as always, been a team effort. I wish to thank all members of the Public Health Unit for their signifi cant efforts over the past year, and our many colleagues in NHS Grampian, Aberdeen City Council, Aberdeenshire Council and The Moray Council without whose help this report would not have been possible.
This report is also available on the NHS Grampian website
www.nhsgrampian.org
If you would like:
• additional copies of this report
• this information in an alternative format (eg. large type, audio, Braille or another language)
• other documents referred to in this report
• more information on specifi c issues and initiatives
• to give us your views
• to fi nd out how to ‘get involved’ in helping improve health and services in Grampian....
Please contact:
Corporate CommunicationsWest GateAberdeen Royal Infi rmaryForesterhillAberdeen AB25 2ZNTel: 01224 554400email: [email protected]
It is not possible in this report to detail all activity or examine every issue in detail, and, as always, I must take responsibility for any errors of omission or commission.
DR ERIC BAIJALDirector of Public Health
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NHS Grampian believes that people in Grampian deserve the best health possible. To make our contribution to this, we need to realise our vision of an integrated, connected and collaborative health system, working together to ensure that we:
• sponsor and support the promotion of health
• infl uence and work effectively with our partner organisations to improve the wide range of factors which infl uence health
• develop health services to maximise opportunities for health gain.
I am pleased to report that these aspirations are refl ected in the visions of our three local Community Planning Partnerships:
Our joint strategic objectives are shaped by national policy. A number of important national policy documents were published in 2002. In addition to Partnership for Care, mentioned above, these included the proposed new national contract for GPs, and importantly, Improving Health in Scotland: the Challenge2.
This latter policy document focuses on actions to deliver a direct improvement in the health of the Scottish population. Helpfully, it groups the national priorities into four main themes: Early Years, Teenage Transition, The Workplace, and Communities. These themes have become known as the ‘Focus on Four’. This report will illustrate how these national priorities are also priorities for Grampian. They are not however the only - or most important - health priorities for Grampian, as I suggest later in this report.
Ensuring that we all agree on the health priorities for Grampian requires NHS Grampian to engage in active debate, not only internally, but with all our partner organisations and communities.
Developing an explicit process - involving the NHS Board - to confi rm our local health priorities is fundamental to developing the Local Health Plan for Grampian. I hope that this report will be a useful building block in the process.
Over the past year, NHS Grampian and its partners have sought to deliver on a number of strategic objectives to move us towards the vision of a healthy Grampian.
“The city will be known as a place of good health and social wellbeing, where we promote healthy communities and target inequalities”
(Aberdeen City)
“Achieving a better quality of life for everyone in Moray”
(Moray)
“Working together for the best quality of life for everyone in Aberdeenshire”
(Aberdeenshire)
SECTION ONESTRATEGIC OBJECTIVES
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The Grampian Health Plan has three main strategic planks: improving health, planning for a progressive health service, and developing the health workforce. The Health Plan for 2003/043 identifi es actions to help us locally ‘Focus on Four’. The Health Plan for next year needs to do not only the same, but also focus on action on all the local health priorities which we have agreed following the transparent, explicit process of engagement with the stakeholders mentioned above. This will also help us to develop Joint Health Improvement Plans local to each council area, and service plans for specifi c groups in our population. Although having a sense of strategic direction is necessary, it is not suffi cient alone to deliver effective health improvement. NHS Grampian and its partner local authorities also need to demonstrate that they are ‘public health
organisations’ which are fi t for purpose, and which work in partnership with the public they serve.
Change in any organisation is always challenging, requiring not only changes in infrastructure, but also in culture, and in embracing new ways of working when there is evidence that they will better achieve our goals. To gain an objective assessment of our progress, NHS Grampian sponsored an independent evaluation of our journey through organisational change by a researcher from NHS Health Scotland. The leadership of NHS Grampian is to be congratulated on its bravery in sponsoring this evaluation of the current organisational change. We hope that the fi ndings from this work - which were shared with our partners - help us jointly to make a reality the ‘step-change’ in health that we are committed to achieving for our population.
! RECOMMENDATION: NHS Grampian should lead an active debate with its partner organisations and public to agree health priorities for Grampian.
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In this section I review progress in improving health in Grampian under the broad headings of ‘Focus on Four’ - the themes from Improving Health in Scotland: the challenge.2 We have identifi ed a number of milestones along the road to achieving our vision, which refl ect national targets.
EARLY YEARSThis theme is about creating an integrated programme of health improvement in the early years of life. Experiences in early childhood, from conception (when the health of parents is important) infl uence health throughout life in a signifi cant way. Areas of progress over the past year have included screening and nutrition.
Childhood ImmunisationI remain gravely concerned about the uptake of childhood immunisation in Grampian. The percentage uptake of MMR at age two for Grampian resident children was 88.8% at the end of March 2002, contrasting with 97.2% in December 1996. At the end of March 2003 it was 86.8%. The national target is 95%, which is the level we need to prevent the epidemic cycle. I therefore urge all parents and clinicians
working with families to ensure that children are immunised to protect them from measles (which is still a potentially fatal condition in Britain), prevent the problems of congenital rubella, and the unnecessary suffering, hospitalisation, and sometimes serious complications of mumps. I will continue to lead action to remedy this situation.
Antenatal/Neonatal ScreeningNHS Grampian implemented antenatal HIV screening in November 2002. Initial reports suggest that 90% of pregnant mothers in Grampian are agreeing to this test.
Screening of neonatal babies for cystic fi brosis began in February 2003, and has already identifi ed a baby likely to develop this condition. We expect this test to help us identify early 2-3 such babies every year, and another 2-3 who are carrying the gene for this condition.
We are currently working on plans to introduce what is known as the universal hearing test for neonatal babies, and eye tests for four year-olds. However, in our current fi nancial situation, every proposed new development must be compared with others to determine priorities.
BreastfeedingGood progress is being made in taking forward priority actions in the Grampian Breastfeeding Strategy4. This has included better help and
! RECOMMENDATION: NHS Grampian and its partner organisations should support action to redress the decline in the uptake of childhood immunisation.
SECTION TWOFORCES AND DRIVERS
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support for breastfeeding mums, such as the Banff and Buchan Breastfeeding Coaching Project. This offers new mums the benefi ts of being ‘coached’ by other mums who are experienced breastfeeders. Further training initiatives and support for midwives and health visitors are also underway, and a second edition of the directory Where to breastfeed in Grampian has been produced due to popular demand.
I am concerned that, despite my recommendation in previous reports, NHS Grampian has not yet implemented the national child health computer system adequately to allow meaningful monitoring of breastfeeding rates. This is important, because evidence shows beyond doubt that breastfeeding is one of the most important, health promoting and illness-preventing measures we can take for our children. We know that there is a wide difference in rates between the more affl uent and deprived communities in Grampian, but this system would help us target our efforts more effectively.
Child Health SurveillanceA guidance manual has been produced for health visitors and GPs delivering the Pre-school Child Health Surveillance programme, which is in line with the national policy document Health for All Children (Hall 4)5, the latest guidance on best practice in this fi eld. At the same time, we await the outcome of the national review on this issue.
Children with Special NeedsInitial work has commenced on the ‘early years’ component of the planned Child Health Strategy for Grampian. A review of services for children with special needs has been conducted by Capability Scotland. This is being followed by review of pre-school services for children with special needs with a focus on Aberdeen City.I am pleased to report that this is very much a partnership between health, education and social work.
TEENAGE TRANSITIONThe years from the early stages of secondary school education and adolescence to adulthood are a time of great change, and a time when young people are subject to major external infl uences. Locally we want to create a set of circumstances where young people feel supported to the extent that they fulfi l their potential, maintain self-esteem, and avoid a wide range of health-damaging behaviours and other hazards. This approach requires specifi c strands dealing with issues like smoking, drugs, sexual health, alcohol, mental health and well-being, diet and physical activity. However, we want to do much more than the sum of these individual component parts.
Schools, in partnership with the home and community, can make a difference to the health-related behaviour of young people.
The concept of the Health Promoting School is central to the national New Community Schools initiative6. Within Health Promoting Schools, not only is health education integral to the curriculum, but the school ethos, policies, services, extra-curricular activities and partnerships foster mental, physical and social well-being and healthy development. The health input to the initiative is crucial. New or Integrated Community Schools, as they are now known, have the twin aims of raising attainment and improving what we call social inclusion. A key element of this is to deliver integrated services for pupils and their families.
I am pleased to report that NHS Grampian’s three partner local authorities have taken an active approach to the rollout of the Integrated Community School model locally.
Recognising the value of the existing health improvement work, in Peterhead and Turriff, Aberdeenshire intends to commit New Community Schools funding for three new health posts, alongside the two existing posts. These workers will provide direct support to
! RECOMMENDATION: NHS Grampian must implement a system to allow meaningful monitoring of breastfeeding rates.
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whole school communities in taking the Health Promoting School initiative forward in the Fraserburgh, Banff, Oldmeldrum, Portlethen and Laurencekirk areas.
In Aberdeen City, training developed by NHS Grampian to help schools become Health Promoting Schools has been accessed by virtually all schools. The roll out of Aberdeen Futures7 (the Aberdeen City Community Plan), will provide more opportunity to strengthen partnership-working and health improvement within the three neighbourhood areas.
The Moray Council has been a consistent supporter of the Health Promoting School concept. The appointment of a dedicated health improvement worker to help schools to work towards becoming health promoting, illustrates the Moray commitment. The New Community Schools model was rolled out to all schools in Moray in 2002, and all 54 schools in Moray are engaged in activity to improve health.
Improving health within the school setting is a fundamental drive locally and nationally, with the Scottish Executive requiring all schools in Scotland to be Health Promoting Schools by 2007. We continue to work with school health service colleagues (who have a statutory responsibility for health in schools), in addition to our community planning partner organisations, to maximise our collective effort to improve health for our young people and their families.
Give Kids a ChanceGive Kids a Chance8 is a component of the work undertaken by NHS Grampian under the headings of Teenage Transition and Communities, recognising that improving the health and wellbeing of young people requires both good self-esteem and strong personal skills. Helping our most vulnerable young people in Grampian requires partner organisations to work together to share resources, knowledge and expertise.
This is just what has happened with Give Kids a Chance. Partners have come together to identify and support young people, and provide the funding to introduce them to social and
leisure activities. While NHS Grampian has taken the role of lead partner to co-ordinate the scheme, funding has been provided by private sector partners such as Shell UK Exploration & Production, The Wood Group, Stena Drilling, Ledingham Chalmers and Scotoil. Community Safety Partnerships in the three local authority areas of Grampian have also supported the project, including a grant of £25,000 from the Aberdeen City Common Good Fund. Individuals have also contributed to the project by organising their own fundraising events, and eight volunteers offer their time, skills and experience in coaching and providing transport.
Give Kids a Chance aims to encourage and support vulnerable young people to develop and sustain interests and hobbies which will divert them from negative pastimes, such as alcohol or drug misuse, or anti-social behaviour. Young people are nominated for a place on the scheme by community workers and social workers in the Aberdeen City areas of Tullos/Torry, Kincorth, Seaton, Fersands/Printfi eld, Middlefi eld, Powis and St Machar.
Give Kids a Chance also operates in Fraserburgh, Peterhead and Moray. In these areas, wider networks of professionals meet together to prioritise nominations to the scheme.
SMSSMS is a young people’s drop-in, funded by the Health Improvement Fund, which opened its doors to the young people of Moray on 1 June 2002. A variety of services and support are on offer from one-to-one and group advice on all lifestyle topics including alcohol, drugs, smoking, STI/sexual health, exercise, healthy eating, and stress. The drop-in offers an adapted family planning service, staffed by a family planning doctor, specialist nurse and health information assistant, open for two hours each Saturday afternoon.
The service has been tailormade by young people, for young people, and this is refl ected in the 309 boys and 340 girls who have used the service so far, and the positive feedback they have given. Young people were involved in all aspects of the project from initial planning to the advertising campaign and the recruitment and
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selection of staff. The age range of the young people ‘dropping-in’ is from 13-19, the young people coming either individually or in single sex or mixed groups, which seems to give them the added confi dence to ask for advice.
TobaccoThe Grampian Tobacco Alliance Network supports our colleagues in Trading Standards in reducing access to age-restricted products. Trading Standards departments are the obvious lead organisations, and close networking between the three Grampian departments exists, monitoring progress, and keeping abreast of developments on a national and local level. Local activity is reported to the relevant council committees, and communicated more widely through the Grampian Tobacco Alliance Network. I am pleased to note that Moray has become a test site for the Lord Advocate’s review of guidelines on the sale of tobacco to children.
Moray has also become a pilot site for the ASH Scotland and NHS Health Scotland projects specifi cally designed to help young people stop smoking, with local young people actively involved in developing the three-year funded Fag Break initiative.
National developments mean there is now a way of providing Nicotine Replacement Therapy (NRT) to young people. Grampian’s Smoking Advice Service added a community pharmacy service in January 2003 which has helped people of all age groups who want to stop smoking to use NRT and other aids to giving up.
Addressing smoking is also incorporated into general youth work. For example, the Mobile Information Bus (MIB), - which involves a partnership between NHS Grampian, Moray and Aberdeenshire Councils, and also involves youth and other local services - provides advice and help for young people in relation to smoking.
To support staff and volunteers who work with young people on the issue of smoking, specialist ‘young people and tobacco’ training has been developed by NHS Grampian, with input from young people themselves. Over 2002/2003 a total of 33 delegates attended, including workers
from other areas in Scotland who are involved in the ASH Scotland/Health Scotland young people pilot projects.
Supported by the three Grampian local authorities, a Health Promoting School resource pack was produced on tobacco and supplied to all schools in Grampian. The pack was developed with the help of staff from all sections of the school community and topic advisors.
THE WORKPLACEThe workplace setting is a major opportunity for health improvement. Part of our strategy for health improvement must be to ensure that individuals maintain healthy lifestyles throughout adult life, are not made ill by their work, have access to programmes and services aimed at maximising their functional capacity, are able to continue to be economically active, enjoy good physical and mental health, and remain independent for as long as possible.
With an ageing population (see page 13), improved business growth and performance will depend in part on our ability to improve the health of the workforce, and to maintain and increase the number of people in employment. Promoting good mental health in the workplace is vital. This includes supporting job retention for people who develop mental health problems at work, and securing more and better employment opportunities for people with mental health problems or who have experienced mental health problems. Some key linkages are set out in The Way Forward - Framework for Economic Development in Scotland9:
• Working age people suffer from high levels of heart disease, cancer, diabetes and respiratory disease. If we were able to make an impact on these diseases, it would go a long way to addressing the relatively poor life expectancy of people in Scotland compared with the rest of the UK and Europe.
• The workplace is an ideal setting not just for interventions that protect the workforce
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from hazards but also to prevent ill-health and promote good health.
• Occupational health services and employer organisations have a key role in supporting these interventions and providing clinical assessment and care. However, not all employees across Scotland have access to an occupational health service.
• Our systems for rehabilitation, job retention and helping people return to work are less well developed than in many comparable countries. Occupational therapists, physiotherapists and employers can play a leading role in improving this situation.
In the past, health in the workplace was primarily focused on preventing accidents and injuries. This remains important, with continuing progress being maintained through UK health and safety legislation and the work of the Health and Safety Executive. More recently, progress has been made in other areas. For example, the Working Time Directive makes it possible for employees to decline to work excessive hours, thereby protecting their physical and mental health.
Grampian is in the vanguard of such work, with NHS Grampian hosting the management of the national Scotland’s Health at Work scheme (SHAW)10. NHS Grampian’s workplace programme adopts a business approach to engaging with employers in Grampian, using Scotland’s Health at Work as the basis for all workplace health activity.
In 2002/2003, the focus was on the small business sector. Seventy-two new Small to Medium sized Enterprises (SMEs) were recruited onto the SHAW scheme, and a number of very successful workshops were delivered.
Locally the scheme now covers almost 40% of the Grampian working population, which is close to the national target. Of participating employers, 60% have achieved an award. Large employers have been encouraged to act as mentors for small businesses and voluntary sector organisations with considerable success. Community Planning partner organisations are also being encouraged to lead by example in relation to workplace health
and achieving SHAW awards. One excellent outcome so far is the sharing of good practice in relation to developing drug and alcohol policies, using the SHAW standard as a benchmark.
NHS Grampian’s role in managing the scheme on a national basis involves providing leadership and direction to SHAW staff across the other 14 NHS Boards. Thirty-one new staff were recruited across Scotland in 2002/03 as a direct result of additional funding from the Scottish Executive.
Grampian’s Smoking Advice Service provides support for all employees in Grampian who want help to stop smoking. Eighteen local workplaces have had site-specifi c stop-smoking groups established and staff can also join community-based groups in their own local area.
NHS Grampian supports the national No Smoking Day every March as a useful public awareness initiative, and distributes information about this to all local workplaces registered on the workplace team’s Resources Direct scheme.
Training and support is also provided for developing workplace policies on tobacco, as part of the SHAW programme.
For NHS Grampian staff, following the launch of the NHS Grampian Tobacco Policy, full details of smoking cessation support are provided for all staff, (including helplines, websites, local and national assistance) as part of the policy leafl et developed with full involvement of staff, union representatives, and the NHS Grampian staff and management partnership forum. Following the expansion of the smoking cessation service into hospital sites, staff have been given even greater fl exibility to attend sessions.
COMMUNITIES
There are a number of forces and drivers which are important infl uences on the health of the public of Grampian. The communities we live in have a considerable infl uence on our health. The inequalities that exist between the health of the worst-off and the health of the better-off within our communities are widely recognised.
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in Grampian compared with almost 7% across Scotland. In the same period, the proportion of ethnic groups in the Grampian population has almost doubled, from 0.87% to 1.63% although still comparatively small. Direct comparison of the numbers in each group is diffi cult because of the introduction of extra categories in 2001 (namely, ‘Black Scottish/Other Black’ and ‘Any Mixed Background’). However, it is apparent that residents from the Indian sub-continent have more than doubled, as have those from Africa or the Caribbean, while the increase in Chinese and other South Asian people has been more moderate. Most of the ethnic population live in Aberdeen City, as the following table of percentage ethnic population in each area shows:
Community Planning is a multi-agency process - led by the local authorities - which has the potential to improve life circumstances, and consequently health and wellbeing. For Community Planning to realise its full potential, there needs to be what we call ‘active citizenship’ on the part of the community concerned, such that it is actively involved and engaged with the agencies to shape plans which are jointly produced.
In this context, the social geography of Grampian is signifi cant. We have ‘communities of interest’, as well as natural geographic communities. There is a natural division between ‘town and county’. Conventionally, household car ownership is often used as an indicator of deprivation or affl uence. However, a car is especially important for people living in rural areas, and car ownership is strongly linked with ‘rurality’. The 2001 Census11 shows a continued trend towards high levels of household car ownership, particularly in rural areas. Aberdeenshire now has the highest level in Scotland, 82%, compared with Moray, 76%, Aberdeen City, 66%, and Scotland overall, 66%. Aberdeenshire also has the highest ratio of vehicles to households.
There is a general increase in the older population in Grampian as a whole, with 15% of the population aged over 65, compared with 16% of the Scottish population. This proportion is expected to rise to 18% by 2031. If this projection holds good, what is known as the ‘dependency ratio’ (the number of economically active individuals per thousand of the total of children and adults over 64), will fall signifi cantly by 2016.
We need to superimpose on these general trends a declining birth-rate, an older population particularly in rural areas, and population shifts within the three local authority areas in Grampian. Aberdeen City expects to see a 7% reduction in population by 2031, while we expect a 3% increase in Aberdeenshire, and around a 3% reduction in Moray over the same period.
Social structure is also changing. Between the 1991 and 2001 Censuses, lone-parent families with children aged 0-15 years increased by 50%, so that these are now almost 5% of all households
Home ownership in Grampian has risen from just over 56% of households being owner-occupiers in 1991 to almost 66% in 2001.
The major shifts within the local economy are documented elsewhere12. The traditional industries of the North-East are now minority employers, having become overshadowed by the service sector.
Health ExperienceThe health experience of the local population is also changing. For the fi rst time, the 2001 Census included a question about general health. Grampian had the second healthiest population (after Orkney), with 72% of people reporting good health, and only 7.5% reporting that their health was “not good”. Aberdeenshire was particularly healthy, with 73.6% of people having good health, second only to East Renfrewshire (74%) amongst Scottish local authorities. There has been a major increase in the number of people describing themselves as having a
Area 1991 2001 Census Census
Aberdeen City 1.46% 2.90%
Aberdeenshire 0.47 0.71
Moray 0.43 0.87
Grampian 0.87 1.63
Scotland 1.3 2.01
Area 1991 2001 Census Census
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limiting long-term illness. This has risen from 10.8% of the Grampian population in 1991 to 16.4% in 2001, a proportionate increase of over 50%. Scotland as a whole has seen the same proportionate rise. It is diffi cult to believe that there has been such a great deterioration in the health of the population in just 10 years, and the cause may be due to a slight change in the question asked on the Census form, where the word ‘handicap’ in 1991 was replaced by ‘disability’ in 2001.
Moray and Aberdeenshire saw greater proportionate rises in long-term illness than did Aberdeen City, but the three council areas maintain the same ranking order as in 1991:
We have more to learn about these changes, as the fi rst detailed breakdown of Census information by health board and council area was only released in mid-February 2003.
Healthcare ServicesWhile it is important for public health organisations in Grampian to share a strategy for improving health, it is crucial that NHS Grampian leads on the development of strategy for healthcare services. I am pleased to report that over the past year the Director of Corporate Planning for NHS Grampian has continued to lead a very successful process for the development of strategy for healthcare services. This has become known as the HealthFit process13. This approach to planning is open and transparent and inclusive of all those who have a stake in clinical services, including representatives of the public.
From this work has evolved a vision of healthcare in Grampian over the next fi ve to ten years. The strategy focuses on integrated networks of care with hospital-based acute services at the hub. Clearer defi nition of specialist services will enable the development of new intermediate care services provided jointly by primary and secondary care clinicians. These services will provide for patients who require more support than normally provided at GP practice level but who do not require the specialist services of acute hospitals. The development of ‘Diagnostic and Treatment Centres’ will allow rapid patient access to such innovation, balancing the need to provide clinically safe services with local convenience and accessibility. My sense is that this strategy has widespread support from the clinical community. Clearly it is important that it is taken forward, and translated into action plans which are implemented despite the challenging fi nancial context for NHS Grampian.
The Protection of HealthWorking closely with environmental health colleagues and other partners, NHS Grampian has a key role to play in protecting the population from hazards which could damage their health. This includes essential activity such as protecting children from vaccine-preventable diseases (childhood immunisation), and addressing bloodborne viruses, sexually transmitted infections and healthcare associated infections. In addition to these local priorities, the issue of bioterrorism is one that is unavoidably high on the agenda for the foreseeable future and which will require a continued programme of awareness and preparation.
Severe Acquired Respiratory Syndrome (SARS)The fi rst global SARS alert was issued on 12 March 2003. At that point we asked GPs to notify all suspected cases, ensure infection control measures (including examining patients at home rather than in surgery) and inform the hospital before referring any suspected case. The Ambulance Service was alerted, and GPs were, from time
!RECOMMENDATION: NHS Grampian should progress the reorganisation of services provided to communities to implement the model of healthcare based on a network of Diagnostic and Treatment Centres, with specialist acute services at their hub.
Area 1991 2001 Census Census
Aberdeen City 12.5% 17.5%
Aberdeenshire 9.5 15.3
Moray 10.1 16.7
Grampian 10.8 16.4
Scotland 13.7 20.3
Area 1991 2001 Census Census
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to time, advised to access the website of the Scottish Centre for Infection and Environmental Health (SCIEH) for updates. In Grampian, our fi rst notifi cation was in mid-March 2003, of an Orkney resident who developed respiratory symptoms suggestive of SARS on return from Hong Kong. Fortunately, this was subsequently not confi rmed to be SARS.
The NHS Grampian Health Protection Team is currently working with hospital, primary care and port health staff to prepare an NHS Grampian SARS management plan, based on draft guidance from the Scottish Executive Health Department. A surveillance and contact tracing database has already been created, based on national guidance.
Bloodborne VirusesBloodborne viruses (HIV, hepatitis B and hepatitis C) continue to be a local priority in Grampian, because we have had high rates of hepatitis B, we have an increasing prevalence of hepatitis C, and a small, but increasing, number of people with HIV.
At June 2002, 1,708 people had been identifi ed with hepatitis C in Grampian, and 73% were associated with a history of injecting drug use. This gives Grampian the second highest rate of people diagnosed as HCV antibody-positive in Scotland, second only to Glasgow. The cost of treating and caring for these people has signifi cant fi nancial implications for NHS Grampian. Although recent outbreaks of hepatitis A and B are now over, prevention activities must continue.
The incidence of HIV continues to rise14. The quest for an HIV vaccine has been fraught with diffi culty. Although recent trials yielded encouraging information, there is still much to learn before an effective vaccination is developed. Our most effective weapon remains prevention. Prevention of infection, and the consequences of HIV, must rely on continually raising awareness about HIV, with particular reference to promoting safer sex and preventing the sharing of injecting equipment. There have been various approaches adopted in Grampian to promote this message both formally and informally.
HIV statistics should be interpreted with caution, as information is only available on people who have
opted to be tested. Due to a variety of reasons, some people are either unaware of their infection or do not choose to be tested. Accordingly, statistics will not refl ect the whole picture.
During the period April 2002 to March 2003, 15 new cases of HIV were diagnosed in Grampian. Twelve of these cases were attributed to heterosexual transmission, two to sexual intercourse between men (MSM), and one to injecting drug use. The last few years have seen a dramatic shift from homosexual to heterosexual transmission. In 2002/03, 80% of all new infections were heterosexually-acquired, compared to 74% in 2001/02, 50% in 2000/01 and 27% in 1999/00. Figure 1 illustrates this.
Of those who have acquired the infection heterosexually, the majority have become infected abroad, as opposed to the homosexuals who have mainly acquired their infection within the UK. This mirrors other areas of Scotland. Since 1996/97, of the 61 individuals who have acquired HIV heterosexually, 67% were imported cases, 23% acquired the infection within the UK, whilst the country of infection for the remaining 10% is unknown. Of the 41 imported HIV infections 30 (73%) acquired their infection in Africa, 3 (7%) in Asia, 4 (10%) in Thailand, 1 in the Caribbean, 1 in Europe (see Figure 2). The number of women infected heterosexually has slightly increased compared to previous years to 44% of those infected heterosexually.
At March 2003, the cumulative total of reported HIV cases in Grampian was 214, of whom 151 are still alive. No new cases of AIDS were diagnosed and no-one died from AIDS during the reporting period, but there are six people known to be living with AIDS in Grampian. Improvements in anti-retroviral treatments have delayed progression from HIV infection to AIDS, and, whilst these changes are encouraging, they also mean that more patients will require long-term care in the future.
Grampian has not only seen a general increase in the incidence of bloodborne viruses but also in drug use and sexually transmitted diseases, resulting in increasing demands on services. The number of new drug users reported by the
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national Information Services Division (ISD) during 2002/2003 for Grampian was 978. This is an increase of 29% compared to the previous year.
The number of people with sexually transmitted infections continues to escalate. For example, 1,492 new cases of chlamydia were diagnosed through the Grampian laboratory during 2002, an increase of 18% from 2000.
There has been a wealth of prevention initiatives aimed at injecting drug users, and which have helped, for example, to keep our proportion of injecting drug users infected with HIV to just 14% of those infected. Work on prevention of sexually transmitted infections continues with
vigour. A Grampian Sexual Health Strategy is currently being developed on a multi-agency basis to provide a coherent, planned approach to promoting sexual health, and to ensure high quality, consistent, appropriate, accessible, healthcare, such that we improve the sexual health and wellbeing of the local population.
The Grampian Bloodborne Virus Group collaborates with all relevant services in the voluntary and statutory sectors to oversee action to raise awareness of bloodborne viruses, encourage timely diagnosis, reduce the spread of these infections, and ensure effective investigation and management of the patients affected.
Figure 1- Newly reported HIV infected persons by risk factor (cumulative to March 2003)
Figure 2 - Trends in HIV heterosexual transmission by geographic area of exposure
0
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92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/2000 2000/01 2002/03
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1996-97 1997-98 1998-99 1999-00 2000-01 2001-02 2002-03
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Alcohol and Other DrugsIn my last annual report, I raised concerns about the alcohol consumption of young people. However, this is only one part of the challenge that alcohol presents to health in Grampian. In the calendar year 2002, almost 13% of drivers breathalysed were reported for offences related to driving, or being in charge of a vehicle while unfi t through drink or drugs or while over the legal drink drive limit15.
In 2002, 27 people were arrested for drunk and incapable offences in Aberdeen. There were 20 cases of licensed premises selling alcohol to under 18 year olds, and three people were charged with purchasing alcohol for under 18 year olds. Despite these fi scal interventions, there were 51 deaths directly attributable to alcohol misuse in Grampian in 2002, of which 29 were in Aberdeen. This statistic relates only to sudden deaths reported by the Police to the Procurator Fiscal where alcohol or alcohol intoxication has been given as a contributory cause of death. It does not include deaths due to illnesses or medical conditions brought on by alcohol abuse.
Local work includes the Moray Drug and Alcohol Action Team (DAAT) identifying that culture change in adults is needed to support young people’s alcohol consumption, and drink driving. A study will be carried out by NHS Grampian and Grampian Police with convicted drink drivers to develop appropriate messages.
CancerCancer remains a serious problem, causing about four of the 14 or so deaths that occur every day in Grampian, and, as such, is our biggest killer. It is therefore gratifying to report that we continue to achieve high uptake for breast and cervical screening, including Aberdeen City, where uptake in some areas is less good (although still above targets).
Breast ScreeningNHS Quality Improvement Scotland visited the North East Scotland breast-screening service at the end of March 2003. Initial feedback on the day was generally good, and there were many positive observations in the subsequent report. One area highlighted is the diffi culty the service
has in ensuring certain multi-disciplinary meetings take place. This is due to pressure on the scarce medical staff. This is especially true of radiology and pathology where recruitment is very diffi cult. However, plans are well advanced to bring in the age extension to 69 years by the deadline of March 2004.
Cervical ScreeningThere has been diffi culty in recent months relating to the time women wait to receive the result of their smear test. The average time between a smear being taken and being read went up from 2.6 weeks in January 2003 to 5.7 weeks in May 2003. This has been for two reasons. Recruiting and retaining laboratory staff continues to be diffi cult. The other reason was the need last March to take screening staff off smear reading for a time to enable them to be trained in reading the new Liquid Based Cytology (LBC) smears.
We have now rolled out LBC to all practices in Grampian and are intending to have conventional smears phased out by the end of June 2004. Grampian took part in the LBC pilot two years ago and we are very hopeful that this will be a popular development with primary care staff, with women (as fewer smears will need to be repeated for being ‘unsatisfactory’) and with the laboratory staff. We hope that reporting times will start to improve over the next few months.
Coronary Heart DiseaseCoronary heart disease remains a serious problem, causing about three deaths of the average 14 that occur every day in Grampian.
A review of local cardiac rehabilitation services for people who have suffered a heart attack in Grampian was complemented by work by Grampian Local Health Council to gather the views of people using these services, and this has helped us improve the service. Additional funding has been sought, such as the Health Improvement Fund (HIF) and the New Opportunities Fund (NOF), and this has provided more opportunity to develop this service in local communities. In particular, the NHS Grampian Smoking Advice Service has been integrated into cardiac and coronary care and stroke units, and advice on prescribing Nicotine Replacement Therapy (NRT)
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has been issued to all staff in relation to cardiology patients.
In partnership with the local authorities in Moray, Aberdeenshire and Aberdeen City and the voluntary sector, local instructors have undergone British Association for Cardiac Rehabilitation (BACR) training to expand local opportunities for ‘phase 4’ exercise classes for patients.
Mental HealthA national survey in 2001 revealed that one in four of the Scottish population has experienced a mental health problem, and nearly three-quarters know someone who has been diagnosed with one. An estimated 25-31% of adults in Grampian are suffering from mental ill-health. Around 10% of these have a diagnosis of mental illness with approximately 2% being referred to mental health services for critical intervention. Promoting positive mental health, reducing the stigma associated with mental health problems, and providing high quality mental health services are central to the health improvement agenda. However, the shame of having a mental health problem is so high that 50% of respondents said if they developed a mental health problem they would not want anybody to know about it. This has a considerable impact on the number of people coming forward for help.
In 2002, NHS Grampian led local efforts to take forward locally the national campaign to reduce the stigma surrounding mental ill-health in Grampian, in addition to generally improving the mental health of the Grampian population.
A subsequent regional evaluation revealed a greater level of awareness of the issues in Grampian than anywhere else in Scotland, and the national campaign used Grampian as a model case study in their approach to the Scottish Executive for further funding, and as a useful framework for other NHS areas to adopt or adapt. I am pleased to be able to report that, perhaps unsurprisingly given such recognition, the Grampian Mental Health Month campaign won fi rst place in the service-specifi c category of the UK’s National Association of Healthcare Communicators Awards 2003. It also received a bronze award at the Scottish PR Awards 2003 for
Best Community Campaign.
Smoking CessationOver the last year the NHS Grampian Smoking Advice Service has continued to ensure all smokers who would like help to stop smoking in Grampian have access to support that suits their needs. To date, 11,555 clients have been referred to the service, with 8,469 clients choosing to register for a programme of intensive smoking cessation support. Community hospitals, together with GP practices and other local community venues, are used to provide this service within our communities.
Further developments this year include a community pharmacist scheme (currently 105 clients with 53 pharmacists registered), an integrated hospital based service and ASH Scotland/Health Scotland funding for a young person’s pilot project.
Helping people in hospital to stop smoking has been prioritised across four main hospital sites: Aberdeen Royal Infi rmary, Dr Gray’s in Elgin, Woolmanhill, and Cornhill. Services are provided in the following clinical specialities:
• Respiratory, thoracic, chest clinic
• Cardiac and coronary care & stroke services (linking with the developing managed clinical network for CHD and stroke
• Diabetes services
• Pre-operation outpatients clinic
• Maxillo-facial department
• Mental health services
• Maternity services, to address a national and local priority in terms of smoking in pregnancy.
To date, 163 clients have been seen while in hospital, with those who wish being allocated places in a community group following discharge.
The Smoking Advice Service works closely with GPs in Grampian to ensure that best use is made of drugs (such as Zyban) which can help people to give up smoking.
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Various local projects to examine the health issues affecting people on low incomes have all contributed to increasing our understanding of how we can best support people in all our communities who wish to gain the health (and fi nancial) benefi ts of stopping smoking. This work has also helped us to adopt a ‘holistic’ approach to helping people to improve their health, whilst providing specialist training for professionals and volunteers working in our communities.
Food and HealthOne example of work over 2002/2003 has been the multi-agency Moray Food & Health Group accessing Quality of Life funding from The Moray Council to undertake community health promotion work. This project addresses the key obesity and diet-related issues in Eating for Health - A Diet Action Plan for Scotland16, by designing a strategy to inter-link local food initiatives. The project focuses on the key issues of:
Food access - make better food choices more available to more people in Speyside and Lhanbryde, particularly fruit and vegetables, supporting the role of rural shops, and encouraging food co-ops to support communities which do not currently have a shop.
Food skills - encourage the development of food skills such as purchasing, preparation, handling, budgeting and creating a balanced diet, through the training of community-based facilitators, pursuing accreditation for participants, and investigating food preparation education for pupils in secondary years 3, 4 and 5.
Food and weight - provide improved and convenient help for people to manage their own weight, including training for community and local NHS staff to help them deliver a locally-based service based on the Healthy Helpings service previously developed by Health Promotions.
Food in schools - work with schools through the Health Promoting Schools initiative to
develop School Nutrition Action Groups to involve children, teachers, catering staff and the community in addressing school meals, tuck shops and vending machines.
Given the growing importance of obesity and diabetes as health problems, I look forward to reporting on the progress in this important work in my next annual report.
Dental HealthThe poorest 10% of children have 50% of the tooth decay which occurs in children. The national target for the year 2010 is for 60% of fi ve-year olds to have no experience of dental decay. At the moment, the percentage is 44%.
Grampian fares poorly against the national average for the ratio of General Dental Practitioners per head of population, particularly in our more rural areas. This is compounded by a shortage of clinical staff across all areas of the dental service, threatening the viability of some services in certain locations. Preventing dental disease, and providing appropriate services, are the two strands to improving dental health in Grampian. In my last two annual reports, I have commented on the need for NHS Grampian to work actively with the dental profession to improve the availability of manpower in local dental services. I am
! RECOMMENDATION: NHS Grampian needs to develop a strategic framework for dental health services in Grampian and implement plans based on it.
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disappointed at the slow progress on this issue. The availability of NHS dentistry in Grampian remains a matter of concern.
Health and HomelessnessEvery area of Scotland faces the blight of homelessness. Given that the homeless are among the most disadvantaged in society, addressing homelessness is an essential element of the ‘social justice’ agenda. Surveys show that the majority of homeless people have no educational qualifi cations and are not in work. While these factors are important infl uences on health in their own right, the health of the homeless is a particular concern for the NHS.
Homeless people have worse health, and die earlier, than the wider population. In particular, they have poorer mental health. Misuse of alcohol and drugs - along with the resulting problems - is more common in homeless people. They also have poorer dental health.
Evidence also shows that this poorer health is not confi ned to people sleeping rough, but is shared by those living in the poor conditions of various types of temporary accommodation. Of particular concern must be the health of the children of homeless families. Evidence indicates that they have higher levels of illness and infection, suffer delayed development, and are more prone to behavioural disturbance and accidental injury.
I am therefore pleased to report that in response to national guidance on this issue, NHS Grampian and its partner agencies in this fi eld have drawn up an action plan to tackle health and homelessness17. This includes work to gather
evidence around homelessness in Grampian, as well as improving access to healthcare and developing services geared to needs. I look forward to being able to report on meaningful progress in implementing this plan in my next annual report.
Social InclusionPublic policy is tackling complex, cross-boundary issues, which require a holistic approach to problem solving. Shifting the focus from a single organisation’s agenda to organisations working in partnership requires the public health system to build effective relationships with a wide range of partners. We need to make connections between problems, solutions, the mobilisation of effort, and the available resources.
I am encouraged by the commitment of NHS Grampian to achieve health gain through ensuring that health services are accessible to all. However, in the coming year I am keen to see the development, implementation and evaluation of an integrated Health Inequalities Strategy and Action Plan - within an agreed framework for social inclusion for NHS Grampian - and that this is refl ected in the Grampian Health Plan18 and Joint Health Improvement Plans in each local authority area. This will entail infl uencing specifi c partnerships, (which may be currently outwith the Community Planning partners) to include a range of health indicators, measurement tools, and monitoring mechanisms within the strategic planning frameworks of, for example, Aberdeen’s Great Northern Social Inclusion Partnership, and Moray Youthstart19.
ConclusionIn conclusion, the changes in population and social structure will have a signifi cant effect on the life circumstances - and therefore the health - of communities in Grampian over the next few years. Given the available evidence, my view is that, in additional to national priorities for health, NHS Grampian and its partners should formally adopt mental health, dental health and the protection of health as local priorities.
!RECOMMENDATION: Partner public health organisations in Grampian should debate and discuss proposed local health priorities, fully involving the public, before formally adopting these priorities.
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One of the biggest challenges facing NHS Grampian and its partners is simply to ‘make it happen’, to deliver change which will bring a marked improvement to health, enhance health services, and be visible to everybody in Grampian.
MAKING IT HAPPEN......through Community Planning
NHS Grampian, together with its partners, needs to build on work already underway to encourage, support and enable individuals and communities to take shared responsibility for their own health, and to work together to bring about improvements. It needs to foster ‘active citizenship’, with people actively engaged in the efforts of their communities to bring about health improvement.
I believe that Community Planning has a crucial role to play in improving health and well-being in the various natural communities of Grampian. It provides the mechanism to improve the health and wellbeing of communities in ways that meet the needs of the individual community and provide a multi-faceted strategy to improve its health, wellbeing and economic productivity.
Community Planning Partnerships can improve life circumstances for local people through
establishing shared priorities for local communities and ensuring an integrated approach to addressing them.
Housing, transport, employment, recreational facilities and a wide range of public services all have an impact on the health and wellbeing of communities. Community Planning can support action to address poverty, lack of physical activity and leisure facilities, poor housing and other factors that contribute to inequality. By taking a broad, multi-agency view of a community, we can, together, make an impact to improve the life circumstances of the members of that community.
The Community Planning process gives a strong opportunity to include views from the community receiving the service, together with those providing the service. It is important that this opportunity is grasped. I would like to see us continue the strong local commitment to engaging with, and involving, people and communities in all aspects of not only health (physical, social and mental) but also in the very diffi cult decisions around the limited resources available for healthcare, including health improvement. It is very important that this commitment is not lost in the complexity of organisations working in partnership, and that people and communities are involved and have a role in shaping action and delivering change. Ideally, we wish to empower and support communities to be involved in developing initiatives and solutions themselves.
SECTION THREECHALLENGES
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The policy document Improving Health in Scotland: the challenge2 states that by mid 2004 Community Planning Partnerships (as the overarching framework), together with each local NHS Board area, will have agreed processes with their local authority partners to ensure that we maximise the health improving potential of community plans, Social Inclusion Partnerships (SIPs), healthy living centres and other community-based initiatives. We need to continue to work towards achieving this in Grampian, with the help of the developing Community Health Partnerships in each of our three local authority areas.
...and planning across the North of ScotlandThe other signifi cant challenge is sustaining some of our specialist healthcare services across the North of Scotland. It is vital we do this, in partnership with our two universities, for the benefi t of the communities we serve. There is a national shortage of appropriately-trained professionals in many specialised services, and this makes it even more diffi cult to recruit and retain staff to work in remote and rural areas.
Regional planning across the six NHS boards which make up the North of Scotland, (Grampian, Highland, Tayside, Orkney, Western Isles, and Shetland) presents an opportunity to tackle these issues. However, unless there is a genuine commitment between the boards to work together, we will not succeed in sustaining some of these specialist services in the North, and patients will have to travel to the central belt of Scotland and beyond for many of these. For example, there are critical interdependencies between facilities in Dundee and Aberdeen, and, unless some services are combined as managed clinical networks between the two, they are likely to be lost to both areas. This is a loss not only to the public who want as local a service as possible, but also to the training and development of our local workforce. I am pleased that there
has been good progress in tackling these issues in relation to some of the specialised aspects of children’s healthcare over the past year. However, I am concerned that interdependencies between centres in the North may not be being recognised and acted on. We must address these issues now to secure access to such services in the North of Scotland in the future, or patients will in future have to travel much further.
Fit for purposeTo contribute to achieving a step-change in health improvement and enhanced quality healthcare services, NHS Grampian will need to change quite radically over the coming months. We cannot continue as we are in Grampian and expect something different to happen in terms of people’s health experience. NHS Grampian and its partners need to have the capacity to deliver what is required, and also the capacity to manage ‘change’.
While I welcome this necessary change with enthusiasm, it is important that we manage it in a way that ensures that we continue our daily ‘business’, not only for healthcare and health improvement, but particularly in relation to health protection. Over the past year we have seen rising professional, political and public concern about the emergence of new communicable diseases and the reappearance of others in a way that had not been anticipated. We face the re-emergence of ‘old’ threats to health such as TB and the appearance of new diseases such as variant CJD and SARS. This raises issues about refreshing clinical skills and developing new ones as necessary.
ResourcesIn previous reports I have raised the subject of the hard choices which have to be made by NHS Grampian and its partners in the face of scarce resources.
!RECOMMENDATION: NHS Boards in the North of Scotland must rapidly make decisions, on a North of Scotland basis, to combine specialist services in a way that makes them sustainable.
!RECOMMENDATION: NHS Grampian and partner local authorities should ensure that the capacity of their health protection functions remain appropriate to the risks faced by the local population.
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The NHS cannot spend money it has not got, and must secure services for Grampian residents within its allocated budget. Year on year, the people of Grampian have growing expectations of their health and healthcare, fuelled by the rapid advance of technology and greater awareness and information. NHS Grampian is committed to engaging with the public it serves to agree what the local priorities are, and what will be provided over coming years. This work is in the context of NHS Grampian having to recover its fi nancial position (having spent too much money over recent years particularly 2002/2003). Although there will be signifi cant new investment, this will go specifi cally into wages and salaries with new contracts of employment for GPs, consultants and almost all other NHS staff. The scale of this investment is such that it offers great scope for further improving work practices, the quality of care and outcomes for patients. This does however mean that there will be little extra money for additional demands. This will make it even harder to decide how much of which interventions and services should be provided.
In an era where ‘informed consent’ has become so important as a fundamental ethical principle at individual level, I believe we must strive to achieve the same at population level. Those leading NHS
Grampian and its partner organisations must ensure that the communities they serve are informed, and understand the issues involved in the choices that will have to be made over coming months and years. We need to rapidly arrive at the point where there can be mature discussion of the choices to be made with the communities we serve as equal partners. I believe it is only in this way that we will be able to tackle these diffi cult decisions to deliver effective health improvement and healthcare within the limited resources available to us.
The Way ForwardAs I refl ect on this brief sketch of the health of the people of Grampian over the past year, I struggle to paint the challenge that faces us all more eloquently than Partnership for Care1 does, cautioning that: “Tackling these problems will not be easy. We need to work together to change our own unhealthy lifestyles and the unhealthy circumstances in which too many people live.
“We will encourage people to care about their own health - helping them understand how they can improve their own health. We will work to create a national movement for health improvement.”
Dr Eric BaijalJanuary 2004
References
• 1 Scottish Executive. Partnership for Care. Edinburgh: Scottish Executive, 2003
• 2 Scottish Executive. Improving Health The Challenge. Edinburgh: Scottish Executive. 2003
• 3 NHS Grampian. NHS Grampian Health Plan 2003/04. Aberdeen: NHS Grampian
• 4 NHS Grampian. Grampian Breastfeeding Strategy. Aberdeen: NHS Grampian 2001
• 5 Hall DMB and Elliman D. Health for all children. Oxford: Oxford University Press 2003.
• 6 Scottish Executive New Community Schools Prospectus. Edinburgh: Scottish Executive 1998
• 7 Aberdeen City Council. Aberdeen Futures, Aberdeen City Community Plan. Aberdeen: Aberdeen City Council 2001
• 8 Wilson B & Hinks S, Give Kids a Chance - Evaluation Report, Aberdeen: Department of Public Health, University of Aberdeen 2000
• 9 The Way Forward - Framework for Economic Development in Scotland 2000
• 10 Scotland’s Health at Work Award Scheme, 1996 www.shaw.uk.com
• 11 Population Census 2001 www.statistics.gov.uk
• 12 Baijal, E. Annual Report of the Director of Public Health 2000-01, Aberdeen NHS Grampian 2001
• 13 Offi ce for Public Management. HealthFit: creating the vision for Grampian’s health. Offi ce of Public Management 2002
• 14 Howie H. AIDS Control Act Report 2002-2003. Aberdeen NHS Grampian 2003
• 15 Johnstone, L. Report to Aberdeen City Alcohol Action Team Meeting on 7 February 2003. Aberdeen: Grampian Police 2003
• 16 Scottish Executive. Eating for Health - A Diet Action Plan for Scotland. Edinburgh: Scottish Executive
• 17 NHS Grampian. Health & Homelessness Strategy, Aberdeen: NHS Grampian 2003
• 18 NHS Grampian. Grampian Health Plan 2003-04, Aberdeen: NHS Grampian 2003
• 19 Moray Youthstart www.youthstart.org
!RECOMMENDATION: NHS Grampian and its partners need to develop robust mechanisms to engage with the public, and their staff, to tackle these diffi cult decisions together, so that we continue to improve health and build an effective health system which makes best use of all the resources (including funding) available to us.
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