Introduction

The population of Lothian continues to grow. It is estimated that during the 18 year period from 1991-2009, NHS Lothian saw population growth of around 11% (81,000 people). Population is a key driver of need for health services and over the next 10 years further population growth of just over 64,500 (7.7%) people is anticipated. This is the equivalent of asking existing staff and services to take on meeting the needs of another town, similar in size to Livingston. There are three sources of population growth: increased births, people living longer and inward migration. Lothian is experiencing all three combined with a continued reduction in childhood deaths, an increasing number of adults of working age, premature deaths occurring later in middle age and a slower decline in the population aged over 65 years.

Figure 1

Population projections 2020
Population by age and sex

The health service contribution to continued improvements in healthy life expectancy depends on the continuation of a universal service, free at the point of use, which values continuity of care and delivers prevention, treatment and comfort in an integrated way. Universal services are important because, for most conditions, the burden of disease reduces as income and education levels increase. On average, the most deprived 10% of the Scottish population has 70% more male and female deaths under the age of 70 than the most affluent 10%. However, even in GP practices that serve the most affluent areas, a quarter (24.7%) of deaths in men occur in those aged less than 70 years.

Meeting current and future needs

Patterns of treatment are changing with increased recognition that there is a chronic problem underlying most acute illnesses requiring hospital treatment. This is seen in the alcohol use that results in attendance at accident and emergency or the elderly person who has fallen and broken their hip. For this reason, there is an increasing focus on integrating care between health, local authority and the third (voluntary) sector, as well as between primary care and specialist services. At the same time, the economic situation means that greater attention is being paid to how resources, (expertise, equipment and money) can be used to deliver services that will aid all parts of the population to achieve their potential. This means taking a more systematic approach to assessing the ability of new technologies and interventions to provide benefit to the population of Lothian and ensure the provision of effective care and retention of trust and confidence.

There is also a need to distinguish between need/benefit and demand. Effective and equitable health services do their best to assess need for healthcare, modifying the way that services are provided so that they offer people the most appropriate balance of prevention, cure or comfort. Demand is different. It is influenced by knowledge of services, how, where and by whom they are supplied, perceptions of the balance between risk and benefit, trust in providers and personal preference. Demand for specific interventions is not always driven by ability to benefit. The inverse care law was first described in Britain in 1971 [1]. Since then, researchers and practitioners have worked together to:

Since the risk of future disease and the burden of existing conditions fall more heavily on those with fewer resources and quieter voices, these populations should receive more of our attention.

Primary care: increasing engagement

The health service is delivered largely in primary care. the essence of effective primary healthcare is equitable provision of services, comprehensive care, inter-sectoral action, community involvement and appropriate use of technology [3].

Primary care is the first point of contact for most of the population with the NHS and 90% of patient contact occurs in primary care [2]. Excluding out of hours services, NHS Lothian has 827 General Practitioners working in 124 GP practices with 880,862 registered patients. In Lothian 18 practices have more than 20% of their patients living in the areas with the highest concentration of deprivation while in three practices this affects more than 50% of their population. Lothian is fortunate that primary care professionals who are passionate advocates care for many of our most vulnerable residents. Their patients report high levels of trust and appreciate the flexible, non-hierarchical, patient-centred healthcare offered. For many such patients, the primary care team is the constant in their lives. It provides access to expertise in the practice and in the local community for patients with multiple illnesses drug and alcohol problems, social and housing issues. Most countries that do not have this gate-keeping function have higher rates of socio-economic inequalities in access to planned care and more difficulty in delivering care for people with more than one chronic condition.

Figure 2

Primary Care Consultation Trends in Lothian

Primary care is of central importance for population health. However, in Scotland, as in many other countries, primary care data are a largely untapped source of intelligence about the health needs of the population. Until recently, data about primary care were limited to information collected for management, largely payment purposes, or as answers to specific research questions. However, this fairly limited activity-based data has not been enough to assess whether the needs of individuals and communities are being addressed appropriately. This situation is changing. It has become easier to extract and analyse primary care data securely in ways that mean that individuals are not identifiable. Various groups of health professionals and researchers are examining this data to explore the relationship between need, service use and outcome. As the work of the primary care data group develops, it will contribute to the intelligence required to embed data-collecting processes as routine practice in all health programmes, as has been seen with Keep Well and Alcohol Brief Interventions.

Population screening and case finding activity

Figure 3

Breast screening – three year moving averages [5] % uptake females aged 50-70 years

Figure 4

Cervical screening: Annual uptake % eligible population [6] * #

*Scotland figures excludes Lothian NHS Board for 2000-01 to 2006-07 (data calculated on a different basis - calendar year).

#For 2000-01 to 2006-07 data for Lothian NHS Board are calculated on a different basis - calendar year

Screening offers individuals the opportunity to check for indicators of developing disease, prevent it becoming established – to avoid serious illness and premature death - and reduce the length of treatment and its intensity, for example, breast screening (see Figure 3) and cervical screening (see Figure 4). Unfortunately, even the best screening programmes have side effects; no matter how hard we try to minimise false positive and false negative results, they will still occur. Even with an effective screening programme in place, there are conditions where screening just brings treatment forward in time and does not improve the long-term outcome. In the worst cases, treatment is of limited effectiveness or is so unpleasant that there is a question mark over whether it should be offered outside research efforts to develop better treatments. For these reasons, screening programmes should meet certain criteria before they are introduced. New screening guidelines from the World Health Organisation have been introduced and are at the centre of our efforts to ensure that new screening programmes are designed, delivered and evaluated in partnership with their target populations [4].

Providing safe, effective services

Over the past year, we have been working with colleagues in hospital and community services to improve patient safety. Restrictions in antibiotics, improvements in cleaning and the healthcare environment, attention to hand washing, detailed surveillance and early intervention have enabled rates of Clostridium Difficile and MRSA to fall significantly. Interventions begun by critical care staff have reduced the rates of catheter related blood stream infections consistently. We are now looking at how to concentrate efforts in areas where infection rates are slower to improve. These are often where patients have multiple and complex needs or are otherwise vulnerable. Avoidable harm can be minimised when prevention, treatment and care is organised and delivered in ways that:

One globally-recognised measure of improvement of health services is a reduction of amenable mortality. Amenable mortality is death in people under 75 that should not occur in the presence of timely and effective heath care. Amenable mortality in Lothian has fallen in all socioeconomic groups but, more recently, it has fallen significantly in the lowest and second lowest socio-economic group. Amenable mortality has fallen more rapidly over time than all cause mortality. This may reflect the fact that the most frequent causes of amenable mortality are those for which there have been advances in early intervention and treatment. The Scottish Government Quality Strategy [7], however, has chosen all cause premature mortality as its measure of premature death. This is a major step forward because achieving a significant reduction in premature death requires action to address the social determinants of health such as education, housing, income and environment. It means building on the interventions that have reduced the proportion of children in poverty in Lothian, learning from countries that have lower levels of exposure to violence and addiction, particularly among young people, as well as addressing the main personal and social risk factors for premature disease and death.

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