How many people will need palliative care in Scotland by 2040? A mixed-method study of projected palliative care need and recommendations for service delivery.

OBJECTIVE: To estimate future palliative care need and complexity of need in Scotland, and to identify priorities for future service delivery. DESIGN: We estimated the prevalence of palliative care need by analysing the proportion of deaths from defined chronic progressive illnesses. We described linear projections up to 2040 using national death registry data and official mortality forecasts. An expert consultation and subsequent online consensus survey generated recommendations on meeting future palliative care need. SETTING: Scotland, population of 5.4 million. PARTICIPANTS: All decedents in Scotland over 11 years (2007 to 2017). The consultation had 34 participants; 24 completed the consensus survey. PRIMARY AND SECONDARY OUTCOMES: Estimates of past and future palliative care need in Scotland from 2007 up to 2040. Multimorbidity was operationalised as two or more registered causes of death from different disease groups (cancer, organ failure, dementia, other). Consultation and survey data were analysed descriptively. RESULTS: We project that by 2040, the number of people requiring palliative care will increase by at least 14%; and by 20% if we factor in multimorbidity. The number of people dying from multiple diseases associated with different disease groups is projected to increase from 27% of all deaths in 2017 to 43% by 2040. To address increased need and complexity, experts prioritised sustained investment in a national digital platform, roll-out of integrated electronic health and social care records; and approaches that remain person-centred. CONCLUSIONS: By 2040 more people in Scotland are projected to die with palliative care needs, and the complexity of need will increase markedly. Service delivery models must adapt to serve growing demand and complexity associated with dying from multiple diseases from different disease groups. We need sustained investment in secure, accessible, integrated and person-centred health and social care digital systems, to improve care coordination and optimise palliative care for people across care settings.

Does ethnic diversity explain intra-UK variation in mortality? A longitudinal cohort study.

OBJECTIVES: It has been proposed that part of the explanation for higher mortality in Scotland compared with England and Wales, and Glasgow compared with other UK cities, relates to greater ethnic diversity in England and Wales. We sought to assess the extent to which this excess was attenuated by adjusting for ethnicity. We additionally explored the role of country of birth in any observed differences. SETTING: Scotland and England and Wales; Glasgow and Manchester. PARTICIPANTS: We used the Scottish Longitudinal Study and the Office for National Statistics Longitudinal Study of England and Wales (2001-2010). Participants (362 491 in total) were aged 35-74 years at baseline. PRIMARY OUTCOME MEASURES: Risk of all-cause mortality between 35 and 74 years old in Scotland and England and Wales, and in Glasgow and Manchester, adjusting for age, gender, socioeconomic position (SEP), ethnicity and country of birth. RESULTS: 18% of the Manchester sample was non-White compared with 3% in Glasgow (England and Wales: 10.4%; Scotland: 1.2%). The mortality incidence rate ratio was 1.33 (95% CI 1.13 to 1.56) in Glasgow compared with Manchester. This reduced to 1.25 (1.07 to 1.47) adjusting for SEP, and to 1.20 (1.02 to 1.42) adjusting for ethnicity and country of birth. For Scotland versus England and Wales, the corresponding figures were 18% higher mortality, reducing to 10%, and then 7%. Non-Whites born outside the UK had lower mortality. In the Scottish samples only, non-Whites born in the UK had significantly higher mortality than Whites born in the UK. CONCLUSIONS: The research supports the hypothesis that ethnic diversity and migration from outside UK play a role in explaining Scottish excess mortality. In Glasgow especially, however, a large excess remains: thus, previously articulated policy implications (addressing poverty, vulnerability and inequality) still apply.

Death within 1 year among emergency medical admissions to Scottish hospitals: incident cohort study.

BACKGROUND: It is increasingly recognised that large numbers of hospital inpatients have entered the last year of their lives. AIM: To establish the likelihood of death within 12 months of admission to hospital; to examine the influence on survival of a cancer diagnosis made within the previous 5 years; to assess whether previous emergency admissions influenced mortality; and to compare mortality with that of the wider Scottish population. DESIGN: Incident cohort study. SETTING: 22 hospitals in Scotland. PARTICIPANTS: This study used routinely collected data from 10 477 inpatients admitted as an emergency to medicine in 22 Scottish hospitals between 18 and 31 March 2015. These data were linked to national death records and the Scottish Cancer Registry. PRIMARY OUTCOME MEASURES: 1 year cohort mortality compared with that of the general Scottish population. Patient factors correlating with higher risk of mortality were identified using Cox regression. RESULTS: There were 2346 (22.4%) deaths in the year following the census admission. Six hundred and ten patients died during that admission (5.8% of all admissions and 26% of all deaths) while 1736 died after the census admission (74% of all deaths). Malignant neoplasms (33.8%), circulatory diseases (22.5%) and respiratory disease (17.9%) accounted for almost three-quarters of all deaths. Mortality rose steeply with age and was five times higher at 1 year for patients aged 85 years and over compared with those who were under 60 years of age (41.9%vs7.9%) (p<0.001). Patients with cancer had a higher mortality rate than patients without a cancer diagnosis (55.6%vs16.6%) (p<0.001). Mortality was higher among patients with one or more emergency medical admissions in the previous year (30.1% v 15.1%) (p<0.001). Age/sex-standardised mortality was 110.4 (95% CI 104.4 to 116.5) for the cohort and 11.7 (95% CI 11.6 to 11.8) for the Scottish population, a 9.4-fold increase in risk. CONCLUSION: These data may help identify groups of patients admitted to hospital as medical emergencies who are at greatest risk of dying not only during admission but also in the following 12 months.

Dying younger in Scotland: Trends in mortality and deprivation relative to England and Wales, 1981-2011.

Given previous evidence that not all Scotland's higher mortality compared to England & Wales (E&W) can be explained by deprivation, the aim was to enhance understanding of this excess by analysing changes in deprivation and mortality in Scotland and E&W between 1981 and 2011. Mortality was compared by means of direct standardisation and log-linear Poisson regression models, adjusting for age, sex and deprivation. Different measures of deprivation were employed, calculated at different spatial scales. Results show that Scotland became less deprived compared to E&W between 1981 and 2011. However, the Scottish excess (the difference in mortality rates relative to E&W after adjustment for deprivation) increased from 4% higher (c.1981) to 10% higher in 2010-12. The latter figure equates to c. 5000 extra deaths per year. The increase was driven by higher mortality from cancer, suicide, alcohol related causes and drugs-related poisonings. The size and increase in Scottish excess mortality are major concerns. Investigations into its underlying causes continue, the findings of which will be relevant to other populations, given that similar excesses have been observed elsewhere in Britain.

Predictors of place of death in South West Scotland 2000-2010: Retrospective cohort study.

BACKGROUND: Surveys suggest most people would prefer to die in their own home. AIM: To examine predictors of place of death over an 11-year period between 2000 and 2010 in Dumfries and Galloway, south west Scotland. DESIGN: Retrospective cohort study. SETTING/PARTICIPANTS: 19,697 Dumfries and Galloway residents who died in the region or elsewhere in Scotland. We explored the relation between age, gender, cause of death (cancer, respiratory, ischaemic heart disease, stroke and dementia) and place of death (acute hospital, cottage hospital, residential care and home) using regression models to show differences and trends. The main acute hospital in the region had a specialist palliative care unit. RESULTS: Fewer people died in their own homes (23.2% vs 29.6%) in 2010 than in 2000. Between 2007 and 2010, men were more likely to die at home than women (p < 0.001), while both sexes were less likely to die at home as they became older (p < 0.001) and in successive calendar years (p < 0.003). Older people with dementia as the cause of death were particularly unlikely to die in an acute hospital and very likely to die in a residential home (p < 0.001). Between 2007 and 2010, an increasing proportion of acute hospital deaths occurred in the specialist palliative care unit (6% vs 11% of all deaths in the study). CONCLUSION: The proportion of people dying at home fell during our survey. Place of death was strongly associated with age, calendar year and cause of death. A mismatch remains between stated preference for place of death and where death occurs.

Predicting which people with psychosocial distress are at risk of becoming dependent on state benefits: analysis of routinely available data.

OBJECTIVES: To examine whether there was significant variation in levels of claiming incapacity benefit across general practices. To establish whether it is possible to identify people with mental health problems who are more at risk of becoming dependent on state benefits for long term health problems based on their general practice consulting behaviour. DESIGN: Interrogation of routinely available data in the Scottish Health Surveys and the British Household Panel Survey. SETTING: Scotland and the United Kingdom. PARTICIPANTS: Respondents to the Scottish Health Surveys in 1995, 1998, and 2003 (7932, 12,39 and 11,72 respondents, respectively). Respondents to the British Household Panel Survey, 1991-2007 (more than 5000 households). MAIN OUTCOME MEASURES: Intracluster correlation coefficient for probability of work incapacity by general practice. Caseness according to the general health questionnaire (GHQ-12) and frequency of consultation with general practitioner in years before and after starting to claim incapacity benefit. RESULTS: There was a small and non-significant amount of variation across general practices in Scotland in rate of claims for incapacity benefit after adjustment for other explanatory variables (intracluster correlation coefficient 0.01, P=0.135). There was a significant increase in rates of GHQ-12 caseness from two years before the start of claiming incapacity benefit (odds ratio 1.6, 95% confidence interval 1.3 to 1.9) and an increase in frequent consultation with a general practitioner from three years before the start of claiming incapacity benefit (1.8, 1.3 to 2.4). People with GHQ-12 caseness showed a significant increase in frequent consultations with a general practitioner from two years before the start of claiming incapacity benefit (2.1, 1.4 to 3.2). CONCLUSIONS: There was no variation in levels of claiming incapacity benefit across general practices in Scotland after adjustment for differences in population characteristics and so initiatives targeted at practices with high levels are unlikely to be effective. People with mental health problems who are likely to have problems remaining in work can be identified up to three years before they transit on to long term benefits related to ill health.

'A coal face option': GPs' perspectives on the rise in antidepressant prescribing.

BACKGROUND: Levels of antidepressant prescribing have dramatically increased in Western countries in the last two decades. AIM: To explore GPs' views about, and explanations for, the increase in antidepressant prescribing in Scotland between 1995 and 2004. DESIGN: Qualitative, interview study. SETTING: General practices, Scotland. PARTICIPANTS: GPs in 30 practices (n = 63) purposively selected to reflect a range of practice characteristics and levels of antidepressant prescribing. METHOD: Interviews with GPs were taped and transcribed. Analysis followed a Framework Approach. RESULTS: GPs offered a range of explanations for the rise in antidepressant prescribing in Scotland. Few doctors thought that the incidence of depression had increased, and many questioned the appropriateness of current levels of prescribing. A number of related factors were considered to have contributed to the increase. These included: the success of campaigns to raise awareness of depression; a willingness among patients to seek help; and the perceived safety of selective serotonin reuptake inhibitors, making it easier for GPs to manage depression in primary care. Many GPs believed that unhappiness, exacerbated by social deprivation and the breakdown of traditional social structures, was being 'medicalised' inappropriately. CONCLUSION: Most antidepressant prescriptions in Scotland are issued by GPs, and current policy aims to reduce levels of prescribing. To meet this aim, GPs' prescribing behaviour needs to change. The findings suggest that GPs see themselves as responders to, rather than facilitators of, change and this has obvious implications for initiatives to reduce prescribing.

Factors influencing variation in prescribing of antidepressants by general practices in Scotland.

BACKGROUND: The prescribing of antidepressants has been rising dramatically in developed countries. AIM: As part of an investigation into the reasons for the rise and variation in the prescribing of antidepressants, this study aimed to describe, and account for, the variation in an age-sex standardised rate of antidepressant prescribing between general practices. DESIGN OF STUDY: Cross-sectional study involving analyses of routinely available data. SETTING: A total of 983 Scottish general practices. METHOD: Age-sex standardised prescribing rates were calculated for each practice. Univariate and multivariate regression analyses were undertaken to examine how the variation in prescribing was related to population, GP, and practice characteristics at individual practice level. RESULTS: There was a 4.6-fold difference between the first and ninth deciles of antidepressant prescribing, standardised for registered patients' age and sex composition. The multivariate model explained 49.4% of the variation. Significantly higher prescribing than expected was associated with more limiting long-term illness (highly correlated with deprivation and the single most influential factor), urban location, and a greater proportion of female GPs in the practices. Significantly lower prescribing than expected was associated with single-handed practices, a higher than average list size, a greater proportion of GP partners born outside the UK, remote rural areas, a higher proportion of patients from minority ethnic groups, a higher mean GP age, and availability of psychology services. None of the quality-of-care indicators investigated was associated with prescribing levels. CONCLUSION: Almost half of the variation in the prescription of antidepressants can be explained using population, GP, and practice characteristics. Initiatives to reduce the prescribing of antidepressants should consider these factors to avoid denying appropriate treatment to patients in some practices.

Relationship between antidepressant and anxiolytic/hypnotic prescribing: a mixed-methods study.

BACKGROUND: Antidepressant prescribing has dramatically increased in Scotland, and the cause is unknown. OBJECTIVE: To investigate if the increase in antidepressant prescribing coincided with a reduction in prescribing of anxiolytics and hypnotics; to investigate this relationship at practice level; and to explore whether general practitioners (GPs) explain the increase by their increased use for anxiety. STUDY DESIGN: analysis of routine prescribing data and interviews with GPs. SETTING: Scottish general practices. PARTICIPANTS: 942 practices included in the analysis. Sixty-three GPs in 30 practices completed interviews. MAIN OUTCOME MEASURES: Quantity of antidepressants, anxiolytics, and hypnotics prescribed. Relationship at practice level between anxiolytic/hypnotic and antidepressant prescribing. Spontaneous comments by GPs about prescribing antidepressants for anxiety. RESULTS: Antidepressant prescribing increased from 28.9 million defined daily doses (DDDs) in 1992/3 to 128.3 million in 2004/5. Anxiolytic/hypnotic prescribing fell from 64.2 million to 55.1 million DDDs. There was a weak, positive correlation between levels of antidepressant and anxiolytic/hypnotic prescribing (+0.084, p=0.010). GPs treated anxiety with antidepressants, although many described an overlap between anxiety and depression. Some spontaneously identified a relationship with benzodiazepine prescribing when asked to explain the increase in antidepressant prescribing. CONCLUSION: A small part of the increase in antidepressant prescribing is due to substitution for benzodiazepines to treat anxiety.

Exploring potential explanations for the increase in antidepressant prescribing in Scotland using secondary analyses of routine data.

BACKGROUND: Antidepressant prescribing in general practice has dramatically increased since the beginning of the last decade. AIM: To determine if the increase in antidepressants prescribed in Scotland between 1995 and 2001 was due to increase in incidence, prevalence, care-seeking behaviour by patients, or identification by GPs of depression. METHOD: Secondary analysis of routine data. Prescribing information was obtained from Information and Statistics Division Scotland, psychosocial morbidity from the Scottish Health Surveys of 1995 and 1998 and GP consultations from the continuous morbidity recording (CMR) dataset. Annual trends in antidepressant prescribing for prescriptions, gross ingredient cost and defined daily doses (DDDs) were examined for all Scottish Practices and 54 stable CMR practices (175 955 patients). Prevalence of psychological morbidity in responders with a General Health Questionnaire score > or = 4, their contact probability and contact frequency was compared in the 1995 and 1998 Scottish Health Surveys. Changes in diagnostic and GP consultation patterns in CMR practices were compared. RESULTS: Total prescriptions for antidepressants increased from 1.5 million in 1995-1996 to 2.8. million in 2000-2001. The gross ingredient cost increased from pounds 20 to pounds 44 million and total DDDs from 44.5 to 93.2 million. Prescription trends in CMR practices were similar. Overall prevalence of psychological morbidity was the same in the 1995 and 1998 Scottish Health Surveys. Percentage of consultations in CMR practices for new diagnoses of depression decreased from 1.7 to 1.3%, the depression-related contact rate decreased and annual prevalence rates for depressive illness were stable between 1998-1999 and 2000-2001. CONCLUSIONS: There is no evidence of an increase in incidence, prevalence, care-seeking behaviour or identification of depression during the period of a sharp increase in antidepressant prescribing. Further work is required to explain the increase.